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Jammed Finger
Article Last Updated: Nov 20, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Michael E Robinson, MD, Consulting Staff, Department of Orthopedics, Division of Primary Care Sports Medicine, Permanente Medical Group and Kaiser Hospital
Michael E Robinson is a member of the following medical societies: American Academy of Family Physicians, American Medical Society for Sports Medicine, and Wilderness Medical Society
Editors: Leslie Milne, MD, Assistant Clinical Instructor, Department of Emergency Medicine, Harvard University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital; Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Author and Editor Disclosure
Synonyms and related keywords:
sprained finger, dislocated finger, finger sprain, finger dislocation, jammed digit dislocated digit, sprained digit, finger injury, digit injury, finger trauma, proximal interphalangeal joint trauma, PIP joint trauma, proximal interphalangeal joint dislocation, PIP joint dislocation, proximal interphalangeal joint, PIP joint
Background
The layman's term "jammed finger" often refers to injuries that are incurred around the proximal interphalangeal (PIP) joint of the fingers (see Image 1). Although imprecise in its diagnostic accuracy, jammed finger aptly describes a constellation of injuries that are related to varying degrees of axial loading across the PIP joint.
(See also the eMedicine articles Hand, Finger Nail and Tip Injuries [in the Plastic Surgery section], Dislocations, Interphalangeal [in the Emergency Medicine section], Mallet Finger and Boutonniere Deformity [in the Orthopedic Surgery section], and Mallet Fracture [in the Sports Medicine section], as well as Interventions for Treating Mallet Finger Injuries, Rehabilitation After Surgery for Flexor Tendon Injuries in the Hand, and Assessing the Hands and Wrists in Elderly People on Medscape.) Injury to the PIP joint is common in athletic activities, especially ball-handling sports, but this condition is often minimized by players and coaches. The anatomy of the PIP joint is complex, and several types of injuries can result in permanent disability if they are left undiagnosed or mistreated. The sports medicine practitioner must develop a working knowledge of these common injury patterns so that timely and appropriate treatment can be provided.
For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Broken Finger, Finger Dislocation, and Finger Injuries.
Functional Anatomy
The PIP joint is a hinge joint that permits a range of motion (ROM) from 0-120° (see Image 1).1, 2, 3 Relatively thick collateral ligaments provide lateral stability. Unlike the metacarpophalangeal (MCP) joint, the tension of these ligaments does not vary during ROM. The volar plate forms the floor of the joint and separates the joint space from the flexor tendons. The volar plate is ligamentous at its origin on the proximal phalanx and cartilaginous in its insertion onto the middle phalanx. Dorsally, the central slip of the extensor tendon acts to stabilize the joint and to extend the middle phalanx. The lateral bands, joined by the retinacular ligaments of the intrinsic hand muscles, go around the joint to form the distal extensor tendon and also contribute to joint stability. The common mechanism of injury at the PIP joint involves the simultaneous application of hyperextension forces with some degree of longitudinal compression. Volar plate disruption (see Image 2) - Mild forces may rupture the volar plate at its distal insertion on the middle phalanx; the articular surfaces remain intact. This is a stable injury. Local pain and edema generally produce only short-term disability.
- Occasionally, fractures of the middle phalanx at the attachment of the volar plate occur. These fractures usually involve less than 30-40% of the joint surface and are thought to be stable due to maintenance of collateral ligament integrity. (See also the eMedicine article Phalangeal Fractures.)
Dorsal dislocation (see Image 3) - If the force of injury is great enough, rupture of the volar plate may occur along with longitudinal splitting in the collateral ligament structures, allowing complete dorsal displacement of the middle phalanx. Simple dislocations are readily reduced, often by the player, coach, or trainer on the field. Following reduction, most dorsal dislocations are stable.
- Fractures at the base of the middle phalanx also occur in association with dorsal dislocations. If a fracture involves more than 40-50% of the articular surface, collateral ligament support is lost. Combined with the coexistent volar plate disruption, this reduction of collateral ligament support represents a major loss of joint stability. These injuries are often unstable, exhibiting persistent subluxation of the middle phalanx.
Collateral ligament injury - Angular forces may cause partial or complete rupture of a collateral ligament. When combined with volar plate rupture, lateral dislocation can occur. Most lateral dislocations are easily reduced and do not demonstrate gross instability.
