Emergency Department Care
Splint, ice, and elevate the affected digit. [11, 12] Evaluate neurovascular status before and after transport to the ED. The patient should not participate in sports activities involving the hand.
The patient should have a follow-up evaluation with an orthopedist or hand specialist.
Reduction and postreduction procedures
With the patient's hand or foot securely braced, grasp the dislocated phalanx with dry gauze loosely wrapped around the phalanx (gauze improves grip). Hyperextend the joint slightly with gentle longitudinal traction for a dorsal dislocation or hyperflex for a volar dislocation. Gradually push the dislocated phalanx into its normal anatomic position. [11, 12]
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.
One study showed that management of PIP joint dislocations using controlled early mobilization with figure-of-eight splints provided greater range of motion and fewer hospital visits as compared to other splinting techniques. [19]
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. [14, 15, 20] 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.
Admission may be warranted as dictated by a hand consultant or concurrent injuries. NSAIDs may be taken as needed. If an orthopedic or hand specialist is not immediately available for consultation, transfer patients whose reductions are unsuccessful or those who have an unstable joint, open joint injury, or associated epiphyseal or avulsion fracture. [21]
Complications
Complications are rare with early reduction, although persistent pain or swelling is common. Despite appropriate management with rest, ice, and elevation, pain and swelling may persist for 6-12 months. [11, 12]
Inadequate immobilization after reduction may result in redislocation.
Prolonged immobilization may result in muscle contracture.
Volar plate injury may lead to recurrent dislocation with chronic laxity, hyperextensibility (swan-neck deformity on active extension), or flexion contracture (pseudoboutonnière deformity without DIP hyperextension).
Late or delayed reduction commonly results in loss of joint motion, joint instability, and limitation of hand function.
Proximal interphalangeal joint (PIPJ) injuries often cause complications, such as ankylosis, joint instability, post-traumatic arthritis, and flexion contracture. [18, 22]
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Anteroposterior view of distal interphalangeal (DIP) joint dislocation
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Lateral view of distal interphalangeal (DIP) joint dislocation
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Oblique view of distal interphalangeal (DIP) joint dislocation
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Oblique view of proximal interphalangeal (PIP) joint dislocation
