01Approach to the Critical Patient/attcp44

Immediate threats and alarm features

›High-risk fracture patterns requiring urgent action

›Open fracture — wound communicating with fracture site

›Irrigation and wound care immediately

›Prophylactic antibiotics within 1 hour

›Neurovascular compromise

›Absent capillary refill >2 seconds

›Loss of two-point discrimination

›Malrotation deformity

›Digital overlap when fist is formed

›Requires urgent hand surgery referral

›Jersey finger — FDP avulsion with inability to flex DIP

›Surgical emergency; referral within 7–10 days

›Splint PIP and DIP in slight flexion pending referral

›Escalation triggers

›Polytrauma context

›Systemic survey before isolated digit management

›Trauma team activation if hemodynamically unstable

›Seymour fracture in pediatric patient

›Open physeal injury with nail bed laceration

›Complication rate ~62%; hand surgery consultation

›Vascular injury to digital artery

›Hand surgery or vascular surgery consultation

›Digital replantation consideration

Monitoring and early decision points

›Initial stabilization priorities

›Pain control before examination

›Digital nerve block for procedural analgesia

02History/hx56

Mechanism and injury context

›Mechanism of injury

›Crush injury — most common mechanism (~33%)

›Door-slam, heavy object, machinery

›Associated with tuft fracture and subungual hematoma

›Fall (~23%)

›Axial loading pattern

›Direct blow

›Sports-related

›Ball-striking sports (basketball, football, rugby)

›Jersey pull — forced extension of flexed DIP

›Peak incidence ages 10–14 in pediatric athletes

›Specific injury patterns to elicit

›Forced flexion of extended DIP

›Mallet finger pattern — extensor tendon avulsion

›Forced extension of flexed DIP

›Jersey finger — FDP avulsion

›History of grabbing jersey or clothing

›Crush to fingertip

›Distal tuft fracture

›Subungual hematoma

Symptom characterization

›Primary symptoms

›Pain

›Localized to injured phalanx

›Aggravated by motion

›Swelling and ecchymosis

›Deformity

03Physical Exam/exam53

Inspection and general assessment

›Visual survey

›Swelling, ecchymosis, deformity

›Subungual hematoma

›Dark discoloration beneath nail plate

›Suggestive of underlying tuft fracture

›Open wounds or lacerations

›Any wound communicating with fracture = open fracture

›Nail bed disruption

›Rotational malalignment

›Digit rotation or scissoring at rest

Palpation and range of motion

›Palpation

›Point tenderness over fracture site

›Each phalanx assessed individually

›Joint line tenderness vs. shaft tenderness

›Range of motion

›Active flexion/extension at DIP, PIP, and MCP joints

›Extensor lag at DIP

›Mallet finger pattern

›Inability to actively flex DIP

›Jersey finger pattern

›Inability to extend PIP against resistance

›Central slip rupture (Elson test positive)

Malrotation assessment

›Fist-making cascade test

›All fingertips should point toward scaphoid tubercle

›Overlap of digits = malrotation

04Differential Diagnosis/ddx37

Fracture pattern differentials

›Phalanx fracture subtypes

›Distal phalanx tuft fracture (ICD-10: S62.5)

›Most common phalanx fracture subtype (~43% of phalanx fractures)

›Crush mechanism, often with subungual hematoma

›Mallet finger — distal phalanx dorsal avulsion (ICD-10: S63.207A)

›Forced flexion of extended DIP

›Extensor lag at DIP at rest

›Jersey finger — FDP avulsion (ICD-10: S66.109A)

›Inability to flex DIP

›Surgical emergency

›Middle phalanx fracture (ICD-10: S62.6)

›Apex dorsal angulation (proximal fragment)

›Apex volar angulation (distal fragment)

›Proximal phalanx fracture (ICD-10: S62.6)

