Acute Injuries

Distal phalanx fracture

What is it?

A fracture of the distal phalanx of the finger beneath the nail.

What is the cause?

  • crush injury
  • axial trauma eg hit by a netball

What are the symptoms?

  • pain
  • subungual haematoma (bleed under the nail)
  • deformity

What are the treatment options?

  • tuft fracture – small distal crush fracture. Hand therapy splint for 3 weeks.
  • undisplaced fracture – hand therapy splint for 3-4 weeks.
  • displaced fracture – may need surgery and a temporary pin (K-wire)

When should I see a Surgeon?

  • all fractures require a surgical review

Middle phalanx fracture

What is it?

A fracture of the middle phalanx of the finger between the first (PIP joint) and second finger joints (DIP joints).

What is the cause?

  • crush injury
  • axial trauma eg hit by a netball
  • twisting rotational trauma eg football tackle

What are the symptoms?

  • pain
  • deformity
  • loss of movement

What are the treatment options?

  • undisplaced fracture – hand therapy splint or buddy tape for 3-4 weeks.
  • displaced fracture – may need surgery

When should I see a Surgeon?

  • all fractures require a surgical review

Proximal phalanx fracture

What is it?

A fracture of the proximal phalanx of the finger between the knuckle (MCP joint) and the first finger joint (PIP joint).

What is the cause?

  • crush injury
  • twisting rotational trauma eg football tackle

What are the symptoms?

  • pain
  • deformity
  • loss of movement

What are the treatment options?

  • undisplaced fracture – hand therapy splint or buddy tape for 3-4 weeks.
  • displaced fracture – may need surgery

When should I see a Surgeon?

  • all fractures require a surgical review

Metacarpal fracture

What is it?

A fracture of one of the five main hand bones.

What is the cause?

  • axial load (eg punch injury)
  • direct trauma

What are the symptoms?

  • pain
  • deformity
  • loss of movement

What are the treatment options?

  • undisplaced fracture – hand therapy splint for 3-4 weeks.
  • displaced fracture – may need surgery

When should I see a Surgeon?

  • all fractures require a surgical review

Carpal bone fracture

(non-Scaphoid; 20-30% of wrist bone fractures)

What is it?

A fracture of one of the eight wrist bones (seven excluding scaphoid).  A triquetrum fracture is the most common.

What is the cause?

  • Wrist hyperextension during a fall

What are the symptoms?

  • pain
  • loss of movement

What are the treatment options?

  • undisplaced fracture – short arm cast for 4 weeks.
  • displaced fracture – may need surgery
  • a CT scan is usually required to properly assess carpal bone fractures

When should I see a Surgeon?

  • all fractures require a surgical review

Scaphoid fracture

(70-80% of wrist bone fractures)

What is it?

A fracture of the scaphoid bone which links the proximal and distal carpal rows.

What is the cause?

  • fall on an outstretched hand

What are the symptoms?

  • pain
  • no deformity (therefore a commonly missed fracture)

What are the treatment options?

  • undisplaced fracture – scaphoid cast for 8-12 weeks or surgery
  • displaced fracture – always needs surgery
  • a CT scan is usually required to properly assess scaphoid fractures

When should I see a Surgeon?

  • all fractures require a surgical review

Distal radius fracture

What is it?

The most common fracture of the two forearm bones.

What is the cause?

  • fall on an outstretched hand

What are the symptoms?

  • pain
  • deformity eg classic dinner fork deformity
  • loss of movement

What are the treatment options?

  • undisplaced fracture – short forearm cast for 6 weeks
  • displaced fracture – may need surgery

When should I see a Surgeon?

  • all fractures require a surgical review

Growth plate fracture

What is it?

A fracture of the growing part of a bone.

What is the cause?

  • axial load (it is the weakest part of the bone)
  • forced radial or ulna deviation

What are the symptoms?

  • pain
  • deformity
  • loss of movement

What are the treatment options?

  • undisplaced fracture – immobilisation
  • displaced fracture – may need surgery

When should I see a Surgeon? 

  • all fractures require a surgical review

Finger Hyperextension/ Dislocation

What is it?

Hyperextension of the finger, usually at the proximal interphalangeal joint.  This may be associated with subluxation (partial joint dislocation), or complete dislocation. Three stabilising structures of the interphalangeal joint are progressively injured: the volar plate; radial collateral ligament; and ulna collateral ligament.

What is the cause?

  • a fall on an outstretched hand, hyperextending the fingers
  • axial load on the finger eg a ball forcing the finger backwards

What are the symptoms? 

  • pain, particularly over the palmar side of the joint
  • subluxation or dislocation will cause deformity and loss of movement

What are the treatment options?

