Introduction

Background
Hand injuries are commonly seen in the emergency department. Emergency physicians should be able to identify and manage digital dislocations. Complications can occur if the diagnosis is missed or delayed or if the joint is incompletely reduced or splinted improperly. Patients should be referred to a hand specialist following treatment of hand dislocations.

Pathophysiology
Traumatic force to the hand can be transmitted to bone, soft tissue, nerves, and vascular structures. Because the structures of the hand are close to the surface and near each other, injury often results in a combination of fractures, dislocations, and soft tissue injury. The distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints both have lateral ligaments and a fibrous volar plate. Common dislocations are posterior or lateral. Typical forces resulting in DIP dislocations include a jamming blow to the end of the finger. The forces that commonly lead to dislocation of the PIP joint include an axial load or hyperextension. Lateral dislocations can result from radial- or ulnar-directed force on the joint. Finger metacarpophalangeal (MCP) dislocations are rare and frequently are trapped by the surrounding ligaments, necessitating surgical relocation. MCP or palmar dislocations occur when a hyperextension movement occurs with rotation. The finger is bent back toward the top of the hand and is twisted during the injury. The finger may have been pushed, or compressed, during the injury. MCP dislocations are typically associated with fractures. In thumb metacarpophalangeal (MCP) joint dislocations, the mechanism encountered most often is hyperextension that leads to volar dislocations. A significant lateral force can disrupt the collateral ligaments, resulting in instability. The gamekeeper's (skier's) thumb often results from a fall onto the hand with the thumb in abduction, such as when gripping a ski pole. Carpometacarpal dislocations are not always high-energy injuries. Identification involves careful analysis of subtle findings on radiographs and may require additional radiographic views. Missed diagnosis of carpometacarpal dislocation can result in significant morbidity.

Frequency
United States

The annual incidence of all types of dislocations in the hand is approximately 67,000 in the United States.

Mortality/Morbidity
Anatomical restoration of dislocated joints is imperative to achieve good long-term outcomes. Accurate and stable reduction, early fixation, and initiating range of motion exercise are very important. Dislocations can lead to osteoarthritis, compression neuropathies, and carpal tunnel syndrome. Additional disability from chondrolysis, carpal instability, and traumatic arthritis can also occur.

Median or ulnar neuropathy can occur from direct nerve compression or increased pressure within the median or ulnar nerve canals. Evaluation of the patient's nerve status is especially important in the early evaluation of carpal dislocations. Grip strength must be tested before and after reduction.

Age
Pediatric transcarpal fractures in children are rare, but the emergency physician must be cognizant that they do occur.

Clinical
History
Historical data about the mechanism of trauma can help lead the emergency physicians assessment of hand injuries.

Historical data should include the following: o Traumatic mechanisms such as crush, distraction, and extension o Time of the event o Conditions of the event (important if there are associated contaminated versus

o o o

clean wounds) The patient's right or left hand dominance. The patient's occupation: For therapy following the acute intervention, the specialist or hand therapist should be aware of the patient's occupation. Previous hand injury, presence of fixation devices, or ligamentous laxity

The emergency physician must translate the mechanism of injury into forces, loads, rotations, extensions, reductions, joint deformities, and related forces that caused the dislocation. The emergency physician can then utilize this knowledge for the local or obvious deformity as well as distal or occult injuries. For example, the MCP joint may appear dislocated, but fractures are typically associated with MCP dislocations because rotational and compressive forces are involved. In this case, radiographs are required prior to any reduction attempt.

Physical

With significant injury to the digits, a comprehensive examination may be hindered by pain. A thorough visual inspection of the hand and fingers is the first required step. Inspect for deformity, skin color, skin temperature, skin integrity, and swelling. Distal digital sensation should be checked early and often. Sensation examination includes testing for the following: o Light touch or deep pressure o Detection of sharp Vs dull discrimination o Detecting 2-points separated by 5 mm o Detecting temperature variation The clinician must consider providing rapid pain relief to the patient. Digital block with a local anesthetic is an ideal, quick, and efficacious intervention. However, the clinician must have a working protocol with the hand specialist. In some cases, the hand specialist may want to examine the digit prior to the administration of the anesthetic. Reducing the patient's pain is a priority, but this priority must not occur without regard to performing a very thorough and well-documented neurovascular examination. The emergency physician and the hand specialist must establish some guidelines for eliminating the patient's pain but not compromise the examination and documentation for the provider who will have to provide ultimate follow-up, rehabilitation, and occupational guidelines. The presence of pain can limit the examination. The patient can be made pain free, or the pain tolerable, prior to manipulating the hand or digit. Benefits of an examination with anesthesia include improved assessment of range of motion and digit stability.

