Assessing for Malrotation in Proximal Phalanx Fracture After PIP Joint Dislocation

Key Clinical Questions to Diagnose Malrotation

The American Academy of Orthopaedic Surgeons recommends examining finger alignment during active flexion to assess for malrotation, as rotational deformities become most apparent when the fingers flex toward the scaphoid tubercle, with any scissoring, overlap, or deviation from parallel alignment indicating malrotation requiring immediate intervention 1
The American College of Surgeons suggests asking the patient to actively flex all fingers together into a fist and observe whether the fingernails align in parallel planes, normally all fingers should point toward the scaphoid tubercle without crossing over adjacent digits 1, 2
The American Academy of Orthopaedic Surgeons recommends examining for scissoring during active flexion, where the injured little finger crosses over or under the ring finger, which is the hallmark sign of rotational malalignment 1
Comparing the cascade of the fingers when making a gentle fist, the injured finger should follow the same arc as the contralateral hand, as suggested by the American College of Surgeons 2

The American Academy of Orthopaedic Surgeons states that malrotation assessment must be performed immediately, as the patient is only a few days post-injury and still within the window for non-operative correction if caught early 1

The American Academy of Orthopaedic Surgeons recommends that any degree of persistent or worsening pain during the first few weeks should prompt reevaluation for malrotation or loss of reduction 1, 3
The American College of Surgeons suggests that inability to achieve full active flexion without finger overlap suggests rotational malalignment requiring correction 2

The American Academy of Orthopaedic Surgeons recommends continuing conservative management with the intrinsic-plus brace for a few weeks as planned, if no malrotation is detected 1
The American College of Surgeons suggests instituting immediate active finger motion exercises for all uninvolved joints to prevent stiffness, which is the most functionally disabling complication 1, 3
Obtaining repeat radiographs at 10-14 days to ensure fracture position is maintained, as recommended by the American College of Surgeons 4
The American Academy of Orthopaedic Surgeons recommends performing active finger motion exercises immediately following diagnosis, regardless of treatment method, as finger motion does not adversely affect adequately stabilized fractures but significantly reduces the risk of debilitating stiffness 1, 3