- Because of scar-tissue formation in the healing ligament, these injuries often result in enlargement of the PIP joint ("fat knuckle"). This may be of cosmetic concern to some patients, but good functional recovery can usually be expected.
Boutonniere deformity (see Image 4) - The term "boutonniere" comes from the French word for "buttonhole." This injury involves a disruption of the central slip of the extensor tendon at its insertion on the middle phalanx. The mechanism of injury is a blow to the dorsum of the PIP joint, such as when an athlete's hand is stepped on. Occasionally, a small fleck fracture of the middle phalanx is seen at the central slip insertion. Volar dislocation of the PIP joint is thought to be a component in many cases.
- Little deformity may be noted immediately after an injury that results in a boutonniere deformity. The lateral bands may still act weakly to aid joint extension. Left untreated, the central slip retracts and the lateral bands displace volarly below the axis of rotation, becoming flexors of the PIP joint. Thus, the classic deformity of PIP joint flexion and distal interphalangeal (DIP) joint hyperextension is produced. Once a deformity becomes chronic or fixed, it presents a difficult surgical challenge, with potentially permanent functional deficits.
- Because volar dislocations may be reduced spontaneously or before the office visit and because the symptoms and signs of such injuries may be subtle, practitioners must maintain a high index of suspicion for central slip disruption when evaluating any PIP joint injury. Patients may have more pain dorsally, and there is usually weakness or the inability to fully extend the PIP joint.
History
- The athlete typically sustains an axial loading blow to the finger that is combined with hyperextension.
- Dorsal trauma produces a volar dislocation force with a concurrent central slip injury.
- Radial- or ulnar-directed forces could produce a collateral ligament injury/lateral dislocation.
- Inquire about potential dislocations that were reduced on the field. Careful attention to the mechanism of injury may help pinpoint the diagnosis.
Physical
- Consider obtaining radiographs before physical examination of the affected finger to evaluate for potentially unstable fractures/dislocations.
- Document the integrity of the neurovascular status of the affected finger as well as that of the entire hand.
- Observe and palpate the affected finger, with attention to focal areas of tenderness and edema.
- Assess tendon function and ROM of the affected finger, with particular attention to active extension. Loss of active extension indicates a central slip injury.
- Assess the joint stability of the affected finger.
- If pain of the affected finger precludes a definitive diagnosis, consider using metacarpal block anesthesia to examine the digit's tendon function and stability.
Gamekeeper's Thumb
Mallet Fracture
Metacarpophalangeal Joint Dislocation
Phalangeal Fractures
Skier's Thumb
Other Problems to Be Considered
Collateral ligament injury
Hand, Fracture and Dislocations: Metacarpal
Lab Studies
- Laboratory studies are not indicated for the diagnosis of PIP joint injuries.
Imaging Studies
- Obtain anteroposterior, lateral, and oblique radiographs of the injured digit. Radiographic interpretation includes assessing the PIP joint for dislocation, subluxation, and fractures.
Acute Phase
Rehabilitation Program
Physical Therapy
- Volar plate sprain: Treatment of a mild finger hyperextension injury usually requires only 1-2 weeks of protective buddy taping to an adjacent finger in addition to the institution of early ROM exercises. Taping should continue during athletic or at-risk activities until full pain-free ROM is obtained. Volar plate disruptions that involve fractures of the middle phalanx should be treated as dislocations.
- Dorsal dislocation: Simple dorsal PIP dislocations, including those with small middle phalanx fractures, are generally stable following reduction. The usual treatment is dorsal splinting with the joint in 10-30° of flexion for 2 weeks. Such an extension block splinting limits further injury to the volar plate (see Image 5). The stabilizing tape on the middle phalanx can be removed to allow the finger to flex but not for it to fully extend. Place 2 stabilizing tapes on the proximal phalanx to hold the splint in place. Aluminum foam splints are commonly used, and some commercial devices are available; Coban wrapping (3M Health Care, St Paul, Minn) can be used to control swelling. Following the initial treatment period, begin ROM exercises. Continue protective splinting or buddy taping for 4-6 weeks during athletic or at-risk activities.
- Collateral ligament injury: Partial collateral ligament tears may be treated with buddy taping and early ROM exercises. Lateral dislocations are also typically treated with dorsal splinting in slight flexion for 2 weeks. Additionally, buddy taping to the digit that is ipsilateral to the injured ligament is recommended to help control joint stability. Initiate ROM exercises after 2 weeks. Continue protective buddy taping of the digit for sports activities until pain-free function returns.
