Summary
Finger injuries are often caused by blunt or penetrating trauma and include tendon injuries, phalangeal fractures, nail bed injuries, dislocations, and amputations. A thorough assessment of the injured finger and hand is necessary to determine appropriate management. Examination of the injured finger includes visual inspection for cuts and deformities, assessment of capillary refill, evaluation of sensory function, and testing active range of motion (ROM) and strength against resistance. X-rays are used to assess for fractures and/or foreign bodies. Rarely, MRI or ultrasound may be used to assess ligament or tendon injuries.
Tendon injuries can be closed or open. Open injuries are most commonly caused by a laceration and typically require surgical repair; closed injuries are usually caused by forced extension or flexion of the phalangeal joints and often occur while exercising or playing sports. All closed flexor tendon injuries require surgical repair, but most closed extensor tendon injuries can be managed conservatively with splinting. Long-term complications of closed flexor tendon injuries include joint contractures and chronic deformities. Dislocations at the metacarpophalangeal joint can be simple or complex. Simple dislocations can be managed in the outpatient setting with closed reduction and splinting; complex dislocations require specialist intervention. Management of phalangeal fractures is determined by fracture location and characteristics. If initiated promptly, most fractures can be successfully managed with immobilization and early outpatient follow-up. Traumatic amputation of all or part of the finger requires urgent consultation with hand surgery to preserve viable tissue. Crush injuries from blunt trauma are often associated with open fractures and usually require surgical consultation. Management of nail injuries may include repair of nail bed lacerations and drainage of any associated subungual hematomas. Finger swelling, whether traumatic or atraumatic, can lead to ring entrapment and secondary ischemia. Conservative methods of ring removal (e.g., lubrication of the finger) can be attempted if there is no evidence of vascular compromise, but immediate removal with ring cutters is required if there are signs of ischemia.
See also “High-pressure injection injuries” and “Bite wounds.”
Management approach
- Clinically evaluate the injured finger.
- Obtain x-rays.
- For lacerations:
- Clean and irrigate the wound.
- Provide tetanus prophylaxis if indicated.
- Consult hand surgery urgently for:
- Open, unstable, or intraarticular fractures
- Neurovascular compromise
- Tendon injuries
- High-pressure injection injuries
- Amputations
- Perform fracture and/or dislocation reduction if indicated.
- Treat nail bed injuries.
- Immobilize the finger based on the type of injury.
Consult hand surgery urgently for patients with amputations, high-pressure injection injuries, evidence of neurovascular compromise, and/or wounds that are large, grossly contaminated, or involve a crush injury. [1]
Diagnosis
Most soft tissue finger injuries are diagnosed clinically. X-rays are typically used to identify fractures and dislocations, while advanced imaging can help identify occult fractures or support the diagnosis of soft tissue injuries when the diagnosis is uncertain.
Clinical evaluation of finger injuries
- Determine the mechanism of injury on history.
- Compare physical findings with the uninjured hand.
- Identify obvious deformity, e.g., angulation, displacement, amputation, crush injuries.
- Consider testing for subtle rotational deformity.
- Abnormal finger cascade sign: Fingers do not converge symmetrically toward the scaphoid tubercle when flexed at the MCP and PIP joints. [1]
- Misalignment of the nails: Fingernails are not parallel when the fingers are flexed at the MCP and PIP joints. [2]
- Perform a neurovascular examination.
- Palpate radial and ulnar pulses and perform an Allen test.
- Assess capillary refill time and/or pulse oximetry waveform.
- Evaluate for radial nerve injury, median nerve injury, ulnar nerve injury, and posterior interosseous neuropathy.
- Assess digital nerve integrity using two-point discrimination. [2]
- Assess digital tendon integrity.
Identify injuries that require urgent specialist consultation, surgical repair, or closed reduction prior to imaging, e.g., neurovascular injury, open fractures, and tendon lacerations.
Always evaluate the innervation and blood supply of the entire hand and compare injured fingers to those on the contralateral hand.
Digital tendon integrity testing
Routinely evaluate all of the following muscle tendons with active ROM and against resistance in patients with hand and finger injuries. Consider evaluating other muscles (e.g., thenar muscles, hypothenar muscles, lumbricals, interossei) on a case-by-case basis.
-
Fingers
- Flexors (D2–D5)
- Flexor digitorum profundus (FDP): Assess DIP flexion while holding the PIP and MCP joints in full extension.
