01Approach to the Critical Patient/attcp30

Immediate priorities

›Recognition of a commonly missed injury

›Jersey finger is an FDP avulsion frequently misdiagnosed as a "jammed finger" or sprain

›Delayed diagnosis beyond 10-14 days significantly limits surgical options

›Tendon retraction, myostatic contracture, and sheath obliteration occur

›Inability to actively flex the DIP joint after a forced-extension mechanism is the key alarm feature

›Requires urgent hand surgery referral regardless of radiographic findings

›Ring finger most commonly affected in approximately 75% of cases

›Escalate immediately if open wound over volar finger surface (open jersey finger)

›Surgical emergency requiring OR-level contamination control

›Neurovascular compromise distal to injury level

Time-critical decision points

›Injury timing determines surgical options

›Type I injuries require operative repair within 7-10 days

›Blood supply to tendon lost due to disrupted vincula

›After this window, primary repair may not be feasible

›Type II injuries have somewhat more flexibility but earlier is better

›Partial vincula preservation maintains some vascularity

›Type III injuries less time-critical due to large bony fragment limiting retraction

›ORIF of fragment remains necessary

›Delayed presentations beyond 3 weeks require reconstructive options

›Staged tendon reconstruction with silicone rod

›DIP arthrodesis when reconstruction not feasible

ED stabilization and referral

›Initial ED management

›Splint PIP and DIP joints in slight flexion approximately 30 degrees using dorsal aluminum splint

›Prevents further tendon retraction

›Maintains tendon approximation

02History/hx50

Mechanism and presentation

›Classic mechanism

›Forceful extension of the DIP joint while the finger is actively flexed

›Classically from grabbing an opponent's jersey in football or rugby

›Also seen in basketball, wrestling, and manual labour gripping

›Inability to bend the fingertip (DIP joint) since injury

›Patient may not notice initially if pain distracts from functional deficit

›Pain location

›Typically volar-sided along the finger or palm

›Pain tracking proximally into the palm suggests Type I retraction

Timing and functional history

›Injury timing

›Exact date and time of injury

›Critical for surgical planning and determining viability of primary repair

›Presentation greater than 7-10 days narrows surgical window significantly

›Prior evaluation or diagnosis at another site

›Commonly previously labelled as jammed finger or sprain

›Missed jersey finger is the most common misdiagnosis

›Dominant hand involvement

›Higher functional stakes for repair decision

›Occupational demands and sporting activity level

›Manual labourers and musicians at higher functional risk

Risk factors and precipitants

›Patient demographics

›Young active males

›Peak incidence ages 20-29

›Contact sports participation

›Ring finger biomechanical vulnerability

03Physical Exam/exam39

Volar inspection and palpation

›Finger resting posture

›Affected finger resting in slight extension at the DIP joint

›Loss of normal progressive flexion cascade compared to adjacent fingers

›Comparison with contralateral hand essential

›Swelling and ecchymosis

›Volar aspect of affected finger

›Tender palpable mass along the tendon sheath

›Location of tender mass helps classify injury type

›Mass in palm suggests Type I retraction

›Mass at PIP level suggests Type II

Functional testing

›Active DIP flexion test

›Stabilize the middle phalanx and instruct patient to flex the DIP joint

›Inability to flex DIP = positive for FDP avulsion

›Single most important bedside test for diagnosis

›FDS isolation test

›Hold all other fingers in extension

›Ask patient to flex affected finger at PIP joint

›PIP flexion should be intact as FDS is uninjured

›Confirms injury isolated to FDP

›Tenodesis effect assessment

›Passive wrist extension should cause finger flexion

›Absent DIP flexion during tenodesis confirms FDP discontinuity

Neurovascular assessment

›Digital neurovascular status

›Capillary refill at fingertip

›Greater than 2 seconds suggests vascular compromise

04Differential Diagnosis/ddx40

Tendon injuries

›FDP avulsion (jersey finger)

