Finger Dislocations

Finger dislocations are among the most common hand injuries seen in primary care and emergency departments. The proximal interphalangeal joint (PIPJ), the "workhorse" joint of the finger, is the one most frequently affected.

Mechanism. Ball sports are the most common setting: basketball, football and cricket. The mechanisms are:

• Hyperextension - the most common mechanism, producing dorsal PIPJ dislocation
• Axial loading - the "jammed finger" of sport
• Rotational stress - lateral dislocation with collateral ligament disruption; a rotational force can also dislocate the joint volarly
• Volar displacement - a palm-directed force on a flexed finger, rupturing the central slip

The PIPJ box. The PIPJ is a bicondylar hinge joint stabilised by a three-sided ligamentous "box". Which wall fails dictates the direction of dislocation and the entire treatment pathway.

• Volar: the volar plate. Fibrocartilage that resists hyperextension, with a thick distal attachment to the base of the middle phalanx and a thin, membranous proximal attachment (the check-rein ligaments)
• Lateral: the collateral ligaments. The proper collateral is the primary lateral restraint and is tightest near full extension; the accessory collateral blends with the volar plate
• Dorsal: the extensor mechanism. The central slip inserts on the dorsal base of the middle phalanx, and the lateral bands run laterally

Which wall fails. The direction of dislocation names the injured wall:

• Dorsal dislocation - the volar plate avulses distally, with or without a small bony fragment (the "volar plate sign")
• Volar dislocation - the central slip ruptures; the rupture is obligatory, hence the risk of boutonnière
• Lateral dislocation - the collateral ligament is disrupted

By direction. A PIPJ dislocation is named by where the middle phalanx lies relative to the proximal phalanx. Dorsal is the most common; volar is rare and carries the central slip injury; lateral is a collateral ligament disruption with a rotatory component. By joint involvement, a simple dislocation is soft tissue only and a fracture-dislocation carries a bony avulsion.

Fracture-dislocations: the articular-surface rule. The volar lip fragment is measured on the lateral radiograph as a percentage of the articular surface of the middle phalanx.

• Less than 30% - usually stable; extension block splinting
• 30-50% - borderline; may need surgical stabilisation
• Greater than 50% - unstable; requires surgical fixation

The surgical threshold of 40-50% falls inside the borderline band. There, the decision rests on dynamic stability, the stable arc tested under fluoroscopy, rather than on the percentage alone; the Evidence section sets out why no single cut-off settles it.

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History. Establish the mechanism, then ask the questions that change management:

• Time since injury
• Previous reduction attempts
• Hand dominance and occupation

Examination. Look for the deformity, dorsal or volar, with swelling and bruising, and check skin integrity: open injuries are common at the DIPJ. Palpate for point tenderness and record neurovascular status, capillary refill and sensation.

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Stability after reduction. Take the finger actively through its full arc and note the angle at which it subluxates. Record the stable arc, and the angle of instability if there is one; the collateral ligaments are stressed separately (see the collateral ligament section). The critical post-reduction checks:

1. Can the patient actively extend the PIPJ fully? If so, the central slip is intact
2. Does the joint subluxate in extension? If so, it is unstable (V-sign)
3. Is there rotatory instability, from a lateral ligament injury?
4. Is the joint congruent on a true lateral radiograph after reduction?

The Elson test. It checks central slip integrity after a volar dislocation. Flex the PIPJ to 90° over the edge of a table and ask the patient to extend against resistance. If the central slip is torn, the extensor force is diverted into the lateral bands and the DIPJ goes rigid into extension; a floppy DIPJ means the slip is intact.

Radiographs. AP, lateral and oblique views of the affected finger. The true lateral is essential for classification: isolate the finger from its neighbours, direct the beam perpendicular to its lateral aspect, and check that the condyles are superimposed.

Before and after reduction. The pre-reduction films confirm the direction of dislocation, identify associated fractures and assess joint congruity. The post-reduction films confirm a concentric reduction, look for a V-sign and show where any fracture fragment lies. A small volar plate avulsion fragment is common in dorsal dislocation and is usually treated conservatively if the joint is stable.

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CT. For complex fracture-dislocations, for measuring the percentage of articular involvement, and for planning surgery on comminuted injuries. It defines a depressed fragment and the remaining joint surface when plain films cannot explain instability or guide fixation.

Fluoroscopic stress views. They assess stability through the range of motion, find the angle at which the joint becomes unstable, and so set the angle of an extension block splint.

MRI. Not routine after an acute dislocation, but it can define an occult tendon injury when examination is limited or the diagnosis remains uncertain.

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The swollen, deformed or "jammed" finger has several mimics. The key discriminators are the direction of deformity, active extension capacity, joint congruity on a true lateral film, and whether a mechanical block to reduction is present.

The principle. Direction decides the regimen: a dorsal dislocation is moved early and a volar one is splinted in extension.

Dorsal PIPJ dislocation.

