What are the common types of acute finger injuries. How should tendon and ligament injuries in fingers be diagnosed and treated. When is referral to a specialist necessary for finger injuries. What are the key anatomical structures involved in finger injuries.

Understanding the Anatomy of the Finger

The intricate anatomy of the finger plays a crucial role in diagnosing and treating acute injuries. Each finger, except the thumb, consists of three phalanges (proximal, middle, and distal) and three hinged joints:

• Distal interphalangeal (DIP) joint
• Proximal interphalangeal (PIP) joint
• Metacarpophalangeal (MCP) joint

The thumb, in contrast, has only two phalanges (proximal and distal) and two joints (interphalangeal and MCP). These joints are surrounded by a complex network of tendons, ligaments, and other soft tissues that enable the intricate movements of our fingers.

Key Anatomical Structures

Understanding the following structures is essential for proper diagnosis and treatment of finger injuries:

• Extensor tendons: Located on the dorsal aspect of the finger
• Flexor tendons: Found on the volar (palm) side of the finger
• Collateral ligaments: Stabilize the joints on either side
• Volar plate: A thick ligament on the palmar surface of the joint

Common Tendon Injuries in Fingers

Tendon injuries can significantly impact finger function. Here are some of the most frequently encountered tendon injuries:

Central Slip Extensor Tendon Injury

This injury affects the extensor tendon at the PIP joint. If left untreated, it can lead to a boutonniére deformity over time. How can you identify this injury? Look for tenderness at the dorsal aspect of the PIP joint and an inability to actively extend the PIP joint.

Treatment typically involves splinting the PIP joint in full extension for six weeks. When should you refer this injury to a specialist? Consider referral if there’s an avulsion fracture involving more than 30% of the joint or if full passive extension cannot be achieved.

Mallet Finger (Extensor Tendon Injury at DIP Joint)

A mallet finger occurs when the extensor tendon is damaged at the DIP joint. Patients will present with tenderness at the dorsal aspect of the DIP joint and an inability to actively extend the DIP joint.

How is a mallet finger treated? The standard treatment involves continuous splinting of the DIP joint for six weeks. It’s crucial to monitor patient compliance, as consistent splinting is key to successful outcomes. Referral criteria are similar to those for central slip injuries.

Jersey Finger (Flexor Digitorum Profundus Tendon Injury)

A jersey finger involves injury to the flexor digitorum profundus (FDP) tendon, typically at the DIP joint. Patients will have tenderness at the volar aspect of the DIP joint and an inability to flex the DIP joint when it’s isolated during examination.

What’s the recommended course of action for a jersey finger? All suspected cases should be splinted and referred to an orthopedic or hand surgeon for further evaluation and potential surgical intervention.

Ligament Injuries: Diagnosis and Treatment

Ligament injuries can compromise joint stability and function. Here are the most common ligament injuries affecting the fingers:

Collateral Ligament Injury

Collateral ligament injuries most frequently occur at the PIP joint. How can you diagnose this injury? Look for maximal tenderness at the involved collateral ligament and test the stability of the joint while the finger is in 30 degrees of flexion and the MCP joint is flexed.

Treatment varies based on joint stability. For stable joints, buddy taping for two to four weeks is often sufficient. However, unstable joints or injuries in children may require referral to a specialist. Why the low threshold for referral in children? The growth plate is often involved in these injuries, necessitating expert evaluation.

Volar Plate Injury

Volar plate injuries typically affect the PIP joint. Diagnosis involves identifying maximal tenderness at the volar aspect of the involved joint and testing for full flexion and extension as well as collateral ligament stability.

How should volar plate injuries be treated? For most cases, splinting at 30 degrees of flexion with progressive increase in extension over two to four weeks is recommended. Less severe injuries may be managed with buddy taping. When should you refer? Consider specialist evaluation for unstable joints or large avulsion fragments.

Diagnostic Approach to Finger Injuries

Proper diagnosis is crucial for effective treatment of finger injuries. What steps should be taken in the diagnostic process?

