AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Dislocations in the hand are common injuries in sports and in occupational settings, often appearing to be minor. If the athlete, trainer, or coach has already reduced the dislocation, it appears unimpressive compared to a major knee injury or a shoulder dislocation. However, these injuries have real potential for long-term disability in sports and other areas of life if adequate reduction is not performed, if associated injuries are not identified and appropriately treated or referred, and if potential complications of the injury and its treatment are not foreseen. The judgment of the initial treating physician can be critical in determining the long-term outcome.

Frequency

United States

The annual incidence of all types of dislocations in the hand is approximately 67,000 in the United States. Most hand dislocations are sports or occupational injuries, with a lesser number sustained in falls and traffic collisions (sometimes associated with airbag deployment). Most of these are dislocations at the proximal interphalangeal (PIP) joint because the greater range of motion (ROM) of the PIP joint makes it more vulnerable to injury. Of the PIP dislocations, most are dorsal. Volar dislocations of the PIP joint are much less common, are more difficult to reduce, and are associated with more complications. Distal interphalangeal (DIP) joint dislocations also are uncommon, almost always dorsal, and often open.

In addition to PIP and DIP dislocations in order of decreasing frequency, metacarpophalangeal (MCP) joint dislocations and carpometacarpal (CMC) dislocations also occur. The MCP joint of the 4 fingers usually dislocates posteriorly (simple type) but can, on the rare occasion, become entrapped between the palmar fascia and the palmar plate and become irreducibly dislocated. The CMC joint dislocation is a disabling injury, which is usually dorsal, and may be associated with fractures of the bases of the metacarpals.

Functional Anatomy

The bony anatomy of the PIP joint consists of medial and lateral condyles on the proximal phalanx, with matching concavities on the associated distal phalanx. This allows for a wide ROM in flexion and extension, but it is relatively rigid in abduction and adduction, making it a hinge (ginglymus) joint functionally. DIP joint bony anatomy is similar but with surrounding soft tissue providing more restriction in flexion. The extrinsic flexors across both joints are at least 4 times stronger than the extensors, allowing flexion contractures to develop very rapidly, especially with immobilization in flexion. Adequate ROM, especially at the PIP joint, is critical for normal hand function.

Both types of interphalangeal joints are supported by similar soft tissue structures on all 4 sides, which includes the volar plate on the palmar side (the integrity of this structure is essential to a stable reduction), collateral ligaments on the radial and ulnar sides, and the extensor complex (central slip, lateral bands, and hood) dorsally. These structures attach to and reinforce the joint capsule. For a dislocation to occur, at least 1, often 2, and sometimes 3 of these structures must be significantly injured.

The volar plate is a roughly triangular structure with its base oriented distally, attaching to the volar base of the middle phalanx with its tip attaching to the distal aspect of the proximal phalanx. The volar plate functions largely in limiting hyperextension. Thus, it is nearly inevitably injured in dorsal dislocations.

The collateral ligaments restrict the joint from opening to varus or valgus stress and are also commonly injured in dorsal dislocation. Injury to the radial collateral ligament is about 6 times more common than injury to the ulnar collateral ligament. The extensor complex over the PIP joint consists of the central slip, which attaches to the base of the middle phalanx; the lateral bands, which run dorsolaterally on each side; and the transverse retinacular ligament, which connects these structures and extends laterally. These structures help to limit volar movement of the base of the middle phalanx and are thus commonly injured in volar dislocations at the PIP joint, with the middle phalanx either tearing the central slip from its insertion or buttonholing through the transverse retinacular ligament between the central slip and one of the lateral bands.

The MCP joint is thought to be an ellipsoid joint. The head of the metacarpal consists of medial and lateral condyles and is narrower on its dorsal surface than on its palmar surface; it fits into the concavity of the base of the proximal phalanx. The true collateral ligament attaches to a recess created by the junction of the shoulder and head. The collateral ligament is composed of the following 2 parts: (1) a dorsally placed cord portion and (2) a fan-shaped volar portion or accessory collateral ligament, which extends from the metacarpal to the sides of the volar plate. To accomplish flexion and extension at the MCP joint, the anterior and posterior parts of the capsule must be lax. When the joint is extended, the phalanges have considerable lateral play in abduction and adduction and, therefore, this joint avoids frequent injury; however, if the ligament is torn, dislocation occurs.

The bony anatomy of the CMC joint consists of the 5 metacarpal bases that articulate with the trapezoid, trapezium, capitate, and hamate (in that order) from the radial to the ulnar aspect of the hand. The CMC joint is a relatively fixed joint segment because of the articular congruity of the joint surfaces, with the metacarpal bases acting like concave receptacles to the distal carpal row, and because of the strong interosseous and extrinsic ligament complex. The palmar and dorsal ligaments are distinct, with the palmar ligaments being stronger. The scaphoid acts as a link between the proximal and distal carpal rows. The extensor and flexor tendons pass over this articular area but add no strength to the CMC joint because the bases of the metacarpals dislocate dorsally relative to the distal carpal row.

