eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Dislocation, Hand
Updated: Aug 22, 2008
Introduction
Background
Hand injuries are commonly seen in the emergency department. Emergency physicians should be able to identify and manage digital dislocations. Complications can occur if the diagnosis is missed or delayed or if the joint is incompletely reduced or splinted improperly.
Patients should be referred to a hand specialist following treatment of hand dislocations.
Pathophysiology
Traumatic force to the hand can be transmitted to bone, soft tissue, nerves, and vascular structures. Because the structures of the hand are close to the surface and near each other, injury often results in a combination of fractures, dislocations, and soft tissue injury.
The distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints both have lateral ligaments and a fibrous volar plate. Common dislocations are posterior or lateral. Typical forces resulting in DIP dislocations include a “jamming” blow to the end of the finger. The forces that commonly lead to dislocation of the PIP joint include an axial load or hyperextension. Lateral dislocations can result from radial- or ulnar-directed force on the joint.
Finger metacarpophalangeal (MCP) dislocations are rare and frequently are trapped by the surrounding ligaments, necessitating surgical relocation. MCP or palmar dislocations occur when a hyperextension movement occurs with rotation. The finger is bent back toward the top of the hand and is twisted during the injury. The finger may have been pushed, or compressed, during the injury. MCP dislocations are typically associated with fractures.
In thumb metacarpophalangeal (MCP) joint dislocations, the mechanism encountered most often is hyperextension that leads to volar dislocations. A significant lateral force can disrupt the collateral ligaments, resulting in instability. The gamekeeper's (skier's) thumb often results from a fall onto the hand with the thumb in abduction, such as when gripping a ski pole.Carpometacarpal dislocations are not always high-energy injuries. Identification involves careful analysis of subtle findings on radiographs and may require additional radiographic views. Missed diagnosis of carpometacarpal dislocation can result in significant morbidity.
Frequency
United States
The annual incidence of all types of dislocations in the hand is approximately 67,000 in the United States.
Mortality/Morbidity
Anatomical restoration of dislocated joints is imperative to achieve good long-term outcomes. Accurate and stable reduction, early fixation, and initiating range of motion exercise are very important. Dislocations can lead to osteoarthritis, compression neuropathies, and carpal tunnel syndrome. Additional disability from chondrolysis, carpal instability, and traumatic arthritis can also occur.
- Median or ulnar neuropathy can occur from direct nerve compression or increased pressure within the median or ulnar nerve canals. Evaluation of the patient's nerve status is especially important in the early evaluation of carpal dislocations.
- Grip strength must be tested before and after reduction.
Age
Pediatric transcarpal fractures in children are rare, but the emergency physician must be cognizant that they do occur.
Clinical
History
Historical data about the mechanism of trauma can help lead the emergency physician’s assessment of hand injuries.
- Historical data should include the following:
- Traumatic mechanisms such as crush, distraction, and extension
- Time of the event
- Conditions of the event (important if there are associated contaminated versus clean wounds)
- The patient's right or left hand dominance.
- The patient's occupation: For therapy following the acute intervention, the specialist or hand therapist should be aware of the patient's occupation.
- Previous hand injury, presence of fixation devices, or ligamentous laxity
- The emergency physician must translate the mechanism of injury into forces, loads, rotations, extensions, reductions, joint deformities, and related forces that caused the dislocation. The emergency physician can then utilize this knowledge for the local or obvious deformity as well as distal or occult injuries. For example, the MCP joint may appear dislocated, but fractures are typically associated with MCP dislocations because rotational and compressive forces are involved. In this case, radiographs are required prior to any reduction attempt.
Physical
- With significant injury to the digits, a comprehensive examination may be hindered by pain. A thorough visual inspection of the hand and fingers is the first required step. Inspect for deformity, skin color, skin temperature, skin integrity, and swelling. Distal digital sensation should be checked early and often.
- Sensation examination includes testing for the following:
- Light touch or deep pressure
- Detection of sharp Vs dull discrimination
- Detecting 2-points separated by 5 mm
- Detecting temperature variation
- The clinician must consider providing rapid pain relief to the patient. Digital block with a local anesthetic is an ideal, quick, and efficacious intervention. However, the clinician must have a working protocol with the hand specialist. In some cases, the hand specialist may want to examine the digit prior to the administration of the anesthetic. Reducing the patient's pain is a priority, but this priority must not occur without regard to performing a very thorough and well-documented neurovascular examination. The emergency physician and the hand specialist must establish some guidelines for eliminating the patient's pain but not compromise the examination and documentation for the provider who will have to provide ultimate follow-up, rehabilitation, and occupational guidelines.
- The presence of pain can limit the examination. The patient can be made pain free, or the pain tolerable, prior to manipulating the hand or digit. Benefits of an examination with anesthesia include improved assessment of range of motion and digit stability.
- Physical findings to look for in specific dislocations include the following:
- Thumb MCP joint: Dislocations may be simple or complex. In simple dislocations, the phalanx sits perpendicular to the metacarpal. The volar plate is not trapped. In complex dislocations, the phalanx is positioned parallel to the metacarpal with the volar plate trapped in the joint. The gamekeeper's (skier's) thumb presents with pain and tenderness on the ulnar aspect of the thumb around the MCP joint. The extent of associated laxity depends on the amount of disruption and the ability of the examiner to stress the joint.
- Finger MCP joints: Dislocations may be simple or complex. Simple dislocations can be identified as the base of the phalanx sits on the dorsum of the head of the metacarpal at a right angle. A complex dislocation may reveal a dimple on the palmar surface, and the digit may appear shortened and deviated to the ulnar side.
- Finger PIP joints: Simple dorsal dislocations may include volar plate disruption. The middle phalanx is often perpendicular to the distal aspect of the proximal phalanx. With lateral dislocation, the digit often is deviated to the ulnar side.
- Finger DIP joints: Open dislocations are common because of the strong support of the skin and periarticular structures.
Causes
- Common mechanisms of injury include the following:
- Industrial injuries
- Athletic injuries
- Falls
- Motor vehicle collisions (MVCs)
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Further Reading
Keywords
hand dislocation, dislocated hand, digital dislocations, finger dislocation, wrist dislocation, metacarpophalangeal dislocation, palmar dislocation, thumb metacarpophalangeal joint dislocation, MCP joint dislocation, proximal interphalangeal joint dislocation, PIP joint dislocation, distal interphalangeal joint dislocation, DIP joint dislocation
