In an otherwise healthy adult with a closed finger fracture, is the pain primarily inflammatory, and what first‑line treatment is recommended?

Finger Fracture Pain: Inflammatory vs. Nociceptive Components

In closed finger fractures, pain arises from both direct tissue injury (nociceptive) and secondary inflammatory processes, with inflammation becoming the predominant driver within 24-48 hours post-injury; first-line treatment combines immobilization/splinting with NSAIDs (such as naproxen) and ice application.

Pain Mechanism in Finger Fractures

The pain in finger fractures is not purely inflammatory but represents a mixed picture:

• Immediate phase (0-24 hours): Direct mechanical trauma to bone, periosteum, and surrounding soft tissues generates acute nociceptive pain 1
• Subacute phase (24-48 hours onward): Inflammatory mediators (prostaglandins, cytokines) accumulate at the fracture site, with swelling and local inflammatory response becoming the dominant pain generator 1
• Pain also results from concomitant soft tissue injury including ligaments, joint capsule, and periosteum 2, 3

First-Line Pain Management

Immobilization/Splinting

• Splinting is the cornerstone intervention to reduce pain by preventing motion at the fracture site and limiting further soft tissue injury 1, 4
• The American Heart Association recommends splinting in the position found unless straightening is necessary for safe transport 1, 4
• For distal phalanx fractures: splint the distal interphalangeal joint for 4-6 weeks 3
• For middle/proximal phalanx fractures with minimal angulation (<10 degrees): buddy splinting is appropriate 3

Anti-Inflammatory Therapy

• NSAIDs are first-line pharmacologic treatment because they directly address the inflammatory component of fracture pain 1, 5
• Naproxen 375-500 mg twice daily is effective for musculoskeletal pain, with onset of pain relief within 1 hour and duration up to 12 hours 5
• NSAIDs demonstrate superior gastrointestinal tolerability compared to aspirin while providing comparable analgesic efficacy 5

Adjunctive Measures

• Ice application: 20-minute intervals, 3-4 times daily with a barrier between ice and skin to prevent cold injury 1, 4
• Ice and water mixture in a bag surrounded by damp cloth provides greatest tissue cooling 1
• Elevation of the injured hand above heart level to reduce swelling 4

Critical Assessment Points

When to Suspect Complications

• Unremitting pain during follow-up warrants immediate re-evaluation for complications such as compartment syndrome, infection, or fracture displacement 1
• Blue, purple, or pale digits indicate vascular compromise requiring emergency orthopedic consultation 1, 4
• Local signs (redness, swelling, heat) are suggestive but not confirmatory of infection in the acute setting 1

Early Mobilization Strategy

• Active finger motion exercises should begin immediately for uninvolved digits to prevent stiffness 1
• Finger stiffness results from pain, swelling, and immobilization—early motion of uninjured joints is cost-effective and prevents long-term disability 1
• The injured digit remains immobilized per fracture-specific protocols 3

Common Pitfalls to Avoid

• Do not attempt closed reduction in the emergency department unless documented neurovascular compromise exists that cannot wait for orthopedic consultation 4
• Avoid overtight splinting which can compromise circulation or cause compartment syndrome 1, 4
• Do not place ice directly on skin—always use a barrier cloth to prevent cold injury 1
• Do not combine NSAIDs with aspirin as this increases adverse events without improving efficacy 5

Referral Indications

Immediate orthopedic referral is required for:

• Fractures with >10 degrees angulation, displacement, or malrotation 3
• Irreducible dislocations 2, 3
• Open fractures 1, 2
• Flexor digitorum profundus avulsion fractures 3
• Unstable joint injuries 2, 6, 7