WORKUP	Section 5 of 10
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Lab Studies:

• Laboratory studies are typically not necessary for the patient with an isolated interphalangeal joint dislocation. However, if the dislocation requires open reduction, general anesthesia, or anesthetic limb block, then the hand specialist or anesthetist should be consulted for appropriate preoperative preparation.

• On occasion, therapeutic drug levels, cardiac studies, coagulation studies, or preoperative microbial studies may be required if the dislocation involves an open joint or soft tissue contamination.

• The simple isolated interphalangeal dislocation may be an opportunity for the emergency physician to provide relief of pain and discomfort as well as acute care. The prudent emergency physician will recognize that his or her role in the evaluation and treatment of the interphalangeal joint dislocation is during the acute care phase. Eventually, the patient will follow up with a general orthopedist or hand specialist. The emergency medical director should establish follow-up algorithms and plans for the "routine" patient for the department. It may be an easy technique to reduce an interphalangeal joint dislocation. However, the patient requires reevaluation by a hand specialist, occupational therapist, or physical therapist.

Imaging Studies:

• Edema, tenderness, or deformity at a joint or along the digit should prompt radiographic evaluation. Findings can be subtle; pain out of proportion to x-ray findings should heighten the physician's suspicion for significant injury.

• The following views should be taken:

• Anteroposterior

• Lateral

• Oblique

• Stress views can be examined if ligamentous laxity is documented or suspected.

• Postreduction images must follow even the most "routine" reductions.

	TREATMENT	Section 6 of 10
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Prehospital Care: Rapid pain relief, securing imaging studies, and expeditious reduction (closed or open) must be the triad that drives the emergency department protocol for treating isolated digit or hand dislocations.

• Patients arriving by emergency services
  • Immobilization of the deformed joint, covering soft tissue injury, and providing pain relief are the mainstays of prehospital treatment if the patient is transported to the emergency department by emergency medical services.

  • It is prudent for the emergency department medical director, or designee, to support emergency service protocols concerning prehospital care for the patient with an injured extremity.

  • It benefits the patient to have EMS protocols for joint immobilization and pain management working in concert with emergency department protocols.

  • EMS personnel are skilled at joint immobilization and may already have pain management protocols. The emergency department director should support EMS protocols for prehospital pain management for the patient with a joint injury.

• For patients arriving under their own means or emergency medical services, the emergency department should have protocols in place to provide pain relief, imaging studies, and medical screening.

• Many patients with an isolated digit or hand dislocation can be expeditiously treated from the time they arrive until the initial physician contact if protocols allow the nursing staff to provide analgesia and order the appropriate radiology study.

• Pain management can consist of intramuscular injection of ketorolac or Dilaudid depending on the patient's medical history, allergic reaction profile, and expressed comfort level.

• Oral medication can be problematic if the patient eventually requires open reduction. Therefore, pain management protocols should include intramuscular or parenteral medication administration.

• Imaging studies of the affected digit or hand can easily be part of an isolated extremity or digit evaluation and treatment protocol. Nursing staff and physicians should work in concert to develop triage or initial provider examination skills so that uniform radiographs are ordered. For example, radiographs of the isolated digit can be ordered if the triage or evaluating nurse assesses the patient to have a deformity at the distal or proximal finger joints.

• The patient can receive an intramuscular injection of ketorolac (if requested) prior to the imaging study.

• With an isolated extremity protocol, the patient has the opportunity to receive rapid pain relief and the imaging the physician will need to assess the extent of damage.

• Imaging studies for the isolated digit or hand deformity will be 3 or 5 view plain radiograph views.

• Standard views of the deformed joint include the anteroposterior and lateral views.

Emergency Department Care: Some dislocations may not be reducible by closed means because of the interposition of the volar plate or associated ligaments or tendons in the joint. If several attempts at reduction are not successful, consultation and open reduction and internal fixation (ORIF) often is indicated. A thorough assessment of stability should be performed following a successful reduction.

• Interphalangeal joint of the thumb

• Reductions usually are accomplished via closed means.

• This particular dislocation may present with associated rupture of flexor pollicis longus.

• Following evaluation and reduction, immobilize the involved joint with a thumb spica splint. The period of joint immobilization should be brief to avoid joint stiffening.