Physical Examination

A thorough physical examination should include:

• Inspection for deformity, swelling, and discoloration
• Palpation for areas of tenderness
• Assessment of active and passive range of motion
• Evaluation of joint stability
• Neurovascular examination

Radiographic Evaluation

Radiography plays a crucial role in diagnosing finger injuries. What views should be obtained? A minimum of three views is recommended:

• Anteroposterior (AP) view
• True lateral view
• Oblique view

These views help identify fractures, dislocations, and other bony abnormalities that may be associated with ligament or tendon injuries.

Treatment Principles for Finger Injuries

The primary goal in treating finger injuries is to restore function while preventing further damage. What are the key principles to keep in mind?

Immobilization Techniques

Proper immobilization is crucial for healing. However, it’s important to strike a balance. How can this be achieved? The general rule is to restrict the motion of injured structures while allowing uninjured joints to remain mobile. This approach helps prevent stiffness and promotes faster recovery.

Splinting and Taping

Splinting and taping are effective treatments for many tendon and ligament injuries. What factors should be considered when choosing between splinting and taping?

• Severity of the injury
• Location of the injury
• Patient’s occupation and lifestyle
• Potential for patient compliance

For example, a stable collateral ligament injury might be managed with buddy taping, while a mallet finger requires rigid splinting for optimal outcomes.

When to Refer: Recognizing Complex Cases

While many finger injuries can be managed by family physicians, it’s crucial to recognize when specialist referral is necessary. What are some general criteria for referral?

• Unstable joint injuries
• Injuries involving a significant portion of the joint surface
• Injuries in children involving the growth plate
• Complex tendon injuries, such as jersey finger
• Injuries not responding to initial treatment

Early recognition of these cases and prompt referral can significantly improve patient outcomes.

Patient Education and Follow-up Care

Proper patient education is essential for successful treatment of finger injuries. What key points should be communicated to patients?

Managing Expectations

Patients should be informed that:

• Swelling may persist for an extended period
• Some degree of permanent deformity is possible, even with appropriate treatment
• Full recovery may take several weeks to months

Importance of Compliance

Why is patient compliance crucial in finger injury treatment? Many treatments, particularly for tendon injuries like mallet finger, require consistent adherence to splinting or taping regimens. Failure to comply can lead to suboptimal outcomes or treatment failure.

Follow-up Care

Regular follow-up is important to monitor healing progress and adjust treatment as necessary. What should be assessed during follow-up visits?

• Pain levels
• Range of motion
• Strength
• Functionality in daily activities

Early identification of complications or delayed healing can allow for timely intervention and improved outcomes.

In conclusion, understanding the complex anatomy of the finger and the mechanisms of common tendon and ligament injuries is crucial for proper diagnosis and treatment. While many finger injuries can be managed effectively by family physicians, it’s important to recognize when specialist referral is necessary. By following evidence-based treatment principles and providing thorough patient education, healthcare providers can help ensure optimal outcomes for patients with acute finger injuries.

Acute Finger Injuries: Part I. Tendons and Ligaments

JEFFREY C. LEGGIT, LTC, MC, USA, AND CHRISTIAN J. MEKO, CAPT, MC, USA

Improper diagnosis and treatment of finger injuries can cause deformity and dysfunction over time. A basic understanding of the complex anatomy of the finger and of common tendon and ligament injury mechanisms can help physicians properly diagnose and treat finger injuries. Evaluation includes a general musculoskeletal examination as well as radiography (oblique, anteroposterior, and true lateral views). Splinting and taping are effective treatments for tendon and ligament injuries. Treatment should restrict the motion of injured structures while allowing uninjured joints to remain mobile. Although family physicians are usually the first to evaluate patients with finger injuries, it is important to recognize when a referral is needed to ensure optimal outcomes.

The severity of acute finger injuries is often underestimated, which can lead to improper treatment. Basic knowledge of the anatomy of the finger and a thorough evaluation of the patient can ensure proper diagnosis and treatment. Part I of this two-part article focuses on common tendon and ligament injuries of the finger. Part II¹ discusses common finger fractures, dislocations, and thumb injuries.

Family physicians can manage most finger injuries; however, knowledge of referral criteria is important to ensure optimal outcomes. Treatment should restrict the motion of injured structures while allowing uninjured joints to remain mobile. Patients should be counseled that it is not unusual for an injured digit to remain swollen for some time and that permanent deformity is possible, even after treatment. Table 1 summarizes the evaluation and treatment of common ligament and tendon injuries.

