fractures and dislocations of the fingers

see also:

• fractures of the metacarpal
• the injured hand

• see the injured hand for guide to how to refer these injuries to the plastics team

• these are extremely common injuries and if fracture of the distal phalanx is evident on XRay, then it can be assumed there is a significant nail bed injury associated, and if there has been any bleeding, it can be assumed, that the fracture is compound and at risk of developing osteomyelitis.
• most of these injuries warrant:
  • initial cleansing
  • if severe pain, consider a digital nerve block using Marcain
  • xray
  • if open wound, tetanus prophylaxis
  • if compound fracture, prophylactic antibiotics such as iv cephazolin if being admitted
  • if significant nail bed injury, or there is a compound fracture, then referral to plastics for repair in theatre
• some patients with no fracture evident and only small subungual haematoma, could be managed solely by drainage of the haematoma and local doctor review to ensure infection does not develop in a missed fracture

• these should ideally be manipulated in the ED if there is significant angulation (eg. with the aid of a digital block or perhaps ketamine)
• growth plate injuries generally should not be manipulated after 1wk or so, and thus referrals to plastic surgery outpatients should be within a week of injury

• the following fractures generally need plastic surgery for repair in theatre:
  • fractures of the head of proximal phalanx
  • fractures of the shaft of proximal or middle phalanges unless good alignment and stable (note that the middle phalanx has the poorest blood supply and is at higher risk of failed repair)
  • fractures with substantial sized fragments involving articular surfaces
  • compound fractures
  • rotational or angulated deformity not correctable in ED
  • dislocations unable to be reduced in ED - some may have button-holing of the phalanx through the ligaments which prevent closed reduction