Hand and finger tendon and ligament injuriesMANAGEMENT

FOREARM, WRIST & HAND · 12 SECTIONS

⚲

523 items

☷ Legend

01Approach to the Critical Patient/attcp62

Immediate limb threats

›Limb threats and time-critical triggers

›Digital ischemia

›Pale or cool digit

›Absent or Doppler-only digital signal

›Capillary refill markedly delayed

›Uncontrolled hemorrhage

›Pulsatile bleeding

›Expanding hematoma

›Anticoagulation or bleeding diathesis context

›Open tendon or open joint concern

›Visible tendon

›Deep laceration over MCP, PIP, DIP, or volar sheath zones

›Saline load test consideration for suspected open joint

›Infection risk states

›Human bite or clenched-fist injury

›Animal bite over tendon zones

›Contaminated farm or water exposure

Neurovascular baseline and documentation

›Neurovascular status and documentation

›Perfusion

›Capillary refill

›Color and temperature symmetry

›Doppler digital arteries when uncertain

›Sensory domains

›Median distribution

›Ulnar distribution

›Radial distribution

›Two-point discrimination when feasible

›Motor domains

›FDP function by finger

›FDS function by finger

›Terminal extensor function at DIP

›Central slip function at PIP

›Intrinsic function

›Pre and post immobilization reassessment

›Same elements repeated after splinting

›Same elements repeated after any reduction

Consultation and transfer triggers

›Hand surgery consultation and transfer triggers

›ASSH and ACEP hand trauma consultation and transfer guidance

›Threatened digit perfusion

›Complex tendon injury patterns

›Ring avulsion with vascular compromise

›High risk open injuries needing specialty capability :contentReference[oaicite:0]{index=0}

›Immediate specialist escalation triggers

›Ring avulsion class II or III pattern suspicion

›Jersey finger suspicion with loss of DIP flexion

›Thumb MCP UCL complete tear suspicion with gross laxity or Stener lesion concern