The MCP joint of the thumb has radial and ulnar collateral ligaments, which are loose when the joint is extended and tight when flexed. When the joint is extended, the proximal phalanx has the lateral play achieved by the action of the interosseous muscles. When the thumb is flexed and in a functional position, as in the case of many sports situations (eg, skiing, falls on a gloved hand), the ulnar collateral ligament is the structure at risk and can be ruptured. The ulnar collateral ligament can then be displaced so that the adductor aponeurosis is interposed between the ruptured end of the ligament and its site of bony attachment.

The first CMC joint or the first metacarpotrapezoid joint is a very mobile saddle joint, with articular surfaces that are reciprocally concavoconvex. The most important soft tissue support for this first CMC joint is the deep ulnar or anterior oblique ligament that runs from the volar beak of the metacarpal to the tubercle of the trapezium. This ligament can be ruptured, but it tends to be avulsed with a piece of bone (Bennet fracture dislocation).

Sport Specific Biomechanics

Dislocations of the interphalangeal joints of the hand probably occur most commonly in basketball and football. In basketball, the usual mechanisms of injury include being struck by the ball, catching a finger on the rim, or contact with another player. In football, the finger may be caught on a jersey, slapped against a helmet, or crushed between some combination of other players, their equipment, and the ground. Linemen and defensive players are at highest risk for hand injuries. In both of these sports, return to play almost always requires that the injury can be splinted stably to allow for a power grip.

Dislocations of the MCP and basilar CMC joints occur most commonly with falls on the outstretched hand or the flexed supinated wrist. With this extension vector, the forces are transmitted up through the carpus.

Injuries and dislocations of the thumb, MCP joint, and the CMC basilar joint can commonly occur in falls, with the thumb in abduction. Examples of this type of injury include falls on the gloved hand in baseball or an abduction force applied to a flexed thumb while grasping an object, such as in skiing injuries when the pole impacts the proximal phalanx tearing the radial collateral ligament. This occurs when the wrist is extended at the time of the injury.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

As with any hand injury, the history should begin with determining the patient's age; handedness; sex; and type of participation in sports, hobbies, or occupation because these affect both the presentation of the injury and the goals of treatment. The patient most likely presents with a history of trauma leading to finger deformity. The clinician should inquire about whether other injuries took place to rule out the presence of any life-threatening injury.

Because the patient or others involved at the scene often reduce the dislocation, eliciting the mechanism of injury (eg, hyperextension, axial loading, torsion, radial/ulnar stress, direct blow) and the resultant deformity in the history is important. The patient often is not able to clearly describe the mechanism of injury, but the description of the deformity (volar versus dorsal) is valuable because the associated injuries and the appropriate treatment of these 2 injuries differ significantly. The exact location of pain can be helpful in localizing the injury, but this is more precisely defined by tenderness on physical examination.

Most injuries to the carpus occur when the patient falls on the outstretched hand, as might occur in any sport or accident. When the resultant vector is primarily one of ulnar deviation and intercarpal supination, ligamentous disruption and carpal dislocations tend to result. This mechanism can be observed in glove-side injuries in baseball fielders or hockey goalies.

Past medical and surgical history should focus on prior injuries to the hand and underlying conditions that may affect healing.

Physical

Areas that need to be assessed in the physical examination of a hand dislocation injury may include the following:

• Neurovascular status both prereduction and postreduction



• Sensation - Best assessed with moving 2-point discrimination (<5 mm) if any question exists



• Capillary refill



• Skin assessment
  
  
  • Check for any breaks in the skin.
  
  
  
  • The skin of the fingers is tightly stretched over the underlying structures and adherent to them, especially on the volar aspect and toward the fingertip. This makes the interphalangeal joints more prone to open dislocations than many other joints in the body.
  
  
  
  • Any skin defect in the area of a joint must be presumed to be an open dislocation with direct communication of the joint with potentially contaminating bacterial flora. This flora can be destructive to articular cartilage and, therefore, may require IV antibiotics and consultation with a hand surgeon for irrigation and debridement. One should be suspicious of an open injury in a patient presenting with a laceration over a joint even without deformity because the patient may have reduced the jammed finger prior to examination.
     
• Deformity
  
  
  • Hyperextension - Typical of dorsal PIP dislocations, indicating damage to the volar plate
  
  
  
  • Angulation - Radial or ulnar, indicates damage to one or both of the collateral ligaments
  
  
  
  • Rotation - Common in rotatory subluxation, which is a subtype of volar dislocation versus a separate class of injury (This deformity is best noted by looking at the nails. They should all lie in the same plane; the nail of an injured digit is rotated out of the plane of the others.)
  
  
  
  • Displacement of the more distal phalanx - Volar in volar dislocations, dorsal or dorsolateral in dorsal dislocations (This finding may be obscured by swelling or may be subtle in partially reduced dislocations with entrapped soft tissue.)

The following items should be checked postreduction:

• The point of maximum tenderness may not be easy to determine but helps define damaged structures.
  
