• Initial management: ^{[1] [2]}
  • Clean and cover open wounds.
  • Remove constrictions (i.e., jewelry, watch, gloves, etc.) and assess neurovascular status. and compartment pressure (compartment syndrome).
  • Pain management following neurological assessment (digital nerve or metacarpal block).

• Acute Carpal Tunnel Syndrome in the context of trauma is a surgical emergency ^{[3] [4]}
  • Constant and severe pain and dysesthesias in median nerve distribution.
  • Progressive rapid onset course over hours.

Understanding hand anatomy is important for recognizing and diagnosing hand and finger dislocations.

• Video: Overview of Hand Anatomy (youtube.com)

• Finger Dislocations (phalanges): ^[5]
  • Three joints involved are metacarpophalangeal joint (MCP), proximal interphalangeal joint and distal interphalangeal joint (DIP).
  • Dislocations may be in the dorsal, volar, or lateral planes.
  • MCL dislocations typically result from hyperextension or high energy axial load.
  • PIP dislocations are most common due to sports related injuries “coach’s finger.”
  • DIP dislocations typically associated with fractures and skin injuries.
  • Finger arteries and nerves run along volar aspect of finger.
• Hand Dislocations (metacarpal): ^{[6] [7]}
  • Carpometacarpal (CMC) dislocations are rare, < 1% of all hand injuries.
  • 4^th and 5^th metacarpal most often involved.
  • Often associated with high impact collision or punching.
  • Likely require surgical treatment with Kirschner wires (K-wires) for fixation or open reduction.

• History: ^{[3] [5]}
  • Mechanism of Injury (MOI)
  • Handedness
  • Previous Finger / Wrist Injuries
  • Occupation / Hobbies / Sports
• Hand Exam: ^{[3] [5] [8] [9]}
  • Visual inspection for open wounds, deformity, discoloration, swelling and atrophy.
    • Use tourniquet or anesthetic with epinephrine to ensure a bloodless field for exam.
  • Move fingers / wrist through complete range of motion (ROM).
  • Palpate to determine location of maximal tenderness.
  • For fingers, test hyperextension (volar plate integrity), lateral stresses (collateral ligament assessment) and perform Elson’s test to evaluate for a central slip (see video link below).
  • Check for rotational finger dislocations by having patient make a fist and observe for overlapping of phalanges (scissoring).
  • Thorough neurovascular exam, with comparison to uninjured hand.
    • Capillary refill ≤ 2 seconds.
    • Allen test.
    • Median nerve injury is common sequalae of volar lunate dislocation into carpal tunnel.

Video: Hand Physical Exam ^[8]

Video: Elson’s Test ^[10]

• Imaging:
  • Diagnosis should be made using X-ray anteroposterior (AP), lateral and oblique views.

• Pain Management:
  • Provide via digit nerve, metacarpal or wrist blocks ^{[2] [12] [13]}(see videos below).
  • Video: Peripheral Nerve Blocks for Hand Procedures | NEJM – YouTube
  • Video: Single Injection Volar Digital Block – YouTube
  • Video: Metacarpal block (youtube.com)
• CMC Dislocation: ^{[6] [7] [14] [15]}
  • Post reduction stability is most important factor, most require surgery.
  • Thumb CMC dislocation treatment, closed reduction is possible (little agreement in literature).
  • Metacarpal 2-5, traction of digit with pressure force applied to deformity at base of metacarpal. Cast immobilization for 6 weeks with 70-90° MCP joint flexion, slight flexion of PIP and DIP, and mild wrist extension (i.e., radial or ulnar gutter cast). Schedule follow up X-ray or orthopedic consultation to confirm reduction stability. Loss of reduction is an indication for surgery.
• MCP Dislocation: ^[5]
  • Stabilize the proximal phalanx while applying axial traction to distal phalanges with relocating pressure of the phalangeal base to guide finger back into position.
  • Multiple attempts should not be made as this may indicate volar plate involvement requiring surgery.
  • Splint with wrist in 30° extension, MCP in 30°-60° flexion, duration 3-6 weeks. Following splint removal, use finger buddy taping 2-3 weeks.
• PIP Dislocation: [5]
  • Dorsal dislocation: with one hand apply slight extension and longitudinal traction, with other hand apply pressure to dorsal aspect of proximal phalanx to relocate the dislocated finger.
  • Volar dislocation: Apply traction while PIP and MCP are held in slight flexion
  • Lateral dislocation: Hold wrist in extension, MCP in flexion and rotate the middle phalanx back into position.
  • Apply an extension splint for up 6 weeks. Can introduce buddy taping sooner to reduce edema and allow for earlier rehabilitation.
• DIP Dislocation: [5]
  • Reduce dislocation by stabilizing middle phalanx and applying traction.
  • Splint DIP in 10°-20° flexion for 2-3 weeks.

• Other serious injuries related to trauma.
• Unstable patient.
• Infection.
• Surgery.

• Surgery required, cannot be performed at current facility.
• Current facility unable to manage patient with other trauma related injuries.

