Tuesday Trauma POTD: Lil finger injuries

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Today, we will review some traumatic finger injuries, how to manage them in the ED, and when to call ortho!

Important physical exam components:

  • Tendon/ligament function - have them range each digit and palpate where the tendon is

  • Neuro exam - sensation, strength

  • Vascular exam - a little less relevant for such a distal injury but make sure the digit is well perfused (not white, cool, pale, etc) in the setting of significant trauma or possible vessel injury

  • Look for overlying laceration - important to know if there could be an open fracture

FINGERTIP INJURIES:

  1. Mallet finger

    1. Extensor tendon injury → distal finger pointed DOWN, 45 degress flexion at rest

    2. Exam: UNABLE to actively extend

    3. Look out for avulsion fracture at dorsal base of distal phalynx

    4. Types & management 

      1. Type 1: Tendon-only rupture

        1. Joint immobilization 6-8 wks

        2. Dorsal OR volar splint, maintain full flexion

        3. Ortho f/u 1-2 wks

      2. Type 2: Open

        1. Emergent ortho surgery 

        2. Ancef + Gentamicin

      3. Type 3: Open with deep soft tissue injury

        1. Emergent ortho surgery 

        2. Ancef + Gentamicin

      4. Type 4: Associated fracture

        1. Usually requires surgeryReduce with dorsal pressure 

        2. Splint in extension like type I

        3. Ortho consult if unable to reduce

        4. Ortho f/u within 1 week

  2. Boutonierre deformity

    1. Disruption of extensor digitorum central slip → “jammed finger”

    2. Exam:

      1. Flexed @ PIP and hyperextended @ MCP/DIP

    3. Elson test: Flex PIP 90 degrees, pt must extend PIP while you’re applying pressure to middle phalanx

    4. Management:

      1. Acute injury: Splint PIP in extension with MCP/DIP free to move, 6 weeks--prevents contracture

        1. Ortho f/u 1-2 weeks

      2. Chronic injury: Splint if possible but might be hard if contracture

        1. Ortho f/u for possible surgical repair

      3. Surgical indications: 

        1. Open wound

        2. Acute avulsion fracture from middle phalanx

        3. Chronic injury remaining after 6 wks in splint

  3. Collateral ligament injuries

    1. Disruption of radial or ulnar collateral ligament → finger points left or right

      1. Most involve the thumb (60%): Gamekeeper’s thumb

    2. Exam:

      1. Unstable pinch using affected finger

      2. Varus or valgus laxity

    3. Diagnosis:

      1. Clinical or XR with stress views (not always necessary)

    4. Management:

      1. Buddy tape for 3-6 weeks depending on degree of tear

      2. Ortho f/u 1-2 weeks

      3. Surgery if injury/tear to radial collateral ligament of index finger since it is absolutely needed for pinching

      4. Surgery if persistent pain even after splinting/buddy tape

  4. Gamekeeper’s thumb

    1. Disruption of ulnar collateral ligament of MCP of thumb → thumb radially deviated

    2. Common in skiers

    3. Management:

      1. Partial tear -- thumb spica 4 weeks

      2. Complete tear -- thumb spica with surgical repair within 3 weeks

      3. Ortho f/u 1 week

  5. Jersey Finger

    1. Disruption of flexor digitorum profundum at volar surface of distal phalynx → finger slightly extended at rest

      1. Forced extension

      2. When you grab at something and fail

      3. Commonly involves 4th digit 

    2. Exam:

      1. Finger held slightly extended, unable to flex DIP

      2. Palpate volar surface of entire affected metacarpal/phalanx to locate site of tendon disruption → retraction into palm requires surgery 

      3. Immobilize PIP for isolated test of DIP flexion

    3. Management:

      1. All types require surgical repair

        1. Type I: FDP retracts into palm

          1. Surgery within 1 week

          2. Must have ortho f/u 1-2 days

        2. Types II-IV: Variations that do not have FDP retracting into palm

          1. Surgery within a few weeks

          2. Ortho fu 1 week

      2. Temporizing splint:

        1. Dorsal splint with 30 degrees wrist flexion, 70 degrees MCP flexion, 30-45 degrees DIP/PIP flexion

  6. Distal phalanx fracture

    1. Diagnosed on XR

    2. Management:

      1. Closed fracture -- Finger splint 3 weeks

        1. Closed reduction if significantly angulated or displaced

      2. Open fracture -- may require ortho consult

        1. Requires washout and antibiotics

      3. Ortho consults for fractures that are unstable, irreducible, or intraarticular involving > ⅓ articular surface


Happy finger splinting!

References

https://coreem.net/core/finger-injuries

https://www.aafp.org/afp/2001/0515/p1961.html


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