A young adult male sustained an open dislocation of the PIP for his middle finger while playing rugby.
Hopefully he wasn’t doing a Hopoate.
The finger was neurovascularly intact. The wound was not obviously contaminated.
The finger was anaesthetised using a ring block at the level of the web space and the wound was cleaned.
The clinician puts on gloves to give a better grip. The proximal phalynx was held in the clinicians non-dominant hand with the clinician’s thumb on the palmer aspect where it can be used to stabilise the distal end of the proximal phalynx.
The clinician then grabs the rest of the finger in her/his dominant hand and pulls and hyperextends the middle phalynx. The middle phalynx is then flexed reducing the dislocation.
The PIP joint was grossly unstable indicating disruption of the volar plate – the ligament joining the palmar aspect of the proximal phalynx to the palmar aspect of the middle phalynx. The volar plate prevents hyperextension and dorsal dislocation of the joint.
Where there is a large avulsion fracture, say > 30% of the joint surface talk to hands/ortho about potential fixation of the fragment.
Generally the PIP is splinted with 30˚ of angulation with a zimmer splint (1cm wide malleable aluminium strip with foam on one side). The middle phalynx does not need to be taped to the splint – so it can flex but not extend past 30˚ of flexion. This is called a dorsal blocking splint.
If the joint is not unstable when relocated some advocate simply buddy strapping the finger to one of its neighbour.
The laceration was cleaned and sutured (being careful to avoid the flexor tendons).
Any finger dislocation should be reviewed by a hand therapist at about a week.
Open dislocations should be discussed with hands or ortho who may want to wash the joint.
Diagrams from: http://www.aafp.org/afp/2006/0301/p810.html