- Flexor digitorum superficialis (FDS): Assess PIP flexion while holding the uninjured fingers in full extension
- Extensors
- Extensor digitorum communis (D2–D5): Assess MCP extension with the DIP and PIP joints flexed.
- Extensor indicis (D2): Assess index finger extension while holding the other fingers in full flexion.
- Extensor digiti minimi (D5): Assess little finger extension while holding the other fingers in full flexion.
- Flexors (D2–D5)
-
Thumb (D1)
- Flexor pollicis longus (FPL): Assess IP flexion while holding the MCP joint in full extension.
- Extensor pollicis longus (EPL): Assess thumb extension against resistance.
Imaging
- X-rays
- Other imaging: Ultrasound, CT, and/or MRI may be used to assess for radiographically occult fractures and/or soft tissue injuries, e.g., tendon lacerations. [3]
A true lateral view of the affected finger without superposition of the other fingers is necessary to rule out a fracture.
Tendon and ligament injuries
Overview
| Overview of closed tendon and ligament injuries of the digits [1][2] | ||||
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| Description | Etiology | Clinical features | Definitive management | |
| Jersey finger |
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| Mallet finger |
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| Boutonniere deformity |
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| Gamekeeper's thumb (Skier's thumb) |
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Closed tendon injuries
Jersey finger [1][2]
- Affected tendon: flexor digitorum profundus (FDP); most commonly in the ring finger
- Mechanism of injury
- Clinical features
-
Treatment: Operative repair is always required.
- Immobilize the finger with a dorsal splint.
- Refer to hand surgery within 7 days.
Jersey finger is often misdiagnosed as a sprain and therefore undertreated.
Mallet finger [1][2]
- Affected tendon: extensor digitorum
-
Mechanism of injury
- Sudden hyperflexion of the DIP joint (forced flexion) → rupture of the distal portion of the extensor digitorum tendon and/or avulsion of the extensor digitorum from the distal phalanx
- Often caused by a ball hitting the tip of the finger
- May be associated with an avulsion fracture of the distal phalanx
- Clinical features
- Treatment
Boutonniere deformity [1][2]
- Affected tendon: central slip of the extensor digitorum
-
Mechanism of injury: slippage or disruption of the central band of the extensor digitorum
- Trauma: laceration or blunt injury
- Rheumatoid arthritis
- Clinical features: hyperextension of the DIP joint with flexion of the PIP joint
-
Treatment
- Splint the PIP joint in full extension for 4–6 weeks followed by nighttime splinting.
- Refer to hand surgery within 7 days.
- Surgical repair (e.g., repair of the central slip, tenotomy, arthrodesis) is often required for chronic Boutonniere deformity.
Boutonniere deformity commonly manifests 7–14 days after the original injury. [2]
Complications [1][2]
- Tendon adhesions (most common) and joint stiffness
- Flexion contracture of joints
- Tendon rupture
- Stenosing tenosynovitis
- Swan neck deformity
- Chronic mallet finger deformity
Tendon lacerations
Clinical features [1][2]
- Overlying skin injury
- Complete laceration: inability to flex or extend the finger distal to the injury
- Partial tendon laceration: any of the following findings may be present
Signs and symptoms of a partial tendon laceration may be masked by the function of uninjured tendons; maintain a high index of suspicion for a tendon injury in patients with a hand laceration.
Management [1][2]
Initial management
- Follow the general approach to finger injuries.
- Include open wound care.
- Assess digital tendon integrity against resistance to identify lacerations of tendons that share function with uninjured tendons. [2]
- Consult hand surgery urgently.
- Apply a temporary splint.
Reevaluate patients with a suspected tendon injury after 2–3 days if there is no evidence of injury on initial examination. [2][4]
Definitive treatment
- Complete laceration: surgical repair
- Partial laceration: immobilization or surgical repair depending on injury characteristics
Ligament injuries
Gamekeeper's thumb (Skier's thumb) [1][2][5]
- Affected ligament: UCL of the thumb MCP joint
- Mechanism of injury: hyperextension and forced abduction of the thumb → UCL rupture
- Clinical features
- Imaging: X-rays are indicated for all patients to exclude avulsion fracture at the base of the proximal phalanx.
-
Treatment: based on the clinical evaluation of joint laxity
- < 20° joint opening: Immobilize with a thumb spica splint for 4 weeks.
