Patient assessment

Hand surgery involves a multi-specialty approach to the assessment, treatment, and aftercare of hand trauma. Therefore, the specialized teams should be involved early on according to the specific injury requirements.

A diagnosis is made based on the history, the mechanism of the trauma, clinical examination, and by x-rays in 2 planes.

The outcome of injuries of the fingers may be assessed by three criteria:

Functional return
Clinical assessment
Radiological healing

Recommendations for the definition of extraarticular phalangeal fracture displacement vary. In the following, the definitions of the important relevant displacement are:

No malrotation is accepted
>2 mm of translation or axial displacement
>10° of angular displacement

Freeland AE, Geissler WB, Weiss APC. Surgical treatment of common displaced and unstable fractures of the hand. Instr Course Lect. 2002:51:185–201.

Check for:

Swelling
Open wound
Loss of sensation in the fingers (indicating nerve injuries)
Perfusion (reperfusion of more than 2 seconds may indicate vascular injuries)

General assessment of hand and wrist

Check for anatomical architecture (position and relation) of the whole hand:

Longitudinal arc
Metacarpal arc
Oblique arcs (with thumb in opposition)

Clinical and radiological assessment of middle phalangeal injury: check hand's longitudinal, metacarpal, and oblique arcs.

The tips of the flexed fingers should point to the scaphoid. Check for deviating or overlapping fingers. This will indicate malrotation.

The nails should be aligned.

Clinical and radiological assessment of middle phalangeal injury: check for finger alignment, malrotation, and nail alignment.

Flexing the fingers shows some overlap of the tip of the ring finger with the little finger which indicates rotational malalignment.

Clinical and radiological assessment of middle phalangeal injury: flexed fingers show ring and little finger overlap, indicating rotational malalignment.

Assessment of the middle phalanx

Check for shortening of a finger. An interrupted arch of the DIP joints indicates shortening.

Clinical and radiological assessment of middle phalangeal injury: check for finger shortening and interrupted DIP joint arch.

Check for deformity of a phalanx. In a fracture situation, the distal fragment may be pulled into flexion.

$Clinical and radiological assessment of middle phalangeal injury: check for phalanx deformity, distal fragment flexion in fractures.$

Lateral stress test

Check the MCP, PIP, and DIP joint stability (varus/valgus stress test). Compare this with the contralateral finger.

Lack of lateral stability indicates injury of the collateral ligaments or their bony attachments.

A typical sign of collateral ligament injuries is abnormal lateral mobility of the PIP joint, persisting after reduction of the dislocation, when the patient can flex and extend the finger.

Clinical and radiological assessment of middle phalangeal injury: check for abnormal lateral PIP joint mobility after dislocation reduction.

Lateral (varus/valgus) stress test showing lateral joint instability. This should be performed with slight joint flexion (ca 20°).

Clinical and radiological assessment of middle phalangeal injury: lateral stress test shows joint instability with slight flexion (20°).

Use gentle passive lateral stress to detect instability. If instability is present, this may indicate an impaction fracture or, rarely, avulsion of a collateral ligament.

$Clinical and radiological assessment of middle phalangeal injury: gentle lateral stress detects instability, indicating impaction fracture or collateral ligament avulsion.$

Recognizing detachment of the central slip

Early diagnosis of injuries is important. This is not always easy due to the swelling and often inconclusive x-rays.

Boutonnière deformity is an indication for central band avulsion.

Stark maneuver

Keep the PIP joint hyperextended. Passively flex the DIP joint.

If passive movement of the DIP joint is limited, this strongly indicates a central slip detachment.

Compare this with the uninjured hand.

Clinical and radiological assessment of middle phalangeal injury: hyperextend PIP joint, passively flex DIP joint; limited movement indicates central slip detachment; compare with uninjured hand.

Elson test

The PIP joint of the injured finger is flexed to 90° and, with the hand resting on a table, the finger is positioned over the edge of a table.

Hold the middle phalanx in position and ask the patient to extend the distal phalanx. The test is positive, if there is weak extension at the PIP joint with hyperextension at the DIP joint.

Please create an Alt text of about 100 characters, without your comments or quotation marks, for an illustration with the following text: Clinical and radiological patient assessment in suspected middle phalangeal injury, The PIP joint of the injured finger is flexed to 90° and, with the hand resting on a table, the finger is positioned over the edge of a table.

Alternative to the Elson test

To recognize detachment of the central slip, ask the patient to extend the PIP joint with the MCP joint in hyperextension.

If the PIP joint can be fully extended in this position, the central slip is still attached, and nonoperative treatment may be indicated.

Pitfall: If the MCP joint is not hyperextended, extension of the PIP joint may still be possible, even with a detached central slip. In this case, the intrinsic muscles will extend the joint.

PIP stability check

Ask the patient to flex the finger under image intensification. Ultrasound may be helpful to evaluate the instability of the injury in a dynamic way. Passive lateral movement of the finger under image intensification will help to assess lateral stability.

X-rays

AP view of the whole hand and true lateral view of the finger are needed for diagnosis.

All views need to be inspected to get information about the fracture pattern, eg, the orientation of an oblique fracture plane.

These x-rays show an articular fracture of the 4th middle phalangeal head with extension in the shaft.

Obliquity of the fracture is possible either in the plane visible in the AP view or the plane visible in the lateral view. Always confirm the fracture configuration with views in both planes.

$Please create an Alt text of about 100 characters, without your comments or quotation marks, for an illustration with the following text: Clinical and radiological patient assessment in suspected middle phalangeal injury, Obliquity of the fracture is possible either in the plane visible in the AP view or the plane visible in the lateral view. Always confirm the fracture configuration with views in both planes.$

Ultrasound

Ultrasound evaluation may help define suspected ligament and tendon injuries.

This image shows an avulsion of the volar plate from the proximal phalanx.

This video shows the same soft-tissue lesion under active motion of the PIP joint.

Clinical and radiological assessment of middle phalangeal injury: video shows soft-tissue lesion under active PIP joint motion.

CT imaging

CT imaging is helpful to assess impacted intraarticular fractures, to evaluate the fragmentation and plan for reconstruction.

Coronal and sagittal CT views of the middle phalangeal base showing an articular fracture with central impaction.

$Clinical and radiological assessment of middle phalangeal injury: CT imaging assesses intraarticular fractures, evaluates fragmentation, and aids reconstruction planning; coronal and sagittal CT views show articular fracture with central impaction.$

MRI

Isolated ligamentous injuries may be seen in an MRI.

Often, a subluxation is not immediately apparent on the lateral view. In the lateral x-ray, look for the characteristic “V” sign of diverging joint surfaces, which indicates this injury.

In the lateral view, the dorsal cortical profiles of the proximal and middle phalanges should be collinear. Any axial malalignment is a clear indication of subluxation.