What is the next most appropriate step for a patient with a finger injury and negative X-rays for fracture, considering options such as buddy typing, volar splint, or a splint with an urgent referral to an orthopedic surgeon (orthopedic specialist)?

Management of Finger Injury with Negative X-rays

For a finger injury with negative X-rays, buddy taping is the most appropriate initial management for stable injuries without joint malalignment, while suspected tendon or ligament injuries require advanced imaging (MRI or ultrasound) before definitive treatment.

Initial Clinical Assessment

The key decision point is determining whether there is joint malalignment or suspected soft tissue injury despite negative radiographs:

• If joint alignment is normal and no tendon/ligament injury is suspected: Proceed with buddy taping and active motion 1, 2
• If there is joint malalignment without fracture: Advanced imaging (MRI or ultrasound) is indicated 1
• If tendon or ligament injury is suspected clinically: Advanced imaging is required before treatment 1, 3

Buddy Taping Protocol (For Stable Injuries)

Buddy taping is the preferred treatment for stable finger injuries without joint malalignment or soft tissue disruption 1, 4:

• Tape the injured finger to an adjacent uninjured finger using soft padding between digits 4
• Begin active finger motion exercises immediately - this is critical to prevent finger stiffness, which is one of the most functionally disabling complications 1, 2
• Active motion does not adversely affect adequately stabilized injuries and provides significant impact on patient outcome 1, 2
• Continue buddy taping for 3-4 weeks with clinical follow-up 2, 4

When Volar Splinting is Indicated

A volar splint is not the first-line treatment for most finger injuries with negative X-rays. Rigid splinting should be reserved for:

• Suspected volar plate injuries requiring immobilization in slight flexion 4, 5
• Specific fracture patterns that may not be visible on initial radiographs but are clinically suspected 1, 2

Common pitfall: Over-immobilization with rigid splinting when buddy taping would suffice leads to unnecessary finger stiffness 2

When Urgent Orthopedic Referral is Required

Immediate surgical consultation is indicated for 6, 3, 4:

• Suspected flexor digitorum profundus avulsion (jersey finger): Loss of active DIP flexion requires urgent referral, as early presentation (within 10 days) is associated with superior functional outcomes 3
• Nerve lacerations with loss of function: Immediate surgical exploration is recommended for optimal outcomes 6
• Joint dislocations that cannot be easily reduced: These require specialist evaluation 4
• Volar metacarpophalangeal dislocations: These are rare and warrant referral 4

Advanced Imaging Algorithm (When Initial X-rays are Negative)

If clinical suspicion remains high for occult injury 1:

• For suspected tendon or ligament trauma: MRI without IV contrast or ultrasound are equivalent first-line options 1
• For persistent pain or joint malalignment without fracture: MRI or ultrasound to evaluate soft tissue structures 1
• Repeat radiographs in 10-14 days are an alternative if occult fracture is suspected but soft tissue injury is less likely 1

Critical Action Items

Regardless of treatment chosen 1, 2:

• Instruct the patient to perform active finger motion exercises for all unaffected joints immediately - finger stiffness can be very difficult to treat after healing and may require multiple therapy visits or surgical intervention 1, 2
• Educate patients that finger motion through complete range of motion helps minimize risk of stiffness complications 1
• Schedule follow-up at 3 weeks to assess healing and function 2