›ICD-10 S66.1 injury of flexor tendon at wrist and hand level

›Loss of active DIP flexion

›Forced extension mechanism

›FDP laceration

›Open wound present on volar surface

›Similar functional deficit to avulsion

›Typically from laceration rather than sports mechanism

›Mallet finger (extensor tendon avulsion)

›ICD-10 S63.1 dislocation of finger

›Loss of active DIP extension rather than flexion

›DIP rests in flexion not extension

›Forced flexion mechanism rather than forced extension

›Treated conservatively with extension splinting in most cases

Bony injuries

›Distal phalanx fracture (non-avulsion)

›May have intact DIP flexion if FDP tendon not disrupted

›Crush mechanism rather than forced extension

›Radiograph distinguishes from tendon avulsion

›DIP joint dislocation

›Obvious deformity on exam and radiographs

›Reduction followed by stability testing

Soft tissue and infectious conditions

›Flexor tenosynovitis

›Kanavel signs present

›Fusiform sausage-digit swelling

›Pain with passive extension of finger

05Laboratory Tests/lt26

Pre-operative and baseline labs

›Pre-operative studies when surgery planned

›Complete blood count

›Baseline haemoglobin for surgical planning

›Leukocytosis if open or infected injury

›Basic metabolic panel

›Renal function for anaesthesia planning

›Electrolytes

›Coagulation studies

›PT and INR if on anticoagulation

›Anticoagulation reversal planning pre-operatively

›Group and screen per institutional protocol for operative cases

Inflammatory markers for atypical presentations

›Infection screening if open injury or tenosynovitis suspected

›Complete blood count with differential

›Leukocytosis supports infectious etiology

›Bandemia in early septic tenosynovitis

›C-reactive protein

›Elevation supports inflammatory or infectious process

›Erythrocyte sedimentation rate

›Less specific but elevated in inflammatory arthritis

›Rheumatological workup for atraumatic or recurrent tendon injuries

›Rheumatoid factor

›Positive in rheumatoid arthritis

›Anti-cyclic citrullinated peptide antibody

›More specific for rheumatoid arthritis than RF

›Uric acid

›Elevated in gout-associated tendon pathology

06Diagnostic Tests/dt84

Scoring Systems

›Leddy and Packer classification (modified)

