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Approach to the Critical Patient
Triage priorities
Limb threat screen
Neurovascular compromise
Pallor
Cool digit
Capillary refill delay
Absent Doppler signal
Open joint or open fracture-dislocation
Visible joint capsule
Exposed tendon
Compartment syndrome of hand
Pain out of proportion
Pain with passive stretch of digits
Tense intrinsic compartments
Irreducible dislocation
Skin puckering at volar MCP
Mechanical block to reduction
Immediate actions
Ring and constriction removal
Cut ring if edema threatens perfusion
Gross deformity reduction trigger
Threatened skin or tenting
Neurovascular deficit pre-reduction
Analgesia plan before manipulation
Digital nerve block pathway
Procedural sedation pathway if needed
Consultation and transfer triggers
Hand surgery or orthopedics
Open dislocation
Complex MCP dislocation suspected
Fracture-dislocation
Persistent neurovascular deficit after reduction
Suspected tendon rupture
Volar PIP dislocation
Rotatory PIP dislocation
Emergent OR pathway
Ischemic digit
Open joint contamination
Failed closed reduction with soft tissue interposition
Key concepts
Injury map
DIP dislocation
Dorsal most common
FDP avulsion association risk
PIP dislocation
Dorsal most common
Volar plate injury common
Central slip injury risk
MCP dislocation
Dorsal most common
Volar plate interposition risk
Thumb joints
MCP dislocation
CMC dislocation
Imaging first vs reduce first
Pre-reduction radiographs
Stable neurovascular exam
No threatened skin
Immediate reduction before imaging
Threatened skin
Neurovascular compromise
Severe deformity with pain crisis
Post-reduction non-negotiables
Neurovascular recheck documentation
Pre-reduction status
Post-reduction status
Post-reduction radiographs
Concentric reduction confirmation
Occult fracture detection
Early protected motion principle
Stiffness risk with prolonged immobilization
Stability-dependent splint plan
History
Injury context
Injury details
Mechanism
Hyperextension
Axial load to fingertip
Rotational force
Sports ball impact
FOOSH
Time since injury
Immediate vs delayed presentation
Prior reduction attempt
Hand dominance
Dominant hand functional risk
Occupation and sport
Need for early function
Symptoms and red flags
Pain severity trajectory
Escalating pain after splint
Pain out of proportion
Numbness and tingling
Digital nerve distribution
Weakness
Inability to extend PIP
Inability to flex DIP
Skin break
Wound contamination
Bite mechanism
Risk modifiers
Anticoagulants or bleeding disorder
Hematoma expansion risk
Diabetes or peripheral vascular disease
Ischemia risk
Immunocompromise
Infection risk with open injuries
Prior hand surgery or hardware
Altered anatomy risk
Physical Exam
Hand and digit exam
Inspection and alignment
Deformity pattern by joint
DIP dorsal prominence
PIP dorsal step-off
MCP dorsal prominence
Skin integrity
Open wound over joint
Skin tenting and blanching
Volar skin puckering at MCP
Swelling and ecchymosis
Collateral ligament injury clue
Neurovascular status
Perfusion
Capillary refill
Temperature compared to adjacent digits
Pulses
Radial pulse
Ulnar pulse
Doppler digital artery if concern
Sensation
Two-point discrimination if feasible
Radial and ulnar digital nerve territories
Motor
FDP function
DIP flexion isolated
FDS function
PIP flexion isolated
Extensor mechanism
Active PIP extension
Active DIP extension
Joint stability and soft tissue injury screen
Collateral ligament integrity
Varus and valgus stress at 30 degrees flexion after reduction
Volar plate injury
Hyperextension laxity after reduction
Central slip injury suspicion
Weak PIP extension against resistance
Boutonniere risk counseling trigger
PITFALLS
Missed fracture-dislocation
Volar lip fracture of middle phalanx
Dorsal subluxation on lateral view
Missed tendon injury
FDP avulsion masquerading as simple DIP injury
Persistent rotational deformity
Malrotation on finger flexion cascade
Differential Diagnosis
Traumatic and atraumatic mimics
Traumatic differentials
Phalanx fracture
Proximal phalanx fracture
Middle phalanx fracture
Distal phalanx fracture
Intra-articular fracture
PIP volar lip fracture
MCP metacarpal head fracture
Tendon rupture
Mallet finger