  
  • Lateral - Collateral ligaments (radial and/or ulnar)
  
  
  
  • Volar - Volar plate
  
  
  
  • Dorsal (base of middle phalanx) - Central slip
     
• Active range of motion (AROM) may be difficult to test if the patient is experiencing significant pain. Digital block (after neurologic examination) may be necessary to adequately determine ROM.
  
  
  • The examiner must test full active extension of the PIP joint against resistance. In a PIP joint injury, inability to perform this motion with preservation of passive range of motion (PROM) is diagnostic of a rupture of the central slip of the extensor tendon. This injury must be splinted in extension to avoid development of a boutonniere deformity.
  
  
  
  • The joint should stay reduced throughout the ROM. Instability or redislocation, usually in extension, requires extension block splinting at an angle that preserves the reduction.
  
  
  
  • If both AROM and PROM are reduced, this is consistent with entrapment of a soft tissue structure (eg, volar plate, collateral ligament, flexor or extensor tendon) in the joint and persistent subluxation. This requires a further attempt at closed reduction. If this is unsuccessful, open reduction is urgently indicated.
     
• Stability to gentle passive stress should be checked.
  
  
  • Hyperextension tests the volar plate.
  
  
  
  • Ulnar deviation tests the radial collateral ligament.
  
  
  
  • Radial deviation tests the ulnar collateral ligament. If the joint opens up 20° or more with minimal resistance, this is consistent with a complete collateral ligament tear.
  
  
  
  • Avoid forceful passive testing for stability because this can convert a partial tear to a complete one, and instability of any of these structures to passive stress is unlikely to change the management of an injury that is stable with AROM. The one potential exception to this is complete rupture of the radial collateral ligament of the index finger PIP joint in a young active patient. This injury is often surgically repaired primarily because stability at this joint (required for a normal pinch grip) is more important than ROM.
  
  
  
  • Dorsal deformities can be observed in both MCP joint and CMC joint dislocations. Because of swelling, these dislocations are sometimes hard to clinically identify. Bony prominences at the joints of maximum tenderness may be the most common physical findings.
  
  
  
  • After reduction, stability of the MCP joint should be checked with radial and ulnar deviation with the joint in flexion to determine the functional stability of the radial and ulnar collateral ligaments. The MCP joint should be put through a ROM to determine the stability.
  
  
  
  • In CMC dislocations after reduction, a ROM of the hand in dorsal and palmar flexion should be carried out to determine the intrinsic stability of the CMC joint.
     
• Physical examination testing specific to the thumb includes the following: In addition to AROM, testing of the thumb includes flexion of the MCP joint with radial and ulnar stress testing in extension and flexion with contralateral side-to-side comparison. Increased laxity with pain to palpation suggests an ulnar collateral ligament (UCL) injury (gamekeeper's thumb). Entrapment of the UCL in the aponeurosis (Stener lesion) prevents healing and may require surgical intervention.

Causes

• Sports injuries (usually involving contact sports or a ball forcefully striking the tip of the finger)
• Occupational injuries
• Falls
• Traffic collisions

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Mallet finger
Collateral ligament injury
Chronic deformity

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Laboratory studies are not generally indicated for diagnosing dislocation injuries of the hand.

Imaging Studies

• Radiography
• • Anteroposterior (AP), lateral, and possibly, oblique views of the affected finger (not the whole hand)

  • Postreduction radiographs

  • Stress radiographs (possibly)

  • Radiographs of the affected finger: These help to further define the anatomy of the dislocation, rule out associated fractures, and assess the adequacy of reduction. For dorsal dislocations at the PIP joint, the initial radiographs often are postreduction because the athlete, trainer, or coach commonly reduces the dislocation at the scene. If the finger is still dislocated when the radiographs are obtained, the middle phalanx may be hyperextended and often deviated to the ulnar side. In a volar dislocation, rotation may be noticeable on the lateral view. The head of the proximal phalanx lies in a different plane than the base of the middle phalanx.

  • Common fractures to look for
    • Avulsions at the volar base of the middle phalanx (distal phalanx if DIP) from the volar plate may not affect the treatment plan if small. Larger fractures at this location make the injury a fracture-dislocation, which may be unstable in extension.

    • Avulsions at the dorsal base of the middle phalanx (distal phalanx if DIP) from the extensor tendon should prompt careful testing of extensor function and probably requires splinting in extension. Avoid splinting in hyperextension. Most central slip injuries, however, are soft tissue only.

    • Impacted fractures of the joint surface often are best visualized on a true lateral view, allowing direct comparison of the radial and ulnar articular surfaces.

  • Important points in the radiographic assessment of reduction
    • Congruence of the articular surfaces: The head of the more proximal phalanx should form a U shape that fits symmetrically within the U shape of the base of the more distal phalanx. If the joint space is not equal throughout on both views, this is highly suspicious for persistent subluxation secondary to entrapment of soft tissue structures within the joint.

    • Absence of rotational deformity: A volar PIP dislocation where the head of the proximal phalanx buttonholes between the central slip and the lateral band has a rotational component. This can be observed on the lateral view, where the radial and ulnar aspects of each joint surface would be superimposed.

