Finger Fracture Treatment
For a suspected finger fracture in a healthy adult, obtain standard radiographs (anteroposterior, lateral, and oblique views) immediately, and treat most stable fractures conservatively with splinting while initiating active finger motion exercises from the first encounter to prevent finger stiffness—the most functionally disabling complication. 1, 2, 3
Clarification: "Break" vs "Fracture"
These terms are identical in medical practice—both refer to a disruption in bone continuity requiring the same diagnostic and treatment approach. 3
Initial Diagnostic Approach
Mandatory Radiographic Evaluation
- Obtain three standard views: anteroposterior, lateral, and oblique projections of the affected finger 3
- Never rely on only 2 views, as this is inadequate for detecting fractures in the joints of the extremities 1
- Physical examination must assess for rotation deformity (scissoring), which indicates instability requiring surgical referral 4
When Initial X-rays Are Negative But Pain Persists
- If clinical suspicion remains high despite normal radiographs, obtain MRI without IV contrast (sensitivity 94.2%, specificity 97.7% for occult fractures) 1, 2
- CT without IV contrast is an alternative with shorter acquisition times and easier performance in casted patients 1
- Avoid weight-bearing activities with the affected hand until advanced imaging excludes occult fracture 1
Treatment Algorithm Based on Fracture Type
Distal Phalanx Fractures
- Treat conservatively with splinting regardless of displacement 3
- These fractures heal reliably with minimal intervention 3
Middle and Proximal Phalanx Fractures
- Stable fractures with acceptable reduction: Treat with splinting or buddy taping 3, 4
- Unstable fractures or those with rotation: Immediate referral to orthopedic or hand surgery 3
- Intra-articular fractures with >2mm articular step-off require operative fixation to prevent post-traumatic arthritis 2
Metacarpal Fractures
- Most can be reduced by primary care physicians even with significant angulation 3
- Refer to hand surgery if reduction is unstable or rotation is present 3
Critical Management Principle: Prevent Finger Stiffness
Instruct active finger motion exercises at the first encounter, regardless of whether treatment is operative or non-operative—finger stiffness is the most functionally disabling complication and extremely difficult to treat later. 2
- This applies even to immobilized fractures; move the non-immobilized joints immediately 2
- Early protected movement is the cornerstone of achieving full range of motion 4
Indications for Immediate Surgical Referral
Refer to orthopedic or hand surgery for:
- Irreducible dislocations 3
- Fractures with rotational deformity (scissoring) 3, 4
- Unstable fractures that cannot maintain reduction 3
- Open fractures or extensor mechanism injuries 5
- Intra-articular fractures with >2mm displacement 2
- Large-fragment fracture-dislocations with joint incongruity after reduction 5
- Mallet finger fractures that fail splinting (may require tension band fixation) 6
Common Pitfalls to Avoid
- Do not delay finger motion exercises—this is the single most important factor in preventing long-term disability 2
- Do not accept rotational deformity—even minimal rotation causes significant functional impairment and requires surgical correction 3, 4
- Do not obtain inadequate radiographic views—always get three views minimum 1, 3
- Do not ignore worsening pain after initial negative x-rays—this demands MRI to exclude occult fracture or ligamentous injury 1
Special Considerations
Pediatric Patients
- Phalangeal fractures in children differ considerably from other pediatric fractures 7
- Tolerance of displacement is small, and healing is rapid, allowing malunions to develop quickly 7
- Juxtaarticular or intra-articular fractures require precise reduction despite the general remodeling capacity of pediatric bones 7