Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Fingers and Thumb


Medical Codes

ICD-9-CM:
816.00 - Fracture, Phalanx or Phalanges, Unspecified, Closed
816.01 - Fracture, Middle or Proximal Phalanx or Phalanges, Closed
816.02 - Fracture, Distal Phalanx or Phalanges, Closed
816.03 - Fracture, Phalanges of Hand, Multiple Sites, Closed
816.10 - Fracture, Phalanx or Phalanges, Unspecified, Open
816.11 - Fracture, Middle or Proximal Phalanx or Phalanges, Open
816.12 - Fracture, Distal Phalanx or Phalanges, Open
816.13 - Fracture, Phalanges of Hand, Multiple Sites, Open

Related Terms

  • Broken Finger
  • Broken Thumb
  • Fractures of the Phalanges of Hand
  • Phalangeal Fractures

Overview

© Reed Group
A fracture of the fingers (digits) or thumb refers to a disruption, or break, in any of the bones of these digits. The bones of the fingers and the thumb are called phalanges (plural) or phalanx (singular). Each finger has three phalanges, and each thumb has two. The finger bones are referred to as the distal, middle, and proximal phalanx, depending on their position along the length of the finger. The bones are connected at joints (the knuckles) that allow the fingers to flex (bend) and extend (straighten). The joints are described as the distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joint. The thumb, has only two bones (distal and proximal phalanx) and two joints, interphalangeal and metacarpophalangeal joint.

Any phalanx can be fractured by a direct blow, rotation, and / or by crushing injuries. Dislocations and / or open wounds may accompany the fractures. Fractures of the end of the finger (distal phalanx) may include an injury to the nail bed, which means the fracture must be treated as an open fracture. When the fingers are injured, soft tissue structures can get between the fragments, making realignment of the bones into their anatomically normal position (reduction) difficult, and tendon or ligament damage more likely.

Finger fractures are described by the fracture name and location (e.g., nondisplaced spiral fracture of the proximal phalanx). The fragments may protrude through the skin (open or compound fracture) or may cause deformity of the finger without tearing the skin (closed fracture). Function of the hand is maintained when the fingers and thumb are able to move in correct relation to each other and to the wrist bones. A fracture to any of these small bones has the potential to change this relationship, which can be painful and limit function. Tendon rupture is a significant injury that rarely accompanies finger fractures.

Incidence and Prevalence: Phalangeal fracture incidence is often difficult to determine because of under-reporting, but these fractures are estimated to comprise approximately 10% of all fractures (Divelbiss). A Canadian study of hand fractures found that phalangeal fractures comprised half of the 72,000 hand fractures studied. Annual incidence for hand fracture was estimated to range from 29 per 10,000 for individuals aged 20 or older, to 61 per 10,000 for individuals younger than 20 years (Feehan, 2006). Fractures of the distal phalanx are the most common fractures of the hand and frequently result from industrial accidents (Lyn).

Source: Medical Disability Advisor



Diagnosis

History: Symptoms will vary depending on the mechanism of injury and which bones are broken. Individuals should report trauma to the area. They may complain of pain, swelling (edema), sensations of numbness or coldness, and decreased range of motion in the affected digit.

Physical exam: Bruising (ecchymosis) and edema may be evident in the area of injury. Pressure applied to the finger often elicits pain. Range of motion (ROM) evaluation may suggest loss of tendon function or bone instability. ROM and strength testing of each digit and joint may establish tendon and ligament integrity but pain often limits the examination. Sensory testing may be done to evaluate nerve damage. The injured hand is compared closely with the uninjured (contralateral) one. There may be observable deformity, but the cause may be tendon damage or joint dislocation without fracture.

Examination of the skin and nail bed for bloody effusion or open wounds is done to evaluate the need for antibiotics. It is important to distinguish between new and old injuries during the examination. Previous tendon and bone injuries may otherwise complicate the findings.

Tests: Plain X-rays with anteroposterior (AP), lateral, and oblique views will often reveal the fracture location.