Indications for Surgery:

• CMC Dislocations: joint stability concern, ligamentous or other soft tissue damage, loss of reduction on follow-up X-ray. ^{[6] [7]}
• MCP Dislocations: non-reducible dislocation with high likelihood of volar plate involvement.^[5]
• PIP Dislocations: non-reducible dislocation, joint instability or significant ligament, tendon or soft tissue injury. ^[5]
• DIP Dislocations: irreversible dislocation. ^[5]

Acute Carpal Tunnel Syndrome following trauma is a surgical emergency.

• If patient admitted for surgery, discharge by admitting service.
• Dislocations reduced in ED: ^[1]
  • Pain adequately managed.
  • All associated wounds cleaned and bandaged.
  • Antibiotics & Tetanus booster (if required).
  • Patient education complete (see patient discharge sheets).

1. Patient Discharge Sheet

   Finger, Hand, and Wrist Injuries (HealthLink BC): Finger, Hand, and Wrist Injuries | HealthLink BC

   Dislocated Finger: Care Instructions (Alberta): Dislocated Finger: Care Instructions (alberta.ca)

   Dislocated Finger in Children: Care Instructions (Alberta): Dislocated Finger in Children: Care Instructions (alberta.ca)

   
   
2. • Hand Anatomy Animated Tutorial – YouTube
   • Clinical assessment of hand injuries: physical exam
   • Emergency Medicine Cases Podcast, Episode 178: Hand Injuries – Pitfalls in Assessment | Emergency Medicine Cases
   • Emergency Medicine Cases Podcast, Episode 179: Hand Injuries – Finger Tip Injuries, Jersey Finger, PIP Dislocations, Metacarpal Fractures, Thumb Injuries, Tendon Lacerations | EM Cases (emergencymedicinecases.com)
   
   

1. C. Nickson, “Life in the Fast Lane – Extremity Injuries,” 3 November 2020. [Online]. Available: https://litfl.com/extremity-injuries/.

   
   

2. J. Chandrasoma, K. Harrison, H. Ching, L. Vokach-Brodsky and L. Chu, “Peripheral Nerve Blocks for Hand Procedures,” The New England Journal of Medicine, vol. 379, pp. e(15)1 – e(15)5, 6 September 2018.

   
   

3. T. Bentley, N. Hope and J. Journey, Wrist Dislocation, Treasure Island, Florida: StatPearls, 2023.

   
   

4. K. Schnetzler, “Acute Carpal Tunnel Syndrome,” Journal of the American Academy or Orthopaedic Surgeons, vol. 16, pp. 276-282, May 2008.

   
   

5. M. Taqi and A. Collins, Finger Dislocations, Treasure Island, Florida: StatPearls, 2022

   
   

6. O. I. Feder, J. P. Letzelter and J. H. Hacquebord, “Dorsal Dislocation of the trapezoid with Metacarpal Instability: A Boxing Injury,” Journal of Wrist Surgery, vol. 10, no. 3, pp. 245-248, 2021.

   
   

7. G. Drosos, E. Kayias and K. Tsioros, “”Floating thumb metacarpal” or complete dislocation of the thumb metacarpal. A Case report and review of the literature.,” International Journal of the Care of the Injured, vol. 35, pp. 544-547, 2004

   
   

8. D. M. Distefano and D. A. Sayal, “EP 178 Hand Injuries – Pitfalls in Assessment and Management,” 1 January 2023. [Online]. Available: https://emergencymedicinecases.com/hand-injuries-assessment-management/. [Accessed 27 February 2024].

   
   

9. J. Swartz, R. Donaldson, N. Young, P. O. D. Lin, M. Holtz and C. Kim, “Hand Exam,” 25 October 2023. [Online]. Available: https://wikem.org/wiki/Hand_exam.

   
   

10. M. Hayton, “Elsons Test,” 19 March 2009. [Online]. Available: https://www.youtube.com/watch?v=G9HY0qXWUvE. [Accessed 27 February 2024].

    
    

11. C. Hacking, “Dislocated 2nd DIP joint – importance of orthogonal views,” 18 January 202. [Online]. Available: https://radiopaedia.org/cases/73416. [Accessed 21 April 2024].

    
    

12. P. S. Dalhousie, “Single Injection Volar Digital Block,” 17 February 2015. [Online]. Available: https://www.youtube.com/watch?v=G6jyw7l3bZs. [Accessed 20 April 2024]

    
    

13. P. S. Dalhousie, “Metacarpal block,” 17 February 2015. [Online]. Available: https://www.youtube.com/watch?v=SgFiuyDekcc. [Accessed 20 April 2024].

    
    

14. J. Kim, K. Hussain, D. Higginbotham and A. Tsai, “Management of thumb carpometacarpal joing dislocations: A systematic review.,” Journal of Orthopaedics, pp. 59-63, 2021.

    
    

15. C. Jorgensen and S. Christos, “Carpometacarpal Dislocations with Third Metacarpal Fracture,” Clinical Practice and Cases in Emergency Medicine, vol. 5, no. 4, pp. 488-490, 2021.