FINGER INJURIES



I. General principles
  1. Finger dislocations are categorized as "dorsal", "volar", or "lateral" based on the direction of the more distal to the more proximal portion.
  2. Consider referral to ortho if a finger fracture involves > 30 percent of intra-articular surface or is displaced, oblique, or spiral.

 II. Physical exam for all finger injuries

  1. Finger alignment
  2. Integrity of ligaments
  3. Neurovascular status
  4. Joint ROM in flexion and extension

III. X-rays should have 3 views: AP, lateral, oblique

 IV. Post-reduction evaluation

  1. Stablity through flexion and extension
  2. Evaluate for rotation with active flexion (should be no digital overlap)
  3. Neurovascular status
  4. Check x-rays to assess alignment

 V. Metacarpophalangeal dislocation

  1. Usually dorsal
  2. Soft tissue injuries often impede reduction
  3. Closed reduction should be attempted, with post-reduction x-rays
  4. For simple dislocations, splint in slight flexion + early mobilization

 VI. Proximal interphalangeal joint dislocation

  1. Identify direction (dorsal, volar, lateral)-Usually dorsal
  2. PIP joints are supported by collateral ligaments and volar plates
  3. Dorsal dislocations often involve injury (including avulsion fracture of) the volar plate
  4. Volar dislocations can involve injury to the central slip, with inability to fully extend at PIP joint
  5. Closed reduction should be attempted, by applying traction and volar pressure on the middle phalanx at the PIP joint.  Can often be done w/o anesthesia but can do a local joint block if pain precludes the reduction without it.
  6. Post-reduction:
  1. Pt should be able to obtain full extension
  2. Get post-reduction x-rays to confirm reduction and assess for volar plate fractures (though if small may treat conservatively)
  3. Immobilize:
    1. Volar dislocations: splint in extension IF there is an associated central slip injury x 6wks, w/early mobilization
    2. Dorsal dislocations: splint x 1-2wks, with early mobilization

 VII. Distal interphalangeal joint dislocation

  1. Identify direction (dorsal, volar, lateral)
  2. Attempt reduction
  3. Get post-reduction x-rays
  4. Splint + early mobilization

 VIII. Fracture of the distal phalanx

  1. Usually crush mechanism
  2. Splint DIP joint x 2-4wks then mobilize
  3. Commonly get hyperesthesia, pain, and numbness for up to 6mos

 IX. Mallet fracture

  1. Avulsion fracture of the insertion of the extensor tendon into dorsal aspect of the proximal portion of the distal phalanx
  2. Usually caused by sudden forced flexion of the DIP joint
  3. X-rays will usually show a bony fragment at dorsal aspect of the proximal portion of the distal phalanx
  4. Assess for ability to extend at DIP joint (usually not able to with this injury)
  5. Splint DIP joint in extension x 8wks (any flexion during this time can affect healing)
  6. Check x-rays after splint application to confirm that the fracture fragment is in proper position.
  7. Consider referral if large displaced bony fragment or significant volar subluxation

 X. Flexor digitorum profundus avulsion fracture (aka "Jersey finger")

  1. Occurs on the volar surface of the distal phalanx due to hyperextension of the distal interphalangeal joint
  2. Pt will be unable to flex at DIP joint
  3. X-rays will usually show a bony fragment at volar surface of proximal distal phalanx
  4. Assess for ability to flex at DIP joint (usually not able to with this injury)
  5. Usually referred to orthopedist (because of possibility of retraction of the flexor digitorum profundus)

 XI. Fractures of middle or proximal phalanges

  1. Usually treated with buddy taping and early ROM but repeat evaluation to confirm stability of the fracture
  2. Consider referral if involves > 30 percent of intra-articular surface or is displaced, oblique, or spiral.
(Sources include Core Content Review of Family Medicine, 2012)