Hand and Finger Injuries

Guy Monteleone, M.D.

Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
I. Hand Injuries
A. Distal Interphalangeal Joint (DIP) Injuries
1. Mallet Finger deformity- Occurs with a disruption of the extensor tendon that
normally inserts into the proximal portion of distal phalanx. Mechanism = sudden
forceful flexion of the finger.
a. PE- lack of full extension at
DIP. Pain on palpation of dorsum
of the DIP.
b. Xrays- Usually normal, but
may demonstrate avulsion fx.
c. Treatment- Splint X 6-8 weeks
in full extension. Common
splinting materials are alumifoam
splints and Stack splints. If asymptomatic after 6-8 weeks, then splint with
sports/gym/work for another 2-6 weeks. If continued extension lag,
discuss continued observation vs surgery with patient.

2. Jersey finger- Avulsion of the flexor digitorum profundus (FDP). Hx- Occurs
with hyperextension of the DIP, such as a linebacker grasping for a running back's
jersey.
a. PE- lack of active flexion at the DIP. Pain on palpation of volar aspect
of finger. Point of maximal tenderness may indicate site of tendon
retraction.
b. Xrays-normal, or may show avulsion fracture.
c. Treatment- Data demonstrates that early surgery (within one week) to
reattach tendon achieves the best results.

3. Distal phalanx fractures- Tuft and transverse fractures included in this group.
These crush fractures are very stable and easily managed by family physicians.
a. PE- Pain at tip of finger. + subungual hematoma.
b. Xrays- useful to help determine if possible open fracture.
c. Treatment- supportive, splint with basket or alumifoam splint. Allow
mobility of PIP/DIP joints. Aspirate subungual hematoma if not open
fracture.

B. Proximal Interphalangeal Joint Injuries

1. Extensor tendon injury (central slip injury)- this injury left undiagnosed may
lead to a boutonniere deformity. The extensor tendon at the PIP is comprised of
the central slip and the two lateral bands. Hyperflexion injuries may tear the
Hand and Finger Injuries
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
central slip from its insertion onto
the proximal portion of the middle phalanx.
a. PE- Inability to fully extend at the PIP, pain to palpation of the dorsal
PIP. If the patient did not seek medical attention initially, a boutonniere
deformity may occur. With this deformity, the central slip ruptures from
the middle phalanx. The lateral
bands will migrate volarly,
causing flexion at the PIP and
acting as an extender at the DIP.
b. Xrays- normal, or avulsion
fx. May also see deformity as
described above.
c. Treatment- Splint PIP in full
extension for 6-8 weeks, leave
DIP and MCP mobile. May also combine buddy taping with above splint.
If nontender to palpation after 6 weeks, use an flexion block splint or
buddy taping for another few weeks. Note that classic deformity is not
usually present acutely. Have high index of suspicion. Do not assume that
inability to fully extend at the PIP is due to joint edema. Any questions,
use digital block for better exam.

2. Volar plate injuries- the volar plate is the primary restraint to hyperextension. If
the PIP is hyper extended, the volar plate may tear from the volar surface of the
middle phalanx. This will allow hyperextension at the PIP and flexion at the DIP,
causing the classic swan neck deformity.
a. PE- deformity as above. Pain on volar aspect of the PIP. The volar plate
is more vascular than the extensor tendon, therefore there may be more
joint swelling with this injury.
b. Xrays- normal, avulsion fx, or deformity.
c. Treatment- Splint PIP in 30° flexion, keep DIP/MCP mobile. Consider
adding buddy tape to splint. Duration of splint 6-8 weeks. Remove at 6
weeks if asymptomatic. Buddy tape or extension block with activity for a
few weeks thereafter.

3. Collateral ligament sprain- mechanism = varus or valgus stress.

• Grade 1 = pain with stress testing
• Grade 2 opens when stress tested, but good endpoint (partial tear)
• Grade 3 opening with stress testing and poor endpoint (complete tear)
a. PE- pain or instability with varus/valgus stress testing; may have
Hand and Finger Injuries
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
concomitant volar plate
injury.
b. Xrays- normal, avulsion fx, or deformity.
c. Treatment- Grade 1 and 2, splint in 30° flexion X 2-4 weeks. Grade 3
complete tears can also be splinted. Some authors suggest surgery. If
splinting grade 3 tears, consider surgery if recurrent dislocations.

