Hand Dislocation Treatment & Management

Many hand dislocations can be effectively treated with closed reduction, traction, or both. Some of these injuries become subluxated in extension and require extension block splinting. Grossly unstable joints and those for which closed reduction has failed typically require surgical intervention. Most patients needing surgery for hand dislocation injuries are best served by treatment in the acute phase. Steroid injection may rarely be indicated for a chronically swollen, painful joint in those with a hand dislocation.

Active range-of-motion (AROM) and passive range-of-motion (PROM) exercises are key components of treatment throughout. Ensure early follow-up for reexamination and repeat radiography in questionable cases. Any long-term complications (usually involving stiffness or instability) that develop must be addressed.

Dislocations of the distal interphalangeal (DIP) joint are almost always reducible with longitudinal traction and gentle manipulation in the direction opposite to the deformity. Irreducible dislocations may occur if soft-tissue entrapment develops in the joint or if the patient presents more than a few days out from the injury. ^[11]

Closed reduction is almost always successful for dorsal proximal interphalangeal (PIP) joint dislocations. Volar dislocations are more problematic, especially if the deformity has a rotational component. For all closed reduction maneuvers, be gentle and limit the number of attempts to 2-3. Irreducible dislocations are usually caused by soft-tissue structures (eg, volar plate, collateral ligament, tendons) trapped in the joint, in which case the patient may need to be referred to a hand surgeon for open reduction (see below).

Most dorsal dislocations of the PIP joint can be easily reduced by placing gentle traction on the finger with the wrist and the metacarpophalangeal (MCP) joints flexed, then pressing the base of the middle phalanx in a volar direction while holding the proximal phalanx steady. In a sports setting, the athlete, coach, or trainer usually accomplishes this maneuver. If the reduction is performed immediately after the injury, it can usually be accomplished without anesthesia. If the reduction is delayed, a digital block with 1% lidocaine (without epinephrine) is helpful.

To perform a digital block, first cleanse the skin with povidone-iodine solution. Insert a 25-gauge needle near the base of the finger and through its dorsolateral aspect just lateral to the periosteum of the base of the proximal digit. Advance the needle posteriorly so that it slides just past the base of the phalanx. As the needle is advanced, inject 1 mL of anesthetic while observing for protrusion of the palmar dermis directly opposite the needle path. Another 1 mL of solution is injected as the needle is withdrawn.

This technique should block both the dorsal and volar digital nerve branches. For complete anesthesia of the finger, it is performed both on the medial side and on the lateral side (see the image below). It is important not to use lidocaine with epinephrine. The digital arteries are end arteries that can spasm and cause ischemia of the fingertip and, potentially, necrosis. To avoid the mechanical pressure generated by injecting solution into a potentially confined space, volumes of 2-4 mL should not be exceeded.

Volar PIP dislocations without a rotational component are usually reducible with gentle traction. Place the wrist in the neutral position, and press dorsally on the base of the middle phalanx and volarly on the proximal phalanx. Although these injuries are usually treatable with closed reduction, they commonly involve an avulsion of the central slip of the extensor tendon.

Volar PIP dislocations with a rotational component are often difficult to reduce by closed means, because the head of the proximal phalanx becomes trapped between the central slip and one of the lateral bands of the extensor mechanism. Sometimes, these injuries can be reduced by placing the MCP and PIP joints in 90° of flexion with the wrist extended, applying traction, and rotating the middle phalanx in the direction opposite to the deformity.

MCP dislocations most commonly occur dorsally (simple type). Closed reduction is the treatment of choice and usually is readily accomplished with gentle traction and flexion of the proximal phalanx. A local digital nerve block may facilitate the process.

If closed reduction is not accomplished after several attempts and displacement or subluxation persists, open reduction is indicated. At the time of operation, the capsule has usually impinged between the 2 bones, preventing reduction. In children, the displacement of the proximal phalanx may be more to the ulnar than the dorsal side, and a shearing type of osteocartilaginous fragment often prevents complete reduction.

In early or acute dislocations of the metacarpals, the carpus closed reduction should be attempted and is usually successful. These dislocations occur dorsally, and reduction can be obtained by placing gentle traction on the finger of the associated metacarpal while pressing dorsally on the carpometacarpal (CMC) joint dislocation through the range from flexion to extension.