Clinical recommendation	Evidence rating	References
Patients with finger injuries should receive a minimum of anteroposterior, true lateral, and oblique radiographic views.	C	5
Patient compliance should be monitored when treating mallet finger with splinting, because it is imperative for successful outcomes. All splints for mallet finger achieve similar results.	B	15
Patients with confirmed or suspected jersey finger should be referred to an orthopedic or hand surgeon.	C	18
A low threshold for referral should exist for collateral ligament injuries in children, because the growth plate often is involved.	C	7,11

Injury	Examination	Treatment	Referral criteria
Central slip extensor tendon injury (may cause a boutonniére deformity over time)	Tender at dorsal aspect of the PIP joint (middle phalanx)	Splint the PIP joint in full extension for six weeks.	Avulsion fracture involving more than 30 percent of the joint or inability to achieve full passive extension
	Inability to actively extend the PIP joint
Collateral ligament injury (usually at the PIP joint)	Maximal tenderness at involved collateral ligament	Stable joint: buddy tape for two to four weeks. Do not leave fifth digit exposed if ring finger is taped.	Unstable joint or injury in a child
	Test stability of joint while the finger is in 30 degrees of flexion and the MCP joint is flexed.
Extensor tendon injury at the DIP joint (mallet finger)	Tender at dorsal aspect of the DIP joint	Splint the DIP joint continuously for six weeks.	Avulsion fracture involving more than 30 percent of the joint or inability to achieve full passive extension
	No active extension of the DIP joint
FDP tendon injury (jersey finger)	Tender at volar aspect of the DIP joint	Splint finger and refer to orthopedic or hand surgeon.	All
	Inability to flex the DIP joint
	DIP joint should be isolated during the examination.
Volar plate injury (usually at the PIP joint)	Maximal tenderness at the volar aspect of involved joint	Splint at 30 degrees of flexion and progressively increase extension for two to four weeks.Buddy tape at the joint if injury is less severe.	Unstable joints or large avulsion fragments
	Test for full flexion and extension as well as collateral ligament stability.

Basic Anatomy of the Finger

The anatomy of the finger is complex, but a basic knowledge is necessary to properly treat acute injuries. The index, middle, ring, and fifth digits have proximal, middle, and distal phalanges and three hinged joints: distal interphalangeal (DIP), proximal interphalangeal (PIP), and metacarpophalangeal (MCP). The thumb has a distal and proximal phalanx as well as an interphalangeal and MCP joint. The joints sit in volar plates (collateral ligaments attached to dense fibrous connective tissue), which provide joint stability. ^2,3

The dorsal extensor tendon divides into a central slip that extends the PIP joint and then into two lateral bands that extend the DIP joint. The volar tendons include the flexor digitorum superficialis and the flexor digitorum profundus. The flexor digitorum superficialis tendon attaches to the base of the middle phalanx and flexes the PIP joint. The flexor digitorum profundus tendon is located under and splits the flexor digitorum superficialis tendon. It attaches to the base of the distal phalanx and flexes the DIP.⁴Figure 1 illustrates the basic anatomy of the finger, including joints, ligaments, and tendons.

Evaluation

Neurovascular and active flexion/extension testing will reveal clues to tendon and ligament injuries as well as subtle rotational abnormalities. The neurovascular evaluation should include two-point discrimination and capillary refill assessments. The physician should evaluate active flexion and extension by asking the patient to open and close his or her fist.

Clinical examination alone cannot diagnose fractures, and treatment protocols depend on radiography results. Patients with finger injuries should receive oblique, anteroposterior, and true lateral radiographic views.⁵ True lateral radiography is the most effective way to examine anatomic joint congruity.^6,7 Ultrasonography is emerging as an effective tool to evaluate soft tissue structures.⁸

The evaluation of finger injuries during an athletic event differs from an evaluation in the office. The primary goal on the field is to detect neurovascular compromise and determine if the athlete can safely continue participation. All on-field evaluations must be readdressed in the office for a more thorough examination including radiography. Failure to do so increases the risk of future dysfunction.

Common Injuries

Several techniques may be used to diagnose common ligament and tendon injuries. Most injuries require splinting and follow-up to evaluate the healing process.