›Apex volar angulation from intrinsic-extrinsic imbalance

›Condylar fracture

›Intra-articular; unstable; high malunion risk

Non-fracture diagnoses

›Joint injuries

›PIP or DIP dislocation

›Obvious deformity at joint line

›May coexist with fracture

›Collateral ligament sprain or tear

›Lateral instability on stress testing

›No fracture on imaging

›Volar plate injury

›Hyperextension mechanism

05Laboratory Tests/lt23

Routine labs

›Labs generally not indicated for isolated closed phalanx fractures

›No routine CBC or metabolic panel required

›Evidence supports clinical and radiographic diagnosis without labs

›Selective lab indications

›Open fracture with delayed presentation or signs of infection

›CBC for leukocytosis

›CRP and ESR as inflammatory markers

›Wound cultures if drainage present

›Pre-operative workup if surgical intervention planned

›Per institutional protocol

›CBC, coagulation studies if anticoagulated

Infection workup

›Osteomyelitis consideration in delayed presentations

›Prolonged erythema, warmth, drainage

›CBC with differential

›Leukocytosis supportive but non-specific

›ESR and CRP

›Elevated in osteomyelitis but non-specific

›MRI most sensitive for early osteomyelitis

›Superior to plain radiography

›Bone biopsy and culture for definitive diagnosis

Tetanus status

›Tetanus immunization status for open fractures

›Tetanus toxoid if last booster >5 years ago

›Tetanus immune globulin if unimmunized or unknown status with high-risk wound

06Diagnostic Tests/dt70

Scoring Systems

›Ottawa Hand and Finger Rules — not formally validated for individual phalanges

›Clinical judgment guides imaging decision in most cases

›Radiographs recommended for any suspected phalanx fracture in ED setting

›Pittsburgh Hand Fracture Severity Score

›Not widely validated; hand surgeon assessment guides operative vs. non-operative decision

›Fracture stability criteria

›Stable fracture features

›Non-displaced or minimally displaced (<2 mm)

›Angulation <10–15 degrees

›No rotational deformity

›Extra-articular

›Unstable fracture features

›Displacement >4 mm

›Angulation >15 degrees

›Oblique, spiral, or comminuted pattern

›Intra-articular with step-off

MRI

›MRI indications for phalanx fracture

›Occult fracture with negative radiographs but persistent clinical suspicion

›High sensitivity for bone marrow edema

›Superior to CT for soft tissue injuries

›Soft tissue injury characterization

›Collateral ligament tear assessment

›Volar plate integrity

›Tendon injury without bony avulsion

›Osteomyelitis detection

›Most sensitive modality for early medullary osteomyelitis

›MRI limitations

›Not routinely indicated for acute phalanx fractures

›Cost and availability constraints

›Metallic implants may limit post-operative assessment

CT

›CT indications for phalanx fracture

›Complex intra-articular fractures

›Guides surgical planning for condylar and pilon fractures

›Characterizes articular step-off and fragment count

›Fracture pattern clarification when radiographs inconclusive

›Comminuted fractures benefit from 3D reconstruction

›Pre-operative planning

›Implant selection and fixation strategy

›CT protocol

›Fine-cut CT (1 mm slices) of affected digit

›3D reconstruction where available

›CT limitations

›Rarely needed for most isolated phalanx fractures

›Radiation exposure consideration in pediatric patients

Ultrasound

›Point-of-care ultrasound applications

›Fracture identification at bedside

›Cortical disruption visible on high-frequency probe (15 MHz)

›May be useful when radiograph access limited

›Nail bed laceration assessment

›Identifies laceration not apparent on inspection

›Guides need for nail removal and repair

›Subungual hematoma characterization

›Confirms hematoma extent prior to trephination

›Soft tissue foreign body identification

›Useful when glass or other radiolucent material suspected

›Ultrasound limitations

›Operator dependent

›Cannot replace formal radiography for fracture characterization

›ACR Appropriateness Criteria: radiography is primary imaging for acute hand trauma

Plain Radiography

›Three-view radiograph series — first-line imaging

›AP, lateral, and oblique of the affected digit

›Standard 3-view shows most fractures and dislocations

›ACR Appropriateness Criteria: usually appropriate

›Assess for

›Fracture pattern — transverse, oblique, spiral, comminuted, avulsion

›Displacement and angulation

›Articular involvement and step-off

›Associated dislocation

›Postreduction radiographs mandatory after any reduction

›Repeat radiographs at 7–10 days for reduced fractures to confirm alignment

07Disposition/dispo32

Discharge criteria

›Safe for discharge

›Closed, non-displaced or minimally displaced fracture

›Appropriate splinting applied

›Neurovascular exam intact

›Adequate analgesia achieved

›Stable mallet finger with strict DIP extension splint applied

›Buddy-taped stable proximal or middle phalanx fracture

›Follow-up arranged within 7–10 days

Urgent hand surgery referral indications

›Referral required before discharge or within 24–48 hours

›Jersey finger (FDP avulsion)