ICD-10 M20.0
Jersey finger
FDP avulsion
Ligament injury without dislocation
Collateral ligament tear
Volar plate tear
Infection and inflammatory mimics
Septic arthritis
Hot swollen joint without clear trauma
Crystal arthritis
Acute monoarthritis at MCP or PIP
Coding alignment
Finger joint dislocation
ICD-10 S63.2
Thumb dislocation
ICD-10 S63.1
SNOMED CT concepts for dislocation documentation
Dislocation of finger joint
Dislocation of interphalangeal joint of finger
Dislocation of metacarpophalangeal joint of finger
Laboratory Tests
When labs matter
Minimal labs for isolated closed dislocation
No routine labs for uncomplicated cases
Point-of-care glucose only if sedation risk or diabetes concern
Open injury or bite mechanism
Infection risk labs
CBC for systemic infection concern
CRP for complicated infection concern
Renal function for antibiotic selection
Creatinine and eGFR
Procedural sedation pathway
Targeted testing only
Pregnancy test when applicable
Glucose for altered mental status concern
Hemoglobin for significant bleeding concern
Compartment syndrome or crush injury concern
Rhabdomyolysis screen
CK
Creatinine and potassium
Diagnostic Tests
Scoring Systems
Injury classification and stability cues
PIP fracture-dislocation stability concept
Volar lip fracture size association with instability
Persistent dorsal subluxation on lateral view
MCP dislocation type
Simple dislocation
Complex dislocation with volar plate interposition
Radiographs
Plain radiography strategy
Views
AP
True lateral
Oblique
Timing
Pre-reduction films when stable
Post-reduction films always
Key radiographic findings
Concentric reduction
Avulsion fracture fragments
Volar plate interposition signs
Dorsal subluxation at PIP after reduction
Thumb specific imaging
Thumb CMC views if suspected
Stress views avoided acutely if unstable pain
MRI
Soft tissue characterization
Indications
Suspected central slip rupture with equivocal exam
Suspected volar plate rupture with persistent instability
Persistent pain despite normal radiographs
Limitations
Not first-line in ED for simple dislocation
Management usually guided by exam and radiographs
CT
Complex bony injury definition
Indications
Intra-articular fracture-dislocation with surgical planning need
Occult fracture suspected with high-risk exam
Utility
Articular step-off definition
Fragment size and impaction assessment
Disposition
Site of care and follow-up
Discharge criteria
Concentric reduction confirmed
Post-reduction radiographs acceptable
Stable neurovascular exam
Normal perfusion
Normal or baseline sensation
Pain controlled with oral regimen
Tolerable pain at rest
Reliable follow-up plan
Hand surgery or orthopedics referral timeframe
Admission or transfer criteria
Open dislocation
Antibiotics and operative irrigation pathway
Irreducible dislocation
Suspected soft tissue interposition
Fracture-dislocation unstable
Persistent subluxation after reduction
Neurovascular compromise
Persistent deficit post-reduction
Follow-up timing
Simple stable PIP or DIP dislocation
Hand clinic within 3 to 7 days
Unstable PIP dislocation
Hand surgery within 24 to 72 hours
MCP dislocation
Hand surgery within 3 to 7 days
Thumb CMC dislocation
Hand surgery within 24 to 72 hours
Treatment
Immediate life-saving interventions
Limb threat actions
Ischemic digit pathway
Immediate reduction attempt if deformity likely cause
Hand surgery escalation if no rapid reperfusion
Constriction relief
Ring cutting
Splint loosening if worsening perfusion
Open injury actions
Cover with sterile saline dressing
Avoid probing in ED
Antibiotics and tetanus pathway before definitive management
Timing within 1 hour when feasible
Immobilization and Splinting
Immobilization choices
DIP dislocation post-reduction
Finger splint in extension
Buddy tape if stable and pain allows
PIP dorsal dislocation post-reduction
Extension-block splint
PIP flexion 20 to 30 degrees for 2 to 3 weeks
Buddy taping to adjacent finger
Early protected motion within 1 week as tolerated
PIP volar dislocation post-reduction
Extension splint
PIP in full extension
Longer immobilization if central slip injury suspected
MCP dislocation post-reduction
Dorsal blocking splint
MCP flexion 70 to 90 degrees
