The proximal phalanx has no tendinous attachments, therefore fractures frequently have volar angulation from the forces of the extensor and interosseous muscles. The middle phalanx has the FDS insert on the entire volar surface and the extensor tendon insert at the proximal base; therefore, fractures at the base have dorsal angulation and fractures at the neck result in volar angulation. A direct blow mechanism usually causes a transverse or comminuted fracture, while a twisting mechanism will more often result in a spiral fracture. Most often these fractures are stable and nondisplaced and can be treated with early protected motion by buddy taping. Unstable fractures amenable to closed reduction can be splinted from the elbow to the DIP with the wrist at 20° extension and the MP joint in 90° flexion. Midshaft transverse fractures, spiral fractures, and intraarticular fractures often require internal fixation.
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