›Type I: tendon retracted to palm

›No bony fragment or small fragment

›Both vincula disrupted; blood supply to tendon lost

›Most urgent; surgical repair required within 7-10 days

›Worst prognosis if delayed

›Type II: tendon retracted to PIP joint level

›Small bony fragment caught at chiasm of FDS

›Long vinculum intact; partial blood supply preserved

›Repair can be delayed up to several weeks but earlier is better

›Type III: tendon held at DIP joint level

›Large bony fragment prevents retraction

›ORIF of the bony fragment

›Less time-critical than Types I and II

›Type IV: bony fragment with tendon separately avulsed from fragment

›Fragment at DIP level but tendon retracts proximally

›Combined osseous and tendinous injury requiring dual repair

›Urgent operative management

›Type V: bony avulsion associated with comminuted distal phalanx fracture

›Direct blow mechanism more common than forced extension

›Management variable; may be conservative in some cases

›Classification limitations

›Preoperative ultrasound or MRI improves accuracy of type classification

›Physical exam alone may underestimate retraction level

›Intraoperative findings may reclassify injury type

MRI

›MRI indications for jersey finger

›Equivocal clinical presentation when diagnosis uncertain

›Partial FDP tears where active DIP flexion is diminished but not absent

›Characterizes extent of tendon retraction with precision

›Delayed presentations

›Assess tendon viability and sheath integrity beyond 2-3 weeks

›Tendon quality guides reconstruction versus arthrodesis decision

›Preoperative planning for complex reconstructions

›Sheath obliteration assessment

›Myostatic contracture degree

›MRI protocol considerations

›Dedicated hand or finger coil required

›Small field of view for high-resolution imaging

›Sagittal and axial sequences essential

›T1 and T2 sequences

›T2 demonstrates oedema, sheath fluid, and tendon retraction level

›T1 shows tendon morphology and gap length

›Contraindications

›Metallic implants from prior hand surgery

›Patient unable to cooperate with positioning

CT

›CT indications for jersey finger

›Fracture characterization

›Comminuted distal phalanx fractures in Type V injuries

›Fragment size and location for surgical planning

›Preoperative planning for complex bony avulsions

›3D reconstruction for ORIF planning

›Joint surface involvement assessment

›When radiographs are equivocal for fragment detection

›Non-displaced small avulsion fragments may be radiographically occult

›CT limitations

›Soft tissue resolution inferior to MRI for tendon assessment

›Does not characterize tendon retraction level or viability

›Use MRI when tendon detail is the primary question

›Radiation exposure consideration in young patients

›Finger CT radiation dose is low but should be clinically justified

Ultrasound

›Ultrasound for preoperative tendon localization

›Cost-effective identification of tendon retraction level

›Comparable to MRI for classifying injury type in experienced hands

›Real-time dynamic assessment of tendon continuity

›Can identify location of tendon stump

›Palm versus PIP versus DIP level retraction

›Guides decision for incision planning

›Point-of-care ultrasound feasible in the ED

›Linear high-frequency probe 10-15 MHz

›Longitudinal view of flexor tendon from palm to fingertip

›Ultrasound technique

›Scan from palm to distal phalanx

›Identify tendon gap and retracted stump as hyperechoic structure

›Peritendinous haematoma appears as hypoechoic fluid

›Dynamic assessment with passive DIP flexion

›Absence of tendon movement at insertion confirms avulsion

›Operator experience affects diagnostic accuracy

›Sensitivity and specificity highest with dedicated musculoskeletal ultrasound expertise

›Radiograph as first-line imaging

›Three-view finger radiographs AP, lateral, and oblique

›May show volar avulsion fracture fragment at base of distal phalanx

›Fragment location helps classify injury type

›Normal in pure tendon avulsions without bony fragment (Type I)

›Imaging should not delay referral if clinical exam is diagnostic

07Disposition/dispo30

Surgical referral and admission criteria

›All jersey finger injuries require hand surgery consultation

›Surgical urgency determined by injury type

›Type I: referral within 24-48 hours; surgery within 7-10 days

›Type II: referral within 48-72 hours; surgery within 2-3 weeks

›Type III: urgent but somewhat more flexible timeframe

›Type IV: urgent; similar to Type I

›Open jersey finger

›Operative debridement and repair required urgently

›Admission for IV antibiotics if contaminated

Discharge criteria

›Suitable for discharge from ED when

›Diagnosis confirmed clinically

›Active DIP flexion absent with intact FDS function

›Closed injury without neurovascular compromise

›Normal two-point discrimination

›Normal capillary refill

›Dorsal splint applied in 30 degrees flexion at PIP and DIP

›Patient instructed not to remove splint

›Hand surgery follow-up arranged within 24-48 hours for Type I suspected

›Written referral with injury details and timing provided to patient

Follow-up and recovery expectations

›Post-operative rehabilitation

›Certified hand therapist essential for functional recovery

›Early active mobilization protocols post-repair

›Volar plate augmentation protocols have shown improved outcomes

›Recovery timeline

›6-12 weeks to functional recovery

08Treatment/t73

ED splinting and analgesia

›Splinting

›Dorsal aluminium splint

›PIP and DIP joints in approximately 30 degrees of flexion

›Prevents further tendon retraction

›Do not force into full flexion; gentle position only

›Volar padding under splint

›Protects neurovascular structures

›Prevents pressure injury

›Analgesia

›NSAIDs

›Ibuprofen 400-600 mg PO every 6-8 hours with food

›Naproxen 250-500 mg PO every 8-12 hours as alternative

›Contraindicated with renal impairment or GI bleeding history

›Acetaminophen

›500-1000 mg PO every 6-8 hours

›Maximum 4 g per day in adults

›Reduce to 2 g per day in hepatic impairment

›Opioids rarely needed

›Short course only if severe pain refractory to above

›Tramadol 50-100 mg PO every 4-6 hours if required

›Adjuncts

›Ice application

›15-20 minutes every 2 hours for first 48 hours

›Towel-wrapped ice to prevent frostbite

›Elevation

›Above heart level to reduce oedema

›Sling for comfort if helpful

Surgical management (definitive)

