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Phalangeal Injuries, Hand, Emergency Medicine

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Phalangeal Injuries, Hand, Emergency Medicine

Basics

Description

Injuries may be more difficult to diagnose in children who are unable to cooperate for a full exam.

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.

Consider wound culture if signs of infection present or if there is concern for flexor tenosynovitis.

Open epiphyses make radiographic interpretation less sensitive.

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.

  • 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.

Etiology

  • Trauma (commonly work or sports related)
  • Infectious sequelae:Skin flora: Staphylococcus aureus and StreptococciCat/dog bites: S. aureus and Pasteurella multocidaHuman bites: EikenellaThorns or woody plants puncture: FungalFresh/salt water exposure: Mycobacterium marinum and Pseudomonas aeruginosa
  • Overuse injury (e.g., "gamekeepers thumb " )
  • 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

Diagnosis

Signs and Symptoms

  • 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)
  • 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.
  • 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
  • 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.

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 resistanceNormal 2-point discrimination is ’ ˆ Ό4 " “5 mmMalrotation 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.
  • Isolate and assess each individual joint (PIP, DIP, MCP); range with passive motion and against active resistance
  • Normal 2-point discrimination is ’ ˆ 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
  • Normally, all fingers are directed toward the radius and there should be no overlap or rotation

Diagnosis Tests & Interpretation

  • Plain radiography of involved digits should include AP, true lateral, and oblique views.
  • US can help diagnose tendon tears.

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.
  • Reduction may be successful but prompt the physician to miss significant ligamentous injuries.
  • 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:ThumbSingle digit between PIP and DIP jointsMultiple digitsAmputation in a child
  • 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.
  • 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.
  • Provide longitudinal traction and gently hyperextend the joint while pushing the base of the dislocated phalanx into place.
  • Provide longitudinal traction and gently hyperflex while pushing the base of the dislocated phalanx into place.
  • Provide longitudinal traction and gently hyperextend the joint while correcting the ulnar or radial deformity.
  • 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.
  • Splint the DIP in full extension while allowing full range of motion of the PIP joint.
  • Apply a dorsal splint with the PIP in 20 " “30 ‚ ° of flexion.
  • Splint the PIP and DIP in full extension.
  • Avoid excessive hyperextension or distraction. Gently distract the affected digit and apply volar pressure to the base of the dislocated proximal phalanx.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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 ‚ °.
  • 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.
  • 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.
  • 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.
  • 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).
  • 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.
  • Apply ice to the MP joint acutely.
  • Immobilize with a thumb spica splint (MP joint is flexed to 20 ‚ °) for 3 wk.
  • 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.
  • 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.

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 woundsFor grossly contaminated injury, puncture wounds, or infectious tenosynovitis therapy should be tailored to specific pathogen exposure (e.g., skin flora, fresh water, bites)
  • 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.
  • 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 ruptureDigit dislocation that is irreducibleUnstable joint after attempted dislocation reduction
  • 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)