Physical findings to look for in specific dislocations include the following: o Thumb MCP joint: Dislocations may be simple or complex. In simple dislocations, the phalanx sits perpendicular to the metacarpal. The volar plate is not trapped. In complex dislocations, the phalanx is positioned parallel to the metacarpal with the volar plate trapped in the joint. The gamekeeper's (skier's) thumb presents with pain and tenderness on the ulnar aspect of the thumb around the MCP joint. The extent of associated laxity depends on the amount of disruption and the ability of the examiner to stress the joint. Finger MCP joints: Dislocations may be simple or complex. Simple dislocations can be identified as the base of the phalanx sits on the dorsum of the head of the metacarpal at a right angle. A complex dislocation may reveal a dimple on the palmar surface, and the digit may appear shortened and deviated to the ulnar side. Finger PIP joints: Simple dorsal dislocations may include volar plate disruption. The middle phalanx is often perpendicular to the distal aspect of the proximal phalanx. With lateral dislocation, the digit often is deviated to the ulnar side. Finger DIP joints: Open dislocations are common because of the strong support of the skin and periarticular structures.

Causes

Common mechanisms of injury include the following: o Industrial injuries o Athletic injuries o Falls o Motor vehicle collisions (MVCs)

Differential Diagnoses
Arthritis, Rheumatoid Fractures, Hand Gamekeeper Thumb Hand Injury, Soft Tissue

Workup
Laboratory Studies

Laboratory studies are not typically necessary for the patient with an isolated interphalangeal joint dislocation. However, if 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.

Imaging Studies

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.

The following views should be taken: o Anteroposterior o Lateral o Oblique o Stress views can be examined if ligamentous laxity is documented or suspected. o Postreduction images must follow even the most "routine" reductions.

Treatment
Prehospital Care

For patients with a hand dislocation arriving by EMS, immobilization of the deformed joint, covering soft tissue injury, and providing pain relief are the mainstays of prehospital treatment.

Emergency Department Care

Rapid pain relief, securing imaging studies, and expeditious reduction (closed or open) must be the triad that drives the emergency department protocol for treating isolated digit or hand dislocations. Triage/initial evaluation and treatment

Many patients with an isolated digit or hand dislocation can be expeditiously treated from the time they arrive until the initial physician contact if protocols allow the nursing staff to provide analgesia and order the appropriate radiology study. Pain management can consist of oral medication, intramuscular injection, or intravenous injection if determined by the severity of injury and the patient's medical history, allergic reaction profile, and expressed comfort level. Oral medication can be problematic if the patient eventually requires open reduction. Therefore, pain management protocols should take this into account. Imaging studies of the affected digit or hand can easily be part of an ED protocol. For example, radiographs of the isolated digit can be obtained if the triage or evaluating nurse assesses the patient to have a deformity at the distal or proximal finger joints.

Emergency department Once a hand dislocation is identified and pain control in initiated, then relocation is the next step in patient care. Most hand dislocations are easily reduced by the emergency physician. Some dislocations may not be reducible by closed means because of the interposition of the volar plate or associated ligaments or tendons in the joint. If several attempts at reduction are not successful, consultation and open reduction and internal fixation (ORIF) often is indicated. A thorough assessment of stability should be performed following a successful reduction. Specific reductions

Distal interphalangeal joint of the fingers The DIP joint of the finger is a very vulnerable area. Surprisingly, dislocations in this area are uncommon because of the strong support of the joint by skin and periarticular structures. With the appropriate intensity of force applied, however, the strong support network is unyielding and the skin may tear, leading to an open dislocation.

