Middle Finger X-Ray: Recommended Views and Management
For any acute traumatic middle finger injury, obtain a mandatory 3-view radiographic series (posteroanterior, lateral, and oblique) immediately before any treatment intervention, as two-view examinations miss a significant proportion of fractures that will fundamentally alter management. 1, 2
Essential Radiographic Protocol
The American College of Radiology mandates a minimum three-view series because the oblique view detects phalangeal fractures that are occult on standard PA and lateral views alone, with the addition of this third view changing interpretation in approximately 5% of cases. 1, 2, 3
True lateral and true anteroposterior views are non-negotiable—lack of proper positioning is the most frequent reason (71%) for missed or misdiagnosed finger fractures, particularly when fingers are superimposed on lateral films. 4
Obtain these radiographs before suturing any associated wounds or attempting reduction, as they identify fractures, dislocations, and foreign bodies that will completely change your treatment approach. 1
Critical Management Decision Points Based on Radiographic Findings
Immediate Surgical Referral Required When:
Intra-articular step-off or gap ≥ 2 mm (strongest predictor for operative intervention, kappa = 0.73 inter-observer agreement). 1
Bony avulsion fracture involving ≥ 1/3 of the articular surface at any joint. 5
Volar (palmar) subluxation of any phalanx on lateral view—this is an absolute surgical indication even with small fracture fragments. 5
Interfragmentary gap > 3 mm in any fracture pattern. 5
Open injuries with associated fracture. 5
Malrotation or angulation > 10 degrees in middle or proximal phalanx fractures. 6
Conservative (Non-operative) Management Appropriate When:
Stable fractures with articular displacement < 2 mm, minimal angulation, and no joint subluxation. 1
Simple distal phalanx crush fractures: splint the DIP joint for 4–6 weeks. 6
Uncomplicated middle/proximal phalanx fractures with < 10 degrees angulation: buddy-tape to adjacent finger with immediate mobilization. 1, 6
Special Fracture Patterns Requiring Specific Management
Mallet Finger (Dorsal DIP Avulsion)
Obtain immediate 3-view radiographs to differentiate tendinous from bony mallet finger—delaying films leads to unreliable exclusion of fractures requiring surgery. 5
Apply ice-water mixture for 10–20 minutes with thin towel barrier; never attempt manual straightening before splinting. 5
Strict uninterrupted DIP immobilization for 8 weeks—even brief splint removal restarts the entire healing timeline. 5, 6
Begin active PIP and MCP motion exercises immediately while keeping DIP splinted to prevent stiffness. 5
Flexor Digitorum Profundus Avulsion (Volar Base Fracture)
- Caused by forceful extension when DIP is flexed—usually requires surgery; refer immediately. 6
When Initial Radiographs Are Equivocal
If clinical suspicion remains high despite negative radiographs: splint the finger and repeat radiographs in 10–14 days, or obtain non-contrast CT for superior characterization of intra-articular extension. 1, 2
MRI without contrast is an alternative for detecting occult fractures, though CT is preferred for acute bony injury assessment. 2
Common Pitfalls to Avoid
Never accept poor-quality or inadequately positioned radiographs—superimposition of fingers on lateral views leads to misjudgment of displaced fractures, particularly in the fifth finger. 4
Do not rely on two views alone—this misses fractures in a clinically significant proportion of cases and is considered inadequate by the American College of Radiology. 2, 4
Avoid heat application in the acute phase; use ice therapy for effective short-term pain relief. 5
For pain management, topical NSAIDs are preferred over oral NSAIDs for safety reasons, with oral agents reserved for limited duration if needed. 5