IP joints free for motion
Thumb CMC or thumb MCP dislocation post-reduction
Thumb spica splint
Wrist neutral
Thumb in functional abduction
Splint safety checks
Post-splint neurovascular exam
Capillary refill
Sensation
Active motion of non-immobilized joints
Swelling precautions
No circumferential cast in acute edema phase
Elevation instructions
Reduction
Reduction indications
Neurovascular compromise
Threatened skin
Significant deformity and pain
Fracture-dislocation with gross malalignment
Contraindications and caution triggers
Open dislocation
Antibiotics and tetanus first when feasible
Urgent hand surgery consultation
Suspected complex MCP dislocation
Volar skin puckering
Mechanical block
Pediatric physeal injury suspicion
Gentle technique
Low threshold for specialist involvement
Analgesia and anesthesia
Digital nerve block
Lidocaine 1% without epinephrine
Volume 1 to 3 mL per side of digit
Maximum dose 5 mg/kg
Lidocaine 1% with epinephrine 1:100,000 to 1:200,000 option in healthy digits
Longer duration anesthesia
Avoid in severe peripheral vascular disease
Bupivacaine 0.25% option
Longer duration anesthesia
Maximum dose 2.5 mg/kg
Adjunct analgesia
Acetaminophen PO
15 mg/kg per dose
Maximum 1,000 mg per dose
Ibuprofen PO
10 mg/kg per dose
Maximum 600 mg per dose
Procedural sedation triggers
Multiple digit involvement
Severe anxiety
Failed block or intolerance
Reduction technique principles
Traction and countertraction
Gentle sustained traction
Avoid repeated forceful attempts
Reverse mechanism
Dorsal dislocation
Distal segment hyperextension then flexion
Volar dislocation
Distal segment flexion then extension
Joint-specific maneuvers
PIP dorsal dislocation
Slight hyperextension to disengage
Volar pressure on base of middle phalanx
Controlled flexion into reduction
PIP volar dislocation
Gentle traction
Dorsal pressure on base of middle phalanx
Controlled extension into reduction
DIP dorsal dislocation
Longitudinal traction
Volar pressure on distal phalanx base
Return to extension
MCP dorsal dislocation
Hyperextension of proximal phalanx then reduction over metacarpal head
Avoid excessive in-line traction that may worsen interposition risk
Post-reduction requirements
Neurovascular exam repeat
Sensation documentation
Capillary refill documentation
Radiographs post-reduction
Concentric reduction confirmation
Avulsion fracture assessment
Stability assessment after reduction
Active ROM tolerance
Collateral ligament stress testing when appropriate
Failed reduction pathway
Immediate escalation criteria
Persistent ischemia
Increasing pain with passive stretch
Hand surgery consultation triggers
Suspected complex MCP dislocation
Volar plate or tendon interposition suspected
Recurrent dislocation after reduction
Open fracture medications and timing
Open dislocation and open fracture-dislocation pathway
Antibiotics
Cefazolin IV 2 g
Pediatrics 50 mg/kg IV
Maximum 2 g per dose
Severe penicillin allergy alternative
Clindamycin IV 600 to 900 mg
Pediatrics 10 mg/kg IV
Gross contamination concern
Add gentamicin per local protocol
Tetanus prophylaxis
Tdap if immunization unknown or not up to date
Tetanus immune globulin if high-risk wound and incomplete immunization
Wound care
Irrigation in ED for gross contamination only
Sterile dressing and splint
Bite mechanism
Amoxicillin-clavulanate PO
875/125 mg PO twice daily
Pediatrics 25 to 45 mg/kg/day divided twice daily
Hand surgery consultation low threshold
DVT prophylaxis when relevant
Not routinely indicated for isolated finger immobilization
Consider only if additional major risk factors
Active malignancy
Recent major surgery
Prior VTE
Prolonged lower limb immobilization concurrent
Special Populations
Pregnancy
Pregnancy considerations
Imaging safety
Hand radiographs acceptable with shielding
Avoid unnecessary CT
Analgesia selection
Acetaminophen preferred
NSAID avoidance in later gestation per obstetric guidance
Procedural sedation
Obstetric consultation if advanced gestation and deep sedation anticipated
Geriatric
Older adult considerations
Osteoporosis and fragility mechanism
Low-energy falls with occult fracture risk
Skin integrity risk
Lower threshold for reduction of tenting
Medication sensitivity
