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Approach to the Critical Patient
Triage priorities
Immediate threats
Open fracture or gross contamination
Active hemorrhage
Devitalized tissue
Neurovascular compromise
Capillary refill delay
Absent Doppler signal
Compartment syndrome risk
Pain out of proportion
Pain with passive stretch
Tendon entrapment or rupture
Inability to actively extend DIP
Inability to actively flex DIP
Time critical actions
If ischemia suspected then immediate reduction and splint
Recheck perfusion after reduction
Emergent hand surgery consultation if perfusion not restored
If open fracture then antibiotics within 60 minutes
Irrigation and sterile dressing
Urgent hand surgery consultation
If rotational deformity then reduction attempt in ED
Recheck finger cascade after reduction
Hand surgery consultation if persistent malrotation
Analgesia and immobilization first
Comfort measures
Elevation
Hand above heart level
Remove rings early
Splint before transport to imaging when unstable
Neutral wrist when possible
IP joints supported
Neurovascular checks
Perfusion
Capillary refill
Compare with contralateral
Post reduction recheck
Temperature and color
Pallor or mottling
Cyanosis
Sensation
Two point discrimination
Radial and ulnar digital nerves
Compare with contralateral
Light touch
Volar pulp
Dorsal fingertip
Motor
FDP function
DIP flexion with PIP stabilized
Compare strength
FDS function
PIP flexion with other fingers held in extension
Compare strength
Extensor function
Active DIP extension
Active PIP extension
History
Injury context
History elements
Mechanism
Axial load
Crush
Twist
Laceration or bite
Timing
Time since injury
Prior attempts at reduction or splinting
Hand dominance
Dominant hand involvement
Sport specific use
Occupational demands
Need for fine motor tasks
Need for heavy grip
Prior hand injury
Prior fracture or surgery
Baseline ROM deficits
Symptoms and functional impact
Symptom profile
Pain pattern
At rest
With motion
Deformity perception
Rotation
Shortening
Numbness or tingling
Radial side
Ulnar side
Mechanical block
Locking
Inability to flex or extend
Risk modifiers
Patient factors
Diabetes
Infection risk
Wound healing risk
Smoking or vaping nicotine
Delayed union risk
Infection risk
Anticoagulants or antiplatelets
Hematoma risk
Bleeding risk
Immunosuppression
Steroid use
Transplant
Osteoporosis risk
Low energy mechanism
Prior fragility fracture
Physical Exam
Inspection and alignment
Visual assessment
Skin integrity
Puncture wound
Laceration
Swelling pattern
Localized to phalanx
Diffuse digit swelling
Nail complex
Subungual hematoma
Nail plate avulsion
Finger cascade
Normal flexion cascade
Scissoring or overlap
Rotational deformity
Fingertips pointing toward scaphoid tubercle when flexed
Asymmetry compared with contralateral
Palpation and stability
Palpation findings
Point tenderness
Distal phalanx
Middle phalanx
Proximal phalanx
Crepitus
Suggestive of fracture
Assess gently
Joint line tenderness
DIP
PIP
Stability assessment
Collateral ligaments
PIP varus valgus
DIP varus valgus
Volar plate injury signs
Hyperextension pain
PIP instability
Tendon function screen
Flexor assessment
FDP integrity
Isolated DIP flexion
Pain with attempt
FDS integrity
Isolated PIP flexion
Pain with attempt
Extensor assessment
Mallet pattern
DIP extensor lag
Dorsal DIP tenderness
Central slip pattern
PIP extension weakness
Pain dorsal PIP
PITFALLS
Common misses
Malrotation despite minimal angulation on x ray
Cascade check required
Persistent scissoring requires hand surgery
Seymour fracture in children
Nail plate interposition
Treated as open fracture
Jersey finger FDP avulsion
Absent DIP flexion
Urgent hand surgery within days
Differential Diagnosis
Traumatic digit conditions
Mimics and associated injuries
IP joint dislocation
PIP dorsal dislocation
DIP dislocation
Volar plate injury
PIP hyperextension injury
Avulsion fragment
Collateral ligament rupture
PIP instability
Pain with stress
Extensor tendon injury
Mallet injury
Central slip injury
Flexor tendon injury
FDP avulsion
Partial flexor laceration
Nail bed laceration
Subungual hematoma with laceration
Nail plate disruption
Coding aligned terms
Coding framework
ICD 10 fracture categories
S62.6 fracture of other finger phalanx
S62.5 fracture of thumb phalanx
SNOMED CT concepts
Fracture of phalanx of finger
Open fracture of phalanx of finger
Laboratory Tests
When needed
Lab selection
No routine labs for isolated closed phalanx fracture
Normal vitals
No anticoagulation concerns
Open fracture or contaminated wound
Complete blood count for infection concern
Basic metabolic panel for operative planning when indicated
Significant bleeding or anticoagulant use
Hemoglobin for bleeding concern
INR for warfarin use
Infection risk scenarios
Special wound contexts
Human bite or fight bite
Glucose for diabetes screening when unknown
