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Finger injuries: 5 cases to test your skills.

Just because a finger injury looks benign doesn't necessarily mean emergency treatment is not required. Take our quiz to test your ability to tell the difference.

Some finger injuries require little more than icing; others are more serious, often emergent, conditions with outcomes that are dependent on an accurate diagnosis and rapid initiation of treatment.

The 5 cases that follow describe injuries with varying degrees of severity. Read each case and select the multiple-choice answer you think is most appropriate. Then read on to find out if you were right--and to learn more about the clinical presentation, diagnosis, and treatment for each type of injury.

CASE 1 * A 45-year-old auto body worker walks into your office at 5:30 pm, just as your staff is closing up for the day. A few hours ago, he reports, he was spray-painting a car with a paint gun when he felt a sudden pain in his right index finger. His immediate thought was that he had torn something, but the pain quickly subsided. So he continued to work--until about 45 minutes ago, when the pain became so intense that he knew he needed medical care right away.

Examination reveals redness and increased skin temperature on the radial palmar side of the proximal interphalangeal (PIP) joint of the index finger. Two-point discrimination is decreased to 10 mm, vs 5 mm on the same finger of the opposite hand. The patient can flex his PIP and distal interphalangeal (DIP) joints but complains of pain and stiffness. You obtain x-rays of the injured finger (FIGURE 1).

What's your next step?

A. Send the patient to the nearest emergency department (ED), calling ahead to alert the ED staff that he'll need to be seen right away.

B. Update the patient's tetanus immunization and start him on a broad-spectrum antibiotic.

C. Put a dorsal splint on the injured finger in the "safe hand" position and schedule a return visit in one week.

D. "Buddy tape" the index and long fingers and refer the patient to a hand surgeon.

Answer: Send the auto-body worker to the nearest ED and call ahead (A).

This patient sustained a high-pressure injection injury to the PIP joint of his right index finger. The patient's description of how the injury occurred suggested this, and the radiograph confirmed it by showing some paint under the skin (See arrow, FIGURE 1). Such injuries occur when a high pressure (typically from a hose) forces air or a substance--eg, diesel fuel, paint, or solvent--through the skin into the finger.

Although high-pressure injection injury often has a benign presentation, it is actually a medical emergency. If aggressive surgical debridement does not occur within a 6-hour window, the patient runs a high risk for amputation of the digit. (1) A hand surgeon should be contacted as soon as possible.

The severity of the injury varies, depending on the amount of pressure (amputation rates are as high as 43% when the pressure per square inch [greater than or equal to] 1000), the type of material injected (diesel fuel is the most toxic), and the location. (1,2)

Instruct the patient to remove any jewelry, such as a wedding band or watch, on the affected hand or wrist, and to keep the hand elevated. Broad-spectrum antibiotics should be started right away, and a tetanus booster given, if needed. Do not apply heat or use local anesthesia, as both can increase the swelling. (2)

CASE 2 * A 17-year-old cheerleader comes to see you on Monday afternoon, after injuring her left pinky during a Friday night game. The patient, who is right-handed, points to the left PIP joint when you ask where it hurts, and tells you that the finger is stiff. She has been icing it since the injury occurred, to make sure she is ready to cheer by next weekend.

The injury occurred when she was spotting another cheerleader during a routine, the patient reports, adding that the pinky was "dislocated." The coach "popped" it back in place and buddy-taped the injured finger to her ring finger.

The patient is able to flex and extend the DIP joint on the pinky when the PIP joint is stabilized. She can also flex the PIP joint unassisted, but has difficulty extending it. The digit demonstrates slight flexion of the PIP joint. You note tenderness over both collateral ligaments and the dorsum of the PIP joint, but not over the volar aspect of the injured finger, and order x-rays (FIGURE 2).

What's your next step?

A. Buddy-tape the pinky to the ring finger (again) and tell the patient to keep icing it; clear her to cheer at the upcoming game.

B. Refer the patient to a hand surgeon.

C. Apply an extension block splint so the patient can flex the finger but not extend it, and schedule a follow-up appointment in one to 2 weeks.

D. Apply an aluminum dorsal splint, allowing the DIP joint to be flexed and keeping the PIP joint in full extension for 4 weeks.

Answer: Refer the cheerleader to a hand surgeon (B).

