Avulsion Fracture

A month ago, I thought I tore the A4 pulley in my ring finger. The x-rays and ultrasounds showed no tendon tear, however, but an avulsion fracture.

By Dr. Julian Saunders | July 16th, 2019

A month ago, I thought I tore the A4 pulley in my ring finger. The x-rays and ultrasounds showed no tendon tear, however, but an avulsion fracture. The finger is still swollen and a little tender, but I can climb easy stuff if I just open-hand. My concern is that because it wasn’t splinted, it may be healing in a weakened state, or that the bone shard may be floating. Can I still splint it?

Marie Palmer, Squamish, Canada


X-Ray of right 5th finger showing an avulsion fracture. Photo: MeekMark.

That’s some proper climbing mojo you have, pulling so hard you are breaking bones!

I have seen quite a few fractured fingers over the years. Mostly, they occur in teenagers who train too hard. What starts as a stress fracture ends as what’s called a Salter-Harris fracture, where the fracture involves the growth plate of the bone. Others generate a stress fracture in the mid shaft. The latter is typically so painful that it prohibits bearing any weight and doesn’t progress to a full fracture.


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The most common avulsion fracture in that region is when the tendon insertion of flexor digitorum profundis (FDP) rips a chunk of bone off the front of the distal phalanx. What gets me here is that you say it isn’t painful to pull on in an open-hand position, but rather you couldn’t crimp due to pain. That’s odd. Both should be painful since FDP is the prime mover of finger flexion strength in either grip position. (FYI, crimping would be less painful than open hand if you did an A4).

That makes me think the avulsion fracture could be off the rim of the bone, where the joint capsule attaches. Ultimately, however, it is beside the point since in either case you need to curl up in a cozy corner for at least a month. There is no way of “safely” loading this in relation to the healing process. End of story.


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If it is an FDP avulsion fracture and the chip doesn’t relocate itself, surgical intervention is possible, but not easy if the chip is too small to accommodate a screw. Rest first, then get an MRI or ultrasound in a month or so to see if it is adhering, and then consider your options.


This article was published in Rock and Ice 205 (October 2012).


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