1. Digital block anaesthesia
2. Reduce with longitudinal traction and flexion
3. Assess stability through the range of motion
4. Stable: buddy taping and early motion
5. Unstable: extension block splinting

Volar PIPJ dislocation. The central slip is at risk.

1. Reduce with traction and extension
2. Test active PIPJ extension
3. Static extension splint for 6 weeks
4. Active DIP flexion exercises during immobilisation

An unstable volar dislocation may need open repair.

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Extension block splinting. For a dorsal fracture-dislocation with less than 50% articular involvement, where the joint is stable in some flexion but unstable in extension.

1. Determine the angle of stability under fluoroscopy
2. Splint the PIPJ at that angle, typically 30-40° of flexion
3. Allow full active flexion
4. Radiograph weekly to confirm the reduction
5. Reduce the flexion by 10° a week

When to operate.

• Irreducible dislocation (volar plate interposition)
• Fracture involving more than 40-50% of the articular surface
• Persistent instability despite splinting
• Chronic dislocation, more than 3 weeks old
• Failed closed treatment

Approaches. The approach follows the structure to be dealt with:

• Volar (Bruner) - preferred for extracting the volar plate
• Dorsal - central slip repair
• Lateral - collateral ligament repair

Open reduction through the volar approach.

1. Bruner zigzag incision over the PIPJ
2. Identify and protect the neurovascular bundles
3. Retract the flexor tendons
4. Identify the interposed volar plate
5. Extract it and reduce the joint
6. Repair the volar plate to bone with suture anchors

Choosing the operation for a fracture-dislocation. Match the procedure to fragment size, comminution and chronicity.

Volar plate arthroplasty (Eaton-Littler).

1. Volar approach to the PIPJ
2. Release the A3 pulley if needed
3. Advance the volar plate into the articular defect
4. Secure it with a pull-out suture or an anchor
5. Extension block splinting after surgery

Hemi-hamate arthroplasty. The PIPJ is opened through a volar shotgun exposure, and an osteochondral graft from the hamate reconstructs the deficient volar base of the middle phalanx. Protect both digital neurovascular bundles and avoid proud screws.

1. Harvest a size-matched graft from the dorsal hamate
2. Contour it to match the base of the middle phalanx
3. Fix it with screws or K-wires
4. Early protected motion

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Dynamic external fixation. Indicated for unstable fracture-dislocations. Ligamentotaxis reduces the fracture while the fixator allows early protected motion; the complications are pin-tract infection and stiffness.

The distal interphalangeal (DIP) joint is dislocated far less often than the PIPJ, but when it happens it is almost always dorsal and frequently open, because the dorsal skin over the joint is thin and closely applied to the extensor mechanism. The usual mechanism is an axial load with hyperextension, classically a ball striking the extended fingertip.

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Open until proven otherwise. Even a small dorsal or volar laceration communicating with the joint makes this an open injury. It needs formal irrigation and debridement, tetanus prophylaxis and antibiotics, and reduction in a clean environment rather than a simple bedside reduction in the cubicle. An unrecognised open DIP dislocation risks septic arthritis and osteomyelitis.

Screen the tendons, the nail bed and, in a child, the physis. A lag in active DIP extension suggests a terminal extensor (mallet) injury, developed in the mallet-finger topic; loss of active DIP flexion suggests an FDP avulsion, covered under jersey-finger. Look for a nail-bed laceration. In a child, actively exclude a Seymour-type injury at the nail fold: a displaced physeal fracture of the distal phalanx can masquerade as a DIP dislocation or mallet, and is an open physeal injury requiring nail-plate removal and reduction (see phalangeal-fractures).

Reduction and aftercare. Under digital block, apply longitudinal traction with gentle reversal of the deformity. The reduced DIP is usually stable, since it is unusual for both collateral ligaments and the volar plate to fail together. Splint the DIP, leaving the PIP free, for roughly 2-3 weeks, then move to protected motion: the DIP tolerates short immobilisation, but prolonged splinting causes stiffness.

The irreducible DIP. Rare and, as at the PIPJ, a sign of soft-tissue interposition: most often the volar plate, occasionally the FDP tendon or a trapped sesamoid. It requires open reduction.

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Lateral dislocations and isolated collateral ligament ("sprain") injuries of the PIPJ are common and, because they frequently reduce spontaneously on the field, are easily under-treated. The radial collateral is injured more often than the ulnar.

Grading.

• Grade I - sprain, ligament in continuity, stable to stress
• Grade II - partial tear, painful but stable
• Grade III - complete rupture, demonstrably unstable

Stress testing. Apply radial and ulnar deviation stress with the PIPJ in about 20-30° of flexion, which isolates the proper collateral, always comparing with the same finger on the other hand. Lateral opening of more than 20°, or a soft or absent endpoint, indicates a complete (Grade III) rupture. A stress radiograph documents both the angulation and any condylar avulsion fragment.