- ≥ 20° joint opening: Immobilize with a thumb spica splint and refer to hand surgery for open repair.
Finger sprain [1][2][6]
Initial evaluation
- Follow the approach to finger injuries.
- Perform a lateral stress test on the affected joint.
Management
-
Partial tear (or sprain)
- Immobilize the joint with a malleable finger splint for 10–14 days followed by buddy taping for 5–7 days.
- Follow the POLICE principle.
- Advise activity modification to reduce further injury.
- Complete tear and/or volar plate rupture: Immobilize the finger and refer to hand surgery.
Dislocations
Metacarpophalangeal dislocations [1][7]
-
Definition: displacement of the proximal phalanx relative to the metacarpal head (dorsal dislocation is most common)
- Simple dislocations: Articular surfaces stay in partial contact.
- Complex dislocations: Metacarpal head ruptures through the volar plate.
- Etiology: hyperextension of the MCP joint, e.g., FOOSH injury
-
Clinical features
- Pain and swelling at the MCP joint
- Hyperextension of the proximal phalanx
- 60–90° in simple dislocations
- 20–30° in complex dislocations
- Dimple in the palm near the MCP joint (complex dislocations)
- Imaging: X-rays of the hand (anteroposterior, lateral, oblique) are required for all patients.
-
Management [1][7]
- Simple dorsal dislocations
- Closed reduction
- Splint in 60° of flexion for 7 days followed by buddy taping.
- Consult hand surgery if the dislocation cannot be reduced or is accompanied by a displaced fracture.
- Complex dislocations: Urgently consult hand surgery.
-
Lateral dislocations (uncommon)
- Hand surgery consult is often required.
- Acute injury with no significant fracture: Splint in 50° of flexion for 3 weeks followed by buddy taping for 2–3 weeks.
- Volar dislocation (rare): Consult hand surgery for open reduction.
- Thumb dislocation (rare): Consult hand surgery.
- Simple dorsal dislocations
Interphalangeal dislocations [1][8]
Upper extremity interphalangeal joints (IP joints) include the DIP and PIP joints of the fingers and the IP joint of the thumb.
Approach
- All patients: Follow the approach to finger injuries.
- Dorsal dislocations (common and often easily reduced): Attempt reduction.
- Volar dislocations (uncommon and often associated with central slip tendon injuries): Consider hand surgery consult before reduction.
Reduction of dorsal IP dislocation
- Preparation: Perform a digital block.
-
Steps
- Flex the wrist.
- Consider hyperextending the finger to reduce the potential for volar plate entrapment.
- Apply longitudinal traction to the finger.
- Apply pressure to the dorsal aspect of the base of the dislocated phalanx.
-
Postreduction
- Perform digital tendon integrity testing and lateral stress test of collateral ligaments.
- Repeat finger x-ray.
- Successfully reduced joint without clinical instability and/or fracture: Apply a finger splint with the IP joint in 30° of flexion for 2–3 weeks.
- All other patients: Consult hand surgery.
Phalangeal fractures
The majority of finger fractures can be managed with immobilization with a splint, but some fractures require urgent surgical intervention.
Clinical features
- Swelling and tenderness
- Possible features include:
- Dorsal or volar angulation
- Malrotation: abnormal finger cascade sign or nail misalignment
- Nail plate injury (in distal phalangeal fractures)
Management [1][2][9]
- All fractures: Follow the approach to finger injuries.
-
Open phalangeal fractures [7]
- Irrigate thoroughly and debride as needed.
- Consult hand surgery.
- Prophylactic antibiotics
- Not required for most open distal phalanx fractures
- Consider in patients with contaminated wounds or risk factors for infection (e.g., immune deficiency). [1]
- Use agents that cover skin flora, e.g., cephalexin . [1]
- See also “Nail bed injury.”
Distal phalangeal fractures
- Tuft fractures: Immobilize with a finger cage splint or molded aluminum splint for 3–4 weeks.
- Nondisplaced fractures: Immobilize with a finger cage splint or molded aluminum splint for 3–4 weeks.
-
Displaced transverse fractures
- Reduce the distal fragment with dorsal traction.
- Immobilize with a volar splint for 3–4 weeks.
- Refer to hand surgery if the fracture is irreducible.
- Longitudinal fractures: Splint from the middle to the distal phalanx for 3–4 weeks.
- Avulsion fractures: Consult hand surgery; see also “Mallet finger” and “Jersey finger.”
