New York State Medical Treatment Guidelines for Middle and Proximal Phalangeal and Metacarpal Fractures in workers compensation patients

The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for addressing Middle and Proximal Phalangeal and Metacarpal Fractures. These directives are designed to assist healthcare professionals in identifying appropriate therapeutic approaches within the context of a comprehensive assessment.

Healthcare professionals with expertise in managing Middle and Proximal Phalangeal and Metacarpal Fractures can depend on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic methods for their patients.

It is crucial to emphasize that these guidelines are not meant to substitute clinical judgment or professional expertise. The final decision regarding the management of Middle and Proximal Phalangeal and Metacarpal Fractures should involve collaboration between the patient and their healthcare provider.


Middle and Proximal Phalangeal and Metacarpal Fractures


Fractures involving the proximal and middle phalanges constitute approximately 46% of hand and wrist fractures. While the majority are uncomplicated and don’t require surgery, improper management may lead to permanent impairments. Metacarpal fractures, comprising about one-third of hand fractures, require careful diagnosis and management to prevent long-term disability.


Diagnostic Studies


Recommended for diagnosing phalangeal or metacarpal fractures, including posteroanterior, lateral, and oblique views. A true lateral projection isolating the involved digit is crucial.

MRI, CT, Ultrasound, or Bone Scanning

Not recommended for diagnosing phalangeal or metacarpal fractures.



NSAIDs for Pain Management

Recommended for acute, subacute, or chronic phalangeal or metacarpal fracture pain. NSAIDs are preferred, with over-the-counter agents tried first.

NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

Recommended for high-risk patients, considering cytoprotective medications for gastrointestinal protection.

NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

For patients with cardiovascular risk factors, acetaminophen or aspirin is recommended as the first-line therapy.

Acetaminophen for Pain

Recommended for phalangeal or metacarpal fracture pain, especially in patients with NSAID contraindications.

Opioids for Limited Use

Recommended for limited use (less than seven days) for acute and post-operative pain management, particularly when NSAIDs, acetaminophen, and other treatments are insufficient.

Antibiotic Prophylaxis

Not recommended for open phalangeal fractures.

Tetanus Immunization

Status should be updated as necessary, especially for wounds that are not clean or burns if more than five years have passed since the last tetanus immunization.


Initial Management

Treatment should address soft tissue injuries and pain control after a thorough physical examination. Regional anesthesia may be administered for diagnostic assessment and closed fracture reduction.


Middle and Proximal Phalanx Fractures

Recommended immobilization for treatment. When percutaneous fixation is used, additional stabilization with a splint or cast for three to four weeks is advised.

Non-operative Management

Recommended for non-displaced and stable transverse diaphyseal fractures, with immobilization for three weeks. Tolerance limits for non-operative management are defined by specific criteria.

Non-displaced Oblique Fractures

Recommended for stable fractures, typically requiring rigid immobilization alone.

Closed Reduction with Splinting

Recommended for base phalanx fractures with involvement of less than 40% of the middle phalanx base.




Supervised formal therapy following work-related hand injuries aims to restore functional abilities essential for daily and work activities, with the goal of returning the patient to pre-injury status when feasible. Rehabilitation emphasizes active therapy, requiring internal effort by the patient, while passive interventions are seen as complementary measures. Continuous active and passive therapies at home are encouraged for sustained improvement, and assistive devices may be included for enhanced functional gains.

Active Therapy

Therapeutic Exercise for Post-operative Middle and Proximal Phalangeal and Metacarpal Fractures

Recommended for rehabilitation, with the frequency, dose, and duration of visits varying based on the severity of functional deficits. A home exercise program is vital for ongoing improvement.

Passive Therapy

Ice, Compression, and Elevation for Acute Metacarpal and Phalangeal Fractures

Recommended for controlling edema related to acute fractures.



Surgical Management of Condylar Fractures

Recommended for unstable condylar fractures.

Surgical Management for Malrotated Phalangeal Fractures

Recommended if malrotation cannot be corrected and stabilized by closed reduction. Surgical intervention helps prevent or reduce rotational deformities that may impact hand function.

Non-Operative Treatment of Distal Metacarpal Head Fracture

Recommended for fractures with less than 20% joint involvement. Cases with greater involvement may require open reduction and internal fixation.


Non-Operative Management

Non-operative Treatment of Distal Metacarpal Neck Fracture with Acceptable Angulation

Recommended for fractures with acceptable angulation degrees.

Non-operative Treatment of Fifth Metacarpal Neck Fractures (Boxer’s Fracture)

Recommended before surgical treatment for most fractures with less than 45 degrees angulation.

Use of Functional Therapies for Fifth Metacarpal Neck Fractures

Recommended over casting or ulnar splinting.

X-rays in Follow-up of Non-Operative Fifth Metacarpal Neck Fractures

Recommended for patients at risk of displacement after reduction. Follow-up radiographs are indicated if physical examination suggests loss of reduction or instability.

Shaft Metacarpal Fractures

Shaft metacarpal fractures, commonly transverse, oblique, spiral, or comminuted, involve decisions between non-operative and surgical intervention, weighing potential shortening against surgical risks.

Surgery for Shaft Metacarpal Fractures

Surgical Management of Metacarpal Shaft Fractures

Recommended for fractures that cannot be reduced, are unstable, or involve multiple neighboring shaft fractures.

Surgical Management for Base Fractures of the Proximal Metacarpal

Recommended as these fractures are rarely stable.

Surgical Management for Bennett’s Fracture and Rolando’s Fracture

Recommended due to instability.

Surgical Management for Malrotated Phalangeal Fractures

Recommended to prevent deformity and impairment.

Hardware Removal

Recommended in select cases based on doctor/patient preference and specific indications.


Non-Operative Management

Non-operative Management of Metacarpal Shaft Fractures

Recommended in select patients with stable fractures after achieving adequate closed reduction, involving cast immobilization.

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