eMedicine Specialties > Sports Medicine > Wrist and Hand

Hand Dislocation: Treatment & Medication

Author: Jeff Chan, MD, MS, FACEP, Clinical Instructor, Stanford University; Staff Physician, Department of Emergency Medicine, Regional Medical Center of San Jose
Coauthor(s): Eleby R Washington III, MD, FACS, Associate Professor, Department of Surgery, Division of Orthopedics, Charles R Drew University of Medicine and Science; Igor Boyarsky, DO, Director of Triage, Assistant Professor, Department of Emergency Medicine, King-Drew Medical Center, University of California at Los Angeles
Contributor Information and Disclosures

Updated: Mar 27, 2009

Treatment

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.¹⁰

Acute Phase

Rehabilitation Program

Physical Therapy

Patients with DIP dislocations that are stable may begin immediate AROM exercises. The less common unstable dorsal dislocation should be immobilized in 20° of flexion for 2-3 weeks before instituting AROM exercises. 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.^{1,2,3,4,11,12,13,14,15}

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 (see Image 8 or below). This limits hyperextension, preventing recurrent dislocation and allows a combination of AROM and gentle PROM exercises.

Buddy taping.
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Buddy taping.

An alternative is the use of a dorsal aluminum foam splint (see Image 7 or below).

Hand dislocation. Dorsal aluminum foam splint.
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Hand dislocation. 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 the absence of skin problems.

Following closed reduction of dorsal PIP dislocations, immobilize the joint with a dorsally placed splint in 10-15° of flexion. Once comfortable, the patient can begin active flexion while in the splint. 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

Early AROM exercises should be encouraged 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 that are 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 hand injury should be discussed with the patient.

All patients with these injuries should follow up within a week to be checked for some of the more common complications.¹⁶Dorsal 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. Early on, patients should undergo intermittent repeat radiography 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 hand 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 it 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 with hand dislocations which require 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.