    • Fractures around the MCP and CMC joints: AP, lateral, and oblique views of the entire hand are indicated to rule out fractures around the MCP and CMC joints. In the dorsal dislocation patterns, the oblique or lateral view reveals the dorsal prominence of the affected joint. Common fractures to look for are fractures of the metacarpal bases, avulsion type, associated with the CMC dislocation.

    • Breuerton view of the MCP joints: The Breuerton view of the MCP joints is taken with the fingers flat on the plate, the metacarpals at 65° of inclination to them and the tube at 15° from the ulnar side of the hand. It demonstrates the MCP bony surface.

    • Modified lateral views: Modified lateral views of the metacarpals are sometimes necessary because little of the shaft or head can be observed on a true lateral radiograph of the hand. To study the index and middle finger, the hand should be pronated 30° from the lateral. To study the ring and small fingers, the hand should be supinated 30° from the lateral.

Procedures

• Dislocations of the DIP joint are almost always reducible with longitudinal traction and gentle manipulation in the direction opposite to the deformity. Irreducible dislocations may occur secondary to soft tissue entrapment in the joint or if the patient presents more than a few days out from the injury.
• Closed reduction is almost always successful for dorsal PIP dislocations. Volar dislocations are more problematic, especially if the deformity has a rotary component. For all closed reduction maneuvers, be gentle and limit the number of attempts to 2-3. Irreducible dislocations are usually caused by soft tissue structures (eg, volar plate, collateral ligament, tendons) trapped in the joint; the patient is likely to need referral to a hand surgeon for open reduction.
• • Most dorsal dislocations of the PIP joint can be easily reduced with gentle traction on the finger with the wrist and MCP joints flexed, followed by pressing the base of the middle phalanx in a volar direction while holding the proximal phalanx steady. As noted, the athlete, coach, or trainer usually accomplishes this maneuver. If the reduction is performed immediately after the injury, it can usually be accomplished without anesthesia. If the reduction is delayed, a digital block with 1% lidocaine (without epinephrine) is helpful.

  • Volar PIP dislocations without a rotatory component are usually reducible with gentle traction. Place the wrist in the neutral position and press dorsally on the base of the middle phalanx and volarly on the proximal phalanx. While these injuries are usually treatable with closed reduction, they commonly involve an avulsion of the central slip of the extensor tendon.

  • Volar PIP dislocations with a rotatory component often are difficult to reduce by closed means because the head of the proximal phalanx becomes trapped between the central slip and one of the lateral bands of the extensor mechanism. Sometimes, these injuries can be reduced by placing the MCP and PIP joints in 90° of flexion with the wrist extended, applying traction, and rotating the middle phalanx in the direction opposite to the deformity.

• MCP dislocations most commonly occur dorsally (simple type). Closed reduction is the treatment of choice and is usually accomplished without difficulty, with gentle traction and flexion of the proximal phalanx. This can be facilitated with a local digital nerve block. In those patients in whom the reduction is not obtained after several attempts and displacement or subluxation persists, open reduction is indicated. At the time of operation, the capsule has usually impinged between the 2 bones, preventing reduction. In children, the displacement of the proximal phalanx may be more to the ulnar than the dorsal side and a shearing type of osteocartilaginous fragment often prevents complete reduction.
• Early dislocations of the metacarpals can be reduced by the following:
• • In early or acute dislocations of the metacarpals, the carpus closed reduction should be attempted and is usually successful. These dislocations occur dorsally, and reduction can be obtained by gentle traction on the finger of the associated metacarpal while pressing dorsally on the CMC joint dislocation through the range from flexion to extension. The closed reduction can be facilitated with local anesthetic hematoma or intra-articular blocks at the affected area. After the reduction is accomplished, the wrist and CMC joint should be flexed acutely to determine stability. If closed reduction is successful but the reduction is unstable, continued reduction can be attempted in a dorsiflexion cobra-type cast or by percutaneous Kirschner wire fixation.

  • If reduction by closed methods is unsuccessful, open reduction with removal of the soft tissue in the intra-articular space should be accomplished through a dorsal incision, and the metacarpal base articular surfaces should be fixed in appropriate place with Kirschner wires after being levered into the normal relationship with the carpus. In delayed situations where the metacarpal bases cannot be reduced, repositioning of the metacarpal bases is best accomplished by bony resection of the bases that overlap the carpus pushing the bases into the normal relationship with the carpus.

• To perform a digital block, first cleanse the skin with povidone-iodine solution. Insert a 25-gauge needle near the base of the finger and through its dorsolateral aspect just lateral to the periosteum of the base of the proximal digit. Advance the needle posteriorly to slide just past the base of the phalanx. As the needle is advanced, inject 1 mL of anesthetic while observing for protrusion of palmar dermis directly opposite the needle path. Another 1 mL of solution is injected as the needle is withdrawn. This technique should block both the dorsal and volar digital nerve branches. The same technique is repeated on the medial and lateral sides for complete anesthesia of the finger. Do not use lidocaine with epinephrine. The digital arteries are end arteries that can spasm and cause ischemia of the fingertip and, potentially, necrosis. Volumes of 2-4 mL should not be exceeded to avoid mechanical pressure of injected solution into a potentially confined space.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Although general guidelines have been developed for the treatment of hand injuries, a review of the literature suggests that return-to-play guidelines are dependent on factors such as the severity of the initial injury, age, hand dominance, and the chronicity of injury, which vary with each individual.

