548170

research-article2014
JHS0010.1177/1753193414548170Journal of Hand Surgery (European volume)Giddins

Review Article
JHS(E)
The Journal of Hand Surgery

The non-operative management (European Volume)

2015, Vol. 40E(1) 3341
The Author(s) 2014
of hand fractures Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1753193414548170
jhs.sagepub.com
G. E. B. Giddins

Abstract
Most hand fractures can be treated non-operatively. Some hand fractures, such as open injuries or markedly
displaced intra-articular fractures, are almost always treated operatively. The treatment of many fractures,
such as proximal interphalangeal joint fracture subluxations or spiral phalangeal fractures, is unclear. The
aim of this review is to establish those injuries where the outcome of non-operative treatment is unlikely to be
improved with surgery. This may help to prevent unnecessary surgery, concentrate work on finding the sub-
groups that may benefit from surgery and to establish which injuries do so well with non-operative treatment
that the only valuable clinical research in future will be large cohort studies of non-operative treatment or
randomized controlled trials comparing operative and non-operative treatments. The relevant fractures
are spiral metacarpal fractures, transverse metacarpal shaft and neck (boxers) fractures, base of proximal
phalanx avulsion fractures, thumb metacarpophalangeal joint ulnar and radial collateral ligament injuries and
bony mallet injuries. For the majority of these injuries, current knowledge suggests that the outcome of non-
operative treatment cannot reliably be improved upon with surgery.
Level of evidence IV