›Deep volar laceration with loss of finger flexion

Pain control and procedural readiness

›Analgesia and procedure readiness

›Non-opioid baseline

›Acetaminophen PO 1000 mg

›Ibuprofen PO 400 to 600 mg

›Opioid escalation when needed

›Morphine IV 0.05 to 0.1 mg/kg

›Hydromorphone IV 0.005 to 0.015 mg/kg

›Digital anesthesia options

›Digital nerve block

›Lidocaine 1% without epinephrine 3 to 5 mL per digit

›Bupivacaine 0.25% 3 to 5 mL per digit

›Sedation pathway when required

›Airway equipment at bedside

›Continuous pulse oximetry and capnography when available

›Resuscitation-ready staffing

02History/hx47

Mechanism and timing

›Injury context and timing

›Time since injury

›Immediate swelling onset

›Delayed swelling onset

›Mechanism pattern mapping

›Volar laceration with sharp object

›Dorsal laceration with sharp object

›Forced DIP flexion during active extension

›Forced PIP flexion during active extension

›Forced thumb abduction at MCP

›Forced finger hyperextension at PIP

›Ring caught and traction event

›Dominance and baseline function

›Hand dominance

›Occupational and sport demands

›Prior hand issues

›Prior tendon repair

›Prior fracture or arthritis at involved joint

›Prior dislocation or instability

Symptoms suggesting specific structures

›Symptom structure clues

›Flexor tendon injury clues

›Loss of active flexion at DIP

›Loss of active flexion at PIP

›Pain with attempted flexion

›Extensor tendon injury clues

›Loss of active DIP extension

›Loss of active PIP extension

›Extensor lag progression over hours to days

›Ligament injury clues

›Joint instability sensation

›Pop at time of injury

›Focal collateral pain with stress

›Neurovascular symptoms

›Numbness in a digital nerve distribution

›Coldness or color change

›Severe pain out of proportion

Risk modifiers

›Comorbidities and contamination risks

›Diabetes mellitus

›Peripheral vascular disease

›Immunosuppression

›Tobacco use

›Anticoagulants

›Bite exposure

›Freshwater exposure

›Saltwater exposure

›Farm contamination

›Tetanus immunization status

03Physical Exam/exam62

Inspection and resting posture

›Visual pattern recognition

›Cascade and posture

›Normal finger cascade

›Abnormal cascade suggesting tendon discontinuity

›Skin and wound features

›Laceration location relative to joints and creases

›Visible tendon ends

›Contamination or devitalized tissue

›Deformity patterns

›DIP flexion droop consistent with mallet pattern

›PIP flexion with DIP hyperextension consistent with boutonniere pattern

›PIP hyperextension with DIP flexion consistent with swan neck tendency

›Swelling and bruising distribution

›MCP swelling

›PIP swelling

›DIP swelling

›Thenar swelling

Tendon function testing

›Tendon integrity by joint isolation

›FDP

›Isolated DIP flexion against resistance

›Painful weak flexion vs absent flexion

›FDS

›Isolated PIP flexion with adjacent digits held extended

›Painful weak flexion vs absent flexion

›Terminal extensor

›Active DIP extension from flexed position

›Extensor lag measurement

›Central slip

›PIP extension strength

›Elson test for central slip disruption

›Sagittal band

›Extensor tendon subluxation at MCP with flexion

›Snapping or ulnar drift of extensor tendon

Ligament and joint stability

›Collateral and volar plate evaluation

›PIP collateral ligaments

›Varus and valgus stress at 30 degrees flexion

›Firm endpoint vs no endpoint

›PIP volar plate

›Hyperextension laxity

›Tenderness at volar base of middle phalanx

›Thumb MCP collateral ligaments

›UCL stress in flexion and extension

›RCL stress in flexion and extension

›Comparison to contralateral thumb

›Stener lesion suspicion features

›Palpable mass at ulnar MCP

›Marked valgus laxity without endpoint

Neurovascular exam

›Digital neurovascular domains

›Perfusion

›Capillary refill

›Pulse oximetry waveform on involved digit when available

›Sensation

›Radial and ulnar digital nerve territories

›Two-point discrimination distance

›Motor

›Intrinsics

›Thenar motor

›Finger abduction and adduction

›Ring avulsion severity screen

›Circumferential soft tissue injury

›Venous congestion

›Absent capillary refill

04Differential Diagnosis/ddx28

Tendon injuries

›Tendon injury patterns and mimics

›Flexor tendon disruption

›FDP avulsion at distal phalanx

›Zone I to V flexor laceration

›Extensor tendon disruption

›Terminal extensor disruption at DIP

›Central slip disruption at PIP

›Sagittal band rupture at MCP

›Tendon injury mimics

›Pain-limited motion without rupture

›Locked trigger finger

›Intra-articular fracture causing block

Ligament and volar plate injuries

›Ligament injury patterns and mimics

›Thumb MCP UCL tear

›Stener lesion

›PIP collateral ligament tear

›PIP volar plate injury

›DIP collateral injury

›Joint injury mimics

›Occult avulsion fracture

›Intra-articular fracture subluxation

Vascular and soft tissue threats

›Limb threatening differentials

›Ring avulsion injury

›Urbaniak class II vascular compromise

›Urbaniak class III degloving or amputation

›Compartment syndrome of hand

›Digital artery laceration

›Flexor tenosynovitis after penetrating injury

05Laboratory Tests/lt19

When labs change management

›Lab strategy and indications

›Minimal labs for isolated closed injuries

›No routine labs for stable isolated mallet pattern

›No routine labs for isolated collateral sprain

›Bleeding or operative pathway

›CBC for significant bleeding or large hematoma

›INR and PT for warfarin or liver disease

›Anti-Xa or drug specific levels per local protocol for DOAC context

›Infection concern

›CBC for systemic illness concern

›CRP for deep infection concern

›Rhabdomyolysis risk

›CK for crush or prolonged ischemia

›Creatinine for renal risk with elevated CK

Interpretation pearls and pitfalls

›Lab interpretation limits

›Normal inflammatory markers do not exclude early deep hand infection

›Normal CBC does not exclude tendon laceration

›Anticoagulant history more predictive than any single lab value

›Compartment syndrome is clinical and not a lab diagnosis

06Diagnostic Tests/dt57

Scoring Systems

›Classification systems that guide urgency

›Jersey finger

›Leddy and Packer classification

›Type I retraction to palm with vascular compromise risk

›Prompt operative management within 7 to 10 days for type I pattern :contentReference[oaicite:1]{index=1}

›Ring avulsion

›Urbaniak classification

›Class I adequate circulation

›Class II inadequate circulation

›Class III complete degloving or amputation :contentReference[oaicite:2]{index=2}

›Mallet injury

›Soft tissue mallet vs bony mallet

›Splint duration differences by injury type :contentReference[oaicite:3]{index=3}

