What is the recommended treatment and management for an adult patient with no significant medical history and a fractured finger?

Treatment and Management of Fractured Finger

For an adult with a fractured finger, initiate immediate buddy splinting for stable, minimally displaced fractures (angulation <10 degrees) and begin active range-of-motion exercises of uninjured joints within 3 days to prevent stiffness, while referring unstable fractures with significant angulation (>10 degrees), displacement, malrotation, or intra-articular involvement to an orthopedic or hand surgeon. 1

Initial Assessment and Imaging

• Obtain three standard radiographic views: anteroposterior, lateral, and oblique projections to characterize the fracture pattern, displacement, and angulation 2, 1
• Assess specifically for rotational malposition (check finger alignment when making a fist), angulation degree, displacement, and intra-articular extension 1, 3
• Provide multimodal analgesia immediately, including acetaminophen while avoiding NSAIDs in elderly patients 4

Fracture-Specific Management

Distal Phalanx Fractures

• Uncomplicated crush injuries: Splint the distal interphalangeal (DIP) joint for 4-6 weeks 1
• Dorsal avulsion fractures (mallet finger): Require strict continuous splint immobilization for 8 weeks without any interruption 1
• Flexor digitorum profundus avulsion fractures: Refer immediately for surgical evaluation as these typically require operative repair 1

Middle and Proximal Phalanx Fractures

• Minimal angulation (<10 degrees): Treat with buddy splinting to adjacent finger 1
• Angulation >10 degrees, any displacement, or malrotation: Refer for reduction or surgical fixation 1, 3
• Multiple fractures per finger: Refer for specialist evaluation as these significantly decrease final range of motion 5

Critical Early Mobilization Protocol

Begin active finger motion exercises of all uninjured joints within 3 days of injury to prevent debilitating stiffness. 6, 5

• Start range-of-motion exercises for joints proximal and distal to the immobilized fracture site immediately 6, 4
• Finger stiffness is one of the most functionally disabling complications and becomes extremely difficult to treat after fracture healing 6
• Associated crush injuries, tendon injuries, or skin loss significantly increase risk of stiffness in both fractured and unfractured fingers 5
• Never immobilize a finger fracture for more than one month 3

Indications for Immediate Orthopedic Referral

• Irreducible dislocations 2
• Unstable fractures that cannot maintain reduction 2, 1
• Any rotational deformity (check by having patient make a fist—all fingers should point toward scaphoid) 1, 3
• Open fractures 3
• Intra-articular fractures with displacement 1
• Volar proximal interphalangeal (PIP) joint dislocations 1
• Volar metacarpophalangeal (MCP) joint dislocations 1

Special Considerations for Elderly Patients

In patients over 50 years, a finger fracture may represent an underlying fragility fracture requiring comprehensive osteoporosis evaluation and treatment. 6, 4

• Order vitamin D, calcium, and parathyroid hormone levels at initial visit 4
• Schedule outpatient DEXA scan and refer to bone health clinic 4
• Consider initiating anti-osteoporotic therapy even before DEXA results in patients with typical fragility fracture patterns 4, 7
• Implement orthogeriatric co-management for frail elderly patients with multiple comorbidities 6, 4
• Implement fall prevention programs including balance training to prevent subsequent fractures 6, 4

Common Pitfalls to Avoid

• Do not ignore uninjured fingers: Instruct aggressive finger motion exercises for all non-immobilized digits from day one, as stiffness can develop in unfractured fingers, especially with associated crush injuries 6, 5
• Do not treat as isolated injury in elderly: Failure to address underlying osteoporosis leaves patients at increased risk of subsequent hip or vertebral fractures 4
• Do not miss rotational deformity: Even minimal rotation causes significant functional impairment and requires surgical correction 1, 3
• Do not over-immobilize: Prolonged immobilization beyond 4 weeks causes permanent stiffness 3

Follow-Up Protocol

• Reassess at 1 week for any loss of reduction or development of complications 1
• Monitor for unremitting pain during follow-up, which warrants reevaluation for complications 6
• Continue buddy taping for 2-3 weeks after splint removal to protect healing structures 1
• In elderly patients, ensure systematic follow-up for osteoporosis treatment adherence 4