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Emergency And Acute Medicine – Phalangeal Injuries, Hand
Phalangeal injuries account for a significant proportion of traumatic hand injuries, with the distal phalanx being the most frequently fractured bone in the hand. Dorsal dislocation of the proximal interphalangeal (PIP) joint is the most common finger dislocation. These injuries are typically related to sports, occupational trauma, crush mechanisms, or hyperextension and hyperflexion forces. Infections may complicate puncture wounds, bites, or aquatic exposures, with pathogens varying by mechanism. In children, diagnosis may be more difficult due to limited cooperation, and growth plate injuries are common.
Mechanism of injury provides critical diagnostic clues. Hyperextension injuries often result in ligamentous injury, chip fractures, or “Jersey finger,” which is rupture of the flexor digitorum profundus tendon from its distal insertion. Hyperflexion at the fingertip may cause “Mallet finger,” typically involving an avulsion fracture at the extensor tendon insertion. Crush injuries frequently produce fractures with associated soft-tissue damage. History should include handedness, occupation, comorbidities affecting healing, and tetanus status.
Examination must be systematic. Assess for swelling, deformity, angulation, rotation, shortening, lacerations, burns, nail injury, and neurovascular compromise. Evaluate each joint individually (MCP, PIP, DIP) with active and passive range of motion and resistance testing. Two-point discrimination should normally be 4–5 mm. Rotational deformity is best assessed by flexing the MCP joints while extending the PIP and DIP joints; all fingers should point toward the radius without overlap. Kanavel signs suggest infectious flexor tenosynovitis and include pain with passive extension, fusiform swelling, flexed posture at rest, and tenderness along the flexor sheath. In infants, consider hair tourniquet syndrome when swelling is unexplained.
Radiographs with anteroposterior, true lateral, and oblique views are essential. Ultrasound may assist in diagnosing tendon rupture. In children, open physes make interpretation more challenging, and Salter–Harris fractures may accompany apparent dislocations. Differential diagnosis includes fractures, tendon lacerations or ruptures, fight bites over dorsal MCP joints, and complex open injuries.
Prehospital reduction of finger dislocations is generally discouraged unless transport is prolonged or neurovascular compromise is present, as premature reduction may obscure associated ligamentous injury. Amputated digits should be wrapped in moist saline gauze, placed in a plastic bag, and then placed in a second bag containing ice without direct contact. Reimplantation is particularly considered for thumb injuries, multiple digits, amputations between the PIP and DIP joints, or amputations in children.
Initial management includes removal of rings, immobilization, elevation, and ice. Neurovascular compromise requires immediate reduction to neutral alignment. Interphalangeal dislocations are reduced with longitudinal traction and direction-specific maneuvers depending on dorsal, volar, or lateral displacement. Immobilization depends on the joint involved and direction of injury. MCP dislocations are reduced gently with traction and volar pressure and splinted appropriately. Postreduction stability must be assessed clinically and radiographically.
Closed distal phalanx fractures are typically splinted with DIP immobilization while allowing PIP motion. Middle and proximal phalanx fractures may be managed with buddy taping if stable, or reduced and immobilized in appropriate gutter splints when displaced. Acceptable alignment includes minimal shortening (1–2 mm), up to 10° of angulation, and absolutely no rotational deformity. Mallet finger requires strict DIP extension splinting while preserving PIP mobility. Jersey finger requires urgent specialist referral, with splinting in slight flexion and avoidance of forced DIP extension. Gamekeeper’s thumb is treated with thumb spica immobilization. Subungual hematomas are treated with nail trephination unless associated with significant tuft fracture. Open fractures require urgent surgical consultation and early intravenous antibiotics.
Tetanus status must be addressed. Digital nerve blocks should use anesthetic without epinephrine. Antibiotics are not required for clean uncomplicated wounds but should be tailored to contaminated injuries, bites, or suspected infectious tenosynovitis.
Stable injuries in appropriate splints may be discharged with orthopedic follow-up within one week. Emergent consultation is required for amputations, open fractures or joints, neurovascular compromise, infectious tenosynovitis, high-pressure injection injuries, or irreducible dislocations. Urgent consultation is necessary for unstable fractures, rotational deformity, joint involvement, epiphyseal injuries, tendon rupture, or persistent instability after reduction. Careful assessment of rotational alignment and tendon function is essential, as missed tendon injuries such as Jersey finger may lead to significant long-term dysfunction if not promptly managed.