Keywords
Hand fractures, metacarpal, spiral, transverse, avulsion, mallet

Date received: 30 March 2014; revised: 30 July 2014; accepted: 31 July 2014

Introduction Methods and materials

One hundred years ago hand fractures were rarely
treated operatively. Gradually, over the last 50years,
there has been an increasing trend to surgical treat-
ment of some hand fractures, either with K-wires or
internal fixation, led by the Arbeitsgemeinschaft fr
OsteoDePuy Synthesefragen (AO) group (Diwaker and
Stothard, 1986). Although K-wiring or open reduction
and internal fixation (ORIF) and their variants can be
used for almost all fractures, it does not necessarily
mean they should. It is easy for patients and clinicians
to be misled as to the benefits of these treatments. A
series reporting good results can be presented and
surgeons may believe that the technique should be fol-
lowed. Most hand fractures do well with non-operative
treatment (Barton, 1984), so that even with relatively
unsuccessful surgical treatment, e.g. malunion follow-
ing K-wiring or ORIF, the outcome may still be good.
The aim of this review is to identify the fractures
that can still be treated reliably non-operatively. A
secondary aim is to try to establish where there may
be sub-groups of those fractures requiring surgery
that have not been defined.
Multiple electronic and hand searches of the pub-
lished literature were performed to identify fractures
that do so well with non-operative treatment that it is
difficult for surgery to provide significant further ben-
efit. Inclusion criteria aimed to include all adult frac-
tures distal to the thumb and finger carpometacarpal
joints. Even then, reports often had patients <16 year
old that could not be separated out. The exclusion
criteria were fractures where surgery is plainly
needed and proven to have been beneficial: many
open fractures; replantations; many crush injuries;
displaced intra-articular fractures (excluding bony
mallet injuries and avulsion fractures); and paediat-
ric fractures.
Online databases were sought for relevant arti-
cles. Hand searches were also performed for any
Royal United Hospital, Bath, UK
Corresponding author:
G. Giddins, Royal United Hospital, Bath BA1 3NG, UK.
Email: greygiddins@thehandclinic.co.uk
34 The Journal of Hand Surgery (Eur) 40(1)
Table 1. The outcome of finger proximal phalanx avulsion fractures (the data could not be extracted from many articles).
Article Treatment No. of Mean FU
patients (range)
(fingers) months
Sawant etal., Early 7 (7) 57 (894)
2007 mobilization
Mikami etal., K wiring 4 (5) 43 (3072)
2011
Shewring and ORIF 33 3 26 (1544)
Thomas 2003
DASH: disabilities of arm, shoulder, and hand; FU: follow-up; NR: not recorded; ORIF: open reduction and internal fixation; ROM: range
of movement; VAS: visual analogue scale.
potential missing articles. Articles were included that
had a minimum of five cases. I attempted only to
include articles with a minimum follow-up of 2years.
This proved impractical as so few had such adequate
follow-up, and so all articles with a minimum follow-
up of 6weeks were included.
Results
Spiral or long oblique metacarpal
fractures
These common injuries can be treated surgically with
a variety of techniques and good results have been
reported in a number of studies (Al-Qattan, 2008a,
2008b; Al-Qattan and Lazzam, 2007). Equally good
results have been reported with non-operative treat-
ment (Al-Qattan, 2006). A recent study (Khan and
Giddins, in press) shows that all spiral metacarpal
fractures, even in the presence of mal-rotation, can
be treated non-operatively with very good outcomes
and minimal morbidity (Table 1). In this study, all
patients were treated with early mobilization without
a splint or plaster and encouraged to make a fist at
the first outpatient visit to correct any malrotation
and ensure early mobilization. Of 30 patients, 25 were
reviewed at a minimum follow-up of 6months. They
had full movement, grip strength of at least 90% of
the other hand and only minimal malrotation in one
patient and mild discomfort in another. Previous
authors have expressed concern at the risk of dys-
function caused by shortening of the metacarpals
(Low etal., 1995; Meunier etal., 2004; Strauch etal.,
1998), but a recent biomechnical study has suggested
that shortening up to 5mm is not significant (Wills
etal., 2013). This fits with the results of the study
where shortening is accepted, and even encouraged,
as a means of fracture stabilization (Khan and
Giddins, in press).
Malrotation following spiral metacarpal fractures
almost always corrects with finger flexion. If it does
Mean age Pain Function ROM Grip
(range) (VAS DASH
010)
39 (1668) 0.6 (02) 1.3 (04.2) Full >90%
21 (1157) NR 3.0 (0.810.8) 85 NR
NR NR Full NR
not then further encouragement or manipulation
under local anaesthetic would be appropriate as a
key aim of treatment is avoiding rotational malunion.
Finger transverse metacarpal
fractures shaft and neck
Historically, patients with transverse metacarpal
fractures of the shaft and especially the neck (boxers
fracture) were left to mobilize freely and the patients
healed with some deformity but good function. Barton
(1984) in particular showed the efficacy of plaster or
splint support to reduce the angulation of transverse
metacarpal shaft fractures. Subsequently, the results
of surgical treatments have been reported with very
good results. A key question is: What degree of mal-
union is acceptable?. The answer is unclear. For
metacarpal neck (boxers) fractures it has been vari-
ously suggested as: 50 to 60 flexion (Stern, 2005);
30 (Ali etal., 1999; Smith and Peimer, 1977); and 20
(Bloem, 1971; Kilbourne and Paul, 1958). For little
finger metacarpal shaft fractures, it has been sug-
gested as 30 (Diao and Welbourn, 2004; Stern, 2005).
These recommendations are only expert opinion. A
Cochrane review has shown there is no good evi-
dence that more marked malunion causes reduced
hand function or unacceptable deformity (Poolman
