Dr. Suzanne Steinman shares a case illustrating how a clinical exam can reveal rotational malalignment of finger fractures that may be missed in radiographs.

For more general information on hand fractures, visit our Hand and Upper Extremity Program.

Patient History

Steinman COTM Figure 1

Figure 1

A 9-year-old-male fell into his right hand while playing soccer and bent his index finger backward. After the fall, the patient had pain and swelling at the base of the index finger. He was seen in the Emergency Department and diagnosed with a Salter-Harris II fracture of the proximal phalanx with minimal displacement (Figs. 1 and 2).

Steinman COTM Figure 2

Figure 2

He was splinted and referred for further treatment. At his orthopedic visit, the splint was removed for clinical assessment. Skin was intact, and there was no significant angular malalignment noted (Fig. 3), but check for malrotation revealed significant malalignment with radial rotation of the index finger (Fig. 4).

Patient Diagnosis

Steinman COTM Figure 3

Figure 3

Rotational malalignment of a Salter-Harris II fracture of the index finger proximal phalanx.


Steinman COTM Figure 4

Figure 4

The patient underwent a closed reduction under sedation of the index finger and was treated in a cobra cast for three weeks, followed by three weeks of buddy taping the index finger to the middle finger. This allows the patient to start working on range of motion in a protected manner while the bone completes its healing.


Steinman COTM Figure 5

Figure 5

Rotational malalignment of finger fractures is a frequently missed aspect of a post-injury exam that can lead to serious complications if not corrected. Radiographs do not usually show rotational malalignment so the fingers must be examined clinically. The normal cascade of the fingers when flexed at the metacarpal phalangeal joints and proximal interphalangeal joints has all the fingers pointing at the scaphoid tubercle (Fig. 5 - noninjured hand). This is important to identify because rotational malalignment does not remodel like angular malalignment in children, and malunion can cause difficulty with grip, as the fingers are not aligned. When identified early, these injuries can often be treated with closed reduction under a local anesthetic or light sedation followed by casting. If these are missed, however, then they may require surgical intervention if there are functional deficits.


Steinman COTM Figure 6

Figure 6

The patient went on to heal with restored alignment and returned to all his pre-injury activities without difficulty (Fig. 6).

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