eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Dislocation, Interphalangeal: Treatment & Medication
Updated: Feb 29, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
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 postreduction procedures (also see Joint Reduction, Finger Dislocation and Joint Reduction, Thumb Dislocation)
- 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 that 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 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.
- For a volar DIP dislocation, apply the splint only to the DIP joint on the volar aspect; the DIP should be in full extension. Allow the PIP joint full range of motion.
- In children, the cause of dislocation is 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 postreduction radiographs. Assess functional stability with stress views. This confirms correct joint alignment and congruity and identifies subtle fractures, especially chip or avulsion fractures.
- Assess neurovascular status following reduction.
Consultations
- Joint instability or neurovascular compromise after reduction requires immediate orthopedic or hand consultation.
- Because joint instability or dysfunction and subtle ligamentous, cartilaginous, or bony injury often are obscured by extensive edema and pain immediately after the injury, all finger joint dislocations should be referred for orthopedic or hand specialist evaluation within 2-3 weeks following reduction.
Medication
NSAIDs, analgesics, and anxiolytics are used to treat the pain associated with dislocations.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents are used most commonly for the relief of mild to moderately severe pain. Although the effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.
Ibuprofen (Ibuprin, Advil, and Motrin)
DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, inhibiting prostaglandin synthesis.
Adult
400-800 mg/dose PO q6-8h
Pediatric
10 mg/kg/dose PO q8h; not to exceed adult dose
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT carefully and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in CHF, hypertension, and decreased renal or hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy (instruct patients to monitor for signs of bleeding)
Ketoprofen (Oruvail, Orudis, Actron)
Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small body size, the elderly, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT carefully and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in CHF, hypertension, and decreased renal or hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy (instruct patients to monitor for signs of bleeding)
Flurbiprofen (Ansaid)
Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzymes, inhibiting prostaglandin biosynthesis.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients on anticoagulants (monitor PT carefully and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, decreasing prostaglandin synthesis.
Adult
500 mg PO initial dose, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT carefully and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients with injuries.
Acetaminophen (Tylenol, Panadol, Aspirin-free Anacin)
DOC for treatment of pain in patients with documented hypersensitivity to aspirin and NSAIDs, those with upper GI disease, or those taking oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d
Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, or isoniazid may increase hepatotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/24 h of acetaminophen; higher doses may cause liver toxicity
Oxycodone and aspirin (Percodan)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity; may potentiate anticoagulant effects of warfarin
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; because of association of aspirin with Reye syndrome do not use in children (<16 y) who have flu
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly patients; caution in renal or liver impairment, peptic ulcer disease, and erosive gastritis
Acetaminophen and codeine (Tylenol #3)
Drug combination indicated for treatment of mild to moderately severe pain.
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d
Pediatric
0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
CNS depressants or tricyclic antidepressants may increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen or 5 mg of hydrocodone bitartrate
>12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity
Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
More on Dislocation, Interphalangeal |
| Overview: Dislocation, Interphalangeal |
| Differential Diagnoses & Workup: Dislocation, Interphalangeal |
 Treatment & Medication: Dislocation, Interphalangeal |
| Follow-up: Dislocation, Interphalangeal |
| Multimedia: Dislocation, Interphalangeal |
| References |
| « Previous Page | Next Page » |
References
Banerji S, Bullocks J, Cole P, Hollier L. Irreducible distal interphalangeal joint dislocation: a case report and literature review. Ann Plast Surg. Jun 2007;58(6):683-5. [Medline].
Chinchalkar SJ, Gan BS. Management of proximal interphalangeal joint fractures and dislocations. J Hand Ther. Apr-Jun 2003;16(2):117-28. [Medline].
Cornwall R. Finger metacarpal fractures and dislocations in children. Hand Clin. Feb 2006;22(1):1-10. [Medline].
Deshmukh NV, Sonanis SV, Stothard J. Irreducible volar dislocations of the proximal interphalangeal joint. Emerg Med J. Mar 2005;22(3):221-3. [Medline].
Freiberg A, Pollard BA, Macdonald MR, Duncan MJ. Management of proximal interphalangeal joint injuries. Hand Clin. Aug 2006;22(3):235-42. [Medline].
Gilbert TJ, Cohen M. Imaging of acute injuries to the wrist and hand. Radiol Clin North Am. May 1997;35(3):701-25. [Medline].
Kannan RY, Wilmshurst AD. Unstable proximal interphalangeal joint dislocations: another cause. Emerg Med J. Oct 2006;23(10):819. [Medline].
Kozin SH. Fractures and dislocations along the pediatric thumb ray. Hand Clin. Feb 2006;22(1):19-29. [Medline].
Morisawa Y, Ikegami H, Izumida R. Irreducible palmar dislocation of the distal interphalangeal joint. J Hand Surg [Br]. Jun 2006;31(3):296-7. [Medline].
Nanno M, Sawaizumi T, Ito H. Irreducible palmar dislocation of the proximal interphalangeal joint of a finger evaluated by magnetic resonance imaging: a case report. Hand Surg. Dec 2004;9(2):253-6. [Medline].
Otani K, Fukuda K, Hamanishi C. An unusual dorsal fracture-dislocation of the proximal interphalangeal joint. J Hand Surg Eur Vol. Apr 2007;32(2):193-4. [Medline].
Papadonikolakis A, Li Z, Smith BP, Koman LA. Fractures of the phalanges and interphalangeal joints in children. Hand Clin. Feb 2006;22(1):11-8. [Medline].
Van Ransbeeck H, De Smet L. Double dislocation of both interphalangeal joints in the finger. Case report and literature review. Acta Orthop Belg. Feb 2004;70(1):72-5. [Medline].
Wang QC, Johnson BA. Fingertip injuries. Am Fam Physician. May 15 2001;63(10):1961-6. [Medline].
Further Reading
Keywords
IP, finger, toe, proximal interphalangeal joint, PIP, distal interphalangeal joint, DIP, IP joint dislocations, interphalangeal joint dislocations, interphalangeal dislocations, toe dislocation, finger dislocation, dorsal PIP dislocation, volar IP dislocation, IP joint, PIP joint dislocations, DIP joint dislocations, thumb dislocation