Do not attempt reduction of comminuted tuft fractures.
Middle phalangeal fractures
- Nondisplaced transverse fractures: Immobilize with a dynamic splint and/or buddy taping for 2–3 weeks.
-
Displaced transverse fractures (angulated, shortened, or rotational deformity)
- Refer to hand surgery early in the treatment course.
- Consider reduction if hand surgery is not immediately available. [2]
- If reduced, immobilize both the finger and the wrist with an ulnar gutter or radial gutter splint. [1]
- Fractures at the base: Refer to hand surgery early in the treatment course.
Proximal phalangeal fractures
- Nondisplaced transverse fractures
-
Displaced fractures
- Perform closed reduction.
- After reduction, immobilize the finger with a dorsal splint and the wrist with an ulnar gutter or radial gutter splint.
- Refer to hand surgery early in the treatment course if the fracture is irreducible.
-
Unstable or complex fractures
- Immobilize with an ulnar gutter or radial gutter splint.
- Arrange outpatient follow-up within 7 days for surgical management.
In most cases, fingers should be immobilized in the position of function: 50–90° of MCP flexion and 15–20° of IP joint flexion. Immobilization of the entire finger in extension is usually avoided. [2]
In proximal and middle phalanx fractures, if rotational malalignment persists after reduction, refer to hand surgery; rotational malalignment is never acceptable. [2]
Complications
- Nonunion
- Delayed union
- Fingertip numbness
- Hypersensitivity
Crush injuries
-
Definition
- Local tissue injury caused by traumatic compression of the finger
- Injuries may include:
- Phalangeal fractures (including tuft fractures)
- Closed tendon rupture
- Digital artery injury
-
Clinical features
- Injury may be more extensive than is evident on the surface [2]
- Swelling
- Pallor
- Bleeding (often minimal)
- Diagnostics: X-rays are indicated in all patients to assess for fracture.
-
Management [2]
- Place the hand in a soft, bulky dressing that allows wound drainage.
- Elevate the affected arm.
- Refer to hand surgery.
- Provide antibiotic prophylaxis for open fractures.
-
Complications
- Infection
- Ischemia
Crush injuries of the finger often involve tuft fractures.
Amputations
Initial approach
- Follow the approach to finger injuries.
- Examine the injured finger to identify the site of amputation and any exposed bone.
- Perform digital tendon integrity testing and assess the attachment of the extensor and flexor tendons to the distal phalanx.
Remember to provide tetanus prophylaxis if indicated.
Distal amputation [1][2]
- Description: amputation of the fingertip without disruption of insertion of the FDP or extensor digitorum tendons; bony distal phalanx may or may not be exposed
-
Management [1]
- Consult hand surgery for most patients.
- Small tuft avulsions (nail intact, minimal to no bone exposure, soft tissue loss < 1 cm2) may be treated in the ED or outpatient setting.
- Perform irrigation and debridement of nonviable tissue.
- If necessary, trim a small amount of exposed bone with a rongeur.
- Approximate tissue with loose closure if feasible; otherwise, allow the wound to heal by secondary intention.
- Administer prophylactic antibiotics if the wound is contaminated or the patient is immunocompromised (see “Open phalangeal fracture”). [1]
- Inform patients that discomfort may last for 7–10 days and that healing will take 4–6 weeks.
Proximal amputation [2][10]
- Description: amputation proximal to the insertion of FDP and extensor digitorum tendons
-
Management
- Apply direct pressure to the wound for hemorrhage control; avoid tourniquets, as they increase the risk of local thromboembolic events.
-
Protect the amputated digit.
- Cover the digit with gauze moistened with saline.
- Place in a watertight bag.
- Place the bag in an ice bath in a sealed container.
- Obtain x-rays of the remaining finger and the amputated digit.
- Irrigate the wound gently to avoid further tissue damage.
- Begin IV antibiotics, e.g., cefazolin or, if the patient is allergic to penicillin, vancomycin . [1]
- Consult hand surgery immediately.
-
Reimplantation
- The decision of whether to attempt reimplantation depends on multiple factors: the type of injury, patient motivation, need for fine motor skills, and comorbidities.
- Features that support proceeding with reimplantation include:
- Short ischemia time [10]
- Thumb amputation
- Multiple finger amputation
- Any amputation in a child
- Amputation distal to FDS insertion
-
Complications
- Wound infection: stump pain, erythema, fever, and wound drainage
- Edema
- Contractures, leading to deformities and diminished function in the joint adjacent to the stump
- Skin necrosis over the distal edge of the remaining finger
Do not allow the amputated part of the finger to come into direct contact with ice, as this can cause further damage.
