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Hand Dislocation Workup

  • Author: Jeff Chan, MD, MS, FACEP; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Feb 29, 2016
 

Laboratory Studies

Laboratory studies are not typically necessary for the patient with an isolated interphalangeal joint dislocation. However, if management of the dislocation requires open reduction, general anesthesia, or anesthetic limb block, then preoperative laboratory studies may facilitate patient care. On occasion, therapeutic drug levels, cardiac studies, coagulation studies, or preoperative microbial studies may be required if the dislocation involves an open joint or concurrent soft tissue contamination.

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Radiography

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

If radiographs 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.

A child or adolescent with open growth plates who remains in pain even though radiographs reveal no fracture may have a growth plate injury. Proper splinting and urgent referral may be indicated.

The following views should be taken:

  • Anteroposterior
  • Lateral (to check the lateral radiograph for joint congruency or rotation)
  • Oblique
  • Stress views can be examined if ligamentous laxity is documented or suspected. (see image below)
    Radiograph displaying a stress test of a torn ulna Radiograph displaying a stress test of a torn ulnar collateral ligament.
  • Postreduction images must follow even the most apparently routine reductions

In rare circumstances, computed tomography (CT) or magnetic resonance imaging (MRI) may be necessary to make a definitive diagnosis.[15]

Radiographs of the affected finger help further define the anatomy of the dislocation, rule out associated fractures, and assess the adequacy of reduction. For dorsal dislocations at the proximal interphalangeal (PIP) joint (see the images below), the initial radiographs are often obtained after reduction 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.

Acute dorsal proximal interphalangeal joint fractu Acute dorsal proximal interphalangeal joint fracture-dislocation.
Acute dorsal proximal interphalangeal fracture-dis Acute dorsal proximal interphalangeal fracture-dislocation. A concentric reduction could not be maintained in a splint.
Dorsal thumb interphalangeal dislocation. Dorsal thumb interphalangeal dislocation.
Dorsal thumb interphalangeal dislocation. Dorsal thumb interphalangeal dislocation.

In a volar dislocation (see the image below), rotation may be noticeable on the lateral view. The head of the proximal phalanx lies in a different plane from that occupied by the base of the middle phalanx.

Volar proximal interphalangeal (PIP) joint disloca Volar proximal interphalangeal (PIP) joint dislocation.

Common fractures to look for include avulsions and impacted fractures. Avulsions at the volar base of the middle phalanx (or the distal phalanx, in the case of distal interphalangeal [DIP] joint injury) from the volar plate may not affect the treatment plan if they are small. Larger fractures at this location make the injury a fracture-dislocation, which may be unstable in extension (see the image below).

Complex unstable fracture of the proximal phalanx. Complex unstable fracture of the proximal phalanx.

Avulsions at the dorsal base of the middle phalanx (or the distal phalanx, in the case of DIP joint injury) from the extensor tendon should prompt careful testing of extensor function and probably require splinting in extension; splinting in hyperextension should be avoided. Most central slip injuries, however, involve only soft tissue.

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

Key considerations in the radiographic assessment of reduction include the following:

  • Congruence of the articular surfaces
  • Absence of rotational deformity
  • Fractures around the metacarpophalangeal (MCP) and carpometacarpal (CMC) joints

With respect to articular congruence, 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, the examiner should be highly suspicious for persistent subluxation secondary to entrapment of soft-tissue structures within the joint.

A volar PIP dislocation in which 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.

To rule out fractures around the MCP and CMC joints, anteroposterior, lateral, and oblique views of the entire hand are indicated (see the images below). In the dorsal dislocation patterns, the oblique or lateral view reveals the dorsal prominence of the affected joint. Common fractures to look for include avulsion-type fractures of the metacarpal bases, associated with the CMC dislocation.

Displaced fourth and fifth metacarpal fractures, a Displaced fourth and fifth metacarpal fractures, anteroposterior view.
Displaced fourth and fifth metacarpal fractures, l Displaced fourth and fifth metacarpal fractures, lateral view.
Fourth and fifth metacarpal fractures, oblique vie Fourth and fifth metacarpal fractures, oblique view.
Fourth and fifth metacarpal fractures after intram Fourth and fifth metacarpal fractures after intramedullary pinning, anteroposterior view.
Fourth and fifth metacarpals after intramedullary Fourth and fifth metacarpals after intramedullary pinning, lateral view.

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

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.

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Contributor Information and Disclosures
Author

Jeff Chan, MD, MS, FACEP Clinical Instructor in Surgery (Emergency Medicine), Stanford University School of Medicine

Jeff Chan, MD, MS, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Igor Boyarsky, DO Emergency Room Physician, Kaiser Permanente Southern California

Igor Boyarsky, DO is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Academy of Anti-Aging Medicine, American Osteopathic Association

Disclosure: Nothing to disclose.

Eleby R Washington, III, MD, FACS Associate Professor, Department of Surgery, Division of Orthopedics, Charles R Drew University of Medicine and Science

Eleby R Washington, III, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, International College of Surgeons, National Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Acknowledgements

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Gerard A Malanga, MD Director of Pain Management, Overlook Hospital; Director of PM&R Sports Medicine Fellowship, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Institute of Ultrasound in Medicine, International Spine Intervention Society, and North American Spine Society

Disclosure: Cephalon Honoraria Speaking and teaching; Endo Honoraria Speaking and teaching; Genzyme Honoraria Speaking and teaching; Prostakan Honoraria Speaking and teaching; Pfizer Consulting fee Speaking and teaching

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Carpometacarpal joint dislocation.
Carpometacarpal joint dislocation.
Volar proximal interphalangeal (PIP) joint dislocation.
Dorsal thumb interphalangeal dislocation.
Dorsal thumb interphalangeal dislocation.
Aluminum foam splints.
Hand dislocation. Dorsal aluminum foam splint.
Buddy taping.
Acute dorsal proximal interphalangeal joint fracture-dislocation.
Acute dorsal proximal interphalangeal fracture-dislocation. A concentric reduction could not be maintained in a splint.
Complex second metacarpophalangeal dislocation in a skeletally immature patient (same patient as in the next 2 images). Note the position of the finger and dimpling of skin on volar hand.
Radiograph of the hand of a patient with complex second metacarpophalangeal dislocation (same patient as in the previous and next images).
Intraoperative photo of the second metacarpophalangeal joint (same patient as in the previous 2 images). Note the displaced volar plate between the metacarpal head and the proximal phalanx.
Boutonniere deformity.
Normal lateral band location, dorsal to the axis of rotation of the proximal interphalangeal joint.
After central slip disruption, lateral bands migrate volar to the axis of rotation of the proximal interphalangeal joint.
Lateral view of relevant finger anatomy.
Anteroposterior radiograph displaying a gamekeeper's fracture.
Lateral radiograph displaying a gamekeeper's fracture.
Ruptured ulnar collateral ligament.
Completed UCL repair using suture anchors for fixation (same patient as in the image above).
Radiograph displaying a stress test of a torn ulnar collateral ligament.
Complex unstable fracture of the proximal phalanx.
Displaced fourth and fifth metacarpal fractures, anteroposterior view.
Displaced fourth and fifth metacarpal fractures, lateral view.
Fourth and fifth metacarpal fractures, oblique view.
Fourth and fifth metacarpal fractures after intramedullary pinning, anteroposterior view.
Fourth and fifth metacarpals after intramedullary pinning, lateral view.
Digital block.
 
 
 
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