Management. The overwhelming majority, including reduced lateral dislocations and Grade I-III sprains without a large intra-articular fragment, are stable enough for buddy strapping to the adjacent finger with early motion for 3-6 weeks, and do very well. Surgery is reserved for three situations, the main one a large displaced condylar fragment:

• A displaced condylar avulsion fragment carrying a meaningful portion of the articular surface
• Gross instability
• Soft-tissue interposition blocking reduction

A fixed rotational deformity points to an associated phalangeal or condylar fracture (see phalangeal-fractures) rather than a pure ligament injury. Warn the patient that a lateral PIPJ injury leaves a fusiform, mildly stiff and tender joint for many months, exactly as a dorsal dislocation does.

Stiffness. The most common complication. Fusiform swelling persists for months, and patients should be warned that the finger may stay permanently thickened. Prolonged immobilisation causes it; early protected motion in dorsal dislocations prevents it.

Boutonnière deformity. PIPJ flexion with DIPJ hyperextension, the result of an untreated central slip injury. It is common after a volar dislocation that is wrongly mobilised, and 6 weeks of extension splinting prevents it. An established deformity may still respond to splinting if treated early (less than 6 weeks); a late or fixed deformity may require surgical reconstruction by central slip repair, lateral band release or tendon reconstruction.

Pseudoboutonnière. A volar plate contracture holds the PIPJ in flexion after prolonged flexion splinting. Unlike the true boutonnière, the DIP is unaffected.

Swan-neck deformity. PIPJ hyperextension with DIPJ flexion, from volar plate laxity. It may follow chronic dorsal subluxation, and proper treatment of the volar plate injury prevents it.

Chronic instability and subluxation. Inadequate healing leaves a joint that stays unstable, which an appropriate duration of splinting prevents. Persistent subluxation shows as a V-sign on the radiograph and may require volar plate reconstruction, or a tenodesis or capsulodesis procedure.

Post-traumatic arthritis. More common after fracture-dislocations, and the risk increases with articular involvement greater than 40%. Severe cases may require arthrodesis.

Stable dorsal dislocation. Active motion starts immediately, with the finger buddy-taped to its neighbour. Full range of motion is expected by 4-6 weeks; protect the finger during sport for 6-8 weeks.

Volar dislocation. The extension splint stays on for a minimum of 6 weeks, and progressive PIPJ flexion begins after that.

After surgery. Hand therapy referral is essential, and the protocol runs:

• Extension block splinting for 2-3 weeks
• Progressive extension by 10° a week
• Full motion by 6-8 weeks
• Strengthening at 8-12 weeks

Hand therapy. Therapy addresses oedema, motion and splinting:

• Oedema - elevation for the first 48-72 hours, Coban wrap, active finger pumping exercises
• Motion - tendon gliding, blocked flexion and composite fist-making exercises
• Splints - thermoplastic splints preferred; figure-of-8 splints for collateral injuries; night splinting may continue for 3 months

Counselling. The fusiform swelling persists for 6-12 months, and full range of motion may take 3-6 months. For sport, protective taping is used for 3-6 months with buddy taping during activity, and a finger splint should be considered for contact sports.

Simple dorsal dislocation. An excellent prognosis with early motion: more than 90% achieve functional range of motion. Residual stiffness is common but usually mild, and return to sport comes within 4-6 weeks.

Volar dislocation. Good outcomes if splinted correctly, but a higher complication rate than dorsal, with the risk of boutonnière if treated improperly. Full recovery may take 3-6 months.

Fracture-dislocation. Outcomes depend on articular involvement: the prognosis is good with a fragment less than 30% and guarded with one greater than 50%, and the risk of post-traumatic arthritis increases with severity.

Predictors. Favourable factors:

• Early treatment, within 24 hours
• Simple dislocation without fracture
• A patient compliant with therapy
• Young age

Unfavourable factors:

• Delayed presentation, beyond 1 week
• Large articular fragment, greater than 40%
• Open injury
• Associated tendon injury
• Poor compliance with splinting

The chronic or neglected dislocation. Beyond 3 weeks the chance of closed reduction falls, and beyond 6 weeks open treatment is usually required. Contracture and arthritis are more common, and arthrodesis may be needed as salvage.

Function. Grip strength usually recovers well, pinch strength may be reduced, and DASH scores typically normalise by 6-12 months.

Global epidemiology:

• Finger and hand injuries are among the most common presentations to emergency and acute care worldwide; the PIPJ is the most frequently dislocated digital joint, with dorsal dislocation by far the commonest pattern.
• Peak incidence is in young, active adults; ball and contact sports (basketball, football/soccer, rugby, cricket, volleyball, handball) dominate the mechanism across regions.
• Most simple dorsal dislocations are reduced and managed by emergency physicians or primary care, with specialist hand referral reserved for volar dislocations, irreducible joints and fracture-dislocations.

The evidence base for PIPJ fracture-dislocations is almost entirely Level III-IV; there are no randomised trials comparing surgical techniques, so management remains opinion- and series-driven. Examiners reward candidates who can articulate these grey areas rather than quote a single dogmatic threshold.

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