Blood cultures only if systemic toxicity
Marine or soil contamination
Baseline labs if admission likely
Lactate only if sepsis concern
Diagnostic Tests
Scoring Systems
Classification tools
Open fracture classification
Gustilo Anderson type I
Clean wound less than 1 cm
Minimal soft tissue damage
Gustilo Anderson type II
Wound 1 cm to 10 cm
Moderate soft tissue damage
Gustilo Anderson type III
Extensive soft tissue damage
High contamination or vascular injury
Physeal injury classification
Salter Harris I
Physis only
Often normal x ray
Salter Harris II
Physis and metaphysis
Thurston Holland fragment
Salter Harris III
Physis and epiphysis
Intra articular
Salter Harris IV
Metaphysis physis epiphysis
Intra articular
Salter Harris V
Crush of physis
High growth arrest risk
MRI
MRI indications
Occult fracture with persistent focal tenderness
Normal or equivocal x ray
High demand athlete or worker
Suspected tendon injury with unclear exam
Partial flexor laceration
Extensor mechanism injury
Osteomyelitis concern after open injury
Persistent pain swelling
Wound drainage
MRI limitations
Limited ED availability
Delayed disposition
Often outpatient pathway
Metal artifact
Retained foreign body
Prior hardware
CT
CT indications
Intra articular fracture assessment
Step off quantification
Surgical planning support
Comminuted fracture pattern
Rotational component suspected
Difficult to characterize on x ray
Malunion or nonunion assessment
Delayed presentation
Persistent deformity
CT limitations
Radiation exposure
Prefer x ray first line
Pediatrics risk consideration
Soft tissue detail inferior to MRI
Tendon evaluation limited
Ligament evaluation limited
Ultrasound
Ultrasound uses
Tendon evaluation
FDP discontinuity
Extensor tendon discontinuity
Foreign body detection
Radiolucent material
Localization for removal planning
Hematoma assessment
Soft tissue collection
Guidance for aspiration when indicated
Ultrasound limitations
Operator dependence
Variable sensitivity
Requires experience
Bone detail limited
Not a replacement for x ray
Adjunct only
Disposition
ED discharge criteria
Discharge suitability
Closed fracture
No neurovascular deficit
No open wound
Acceptable alignment after reduction or immobilization
No malrotation on cascade exam
Stable in splint
Pain controlled with oral regimen
Able to sleep
Able to mobilize safely
Reliable follow up
Hand surgery or fracture clinic arranged
Return precautions understood
Admission or urgent transfer criteria
Higher level care triggers
Open fracture
Antibiotics started
Operative washout pathway
Neurovascular compromise
Persistent after reduction
Vascular surgery support needed
Compartment syndrome concern
Escalation to OR evaluation
Continuous reassessment
Irreducible fracture dislocation
Entrapped volar plate
Interposed tendon
Complex fracture patterns
Intra articular with step off
Unstable comminution
Treatment
Immobilization principles
Splinting strategy
Position of function
Wrist slight extension
MCP flexion 70 to 90 degrees when gutter used
Buddy taping indications
Stable non displaced fractures
No malrotation
Gutter splint indications
Unstable fracture patterns
Post reduction immobilization
Duration planning
Early motion when stable to reduce stiffness
Hand therapy referral when ROM risk high
Reduction and alignment
Closed reduction considerations
Indications
Angulation affecting function
Rotational deformity
Post reduction checks
Cascade and rotation
Neurovascular status
Post reduction imaging
Confirm alignment in 2 views
Document stability in splint
Analgesia and anesthesia
Oral analgesics
Acetaminophen
Adults 1000 mg PO once
Maximum 4000 mg per 24 hours
Maximum 3000 mg per 24 hours if chronic alcohol use or liver disease risk
Pediatrics 15 mg per kg PO once
Maximum 1000 mg per dose
Maximum 60 mg per kg per 24 hours
Ibuprofen
Adults 600 mg PO once
Repeat every 6 hours as needed
Maximum 2400 mg per 24 hours in most ED discharge plans
Pediatrics 10 mg per kg PO once
Repeat every 6 to 8 hours as needed
Maximum 40 mg per kg per 24 hours
Regional anesthesia
Digital nerve block
Lidocaine 1 percent without epinephrine 3 mL to 5 mL total
Maximum lidocaine dose 5 mg per kg
Aspirate before injection
Bupivacaine 0.25 percent 3 mL to 5 mL total
Maximum bupivacaine dose 2 mg per kg
Longer duration option
Procedural sedation pathway
Severe pain or multiple digits
Local block inadequate
Reduction not tolerated
Antibiotics and tetanus
Open fracture antibiotic options
Cefazolin
Adults 2 g IV once
Repeat every 8 hours if ongoing inpatient care
Add gram negative coverage if severe contamination
Pediatrics 25 mg per kg IV once
Maximum 2000 mg
Repeat every 8 hours if ongoing inpatient care
Penicillin allergy option
Clindamycin
Adults 600 mg IV once
Repeat every 8 hours if ongoing inpatient care
Add gram negative agent if indicated
