Finger fractures
Illustration of an oblique fracture to the middle phalange of the index finger

Definition

Fractures of the finger occur in the bones called phalanges.

Anatomy of the hand demonstrating the phalanges of the fingers and thumb in relation to the metacarpal bones

Pathology

The hand has 14 phalanges, which are tubular bones extending from the metacarpal bones to the fingertips. Finger phalanges include the proximal, middle and distal phalange. Besides the thumb with two of them, the other fingers have three phalanges. Phalanges are separated by a set of joints that articulate each bone with the adjacent bone.

Fractures of the fingers' phalanges account for up to 10% of all fractures. Although they may be considered less severe compared to other bone fractures, finger fractures can generate significant complications and even disabilities. They can be located at the distal, middle or proximal phalange. Within the phalanges, fractures may be positioned in the neck, just below the head (more frequently), along the shaft or at the base. Depending on the energy applied to the hand, finger fractures may involve injuries to the cartilage, joint capsule, tendons, ligaments, palmar fascia, the dorsal hood as well as the nerves.

Examples of fractures to the distal phalanges

Classification

Fractures of the distal phalanges are the most common. They often result from crush injuries to the tip of the fingers leading to blood accumulation below the nail or subungual haematoma, soft tissue injuries, nail bed damage and open lesions. Following crush injuries, amputations of the distal phalange are relatively frequent.

Distal phalange fractures comprise:

Distal tuft fractures: mostly at the finger extremity, often being open fracture caused by crush injury (hammer)

Shaft fractures: located at the central portion of the distal phalange

Depiction of an oblique and spiral fracture of the middle phalange of the middle finger

Middle and proximal phalange fractures comprise:

Transverse fracture caused by axial compression resulting into unstable fractures (blow on the bent knuckle, or to the extremity of the finger)

Oblique fracture from a bending force (sport, catch finger in door) causing malrotation

Spiral fracture following finger twisting, often displaced and unstable

Comminuted fracture of the proximal phalange head (fall on knuckle) requiring surgery. These fractures can be associated with a tear of the flexor tendon.

Index finger spyral fracture of the proximal phalange after a football injury

Finger fractures are also classified in relation to the phalangeal joints:

Extra-articular fractures: occur in the phalange shaft distant from the joints leading to rotational deformity (malrotation)

Intra-articular fractures: located at the phalangeal joint surfaces.

Intraarticular avulsion fractures in the joint capsule of the middle (left) and ring finger (right). Note the comminution of the ring fracture

Intra-articular fractures include:

Intra-articular fracture at the base of the proximal phalange. If displaced it requires surgical reconstruction to achieve a normal joint anatomy and function

Avulsion fracture at the proximal inter-phalangeal (PIP) joint can be associated with a volar plate ligament fracture

Fracture to one of the proximal phalange (condyles) located at the metacarpo-phalangeal (MCP) joint. It requires surgical reconstruction.

Using heavy tools and machineries in carpentry and mechanic work can cause finger fractures

Causes

Finger fractures are caused by a variety of mechanisms, which put axial forces to the fingers. They include crush injuries, a direct blow of a hard object onto the fingers or torsion energy. The most common causes are:

Catching a ball in sports (football, basketball, soccer, rugby)

Catching fingers in carpentry machineries (mixers, saws)

Crush injuries (car doors, hammers)

Falls onto fingers/hands

Other forms of direct blows (sport bats)

Boxing is a risk factor for finger fractures

Risk factors

The following activities represent the main risk factors possibly leading to finger fractures:

Contact sports and ball sports (football, basketball, rugby)

Bat sports (hockey, cricket)

Manoeuvring of tools and machineries (mixers, saws)

Boxing

Lacerations and swelling are typical symptoms of finger fractures

Symptoms

The symptoms arising from finger fractures include:

Pain

Swelling

Bruising

Lacerations

Movement restrictions

Hand deformity

Knuckle asymmetry/depression

Testing finger movement, flexion and extension is the core of medical examination

Diagnosis

A suspected fracture to the fingers should be assessed immediately after an injury has occurred and treated accordingly. The clinical evaluation begins with the medical history of the patient to then focus on the mechanisms of injury. The examiner will determine:

Changes in the anatomy of the affected finger(s) against the healthy fingers

Presence of skin lacerations

Digit malrotation when closing the fist

Tenderness with axial compression of the finger

X-rays are taken under antero-posterior, lateral and oblique view to better assess the fracture characteristics. CT scan and MRI scans may be required in case of complex fractures to identify possible damage to soft tissues and ligaments.

Treatment

A splint is often applied for conservative treatment of finger fractures

Nonoperative treatment

Management of finger fractures varies in relation to the fracture site and characteristics. In case of a stable fracture without misalignment surgery is not required and treatment with a hand cast or splint provided with a metal finger extension will last for 3-4 weeks. Sometimes a closed reduction is necessary to re-align the fractured phalanges. Unstable fractures are immobilised with a cast to maintain a functional position of the hand and facilitate correct bone healing. Immobilisation of the fractured finger with a 50-70 degree flexion is used especially with the associated fracture of the metacarpal head. Additional management includes:

Finger taping (healthy finger or buddy, with fractured finger)

Rest

Hand elevation

Ice pads

Painkillers

Administration of NSAIDs

Physiotherapy with gentle finger exercises whilst the hand is in a cast or splint

External fixation is a strategy for the treatment of a fracture to the little finger

Surgical treatment

Surgery is required in significantly displaced, or comminuted phalangeal fractures especially when the joints are involved. Different methods are available for fixation depending on the type of fracture:

Open reduction and internal fixation (ORIF) is done in displaced fractures with placement of screws, plates, intramedullary pins and k-wires.

External fixation is used in unstable fractures. A closed reduction with percutaneous pining using k-wires is also a frequent option.

Complications

Complications after finger fracture include: 

Non-union of the phalanges or inter-phalangeal joints, if fractures are neglected, treated too late, or in very unstable fractures. This leads to finger misalignment and improper finger rotation

Finger stiffness

Damage to nerves and vessels

Infection (open fractures or after surgery)

Ball exercises are useful to restore flexibility and strength after finger fractures

Rehabilitation

With or without surgery, a cast or splint is worn for 3 weeks after a finger fracture. The prognosis depends on the severity of the fracture. Physical activities should commence as soon as possible to prevent stiffness of the finger joints. This includes guided movements of the wrist, hand and fingers. A physical or occupational therapist will recommend exercises to restore flexibility and strength of the fingers. Education is critical to inform the patient on how to modify activities to avoid recurrent injuries. Rehabilitation includes:

Finger taping

Massage

Joint mobilisation

Stretches

Electrotherapy

Ball exercise

Activity modification advice

Return to activity plan

Wearing special gloves protects the hands and fingers during manual work.

Prevention

In order to prevent finger fractures, it is suggested to reduce the risk of falls and protect the hand during physical activities that expose the hands. For those individuals who had previous finger fractures, it is critical to avoid recurrent injuries. Common preventive strategies are:

Finger taping

Use of hand protective gear in sport and carpentry work

Implementation of occupational health and safety regulation in the workplace

Use of devices to improve elderly patient stability and avoid falls

Modification of physical activities

Exercise to improve fingers’ flexibility and posture

DefinitionPathologyClassificationCausesRisk FactorsSymptomsDiagnosisTreatmentPreventionAuthor