›All jersey finger types require operative repair or reconstruction

›Type I: primary tendon reinsertion

›Pull-out suture technique or suture anchor to volar base of distal phalanx

›Must be performed within 7-10 days of injury

›After this window, primary repair usually not possible

›Type II: primary tendon reinsertion

›Similar technique to Type I

›Can be delayed up to several weeks given preserved vincula

›Outcomes better with earlier repair

›Type III: open reduction and internal fixation of bony fragment

›Fragment reduction and screw or wire fixation

›Tendon integrity usually preserved

›Type IV: combined repair

›ORIF of bony fragment plus separate tendon reinsertion

›Technically demanding; specialist hand centre preferred

›Delayed presentation reconstruction options

›Staged silicone rod tendon reconstruction (Hunter technique)

›Single-stage tendon grafting when sheath preserved

›Z-plasty lengthening at the wrist for select cases

›DIP arthrodesis when functional demands are low or reconstruction not feasible

Post-operative antibiotics for open injuries

›Open jersey finger antibiotic coverage

›Cephalexin 500 mg PO every 6 hours for clean open injuries

›Duration 5-7 days or per surgical team direction

›Amoxicillin-clavulanate 875 mg PO every 12 hours

›Preferred for bite-contaminated wounds or soil contamination

›Covers gram-positive, gram-negative, and anaerobic organisms

›If penicillin allergy

›Clindamycin 300-450 mg PO every 6-8 hours

›Plus ciprofloxacin 500 mg PO every 12 hours for gram-negative coverage

›IV antibiotics for heavily contaminated or delayed open injuries

›Piperacillin-tazobactam 4.5 g IV every 6 hours

›Consult infectious disease if MRSA concern

Post-operative rehabilitation

›Hand therapy protocol

›Early active mobilization post-repair

›Controlled active flexion protocols reduce adhesion formation

›Dorsal protective splinting between exercises

›Passive range of motion

›Begin when surgeon clears

›Typically 3-6 weeks post-repair depending on repair strength

›Strengthening

›Progressive resistance exercises after tendon healing

›Typically begins 8-12 weeks post-repair

›Smoking cessation counselling

›Nicotine impairs tendon healing and microvascular perfusion

›Cessation at least 4-6 weeks before elective reconstruction

›Nicotine replacement or pharmacotherapy referral if indicated

09Special Populations/sp60

Pregnancy

›Pregnancy considerations for jersey finger

›Relaxin effect on connective tissue

›Ligament and tendon laxity increased during pregnancy

›May predispose to avulsion injuries with lesser forces

›Surgical timing decisions

›First trimester: elective surgery deferred when possible

›Second trimester: safest period for anaesthesia if urgent repair needed

›Third trimester: anaesthetic risk and positioning challenges

›Imaging in pregnancy

›Plain finger radiographs acceptable with abdominal shielding

›Radiation dose to finger is negligible to fetus

›MRI without gadolinium preferred over CT for soft tissue detail

›Gadolinium contrast avoided particularly in first trimester

›Anaesthesia considerations

›Regional anaesthesia (digital block or wrist block) preferred over general

›Avoids systemic fetal drug exposure

›Lidocaine 1-2% digital block without epinephrine is safe

›NSAIDs avoided in third trimester

›Risk of premature ductus arteriosus closure

›Acetaminophen preferred for analgesia throughout pregnancy

Geriatric

›Older adult considerations

›Tendon degeneration and comorbidities affect outcomes

›Degenerative tendinopathy makes suture anchor hold less reliable

›Diabetes and peripheral vascular disease impair wound healing

›Anaesthetic risk stratification

›Cardiac and pulmonary comorbidities increase operative risk

10Background/b60

Epidemiology

›Incidence and population affected

›Peak incidence in young active males aged 20-29 years

›Contact sports predominance: football, rugby, basketball, wrestling