›PIP volar plate injury

›Eaton classification reference

›Keifhaber-Stern stable vs unstable patterns :contentReference[oaicite:4]{index=4}

Radiographs

›X-ray use and views

›Standard views by region

›Finger

›AP

›Lateral

›Oblique

›Thumb

›AP

›Lateral

›Oblique

›Indications

›Suspected avulsion fracture at tendon insertion

›Joint subluxation suspicion

›Open injury near joint

›Unreliable exam due to pain

›Mallet injury imaging

›Bony mallet fragment identification

›Volar subluxation of distal phalanx

›Thumb UCL imaging

›Avulsion fracture at proximal phalanx base

›Stress views caution with pain and potential fracture

›PIP volar plate imaging

›Volar lip avulsion fragment

›Dorsal subluxation features

MRI

›MRI roles and limitations

›Indications

›Suspected UCL complete tear with equivocal exam

›Suspected Stener lesion when ultrasound unavailable or nondiagnostic

›Occult ligament injury with persistent instability

›Limitations

›Time to MRI can delay definitive care

›Clinical instability can be sufficient for surgical referral

›Alternatives

›Point-of-care or formal ultrasound for UCL evaluation when available

›CT roles

›Indications

›Complex intra-articular fracture with tendon or ligament injury

›Surgical planning for comminuted avulsion patterns

›Low yield scenarios

›Isolated mallet pattern without complex fracture

›Isolated collateral sprain

07Disposition/dispo30

Discharge vs urgent referral

›Disposition decision framework

›Safe discharge criteria

›Intact perfusion

›No progressive neuro deficit

›Closed injury or adequately managed superficial wound

›Stable immobilization plan

›Reliable follow-up access

›Same day or next day hand surgery follow-up

›Suspected flexor tendon laceration

›Suspected extensor tendon laceration over zones with functional loss

›Thumb UCL injury with significant laxity

›PIP fracture-subluxation patterns

›Immediate transfer or emergent consultation

›Ring avulsion with vascular compromise

›Pulseless or ischemic digit

›Open joint concern

›Uncontrolled bleeding

›Multiple tendon injuries or complex wounds :contentReference[oaicite:5]{index=5}

Follow-up timing targets

›Follow-up timing guidance

›Mallet finger

›Early follow-up within 1 week for splint fit and skin check

›Continuous splinting full time 6 to 8 weeks depending on injury type :contentReference[oaicite:6]{index=6}

›Thumb UCL

›Shared decision on definitive treatment within 2 weeks for significant laxity :contentReference[oaicite:7]{index=7}

›Jersey finger

›Urgent surgical referral

›Best outcomes with early repair time windows :contentReference[oaicite:8]{index=8}

›PIP volar plate injury

›Early hand therapy follow-up when available

›Reassessment within 1 to 2 weeks for stability and ROM plan :contentReference[oaicite:9]{index=9}

08Treatment/t103

Immediate life-saving interventions

›Immediate threats and stabilization

›Ring and constriction removal

›Early ring removal before swelling progression

›Ring cutter pathway when needed

›Hemorrhage control

›Direct pressure

›Hemostatic dressing when needed

›Tourniquet time tracking when used

›Ischemic digit actions

›Rapid warming and reassessment

›Splint in neutral position

›Immediate hand surgery consultation for persistent ischemia :contentReference[oaicite:10]{index=10}

›Open injury priorities

›Sterile saline irrigation

›Moist sterile dressing

›Early antibiotics when indicated

›Tetanus prophylaxis

Immobilization and Splinting

›Immobilization principles and options

›Positioning principles

›Intrinsic plus position for many hand injuries

›Avoid excessive flexion that risks stiffness

›Mallet finger splinting

›DIP in full extension or slight hyperextension

›Continuous wear requirement

›Full time duration 6 to 8 weeks depending on injury type :contentReference[oaicite:11]{index=11}

›Boutonniere suspected splinting

›PIP extension splint

›DIP free for ROM

›Continuous extension requirement to prevent deformity progression :contentReference[oaicite:12]{index=12}

›PIP volar plate injury splinting

›Extension block splint

›PIP in 20 to 30 degrees flexion for stable patterns :contentReference[oaicite:13]{index=13}

