ABSTRACT: Proximal phalangeal fractures often lead to motion loss at the proximal interphalangeal joint primarily because of adhesions between the zone 4 extensor tendon and the fracture site. This most commonly manifests as an extensor lag at the proximal interphalangeal joint, but can also include incomplete recovery of flexion range. The occurrence of the fracture alone likely generates some degree of insurmountable motion loss. Additional motion loss may be iatrogenic based on the specific surgical technique and rehabilitation strategy. It has been promoted that percutaneous pinning methods, as opposed to open fixation methods, produce less of a motion deficit. Although percutaneous pinning solves many fractures of the proximal phalanx, some fracture patterns will not be adequately treated by percutaneous pinning and will benefit from direct open reduction and internal fixation. Spiral fractures with a significant rotational deformity are well treated by lag screws. Comminuted fractures are well treated by plate fixation. When performing such fixations, the soft tissue approach to the fracture site plays a substantial role in determining the ultimate functional recovery. This article covers the specific technical details of optimizing soft tissue management when performing open fixation for proximal phalanx fractures.