This patient has a rupture of the central extensor tendon of the pinky finger at the PIP joint. The mechanism of injury and her inability to completely extend the injured finger at the PIP joint alert you to this type of injury. An x-ray may sometimes be normal but in this case, it shows the flexion of the PIP joint. Surgical repair of the rupture should be scheduled without delay. (3)

Most injuries at this joint occur from forced extension, not flexion, and result in a volar plate rupture. (4) If swelling and pain make evaluation of an acute dislocation injury difficult, splinting in the "safe hand" position for 72 hours while icing the injured finger will make it possible to do a more detailed follow-up exam. (3)

Extended periods of splinting can make the PIP joint very stiff, however--and harder to treat than the original injury. (5) If the rupture of the central extensor tendon is undetected or simply not treated, a Boutonniere deformity, in which the PIP joint is flexed and the DIP joint is hyperextended, is the likely result?

CASE 3 * A 24-year-old man "jammed" his right ring finger while trying to catch a ball that was passed to him during a pick-up basketball game. He has rested and iced the finger for a couple of days, but it's still painful and hard to move. He has no significant medical history and has been taking only acetaminophen for the pain.

Examination reveals that the injured finger has good capillary refill, 2-point discrimination is intact at 5 mm, and the other fingers on his right hand have no deformities and a normal range of motion. On the injured finger, however, the DIP joint is swollen and tender; it cannot be fully extended (FIGURE 3).

What's your diagnosis?

A. Jersey finger.

B. Distal tuft fracture.

C. Mallet finger.

D. Finger sprain.

E. Trigger finger.

Answer: The basketball player has mallet finger (C).

Mallet finger typically occurs on the dominant hand. The key physical finding is that the joint is "stuck" in flexion, which is evident during an exam and on x-ray. Although the DIP joint may be passively fully extended, the patient with mallet finger is unable to actively extend it.

Mallet injuries, which are common in sports and associated with minor trauma, are typically caused by sudden forced flexion of the DIP joint during active extension of the finger. This can either stretch or tear the extensor tendon or lead to avulsion of the tendon insertion from the dorsum of the distal phalanx, with or without a fragment of bone. The injury is called a "soft" mallet finger when there is no bone involvement and a "bony" mallet finger when an avulsion is present, like the one that is evident on the FIGURE 3 x-ray (see arrow).

On clinical examination, the finger may or may not have an obvious deformity; similarly, you won't always see bruising, swelling, or tenderness over the DIP joint. (6) The work-up should include posterior/anterior, oblique, and lateral x-rays, followed by an examination of the soft tissue and a range-of-motion evaluation of the metacarpophalangeal and PIP joints. In acute injuries, tenderness is elicited with palpation over the dorsal aspect of the DIP joint. Although most patients develop an extensor lag at the DIP joint immediately after injury, the deformity may be delayed by a few hours or even days. (6,7)

Nonsurgical management is the standard of care for most mallet injuries, including mallet fractures involving less than one-third of the articular surface with no associated DIP joint subluxation. (7)

If there is no displacement, round-the-clock splinting to keep the joint in extension for a minimum of 6 weeks is indicated, followed by 2 to 3 weeks of nighttime splinting. It is important that the splinting allow for complete extension of the DIP joint but flexion of the PIP joint. Keeping the PIP in extension for prolonged periods can lead to permanent stiffness of the joint, while failure to provide any immobilization may lead to permanent deformity.

Surgery is indicated for a fracture fragment involving >30% of the joint surface (as demonstrated in the radiograph), volar subluxation, or a swan neck deformity--and when conservative therapy fails. (7)

CASE 4 * An 18-year-old high school football player presents with pain and swelling at the tip of his right ring finger from an injury that occurred a week ago. When the player he was trying to tackle broke away, the patient says, he immediately felt pain and a "pop" in the finger.

The DIP joint of his right ring finger is swollen (FIGURE 4), but appears normal otherwise. When you isolate the joint, however, the patient is unable to flex it. You can palpate a stump on the volar surface of the finger.

What's your next step?

A. Provide a stat referral to a hand surgeon

B. Treat with splinting, RICE (rest, ice, compression, and elevation), and nonsteroidal anti-inflammatory drugs.

C. Order an ultrasound of the finger and palm.

D. Order magnetic resonance imaging (MRI) of the hand.

Answer: Order an ultrasound of the football player's finger and palm (C).

This patient has Jersey finger, caused by a traumatic avulsion of the flexor digitorum profundus (FDP) from the distal phalanx and diagnosed based on the mechanism of injury and the patient's inability to flex the DIP joint. The injury often does not show on x-rays, and the diagnosis may be missed for several weeks.

