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Acute closed central-slip rupture of the finger — MSRA MCQ

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HardSoft Tissue InjuryAcute closed central-slip rupture of the fingerMSRA

A 31-year-old right-hand-dominant dentist attends a GP-led urgent treatment centre 5 hours after a basketball struck the tip of his left middle finger, forcibly flexing the proximal interphalangeal (PIP) joint. He has dorsal PIP swelling and focal tenderness. There is no wound. He can actively extend the PIP joint fully, although this is painful. Active flexion and extension at the distal interphalangeal (DIP) joint are preserved. True anteroposterior and lateral radiographs of the individual finger show no fracture, avulsion fragment or dislocation. With the PIP joint flexed to 90 degrees over the edge of a table, resisted attempted PIP extension produces no appreciable extension force and the DIP joint becomes rigid in extension. Sensation and capillary refill are normal. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Apply a PIP extension splint leaving the DIP joint free, and arrange prompt hand-trauma or hand-therapy review

Explanation lettering: C = shown as A · D = shown as B · B = shown as C · E = shown as D · A = shown as E

This is an acute closed central-slip injury. Forced PIP flexion with dorsal PIP tenderness is the characteristic mechanism and site. The initially preserved ability to extend the PIP joint does not exclude central-slip rupture because the lateral bands may temporarily maintain extension. The positive Elson test is the key discriminator: absent PIP extension force with a rigid DIP joint during resisted extension from a flexed PIP position indicates loss of central-slip integrity. Normal radiographs exclude an associated visible avulsion fracture but do not exclude a purely tendinous injury. The appropriate immediate treatment is continuous PIP extension splintage, with the DIP left free to move, plus prompt specialist hand follow-up. This permits healing in extension and reduces the risk of a fixed boutonniere deformity. A is appropriate for a stable collateral-ligament or minor volar-plate injury, not central-slip rupture. B is used for selected hyperextension/volar-plate injuries where an extension block is needed. C treats mallet injury, which affects terminal extensor function at the DIP joint. E would be appropriate for an open tendon injury, neurovascular compromise, major associated fracture, or established deformity requiring specialist assessment; none is present here.

Reference: Hand Injuries Document: Central Slip Injury—Boutonniere Deformity (Published 26 November 2025) — https://www.rightdecisions.scot.nhs.uk/media/jujp5l25/hand-injuries-dec-24.pdf Rupture of the central slip of the extensor hood of the finger: A test for early diagnosis (1986) — https://pubmed.ncbi.nlm.nih.gov/3958008/ Diagnosis of closed central slip injuries: A cadaveric analysis of non-invasive tests (1997) — https://pubmed.ncbi.nlm.nih.gov/9230945/