Approach to the Critical Patient

Alarm features requiring immediate action

Vascular compromise indicators

Open injury indicators

Irreducible dislocation

Stabilization priorities

Initial stabilization steps

Key decision points

Mobile versus fixed deformity determination

History

Mechanism and onset

Injury mechanism

Timing and progression

Symptoms

Pain characterization

Neurological symptoms

Risk factors and context

Occupational and sport context

Predisposing conditions

Pertinent negatives

Features distinguishing traumatic from rheumatoid etiology

Physical Exam

Inspection and deformity assessment

Classic deformity pattern

Soft tissue findings

Palpation

Tenderness localization

Range of motion and special tests

Active range of motion

Elson test (central slip integrity)

Intrinsic-plus (Bunnell) test

Retinacular ligament test (Haines-Zancolli)

Volar plate stress test

Malrotation assessment

Rotational alignment

Differential Diagnosis

Primary traumatic diagnoses

Mallet finger (Zone I extensor injury)

PIP joint dorsal dislocation

Volar plate injury without established deformity

Deformity mimics

Boutonniere deformity

Pseudo-boutonniere deformity

PIP joint fracture-dislocation

Rheumatoid swan neck deformity

Collateral ligament injury

Laboratory Tests

Routine labs (rarely indicated for isolated injury)

Complete blood count

Inflammatory markers

Erythrocyte sedimentation rate and C-reactive protein

Rheumatoid factor and anti-CCP antibodies

Uric acid

Pre-operative labs

Basic metabolic panel

Diagnostic Tests

Scoring Systems

Nalebuff classification of swan neck deformity (staging)

PIP joint stability grading

Strickland scoring for tendon function

MRI

Indications for MRI of the finger

MRI findings in swan neck deformity

MRI protocol considerations

CT

Indications for CT of the finger

CT findings relevant to swan neck deformity

CT protocol

Ultrasound

Point-of-care ultrasound indications

Ultrasound findings in swan neck deformity

Ultrasound technique

Disposition

Discharge criteria

Criteria for ED discharge

Admission and observation indications

Indications for inpatient or observation admission

Hand surgery referral thresholds

Emergent referral (same-day operative)

Urgent referral (within 24-48 hours)

Elective referral (within 1-2 weeks)

Follow-up planning

Follow-up timeline

Treatment

Analgesia

Systemic analgesia

Regional anesthesia

Wound care and tetanus prophylaxis

Open wound management

Reduction technique

Closed reduction of PIP dorsal dislocation

Splinting protocols

Mallet finger splinting (DIP component)

Volar plate injury splinting

PIP hyperextension blocking splint

Surgical management

Indications for operative intervention

Surgical options by severity

Post-reduction and post-operative medications

Antibiotic prophylaxis

Corticosteroid injection contraindication

Special Populations

Pregnancy

Physiologic considerations

Medication safety in pregnancy

Imaging considerations in pregnancy

Surgical timing in pregnancy

Geriatric

Age-related physiologic considerations

Comorbidity considerations

Medication adjustments

Pediatrics

Age-specific injury patterns

Growth plate considerations

Pediatric medication dosing

Pediatric splinting

Background

Epidemiology

Prevalence and incidence

Functional impact

Pathophysiology

Extensor mechanism anatomy

Traumatic causation pathways

Deformity progression

Therapeutic Considerations

Conservative versus surgical decision framework

Surgical outcome evidence

Rehabilitation principles

Evidence base limitations

Patient Discharge Instructions

copy discharge instructions

Diagnosis explanation

Splint instructions

Activity restrictions

Wound care (if open injury)

Medications

Follow-up appointment

Return to the emergency department immediately if

References

Guidelines and key sources

McKeon KE, Lee DH

Elzinga K, Chung KC

Childress MA, Olivas J, Crutchfield A

Dinh V, Market M, Cheung K

Chalmer J, Blakeway M, Adams Z, Milan SJ

Surgical outcome references

Charruau B, Laulan J, Saint-Cast Y

Wei DH, Terrono AL

Clavero JA, Golano P, Farinas O et al

Soni P, Stern CA, Foreman KB, Rockwell WB

Hanson ZC, Thompson RG, Andrews JR, Lourie GM