Acute Phase

Rehabilitation Program

Physical Therapy

Patients with DIP dislocations that are stable may begin immediate AROM. The less common unstable dorsal dislocation should be immobilized in 20° of flexion for 2-3 weeks prior to instituting AROM. Complete collateral ligament injuries should be protected from lateral stress for at least 4 weeks. Palmar DIP dislocations may involve disruption of the insertion of the terminal extensor tendon as well as collateral ligaments and the palmar plate. Splinting the joint in extension for 8 weeks is required for the extensor tendon to heal.

The duration and position of immobilization of PIP injuries depends on the structures involved and the severity of any disruptions. Dorsal PIP dislocations that are stable postreduction can generally be treated with buddy taping. This limits hyperextension, preventing recurrent dislocation and allows a combination of AROM and gentle PROM. An alternative is the use of a dorsal aluminum foam splint. In the case of a significant collateral ligament injury, the finger used as a splint should be on the side of the injured collateral ligament whenever possible. Uncomplicated PIP dislocations are usually immobilized in extension for 7-10 days. More serious injuries may be followed by up to 6 weeks of buddy-taped AROM. The patient should follow up within 2 weeks to confirm proper splinting and absence of skin problems.

Following closed reduction of dorsal PIP dislocations, immobilize the joint with a dorsally placed splint in 10-15° of flexion. The patient can begin active flexion while in the splint once comfortable. After 2 weeks, the splint can be discontinued and the finger buddy taped for 2 more weeks. Dorsal PIP dislocations that are unstable in extension (including fracture-dislocations) should be initially treated with extension block splinting at the angle required to keep the joint and the fracture (if present) reduced. This splint is often placed dorsally as an outrigger splint anchored in a short-arm cast with the splint taped to the cast to maintain the flexion angle. The proximal phalanx must be immobilized (taped to the splint) to prevent the patient from achieving too much PIP extension by flexing the MCP joint while the middle and distal phalanges are left free.

Volar dislocations with an intact extensor mechanism that are stable postreduction can usually be treated with buddy taping. If open reduction is required without extensive surgical repair, the joint can usually be immobilized for a few days and then buddy taped. Volar dislocations accompanied by central slip injury require splinting of the PIP joint in extension (leaving the DIP joint free) usually for 4-6 weeks followed by daytime dynamic and nighttime static extension splinting for 2 weeks. The DIP joint should be actively flexed throughout the entire recovery phase.

All of these injuries should be aggressively treated to minimize swelling. Routine elevation consists of propping the forearm and hand up on a pillow at night, wearing a sling, or consciously holding the arm up during the day. Ice is used as needed, especially during the first few days. Wrapping the finger with Coban tape can also be used to treat edema.

For patients seen early after dorsal MCP dislocations that are stable after reduction, rubber band extension block splinting (about 20°) for 2-3 weeks should be tried to prevent recurrence through hyperextension. Collateral ligament injuries should be immobilized in incomplete flexion (50°) for 3 weeks, followed by AROM with the digit buddy taped to protect against lateral deviation stress. Additional physical therapy should be completed with modalities to prevent hand edema and maintain mobilization of all of the joints of the hand.

In CMC dislocations, the hand and wrist are frequently placed in an extension-type splint or cobra-type (extension) cast. Initial therapy should be directed at elevating the hand, decreasing the swelling, and mobilizing all of the stable joints of the hand.

Occupational Therapy

AROM exercises should be encouraged early on with almost all of these injuries. This is relatively easy to achieve with injuries that have been treated with buddy taping or extension block splinting. PROM exercises have a very limited role in the early stages of treatment, with the exception of volar dislocations associated with central slip injuries. These need aggressive AROM and PROM exercises of the DIP joint while maintaining the PIP joint in full extension. This helps to minimize both stiffness at the DIP joint and adhesions between the 2 flexor tendons.

In the early stages of MCP and CMC dislocations, the role of occupational therapy is usually limited. However, aggressive mobilization of the fingers of the hand and the wrist joint are carried out after the dislocation is stable and as early in the course of treatment as possible.

Medical Issues/Complications

Appropriate expectations regarding the outcome of any injury should be discussed with the patient.

All patients with these injuries should follow up within a week to check for some of the more common complications. Dorsal PIP dislocations that initially appear stable may develop subluxation with extension, requiring more aggressive treatment. Volar PIP dislocations may also lose reduction, or they may have an occult central slip injury at initial presentation (usually reflected by tenderness over the insertion) that progresses to a complete rupture over the next few days. Stiffness is a common complication at all stages of treatment, especially with PIP dislocations. The patient should perform gentle AROM exercises of any joint that does not require rigid immobilization. Resolution of stiffness and soreness may take as long as 12-18 months, and permanent residual enlargement of the joint is a possibility.