- Boutonniere deformity: Treatment of an acute central slip injury consists of splinting the PIP joint in full extension for 6 weeks (see Image 6); DIP joint ROM exercises are encouraged. Typically, an aluminum foam splint is placed over the dorsum of the joint. Some commercial splints are available, including dynamic spring devices (see Image 7). After 6 weeks, ROM exercises are initiated. The use of a static splint at night or a dynamic ROM splint device for an additional 2 weeks is often recommended. The use of protective splinting in extension is advised during sports or at-risk activities for 4-6 weeks or until full pain-free function is restored.
Surgical Intervention
- Any dislocation that cannot be easily reduced by the usual means may indicate the interposition of soft-tissue structures. This should prompt consultation with an orthopedic surgeon for open reduction.4, 5, 6
- Fracture-dislocations that are unstable, exhibit persistent subluxation of the middle phalanx, or involve large portions of the articular surface should be referred for surgical fixation.6, 7
- Grossly unstable collateral ligament injuries may be considered for surgical repair.
- Surgical reconstruction is the treatment of choice for chronic boutonniere deformity.3, 8
Nonsteroidal anti-inflammatory drugs (NSAIDs) and analgesics are generally used to treat the pain that is associated with a PIP joint injury.
Drug Category: Nonsteroidal anti-inflammatory drugs
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
| Drug Name | Ibuprofen (Motrin, Ibuprin) |
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| Description | DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis |
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| Adult Dose | 400-800 mg PO tid with food |
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| Pediatric Dose | 10 mg/kg PO tid with food |
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| Contraindications | Documented hypersensitivity; patients who have peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding |
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| Interactions | Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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| Precautions | Category D in third trimester of pregnancy; caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy |
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| Drug Name | Ketoprofen (Oruvail, Orudis, Actron) |
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| Description | For the relief of mild to moderate pain and inflammation.
Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects.
Administer high doses with caution and closely observe the patient for response. |
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| Adult Dose | 25-50 mg PO q6-8h prn; not to exceed 300 mg/d |
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| Pediatric Dose | 3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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| Precautions | Category D in third trimester of pregnancy; caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy |
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| Drug Name | Naproxen (Naprelan, Anaprox, Naprosyn, Aleve) |
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| Description | For the relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis |
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| Adult Dose | 500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d |
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| Pediatric Dose | <2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency |
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| Interactions | Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
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| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug. |
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Drug Category: Narcotic analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries.
| Drug Name | Acetaminophen and codeine (Tylenol #3) |
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| Description | For the relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis |
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| Adult Dose | 30-60 mg/dose based on codeine q4-6h; not to exceed 12 tab/24 h |
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| Pediatric Dose | Codeine dose: 0.5-1 mg/kg/dose
Acetaminophen: 10-15 mg/kg/dose q4-6 h |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency |
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| Interactions | The toxicity of this drug increases when administered concurrently with CNS depressants; coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | |
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| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug |
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| Drug Name | Hydrocodone bitartrate and acetaminophen (Vicodin ES, Lortab, Lorcet-HD) |
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| Description | Drug combination that is indicated for moderate to severe pain |
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| Adult Dose | 1-2 tab or cap PO q4-6h prn |
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| Pediatric Dose | <12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
|
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| Contraindications | Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP) |
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| Interactions | Coadministration with phenothiazines may decrease the analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
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| Precautions | Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction |
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| Drug Name | Propoxyphene and acetaminophen (Darvocet-N 100, Wygesic) |
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| Description | Drug combination that is indicated for mild to moderate pain |
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| Adult Dose | 1-2 tab PO q4h prn; not to exceed 600 mg/d |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity |
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| Interactions | May increase serum concentrations of MAO inhibitors, tricyclic antidepressants, carbamazepine, phenobarbital, and warfarin |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
|
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| Precautions | Caution in patients who are dependent on opiates because the substitution may result in acute opiate withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction |
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Return to Play
The time frame for an athlete's return to play is dependent on the severity of the finger injury. An athlete with a mild PIP joint sprain without ligamentous disruption may be permitted to return to play after being evaluated on the sideline, provided the finger is properly buddy-taped. Those individuals with more severe sprains or dislocations/fractures may be recommended to remain out of competition for a longer period (2-6 wk). Protective splinting or buddy taping is advised during athletic or at-risk activities until full pain-free function is restored.