›Thumb UCL splinting

›Thumb spica splint

›MCP immobilization with IP free when feasible

›Jersey finger immobilization

›DIP and PIP comfort position

›Avoid forced extension against absent FDP

›Buddy taping

›Stable collateral sprains after brief immobilization

›Adjacent digit as functional splint

Reduction

›Reduction principles for associated dislocation or subluxation

›Indications

›Joint subluxation on x-ray

›Neurovascular compromise

›Threatened skin

›Contraindications or caution triggers

›Open joint suspicion requiring operative washout pathway

›Irreducible fracture-dislocation requiring specialist

›Analgesia and anesthesia options

›Digital block strategy

›Local anesthetic selection

›Lidocaine 1% without epinephrine

›Bupivacaine 0.25%

›Volume limits

›Typical total 3 to 5 mL per digit

›Complication mitigation

›Avoid intravascular injection

›Aspiration before injection

›Procedural sedation when required

›Monitoring and readiness

›Continuous pulse oximetry

›Capnography when available

›Medication options

›Ketamine IV 0.5 to 1 mg/kg for dissociation when appropriate

›Propofol IV titration per local protocol with airway readiness

›Technique concepts

›Traction and countertraction

›Reversal of deforming force

›Gentle sustained force

›Avoid repeated forceful attempts

›Post-reduction requirements

›Immediate neurovascular reassessment

›Post-reduction x-ray confirmation

›Immobilization in position of stability

›Failed reduction pathway

›Immediate hand surgery escalation for irreducible joint

›Transfer if specialist capability not available :contentReference[oaicite:14]{index=14}

Open fracture medications and timing

›Antibiotics and tetanus logic for open injuries near tendon and joint

›Antibiotic selection

›Clean open hand wound with deep structure exposure

›Cefazolin IV 2 g

›Repeat dosing per operative timing and local protocol

›Penicillin anaphylaxis alternative

›Clindamycin IV 600 to 900 mg

›Bite related deep hand injury coverage

›Ampicillin-sulbactam IV 3 g

›Amoxicillin-clavulanate PO when outpatient appropriate

›Tetanus prophylaxis

›Tdap if immunization incomplete or uncertain

›Tetanus immune globulin for high risk wound with incomplete immunization

›Wound care timing principles

›Early irrigation

›Avoid tight primary closure if contamination or bite

›Early specialist evaluation for deep structure injuries

DVT prophylaxis when relevant

›DVT prophylaxis considerations

›Low relevance for isolated hand and finger immobilization

›Routine prophylaxis typically not indicated

›Exceptions

›Concurrent lower limb immobilization

›Prolonged hospitalization for polytrauma

›Documentation

›Rationale for no prophylaxis in isolated hand injury

09Special Populations/sp28

Pregnancy

›Pregnancy specific considerations

›Imaging strategy

›X-ray with shielding when needed

›MRI without gadolinium when indicated

›Analgesia

›Acetaminophen preferred baseline

›NSAID avoidance in later gestation per obstetric guidance

›Referral thresholds

›Lower threshold for specialist involvement with infection concern

Geriatric

›Older adult considerations

›Skin fragility and splint complications

›Higher pressure injury risk

›More frequent skin checks

›Anticoagulation context

›Hematoma expansion risk

›Prolonged bleeding after laceration

›Stiffness risk

›Early hand therapy engagement when safe

Pediatrics

›Pediatric considerations

›Growth plate and avulsion patterns

›Low threshold for x-ray with joint tenderness

›Occult avulsion at tendon insertions

›Splint tolerance and adherence

›Increased risk of mallet splint nonadherence

›Caregiver education emphasis

›Nonaccidental trauma consideration

›Inconsistent history

›Multiple injuries in different stages of healing

10Background/b41

Epidemiology

›Epidemiology and frequency signals

›Tendon injuries common even with small lacerations

›Tendon injury reported in 54.8% of small lacerations in one series :contentReference[oaicite:15]{index=15}

›Tendon injury reported in 92.5% of deep injuries through small lacerations in one series :contentReference[oaicite:16]{index=16}

›Thumb UCL injuries common in skiing

›Reported rate 2.3 to 4.4 per 1000 skiing days :contentReference[oaicite:17]{index=17}

›Thumb UCL injury burden in athletics

›Reported incidence up to 50 per 100000 in one review :contentReference[oaicite:18]{index=18}

