AdultPediatric
Pediatric hand and finger injuries are dominated by crush, jamming, and twist mechanisms. Open physes mean Salter-Harris fractures are common where adults sprain. Tendon avulsions (mallet, jersey) and rotational deformity are frequently missed and lead to permanent dysfunction.
🚩 Red-flag clues (must not miss)
- •Rotational malalignment (overlapping or scissoring fingers when making a fist) = displaced metacarpal/phalangeal fx — needs reduction
- •Inability to extend DIP (mallet) or flex DIP against resistance (jersey) = tendon avulsion
- •Fight bite (laceration over MCP, especially 4th/5th) — high infection risk; explore, IV abx, hand surgery
- •Snuffbox tenderness in adolescent after FOOSH = scaphoid fracture even with normal XR
- •High-pressure injection injury — innocuous-looking entry, devastating; emergent hand surgery
- •Open fracture, neurovascular compromise, compartment swelling = emergent ortho
- •Atraumatic swelling + fever / extreme pain with passive motion = septic flexor tenosynovitis (Kanavel signs)
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Labs
Imaging
Meds
History
- Mechanism — jam (axial), crush (door, weight), twist, laceration, bite, high-pressure tool
- Hand dominance, occupation/sport, time since injury, tetanus status
- Loss of motion or sensation, color change, prior injury
Exam
- Inspect for rotational alignment (nails should align, fingers point to scaphoid on flexion)
- Palpate each phalanx, MCP, CMC, snuffbox, scaphoid tubercle
- Active ROM — isolate FDP (DIP flexion) and FDS (PIP flexion with adjacent fingers held extended); extensor mechanism (DIP extension)
- Neurovascular — 2-point discrimination (< 6 mm normal), cap refill, radial/ulnar pulses
- Kanavel signs (flexor tenosynovitis): fusiform swelling, finger held in flexion, tenderness along sheath, pain with passive extension
Labs
- Generally not needed for trauma
- Bites / cellulitis / suspected septic tenosynovitis: CBC, CRP, blood cx, wound cx
Imaging
- Hand XR — PA, lateral, oblique (true lateral of injured finger to evaluate volar/dorsal avulsion)
- Dedicated finger views if isolated digit injury — hand films often miss small avulsions
- Scaphoid views (PA in ulnar deviation) for snuffbox tenderness; if negative, thumb spica + repeat XR or MRI in 7–14 d
- US for foreign body, abscess, tenosynovitis
- MRI for occult scaphoid fx, tendon injury, osteomyelitis
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| Distal phalanx tuft fracture | Crush mechanism, nail bed injury | Repair nail bed, splint DIP × 2–3 wk; consider abx if open |
| Mallet finger (extensor avulsion ± bony fragment) | Jammed DIP, cannot actively extend | Continuous DIP extension splint × 6–8 wk; ortho if > 30% articular surface or subluxed |
| Jersey finger (FDP avulsion) | Forced extension while gripping (ring finger common); can't flex DIP | Splint, urgent hand surgery (repair within 7–10 d) |
| Volar plate / PIP dislocation | Hyperextension jam, dorsal dislocation | Reduce, buddy tape, dorsal block splint, hand follow-up |
| Boutonnière deformity | Central slip injury — PIP flexion, DIP hyperextension (may evolve over days) | PIP extension splint × 6 wk, hand referral |
| Phalangeal Salter-Harris fracture | Tenderness over physis, often subtle | Reduce if angulated, splint in safe position, ortho follow-up |
| Metacarpal neck fracture (boxer's, 5th MC) | Punch injury, dorsal angulation | Ulnar gutter splint; reduce if > 40° (5th), > 30° (4th), > 20° (2nd/3rd); rule out fight bite |
| Bennett / Rolando fracture (1st MC base) | Axial load on thumb, intra-articular CMC fx | Thumb spica, ortho — usually surgical |
| Gamekeeper's / skier's thumb (UCL injury) | Forced thumb abduction, MCP instability | Thumb spica, hand referral; surgery if Stener lesion or > 30° instability |
| Scaphoid fracture | FOOSH + snuffbox tenderness, often XR-occult | Thumb spica × 7–14 d, repeat XR or MRI, ortho |
| Fight bite (clenched-fist injury over MCP) | Small laceration over knuckle, often denied | Explore (extensor tendon, joint), irrigate, amoxicillin-clavulanate, hand surgery, leave open |
| Subungual hematoma | Crush, painful blue-black under nail | Trephination if > 50% nail bed and intact margins; repair nail bed if disrupted |
| Paronychia / felon | Periungual or pulp space abscess | I&D, warm soaks, oral abx (clindamycin or amox-clav) |
| Septic flexor tenosynovitis | Kanavel signs (4) | Emergent hand surgery, IV abx (vanc + ceftriaxone) |
| High-pressure injection injury | Pinpoint entry on volar finger | Emergent hand surgery — admission regardless of appearance |
Medications & dosing
| Drug | Dose | Notes |
|---|---|---|
| Ibuprofen | 10 mg/kg PO q6–8h (max 600 mg/dose) | |
| Acetaminophen | 15 mg/kg PO q4–6h (max 1 g/dose) | |
| Amoxicillin-clavulanate (bites, paronychia) | 45 mg/kg/day PO div BID (amox component); max 875 mg BID | |
| Clindamycin (PCN allergy, MRSA) | 10 mg/kg PO q6–8h (max 450 mg) | |
| Cefazolin (open fx, IV) | 25–50 mg/kg IV q8h (max 2 g) | |
| Tetanus | Td/Tdap if > 5 y since last dose for clean wounds, > 5 y for dirty |
Management / next steps
- Step-by-step: ABC → neurovascular → rotational alignment → tendon function (FDP, FDS, extensor) → palpate each bone/joint → image → splint in safe position (MCP 70–90° flexion, IP extended)
- Always re-examine after splinting and document neurovascular status
- Open/contaminated wounds → irrigate, abx, tetanus, hand surgery for tendon/joint involvement
- Discharge precautions: return for ↑ pain, swelling, color/sensation change, fever, drainage
Pearls
- Children rarely 'sprain' fingers — assume Salter-Harris fracture and splint.
- A normal XR with snuffbox tenderness is still a scaphoid fracture until repeat imaging proves otherwise.
- Rotational malalignment is judged with the fingers flexed — extended fingers can mask deformity.
- Fight bite over the MCP is the classic 'innocent-looking' wound that destroys joints when missed.