Phalangeal injuries account for a significant proportion of traumatic hand injuries, with the distal phalanx being the most frequently fractured bone in the hand. Dorsal dislocation of the proximal interphalangeal (PIP) joint is the most common finger dislocation. These injuries are typically related to sports, occupational trauma, crush mechanisms, or hyperextension and hyperflexion forces. Infections may complicate puncture wounds, bites, or aquatic exposures, with pathogens varying by mechanism. In children, diagnosis may be more difficult due to limited cooperation, and growth plate injuries are common.
Mechanism of injury provides critical diagnostic clues. Hyperextension injuries often result in ligamentous injury, chip fractures, or “Jersey finger,” which is rupture of the flexor digitorum profundus tendon from its distal insertion. Hyperflexion at the fingertip may cause “Mallet finger,” typically involving an avulsion fracture at the extensor tendon insertion. Crush injuries frequently produce fractures with associated soft-tissue damage. History should include handedness, occupation, comorbidities affecting healing, and tetanus status.
Examination must be systematic. Assess for swelling, deformity, angulation, rotation, shortening, lacerations, burns, nail injury, and neurovascular compromise. Evaluate each joint individually (MCP, PIP, DIP) with active and passive range of motion and resistance testing. Two-point discrimination should normally be 4–5 mm. Rotational deformity is best assessed by flexing the MCP joints while extending the PIP and DIP joints; all fingers should point toward the radius without overlap. Kanavel signs suggest infectious flexor tenosynovitis and include pain with passive extension, fusiform swelling, flexed posture at rest, and tenderness along the flexor sheath. In infants, consider hair tourniquet syndrome when swelling is unexplained.
Radiographs with anteroposterior, true lateral, and oblique views are essential. Ultrasound may assist in diagnosing tendon rupture. In children, open physes make interpretation more challenging, and Salter–Harris fractures may accompany apparent dislocations. Differential diagnosis includes fractures, tendon lacerations or ruptures, fight bites over dorsal MCP joints, and complex open injuries.
Prehospital reduction of finger dislocations is generally discouraged unless transport is prolonged or neurovascular compromise is present, as premature reduction may obscure associated ligamentous injury. Amputated digits should be wrapped in moist saline gauze, placed in a plastic bag, and then placed in a second bag containing ice without direct contact. Reimplantation is particularly considered for thumb injuries, multiple digits, amputations between the PIP and DIP joints, or amputations in children.
Initial management includes removal of rings, immobilization, elevation, and ice. Neurovascular compromise requires immediate reduction to neutral alignment. Interphalangeal dislocations are reduced with longitudinal traction and direction-specific maneuvers depending on dorsal, volar, or lateral displacement. Immobilization depends on the joint involved and direction of injury. MCP dislocations are reduced gently with traction and volar pressure and splinted appropriately. Postreduction stability must be assessed clinically and radiographically.
Closed distal phalanx fractures are typically splinted with DIP immobilization while allowing PIP motion. Middle and proximal phalanx fractures may be managed with buddy taping if stable, or reduced and immobilized in appropriate gutter splints when displaced. Acceptable alignment includes minimal shortening (1–2 mm), up to 10° of angulation, and absolutely no rotational deformity. Mallet finger requires strict DIP extension splinting while preserving PIP mobility. Jersey finger requires urgent specialist referral, with splinting in slight flexion and avoidance of forced DIP extension. Gamekeeper’s thumb is treated with thumb spica immobilization. Subungual hematomas are treated with nail trephination unless associated with significant tuft fracture. Open fractures require urgent surgical consultation and early intravenous antibiotics.
Tetanus status must be addressed. Digital nerve blocks should use anesthetic without epinephrine. Antibiotics are not required for clean uncomplicated wounds but should be tailored to contaminated injuries, bites, or suspected infectious tenosynovitis.
Stable injuries in appropriate splints may be discharged with orthopedic follow-up within one week. Emergent consultation is required for amputations, open fractures or joints, neurovascular compromise, infectious tenosynovitis, high-pressure injection injuries, or irreducible dislocations. Urgent consultation is necessary for unstable fractures, rotational deformity, joint involvement, epiphyseal injuries, tendon rupture, or persistent instability after reduction. Careful assessment of rotational alignment and tendon function is essential, as missed tendon injuries such as Jersey finger may lead to significant long-term dysfunction if not promptly managed.
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