Reduction of Thumb Dislocation Periprocedural Care

Updated: Apr 13, 2017
  • Author: Moira Davenport, MD; Chief Editor: Erik D Schraga, MD  more...
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Periprocedural Care

Patient Education and Consent

Explain the procedure and its benefits, risks, alternatives, and complications to the patient or the patient’s representative. Obtain signed informed consent. Ask the patient or the patient’s representative if he or she would like others to be present for the procedure.

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Preprocedural Planning

Obtain and document a thorough preprocedural history that includes hand dominance, prior injuries, mechanism of trauma, description of presenting symptoms, subjective loss of strength or sensation, and the patient's age in reference to skeletal maturity.

Remove all rings, jewelry, or potentially constricting objects from the patient’s wrist and all digits of the patient’s hand.

Perform and document a thorough physical examination, noting ecchymoses, swelling, pallor, abrasions, lacerations, paresthesias, weakness, passive and active range of motion (ROM) of the metacarpophalangeal (MCP) and interphalangeal (IP) joints of the thumb, and capillary refill of the distal nail bed.

Obtain prereduction radiographs of the hand, including adequate anteroposterior (AP), lateral, and oblique views of the carpometacarpal (CMC), MCP, and IP joints of the first digit. These allow documentation of the presence and direction of the joint dislocation while excluding the presence of a fracture of the carpals, the first metacarpal, or the first proximal or distal phalanx. In some cases, noncontrast computed tomography (CT) or magnetic resonance imaging (MRI) of the thumb may be considered. [12]

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Equipment

Equipment employed for thumb joint reduction includes the following:

  • Needles, 20 and 25 gauge
  • Syringe, 10 mL
  • Alcohol wipes
  • Lidocaine 1% without epinephrine
  • Basin of lukewarm water
  • Plaster rolls, 2-3 in.
  • Cotton padding for under the cast, two or three rolls
  • Elastic bandages, 1-2 in.
  • Nonsterile gloves
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Patient Preparation

Anesthesia

Provide adequate analgesia to the injured thumb by regional injection, and, if necessary, systemic opioids. The median and radial nerves provide sensory innervation to the thumb and may be blocked as follows. (See Hand Anesthesia.)

A median nerve block is accomplished by injecting 3-5 mL of 1% lidocaine without epinephrine into the nerve distribution at the volar aspect of the wrist. The area of injection is located just deep to the palmaris longus tendon or slightly radial to it, between the palmaris longus and the flexor carpi radialis tendons in a plane just proximal to the proximal palmar crease, at a depth of 1 cm or less. The needle should be inserted perpendicular to the skin and through the flexor retinaculum, but the nerve itself is actually quite superficial.

A radial nerve block is accomplished by injecting 2-5 mL of 1% lidocaine without epinephrine just lateral to the radial artery at the level of the proximal palmar crease and at a depth of 0.5 cm. From this initial injection site, another 5-6 mL of local anesthetic is injected in a circumferential arc around the radial half of the wrist to the dorsal midline so that the lidocaine can reach the dorsal nerve branches of the radial nerve.

An ulnar nerve block is not necessary for thumb joint reductions.

Positioning

Position the patient’s hand so that the radial dorsal surface is facing the physician and the hand is at approximately chest level, within comfortable reach of the physician’s grasp. This may be aided by having the patient rest his or her elbow on a firm flat surface, with the elbow flexing the hand into an upright position.

Firmly grasp the patient’s thumb either on the distal phalanx, for reduction of an IP joint dislocation, or on the proximal phalanx, for reduction of an MCP joint dislocation. Use your nondominant hand to hold the patient's wrist. Keep the MCP joints of the index through small digits in comfortable extension, and maintain the wrist in passive flexion to relax the tendons.

When reducing a dorsal IP joint dislocation, hold the IP joint in gentle hyperextension. When reducing a dorsal MCP dorsal dislocation, gently hyperextend the MCP joint and actively hold it in this position. The objective is to initially exaggerate the injury.

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