To develop a clinical decision guide for the diagnosis and treatment of hyperextension injuries of long fingers.

Consecutive patients age <16 years (n = 300) with an acute proximal interphalangeal (PIP) joint hyperextension injury were included. High-risk and low-risk measures for severe injury were established with a standardized clinical examination and anteroposterior and lateral radiographs of the injured finger. Four clinical variables were assessed: location of pain; swelling and bruising, stability, and mobility. Pathological radiographic findings were compiled, and the risk of late complications was analyzed. The predictive value of the clinical examination in the identification of low-risk injuries was assessed.

The majority (67%) of children consulting for a hyperextension finger trauma did not have a fracture. No child with a low-risk clinical examination had a subsequent high-risk diagnosis (eg, relevant intra-articular fracture, dislocation). Among 64 clinical high-risk diagnoses only 12 significant fractures were found.

Treatment decisions after PIP hyperextension injuries can be based on a clinical examination using a standardized evaluation protocol. Application of the clinical decision guide presented here has a sensitivity of 100% to rule out a significant injury. Present results showed that the majority of radiographs currently performed are avoidable. Once the decision rule is validated, its clinical application will improve patient care, reduce waiting times in emergency departments, avoid unnecessary radiation exposure, and possibly reduce costs.