Collateral ligament injuries (usually radial) commonly accompany finger dislocations and usually respond well to closed treatment with no significant long-term disability. However, the patient should be made aware that the pain from these injuries may take months, up to a year, to completely resolve and that permanent enlargement of the joint is a common sequela. Complications associated with MCP and CMC dislocations usually fit into the following 3 categories:

• Skin problems



• Recurrent subluxations or dislocations



• Stiffness or lack of motion of the joints

The patient should be monitored in the week following the dislocation to evaluate whether any posttraumatic skin ulceration, slough, or breakdown is present that may need to be treated with wound care or antibiotics. The patients should undergo repeat radiography intermittently early on to verify that the reduction is maintained.

After appropriate immobilization, patients can have evidence of dislocation or subluxation of the extensor tendon to the radial or ulnar side of the MCP joints occupying a place between the 2 metacarpal heads. This is best treated by surgical intervention and proper repair of the torn extensor expansion with a row of interrupted sutures.

In long-term dislocation or recurrences, surgery is suggested to expose the joint dorsally and to perform a capsulectomy on either side of the MCP joint to achieve stable reduction. In some cases of acute MCP joint dislocation, the collateral ligament may rupture where it attaches to the tubercle of the metacarpal. This may lead to recurrent instability but can usually be treated nonoperatively, except when the collateral ligament rupture occurs on the radial side of the MCP joint of the little finger. In this case, the short abductor muscle of the little finger may pull it into ulnar deviation, requiring operative repair.

Surgical Intervention

Surgery is indicated for any open dislocation (irrigation and debridement [I & D]) and any dislocation not reducible by closed means (open reduction). Any joint that is grossly unstable or that cannot maintain reduction with buddy taping or extension block splinting may require repair of supporting structures (volar plate or collateral ligaments) to maintain the reduction. Volar dislocations accompanied by complete loss of extension at the PIP joint may require open reattachment of the central slip.

DIP injuries are considered chronic after 3 weeks. Chronically subluxed joints may require opening to resect scar tissue to allow tension-free reduction.

Complex fracture dislocations may require surgery for some combination of open reduction, internal fixation, and repair of supporting structures. External fixation (compass hinge) has been used on some complex PIP fracture dislocations to provide distraction across the joint, maintain reduction, and allow controlled ROM. Details of surgical therapy for MCP and CMC dislocations were addressed under Procedures.

Consultations

A hand surgeon should see any patient who requires or may require surgery. In addition to the above surgical indications, referral to a hand surgeon is usually indicated for fracture-dislocations, most volar dislocations, and any dislocation with associated tendon injury.

Other Treatment

Other forms of treatment for hand dislocations are rarely indicated.

Recovery Phase

Rehabilitation Program

Occupational Therapy

Stable injuries should continue to be treated with gentle AROM exercises and should not require extensive formal occupational therapy unless complications develop. Boutonniere injuries should be treated by occupational therapy early on to ensure that ROM exercises are done properly and often, as well as for splint fabrication and more aggressive ROM when full-time immobilization is discontinued. Occupational therapy is also important in most postoperative patients, in fracture-dislocations, and in any patient who begins to develop significant stiffness at any point in the course of recovery.

Medical Issues/Complications

Several complications can arise during this phase. At the first follow-up, the examiner should specifically look for recurrent instability/subluxation in the joint. Early boutonniere deformity (ie, hyperextension at the DIP joint with fixed flexion at the PIP joint) is indicative of a central slip injury and often progresses to a disabling deformity without appropriate treatment. Stiffness can occur in any of these injuries. This can be minimized in most cases by avoidance of excess immobilization and appropriate involvement of occupational therapy and hand surgery at an early stage in high-risk injuries.

In MCP and CMC dislocations, the same problems that are observed in the acute phase can be observed in the recovery phase. However, stiffness becomes a more predominant complication, and it can occur in any of the joints of the fingers, the MCP joints, and the CMC joints. Treatment involves aggressive occupational therapy to prevent joint ankylosis.

Surgical Intervention

Most patients needing surgery for these injuries are best served by treatment in the acute phase. If surgery is needed, it is most likely for the reasons below (see Consultations).

Consultations

A hand surgeon should be involved early on in the treatment of any complicated PIP or DIP injury. The need for such consultation would be indicated if the patient presents late, was inadequately assessed at initial presentation, or develops an unforeseen complication such as recurrent subluxation in a joint that appeared to be stable after reduction.

Other Treatment (Injection, manipulation, etc.)

Other forms of treatment are rarely indicated.

Maintenance Phase

Rehabilitation Program

Physical Therapy

Most patients with uncomplicated dislocations should recover good function and do not require ongoing treatment in the maintenance phase.

Occupational Therapy

Any patient with significant chronic stiffness, especially in the PIP joint, can benefit from occupational therapy. Even if surgery is planned, the patient benefits the most if ROM is maximized by dynamic splinting and exercises preoperatively.