Source: Medical Disability Advisor



Treatment

Treatment for finger and thumb fractures depends on the type of break and the amount of soft tissue damage. All treatment seeks to provide the most stable configuration for healing while avoiding invasive treatment that might disrupt soft tissue, tendons, and bones of the fingers unnecessarily. It may consist of buddy taping the damaged finger to an adjacent finger, splinting, or casting, with instructions to move the involved digit as soon as possible, and uninvolved digits immediately. More severe or open fractures may require surgery, with pins, screws, or wires to hold the bone fragments in place (open reduction, internal fixation [ORIF]). Injury specific therapy may include moving the fingers as soon as possible to prevent stiffness associated with finger and thumb fractures.

Source: Medical Disability Advisor



Prognosis

Restoration of function and healing of the fracture can be expected in uncomplicated fractures although some stiffness (loss of range of motion) is common. Permanent disability often occurs if the rotation and alignment are not corrected and maintained during healing or if complications are encountered. Prognosis is good to excellent with uncomplicated fractures, good care, and proper rehabilitation.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Hand Surgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist

Source: Medical Disability Advisor



Rehabilitation

Individuals who sustain fractures of the fingers or thumb may require outpatient therapy. In such cases, rehabilitation can be administered by a physical therapist, occupational therapist, or hand therapist. The duration of treatment is related to the location, type of fracture, soft tissue injury, and length of immobilization. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative). Hand dominance and the involved extremity will greatly influence the patient's degree of disability. The main focus of rehabilitation should emphasize restoring full range of motion and strength while maintaining independence in as many activities of daily living as possible. Resumption of pre-injury status is the goal with consideration of any residual deficit (Jupiter; Krop).

The goal of rehabilitation is to decrease pain and restore function. Modalities such as cold packs may be beneficial for controlling pain and reducing edema. Special attention should be paid to preserve full function of the uninvolved fingers, especially if the dominant hand is involved, provided this is not contraindicated by fracture stability. When indicated, the therapist will initiate range of motion and strengthening exercises of the involved digits, paying special attention to both the intrinsic and extrinsic hand muscles (these are the small muscle between the fingers located in the palm) (Feehan). Emphasis must be placed on regaining full range of motion at each joint. Most fractures require only limited immobilization, and early return to movement is encouraged (Browner). Simple closed fractures may do better with range of motion beginning within 21 days of the initial injury as long as the fracture site is protected (Brault). Tendon gliding exercises should be included to reduce the chance of scarring around nearby tendons that may cause loss of motion (Hardy; Meals). Mild contractures can usually be dealt with by increased hand therapy (Netscher). Fractures involving joints, multiple fractures, and spiral or oblique fractures are more complex and will usually require increased therapy. Exercise intensity and difficulty should be progressed until full function is achieved (Krop).

Occupational therapy may be indicated to assist with activities of daily living. Return to activities of daily living and work as tolerated is encouraged as part of therapy (Calandruccio).

If a finger or thumb fracture is operatively managed, the protocol of rehabilitation will be guided by the treating physician. In most cases hardware removal may be required after the initial surgery.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Fingers and Thumb
Occupational / Hand / Physical TherapistUp to 8 visits within 4 weeks
Surgical
SpecialistFracture, Fingers and Thumb
Occupational / Hand / Physical TherapistUp to 10 visits within 4 weeks
Surgical (complex/multiple fractures)
SpecialistFracture, Fingers and Thumb
Occupational / Hand / Physical TherapistUp to 18 visits within 6 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Possible complications of finger and thumb fractures include malrotation, degenerative arthritis, adhesion of tendon to bone (more likely to occur with open or widely angulated fractures), joint contracture, nonunion, and malunion. Nonunions are rare, but malunions are the most common complication of phalangeal fracture (Divelbliss). Malunions include rotation or angulation of the bone at the fracture site. Dexterity of the affected finger can be compromised if the malunion exceeds 20°. Improperly treated middle phalanx fractures may be complicated by a boutonniere deformity, characterized by flexion of the proximal interphalangeal joint (PIP) and hyperextension of the distal interphalangeal (DIP) joint or Swan Neck deformity (PIP hyperextension with DIP flexion). Contaminated open wounds may result in infection, especially when phalangeal fracture is not treated promptly.

