Digit Dislocation and Reduction

imagesClinical suspicion of joint dislocation


   imagesIncidence of dislocations: Dorsal proximal interphalangeal (PIP) >> volar PIP >> dorsal metacarpal (MCP) thumb > dorsal MCP finger >> volar MCP dorsal distal interphalangeal (DIP) >> volar DIP


imagesRadiographic evidence of dislocation


CONTRAINDICATIONS



imagesComplex dislocation—rupture of or entrapment in the joint of ligaments or tendons surrounding the joint requires open reduction and repair


imagesChronic dislocation (>3 weeks duration)


imagesOpen dislocation


imagesUnstable joint


imagesMultiple failed reduction attempts can convert a simple dislocation into a complex dislocation and prompt urgent orthopedic consult



imagesGeneral Basic Steps


   imagesNeurovascular examination


   imagesPrereduction radiograph


   imagesAnalgesia


   imagesReduction


   imagesPostreduction neurovascular examination


   imagesImmobilization


   imagesPostreduction radiograph


LANDMARKS



imagesNerves run on the lateral surface of each digit at the 2, 4, 8, and 10 o’clock positions


imagesFlexor tendons run on the volar surface of the digit


imagesExtensor tendons run on the dorsal surface of the digit


imagesPIP joint


   imagesDorsal dislocation: The fibrous volar plate resists dorsal dislocations (FIGURE 68.1)


      imagesComplex dislocation: Head of proximal phalanx or ruptured volar plane can become entrapped in the joint space (FIGURE 68.2)


      imagesVolar dislocation: Three bands of the extensor tendon (central slip, radial and ulnar lateral bands) resist volar dislocations (FIGURE 68.3)


      imagesComplex dislocation: Extensor slip tendons can rupture and become entrapped within the joint space (FIGURE 68.4)


   imagesLateral dislocation: Radial collateral ligaments resist ulnar dislocation, ulnar collateral ligaments resist radial dislocation


imagesDIP and thumb IP: Mechanisms of dislocation and reduction are anatomically analogous


RISKS/CONSENT ISSUES



imagesRisks in joint reduction include swelling with permanent joint enlargement, residual pain, stiffness, or deformity and conversion into complex dislocation including fracture


imagesRisks in anesthesia



images


FIGURE 68.1 Fibrous volar plates are found at the MCP and IP joints where they reinforce the joint capsules and limit hyperextension. (From Leggit, JC, Meko CJ. Acute finger injuries: Part I. Tendons and ligaments. Am Fam Physician. 2006;73(5):810–816.)



images


FIGURE 68.2 Complex dorsal PIP dislocation indicated by (A) rupture of PIP volar plate and (B) entrapment of volar plate fibers and head of proximal phalanx into the joint space. (Jackimczyk K, Shepherd SM, Blackburn P. Hand injuries. In: Wolfson AB, ed. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Williams & Wilkins; 2009, with permission.)



images


FIGURE 68.3 Extensor tendon mechanism trifurcates at the dorsum of the proximal phalanx (Reichman EF. Emergency Medicine Procedures. 2013. Permission pending.)


SUPPLIES



imagesAnesthesia


imagesReduction: 3″ Webril or gauze padding, 3″ plaster roll, 3″ Ace bandage, aluminum finger splint, adhesive tape, scissors


NEUROVASCULAR EXAMINATION



Any deficit indicates a complex dislocation and urgent orthopedic consultation


imagesInspection


   imagesExclude open dislocation


   imagesComplex dislocation presents with less angulated deformities, with skin dimpling, or rotational deformity of the involved phalanges


imagesPalpation—frank fracture fragments


imagesSensation—normal two-point discrimination on finger pad is between 2 to 4 mm


imagesVascular—radial and ulnar pulse-Doppler signal


imagesRange of motion with stress—assess joint stability with the finger in full extension and in moderate flexion. If displacement occurs, the joint is unstable.



images


FIGURE 68.4 Central slip of the extensor tendon can rupture in sudden IP hyperflexion and can require operative repair. (From Leggit JC, Meko CJ. Acute finger injuries: Part I. Tendons and ligaments. Am Fam Physician. 2006;73(5):810–816.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Digit Dislocation and Reduction

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