Scoping review of comminuted fractures of the proximal phalanx in horses.
Authors: de Chaisemartin Charles, Vandeweerd Jean-Michel, Schramme Michael
Journal: Equine veterinary journal
Summary
# Comminuted Fractures of the Proximal Phalanx: A Scoping Review of Treatment Outcomes Comminuted fractures of the proximal phalanx represent a significant clinical challenge in adult horses, yet consensus remains elusive regarding optimal management strategies. De Chaisemartin and colleagues synthesised 39 peer-reviewed papers encompassing 409 cases to evaluate survival rates across treatment modalities, stratifying fractures by severity: moderately comminuted (MCFPP, with an intact cortical strut) versus severely comminuted (SCFPP, without structural continuity). Overall survival rates differed substantially between groups—77% for MCFPP versus 51% for SCFPP (OR: 3.16)—demonstrating that fracture classification meaningfully predicts prognosis. Lag screw fixation alone emerged as the superior approach for MCFPP, achieving 85% survival and outperforming lag screws combined with transfixation casting; conversely, cast immobilisation alone yielded paradoxically better results for SCFPP cases (85% survival) compared to surgical intervention, suggesting that severely comminuted fractures may benefit from a more conservative approach when surgical expertise or owner circumstances are limiting. The heterogeneity of existing literature—varying fracture definitions, follow-up protocols, and data collection periods—means these pooled survival figures should be contextualised as estimates rather than definitive benchmarks, highlighting the need for prospective studies with standardised classification and outcome measurement. Practitioners can reasonably counsel owners that CFPP carries survival expectations ranging from 35–85% depending on fracture type and chosen treatment, positioning cast immobilisation as a legitimate non-surgical option worthy of discussion for both fracture classifications.
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Practical Takeaways
- •For moderately comminuted proximal phalanx fractures, lag screw fixation alone provides good outcomes (85% survival); adding transfixation casting reduces success rates.
- •For severely comminuted proximal phalanx fractures, conservative cast immobilisation should be seriously considered as an alternative to surgery, achieving 85% survival and avoiding surgical complications.
- •All treatment options for proximal phalanx fractures show highly variable outcomes (35-85% survival); thorough owner communication about prognosis and realistic expectations is essential before choosing treatment approach.
Key Findings
- •Overall survival rate was 77% for moderately comminuted fractures and 51% for severely comminuted fractures (OR: 3.16; p < 0.001)
- •Lag screw fixation achieved 85% survival rate in moderately comminuted fractures and was superior to lag screw fixation with transfixation cast (p = 0.02)
- •Cast immobilisation alone yielded 85% survival rate in severely comminuted fractures and showed significantly superior results compared to surgical fixation with transfixation cast (OR: 6.65; p = 0.04) and plate fixation with arthrodesis (OR: 9.60; p = 0.006)