Management of Suspected Finger Fracture
Obtain a minimum 3-view radiographic examination (posteroanterior, lateral, and oblique views) of the injured finger immediately before any treatment, as this is essential to detect fractures, assess for rotational deformity, and guide management. 1, 2
Initial Imaging Protocol
- A 2-view examination is inadequate and will miss fractures—always obtain three views: PA, lateral, and oblique projections 1
- The oblique view is critical for detecting phalangeal fractures that may be invisible on standard PA and lateral views 1, 2
- You can either obtain a PA view of the entire hand or focus on the injured finger alone—both approaches are acceptable 1, 2
- For crush injuries specifically, radiographs must be obtained before suturing any wound to identify fractures, dislocations, and foreign bodies that fundamentally alter management 2
Clinical Assessment During Examination
- Evaluate the digital cascade for rotational deformity by having the patient make a fist—all fingers should point toward the scaphoid tubercle 3
- Assess for coronal plane malalignment (angulation >10 degrees typically requires reduction or surgery) 4, 3
- Check for functionally significant shortening of the finger 5
- Examine for open fractures, which require surgical management 5
Management Based on Fracture Type
Uncomplicated, Non-Displaced Fractures
- Splint immobilization with early mobilization as soon as the fracture is stable in motion—this is often possible immediately 5
- Never immobilize a broken finger for more than one month to prevent finger stiffness, which is one of the most functionally disabling complications 1, 5
- Buddy splinting is appropriate for middle and proximal phalanx fractures with minimal angulation (<10 degrees) 4
Distal Phalanx Fractures
- Splint the distal interphalangeal joint for 4-6 weeks 4
- These are typically caused by crush injuries and can be managed conservatively 4, 6
Fractures Requiring Referral or Surgery
- Angulation >10 degrees, displacement, or malrotation require reduction or surgical management 4, 3
- Open fractures require surgical intervention 5
- Fractures that remain in malposition despite proper immobilization require surgery 5
- Unstable fractures after attempted closed reduction need surgical management, preferably closed reduction and percutaneous pinning 3
- Intra-articular fractures involving >1/3 of the articular surface require operative fixation to prevent long-term osteoarthritis 1, 2
If Initial Radiographs Are Negative But Clinical Suspicion Remains High
- Place the finger in a short arm cast and repeat radiographs in 10-14 days 1, 2
- Alternatively, obtain MRI without IV contrast to detect occult fractures (sensitivity 94.2%, specificity 97.7%) 7
- CT without IV contrast is another option for detecting occult fractures, particularly useful for complex anatomy 1
Critical Pitfall to Avoid
The most common and preventable complication is finger stiffness from prolonged immobilization. Instruct patients at the first encounter to perform active finger motion exercises regularly through complete range of motion for all non-immobilized digits 1. This cost-effective intervention requires no additional visits but significantly impacts patient outcome and prevents the need for extensive therapy or additional surgical intervention later 1.