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Approach to the Critical Patient
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
Hand surgery consultation triggers
Open fracture
Rotational deformity
Intra-articular fracture with step or instability
Irreducible or unstable fracture after reduction
Tendon or nail bed injury concern
Imaging escalation
If X-ray negative and focal bony tenderness then treat as occult and arrange follow-up imaging
If complex intra-articular pattern then CT for surgical planning
PITFALLS
Common misses
Rotation only visible with finger flexion cascade
Mallet fracture with volar subluxation of distal phalanx
Harmful interventions
Circumferential casting during swelling phase
Prolonged immobilization without early motion plan
History
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
Physical Exam
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
Compartment and adjacent joints
Hand compartment concern
Thenar or hypothenar firmness
Pain with passive stretch
Joint above and below
MCP stability and tenderness
Wrist and metacarpal tenderness if high-energy mechanism
Differential Diagnosis
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
Laboratory Tests
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
Diagnostic Tests
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
MRI
Indications
Occult fracture with negative radiographs and persistent focal pain
Suspected tendon or pulley injury when exam equivocal
Utility limitations
Limited role in routine acute phalanx fractures
Time and access constraints in ED
CT
Indications
Complex intra-articular base fracture
Surgical planning need
Utility
Articular step visualization
Fragment geometry for fixation strategy
Disposition
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
Treatment
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
Reduction
Indications
Rotational deformity
Marked angulation or displacement
Analgesia and anesthesia options
Digital nerve block
Lidocaine 1 percent without epinephrine typical option
Bupivacaine 0.25 percent for longer duration option
Procedural sedation when required
Monitoring and airway readiness
Post-sedation neurovascular reassessment
Technique principles
Longitudinal traction and countertraction
Reverse mechanism when clear
Avoid repeated forceful attempts
Post-reduction requirements
Immediate neurovascular re-check
Post-reduction radiographs
Immobilization in position of stability
Failed reduction pathway
If persistent rotation then urgent hand surgery consultation
If worsening pain and tightness then compartment syndrome evaluation and escalation
Open fracture medications and timing
Antibiotics framework
First-generation cephalosporin typical for low-grade open fracture
Add gram negative coverage for severe contamination or high-grade injury
Tetanus prophylaxis framework
If unknown or incomplete immunization then vaccine plus immune globulin per standard guidance
If immunization up to date then booster based on wound risk and time since last dose
Duration principles
Stop within 72 hours or after definitive closure whichever is sooner per hand trauma standards
DVT prophylaxis when relevant
Upper extremity isolated injuries
Routine pharmacologic prophylaxis usually not indicated
Individual risk assessment if prolonged immobilization and additional risk factors
Special Populations
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
Background
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
Therapeutic Considerations
Nonoperative success conditions
Stable alignment
No rotation
Operative indications concepts
Unstable fracture pattern
Intra-articular incongruity with instability
Mallet injury evidence concepts
Continuous DIP extension splinting commonly 6 weeks then night splinting 2 to 6 weeks
Surgery for volar subluxation of distal phalanx or large articular fragment with instability
Guideline style evidence tags
Splinting first-line for stable closed phalangeal fractures
Expert consensus Class I
Early antibiotics for open fractures
Expert consensus Class I
Procedural sedation safety standards for ED reductions
ACEP Level B for monitoring and preparedness frameworks
Patient Discharge Instructions
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
References
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
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