01Approach to the Critical Patient/attcp41

Immediate priorities

›Limb threat screen

›Open fracture concern

›Visible bone

›Wound near fracture site

›Neurovascular compromise

›Capillary refill delay

›Cool or pale digit

›Compartment syndrome in hand

›Pain out of proportion

›Pain with passive finger extension

›Ring and constriction removal

›Ring removal before swelling peaks

›Cut ring if nonremovable

›Stabilization and analgesia

›Splint in position of function

›Intrinsic plus position for most phalangeal fractures

›DIP extension if mallet injury pattern

›Early pain control

›Acetaminophen and NSAID unless contraindicated

›Opioid only if severe pain and brief course

›Infection pathway if open

›Antibiotics as early as feasible

›Tetanus status and prophylaxis logic

Key decision points

›Reduction urgency

›If neurovascular deficit then immediate reduction attempt

›If threatened skin then immediate reduction attempt

02History/hx25

Mechanism and timing

›Injury context

›Axial load

›Crush injury

›Sports ball impact

›Torsion

›Finger caught on object

›Rotational force during fall

›Hyperextension or hyperflexion at DIP

›Mallet injury pattern

›Volar plate injury pattern

›Time course

›Time since injury

›Any attempted reduction or splinting prior to arrival

Function and risks

›Baseline hand function

›Hand dominance

›Occupation and sport demands

›Red flags

›Numbness or tingling

›Increasing tightness or escalating pain

›Bleeding and healing risks

›Anticoagulant or antiplatelet use

›Diabetes or immunosuppression

›Prior hand pathology

›Prior fracture or surgery

›Prior tendon injury

03Physical Exam/exam31

Inspection and alignment

›Global assessment

›Swelling and ecchymosis

›Skin integrity and wounds

›Deformity pattern

›Malalignment at MCP PIP DIP

›Rotational deformity with finger flexion cascade

›Nail and fingertip

›Subungual hematoma

›Nail plate disruption

Neurovascular and tendon function

›Neurovascular status

›Capillary refill

›Digital artery Doppler signal if equivocal perfusion

›Sensory domains

›Radial digital nerve distribution

›Ulnar digital nerve distribution

›Tendon checks

›FDP function

›DIP flexion against resistance with PIP stabilized

›Pain or weakness suggesting tendon injury

›FDS function

›PIP flexion with adjacent fingers held in extension

›Pain or weakness suggesting tendon injury

›Extensor mechanism

›DIP extension lag suggesting mallet

›PIP extension lag suggesting central slip injury

04Differential Diagnosis/ddx25

Mimics and co-injuries

›Nonfracture injuries

›Tendon rupture

›Mallet tendon without fracture

›Jersey finger FDP avulsion

›Ligament injury

›Volar plate injury

›Collateral ligament injury at PIP

›Dislocation patterns

›PIP dislocation with collateral ligament disruption

›DIP dislocation with mallet or volar plate injury

›Nail complex injury

›Nail bed laceration

›Seymour fracture pattern in children

High-risk conditions

›Infection and soft tissue

›Fight bite with occult joint penetration

›Flexor tenosynovitis

›Vascular compromise

›Digital artery injury

›Ring constriction syndrome

Coding aligned terms

›ICD-10 fracture family

›S62.6 fracture of finger phalanx

›S62.5 fracture of thumb phalanx

›SNOMED CT aligned terms

›Fracture of phalanx of finger

›Open fracture of phalanx of finger

05Laboratory Tests/lt12

Minimal labs for isolated closed fractures

›Low utility labs

›No routine labs for uncomplicated closed injury

›Pain control decisions not lab-dependent

Labs when escalation pathways present

›Open fracture or major soft tissue injury

›Complete blood count for infection or bleeding concern

›Basic metabolic panel for perioperative planning

›Procedural sedation pathway

›Glucose if altered mental status or diabetes

›Pregnancy test if applicable and results change management

›Crush injury or prolonged ischemia

›Creatine kinase for rhabdomyolysis concern

›Creatinine and potassium for renal and electrolyte risk

06Diagnostic Tests/dt37

Scoring Systems

›Classification and pattern language

›Anatomic level

›Distal phalanx

›Middle phalanx

›Proximal phalanx

›Location within bone

›Base intra-articular

›Shaft

›Neck

›Soft tissue modifiers

›Open fracture Gustilo-Anderson framework for antibiotic urgency

›Nail bed injury modifier for tuft and Seymour patterns

Radiographs

›Standard imaging set

›Finger series

›AP view

›Lateral view

›Oblique view if pattern unclear

›Intra-articular extension suspicion

›Subtle spiral or oblique fracture

›Technique pearls

›True lateral of injured digit

›Include adjacent joint for base fractures

›Post-reduction imaging

›Required after manipulation

›Compare alignment and joint congruity

07Disposition/dispo13

ED discharge criteria

›Stable closed fracture

›Intact neurovascular exam after splint

›Pain controlled on oral regimen

›Clear follow-up plan

›Hand clinic or orthopedics within 5 to 10 days for most fractures

›Earlier within 24 to 72 hours if unstable pattern concern

Admission or transfer criteria

