Basics
Description
- 1/3 of all traumatic injuries affect the hand.
- Phalanges account for 1 of the most frequently fractured parts of the skeletal system with the distal phalanx being the most commonly fractured bone in the hand.
- Dorsal displacement of the proximal interphalangeal joint of the finger is the most frequent dislocation.
Injuries may be more difficult to diagnose in children who are unable to cooperate for a full exam.
Etiology
- Trauma (commonly work or sports related)
- Infectious sequelae:
- Skin flora: Staphylococcus aureus and Streptococci
- Cat/dog bites: S. aureus and Pasteurella multocida
- Human bites: Eikenella
- Thorns or woody plants puncture: Fungal
- Fresh/salt water exposure: Mycobacterium marinum and Pseudomonas aeruginosa
- Overuse injury (e.g., "gamekeepers thumb " )
Diagnosis
Signs and Symptoms
History
- Mechanism of injury:
- Hyperextension injuries most commonly cause ligamentous injury (e.g., "Jersey finger " which is a rupture of the flexor digitorum profundus tendon from its distal attachment) or chip fractures.
- Hyperflexion injury to the tip of digits may cause "Mallet finger " injury with avulsion fracture at the insertion of the extensor tendon on the distal phalanx.
- Crush injuries most commonly cause fractures and diffuse soft-tissue injury.
- Handedness
- Occupation/hobbies
- Other factors may affect healing (e.g., age, diabetes, immune suppression, anticoagulation)
Physical Exam
- Swelling and/or deformity (e.g., amputation, rotation, shortening, or angulation)
- Skin changes (e.g., ecchymosis, laceration, burn, pallor) or associated nail injury
- Decreased range of motion or weakness
- Pain or change in sensation in the area of injury
Kanavel signs (infectious flexor tenosynovitis)
- Pain along the tendon with passive extension (early sign)
- Symmetric enlargement of the affected digit
- Slightly flexed finger at rest
- Tenderness along the course of the flexor sheath (later sign)
- Trigger finger (stenosing flexor tenosynovitis):
- Noninfectious inflammation of the flexor tendon sheath.
- Painful "snapping " sensation with flexion of the affected digit.
- May awaken with the finger locked in the palm, with gradual "unlocking " as the day progresses.
In an infant with a painful or swollen digit, it is important to consider a deeply embedded hair tourniquet that may not be readily obvious on superficial exam.
Essential Workup
- Special attention directed at assessing individual tendon status, neurovascular integrity, and identifying rotational deformity:
- Isolate and assess each individual joint (PIP, DIP, MCP); range with passive motion and against active resistance
- Normal 2-point discrimination is ’ Ό4 " 5 mm
- Malrotation can be evaluated by positioning the fingers with the MCP joints in flexion and the PIP and DIP in extension:
- Normally, all fingers are directed toward the radius and there should be no overlap or rotation
- Exam conducted 1st to assess function, then under anesthesia, and finally with tourniquet if needed to allow a bloodless field for better exam of lacerated areas.
Diagnosis Tests & Interpretation
Lab
Consider wound culture if signs of infection present or if there is concern for flexor tenosynovitis.
Imaging
- Plain radiography of involved digits should include AP, true lateral, and oblique views.
- US can help diagnose tendon tears.
Open epiphyses make radiographic interpretation less sensitive.
Differential Diagnosis
- Tendon laceration/rupture partial/complete
- Complicated open injuries may include several injuries, and the entire hand should be examined carefully.
- Beware of lacerations over dorsal metacarpal " phalangeal areas, which may be "fight bites " (human bites).
- Many fractures in children are torus (buckle) fractures of the phalanges.
- The growth plates are typically weaker than the surrounding ligaments, thus dislocations are commonly accompanied by Salter " Harris fractures.
Treatment
Pre-Hospital
- Reduction of a phalangeal dislocation at the scene SHOULD NOT be considered UNLESS there will be an unusually long transport time or there is vascular or neurologic compromise.
- Reduction may be successful but prompt the physician to miss significant ligamentous injuries.
- Bleeding should be treated with appropriate direct pressure dressings.
- Amputated digits or tissue should be placed in clean moist saline gauze, placed in plastic bag, and then placed in a separate bag with ice. Do not place digit in direct contact with ice!