Source: Medical Disability Advisor



Factors Influencing Duration

Disability is dependent on whether the dominant or nondominant hand is involved, work requirements, the digit/digits involved, and the presence of complications. Since the thumb is used in most hand functions, and since many hand functions can be done using only some of the fingers, thumb fractures are much more likely to limit hand function. Fractures in multiple digits typically involve much higher forces (more violent injuries) and thus have more soft tissue damage. Thus function is more limited both by more digits being involved, and more severe injury in each digit.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions and accommodations will vary with severity of the fracture and the amount of exertion or dexterity required for the individual's job. For example, typists or surgeons would require the use of all digits to perform their duties and may need to reduce or modify their duties until fully healed. In some cases, alternatives to a standard keyboard, such as speech recognition software or one-handed keyboards, may be appropriate accommodations. Individuals with finger and thumb injuries may need to take breaks to elevate and ice the injured hand to reduce swelling and pain. Individuals who require great grip strength to perform their duties may need to modify their duties until healed. Such individuals may also find ergonomically adjusted or pneumatic tools useful during the healing period.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was diagnosis of fracture confirmed by x-ray?
  • How many fractures in how many digits occurred?
  • Were there recognized injuries to tendons, nerves, or joints that delay or complicate treatment and recovery?
  • Did individual experience any complications?
  • Does individual have an underlying condition that may affect recovery?

Regarding treatment:

  • Was open reduction and internal fixation required?
  • What is the expected outcome?

Regarding prognosis:

  • Has individual followed prescribed rehabilitative therapy?
  • Would the individual benefit from a consultation with a specialist, such as an orthopedic surgeon, hand surgeon, occupational therapist, physical therapist, or physiatrist?

Source: Medical Disability Advisor



References

Cited

Brault, Jeffrye S., et al., eds. "Chapter 27 - Flexor Tendon Injuries." Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Calandruccio, James H. "Chapter 64 - Fractures, Dislocations and Ligamentous Injuries." Campbell's Operative Orthopaedics. Eds. Mark Jobe, James H. Beaty, and . 11th ed. Philadelphia: Mosby Elsevier, 2008.

Divelbiss, Brian J. "Phalangeal Fractures." eMedicine. Ed. Harris Gellman. 3 Jun. 2011. Medscape. 22 Jan. 2013 <http://emedicine.medscape.com/article/1240218-overview>.

Feehan, L. M., and K. Bassett. "Is There Evidence for Early Mobilization Following an Extraarticular Hand Fracture." Journal of Hand Therapy 17 2 (2004): 300-308. National Center for Biotechnology Information. National Library of Medicine. 24 Nov. 2008 <PMID: 15162112>.

Hardy, M. A., ed. "Principles of Metacarpal and Phalangeal Fracture Management. A Review of Rehabilitation Concepts.." Journal of Orthopadedic Sports Physical Therapy 34 (2004): 78-99.

Islam, Syed S., et al. "Incidence and Risk of Work-Related Fracture Injuries: Experience of a State-Managed Workers' Compensation System." Journal of Occupational and Environmental Medicine 43 2 (2001): 140-146. National Center for Biotechnology Information. National Library of Medicine. 17 Aug. 2006 <PMID: 11227632>.

Jupiter, Jesse B., Terry S. Axelrod, and Mark Belsky. "Chapter 38 - Fractures and Dislocations of the hand." Skeletal Trauma. Eds. Bruce D. Browner, et al. 4th ed. W.B. Saunders, 2008.

Krop, P. N. "Fractures: General Principles of Surgical Management." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002.

Lyn, Everett, and Robert E. Antosia. "Hand." Rosen's Emergency Medicine: Concepts and Clinical Practice. Eds. J. A. Marx, et al. 6th ed. Philadelphia: Mosby Elsevier, 2006.

Meals, Roy A., and G. Neil, eds. "Extraarticular Hand Fractures in Adults: A Review of New Developments." Clinical Orthopaedics and Related Research 455 133-145.

Netscher, D., and N. Fiore. "Chapter 74, Section XIII - Hand Surgery." Sabiston Textbook of Surgery. Ed. C. M. Townsend. 18th ed. St. Louis: Saunders, 2008.

Source: Medical Disability Advisor