etal., 2005 (updated 2009)). It may be that more
marked deformities do give functional problems. If
proven, this would indicate a role for surgery, where
the deformity could not be reduced adequately
non-operatively.
The outcome of non-operative treatment has been
reported widely, and apart from a mild cosmetic
abnormality, there is typically an excellent functional
outcome (Poolman etal., 2005 (updated 2009)).
Although there is some limited evidence that ante-
grade intra-medullary nailing may be the best of the
reported surgical techniques (Yammine and Harvey,
2014), no one technique of non-operative manage-
ment has been shown to be superior in the published
Giddins 35
studies (Poolman etal., 2005 (updated 2009);
Yammine and Harvey, 2014). Many surgical tech-
niques have been described, including: intramedul-
lary nailing (Orbay and Touhami, 2006); K-wire
(bouquet) fixation (Downing and Davis, 2006; Faraj
and Davis, 1999; Foucher, 1995); intraosseous loop
wire fixation (Al-Qattan, 2006); and external fixation
(Margic, 2006). The results are not reliably better
than non-operative treatment and they introduce
complications not seen with non-operative treat-
ment. Non-operative treatment has complications,
not least related to immobilization in a plaster or
splint. As yet operative treatment has not been
shown to give better results than good non-operative
treatment.
Comparative studies offer the best way to assess
different treatments, especially randomized con-
trolled trials (RCTs). As often in hand surgery, excel-
lent RCTs are not available, but there are some useful
comparative studies. Westbrook etal. (2008) com-
pared non-surgical and surgical treatment of meta-
carpal neck and shaft fractures in a large retrospective
study. They reported on metacarpal neck and shaft
fractures: 105 metacarpal neck fractures treated
non-operatively versus 18 treated operatively (13
intramedullary K-wiring and five plating); and 113
metacarpal shaft fractures treated non-operatively
versus 26 treated surgically (four K-wiring and 22
plating). At a minimum follow-up of 2years there
were no differences in DASH score, grip strengths or
aesthetics between the non-operative and operative
groups, but a significant complication rate in the
operative groups was not present in the non-
operative group. Follow-up rates were low (17% for
non-operative treatment and 54% for operative treat-
ment) as is typical in this patient group. A randomized
study on metacarpal neck fractures (Strub etal.,
2010) has suggested that surgery may be very slightly
better than non-operative treatment, primarily in giv-
ing a better cosmetic result owing due to less malun-
ion. This study had two groups each of 20 patients
who were pseudo-randomized. The patients treated
with intramedullary (bouquet) wiring required two
operations each; one to insert and one to remove the
wires. The only complications were in the operative
group, which had more dissatisfied as well as more
very satisfied patients. Again, this study did not take
into account the inconvenience and costs to the
patient or the healthcare system.
Finger proximal phalanx collateral
ligament avulsion fractures
Bekler etal. (2006) noted that avulsion fractures of
the bases of the phalanges are challenging injuries to
treat, but also stated that: Avulsion fractures (of the
bases of the phalanges) are intraarticular according
to their configuration and need anatomic reduction.
Yet proximal phalanx avulsion fractures are a group
of injuries that attract a greater range of proven
advice than almost any other injury. For finger proxi-
mal phalanx avulsion fractures, early protected
mobilization seems to give very reliable results
(Sawant etal., 2007). In contrast, some authors have
recommended that all base-of-finger avulsion frac-
tures should be treated surgically because of the high
rate of symptomatic non- or delayed union (Bischoff
etal., 1994; Gee and Pho, 1982; Gross and Moneim,
1998; Mikami etal., 2011; Schubiner and Mass, 1989;
Shewring and Thomas, 2003). Shewring and Thomas
(2003) reported that of eight of their patients treated
non-operatively, all had delayed union and seven
were treated with ORIF and bone grafting. They report
very good results at discharge from follow-up at
3months with operative treatment. It appears that for
avulsion fractures of up to 25% of the articular sur-
face on the postero-anterior radiograph, protected
mobilization gives results that cannot easily be
improved by surgery (Table 2). The available data are
limited, as these are either small series or contain
limited follow-up. The dichotomy with the experience
of Shewring and Thomas (2003) who reported symp-
tomatic delayed union in eight consecutive patients
and the excellent results of Sawant etal. (2007) may
be that many of these injuries may not unite with
bone (as for thumb metacarpophalangeal (MP) joint
ulnar collateral ligament avulsions (Sorene and
Goodwin, 2003)), but heal with sufficient stability that
surgery is not required.
Thumb MP joint avulsion fractures
Ulnar collateral ligament injuries.The outcome of
thumb MP joint avulsion fractures is also disputed. It
is clearly understood that the presence of a Stener
lesion, whether or not there is a bony avulsion, will
give a poor outcome with non-operative treatment
(Giele and Martin, 2003). Some authors have reported
poor outcomes of avulsion fractures treated non-
operatively: Dinowitz etal. (1997) reported on nine
cases with minimally displaced fractures (up to 2mm)
treated in plaster within 6days. They reported that all
had persistent pain, largely resolved with surgical
stabilization. Kuz etal. (1999) reported on 30 patients
treated non-operatively; 30 were reviewed by ques-
tionnaire and of these 20 were seen in person. Nine-
teen of the 30 had no pain, all reported being satisfied
by their treatment and none had had to change their
jobs. Of the 20 assessed in person, there was no sta-
tistically significant reduction in pinch or grip strength,
36 The Journal of Hand Surgery (Eur) 40(1)