›All cases require surgical repair

›Optimal window within 7–10 days

›Open fractures

›Operative irrigation and debridement

›Antibiotics initiated in ED

›Malrotation deformity

›Failed closed reduction

›Intra-articular fracture with >30% articular surface involvement

›Oblique, spiral, or comminuted unstable fractures

›Neurovascular compromise

Admission indications

›Rarely required for isolated phalanx fractures

›Polytrauma with other admission-level injuries

›Open fracture requiring operative washout same admission

›Vascular compromise requiring operative intervention

›Signs of septic joint or early osteomyelitis

08Treatment/t87

Analgesia and nerve block

›Systemic analgesia

›NSAIDs first-line

›Ibuprofen 400–600 mg PO every 6 hours

›Naproxen 500 mg PO every 12 hours

›Acetaminophen as adjunct

›500–1000 mg PO every 6–8 hours

›Maximum 4 g/24 hours

›Opioid avoidance for isolated digit fractures

›Digital nerve block

›1–2% lidocaine without epinephrine (traditional)

›Evidence supports safe use with epinephrine for digital blocks

›Block techniques

›Dorsal web space block — preferred for dorsal injuries

›Volar subcutaneous block — preferred for volar injuries

›Transthecal block — through flexor tendon sheath at A1 pulley

›Ring block — circumferential at base of digit

›Volume: 1–2 mL per nerve; total 3–4 mL for complete ring block

Distal phalanx fracture management

›Tuft fracture

›Protective splint

›U-shaped aluminum splint, fingertip guard, or volar splint

›DIP in full extension

›Duration: 4–6 weeks

›Subungual hematoma trephination

›Electrocautery device or 18-gauge needle through nail plate

›Safe regardless of hematoma size or presence of underlying fracture

›Immediate pain relief

›Mallet finger

›Strict DIP splinting in full extension to slight hyperextension

›Duration: 8 weeks minimum

›Premature flexion resets the 8-week clock

›Stack splint or thermoplastic DIP extension splint

›Indications for surgical referral

›>30% articular surface involvement

›Volar subluxation of distal phalanx

›Failure of conservative splinting

›Jersey finger

›Splint PIP and DIP in slight flexion pending referral

›Surgical repair required in all cases

›Optimal window: within 7–10 days of injury

›FDP reattachment to distal phalanx

Middle and proximal phalanx fracture management

›Stable minimally angulated fractures (<10 degrees)

›Buddy taping to adjacent digit

›Duration: 3–4 weeks

›Gentle mobilization of buddy-taped digits to prevent stiffness

›Clinical and radiographic reassessment at 7–10 days

›Angulated or displaced fractures requiring reduction

›Digital nerve block for procedural analgesia

›Closed reduction technique

›Longitudinal traction on distal segment

›Guide bone into anatomic alignment

›Correct angulation and rotation simultaneously

›Post-reduction splinting

›Ulnar gutter splint for ring and small finger fractures

›Radial gutter splint for index and long finger fractures

›MCP in 70–90 degrees flexion (intrinsic-plus position)

›IP joints in extension

›Postreduction radiograph mandatory

›Unstable fractures — surgical referral

›Oblique, spiral, rotational, intra-articular

›Displacement >4 mm or angulation >15 degrees

›Surgical options include K-wire fixation, lag screws, mini-plate fixation

›Plate fixation: higher stiffness risk than K-wire fixation

Open fracture management

›Wound care

›Copious saline irrigation

›Removal of gross contamination

›Sterile dressing application

›Antibiotic prophylaxis

›First-generation cephalosporin (cephalexin or cefazolin)