Complications
Possible complications that follow a PIP joint injury include persistent pain and swelling, stiffness, weakness, instability, and boutonniere deformity.
Prevention
Most cases of jammed finger injuries are not preventable in sports activities.
Prognosis
The prognosis for a jammed finger is excellent with the proper treatment and protection.
Medical/Legal Pitfalls
- Failure to recognize an unstable injury and failure to initiate an appropriate referral to an orthopedic specialist
- Failure to recognize a central slip injury, resulting in chronic boutonniere deformity
| Media file 1:
Anatomy of the proximal interphalangeal joint. The central slip passes directly over the joint and inserts on the base of the middle phalanx. The lateral bands pass around the joint, combine with the retinacular ligaments, and unite to form the extensor tendon that attaches on the distal phalanx. Lateral motion is minimized by the collateral ligaments, and extension is limited to 0º by the thick volar plate. |
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Media type: Illustration
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| Media file 2:
Volar plate disruption with a stable, nondisplaced avulsion fracture of the middle phalanx. |
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Media type: X-RAY
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| Media file 3:
Dorsal dislocation of the proximal interphalangeal joint. |
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Media type: X-RAY
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| Media file 5:
Extension block splint with the proximal interphalangeal joint at 30°. |
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Media type: Photo
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| Media file 6:
Proximal interphalangeal joint that has been splinted in extension for the treatment of a central slip injury. |
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Media type: Photo
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| Media file 7:
Dynamic spring extension splint for the treatment of a boutonniere finger deformity. |
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Media type: Photo
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- Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. Philadelphia, Pa: WB Saunders Co; 1992.
- Rockwood CA, Green DP, Bucholz RW, eds. Rockwood and Green's Fractures in Adults. 3rd ed. Philadelphia, Pa: JB Lippincott; 1991.
- Robinson ME, Sallis RE, Massimino F, eds. Fracture diagnosis and management of common injuries. ACSM's Essentials of Sports Medicine. St Louis, Mo: Mosby; 1997:509-16.
- Houshian S, Chikkamuniyappa C. Distraction correction of chronic flexion contractures of PIP joint: comparison between two distraction rates. J Hand Surg [Am]. May-Jun 2007;32(5):651-6. [Medline].
- Freiberg A, Pollard BA, Macdonald MR, Duncan MJ. Management of proximal interphalangeal joint injuries. Hand Clin. Aug 2006;22(3):235-42. [Medline].
- Hamilton SC, Stern PJ, Fassler PR, Kiefhaber TR. Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations. J Hand Surg [Am]. Oct 2006;31(8):1349-54. [Medline].
- Ellis SJ, Cheng R, Prokopis P, et al. Treatment of proximal interphalangeal dorsal fracture-dislocation injuries with dynamic external fixation: a pins and rubber band system. J Hand Surg [Am]. Oct 2007;32(8):1242-50. [Medline].
- Hoffman DF, Schaffer TC. Management of common finger injuries. Am Fam Physician. May 1991;43(5):1594-607. [Medline].
- Claudet I, Toubal K, Carnet C, Rekhroukh H, Zelmat B, Debuisson C. [When doors slam, fingers jam!] [French]. Arch Pediatr. Aug 2007;14(8):958-63. [Medline].
- Cornwall R, Ricchetti ET. Pediatric phalanx fractures: unique challenges and pitfalls. Clin Orthop Relat Res. Apr 2006;445:146-56. [Medline].
- Kawamura K, Chung KC. Fixation choices for closed simple unstable oblique phalangeal and metacarpal fractures. Hand Clin. Aug 2006;22(3):287-95. [Medline].
- Lindley SG, Rulewicz G. Hand fractures and dislocations in the developing skeleton. Hand Clin. Aug 2006;22(3):253-68. [Medline].
- Rettig AC. Epidemiology of hand and wrist injuries in sports. Clin Sports Med. Jul 1998;17(3):401-6. [Medline].
- Theivendran K, Pollock J, Rajaratnam V. Proximal interphalangeal joint fractures of the hand: treatment with an external dynamic traction device. Ann Plast Surg. Jun 2007;58(6):625-9. [Medline].
Jammed Finger excerpt Article Last Updated: Nov 20, 2007
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