Introduction
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.
Clinical
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.
More on Jammed Finger |
 Overview: Jammed Finger |
| Differential Diagnoses & Workup: Jammed Finger |
| Treatment & Medication: Jammed Finger |
| Follow-up: Jammed Finger |
| Multimedia: Jammed Finger |
| References |
| Next Page » |
References
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].
Further Reading
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