Lower opioid dosing
Delirium risk with sedatives
Follow-up needs
Earlier reassessment for swelling and splint tolerance
Pediatrics
Pediatric considerations
Physeal injury risk
Salter-Harris patterns near PIP and MCP
Gentle reduction technique
Nonaccidental trauma screen when inconsistent story
Age-inappropriate mechanism
Multiple injuries
Weight-based dosing
Local anesthetic maximum dose calculation
NSAID dosing per kg
Immobilization tolerance
Cast or splint integrity monitoring
Caregiver education emphasis
Background
Epidemiology
Epidemiology summary
PIP dislocation
Most common finger dislocation type
MCP dislocation
Rare incidence
Less than 1 per 100,000 annually reported for MCP dislocations
Sports association
Ball sports and falls common mechanisms
Anatomic distribution notes
Non-thumb MCP dislocation
Index finger most commonly involved
Pathophysiology
Mechanism to injury mapping
Dorsal PIP dislocation
Hyperextension force
Volar plate disruption
Possible volar lip avulsion fracture
Volar PIP dislocation
Axial load with flexion
Central slip disruption risk
Dorsal MCP dislocation
Hyperextension with metacarpal head buttonholing risk
Volar plate interposition mechanism for complex dislocation
DIP dislocation
Axial load to distal phalanx
FDP avulsion association risk
Therapeutic Considerations
Reduction rationale
Skin and soft tissue protection
Reduce tenting and ischemia risk
Joint congruity restoration
Cartilage injury mitigation
Early motion importance
Stiffness prevention
Function restoration
Splinting rationale
Dorsal PIP dislocation
Extension-block splint to protect volar plate
Volar PIP dislocation
Extension splint to protect dorsal structures
MCP dislocation
Flexion splint to relax volar plate and collateral ligaments
Evidence framing
Extension-block splinting at 20 to 30 degrees flexion for dorsal PIP dislocation supported in primary care guidance
Protected early motion within 1 week encouraged as tolerated
Lidocaine with epinephrine in digital blocks reported safe in healthy patients
Concentrations 1:100,000 to 1:200,000 commonly cited
Complex MCP dislocation typically requires operative management when closed reduction fails
Volar plate interposition common block
Patient Discharge Instructions
copy discharge instructions
Discharge instructions
Splint care
Keep splint clean and dry
Elevation above heart for first 48 to 72 hours
Ice over splint 10 to 15 minutes at a time
Activity restrictions
No sports until cleared
No lifting or gripping with injured hand until follow-up
Pain plan
Acetaminophen as directed
Ibuprofen as directed if safe
Finger motion plan
Move non-splinted joints several times daily
Buddy tape care if provided
Return to ED immediately for
Increasing pain not controlled by medication
New numbness or worsening tingling
Pale or blue fingertip
Cold fingertip
Swelling causing tight splint pressure
Inability to move fingertip after reduction
Wet or broken splint
Fever
Redness, pus, or worsening wound drainage
Follow-up
Hand clinic or orthopedics within recommended timeframe
Earlier follow-up if splint discomfort or swelling progression
References
Clinical guidelines and evidence-based sources
References
AAFP Common Finger Fractures and Dislocations
Dorsal PIP extension-block splint 20 to 30 degrees for 2 to 3 weeks
Early protected motion within 1 week as tolerated
StatPearls Finger Dislocation
MCP dislocation reduction principles
Volar plate interposition risk in complex dislocations
Orthobullets MCP Dislocations
MCP incidence rare
Open reduction indication when soft tissue interposition blocks reduction
Orthobullets Phalanx Dislocations
Extension-block splinting for unstable dorsal PIP
Extension splinting duration considerations for volar PIP
AAFP Proper Technique for Reduction of MCP Dislocations
Hyperextension maneuver and reduction mechanics
Systematic review Safety of epinephrine in digital nerve blocks
Epinephrine 1:100,000 to 1:200,000 safety in healthy digits
Cochrane review Adrenaline with lidocaine for digital nerve blocks
Evidence synthesis on safety and effects
Digital nerve blocks systematic review and meta-analysis
Technique comparisons for onset and duration
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.