›Less common in females but occurs in all sports involving gripping

›Ring finger accounts for approximately 75% of cases

›Biomechanically weakest FDP insertion

›Longest finger during grip accentuates tensile loading

›Commonly missed in the ED

›Frequently misdiagnosed as jammed finger or sprain on initial presentation

›Delayed referral is the primary cause of poor functional outcomes

›All jersey finger injuries require surgical consultation

›Most types require operative repair for restoration of DIP flexion

›Non-operative management reserved for patients with very low functional demands

Pathophysiology

›Mechanism of injury

›Forced extension of an actively flexing DIP joint

›FDP tendon under maximal eccentric load

›Tensile failure at the weakest link: the bony insertion

›Avulsion spectrum

›Pure tendon avulsion without bone (Type I/II)

›Bony avulsion with fragment of varying size (Type II/III/IV)

›Associated distal phalanx fracture (Type V)

›Tendon blood supply consequences

›Vincula brevia and longa supply FDP via mesotenon

›Type I injury: both vincula disrupted with loss of intrinsic blood supply

›Tendon survival depends on synovial fluid diffusion only

›Window for viable primary repair is narrow: 7-10 days

11Patient Discharge Instructions/pdi31

copy discharge instructions

›Jersey finger home care instructions

›Your finger has an avulsion of the flexor tendon called a jersey finger

›This means the tendon that bends the tip of your finger has pulled away from the bone

›Surgery is almost always needed to fix this properly

›Keep your splint on at all times

›Do not remove the splint until told by your hand surgeon

›If it gets wet or feels too tight, return to the emergency department

›Ice and elevation

›Apply ice wrapped in a cloth for 15-20 minutes every 2 hours for the first 48 hours

›Keep your hand elevated above heart level to reduce swelling

›Pain medications

›Ibuprofen or naproxen with food as directed

›Acetaminophen as directed

›Take both together if pain is not controlled with one

›Follow-up instructions

›Hand surgery appointment

›You must see a hand surgeon within 24-48 hours if injury happened today or yesterday

›If injury happened more than a few days ago, see a hand surgeon within the week

›Do not wait; delays cause permanent inability to bend the fingertip

›Do not use the injured hand

›No gripping, lifting, or pushing until cleared by hand surgeon

›Warning signs to return to the emergency department

›Increasing pain, swelling, or redness despite keeping splint on

›Could indicate infection or worsening injury

›Numbness or cold discolouration of the fingertip

›Could indicate loss of blood supply

›Fever above 38.5 degrees Celsius

12References/r18

Guidelines and key sources

›Primary references

›Leddy JP, Packer JW. Avulsion of the profundus tendon insertion in athletes. Journal of Hand Surgery, 1977

›Original classification system for jersey finger

›Foundation of all subsequent management algorithms

›Ruchelsman DE, Mudgal CS. Flexor tendon injuries in the hand. Journal of the American Academy of Orthopaedic Surgeons, 2011

›Comprehensive review of FDP avulsion management

›American Society for Surgery of the Hand position on flexor tendon avulsions

›Supports urgent referral within 24-48 hours for Type I injuries

›Emergency medicine references

›Tintinalli's Emergency Medicine: A Comprehensive Study Guide - hand injuries chapter

›Standard ED approach to jersey finger including splinting and referral protocols

›Roberts and Hedges Clinical Procedures in Emergency Medicine - flexor tendon injuries

›Point-of-care assessment and disposition guidance

›Coding standards

›ICD-10 S66.1 injury of flexor tendon at wrist and hand level

›Specific codes vary by digit and laterality

›ICD-10 M66.3 spontaneous rupture of flexor tendons for atraumatic presentations

›SNOMED CT 444798002 avulsion of flexor digitorum profundus tendon

Evidence & Review

Evidence & Review