Management of Intra‑articular Middle Phalanx Fractures

Diagnostic Imaging

The American College of Radiology recommends obtaining a minimum three‑view radiographic series (postero‑anterior, lateral, and oblique) as the standard initial imaging for suspected middle‑phalanx fractures, because two‑view examinations miss a significant proportion of fractures. 1, 2
When the oblique view is included, detection of phalangeal fractures that are occult on standard PA and lateral views improves markedly. 1, 2
If initial radiographs are equivocal but clinical suspicion remains high, the guideline advises splinting the finger and repeating radiographs after 10–14 days, or obtaining a non‑contrast CT scan for superior characterization of intra‑articular extension. 1

Articular step‑off or gap ≥ 2 mm is the strongest radiographic predictor for surgical intervention, with substantial inter‑observer agreement (kappa = 0.73). 1
Stable fractures with articular displacement < 2 mm are appropriate for conservative treatment. 1
Operative fixation that restores the joint to a residual articular step‑off < 2 mm is required to prevent long‑term post‑traumatic osteoarthritis. 1, 2

Indicated for patients with stable middle‑phalanx fractures demonstrating < 2 mm articular displacement, minimal angulation, and no joint subluxation or dislocation. 1
Management consists of buddy‑taping the injured finger to an adjacent finger with immediate mobilization. (guideline‑derived practice)

Indicated when an intra‑articular step‑off or gap exceeds 2 mm, or when the fracture is unstable and cannot maintain reduction. 1

Achieving a postoperative residual articular step‑off of less than 2 mm is associated with a lower risk of developing chronic osteoarthritis of the finger joint. 1, 2

The American College of Radiology recommends obtaining radiographs of the injured finger before suturing any crush injury to identify fractures, dislocations, and foreign bodies that will fundamentally alter the management approach 3, 4
A minimum 3-view radiographic examination (posteroanterior, lateral, and oblique views) is essential for any finger crush injury before proceeding with wound closure, as a 2-view examination may miss fractures 4
The oblique view is critical for detecting phalangeal fractures, and both approaches of obtaining a PA view of the entire hand or focusing on the injured finger alone are acceptable 4
Foreign bodies, particularly radiopaque materials, are best detected on initial radiographs 3
Intra-articular fractures may require surgical intervention to prevent long-term osteoarthritis 5

If clinical suspicion remains high despite negative radiographs, place the finger in a short arm cast and repeat radiographs in 10-14 days 4
Consider MRI without IV contrast to detect occult fractures 4