You Gave Me the Finger!

Common Finger Fractures and Dislocations - April 15, 2012 - American Family Physician

Spring greetings to all. Of course, spring means more spring sports, and that means hand injuries in our express cares. I linked up to a very informative and succinct hand injury summary. Please read the article, as I promise you will be a better healthcare provider because of it...and that is the highest compliment I can give an article. Here are some quick highlights that I thought really stood out:

1. Be sure to counsel and remind patients with distal phalanx (tuft) fractures that these fractures are routinely complicated by hyperesthesia, pain and numbness for up to SIX months post injury. This counseling will likely prevent patient worry, doubt, and unneeded callbacks.

2. For mallet fractures (forced flexion at the DIP joint producing a bone fragment at the dorsal surface of the proximal part of the distal phalanx..whew, say that 3 times fast), recall that the clinical result is a DIP that cannot be extended. For these, 2 caveats. First, splint in full extension for EIGHT, not 6, weeks. Document and remind patients that the extension/splint MUST never be taken off in this period, because if you remove the splint, you "break the healing"and essentially reset the healing clock back to zero. Second, for these mallet FRACTURES, once you splint in full extension, REPEAT an x-ray with the splint to document and ensure congruity between the fractured piece and the distal phalanx.

3. Conversely, for the jersey fingers (forced extension at the DIP joint producing a bone fragment at the VOLAR surface of the proximal distal phalanx), along with the fracture you have clinically an inability to flex the DIP. Note that these volar surface DIP issues also involve damage to the flexor digitorum profundus tendon. Take home point- unlike the dorsal DIP mallet finger/fractures, it is very important to have these jersey fingers sent to orthopedics/hand specialists, due to tendon retraction risk.

4. Feel free to comment below, but I was always told in my training that in your exam, be sure to ISOLATE, each joint individually, say on the edge of a table, to avoid "tendon and collateral cheating" to ensure each DIP/PIP/MCP is fully evaluated. From the edge of the table, flex and extend each joint individually, with the other joints fully at rest. Don't forget to check active and passive ROM.

5. One last reminder-we are all human and as such we forget things. Hence, when reviewing this or any other hand article, don't be shy or ashamed to open up and have the old Netter/ Grants atlas at your side. Often, these anatomy reviews really help your mind correlate the injury mechanism with the x-rays and the possible complications.

Please email me if you cannot access the article, and I will gladly let you borrow my AAFP password. Review the article though- you will be glad you did!