›Cefazolin 1 g IV for operative cases

›Cephalexin 500 mg PO QID for minor open wounds

›Add gram-negative coverage for highly contaminated wounds

›MRSA coverage if prior MRSA history

›Tetanus prophylaxis

›Toxoid if last booster >5 years ago

›Immune globulin if unimmunized

›Hand surgery referral for operative irrigation and debridement

Nail bed management

›Subungual hematoma trephination

›Indication: any painful subungual hematoma

›Safe regardless of size or fracture status

›Technique

›Electrocautery through nail plate

›Or heated 18-gauge needle

›No nail removal required unless nail bed repair needed

›Nail bed laceration repair

›Nail removal to expose laceration

›Repair with 5-0 or 6-0 absorbable suture

›Replace nail plate as biologic splint or use silastic sheet

09Special Populations/sp66

Pregnancy

›Analgesia considerations in pregnancy

›Acetaminophen preferred analgesic throughout pregnancy

›Standard doses safe for short-term use

›NSAIDs

›Avoid after 20 weeks gestation — risk of premature ductus arteriosus closure

›Short-term use generally acceptable in first trimester

›Opioids

›Use sparingly if acetaminophen inadequate

›Neonatal abstinence syndrome risk with prolonged use

›Imaging in pregnancy

›Plain radiographs of digit: minimal radiation exposure

›Effective dose negligible with digit shielding

›Radiography acceptable when clinically indicated

›Lead shielding of abdomen and pelvis recommended as standard practice

›Surgical considerations

›Elective surgery deferred to postpartum when possible

›Urgent surgical cases (open fracture, vascular compromise): anesthetic plan with obstetrics involvement

›Regional anesthesia preferred over general if surgery required

Geriatric

›Fracture pattern differences

›Lower-energy mechanisms sufficient due to osteoporosis

›Crush from minimal force (door, household objects)

›Comminuted patterns more common

›Medical considerations

›Anticoagulant use common

›Increased hematoma and bleeding risk

›Review anticoagulation reversal if operative

10Background/b81

Epidemiology

›Incidence and prevalence

›Phalanx fractures are the second most common upper extremity fracture

›Among the most frequent ED presentations for hand trauma

›Distribution by location

›Distal phalanx: ~43% (most common)

›Proximal phalanx: second most common

›Middle phalanx: least common of the three

›Management approach

›~74% managed conservatively

›~26% require surgical intervention

›Demographics

›Male to female ratio approximately 2.7:1

›Mean age in adults approximately 40 years

›Bimodal distribution

›Young males — sports and occupational trauma

›Older adults — low-energy mechanisms and osteoporosis

›Mechanism distribution

›Crush injury: ~33% (most common)

›Fall: ~23%

›Sports-related: significant proportion in adolescents

Pathophysiology

›Fracture mechanics and deforming forces

›Distal phalanx

›Tuft fracture: axial compression from crush

›Mallet fracture: avulsion of extensor digitorum communis insertion

›Jersey finger: avulsion of FDP from base of distal phalanx

›Middle phalanx

›Fracture proximal to FDS insertion: apex dorsal angulation

›FDS pulls distal fragment volarly

›Fracture distal to FDS insertion: apex volar angulation

›FDS pulls proximal fragment volarly

›Proximal phalanx

›Apex volar angulation

›Intrinsic muscles flex proximal fragment

›Extensor mechanism extends distal fragment

›Fracture stability determinants

›Pattern: transverse > oblique > spiral (increasing instability)

›Comminution: increases instability

›Articular involvement: intra-articular fractures inherently unstable

›Deforming muscular forces: greater with more proximal fracture

›Tissue injury complications

›Tendon adhesions — most common complication after operative fixation

›Stiffness — common long-term sequela

›Malunion and malrotation

›Nonunion — uncommon in digits

›Infection — higher risk in open fractures and diabetics

›Growth arrest — pediatric physeal injuries

›Nail deformity — after nail bed injury

Therapeutic Considerations

›Conservative vs. operative decision framework

›Conservative management (majority of cases)

›~74% of phalanx fractures managed without surgery

›Non-displaced or minimally displaced extra-articular fractures

›Stable mallet finger without volar subluxation

›Surgical indications

›Unstable fracture patterns (oblique, spiral, comminuted)

›Failed closed reduction

›Intra-articular with significant articular step-off

›Open fractures requiring operative debridement

›Jersey finger (FDP avulsion)

›Splinting principles

›Intrinsic-plus position for proximal and middle phalanx fractures

›MCP in 70–90 degrees flexion

›IP joints in extension

›Prevents collateral ligament contracture

›DIP extension splinting for mallet finger

›Strict compliance critical: premature flexion resets 8-week clock

›Buddy taping for stable shaft fractures

›Allows early protected mobilization

›Smoking and fracture healing

›Smoking impairs periosteal blood flow and fracture healing

›Increased infection risk in open fractures

›Smoking cessation strongly recommended

›Surgical fixation options

›K-wire fixation

›Low-profile, removable

›Less stiffness than plate fixation

›Lag screw fixation — for long oblique or spiral fractures

›Mini-plate fixation — for comminuted or unstable shaft fractures

›Higher stiffness risk vs. K-wire

›Rehabilitation

›Early protected mobilization reduces stiffness

›Hand therapy referral post-operatively

11Patient Discharge Instructions/pdi26

copy discharge instructions

›Diagnosis and injury explanation

›You have been diagnosed with a fracture of one of the small bones in your finger (phalanx fracture)

