The Middle Finger
Author: Bryan Knoedler, MD
Peer-Reviewer: Mark Hopkins, MD, CAQ-SM
Final Editor: Alex Tomesch, MD, CAQ-SM
A 15-year-old female sustains a jammed right middle finger while playing basketball. She presents to the ED with pain and swelling over the volar aspect of the proximal interphalangeal joint. X-ray is as follows below.
Image 1. Case courtesy of Rob Foley, Radiopaedia.org, rID: 81457
What is the diagnosis?
Avulsion fracture at the volar base of the middle phalanx, at the location of the volar plate.
-
Pearl: The volar plate resists joint hyperextension, while the collateral ligaments that insert onto the volar base of the proximal interphalangeal phalanx are the primary restraints to motion side-to-side [1,2,3].
-
Pearl: Phalanx fractures are common and account for 10% of all fractures and 26% of all missed fractures [4,5].
Image 2. Annotation of previous image by author. Case courtesy of Rob Foley, Radiopaedia.org, rID: 81457
What are the recognized complications?
Mismanagement or delayed treatment can result in chronic PIP joint problems to include stiffness, subluxation, and swan neck deformities (Image 3), leading to weakness of grip and poor function [2,14]. Similarly, prolonged splinting can lead to stiff joints.
Image 3. Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 22945
References
[1] Miller EA, Friedrich JB. Management of finger joint dislocation and fracture-dislocations in athletes. Clinics in Sports Medicine. 2020;39(2):423-442. doi:10.1016/j.csm.2019.10.006
[2] Blazar PE, Steinberg DR. Fractures of the proximal interphalangeal joint: Journal of the American Academy of Orthopaedic Surgeons. 2000;8(6):383-390. doi:10.5435/00124635-
[3] Kiefhaber TR, Stern PJ, Grood ES. Lateral stability of the proximal interphalangeal joint. The Journal of Hand Surgery. 1986;11(5):661-669. doi:10.1016/S0363-5023(86)
[4] Kee C, Massey P. Phalanx fracture. In: StatPearls. StatPearls Publishing; 2023. Accessed July 19, 2023. http://www.ncbi.nlm.nih.gov/
[5] Haughton D, Jordan D, Malahias M, Hindocha S, Khan W. Principles of hand fracture management. TOORTHJ. 2012;6(1):43-53. doi:10.2174/
[6] Leclère FM, Mathys L, Juon B, Vögelin E. The role of dynamic ultrasound in the immediate conservative treatment of volar plate injuries of the pip joint: a series of 78 patients. Plast Surg (Oakv). 2017;25(3):151-156. doi:10.1177/2292550317716122
[7] Weber DM, Kellenberger CJ, Meuli M. Conservative treatment of stable volar plate injuries of the proximal interphalangeal joint in children and adolescents: a prospective study. Pediatric Emergency Care. 2009;25(9):547-549. doi:10.1097/PEC.
[8] Pattni A, Jones M, Gujral S. Volar Plate Avulsion Injury. Eplasty. 2016;16:ic22. Published 2016 Jun 1.
[9] Borchers JR, Best TM. Common finger fractures and dislocations. Am Fam Physician. 2012;85(8):805-810
[10] Kiefhaber TR, Stern PJ. Fracture dislocations of the proximal interphalangeal joint. The Journal of Hand Surgery. 1998;23(3):368-380. doi:10.1016/S0363-5023(05)
[11] Eaton RG, Malerich MM. Volar plate arthroplasty of the proximal interphalangeal joint: A review of ten years’ experience. The Journal of Hand Surgery. 1980;5(3):260-268. doi:10.1016/S0363-5023(80)
[12] Body R, Ferguson CJ. Early mobilisation for volar plate avulsion fractures. Emergency Medicine Journal. 2005;22(7):505-505. doi:10.1136/emj.2005.026559
[13] Lunger A, Lunger L, Bach A, Frey C, Jandali AR, Sproedt J. [Early active motion management of volar plate disruption of the proximal interphalangeal joint after finger hyperextension injury: extension block splinting versus buddy taping]. Handchir Mikrochir Plast Chir. 2017;49(5):297-303. doi:10.1055/s-0043-117736
[14] Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J Orthop Sports Phys Ther. 2004;34(12):781-799. doi:10.2519/jospt.2004.34.12.