• Metacarpophalangeal joint of the thumb

• Anterior dislocations are classified as simple or complex. The appropriate method of reduction of a dislocation depends on the type of dislocation.

• For simple dislocations the clinician should avoid pure traction, as this can convert a simple dislocation into a complex dislocation. Reduction is achieved by emphasis of pushing the phalanx into the MCP joint rather than pulling it into place.

• After 1-2 attempts at reduction are unsuccessful, an open reduction must be performed. More aggressive and repeated attempts at reduction may lead to fracture.

• An interposed volar plate or intrinsic muscle may be the reason for failed attempts at closed reduction.

• After the dislocation is reduced, immobilize the joint with a thumb spica splint.

• The length of immobilization varies, but clinicians should avoid extended immobilization and minimize immobilization of unaffected areas.

• Instability of the thumb is an indication for referring the patient to a hand specialist.

• Metacarpophalangeal joints of the fingers

• Dislocation of an MCP joint of the fingers most often involves the index or small finger.

• Dislocations here are relatively uncommon because of the strength of the periarticular structures.

• Dislocations may be simple or complex. A complex dislocation nearly always needs open reduction because of an interposed volar plate.

• Closed reduction may be accomplished by using traction along the axis of the hyperextended phalanx and firmly pushing the base of the dislocated phalanx toward the MCP joint.

• Assess stability of the joint after reduction and follow by immobilization.

• Again, some controversy exists regarding length and position of immobilization. Some authors recommend early range of motion if no evidence of postreduction instability is observed.

• Proximal Interphalangeal joint of the fingers

• Dorsal dislocations are reduced by applying longitudinal traction and mild hyperextension with dorsal pressure on the proximal aspect of the middle phalanx.

• Immobilization of simple dislocations without instability should be brief.

• If the patient continues to perform activities that may put the digit at risk for subsequent dislocations, the digit should be protected with buddy taping and/or splinting during the activity.

• Volar dislocation of the PIP joint of a finger is relatively uncommon. When a volar dislocation occurs, the proximal phalanx can rupture through the transverse retinacular fibers between the lateral band and the central tendon. The lateral bands may become interposed, making closed reduction difficult. If the volar plate is ruptured and the extensor mechanism avulsed, a Boutonnière deformity may result. Open reductions normally are performed for these injuries. Occasionally, closed reduction may be performed. If the joint remains stable, immobilize the digit briefly in a slightly flexed position.

• Distal interphalangeal joint of the fingers

• The DIP joint of the finger is a very vulnerable area. Surprisingly, dislocations in this area are uncommon because of the strong support of the joint by skin and periarticular structures. With the appropriate intensity of force applied; however, the strong support network is unyielding and the skin may tear, leading to an open dislocation.

• Reduce the dislocation with longitudinal traction and hyperextension, with firm dorsal pressure on the base of the distal phalanx. Open reduction rarely is needed in this type of dislocation.

• After the dislocation is reduced, assess stability of the joint to rule out evidence of tendon injury.

• Immobilize the joint with a dorsal splint in flexion if volar dislocation has occurred without tendon injury, and in extension if the dislocation is dorsal and without tendon injury.

	MISCELLANEOUS	Section 9 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Medical/Legal Pitfalls:

• Failure to take special precautions and considerations. As with other dislocations of the extremities, however, the majority of hand dislocations are fairly obvious as a result of the associated deformity.

• Failure to consider an occult fracture. If x-rays are obtained and no identifiable fracture is visible, yet the patient remains in a significant amount of discomfort, an occult fracture may be present. Proper splinting and urgent referral may be indicated.

• Failure to consider a growth plate injury. A child or adolescent with open growth plates who remains in pain even though x-rays reveal no fracture may have a growth plate injury. Proper splinting and urgent referral may be indicated.

Special Concerns:

• Every emergency physician should have a firm understanding of the acute management of simple dislocations of the digits. Historical, physical, and radiographic findings often guide the management of the dislocation. When the dislocation is complicated, consult with and/or refer to a hand surgeon. Generally, reduced dislocations without evidence of instability and near-normal range of motion can be treated by brief immobilization and subsequent referral.