Table 2. The outcome of finger proximal phalanx avulsion fractures (data could not be extracted from many articles).

Article Treatment No. of Mean FU Mean age Pain Function ROM Grip
patients (range) (range) (VAS DASH
(fingers) months 010)
Sawant etal., Early 7 (7) 57 (894) 39 (1668) 0.6 (02) 1.3 (04.2) Full >90%
2007 mobilization
Mikami etal., K-wiring 4 (5) 43 (3072) 21 (1157) NR 3.0 (0.810.8) 85 NR
2011
Shewring and ORIF 33 3 26 (1544) NR NR Full NR
Thomas, 2003

DASH: disabilities of arm, shoulder, and hand; FU: follow-up; NR: not recorded; ORIF: open reduction and internal fixation; ROM: range
of movement; VAS: visual analogue scale.

Table 3. Thumb MP joint ulnar collateral ligament bony avulsions.

Article and Treatment No of Mean FU Mean age ROM of MP Grip Notes

year patients (range) (range) joint
(thumbs) months
Kozin and Tension band 9 26 20 (1541) 77% 96%
Bishop, 1994a wiring
Kuz etal., 1999 Plaster cast 30 3.1 (15.2) 30 The same NR No pain in 19 of 30.
or splint for Unstable in 2/20. Non-
4weeks union 5/20
Landsman Thumb spica 12 38 (1260) 30 (1748) 84 (60100) % 92 (80100) % All healed but data on
etal., 1995 splint for ROM and strength includes
812weeks tendinous injuries, which
overall did worse than the
avulsion injuries
Sorene and Plaster cast 28 30 (1248) 34 (1762) NR 97% No pain in 26
Goodwin, 2003 Non-union 17
aTwo were RCL injuries.

FU: follow-up; MP: metacarpophalangeal; NR: not recorded; ROM: range of movement.

but two had some instability. They reported a non-
union rate of 0.25 (5 of 20). Sorene and Goodwin (2003)
reported on 28 cases of avulsion fractures stable at
original assessment who were treated with immobili-
zation in plaster for 6weeks and followed up for a
mean of 2.5years (range 14). They reported that 26 of
the 28 had no pain on movement, all patients had the
same pinch and grip strength as the other side, yet
radiologically 60% had persistent non-union. Compa-
rable results have been reported in many surgical
series (Bischoff etal., 1994; Kozin and Bishop, 1994).
At present it appears that stable bony avulsions can
probably be immobilized in plaster with the expecta-
tion of a good outcome (Table 3).
The treatment of unstable injuries is less clear,
but at present surgery is probably the default posi-
tion. As so often found, the data are inadequate.
There is a considerable range of different types of
thumb ulnar collateral ligament avulsions injuries,
ranging from small bony avulsions, which seem to be
primarily a soft tissue problem, to large rotated bony
avulsion fragments. This is very likely to be an injury
with subtypes that will benefit from surgery and oth-
ers that will not. As yet this remains unproven. An
adequately powered (probably quite large to identify
the subtypes) multicentre RCT is needed. In particu-
lar, surgeons need to be aware that there are a range
of injuries, and as yet the best treatment for each
subgroup is unclear.
Radial collateral ligament injuries.There are fewer
reports of the treatment of radial collateral ligament
(RCL) injuries. In theory, as there is no adductor hood
to cause a Stener-type lesion, non-operative treat-
ment should suffice; typically immobilization in plas-
ter for 46weeks. Nonetheless, the role of surgery
has been debated for some time (Edelstein etal.,
2008; Katz etal., 1998; Melone etal., 2000; Smith,
1977). There are also rare reports of radial sided
Stener lesions (Camp etal., 1980; Doty etal., 2010).
Giddins 37

Table 4. The outcome of treatment of bony mallet injuries with fracture fragments more than or equal to one-third and
follow-up of a minimum of 12months.

Article and year Treatment No. of Mean FU Mean age DIPJ ROM % of bone Crawford (or OA
patients (range) months (range) in degrees involved other) score
(fingers) years
Damron and Pull through 18 97 (24147) 23 (1732) 169 (15 51 (3867) 10 painfree, 13 7 of 15
Engber, 1994 suture and patients) no functional
K-wire limitation
Darder-Prats K-wire 22 25 (1848) 23 (1434) NK >33 18E, 3G, 1F 0
etal., 1998
Fritz etal., 2005 K-wire 24 Mean unclear 31 (1553) 172 >33 19 no pain
(min. 12 months) W and N
criteria
Okafor etal., Splint for 7 11 66 (but includes NK 951 NR NR 10 of 11
1997 (612) weeks tendinous as
well)
Hofmeister etal., Closed 23 (24) >1 year 24 477 40 22E/G, 2F
2003 K-wiring
Takami etal., Open reduction 33 29 32 (1963) 467 >33 NR
2000 and K-wiring
Tetik and Closed 18 27 29 (2247) 281 40 NR
Gudemez, 2002 K-wiring

DIPJ: ; FU: follow-up; NK: ; NR: not recorded; OA: ; ROM: range of movement.