EXTENSOR TENDON INJURY AT THE DIP JOINT

Injury to the extensor tendon at the DIP joint, also known as mallet finger (Figure 2), is the most common closed tendon injury of the finger. Mallet finger usually is caused by an object (e.g., a ball) striking the finger, creating a forceful flexion of an extended DIP. The extensor tendon may be stretched, partially torn, or completely ruptured or separated by a distal phalanx avulsion fracture.⁹

Patients with mallet finger present with pain at the dorsal DIP joint; inability to actively extend the joint; and, often, with a characteristic flexion deformity. It is important to isolate the DIP joint during the evaluation to ensure extension is from the extensor tendon and not the central slip. The absence of full passive extension may indicate bony or soft tissue entrapment requiring surgical intervention.^4,7,10 Bony avulsion fractures are present in one third of patients with mallet finger.^11,12

If no avulsion fracture is present on radiographs, the DIP joint should be splinted in a neutral or slight hyper-extension position for six weeks¹³; the PIP joint should remain mobile. A Cochrane review^14,15 confirmed that all available splints achieve similar results. Furthermore, the use of surgical wires (i.e., fixing the affected joint in a neutral position by drilling a wire through the DIP joint to the PIP joint) did not improve clinical outcomes.^14,15Figure 3 describes different types of splints.

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

Physicians should advise patients with mallet finger not to flex the DIP joint during treatment; the splinting period must restart every time flexion occurs. A Cochrane review¹⁵ showed that patient compliance is the most important factor in the success of splint treatments. The distal phalanx should be supported during splint changes.¹⁶ This is difficult to achieve alone, and the patient may need to return to the physician’s office for splint changes. Necrosis of the skin can occur if the DIP joint is overextended during splinting. If the skin blanches, the DIP joint is overextended. Allowing the skin to “breathe” for 10 to 20 minutes between splint changes minimizes the risk of maceration.

Patients may continue to participate in athletic events during the splinting period, and physicians should follow up with patients every two weeks to ensure compliance. After six weeks of splinting, the joint should be reexamined. If active extension is present, splinting can be limited to when the patient is sleeping and during athletic events for another six weeks.

Conservative treatment is successful for up to three months, even with delayed presentation.¹¹ Referral criteria include bony avulsions involving over 30 percent of the joint space or the inability to achieve full passive extension. Despite proper treatment of mallet finger, permanent flexion of the fingertip is possible. The finger can become deformed if the injury is left untreated. ¹⁷

FLEXOR DIGITORUM PROFUNDUS TENDON INJURY

Disruption of the flexor digitorum profundus tendon, also known as jersey finger (Figure 4), commonly occurs when an athlete’s finger catches on another player’s clothing, usually while playing a tackling sport such as football or rugby. The injury causes forced extension of the DIP joint during active flexion. The ring finger is the weakest finger and accounts for 75 percent of jersey finger cases.¹⁸ The injury can occur if the force is concentrated at the middle phalanx or at the distal phalanx.

A patient with jersey finger may present with pain and swelling at the volar aspect of the DIP joint and the finger may be extended with the hand at rest. There may be a tender fullness if the tendon has been retracted. The digitorum profundus tendon should be evaluated by isolating the affected DIP joint (i.e., holding the affected finger’s MCP and PIP joints in extension while the other fingers are in flexion) and asking the patient to flex the DIP joint. ^18,19 If the digitorum profundus tendon is damaged, the joint will not move. The flexor digitorum superficialis tendon should be evaluated by holding the unaffected fingers in extension and asking the patient to flex the injured finger.¹⁹ An injured flexor digitorum superficialis tendon will produce no movement. Figure 5 illustrates these techniques.

The prognosis for patients with jersey finger worsens if treatment is delayed and if severe tendon retraction is present.²⁰ Patients with confirmed or suspected jersey finger should be referred to an orthopedic or hand surgeon for treatment.¹⁸

CENTRAL SLIP EXTENSOR TENDON INJURY

Central slip extensor tendon injury occurs when the PIP joint is forcibly flexed while actively extended; it is a common injury in basketball players. Volar dislocation of the PIP joint also can cause central slip ruptures.²¹

The PIP joint should be evaluated by holding the joint in a position of 15 to 30 degrees of flexion. If the PIP joint is injured, the patient will be unable to actively extend the joint; however, passive extension should be possible. Tenderness over the dorsal aspect of the middle phalanx will be present. A delay in proper treatment may cause a boutonnière deformity (flexion of the PIP joint coupled with hyperextension of the DIP and MCP joints) (Figure 6). A boutonnière deformity usually develops over several weeks as the intact lateral bands of the extensor tendon slip inferiorly. Occasionally, boutonnière deformities occur acutely.

