Just the Important Tips: Fingertip Injuries

Can you distinguish Jersey vs. Mallet finger? Do you know the splinting pitfall?

They may be tiny, but fingertip injuries can cause outsized trouble. From nail bed lacerations to jersey finger, here’s some pointers to managing hand trauma like a pro.

Subungual Hematoma

• Cause: Direct crush injury → bleeding under nail plate.

• Diagnosis: Clinical; consider X-ray hand (AP, lateral, oblique) to rule out distal phalanx fracture. EXAM TIP: For short answer management problems (being retired in 2027!) always list the body part when ordering imaging. "X-ray" is marked wrong.
  

• Management:

  • Small, painless → observation, elevation, ice.

  • Painful/enlarging → nail trephination (heated paper clip or trephination tool).

    
    

• Referral: Only if complex/open fracture present.

Nail Bed Laceration

• Cause: Crushing trauma; may be simple, complex, or stellate.

• Associated: Tuft fractures common → order 3-view radiographs "X-ray finger"

• Repair (if chosen):

  • Digital nerve block ± tourniquet.

  • Antimicrobial prep (e.g., povidone-iodine).

  • Closure with 6-0 or 7-0 absorbable sutures or topical glue.

• Splinting: Controversial; options include native nail, sterile foil, Xeroform, petrolatum gauze; keep 2–3 weeks or simple glue.

• Other: Tetanus update if >5 years since last dose for dirty wounds.

• Referral: Complex/stellate lacerations → hand surgeon.

Distal Interphalangeal (DIP) Joint Dislocation

• Cause: Hyperextension (dorsal) or hyperflexion (volar) injury; sports/accidental trauma.

• Diagnosis: Clinical + 3-view radiographs to confirm and r/o fracture.

• Management:

  • Closed reduction under digital block.

    • Dorsal dislocation → traction + volar pressure → splint 15–30° flexion x 2–3 weeks.

    • Volar dislocation → traction + dorsal pressure → splint in full extension x 2–3 weeks.

  • Buddy tape to adjacent finger.

• Referral: Large avulsion fracture, irreducible dislocation, open injury.

Distal Phalanx Fractures

• Types: Tuft, transverse, oblique, vertical, base (non–intra-articular or intra-articular).

• Diagnosis: X-ray (AP, lateral, oblique).

• Management:

  • Most stable fractures → splint/buddy tape 3–4 weeks.

  • Displaced/unstable fractures → possible open reduction/internal fixation.

  • Intra-articular fracture → hand surgeon referral

• Other: No routine prophylactic antibiotics.

Mallet Finger

• Cause: Axial load → forceful DIP flexion during active extension → extensor tendon rupture (tendinous) or dorsal base avulsion fracture (bony mallet).

• Diagnosis: Clinical; confirm with X-ray finger for fracture.

• Management:

  • Splint DIP in neutral/slight hyperextension:

    • Bony mallet: 6–8 weeks continuous splinting + 2 weeks nighttime splinting.

    • Tendinous mallet: 8–12 weeks continuous splinting + 2 weeks nighttime splinting.

  • PIP joint does not require immobilization.

  • Restart timeline if DIP flexes during treatment. ⚠️ PITFALL: Permanent stiffness can occur if the wrong splint is used. Make sure you are using the right type of finger splint and splinting only the affected joint.
    

• Referral: Distal phalanx fracture, joint involvement, volar subluxation, failed conservative treatment.

Jersey Finger

• Cause: Forceful DIP extension during active flexion (often ring finger); FDP tendon avulsion ± fracture.

• Diagnosis: Inability to flex DIP; positive sweater finger sign; X-ray finger ± US/MRI.

• Management: Splint DIP/PIP in slight flexion; urgent hand surgeon referral for surgical repair.

• Reason for urgency: Prevent tendon retraction, ischemia, and poor surgical outcomes.

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