›Most finger fractures heal well without surgery with proper splinting

›Splint and wound care

›Keep your splint clean, dry, and intact at all times

›For mallet finger: do not remove the splint or bend the fingertip — doing so restarts the 8-week healing clock

›For buddy-taped fingers: gently move the fingers as tolerated to prevent stiffness

›Change wound dressings as instructed if you have an open wound

›Medications

›Take ibuprofen 400–600 mg every 6 hours with food for pain

›Acetaminophen 500–1000 mg every 6–8 hours (max 4 g per day) can be used with or alternating with ibuprofen

›Take antibiotics as prescribed if given for an open fracture — complete the full course

›Follow-up appointment

›Return for your scheduled follow-up in 7–10 days for repeat X-rays to confirm alignment

›Continue follow-up every 2 weeks until healed

›Expect healing to take 4–6 weeks for most fractures; mallet finger requires 8 weeks of splinting

›Return to the emergency department immediately if

›Increasing pain, swelling, or numbness despite the splint

›Signs of infection: redness, warmth, drainage, or fever >38 degrees C

›Splint becomes loose or your finger appears rotated or bent out of position

›You cannot move your finger after the splint is removed at follow-up

›Fingertip turns white, blue, or cold — sign of poor circulation

›Lifestyle

›Keep the injured hand elevated above heart level for the first 48–72 hours to reduce swelling

›Avoid smoking — it significantly impairs bone healing and increases infection risk

›Expect some stiffness during recovery; hand therapy may be recommended after healing

12References/r22

Guidelines and key sources

›Ganesh Kumar N, Chung KC. An Evidence-Based Guide for Managing Phalangeal Fractures. Plastic and Reconstructive Surgery. 2021. PMID: 33890906

›Primary evidence base for fracture epidemiology, management, and outcomes

›Kremer L, Frank J, Lustenberger T, Marzi I, Sander AL. Epidemiology and Treatment of Phalangeal Fractures: Conservative Treatment Is the Predominant Therapeutic Concept. European Journal of Trauma and Emergency Surgery. 2022. PMID: 32451567

›Conservative vs. operative distribution data; ~74% conservative management

›Childress MA, Olivas J, Crutchfield A. Common Finger Fractures and Dislocations. American Family Physician. 2022. PMID: 35704814

›Classification, splinting principles, mallet and jersey finger management

›Hilgefort J, Becker J, Chu J. Fingertip Injuries. American Family Physician. 2025. PMID: 40736493

›Digital nerve block techniques and subungual hematoma management

›Gottlieb M, Penington A, Schraft E. Digital Nerve Blocks: A Comprehensive Review of Techniques. Journal of Emergency Medicine. 2022. PMID: 36229322

›Digital block evidence including epinephrine safety

›Abzug JM, Dua K, Bauer AS, Cornwall R, Wyrick TO. Pediatric Phalanx Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2016. PMID: 27755266

›Pediatric fracture patterns, Seymour fracture, Salter-Harris classification

›Expert Panel on Musculoskeletal Imaging, Torabi M, Lenchik L, et al. ACR Appropriateness Criteria Acute Hand and Wrist Trauma. Journal of the American College of Radiology. 2019. DOI: 10.1016/j.jacr.2019.02.029

›Radiography as primary imaging modality; CT and MRI indications

›Seaberg DC, Angelos WJ, Paris PM. Treatment of Subungual Hematomas With Nail Trephination: A Prospective Study. American Journal of Emergency Medicine. 1991. PMID: 2018587

›Safety of trephination regardless of hematoma size or fracture status

›Heifner JJ, Rubio F. Fractures of the Phalanges. Journal of Hand Surgery, European Volume. 2023. PMID: 37704026

›Contemporary review of fracture classification and surgical options

›Henry MH. Fractures of the Proximal Phalanx and Metacarpals in the Hand: Preferred Methods of Stabilization. Journal of the American Academy of Orthopaedic Surgeons. 2008. PMID: 18832602

›Fixation method comparison and intrinsic-plus positioning rationale

›Lankachandra M, Wells CR, Cheng CJ, Hutchison RL. Complications of Distal Phalanx Fractures in Children. Journal of Hand Surgery. 2017. PMID: 28465015

›Seymour fracture complication rate ~62%

Evidence & Review

Evidence & Review