  • reduction of a dislocation can usually be achieved in the Emergency Department
  • stable injuries – sometimes require a hand therapy splint
  • unstable injuries – always require a hand therapy splint
  • fractures – sometimes need an operation

When should I see a Surgeon?

  • if the joint cannot be reduced immediately
  • if there is a fracture

Nailbed injury

What is it?

A crush injury to the tip of the finger results in a tear of the pale pink nailbed (sterile matrix), beneath the nail.  An accumulation of blood develops under the nail (subungual haematoma).  The injury is often associated with a small fracture of the distal phalanx (tuft fracture).

What is the cause?

  • crush injury eg crushed in a car door or hit with a hammer

What are the symptoms?

  • pain
  • subungual haematoma
  • partial or complete nail avulsion

What are the treatment options? 

  • no treatment – small subungual haematoma < 25% of nail area
  • trephine (pinhole to drain the accumulated blood) – 25-50% of nail area (often performed in the Emergency Department)
  • surgery – subungual haematoma > 50% of nail area or underlying fracture

When should I see a Surgeon?

  • if there is a fracture
  • subungual haematoma > 50% of the nail area
  • if a patient has concerns about the future nail appearance. A nailbed laceration can heal with a gap or step due to scar tissue.  This can cause temporary or permanent ridging or changes to the overlying nail.

Jersey finger / Rugby finger

What is it?

An avulsion of the flexor tendon insertion onto the distal phalanx.  May be associated with a fracture.

What is the cause?

  • forced hyperextension whilst gripping eg tackling a rugby player’s jersey

What are the symptoms?

  • pain
  • loss of flexion

What are the treatment options?

  • surgery

When should I see a Surgeon?

  • all flexor tendon avulsions require a surgical review

Mallet finger

What is it?

An avulsion of the extensor tendon insertion onto the distal phalanx.  May be associated with a fracture.

What is the cause?

  • hyperflexion of the distal interphalangeal joint

What are the symptoms?

  • pain
  • loss of finger extension (extensor lag)

What are the treatment options?

  • pure tendon avulsion or small fracture – mallet (extension) splint for up to 8-12 weeks
  • large fracture – may need surgery

When should I see a Surgeon?

  • all mallet injuries require a surgical review

Scapholunate Ligament Injury

What is it?

A partial or complete tear of the ligament joining the scaphoid and lunate bones in the proximal carpal row of the wrist.

What is the cause?

  • sudden forced hyperextension of the wrist

What are the symptoms?

  • pain
  • wrist clunking

What are the treatment options?

  • Acute (< 4 weeks) partial tear – arthroscopy, K wire pinning
  • Acute complete tear – open ligament repair
  • Chronic (> 6 months) complete tear – open ligament reconstruction

When should I see a Surgeon?

  • all injuries require a surgical review

Tendon laceration

What is it?

Tendons are like ropes which flex and extend the wrist, hand, and fingers.  Sharp injuries such as a knife laceration commonly injure the tendons.  Partial tendon injuries can rupture with ongoing use.

What is the cause?

  • laceration with sharp object eg a knife

What are the symptoms?

  • pain
  • loss of movement

What are the treatment options?

  • open tendon injury – always needs surgery

When should I see a Surgeon?

  • all tendon injuries require a surgical review

Triangular Fibrocartilage Complex (TFCC) Injury

What is it?

The TFCC is like the meniscus in the knee.  It separates the ulna from the carpal bones and can be torn.

What is the cause?

  • axial load with pronation
  • chronic tears can occur due to a long ulna bone (positive ulnar variance and ulnocarpal impaction)

What are the symptoms?

  • pain
  • wrist clunking

What are the treatment options?

  • acute tear, stable ulna – cast for 6-8 weeks
  • acute tear, unstable ulna – surgical repair/ reinsertion
  • chronic central tear from impaction – arthroscopic debridement

When should I see a Surgeon?

  • all injuries require a surgical review

Ulna Collateral Ligament Injury of the Thumb MCP Joint (Skier’s Thumb/ Gamekeeper’s Thumb)

What is it?

A partial or complete tear of the ulna collateral ligament of the MCP joint of the thumb.  This ligament is important in stabilising the thumb during pinching.  The ligament injury may be associated with an avulsion fracture.

What is the cause?

  • forced abduction of the thumb eg a ski pole being pulled out of the hand

What are the symptoms?

  • pain
  • instability

What are the treatment options?

  • Partial tear – hand therapy splint for 6 weeks
  • Complete tear, stable joint – hand therapy splint for 6 weeks
  • Complete tear, unstable joint – surgery (open ligament repair)
  • In some complete tears a Stener lesion occurs where the ulna collateral ligament is unable to heal back to its insertion. Surgery is always required with a Stener lesion.

When should I see a Surgeon?

  • all UCL injuries require a surgical review