Pediatrics 10 mg per kg IV once
Maximum 600 mg
Repeat every 8 hours if ongoing inpatient care
Bite wound coverage
Amoxicillin clavulanate
Adults 875 mg PO once
Twice daily course when outpatient
Typical duration 5 days to 7 days
Pediatrics 22.5 mg per kg amoxicillin component PO once
Twice daily course when outpatient
Maximum 875 mg per dose
Tetanus prophylaxis
Immunization status review
Clean minor wound booster if more than 10 years
Dirty wound booster if more than 5 years
Tetanus immune globulin indications
Unknown or incomplete immunization and dirty wound
Open fracture with contamination and no documented series
Evidence levels and recommendations
Consensus based recommendations
Class I expert consensus for urgent antibiotics in open fractures
Earlier administration associated with lower infection risk
Do not delay for imaging or consult
Class I expert consensus for malrotation correction
Malrotation poorly tolerated functionally
Requires reduction or operative fixation
ACEP Level C style consensus for routine x ray imaging in suspected fracture
Three view hand or finger series preferred
Post reduction imaging recommended
Special Populations
Pregnancy
Pregnancy considerations
Imaging choices
Plain radiographs acceptable with shielding
CT only if benefits outweigh risks
Medication considerations
Avoid NSAIDs in third trimester when possible
Acetaminophen preferred first line
Thromboembolism risk
Immobilization counseling
Mobilize unaffected joints
Geriatric
Older adult considerations
Bone quality
Osteoporosis risk assessment
Low energy fracture patterns
Stiffness risk
Early hand therapy referral
Short immobilization when stable
Anticoagulation
Hematoma monitoring
Skin breakdown risk under splint
Pediatrics
Pediatric considerations
Physeal injuries
Salter Harris pattern awareness
Growth arrest counseling
Seymour fracture pathway
Nail plate injury with distal phalanx physeal fracture
Treat as open fracture with urgent hand surgery
Immobilization
Weight based analgesia dosing
Splint fit checks and skin protection
Background
Epidemiology
Epidemiologic notes
Frequency
Common upper extremity fracture group in ED settings
Often sports and work related
Injury distribution
Distal phalanx common with crush
Proximal phalanx common with axial load and twist
Complication patterns
Stiffness common after prolonged immobilization
Malrotation causes functional impairment
Pathophysiology
Mechanisms
Axial load
Transverse or oblique shaft fractures
Intra articular base fractures possible
Crush
Tuft fractures
Nail bed lacerations
Avulsion
Extensor avulsion at DIP
Volar plate avulsion at PIP
Healing biology
Phalanx fracture union
Usually reliable with stable alignment
Malalignment causes tendon imbalance
Therapeutic Considerations
Treatment goals
Alignment that preserves function
Rotation zero tolerance
Joint congruity when intra articular
Immobilization balance
Stability for union
Early motion to prevent stiffness
Surgical indications
Unstable fractures
Intra articular displacement
Complication prevention
Skin care under splints
Pressure point checks
Edema accommodation
Hand therapy
Early referral for PIP involvement
Home ROM program when cleared
Patient Discharge Instructions
copy discharge instructions
Discharge instructions
Splint and hand care
Keep splint clean and dry
Elevation above heart for first 48 hours
Activity
No lifting with injured hand
Buddy taped finger move as directed
Pain control
Acetaminophen as directed on label
Ibuprofen as directed on label if allowed
Follow up
Hand surgery or fracture clinic within 3 to 7 days
Earlier within 24 to 48 hours for open injury or tendon concern
Return to ED now
Increasing pain not controlled with medication
New numbness or tingling
Fingers turning pale blue or cold
Increasing swelling with tight splint sensation
Fever or spreading redness
Drainage or foul smell from wound
Splint breakage or loss of alignment
References
Guidelines and core sources
Key sources
Hand surgery and orthopedic fracture texts for phalanx fracture management
Principles of fracture immobilization and early motion
Indications for fixation in unstable and intra articular fractures
Open fracture antibiotic timing consensus statements
Early first dose approach
Coverage based on wound severity and contamination
Pediatric Seymour fracture literature
Treated as open fracture with nail plate interposition risk
Infection and growth plate complication risk
Evidence grading conventions used
Evidence labels
ACEP Level C used for expert consensus style recommendations when high quality trials absent
Imaging selection in suspected fracture
Post reduction reassessment
Class I expert consensus used for standard of care actions with broad agreement
Antibiotics for open fractures
Malrotation correction and urgent specialty involvement
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.