The closed reduction can be facilitated with local anesthetic hematoma or intra-articular block at the affected area. After the reduction is accomplished, the wrist and CMC joint should be flexed acutely to determine stability. If closed reduction is successful but the reduction is unstable, continued reduction can be attempted with a dorsiflexion cobra-type cast or percutaneous Kirschner wire (K-wire) fixation. ^[18]

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. ^[19]

Patients with stable DIP dislocations may begin immediate AROM exercises. Unstable dorsal dislocations (which are less common) should be immobilized in 20° of flexion for 2-3 weeks before AROM exercises are begun. 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. ^{[3, 4, 5, 6, 20, 21, 22, 23, 24]}

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 after reduction can generally be treated with buddy taping (see the first image below). This limits hyperextension, prevents recurrent dislocation, and allows a combination of AROM and gentle PROM exercises. An alternative is the use of a dorsal aluminum foam splint (see the second image below).

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.

After closed reduction of dorsal PIP dislocations, immobilize the joint with a dorsally placed splint in 10-15° of flexion. Once the patient is comfortable, he or she 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 that is anchored in a short-arm cast and 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.

A study by Waris et al evaluated the outcomes of extension block pinning used to treat unstable dorsal fracture dislocations of the proximal interphalangeal (PIP) joint. The study concluded that the extension block pinning technique is a simple and valuable technique for treating unstable dorsal PIP fracture-dislocation injuries producing satisfactory long-term results. ^{[25, 26]}

Volar dislocations with an intact extensor mechanism that are stable after reduction 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 (with the DIP joint left 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.

With almost all of these injuries, early AROM exercises should be encouraged. This is relatively easy with injuries that have been treated with buddy taping or extension block splinting. In general, PROM exercises have a very limited role in the early stages of treatment. The exception involves volar dislocations associated with central slip injuries, which call for aggressive AROM and PROM exercises of the DIP joint with 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 should be carried out after the dislocation is stable and as early in the course of treatment as possible.

Surgery is indicated for any open dislocation (irrigation and debridement) and any dislocation that is not reducible by closed means (open reduction).

When reduction by closed methods is unsuccessful, open reduction with removal of the soft tissue in the intra-articular space should be accomplished through a dorsal incision, and the metacarpal base articular surfaces should be fixed in appropriate positions with K-wires after being levered into the normal relationship with the carpus.

In situations where management is delayed and the metacarpal bases cannot be reduced, repositioning of the metacarpal bases is best accomplished by bony resection of the bases that overlap the carpus and pushing the bases into the normal relationship with the carpus.

Any joint that is grossly unstable or that cannot maintain reduction with buddy taping or extension block splinting may require repair of supporting structures (eg, the 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 subluxated joints may have to be opened so that scar tissue can be resected 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 range of motion (ROM).

A number of procedures are possible to treat instability, stiffness, and fracture nonunions in and around the interphalangeal joints. Severe DIP problems may be treated with arthrodesis, depending on the demands placed on the hand. However, this is not a good option for the PIP joint. Any procedure on the PIP joint is likely to result in some loss of ROM. Therefore, compliance with occupational therapy is critical.

In the recovery phase, stable hand injuries should continue to be treated with gentle AROM exercises and should not require extensive formal occupational therapy unless complications develop. Boutonniere injuries should be treated by early occupational therapy to ensure that ROM exercises are done properly and often, as well as for splint fabrication and more aggressive ROM when full-time immobilization is discontinued.

Occupational therapy is also important in most postoperative patients, in patients with fracture-dislocations, and in any patient whose injury begins to develop significant stiffness at any point in the course of recovery.

Several complications can arise during the recovery phase. At the first follow-up, the examiner should specifically look for recurrent instability or subluxation in the joint. Early boutonniere deformity (ie, hyperextension at the DIP joint with fixed flexion at the PIP joint) is indicative of a central slip injury and often progresses to a disabling deformity without appropriate treatment.

Stiffness can occur in any of these injuries; this can be minimized in most cases by avoidance of excess immobilization and appropriate involvement of occupational therapy and hand surgery at an early stage in high-risk injuries.