It is well recognized that mildly displaced RCL avul-
sion fractures treated non-operatively usually achieve
a very good outcome (Kttstorfer etal., 2013). The
role of surgery for more widely displaced or unstable
injuries is unclear. Many authors believe that surgery
is required on the basis that considerable displace-
ment of torn ends can prevent the RCL from healing
(Kttstorfer etal., 2013). These authors have shown
good results with surgery for more unstable injuries,
but the original premise that the ligament will not
heal with marked displacement or instability is
unproven. Again RCL injuries cannot be assumed to
be a single problem requiring one type of treatment.
The optimal treatment for each subgroup is not yet
established. One particular problem may be the long
time to recover fully from thumb MP joint collateral
ligament avulsion injuries, which skews the clinical
impression of treatment outcome in short-term
reviews.
Bony mallet injuries
There has been a plethora of articles reporting tech-
niques for reducing and holding the dorsal avulsion
fracture fragment in bony mallet injuries
(Auchingloss, 1982; Badia and Riano, 2004; Bauze
and Bain, 1999; Cheon etal., 2011; Damron and
Engber, 1994; Darder-Prats etal., 1998; Fritz etal.,
2005; Hiwatari etal., 2014; Ishiguro etal., 1997; King
etal., 2001; Kronlage and Faust, 2004; Pegoli etal.,
2003; Rocchi etal., 2006; Teoh and Lee, 2007). This
is an operation with an acknowledged high risk of
complications (Bischoff etal., 1994; Stern and
Kastrup, 1988; Webhe and Schneider, 1984). Authors
of more recent techniques report a lower risk of
complications, particularly the risks of skin break-
down (Auchingloss, 1982; Badia and Riano, 2004;
Bauze and Bain, 1999; Cheon etal., 2011; Damron
and Engber, 1994; Darder-Prats etal., 1998; Fritz
etal., 2005; Hiwatari etal., 2014; Ishiguro etal.,
1997; King etal., 2001; Kronlage and Faust, 2004;
Pegoli etal., 2003; Rocchi etal., 2006; Teoh and Lee,
2007). In general, reasonably consistent good
results are reported for various surgical treatments
of bony mallet injuries with a dorsal fracture frag-
ment of oone-third or more (Table 4). The recom-
mendation to treat fractures of one-third or more
has come from a number of authors, most particu-
larly Stark etal. (1987). There are concerns about
needing anatomical reduction of the fracture and
preventing subluxation of the main distal phalanx
fracture fragment (Bauze and Bain, 1999; Cheon
etal., 2011; Damron and Engber, 1994; Darder-
Prats etal., 1998; Fritz etal., 2005; Hiwatari etal.,
2014; Ishiguro etal., 1997; King etal., 2001; Kronlage
and Faust, 2004; Pegoli etal., 2003; Rocchi etal.,
2006; Teoh and Lee, 2007). When subluxation needs
to be treated is unproven, although some cases do
38 The Journal of Hand Surgery (Eur) 40(1)
Figure 1. Stable bony mallet injury as shown by gliding on the extension lateral radiograph.
progress to symptomatic dislocation. In one of the
most widely cited articles (Webhe and Schneider,
1984) the authors reported that among patients with
dorsal fracture fragments of over one-third fol-
lowed-up for a mean of 3.25years the 15 patients
treated non-operatively did as well as the six treated
operatively. They concluded that operative treat-
ment gave no better results than non-operative
treatment. Similarly, a series with a 5year follow-up
has shown that both tendinous and bony mallet inju-
ries treated non-operatively achieve good objective
and very good subjective outcomes (Okafor etal.,
1997). Among the bony mallet injuries were some
with fracture fragments >1/3, but they are
not reported separately. They also reported some
evidence of degeneration at the distal interphalan-
geal (DIP) joint in 10 of 11 patients with large frac-
ture fragments within 5years. Other authors have
reported on degeneration. Webhe and Schneider
(1984) noted no difference between operative and
non-operative treatment in rates of radiographic
osteoarthritis (OA). Other authors have reported
rates of up to 50%, yet some of only 0% (Table 4).
Almost certainly their criteria (which are reported
rarely) differ, making comparison difficult. The risk
of radiographic OA would be a potential concern, but
for the fact that long-term symptomatic degenera-
tive arthritis in the DIP joints is not widely reported
in patients who have had bony mallet injuries, i.e. as
hand surgeons we rarely see patients requiring
treatment for symptomatic DIP joint arthritis who
had bony mallet injuries decades earlier. It would
appear that the majority of patients with bony mallet
injuries do not require surgical treatment.
A Cochrane review reported that there was a pau-
city of good studies and there was no evidence that
surgery was better than non-operative (typically
splint) treatment for all types of mallet injury (Handoll
and Vaghela, 2004 (updated in 2008)). They did, how-
