FINGER DISLOCATION DEFINITION: Dislocated finger. A dislocated finger or thumb is when the two bones of a joint are out of place. To the person with the dislocation, it is obvious and painful. Therapy: Initially an xray is done to evaluate the position and to see if there is an accompaning fracture. It is common to get an avulsion fracture (chip fracture) from a finger dislocation. After the position is determined, pain medicine is commonly used, though not required. The finger dislocation is then reduced. Some finger dislocations are extremely difficult to reduce due to bone anatomy. In these cases, it may need surgery to reduce the dislocation. In the case of a successful reduction, the finger is usually re-xrayed to assure of proper position. The ligament and joint capsule injuries which accompany a dislocation require time for healing. Sometimes the joint will remain somewhat enlarged by the scar tissue formed during the healing process. The usual treatment is to immobilize the joint with a splint while healing begins. The hand should be cold-packed and elevated. Once the swelling and pain are decreased, range-of-motion exercises are prescribed to prevent permanent stiffness of the joint. Some degree of protection is usually necessary for 3 to 4 weeks. It commonly takes 6 weeks for healing to occur, and can take as long as 6 months in some cases. IF PROBLEMS: Call the doctor or return at once if the finger becomes numb, dusky, or severely swollen, or if pain becomes severe. Dislocations, Interphalangeal INTRODUCTION Background: Interphalangeal (IP) joint dislocations of the fingers and toes are common. They are typically associated with forced hyperextension or hyperflexion of the digit and require immediate reduction. The IP joint is a hinge joint that allows only flexion and extension and consists of several ligamentous complexes. The volar plate provides stability against both hyperextension injury and dorsal dislocation of the phalanx. It often ruptures during a dorsal dislocation and may be associated with an avulsion fracture at the base of the phalanx. The strong collateral ligament complex resists hyperextension and lateral dislocation injury. The extensor hood complex stabilizes against hyperflexion injury and volar displacement of the phalanx. Pathophysiology: Forced hyperextension with axial compression causes a dorsal PIP (or DIP) joint dislocation, in which the middle (or distal) phalanx is dislocated dorsal to the proximal (middle) phalanx. Forced hyperflexion results in a volar IP joint dislocation, for example, where the distal phalanx is dislocated volar to the middle phalanx. Any digit that has neurovascular compromise, an open joint dislocation, ligamentous or volar plate rupture, joint instability or an associated fracture should have immediate orthopedic consultation. All finger dislocations should have subsequent reevaluation by an orthopedic or hand specialist to manage potential subtle ligamentous, cartilaginous or bony injury. A lateral or volar PIP joint dislocation, although rare, requires an orthopedist for possible open reduction with internal fixation. A dislocation of the metacarpophalangeal (MCP) joint, although rare in adults, may be more common in children. MCP dislocation usually requires open reduction and should be managed primarily by a pediatric orthopedist. Frequency: In the U.S.: Dorsal PIP dislocation occurs most commonly. Volar IP joint dislocations are relatively uncommon. A PIP joint dislocation occurs more frequently than that of the DIP joint. CLINICAL History: The history will usually reveal a traumatic athletic injury or entrapment of the finger between objects. Typically, the finger was jammed or bent backwards during basketball, football or other sports activity. There will often be diffuse pain, swelling and tingling. The clinician should ask about the following: Handedness and which hand is injured Occupation Where injury took place (e.g. job or assault) Time since initial injury Physical: An accurate and detailed examination often requires digital block anesthesia. The clinician should test and document each of the following: Gross deformity, diffuse edema, ecchymosis and tenderness of the involved digit Possible anesthesia or paresthesia distal to involved digit Range of motion, function and stability of involved joint Detailed neurovascular examination of entire involved hand Restricted active flexion and extension, especially against resistance, which suggests tendinous or ligamentous rupture or intra-articular osteochondral fragment Test the integrity of the volar plate by passive hyperextension. Test the collateral ligaments by exerting radial and ulnar stress. Skin laceration after a blunt hyperextension injury suggests volar plate rupture. Causes: Axial compression or lateral forces directed to the digit Forced hyperextension or hyperflexion of digit from traumatic athletic injury, entrapment of finger between objects or fall Predisposition to ligamentous injury possible in those with lax ligaments (e.g. Down's syndrome) DIFFERENTIALS Dislocations, Hand Fractures, Hand Gamekeeper Thumb (Skier thumb) Hand Injuries, Soft-tissue WORKUP Imaging Studies: X-rays AP, true lateral and