In MCP and CMC dislocations, the same problems that are observed in the acute phase can be observed in the recovery phase. However, stiffness becomes a more predominant complication, and it can occur in any of the joints of the fingers, the MCP joints, and the CMC joints. Treatment involves aggressive occupational therapy to prevent joint ankylosis.

The majority of patients with uncomplicated hand dislocations should recover good function and do not require ongoing treatment in the maintenance phase. Most long-term complications of finger dislocations are related to either stiffness or instability. Stiffness, especially in the PIP joint, is initially best treated with intensive occupational therapy, but a hand surgeon should assess all significant contractures. Even if surgery is planned, the patient benefits the most if ROM is maximized by means of dynamic splinting and exercise preoperatively.

Lateral instability is usually due to collateral ligament injury, instability in extension to volar plate injury, or a missed fracture. ^[27] Most volar plate injuries heal with immobilization that prevents hyperextension (usually buddy taping); consequently, this complication is often preventable. Depending on the demands of the activity that caused the dislocation, the finger and specific structures involved, and the degree of instability, some of these problems may benefit from surgery.

To a limited extent, hand dislocations may be preventable. They are essentially inevitable in contact sports, but taping the fingers in especially high-risk sports (eg, football) may help minimize them. Failure to adequately treat a jammed finger with an isolated partial collateral ligament tear may predispose the athlete to repeat injury and possible dorsolateral dislocation. Finger injuries should be adequately assessed by the team physician or trainer and buddy-taped or splinted as necessary to allow healing and prevent recurrence.

In general, athletes with simple dorsal dislocations of the PIP joint may return to play with buddy taping or splinting as soon as the same game if a stable reduction is achieved; exceptions are players whose position places unusual demands on the finger (eg, quarterbacks or pitchers with an injury to the dominant hand).

Athletes with dorsal fracture-dislocations of the PIP joint and dislocations that are unstable in extension require a minimum of 3-4 weeks (the time during which extension block splinting is required) before return to play. Open reduction or volar plate repair necessitates 6 weeks away from sports.

Patients with volar PIP dislocations are more likely to be kept from rapid return by associated injuries and problems with reduction. Injury to the central slip of the extensor tendon is common with volar dislocations and necessitates splinting the DIP joint in extension for approximately 6 weeks. If this does not interfere with function, the athlete may return to play, although ball handlers may have some difficulty with the splint.

Patients with volar dislocations requiring open reduction may return to play after a few days of immobilization if the central slip is intact. As with dorsal dislocations, if internal fixation or repair of structures around the joint is required, the athlete may be out for 6 weeks. Most DIP dislocations should not require time away from play, except for a few days postoperatively if open reduction or irrigation and debridement is necessary.

Athletes with MCP joint or CMC joint dislocations generally remain out of sports for 6-8 weeks. This time includes a period for extension block splinting or extension cobra casting, as well a period for regaining full functional mobilization of the fingers, hand, and wrist with appropriate return of grip and wrist flexion and extension strength.

A hand surgeon should see any patient with hand dislocations which require or may require surgery. In addition to the surgical indications previously mentioned (including open dislocation and failure of closed reduction), referral to a hand surgeon is usually indicated for fracture-dislocations, most volar dislocations, and any dislocation with associated tendon injury.

A hand surgeon should be involved early in the treatment of any complicated PIP or DIP injury. The need for such consultation would be indicated if the patient presents late after the injury, was inadequately assessed at initial presentation, or develops an unforeseen complication (eg, recurrent subluxation in a joint that appeared to be stable after reduction).

Most patients with chronic instability or stiffness in a finger (especially if it involves the PIP joint) should be referred for assessment by a hand surgeon.

Appropriate expectations regarding the outcome of any hand injury should be discussed with the patient.

All patients with hand dislocations should follow up within 1 week to be checked for some of the more common complications. ^[28] Dorsal PIP dislocations that initially appear stable may become subluxated with extension, requiring more aggressive treatment. Volar PIP dislocations may also lose reduction, or they may be associated with 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 (or even as long as a year) to resolve completely 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, sloughing, or breakdown is present that may have 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 may show 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 collateral ligament rupture may lead to recurrent instability, but it can usually be treated nonoperatively, except when the 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, necessitating operative repair.