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Keywords

Clinical Practice in Athletic Training

Abstract

Background: Intra-articular fracturs of the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints occur primarily from impacted shear force. With continued participation, fractures have a high possibility of nonunion or malunion. While accounting for patients’ requests may not always be possible, extreme modification of activity may permit their requests. Patient: The patient is a college-aged female volleyball athlete who plays in the front row. The initial report showed a fracture of the right fifth phalange from incomplete range of motion (ROM), swelling, and bruising after an impacted shear force was placed on her finger from a block. She was referred to have an X-ray. The initial X-ray showed a displaced bony mallet fracture of the distal phalanx and a comminuted intra-articular volar radial fracture of the middle phalanx. Intervention: The initial plan was to restrict movement of DIP with intermittent PIP motion. The athlete participated in modified practice ten days after initial injury with a splint that extended DIP and flexed PIP. The day following, the hand specialist stated that there was no need for surgery as the proximal fracture was stable and the distal fracture was not warranting surgery yet. Surgical intervention would have been more effective in the long-term, yet she expressed concerns about not having surgery as well, because she did not want to be removed from her sport for a long period of time. Following this, the PIP was to be in full extension at all times with no clearance to play and active assisted ROM of PIP needed to be performed every two hours. The 2nd week follow-up x-ray shows distal phalanx is healing and middle phalanx fracture is incomplete, she is clear for return-to-play (RTP) with conditions of no blocking with injured hand and Alumafoam splint with buddy tape. Active assisted ROM rehabilitation process begins and a Stax splint is worn on DIP joint at night. The 4th week post injury, another x-ray is performed showing distal phalanx mallet fracture has widened slightly and there is healing on middle phalanx. She continues to splint in practice with modification of it being a curved splint and Stax splint when outside of practice including during sleep. Following this, she started to have pain in metacarpal phalangeal joint and “pitch count style” was implemented to limit stress on her finger of twenty-eight attempts of hits per day with no blocking of right hand. In the 7th week since initial injury, the x-ray showed healing of distal fracture with incomplete but stable fracture of middle phalanx with no change in alignment and incomplete remodeling. Without the complete removal of play, the athlete was able to finish her final season in volleyball without permanent injury. Outcomes: At 7 weeks since initial injury, the x-ray showed healing of distal fracture with incomplete but stable fracture of middle phalanx. At 19 weeks post-injury, she still has mild pain, swelling, and stiffness, but the finger is functional. She is cleared to return to normal activities, with low probability of reinjury. Conclusion: The injury is a displaced bony mallet fracture of the distal phalanx and a comminuted intra-articular volar radial fracture of the middle phalanx. In the nineteen-week time period, she was minimally removed from sport with the implementation of extreme modification of activity per the athlete’s request. Clinical Bottom Line: This case shows the importance of her sport to her as an athlete and the modification techniques implemented by her healthcare team to allow continued participation safely. In cases similar, accounting for patient requests with precautionary measures allows for continued participation without surgical intervention. By furthering research in modifications of activity, surgical intervention and removal of play has greater potential to be eliminated.

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