oblique radiographs of the affected digit should be taken. The clinician must obtain 3 views prior to and after reduction. A physeal, avulsion or distal tuft fracture as well as osteochondral fragments are often subtle and seen only on 1-2 views. Stress views may be obtained to assess joint stability. Other Tests: Tests should be conducted as appropriate for the evaluation of other trauma. Procedures: Digital block anesthesia should be adminstered 10-15 minutes before any reduction maneuver. Be sure to remove all rings. TREATMENT Prehospital Care: Splint, ice and elevate the affected digit. Evaluate neurovascular status before and after transport to the ED. Emergency Department Care: Reduction and post-reduction procedures With the patient's hand or foot securely braced, grasp dislocated phalanx with dry gauze loosely wrapped around the phalanx. (Gauze improves grip.) Hyperextend joint slightly with gentle longitudinal traction for a dorsal dislocation, or hyperflex for a volar dislocation. Gradually push dislocated phalanx into its normal anatomical position. Do not apply vigorous traction in a child because it may interpose soft tissue or an osteochondral fragment into the distracted joint space and prevent reduction. After reduction, examine the affected joint for flexor-extensor tendon function, active range of motion, localized tenderness and instability in the medial-lateral and dorsal-volar directions. Immobilize the joint with a foam-padded splint immediately after reduction to prevent redislocation or instability. Immobilize for 14-21 days for a PIP joint dislocation and for 10-14 days for a DIP joint dislocation. Buddy taping for 3-6 weeks thereafter allows active range of motion and prevents hyperextension. For a dorsal PIP dislocation, apply the splint dorsally with the joint in 20-30 degrees of flexion. Allow the PIP joint full range of motion. For a volar DIP dislocation, apply the splint only to the DIP joint on the volar aspect; the DIP should be in full extension. In the child whose cause of dislocation was more likely ligamentous laxity rather than rupture, immobilization by buddy taping to an adjacent digit for 10-14 days is an acceptable alternative treatment. Obtain post-reduction radiographs. Assess functional stability with stress views. This confirms correct joint alignment and congruity and identifies subtle fractures, especially chip or avulsion fractures. Consultations: Any joint instability or neurovascular compromise after reduction requires immediate orthopedic or hand consultation. All finger joint dislocations should be referred for orthopedic or hand specialist evaluation within 2-3 weeks following reduction. Joint instability or dysfunction and subtle ligamentous, cartilaginous or bony injury are often obscured by extensive swelling and pain. MEDICATION Drug Category: Non-steroidal anti-inflammatory drugs (NSAIDs) Drug Name Ibuprofen Adult Dose 400-800 mg/dose q6-8h Pediatric 10 mg/kg/dose q8h (to max adult doses) Contraindications Renal disease Pregnancy A - Safe in pregnancy FOLLOW-UP Further Inpatient Care: Admission may be warranted as dictated by a hand consultant or other concurrent injuries. Further Outpatient Care: Apply ice and elevate the digit. Splint at all times. The patient should not participate in sports activities involving the hand. The pateint should have follow-up evaluation with an orthopedist or hand specialist. In/Out Patient Meds: NSAIDs may be taken as needed. Transfer: If an orthopedic or hand specialist is not immediately available for consultation, transfer is prudent for patients whose reduction is unsuccessful or those who have an unstable joint, open joint injury or associated epiphyseal or avulsion fracture. Deterrence: Patients may use supportive taping during future sports activities. Complications: Complications are rare with early reduction, although persistent pain or swelling is common. Despite appropriate management with rest, ice and elevation, pain and swelling may persist for 6-12 months. Inadequate immobilization after reduction may result in redislocation. Prolonged immobilization may result in muscle contracture. Volar plate injury may lead to recurrent dislocation with chronic laxity, hyperextensibility (swan-neck deformity on active extension) or flexion contracture (pseudo-boutonniere deformity without DIP hyperextension). Late or delayed reduction commonly results in loss of joint motion, joint instability and limitation of function of the hand. Prognosis: The prognosis is excellent with proper reduction and follow-up evaluation by orthopedic or hand specialist. MISCELLANEOUS Unsuccessful reduction Typical causes include intra-articular entrapment of the volar plate, extensor hood ligaments or osteochondral fragment from an associated avulsion fracture. Buttonhole dislocation of the phalangeal neck through the joint capsule may also complicate reduction. Failure to diagnose any of the following: Unstable joint Open joint injury Associated epiphyseal or avulsion fracture Special Concerns: In a patient whose occupation requires manual dexterity, especially if dominant hand injured, the following should be carefully documented: Range of joint motion Neurovascular status