Most middle phalanx injuries are managed by closed management, although surgical reduction and stabilization may be required in displaced fractures Fractures of the head of the phalanx require close management by a hand specialist because of a high rate of complications Avulsion fractures of the middle phalanx at the insertion of the volar plate or extensor central slip are common Avulsions on the volar side generally are from hyperextension Often, the fragment does not reattach Prolonged immobilization may result in chronic stiffness and has potential for permanent loss of range of motion Splinting is performed initially, but early range of motion is often started a week later Small avulsions on the extensor side are treated similarly, though larger fragments are treated with longer splinting, and injuries with displaced and larger fracture fragments with articular involvement may require open reduction ( Fig 109.9 )