The PIP joint should be splinted in full extension for six weeks if there is no avulsion or if the avulsion involves less than one third of the joint. All available splints (Figure 3) can be used to treat PIP injuries, except for the stack splint, which is used only for DIP injuries. As with mallet finger, extension of the PIP joint must be maintained continuously. If full passive extension is not possible, the physician should refer the patient to an orthopedic or hand surgeon.

Patients with PIP joint injuries may continue to participate in athletic events during the splinting period, although some sports are difficult to play with a fully-extended PIP joint. Splinting duration is the same as with mallet finger.

COLLATERAL LIGAMENT INJURIES

Forced ulnar or radial deviation at any of the interphalangeal joints can cause partial or complete collateral ligament tears. The PIP joint usually is involved in collateral ligament injuries, which are commonly classified as “jammed fingers.”

Collateral ligament injuries present as pain located only at the affected ligament. The injury should be evaluated by applying valgus or varus stress to the involved joint in 30 degrees of flexion while the MCP joint is flexed at 90 degrees; an extended MCP joint will tighten the collateral ligaments, inhibiting the evaluation. The physician should compare the laxity of the injured finger with an unaffected finger. Radiography may demonstrate an avulsion fracture at the ligamentous insertion point.

If the joints are stable and no large fracture fragments are present, the injury can be treated with buddy taping (i.e., taping the injured finger, above and below the joint, to an adjacent finger) (Figure 7). If the ring finger is involved, it should be secured to the fifth digit, because the fifth digit is naturally extended and easily injured if exposed.

Patients with collateral ligament injuries may continue participating in athletic events as symptoms allow. If joints are unstable with active ranges of motion, patients should be referred to an orthopedic or hand surgeon. A low threshold for referral should exist for collateral ligament injuries in children, because the growth plate often is involved.^7,11

VOLAR PLATE INJURY

Hyperextension of a finger joint, such as a dorsal dislocation, can injure the volar plate (Figure 8). The PIP joint usually is affected, and collateral ligament damage often is present. The volar plate can be partially or completely torn, with or without an avulsion fracture. ¹¹ The subsequent loss of joint stability may allow the extensor tendon to gradually pull the joint into hyperextension, causing deformity.

Maximal tenderness will be located at the volar aspect of the affected joint. Full extension and flexion will be possible if the joint is stable. The collateral ligaments should be tested as with collateral ligament injuries. Radiographs may show an avulsion fragment at the base of the involved phalanx.

A stable joint without a large avulsion fragment should be splinted with a progressive extension splint (“block splint”) (Figure 9) starting at 30 degrees of flexion^7,22 for two to four weeks, depending on injury severity; buddy taping should follow. Increasing the extension of a dorsal aluminum splint weekly will progressively increase range of motion.²² In less severe injuries, the injured joint should be buddy taped. This will restrict some extension and provide support. These two techniques may allow a patient to continue participating in athletic events sooner; however, participation depends on the athlete’s sport and position; it is difficult to play some sports with a flexed PIP joint. Referral criteria include an unstable joint or a large avulsion fragment.

Hand tendon repair – NHS

If any of the tendons in your hand are damaged, surgery may be needed to repair them and help restore movement in the affected fingers or thumb.

What are tendons?

Tendons are tough cords of tissue that connect muscles to bones.

When a group of muscles contract (tighten), the attached tendons will pull on certain bones, allowing you to make a wide range of movements.

There are 2 groups of tendons in the hand:

• extensor tendons – which run from the forearm across the back of your hand to your fingers and thumb, allowing you to straighten your fingers and thumb
• flexor tendons – which run from your forearm through your wrist and across the palm of your hand, allowing you to bend your fingers

Surgery can often be used to repair damage to both these groups of tendons.

When hand tendon repair is needed

Hand tendon repair is needed when 1 or more tendons in your hand rupture (break or split) or are cut, leading to the loss of normal hand movements.