ever, acknowledge that there may be a subgroup of
these injuries that would benefit from surgery.
The main area of concern is when there is a large
fracture fragment >33% of the articular surface on the
lateral radiograph, which may lead to volar subluxa-
tion of the main distal fracture fragment of the distal
phalanx. Recent work (Giddins, unpublished data) has
shown that the risk of subluxation can be assessed by
a lateral hyperextension radiograph performed within
12weeks of injury. If there is gliding of the joint
(Figure 1), i.e. it remains congruent as it goes into
extension, then this is a stable joint. The presumption
is that there has not been so much collateral ligament
injury that subluxation will occur. If there is pivoting
(Figure 2), then subluxation will usually occur,
although this may only be mild. Exactly what level of
subluxation requires treatment is unclear. The data, if
established, will help narrow down further the indica-
tions for surgery in these patients. As with the above
examples, surgery has not been shown reliably to
improve the outcome for most patients with bony mal-
let injuries over non-operative treatment. But in this
group of patients, there is clearly a subgroup of
patients who do badly suffer DIP joint stiffness and
pain following significant volar subluxation and even
dislocation of the main distal phalanx fracture frag-
ment. This subgroup will almost certainly benefit from
different treatment possibly surgery.
Discussion
There are many problems with the existing literature,
not least the paucity of RCTs. There is bias in many of
Giddins 39
Figure 2. Unstable bony mallet injury as shown by pivoting on the extension lateral radiograph.
the studies, and often incomplete data or outdated
outcome reporting. In addition, while the operative
treatments are typically well described (although the
post-operative care often less so) the non-operative
treatment is often described in little detail. There is a
considerable difference between uninhibited mobili-
zation, supervised mobilization with regular follow-
up and immobilization in a plaster or splint. The
quality of the follow-up almost certainly varies
greatly. The outcome of, and indications for, non-
operative treatment also depend upon other factors,
such as clinic availability, patient availability (some
have to travel long distances making regular follow-
up difficult) and therapy.
The available data suggest that for the above frac-
tures surgery does not reliably confer benefit over
good non-operative treatment. As surgery typically
costs more, both in terms of patient risk and health-
care costs, it suggests that for these fractures non-
operative treatment should be the default position,
accepting the need for clinical judgement for indi-
vidual cases. In time, there may be newer techniques
allowing much earlier return to function, with lower
risks that may supersede non-operative treatment.
The dichotomies of different authors recommend-
ing such radically different treatments may have
occurred for a number of reasons: surgeon prefer-
ence/bias; a misunderstanding of the anatomy and
pathology of the injury; an over-emphasis on biome-
chanical or cadaveric studies that may not apply in
clinical practice; an over emphasis on bone union that
may not affect outcome in many cases; and possibly
most of all, the variability of the injuries such that a
small sub-group of each pattern of injury does poorly
with non-operative treatment and this skews the
impression of the success of each type of treatment.
As a speciality, we should try to focus our research
efforts on areas where we might make a significant
difference ahead of tackling those with marginal gains.
Different patterns of displaced phalangeal fractures,
and proximal inter-phalangeal joint fracture subluxa-
tions or pilon fractures, are two topics where the opti-
mal treatments are very unclear and where research
could make a considerable difference.
This is not a diatribe against surgical treatment of
these fractures. Rather, I believe, the review high-
lights the need to identify the subgroups that do
badly with non-operative treatment (if they exist),
such as through large cohort studies of non-opera-
tive treatment or to identify new insights, for exam-
ple the role of gliding or pivoting in bony mallet
injuries. In addition, any future studies of these inju-
ries that report an improvement in outcome with
surgery, should ideally be run as RCTs in compari-
son with vigilant and clearly described non-operative
treatment, as the established non-operative out-
comes are so good that a cohort or case series of
operative treatment is very unlikely to improve on
the published data.
Conflict of interests
None declared.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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