Patient age and gender:
66 yearold Male
History of present illness:
A 66yearold righthand dominant male presented
with acute right small finger pain and deformity following a fall down stairs
while renovating his home. He reported immediate hand pain after the injury.
He presented to urgent care two days prior where he was placed in an ulnar
gutter brace and referred to the Hand Clinic.
Relevant past medical history:
Type 2 diabetes mellitus, prior left second toe
amputation for osteomyelitis
Relevant physical findings:
Inspection of the right hand revealed swelling and
ecchymosis at the base of the small finger with some ulnar deviation of the
digit. There was significant localized tenderness at the proximal phalanx base.
Range of motion at the small finger was limited, with flexion from 0 to 30
degrees at the MP joint due to pain. The Neurovascular exam was normal.
Interpretation of laboratory and imaging studies:
Preoperative radiographs of
the right hand demonstrated a displaced intraarticular fracture involving the
volar radial base of the proximal phalanx of the small finger, with articular
extension and significant displacement of the fracture fragment. CT scan
showed a 7x3mm displaced intraarticular fragment off the small finger radial
proximal phalanx base rotated 90 degrees, with 56mm of displacement.
Preoperative glucose from prior labs was 103-145 mg/dL. HgA1c 8.3
Diagnoses (differential diagnoses):
Closed displaced intraarticular fracture of
the proximal phalanx base of the right small finger
Treatment plan (operative and nonoperative options:
: Nonop: Nonoperative
management options included splinting or casting of the right small finger,
activity modification, and pain control with NSAIDs. However, due to the intraarticular nature of the displaced proximal phalanx fracture, nonoperative treatment was considered to potentially result in persistent articular
incongruity, instability, and development of posttraumatic arthritis and pain.
Operative: Open reduction and internal fixation of the right small finger
proximal phalanx base fracture, with possible fragment excision, was
recommended to restore joint congruity and minimize the risk of chronic pain,
stiffness, and loss of motion. Shared decisionmaking was used to determine
surgical intervention given the limitations of nonoperative care for this injury
pattern.
Primary surgical indications:
Primary surgical indications: The patient sustained a displaced intraarticular
fracture at the base of the right small finger proximal phalanx with significant
articular involvement and ulnar deviation. Given the degree of displacement,
nonoperative treatment was likely to result in poor functional outcomes,
ongoing pain, and a higher risk of joint degeneration. The patient’s functional
expectations and the anatomical disruption supported pursuing operative
fixation to improve alignment, improve joint motion, and reduce the likelihood
of longterm morbidity.
Procedure(s) and date(s) of surgery:
04/24/2024 Open reduction and internal
fixation of proximal phalanx of right small finger
Length of surgery:
1 hours 18 minutes.
Estimated blood Loss:
2 cc
Postoperative course:
POD 0: splint applied. POD 14: remained in postop
splint, incision healing well, no pain, transitioned out of splint, ROM started,
hand therapy referral placed, WB 〈1 lb to RUE. PO 6 wk: wellhealed scar, no
infection, nearly full fist, 2 cm small fingertip to palm, 20° PIP/DIP flexion
contracture, PT ongoing, continue PT, WBAT. PO 5 mo: wellhealed scar, no
tenderness over incision, 15° PIP flexion contracture, 1 cm palm distance,
oval 8 brace for PIP at night, continue PT as needed, WBAT. PO 9 mo: mild
residual stiffness, 10° PIP contracture, no tenderness over plate, PT
continued for AROM, consider nighttime extension brace, WBAT, f/u prn.
Date of most recent followup:
1/7/2025
Total length of followup:
37 weeks
Is the patient happy with the outcome?
Yes, the patient reported satisfaction with the outcome, resumed work with his hands, and noted overall
improvement with only mild residual stiffness and occasional limitations in
hand movement. He does not find the mild stiffness bothersome.
Are you happy with the outcome?
Yes, the patient regained functional hand
use and resumed desired activities, although some stiffness and minor loss of
full extension persisted at final followup.
Were there complications?
No (Yes?)
What went well in this case?
The patient healed the proximal phalanx fracture
with rigid fixation and was able to achieve a useful range of motion, return to
desired activity, and avoid infection or implant problems. Physical therapy
supported motion gains, and the patient did not require further intervention.
What might you do differently in future?
I would consider discussing earlier
initiation of motion or bracing strategies to address flexion contracture sooner
and further reduce residual stiffness.