C. Hand/Finger Fractures
1. Metacarpal fractures-
a. Neck Fractures- Classic metacarpal fx is fx of the neck of the fifth
metacarpal = Boxer’s fracture. While the metacarpal neck of the second
thru fifth metacarpals can fracture, the boxer’s fracture is limited to the
fifth digit, resulting in volar angulation of the distal fragment.
i. PE- pain, edema and ecchymosis at MCP. Loss of knuckle
prominence may be seen.
ii. Rx- depends upon amount of angulation. Accept up to 40o volar
angulation of the 4th and 5th digits, up to 10o of volar angulation of
the 2nd and 3rd digits. If more than this angulation referral to
ORTHO required. Should attempt reduction of this angulation.
However, evidence is conflicting on how to splint/cast this
fracture. Splinting with the MCP at 70-90o flexion has not been
definitively shown to reduce pain and improve motion and
function. Therefore, splinting with the MCP in position of neutral
is still reasonable.
D. Thumb Injuries
1. Ulnar collateral ligament sprain (Gamekeeper's thumb)- hyper abduction injury
to the 1st MCP. This injury can
occur when skier falls on a pole,
or when hockey player crashes
the boards with stick in hand.
a. PE- stress test MCP in
flexion. The same
grading system as above
applies. Some authors
suggest pre-stress test
xray to assess if avulsion
fracture off the proximal
phalanx.
b. Xrays- normal,
Hand and Finger Injuries
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
avulsion fx.
c. Treatment- Grade 1 and 2 can be taped to prevent hyper abduction or
splinted in a thumb spica splint for 2-4 weeks. Universal thumb splint also
useful. Grade 3 tears require surgery since high incidence (60%) of
interposition of the adductor aponeurosis between the two torn UCL
fragments (AKA Stener’s lesion). Note: grade 3 injuries involve
avulsion fractures, however, can be adequately treated with a thumb
spica hand cast x 3-6 weeks.

2. Bennett's fracture- intra-articular fracture of the base of the first metacarpal.

a. Mechanism = fall on outstretched hand.
b. PE- pain, edema, crepitus
c. Xray- fracture with classic displacement of shaft fragment proximally
(due to pull of the abductor pollicis longus). The deep ulnar ligament
holds the base fragment stable. A comminuted Bennett's fracture is also
known as a Rolando's fracture.
d. Treatment = referral to ORTHO. Bennett’s fx requires surgical Rx.
Rolando's fx treated with cast immobilization.
Hand and Finger Injuries
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
monteleoneg@wvuh.com
REFERENCES
Gutierrez G. Office management of scaphoid fractures.Phys and SportsMed. 24(8):60-70, 1996.

Jupiter JB. Current concepts review fractures of the distal end of the radius. J Bone Joint Surg. 73A(3):461-9, 1991.

Katz RT. Carpal tunnel syndrome: a practical review. Am Fam Phys. 49(6): 1371-9, 1994.

Lane LB. The scaphoid shift test. J Hand Surg. 18A((2):366-8, 1993.

Leggit JC, Meko CJ. Acute finger injuries 1. Tendons and ligaments. 73(5):810-6, 2006.

Leggit JC, Meko CJ. Acute finger injuries 2. Fractures, dislocations and thumb injuries. 73(5):827-34, 2006.

Markiewitz AD, Andrish JT. Hand and wrist injuries in the preadolescent and adolescent athlete. Clin in Sport Med.
11(1):203-25, 1992.

Mellion MB, Walsh WM, Shelton GL. The team physician's handbook. 2nd edition.Mosby, Phila, PA, 1996.

Morgan RL, Linder MM. Common wrist injuries. AFP. 55(3): 857-68, 1997.

Muller MGS, Poolman RW, Hoogstraten MJ, et al. Immediate mobilization gives good results in boxer’s fractures
with volar angulation up to 70 degrees. Arch Orthop Trauma Surg. 123:534-7, 2003.

Ruby LK. Carpal instability. Instruct Course Lect. 1996.

Schaffer TC. Common hand fractures in family practice. Arch Fam Med. 3:982-87, 1994.

Tavassoli J, Ruland RT, Hogan CJ, et al. Three cast techniques for the treatment of extra-articular metacarpal
fractures. J Bone Joint Surg (Am). 87: 2196-201, 2005.