Medical Issues/Complications

Most long-term complications of finger dislocations are related to either stiffness or instability. Stiffness is initially best treated with intensive occupational therapy, but a hand surgeon should assess all significant contractures. Lateral instability is usually due to collateral ligament injury, instability in extension to volar plate injury, or a missed fracture. Most volar plate injuries heal with immobilization that prevents hyperextension (usually buddy taping), so this complication often is preventable. Depending on the demands of the sport and position played, the finger and specific structures involved, and the degree of instability, some of these problems may benefit from surgery.

Surgical Intervention

A number of procedures are possible to treat instability, stiffness, and fracture nonunions in and around the interphalangeal joints. Severe DIP problems may be treated with arthrodesis depending on the demands placed on the hand. However, this is not a good option for the PIP joint. Any procedure on the PIP joint is likely to result in some loss of ROM. Therefore, compliance with occupational therapy is critical.

Consultations

Most patients with chronic instability or stiffness in a finger (especially PIP joint) should be referred for assessment by a hand surgeon.

Other Treatment

Steroid injection may rarely be indicated in a chronically swollen painful joint.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Drugs used for injuries involving the hand include various analgesics. Local anesthetics are also used for digital blocks when necessary.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

Most commonly used for the relief of mild to moderate pain. Anti-inflammatory effects may be useful as well. Although the effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the drug of choice (DOC) for initial therapy. Other options include ketoprofen and naproxen.

Drug Category: Analgesics

Used for pain relief. Tylenol is used in patients with mild pain, especially those with a contraindication to NSAID use. Narcotics are used in those with moderate to severe pain.

Drug Category: Local anesthetics

Used for digital block to facilitate reduction or examination of finger.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Return to Play

Athletes with simple dorsal dislocations of the PIP joint may return to play with buddy taping or splinting as soon as the same game if a stable reduction is achieved, unless their position places unusual demands on the finger (eg, quarterbacks, pitchers with an injury to the dominant hand).

Athletes with dorsal fracture/dislocations of the PIP joint and dislocations that are unstable in extension require a minimum of 3-4 weeks (the time during which extension block splinting is required) before return to play. Open reduction or volar plate repair necessitates 6 weeks away from sports. Patients with volar PIP dislocations are more likely to be kept from rapid return by associated injuries and problems with reduction. Injury to the central slip of the extensor tendon is common with volar dislocations and necessitates splinting the DIP joint in extension for approximately 6 weeks. If this does not interfere with function, the athlete may return to play, although ball handlers may have some difficulty with the splint.

Volar dislocations requiring open reduction may return to play after a few days of immobilization if the central slip is intact. As with dorsal dislocations, if internal fixation or repair of structures around the joint is required, the athlete may be out for 6 weeks. Most DIP dislocations should not require time away from play except for a few days postoperatively if open reduction or I & D is necessary.

Athletes with MCP joint or CMC joint dislocations generally remain out of sports for 6-8 weeks. This is the time that the extension block splinting or extension cobra casting is needed, plus a period to arrange for full functional mobilization of the fingers, hand, and wrist with appropriate return of grip and wrist flexion and extension strength.

Complications

Joint stiffness, flexion deformity, and instability may develop from the injury or from immobilization during treatment. Boutonniere deformity may result from undiagnosed/untreated central slip injury associated with volar PIP dislocation. Overly forceful attempts at reduction may result in phalangeal fractures. Associated intra-articular fractures may predispose to degenerative joint disease (DJD).

Prevention

A limited role for prevention of these dislocations is possible because they always occur to some degree in contact sports. Taping of the fingers in high-risk contact sports, such as football, may help to prevent these injuries. Failure to adequately treat the jammed finger with an isolated partial collateral ligament tear may predispose the athlete to reinjury and possible dorsolateral dislocation. Finger injuries should be adequately assessed by the team physician or trainer and buddy-taped or splinted as necessary to allow healing and prevent recurrence.

Prognosis

Prognosis is good in simple PIP dislocations and most DIP dislocations and volar dislocations with the central slip intact (rotatory subluxations). Frequently, some loss of ROM occurs, but with adequate rehabilitation, a functional range can be maintained. Prognosis is fair in volar dislocations with avulsion of the central slip, if the diagnosis is made at the time of initial evaluation and proper treatment initiated; however, prognosis is fair to poor in dorsal fracture-dislocations. Prognosis is poor in any dislocation that is incompletely reduced for more than a few days and is very poor for a dorsal fracture-dislocation or a volar dislocation with central slip injury if the diagnosis is not made and appropriate treatment instituted early in the course. Prognosis is good in most early treated MCP joint and CMC joint dislocations. Delay in diagnosis and treatment may progressively worsen the prognosis. Long-term sequelae with injury to the joint surface include instability, ankylosis, and arthrosis.

Education

All athletes in high-risk sports should know to have significant finger injuries evaluated and treated by the team physician or trainer at the time they occur. This helps to avoid some of the morbidity from fracture-dislocations, boutonniere injuries, and incompletely reduced dislocations. All athletes who sustain these injuries should be made aware of the importance of timely follow-up, of the expected duration of immobilization, and of the rehabilitation plan, goals, and timetable.

