What is the diagnosis?

The patient is presenting with signs and symptoms of a proximal phalanx fracture.  

• Pearl: Proximal phalanx fractures are the most common pediatric hand fractures [3]. 

What is the mechanism of injury?

Fractures of the proximal phalanx are typically caused by direct blows to the digit or twisting injuries. 

• Pearl: Direct blow injuries typically produce transverse fractures while twisting injuries result in oblique or spiral fractures [2]. 

• Pearl: Hyperextension and ulnar or radial deviation can result in collateral ligament injury. However, this is uncommon in digits other than the thumb [2]. 

What physical exam findings are expected?

Pain at the phalanx is expected, along with swelling and bruising. Range of motion of the finger is often limited. 

• Pearl: Be sure to examine for rotational deformities. This can be accomplished by evaluating finger cascade - when flexed at the MCP and PIP joints, the fingers should converge to the scaphoid tubercle. 

Which imaging modalities can be used?

Three-view plain films are ideal for identifying displacement, angulation and rotation of phalanx fractures. 

What is the management in the ED?

Nondisplaced, stable fractures can be splinted with a volar finger, ulnar gutter or radial gutter splint. An attempt at closed reduction should be made for displaced or angulated fractures, with arrangement for close orthopedic follow up. 

• Pearl: Prior to reduction, be sure to provide adequate analgesia by using a digit block. 

• Pearl: To perform a closed reduction, slightly extend the wrist and flex the MCP and PIP joints to 90 degrees. This allows for relaxation of the interosseous muscles and stabilizes the collateral ligaments, making for an easier reduction. 

Image 2. Status post closed reduction. Author’s own images

Image 3. Status post closed reduction. Author’s own images

When do you consult orthopedics?

All open fractures or fractures with neurovascular compromise should be emergently discussed with a hand surgeon. Additionally, all intra-articular, rotated, shortened, comminuted or angulated fractures should be referred to hand surgery for definitive care after closed reduction and splinting. 

• Pearl: Inadequate reduction of rotational deformities can lead to “scissoring” of the fingers and functional impairment [1]. 

• Pearl: The majority of oblique and spiral fractures are unstable and require specialist referral [1].