Reduce the dislocation with longitudinal traction and hyperextension, with firm dorsal pressure on the base of the distal phalanx. Open reduction rarely is needed in this type of dislocation. After the dislocation is reduced, assess the stability of the joint to rule out evidence of tendon injury. Immobilize the joint with a dorsal splint in flexion if volar dislocation has occurred without tendon injury and in extension if the dislocation is dorsal and without tendon injury. (Also see, Joint Reduction, Finger Dislocation.) Proximal interphalangeal joint of the fingers Dorsal dislocations are reduced by applying longitudinal traction and mild hyperextension with dorsal pressure on the proximal aspect of the middle phalanx. Immobilization of simple dislocations without instability should be brief. If the patient continues to perform activities that may put the digit at risk for subsequent dislocations, the digit should be protected with buddy taping and/or splinting during the activity. Volar dislocation of the PIP joint of a finger is relatively uncommon. When a volar dislocation occurs, the proximal phalanx can rupture through the transverse retinacular fibers between the lateral band and the central tendon. The lateral bands may become interposed, making closed reduction difficult. If the volar plate is ruptured and the extensor mechanism avulsed, a Boutonnire deformity may result. Open reductions normally are performed for these injuries. Occasionally, closed reduction may be performed. If the joint remains stable, immobilize the digit briefly in a slightly flexed position. Metacarpophalangeal joints of the fingers Dislocation of an MCP joint of the fingers most often involves the index or small finger. Dislocations here are relatively uncommon because of the strength of the periarticular structures. Dislocations may be simple or complex. A complex dislocation nearly always needs open reduction because of an interposed volar plate. Closed reduction may be accomplished by using traction along the axis of the hyperextended phalanx and firmly pushing the base of the dislocated phalanx toward the MCP joint. Assess stability of the joint after reduction and follow by immobilization. Some controversy exists regarding length and position of immobilization. Some authors recommend early range of motion if no evidence of postreduction instability is observed. Interphalangeal joint of the thumb Reductions usually are accomplished via closed means. This particular dislocation may present with associated rupture of flexor pollicis longus. Following evaluation and reduction, immobilize the involved joint with a thumb spica splint. The period of joint immobilization should be brief to avoid joint stiffening. Metacarpophalangeal joint of the thumb

Anterior dislocations are classified as simple or complex. The appropriate method of reduction of a dislocation depends on the type of dislocation. For simple dislocations, the clinician should avoid pure traction, as this can convert a simple dislocation into a complex dislocation. Reduction is achieved by

emphasis of pushing the phalanx into the MCP joint rather than pulling it into place. After 1-2 attempts at reduction are unsuccessful, an open reduction must be performed. More aggressive and repeated attempts at reduction may lead to fracture. An interposed volar plate or intrinsic muscle may be the reason for failed attempts at closed reduction. After the dislocation is reduced, immobilize the joint with a thumb spica splint. The length of immobilization varies, but clinicians should avoid extended immobilization and minimize immobilization of unaffected areas. Instability of the thumb is an indication for referring the patient to a hand specialist. (Also see, Joint Reduction, Thumb Dislocation.)

Consultations
Complex and open dislocations should be evaluated by a hand surgeon for open reduction. In addition, those individuals with fracture-related dislocation require further evaluation by a hand surgeon.

Medication
Near immediate pain relief can be provided when the patient receives an injection of a local anesthetic along the path of the digital nerve, also known as a digital block, web-space, or palmar block. Of course, the digital nerve block must follow a very thorough neurosensory examination and (when indicated) discussion with the hand specialist. Oral medications should be prescribed for the patient who is being discharged from the emergency department. Medications types may include nonsteroidal anti-inflammatory drugs with or without opiates.

Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained injuries.

Lidocaine (Dilocaine, Xylocaine)

Amide local anesthetic used in 1-2% concentration. Inhibits depolarization of type C sensory neurons by blocking sodium channels. Must be used without epinephrine for digital block. Local anesthetic injection can be improved: Use smaller gauge needles, such as 27 gauge or 30 gauge. Make sure the solution is at body temperature. Infiltrate very slowly to minimize the pain. Use buffered lidocaine. Buffering solution is effective in reducing pain of local lidocaine injection. Sodium bicarbonate can be added to injectable lidocaine vial to produce "buffered" lidocaine. Shelf-life of buffered lidocaine is approximately 1 wk. All vials should be marked "buffered" and labeled with the time and date and signed by individual who created the buffered mixture. Add ratio of 1 part bicarbonate to 9 parts lidocaine. Stable at room temperature for 1 wk. Cool skin before injection with ethyl chloride.