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Broken Hand.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Missing a boutonniere injury associated with a volar PIP dislocation
• • Always check active extension at the PIP joint against resistance. Failure to adequately assess stability of reduction is a concern.

  • Some of these injuries sublux in extension and require extension block splinting.

  • Grossly unstable joints require surgical intervention.

  • Ensure early follow-up for re-examination and repeat radiography in questionable cases.

  • Failure to diagnose persistent subluxation/tissue trapped in joint because of absence of gross deformity is a concern.

  • Always check the lateral radiograph for joint congruency/rotation.

  • Be suspicious of decreased ROM to avoid missing an open dislocation because it has been reduced prior to presentation.

  • Be suspicious of any lacerations near interphalangeal joints in a patient with a jammed finger.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Hand dislocation. Carpometacarpal joint dislocation.
	View Full Size Image
Media type:  X-RAY

Media file 2:  Hand dislocation. Carpometacarpal joint dislocation.
	View Full Size Image
Media type:  X-RAY

Media file 3:  Hand dislocation. Volar proximal interphalangeal (PIP) joint dislocation.
	View Full Size Image
Media type:  X-RAY

Media file 4:  Hand dislocation. Dorsal thumb interphalangeal dislocation.
	View Full Size Image
Media type:  X-RAY

Media file 5:  Hand dislocation. Dorsal thumb interphalangeal dislocation.
	View Full Size Image
Media type:  X-RAY

Media file 6:  Hand dislocation. Aluminum foam splints.
	View Full Size Image
Media type:  Photo

Media file 7:  Hand dislocation. Dorsal aluminum foam splint.
	View Full Size Image
Media type:  Photo

Media file 8:  Hand dislocation. Buddy taping.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Bach AW. Finger Joint Injuries in Active Patients. Physician Sportsmed [serial online]. 27(3):Available at http://www.physsportsmed.com/issues/1999/03_99/bach.htm.
• Freiberg A, Pollard BA, Macdonald MR, Duncan MJ. Management of proximal interphalangeal joint injuries. J Trauma. Mar 1999;46(3):523-8. [Medline].
• Gurland M. Carpometacarpal joint injuries of the fingers. Hand Clin. Nov 1992;8(4):733-44. [Medline].
• Hubbard LF. Metacarpophalangeal dislocations. Hand Clin. Feb 1988;4(1):39-44. [Medline].
• Inoue G, Maeda N. Irreducible palmar dislocation of the proximal interphalangeal joint of the finger. J Hand Surg [Am]. Mar 1990;15(2):301-4. [Medline].
• Isani A, Melone CP Jr. Ligamentous injuries of the hand in athletes. Clin Sports Med. Oct 1986;5(4):757-72. [Medline].
• Kahler DM, McCue FC 3rd. Metacarpophalangeal and proximal interphalangeal joint injuries of the hand, including the thumb. Clin Sports Med. Jan 1992;11(1):57-76. [Medline].
• Kiefhaber TR, Stern PJ, Grood ES. Lateral stability of the proximal interphalangeal joint. J Hand Surg [Am]. Sep 1986;11(5):661-9. [Medline].
• Kovacic J, Bergfeld J. Return to play issues in upper extremity injuries. Clin J Sport Med. Nov 2005;15(6):448-52. [Medline].
• Lairmore JR, Engber WD. Serious, Often Subtle, Finger Injuries: Avoiding Diagnosis and Treatment Pitfalls. Physician Sportsmed [serial online]. 1998;26(6):Available at http://www.physsportsmed.com/issues/1998/06jun/lairmore.htm.
• Liss FE, Green SM. Capsular injuries of the proximal interphalangeal joint. Hand Clin. Nov 1992;8(4):755-68. [Medline].
• Lubahn JD. Dorsal fracture dislocations of the proximal interphalangeal joint. Hand Clin. Feb 1988;4(1):15-24. [Medline].
• McDevitt E. On-Site Treatment of PIP Joint Dislocations. Physician Sportsmed [serial online]. 1998;26(8):Available at http://www.physsportsmed.com/issues/1998/08aug/mcdevitt.htm.
• Melone CP Jr. Joint injuries of the fingers and thumb. Emerg Med Clin North Am. May 1985;3(2):319-31. [Medline].
• Stern PJ, Lee AF. Open dorsal dislocations of the proximal interphalangeal joint. J Hand Surg [Am]. May 1985;10(3):364-70. [Medline].
• Thayer DT. Distal interphalangeal joint injuries. Hand Clin. Feb 1988;4(1):1-4. [Medline].
• Vicar AJ. Proximal interphalangeal joint dislocations without fractures. Hand Clin. Feb 1988;4(1):5-13. [Medline].
• Wilson RL, Liechty BW. Complications following small joint injuries. Hand Clin. May 1986;2(2):329-45. [Medline].

Article Last Updated: Apr 26, 2006