What is the appropriate management for a bony avulsion injury at the first metacarpophalangeal joint?

From the Guidelines

For a 35-year-old male with a small bony avulsion injury at the first metacarpal phalangeal joint, I strongly recommend immobilization with a wrist brace that specifically stabilizes the right thumb (first finger) and referral to a hand surgeon for further assessment, as indicated by the American College of Radiology's appropriateness criteria for acute hand and wrist trauma 1.

The patient's complaint of pain when moving his right first finger suggests that the injury is causing significant discomfort and potentially affecting the function of the thumb. Given the presence of a bony avulsion injury, it is crucial to immobilize the affected area to allow for proper healing and prevent further complications. A wrist brace that stabilizes the right thumb will help to minimize movement and reduce pain.

According to the American College of Radiology's guidelines, radiographs are sufficient for the evaluation of osseous "mallet" injuries, which include bony avulsion at the insertion of the extensor mechanism of the finger to the distal interphalangeal joint 1. However, in this case, the avulsion injury is located at the first metacarpal phalangeal joint, which may require more specialized evaluation to determine the need for operative fixation.

The patient's initial decline of pain medication and ice may indicate a need for further education on the importance of pain management and swelling reduction in the healing process. Although the patient has declined pain medication, it is essential to inform him that over-the-counter options like acetaminophen or ibuprofen can help manage discomfort if he reconsiders.

Key considerations for the patient's treatment plan include:

• Immobilization with a wrist brace for 4-6 weeks to allow proper healing of the avulsed bone fragment
• Referral to a hand surgeon for further assessment and potential surgical intervention
• Elevation of the hand and application of ice for 15-20 minutes several times daily to reduce swelling
• Pain management with over-the-counter medications if necessary
• Avoidance of activities that cause pain or stress to the thumb joint

By following this treatment plan and seeking specialized evaluation, the patient can optimize his chances of a full recovery and minimize the risk of long-term complications.

From the Research

Treatment of Bony Avulsion Injury

• The patient's bony avulsion injury at the first metacarpal phalangeal joint can be treated with immobilization to reduce pain and facilitate healing, as supported by the use of braces and splints for common musculoskeletal conditions 2.
• A wrist brace immobilizing the right first finger can be prescribed to protect the joint and reduce pain, which is a common practice for treating injuries such as this one.

Consultation with a Hand Surgeon

• A consult with a hand surgeon is requested for further assessment of the patient's condition, which is a suitable course of action given the complexity of the injury and the need for specialized care.
• Occupational therapy interventions, including splinting, have been shown to be effective in treating musculoskeletal disorders of the forearm, wrist, and hand, and may be recommended by the hand surgeon 3, 4.

Patient Care and Management

• The patient's decision to decline pain medications and ice at the time of the injury and at the current appointment should be respected, and alternative methods of pain management can be explored.
• The patient's concern about the standard procedure for treating this type of injury can be addressed through education and explanation of the treatment plan, including the use of a wrist brace and consultation with a hand surgeon.