Pathophysiology

›Structure failure patterns

›Mallet mechanism

›Terminal extensor disruption at distal phalanx insertion

›Bony avulsion variant at dorsal base of distal phalanx

›Central slip disruption

›Loss of PIP extension drive

›Lateral band migration leading to boutonniere deformity risk

›Jersey finger mechanism

›FDP avulsion with forced extension during active flexion

›Tendon retraction patterns guide urgency :contentReference[oaicite:19]{index=19}

›Thumb UCL mechanism

›Valgus stress at MCP

›Stener lesion as interposition preventing healing :contentReference[oaicite:20]{index=20}

›PIP volar plate injury mechanism

›Hyperextension injury

›Volar lip avulsion with dorsal subluxation risk :contentReference[oaicite:21]{index=21}

›Ring avulsion mechanism

›Traction degloving with vascular injury risk

›Classification by circulation guides salvage options :contentReference[oaicite:22]{index=22}

Therapeutic Considerations

›Treatment rationale and key time windows

›Mallet splint principle

›Continuous extension to allow tendon healing

›Full time splinting 6 to 8 weeks depending on injury type :contentReference[oaicite:23]{index=23}

›Thumb UCL management

›Nonoperative care for stable partial tears

›Definitive decision within 2 weeks when significant laxity present :contentReference[oaicite:24]{index=24}

›Jersey finger outcomes

›Early repair associated with better outcomes

›Prompt operative treatment windows for certain types :contentReference[oaicite:25]{index=25}

›PIP volar plate stability thresholds

›Injuries involving more than 40% to 50% articular surface with instability favor surgery :contentReference[oaicite:26]{index=26}

›Ring avulsion urgency

›Vascular compromise requires urgent microsurgical capability :contentReference[oaicite:27]{index=27}

11Patient Discharge Instructions/pdi25

copy discharge instructions

›Discharge instructions set

›Splint care

›Keep splint clean and dry

›Do not remove mallet splint if prescribed continuous wear

›Swelling control

›Elevation above heart as much as possible for 48 to 72 hours

›Ice 10 to 15 minutes at a time with skin protection

›Activity limits

›No gripping or lifting with injured digit until cleared

›Buddy tape only if specifically instructed

›Pain plan

›Acetaminophen as first line

›NSAID use if safe for patient and no contraindications

›Return to ED now for any of the following

›Increasing pain not controlled with medication

›New numbness or tingling

›Pale, blue, or cold finger

›Increasing swelling with tight splint sensation

›Bleeding that does not stop with pressure

›Fever or spreading redness

›Drainage or foul odor from wound

›Follow-up plan reminders

›Mallet finger splint must stay on continuously for prescribed duration :contentReference[oaicite:28]{index=28}

›Thumb UCL injuries with instability need timely specialist review :contentReference[oaicite:29]{index=29}

›Jersey finger requires urgent surgical evaluation :contentReference[oaicite:30]{index=30}

12References/r21

Clinical guidelines and evidence sources

›Key references for bedside use

›ASSH and ACEP hand surgery consultation and transfer guidelines :contentReference[oaicite:31]{index=31}

›AAOS OrthoInfo mallet finger splinting duration guidance :contentReference[oaicite:32]{index=32}

›BSSH trauma standards for mallet injuries :contentReference[oaicite:33]{index=33}

›BSSH BEST guideline for acute thumb UCL injuries :contentReference[oaicite:34]{index=34}

›Consensus statement summary on acute thumb UCL management timing :contentReference[oaicite:35]{index=35}

›NCBI Bookshelf StatPearls jersey finger overview :contentReference[oaicite:36]{index=36}

›NCBI Bookshelf StatPearls extensor tendon lacerations overview :contentReference[oaicite:37]{index=37}

›Volar plate avulsion injury review with extension block splint guidance :contentReference[oaicite:38]{index=38}

›Epidemiology series on incidence of acute traumatic tendon injuries in the hand :contentReference[oaicite:39]{index=39}

Coding and terminology

›Coding alignment examples

›ICD-10-CM S66.0 injury of flexor muscle fascia and tendon at wrist and hand level

›ICD-10-CM S66.3 injury of extensor muscle fascia and tendon of finger at wrist and hand level

›ICD-10-CM S63.4 sprain of metacarpophalangeal joint and ligament of finger

›ICD-10-CM S63.64 sprain of metacarpophalangeal joint of thumb

›SNOMED CT concepts

›Flexor tendon laceration of finger

›Extensor tendon rupture of finger

›Ulnar collateral ligament sprain of thumb MCP joint

›Volar plate injury of PIP joint

›Ring avulsion injury of finger

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.