Use "imaging" discussion during the injection. Time from administration to onset of action is 2-5 min with a duration of 1.5-2 h. 1% Xylocaine contains 10 mg of lidocaine for each 1 mL of solution. 2% Xylocaine contains 20 mg of lidocaine for each 1 mL of solution.

Adult

Dosing Interactions Contraindications Precautions

3 mg/kg injection locally

Pediatric

Administer as in adults

Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Adult

Dosing Interactions Contraindications Precautions

1-2 tab or cap PO q4-6h prn

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen or 5 mg hydrocodone bitartrate/dose >12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d acetaminophen or 10 mg hydrocodone bitartrate/dose

Dosing Interactions Contraindications Precautions Dosing Interactions

Contraindications Precautions Dosing Interactions Contraindications Precautions

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirinhypersensitive patients. Different strengths available.

Adult

Dosing Interactions Contraindications Precautions

1-2 tab or cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone

Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Oxycodone and aspirin (Percodan)

Drug combination indicated for relief of moderately severe to severe pain.

Adult

Dosing Interactions Contraindications Precautions

1-2 tab or cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone

Dosing Interactions Contraindications

Anxiolytics
Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to administer a smaller analgesic dose to achieve the same effect.

Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Lorazepam (Ativan)

Sedative hypnotic in benzodiazepine class that has short onset of effect and relatively long halflife. By increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation. Excellent for patients who need to be sedated for >24 h.

Adult

Dosing Interactions Contraindications Precautions

1-10 mg/d PO divided bid/qid; not to exceed 4 mg/dose

Pediatric

0.05-0.1 mg/kg IV slowly over 2-5 min; may repeat a dose of 0.05 mg/kg IV slowly

Nonsteroidal anti-inflammatory agents (NSAIDs)

These agents are most commonly used for the relief of mild to moderately severe pain. Although the effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include ketoprofen and naproxen.

Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Ibuprofen (Ibuprin, Advil, Motrin)

DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, inhibiting prostaglandin synthesis.

Adult

Dosing Interactions Contraindications Precautions

200-400 mg PO q4-6h prn; not to exceed 3.2 g/d

Pediatric

<6 months: Not established 6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid >12 years: Administer as in adults

Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small body size, elderly persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.

Adult

Dosing Interactions Contraindications Precautions

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established 3 months to 12 years: 0.11 mg/kg PO q6-8h > 12 years: Administer as in adults

Dosing Interactions Contraindications

Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Adult

Dosing Interactions Contraindications Precautions

500 mg PO initial dose, followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric

<2 years: Not established >2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Follow-up
Further Inpatient Care

Patients with dislocations that are not reducible in the ED should be admitted to a hand specialist. Patients with open joints or other significant hand injuries may also need admission.

Further Outpatient Care

Patients treated and discharged from the ED should have oral analgesia prescribed as part of their outpatient care.

Transfer

Patients requiring a hand specialist, without one immediately available, may need to be transferred to a facility with a higher level of care.

Complications

Instability, joint stiffness, hyperextension, and flexion deformity may develop as a result of the dislocation or damaged periarticular structures. Additionally, overly aggressive attempts at reduction of a dislocation can lead to fracture of the digit.

Patient Education

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Broken Hand.

Miscellaneous
Medicolegal Pitfalls

Failure to take special precautions and considerations: As with other dislocations of the extremities, the majority of hand dislocations are fairly obvious as a result of the associated deformity. Failure to consider an occult fracture: 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. Failure to consider a growth plate injury: 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.

Special Concerns

Every emergency physician should have a firm understanding of the acute management of simple dislocations of the digits. Historical, physical, and radiographic findings often guide the management of the dislocation. When the dislocation is complicated, consult with and/or refer to a hand surgeon. Generally, reduced dislocations without evidence of instability and near-normal range of motion can be treated by brief immobilization and subsequent referral.