- Indications for reimplantation in amputation:
- Thumb
- Single digit between PIP and DIP joints
- Multiple digits
- Amputation in a child
Initial Stabilization/Therapy
- Remove all rings from injured hand.
- Immobilize the involved areas by proximal-to-distal splinting.
- Intermittent ice pack application with constant elevation for the 1st 24 hr.
- Dislocations or severely deformed fractures producing vascular compromise should be reduced immediately to a neutral position and immobilized.
Ed Treatment/Procedures
- Interphalangeal reduction:
- Dorsal dislocation:
- Provide longitudinal traction and gently hyperextend the joint while pushing the base of the dislocated phalanx into place.
- Volar dislocation:
- Provide longitudinal traction and gently hyperflex while pushing the base of the dislocated phalanx into place.
- Lateral dislocation:
- Provide longitudinal traction and gently hyperextend the joint while correcting the ulnar or radial deformity.
- Interphalangeal immobilization:
- DIP dorsal or lateral finger dislocation:
- Splint the DIP in full extension while allowing full range of motion of the PIP joint.
- PIP dorsal or lateral finger dislocation:
- Apply a dorsal splint with the PIP in 20 " 30 ° of flexion.
- Volar finger dislocation:
- Splint the PIP and DIP in full extension.
- Metacarpophalangeal dislocation:
- Avoid excessive hyperextension or distraction. Gently distract the affected digit and apply volar pressure to the base of the dislocated proximal phalanx.
- Metacarpophalangeal immobilization:
- Finger dislocation: Splint the digit in 90 ° of flexion at the MCP joint.
- Thumb dislocation: Apply a thumb spica splint with the MCP joint in 20 ° of flexion.
- Open fracture:
- Immediate referral to a hand surgeon for treatment within 4 " 6 hr after trauma.
- Prophylactic antibiotics directed against gram-positive and gram-negative organisms should be administered parenterally within 6 hr.
- Closed fracture:
- Distal phalanx:
- Stable injuries may be splinted with the DIP in flexion and the PIP free; extend tip of splint beyond the end of the digit for added protection; maintain for 3 " 4 wk.
- Middle phalanx:
- Nondisplaced stable fractures can be buddy taped to an adjacent digit.
- Displaced/angulated fractures may be reduced (using longitudinal traction with 3-point pressure to align the fragment) and immobilized (buddy tape and ulnar/radial gutter splint).
- Splinting should be done with the wrist in 20 " 30 ° of extension, the MCP joints in 70 " 90 ° of flexion, and the PIP and DIP joints flexed 5 " 10 °.
- Proximal phalanx:
- A nondisplaced, nonangulated, stable injury can be buddy taped to an adjacent finger; ulnar/radial gutter or Burkhalter splint may be added for comfort.
- A displaced or angulated fracture may be reduced by flexing the MCP and PIP joints to 90 °, then using a 3-point reduction technique to reduce the proximal fragment dorsally and the distal fragment volarly. Once reduced, the PIP joint should be extended (to avoid a flexion contracture), the MCP joint should remain in 70 " 90 ° of flexion and a radial or ulnar gutter splint should be placed with the fractured finger buddy taped to an adjacent finger.
No more than 1 or 2 mm of displacement or shortening is acceptable. Up to 10 ° of angulation is acceptable but NO amount of rotation is permitted.
- Mallet finger:
- Immobilize the DIP joint in full extension or slight hyperextension (5 " 15 °), while allowing full range of motion of the PIP joint.
- Do not to reduce any displaced fractures before splinting because any reduction is unlikely to be maintained without surgery; refer for urgent orthopedic consult.
- Jersey finger:
- Apply an aluminum splint with the PIP joint and the DIP joint slightly flexed.
- DIP extension should be avoided until the digit can be evaluated by a hand specialist (definitive treatment of complete tendon rupture is surgery).
- Trigger finger:
- Immobilize by buddy taping to the adjacent finger for 4 " 6 wk.
- A metal or thermoplastic finger splint can be used if buddy taping is unsuccessful.
- Gamekeepers thumb:
- Apply ice to the MP joint acutely.
- Immobilize with a thumb spica splint (MP joint is flexed to 20 °) for 3 wk.
- Subungual hematoma:
- Nail trephination using a heated paper clip, electric cautery, or an 18G needle.
- This injury does not have to be treated as an open injury unless there is an underlying tuft fracture.