Jersey finger usually happens in sports like football or rugby, where players tackle each other, and involves forced, passive extension of the DIP joint at a time of active flexion. Management of Jersey finger starts with splinting, with both the DIP and PIP in slight flexion. Surgical reattachment of the flexor tendon is needed, with best results when it is done within 7 to 10 days of injury. (4)

You may be able to palpate the tendon stump in the palm or along the digit; bony avulsions can be trapped at the flexor sheath. Soft tissue swelling can be misleading, however, and the point of maximal tenderness is not an accurate means of identifying the avulsed tendon stump. (8)

Ultrasound is effective in differentiating between a partial and full thickness rupture and in localizing the distal tendon stump. (8) MRI is usually reserved for precise evaluation of the tendon edges, to aid in operative planning. If the tendon is retracted to the palm, scarring may be irreversible because of the lack of blood supply.

Athletes typically return to play 12 weeks after injury, starting with protected activity and progressing to full gripping/grasping. Physical therapy and/or occupational therapy will be needed after the surgical wound has healed.

CASE 5 * A 40-year-old construction worker who smashed his left index finger with a hammer one day ago presents with severe pain in his fingertip, which he is unable to move. On examination, you find that the distal finger is swollen and there is extensive ecchymosis and swelling underneath the nail. The finger has normal sensation, but you are unable to see capillary refill due to a large hematoma.

X-rays (FIGURE 5) reveal a distal tuft fracture. The patient's main concern is the pain, and he asks what you can do to relieve it.

What's your next step?

A. Prescribe an opioid and schedule a follow-up visit in 2 weeks.

B. Perform fenestration of the nail.

C. Refer the patient to a hand surgeon.

D. Order computed tomography of the hand.

Answer: Perform fenestration of the construction worker's nail (B).

This patient has a closed fracture of the : distal phalanx, called a tuft fracture, and a subungual hematoma, evident from the x-ray and the physical presentation.

Subungual hematoma requires fenestration with a needle to create small holes in the nail. If the nail bed is lacerated, the nail is removed and the injured nail bed repaired with sutures.

Tuft fractures sometimes require reduction. More often, they are stable and minimally displaced and can be managed conservatively, with splinting with a padded aluminum splint or a fingertip guard (Stax splint) for 3 to 4 weeks. Antibiotics are not indicated unless there is suspicion of an overlying or secondary infection. Referral to a hand surgeon is required for severe crush injuries, avulsion of the nail matrix, and open fractures of the distal phalanx. (5,6)

ACKNOWLEDGEMENT;

The authors thank Linda Savage for her assistance in the preparation of this manuscript.

References

(1.) Hogan CJ, Ruland RT. High-pressure injection injuries to the upper extremity: a review of the literature. J Orthop Trauma. 2006;20:503-511.

(2.) Gonzalez R, Kasdan ML. High pressure injection injuries of the hand. Clin Occup Environ Med. 2006;5:407-411.

(3.) Freiberg A. Management of proximal interphalangeal joint injuries. Can J Plast Surg. 2007; 15:199-203.

(4.) Perron AD, Brady WJ, Keats TE, et al. Orthopedic pitfalls in the emergency department: closed tendon injuries of the hand. Am J Emerg Med. 2001;19:76-80.

(5.) Oetgen ME, Dodds SD. Non-operative treatment of common finger injuries. Curr Rev Musculoskel Med. 2008; 1:97-102.

(6.) Anderson D. Mallet finger. Aust Fam Physician. 2011;40:91-92.

(7.) Smit JM, Beets MR. Treatment options for mallet finger: a review. Plast Reconstr Surg. 2010;126:1624-1629.

(8.) Goodson A, Morgan M. Current management of Jersey finger in rugby players: cases series and literature review. Hand Surg. 2010;15:103-107.

James M. Daniels, MD, MPH; Alexei DeCastro, MD; Ra Nae Stanton, MD Southern Illinois University School of Medicine, Department of Family and Community Medicine, Quincy (Drs. Daniels and Stanton); Medical University of South Carolina, Department of Family Medicine, Charleston (Dr. DeCastro)

jdaniels@siumed.edu

The authors reported no potential conflict of interest relevant to this article.

CORRESPONDENCE

James M. Daniels, MD, MPH, Southern Illinois University School of Medicine, 612 North 11th Street, Quincy, IL 62301; jdaniels@siumed.edu
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Author:Daniels, James M.; DeCastro, Alexei; Stanton, Ra Nae
Publication:Journal of Family Practice
Article Type:Case study
Date:Jun 1, 2013
Words:2482
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