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Am Fam Physician. 2022;105(6):631-639

Patient information: A handout on this topic is available at https://www.aafp.org/afp/2006/0301/p839.html.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Finger fractures and dislocations are commonly seen in the primary care setting. Patients typically present with a deformity, swelling, and bruising with loss of function. Anteroposterior, lateral, and oblique radiography should be performed to identify fractures and distinguish uncomplicated injuries from those requiring referral. Uncomplicated distal phalanx fractures, caused by a crush injury to the end of the finger, require splinting of the distal interphalangeal joint for four to six weeks. Uncomplicated dorsal avulsion fractures (mallet finger) of the distal interphalangeal joint, caused by forced flexion against resistance, require strict splint immobilization for eight weeks. Flexor digitorum profundus fractures are caused by forceful extension of the distal interphalangeal joint when in a flexed position, resulting in an avulsion fracture at the volar base of the distal phalanx, and usually require surgery. Uncomplicated middle and proximal phalanx fractures, typically caused by a direct blow, can be treated with buddy splinting if there is minimal angulation (less than 10 degrees); however, larger angulations, displacement, and malrotation often require reduction or surgery. Dorsal proximal interphalangeal joint dislocations require reduction and buddy splinting in slight flexion with an extension-block splint. Volar proximal interphalangeal joint dislocations require reduction and splinting in full extension for four to six weeks. Distal interphalangeal joint dislocations require reduction and splinting in full extension (for volar dislocations) or 15 to 30 degrees of flexion (for dorsal dislocations) for two to three weeks. Dorsal metacarpophalangeal joint dislocations are managed with reduction and splitting, but referral to an orthopedic specialist is required if the dislocation is not easily reduced. Volar metacarpophalangeal dislocations are rare and warrant referral.

Finger fractures and dislocations are commonly seen in the primary care setting, and finger fractures are the most common type of fracture in sports.1 Patients often present with a deformity, swelling, and bruising with loss of function. Radiography can identify fractures and distinguish uncomplicated injuries that can be managed by a primary care physician. Appropriate management strategies help the patient return to normal function while minimizing complications.

Fractures

To evaluate suspected finger fractures, anteroposterior, lateral, and oblique radiography should be performed.2 Primary care physicians can manage most nondisplaced, well-approximated fractures with simple immobilization. Diagnosis and management recommendations for finger fractures are outlined in Table 1. The recommendations for fractures in this article apply to adolescent and adult patients without evidence of open growth plates on plain radiography and do not apply to children.
Type of fractureHistory/evaluationManagementFollow-upIndications for referralCommon complications
Distal phalanx fractureCommon in crush or axial load injuries
Swelling, deformity, or subungual hematoma may be noted
Radiography
Splint with DIP joint in full extension for 4 to 6 weeks
U-shaped padded aluminum splint, fingertip guard, or volar splint
Every 2 weeks
May take 4 to 6 weeks to heal
Open fracture (consider with subungual hematoma)
Angulated or difficult-to-reduce transverse fractures
Nonunion
Inability to flex or extend the DIP joint or loss of distal sensation
Chronic hyperesthesia or swelling
Nonunion
Dorsal avulsion fracture or extensor tendon rupture (mallet finger)Axial load injury while DIP joint is in extension (forceful flexion)
Slight flexion at rest may be noted
Radiography
Splint with DIP joint in full extension to slight hyperextension for 8 weeks
Premature joint flexion can prolong recovery
Dorsally padded aluminum splint, volar splint, or thermoplastic stack splint
Every 2 weeks
May take 6 to 10 weeks to heal
> 30% intra-articular involvement
Open fracture
Inability to passively extend the joint
Extension lag (lack of full extension)
Flexor digitorum profundus avulsion fracture (jersey finger)Injury caused by forceful extension of the DIP joint when in a flexed position
Radiography
Expedited referral for surgery (may splint with proximal interphalangeal and DIP joints in slight flexion until surgery evaluation)
DIP joint may be in slight extension at rest
Recovery may take 6 to 12 weeks
Extensive hand therapy
All flexor digitorum profundus avulsion fractures require referral for surgeryContractures of the flexor digitorum profundus (flexion deformities)
Middle or proximal phalanx fractureDirect blow or axial load injury
Evaluation for malrotation
Radiography
Reduce if indicated
Buddy taping for 3 to 4 weeks if minimally angulated
Ulnar or radial gutter splint if fracture had to be reduced (Figure 5); perform postreduction radiography in splint
Repeat radiography in 7 to 10 days to evaluate for alignment
Follow-up every 2 weeks
May take 4 to 6 weeks to heal
Open fracture
Intra-articular, oblique, spiral, and rotational fractures
Malrotation
Malunion (includes malrotation and rotation)
Nonunion

DISTAL PHALANX

Distal phalanx fractures are typically the result of a crush or axial load injury (i.e., direct force to the end of the finger). Physical examination usually shows swelling, bruising, or a subungual hematoma. Radiography demonstrates the location and degree of the bony injury. 

It is important to assess the patient's ability to fully flex and extend the distal interphalangeal (DIP) joint. Distal sensation should also be evaluated. The inability to flex or extend the joint, loss of distal sensation, and complex fractures warrant evaluation by an orthopedic specialist. 

In the absence of these concerns, splinting the DIP joint in full extension for four to six weeks is usually sufficient.3 Large (greater than 50% of the nail surface) or painful subungual hematomas benefit from drainage through the nail using a sterile bore or a heat or cautery instrument.4

DORSAL AVULSION FRACTURE OR EXTENSOR TENDON RUPTURE (MALLET FINGER)

Mallet finger occurs when the DIP joint is forced to flex against resistance (Figure 15). This can cause avulsion of the extensor tendon from its attachment at the dorsal base of the distal phalanx, with or without avulsion of a bone fragment at the end of the tendon.6 Absence of a bony avulsion indicates a pure tendon rupture.

Patients with mallet finger have swelling, bruising, pain, and the inability to actively extend the DIP joint, which is typically slightly flexed due to the unopposed flexor tendon. Radiography is needed to evaluate intra-articular involvement because injuries involving greater than one-third of the joint surface require referral for possible surgical repair. Injuries in which the joint cannot be passively extended require referral to an orthopedic specialist.7 

In the absence of indications for referral, mallet finger (with or without an avulsion fracture) can be effectively treated with strict immobilization.8 The DIP joint should be splinted in full extension to slight hyperextension for eight weeks.9,10 A dorsally padded aluminum splint, a volar splint, or a thermoplastic stack splint can be used.11 It is important to adhere to the immobilization period because premature flexion of the DIP joint can disrupt the healing process and require an additional eight weeks of hyperextension from the time of premature flexion.

FLEXOR DIGITORUM PROFUNDUS AVULSION FRACTURE

A flexor digitorum profundus avulsion fracture (jersey finger) is typically caused by forceful extension of the DIP joint when in a flexed position (Figure 25). This forceful extension leads to an avulsion fracture at the site where the flexor digitorum profundus tendon attaches to the volar base of the distal phalanx.5 Although flexor digitorum profundus avulsion fractures can occur in any finger, they most commonly affect the ring finger.

The examination usually reveals swelling, volar-sided pain, and a slightly extended finger when at rest, and patients are usually unable to actively flex the DIP joint.12 These findings alone (regardless of radiography results) require expedited referral to an orthopedic specialist because flexor digitorum profundus avulsion fractures can benefit from surgery within seven to 10 days. 

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