If your extensor tendons are damaged, you’ll be unable to straighten 1 or more fingers. If your flexor tendons are damaged, you’ll be unable to bend 1 or more fingers.

Tendon damage can also cause pain and swelling (inflammation) in your hand.

Sometimes, damage to the extensor tendons can be treated without the need for surgery, using a rigid support called a splint that’s worn around the hand.

Common causes of tendon injuries include:

• cuts – cuts across the back or palm of your hand can result in injury to your tendons
• sports injuries – extensor and flexor tendons can be injured when playing sports like rugby, and the pulleys holding flexor tendons can rupture if you do a lot of strenuous gripping like in rock climbing
• animal and human bites – these type of bites can cause tendon damage, and a person may damage their hand tendon after punching another person in the teeth
• crushing injuries – jamming a finger in a door or crushing a hand in a car accident can divide or rupture a tendon
• rheumatoid arthritis – rheumatoid arthritis can cause tendons to become inflamed which, if severe, can lead to them rupturing

Tendon repair surgery

Tendon repair may involve a surgeon making a cut (incision) in your wrist, hand or finger so they can locate the ends of the divided tendon and stitch them together.

Extensor tendons are easier to reach, so repairing them is relatively straightforward.

Read more about how hand tendon repair is performed.

Recovering from surgery

Both types of tendon surgery require a lengthy period of recovery (rehabilitation) because the repaired tendons will be weak until the ends heal together.

Depending on the location of the injury, it can take up to 3 months for the repaired tendon to regain its previous strength.

Rehabilitation involves protecting your tendons from overuse using a hand splint. You’ll usually need to wear a hand splint for several weeks after surgery.

You’ll also need to perform hand exercises regularly during your recovery to stop the repaired tendons sticking to nearby tissue, which can prevent you being able to fully move your hand.

When you can return to work will depend on your job. Light activities can often be resumed after 6 to 8 weeks, and heavy activities and sport after 10 to 12 weeks.

Read more about recovering from hand tendon repair.

Results

After an extensor tendon repair you should have a working finger or thumb, but you may not regain full movement.

The outcome is often better when the injury is a clean cut to the tendon, rather than one that involves crushing or damage to the bones and joints.

A flexor tendon injury is generally more serious because they’re often put under more strain than extensor tendons.

After a flexor tendon repair, it’s quite common for some fingers to not regain full movement. But the tendon repair will still give a better result than not having surgery.

Complications can sometimes develop after surgery, such as infection or the repaired tendon snapping or sticking to nearby tissue. In these circumstances, further treatment may be required.

Page last reviewed: 06 September 2021
Next review due: 06 September 2024

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Treatment of damage to the tendons of the fingers in Kyiv – consultation price from 1000 UAH

Injuries are classified as single and multiple. They occur with cuts, bruises, open and closed fractures of bones, and other mechanical influences. Specialists observe frequent injury to the extensor and flexion systems.

Prices of the Department of Operative Orthopedics and Traumatology

Our fingers and hands experience different stresses every day. Some of which lead to serious injuries not only to soft tissues, but also to tendons. Such pathologies significantly impair performance. Tendon injuries have their own specifics. They are unable to recover on their own. Surgery is required. Damage is classified as single and multiple. They occur with cuts, bruises, open and closed fractures of bones, and other mechanical influences. Specialists observe frequent injury to the extensor and flexion systems.

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Causes and treatment

Injuries to the flexor tendons of the fingers are much more common than other types of injuries. The main causes are cuts and deep wounds with sharp objects. The injury often has a deep character, which is a consequence of the loss of flexion functions. It is possible to restore work with a timely operation and long-term rehabilitation.

Injury to the extensor tendons of the fingers is less dangerous, but also results in poor hand and finger function. When receiving such an injury, it is very important to provide the correct first aid. It consists in applying a tourniquet, a sterile bandage and ice. All these actions are necessary to slow down bleeding. After that, the hand must be shown to the doctor to assess the complexity of the disease. Treatment is prescribed depending on the level of the depth of damage.

Injury to the tendons of the fingers requires immediate surgery. Quite often there is a need for microsurgical techniques. In case of serious injuries, doctors apply primary and secondary sutures.

Injury to the tendons of the fingers is a serious problem in which the sooner treatment is started, the sooner the basic functions of the hand are restored.