Nail injuries
Nail plate and nail bed injuries [11][12]
- Definition: disruption of the continuity of the nail bed; typically caused by traumatic injury
-
Clinical features
- Nail plate injury
- Bleeding and/or subungual hematoma
-
Treatment [2]
- Obtain x-rays to evaluate for fracture if clinically indicated.
- Thoroughly examine the wound.
- Consider a digital nerve block to provide procedural pain management. [1]
- Use a finger tourniquet to create a bloodless field.
- Remove the nail plate if there is significant damage or avulsion.
- Removal of a largely intact, adherent nail plate is often unnecessary if surrounding tissue disruption is minimal.
- Clean, debride, and irrigate the wound; see “Acute wound management.”
- Reduce any fractures if indicated.
- Suture the nail bed with 6-0 or 7-0 absorbable interrupted sutures. [1]
- Suture lacerated nail plates with 4-0 sutures on a sturdy needle.
- Reapply the avulsed nail (if available) to serve as a splint and a biological dressing. [1]
- Secure the nail with tissue adhesive or simple sutures.
- Nonadherent gauze can be used if the nail plate is not available or excessively damaged.
Gauze that has adhered to an injured nail bed or fingertip can be removed by soaking the finger in a solution of 1% lidocaine for 20 minutes. [2]
Nail avulsion [11][12]
- Definition: full or partial absence of the nail plate; typically caused by traumatic injury
-
Clinical features
- Associated nail bed injury
- Possible transverse fracture of the distal phalanx
-
Treatment
- Obtain x-rays to evaluate for fracture.
- Lift or remove nonadherent or significantly damaged nails to inspect the nail bed.
- Clean and irrigate the wound.
- Repair nail bed injuries with sutures or tissue adhesive.
- Replace the complete nail (if available) over the repaired nail bed and secure it in place.
- If the nail is not available, apply a nonadherent dressing or nail substitute over the nail bed.
Subungual hematoma [13]
- Definition: a collection of blood under the nail plate, usually following a crush injury of the distal phalanx or nail bed laceration [1][13]
- Clinical features
-
Treatment [7]
- Obtain x-rays (AP, lateral, oblique) to rule out distal phalanx fracture after a crush injury.
- Decompress hematomas covering > 50% of the nail bed. [1]
- Consider a digital nerve block for procedural pain management.
- Create 2–3 holes in the nail plate with an electrocautery unit or an 18-gauge needle. [2][11]
- Drainage may be difficult > 48 hours after the injury because of clot formation.
- Protect the fingertip with a prefabricated splint for up to 3 days. [13]
Adherent nails do not need to be removed to repair a nail bed laceration or drain a subungual hematoma. [7]
Ring-related injuries
Ring entrapment
- Definition: edema and/or ischemia of a digit caused by the tourniquet effect of a ring that cannot be removed
- Etiology: edema caused by local trauma or systemic conditions, e.g., infection, burns, allergic reaction, generalized edema
-
Clinical features may include: [2]
- Finger swelling
- Skin breakdown near the ring site
- Decreased venous return
- Management: ring removal
Ring removal
Indications
- Patient reports pain or inability to remove the ring
- Dusky or cool finger
- Anticipated swelling (e.g., in systemic inflammatory state, hand injury)
Rings should be removed from injured fingers to prevent entrapment due to swelling or deformity. [2]
Procedural steps [1][14]
-
Prior to removal: Attempt to reduce swelling.
- Soak the finger in ice water for 5–10 minutes.
- Elevate the hand.
- Compress the finger with an elastic bandage or a Penrose drain.
- Manual removal can be attempted if there are no open wounds or signs of ischemia; techniques include:
- Ring cutters should be used immediately if the finger appears ischemic.
Standard ring cutters will cut gold, plastic, platinum, silver, stainless steel, and titanium; vice-grip pliers are required to crack tungsten, natural stone, and ceramic rings.
Postprocedural care [14]
- Provide tetanus prophylaxis if skin integrity is compromised.
- Refer to hand surgery if there is neurological or vascular compromise.
- Instruct the patient not to place rings on the finger until the edema resolves.
Complications
- Soft tissue injury
- Foreign body granuloma from residual metal particles