›Immediate specialist care

›Open fracture

›Neurovascular compromise not resolved

›Compartment syndrome concern

›High-risk wound patterns

›Fight bite over MCP

›Deep contamination or devitalized tissue

08Treatment/t58

Immediate life-saving interventions

›Threatened digit perfusion

›If pulseless or poorly perfused digit then immediate reduction and splint

›If persistent ischemia then emergent hand surgery consultation

›Open fracture immediate pathway

›Sterile saline moistened dressing

›Antibiotics early

›Tetanus prophylaxis per status

›Constriction relief

›Ring removal

›Loosen tight dressings and splints if pain escalating

Immobilization and Splinting

›Splint selection

›Distal phalanx tuft fracture

›DIP extension splint

›Protect fingertip from further trauma

›Middle or proximal phalanx stable fracture

›Buddy taping plus dorsal or volar finger splint

›Intrinsic plus support if proximal phalanx

›Unstable or post-reduction fracture

›Ulnar gutter if ring or small finger involvement

›Radial gutter if index or middle finger involvement

›Immobilization principles

›Avoid circumferential casting in acute swelling

›Neurovascular reassessment after splint

›Early motion plan

›If stable then protected range of motion as early as advised by hand specialist

›Stiffness risk with prolonged immobilization

09Special Populations/sp20

Pregnancy

›Imaging and shielding

›Radiographs acceptable when clinically indicated with shielding

›Avoid unnecessary CT

›Analgesia considerations

›Acetaminophen preferred baseline

›NSAID avoidance in later pregnancy per obstetric guidance

Geriatric

›Higher complication risk

›Stiffness and functional decline risk

›Lower threshold for therapy referral

›Bone health context

›Osteoporosis risk counseling and primary care follow-up

›Fall risk mitigation advice

Pediatrics

›Growth plate considerations

›Salter-Harris framework for physeal injury suspicion

›Seymour fracture suspicion with nail bed injury and distal phalanx physeal fracture

›Nonaccidental trauma context

›Injury history inconsistent with development or mechanism

›Multiple injuries or delayed presentation

›Follow-up urgency

›Early hand or ortho follow-up for physeal and Seymour patterns

10Background/b42

Epidemiology

›Population patterns

›Distal and proximal phalanges each approximately 39 percent of traumatic phalangeal fractures in one epidemiology study

›Male predominance around 65 percent in epidemiologic series

›Digit distribution patterns

›Small finger highest incidence around 26 percent in one series

›Ring finger next highest incidence around 24 percent in one series

›Mechanism distribution

›Blunt trauma common mechanism around 46 percent in one series

›Work-related mechanism around 18 percent in one series

Pathophysiology

›Force vectors to patterns

›Axial crush

›Tuft fracture

›Comminution risk

›Torsion

›Spiral fracture

›Rotation deformity risk

›Avulsion at tendon insertions

›Dorsal avulsion mallet fracture at distal phalanx base

›Volar plate avulsion at middle phalanx base

›Complication mechanisms

›Malrotation

›Tendon imbalance and scissoring with flexion

›Grip dysfunction

›Stiffness

›PIP joint prone to contracture

›Prolonged immobilization increases risk

11Patient Discharge Instructions/pdi23

copy discharge instructions

›Splint care

›Keep splint clean and dry

›Do not remove mallet splint if instructed continuous wear

›Elevation and swelling

›Hand elevation above heart as much as possible for 48 to 72 hours

›Ice over splint if safe and tolerated

›Pain plan

›Acetaminophen scheduled as needed

›NSAID as needed if no contraindication

›Activity limits

›No heavy gripping or lifting with injured hand

›Buddy taping care if used

›Return to ED immediately

›Increasing pain not controlled

›New numbness or tingling

›Pale cool or blue finger

›Increasing tightness in splint

›Wet damaged or too tight splint

›Fever or wound drainage

›Follow-up

›Hand clinic or orthopedics within 5 to 10 days

›Within 24 to 72 hours if open fracture or unstable pattern

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

12References/r15

Clinical guidelines and standards

›AAOS OrthoInfo finger fractures overview

›Emphasis on precise alignment to preserve hand function

›Referral to orthopedic evaluation when malalignment or dysfunction risk

›BMJ practice article on common adult hand fractures

›Most closed stable hand fractures heal with immobilisation or protected mobilization

›Emphasis on early recognition of injuries needing specialist input

›BSSH trauma standards open fractures

›Antibiotics stop at 72 hours or after definitive closure whichever sooner

›Early specialist care and explicit aftercare instructions

›Phalangeal fracture epidemiology study

›Distal and proximal phalanx incidence proportions

›Sex and mechanism distributions

›Mallet finger review

›Continuous DIP extension splinting 6 weeks then night splinting 2 to 6 weeks

›Complication awareness including skin ulceration and adherence issues

Evidence & Review

Evidence & Review