- Nail avulsions:
- Clean and repair using fine (e.g., 6-0) absorbable suture.
- Splint the eponychium and germinal matrix with the avulsed nail or small piece of gauze or foil to avoid adhesions.
- Open distal and volar directed fingertip wounds with no protruding bone and smaller than 1 cm may be allowed to heal by secondary intention.
Medication
- Evaluate tetanus status and vaccinate per immunization schedule.
- Digital nerve block should be done with an anesthetic that does NOT contain epinephrine.
- Antibiotics:
- Not indicated for simple clean wounds
- For grossly contaminated injury, puncture wounds, or infectious tenosynovitis therapy should be tailored to specific pathogen exposure (e.g., skin flora, fresh water, bites)
Follow-Up
Disposition
- Patients with a stable injury, in an appropriate splint, may be discharged for orthopedic follow-up and possible repeat imaging in 1 wk time.
Emergent orthopedic consult is required for:
- Amputation
- Open joint injuries or fractures
- Digital neurovascular compromise
- Signs of joint infection or infectious tenosynovitis
- High-pressure injection injury
- Urgent orthopedic consult:
- Unstable fractures (rotational deformity, oblique or angulated fractures, joint involvement, epiphyseal injuries)
- Any joint dislocation with tendon rupture
- Digit dislocation that is irreducible
- Unstable joint after attempted dislocation reduction
Pearls and Pitfalls
- Rotational deformity may not be apparent if finger is straight, exam under flexion is required.
- Jersey finger (FDP tendon rupture) is often misdiagnosed as a "jammed " or sprained finger, but requires more urgent management than these minor injuries.
- Always check for stability postreduction by having patient perform active range of motion and checking a postreduction x-ray.
Additional Reading
- Oetgen ME, Dodds SD. Non-operative treatment of common finger injuries. Curr Rev Musculoskelet Med. 2008;1:97 " 102.
- Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am. 2006;88:2739 " 2748.
- Pang HN, Teoh LC, Yam AK, et al. Factors affecting the prognosis of pyogenic flexor tenosynovitis. J Bone Joint Surg Am. 2007;89:1742 " 1748.
- Tuttle HG, Olvey SP, Stern PJ. Tendon avulsion injuries of the distal phalanx. Clin Orthop Relat Res. 2006;445:157 " 168.
Codes
ICD9
- 816.00 Closed fracture of phalanx or phalanges of hand, unspecified
- 834.00 Closed dislocation of finger, unspecified part
- 959.5 Finger injury
- 883.0 Open wound of finger(s), without mention of complication
- 816.02 Closed fracture of distal phalanx or phalanges of hand
- 834.02 Closed dislocation of interphalangeal (joint), hand
- 842.10 Sprain of hand, unspecified site
- 842.12 Sprain of metacarpophalangeal (joint) of hand
- 883.1 Open wound of finger(s), complicated
ICD10
- S62.609A Fracture of unsp phalanx of unsp finger, init for clos fx
- S63.259A Unspecified dislocation of unspecified finger, init encntr
- S69.90XA Unsp injury of unsp wrist, hand and finger(s), init encntr
- S61.219A Laceration w/o fb of unsp finger w/o damage to nail, init
- S62.669A Nondisp fx of distal phalanx of unsp finger, init
- S63.289A Dislocation of proximal interphalangeal joint of unspecified finger, initial encounter
- S63.498A Traumatic rupture of other ligament of other finger at metacarpophalangeal and interphalangeal joint, initial encounter
- S67.10XA Crushing injury of unspecified finger(s), initial encounter
SNOMED
- 52011008 Injury of finger (disorder)
- 18171007 fracture of phalanx of finger (disorder)
- 125619004 traumatic dislocation of joint of finger (disorder)
- 283812000 Animal bite of finger (disorder)
- 10380004 Crushing injury of finger (disorder)
- 283520007 Puncture wound of finger (disorder)
- 36778005 Fracture of distal phalanx of finger (disorder)
- 38540001 Sprain of interphalangeal joint of finger (disorder)
- 405275001 Rupture of ulnar collateral ligament of thumb (disorder)
- 416709006 Closed traumatic subluxation, proximal interphalangeal joint of digit of hand (disorder)
- 423657003 Hyperextension injury of finger (disorder)