Non-operative treatment of common finger injuries
Matthew E. Oetgen
Seth D. Dodds
Finger fractures are common injuries with a wide spectrum of presentation. Although a vast majority of these injuries may be treated non-operatively with gentle reduction, appropriate splinting, and careful follow-up, health care providers must recognize injury patterns that require more specialized care. Injuries involving unstable fracture patterns, intra-articular extension, or tendon function tend to have suboptimal outcomes with non-operative treatment. Other injuries including terminal extensor tendon injuries (mallet finger), stable non-articular fractures, and distal phalanx tuft fractures are readily treated by conservative means, and in general do quite well. Appropriate understanding of finger fracture patterns, treatment modalities, and injuries requiring referral is critical for optimal patient outcomes.
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Non-operative treatment
Boxers fracture
Bone and joint injuries of the hand are common. While
often viewed as trivial injuries, a poorly treated finger
fracture can have significant functional consequences.
These injuries may result in chronic pain, stiffness, and
deformity; preventing patients from participating in
General principles of treatment
The goal of treatment for any finger injury is to restore
the normal function of the finger. Restoration of bony
anatomy is the basis for returning normal function;
however, an anatomic reduction is not always necessary
to achieve this goal, especially if it comes at the cost of
soft tissue scarring and loss of motion. To initiate early
hand motion, fracture stability must be present either
through the inherent stability of the fracture, splinting, or
internal fixation. Early motion prevents adhesions of the
gliding soft tissues of the extensor and flexor tendon
systems and prevents contracture of the joint capsules.
Immobilization of fingers much beyond 4 weeks will
lead to long-term stiffness due to extensor tendon and
joint capsular scarring. For example, non-articular
phalangeal fractures treated with closed reduction and
splinting are mobilized after 34 weeks, once the
fractured phalanx is less tender. Even if splinting of one
joint is needed, splints should be made small enough to
allow early motion of uninjured joints.
Closed non-displaced or minimally displaced fractures
with acceptable alignment that are the result of a
lowenergy trauma usually have sufficient supporting tissues
remaining intact making them stable and amenable to
treatment by protected mobilization, either with local
splinting of the fracture or buddy taping to adjacent fingers.
Fractures with rotational or angular malaligment may be
amenable to closed reduction and splinting, but these
fractures are at risk for incomplete reduction and recurrent
deformity. These more unstable fractures require careful
and frequent clinical and radiographic follow-up. Surgical
treatment is indicated for any fractures of the articular
surface, open fractures, fractures with significant
shortening or malrotation, and fractures which fail closed
reduction. Delayed treatment of these surgically indicated
fractures is always more difficult, with worse functional
outcomes due to stiffness, incomplete deformity correction,
and post-traumatic arthritis.
The signs of injury are usually obvious: pain, swelling,
tenderness, ecchymosis, deformity, and/or skin abrasions.
The differential diagnosis for finger injuries includes
fracture, collateral ligament rupture, and tendon laceration
or avulsion. A careful examination of the flexor tendons,
extensor tendons, and neurovascular function must be
documented.
At a minimum, three x-ray views of the injured hand
must be obtained with the imaging beam centered over the
metacarpophalangeal (MCP) joint of the long finger. The
posterioranterior (PA), lateral, and oblique views screen
for trauma. PA and lateral views of the injured digit
centered on the PIP joint should be obtained when a particular
digit is of concern.
Principles of closed treatment
Closed reduction may be performed via axial traction
followed by reversal of the deformity. For digital fractures,
the intrinsic muscles can be relaxed by flexion of the MCP
joints. Once the reduction is performed, the digit is
examined to determine the stability of the reduction.
Rotational alignment is checked by active finger flexion,
observing the planes of the nail beds, and assessing for
digital overlap. The fingers should all point toward the
scaphoid tubercle (Fig. 1). If pain prevents active flexion,
use of tenodesis with gentle wrist extension can result in
digital flexion.
A radial or ulnar gutter type splint with the MCP joints
flexed as close to 90 as possible will hold the digits
aligned while relaxing the intrinsics and preventing
collateral ligament contracture. Although splinting at 90 of
MCP flexion is preferable, as little as 60 of MCP flexion is
likely adequate to place the collateral ligaments on
maximal strain, and may be easier to achieve. In the case of (...truncated)