Reduction - Finger dislocation

This procedure is generally performed using a ring block with local anaesthesia (covered separately)

Indications

Finger dislocation

Contraindications (absolute in bold)

Life or limb-threatening injuries

Associated fracture

Open dislocation

Thumb dislocations

Alternatives

Reduction by orthopaedic team in emergency department

Reduction in operating theatre

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Failure (of reduction, recurrence or immobilisation)

Conversion to an open injury

Neurovascular damage

Fracture

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: non-sterile gloves

Area

Any clinical area

Staff

Procedural clinician

Equipment

Syringes and needle (25-27g) for ring block

Splinting material for POSI splint or aluminium digital splint

Positioning

Supine head up at 45 degrees

Medication

5ml lignocaine 1% without adrenaline

Sequence (basic overview)

Examination for other injuries and fractures

Neurovascular assessment of finger (sensation)

Perform a digital nerve block to the affected finger

Obtain X-ray of the finger (assess fractures)

Apply sustained traction to distal digit while exaggerating distal deformity (consider gauze to aid grip)

Apply pressure to proximal end of dislocated bone towards joint (maintaining traction)

Consider flexion of the wrist (relax flexors) or extension of the wrist (relax extensors)

Consult orthopaedic team after two failed reduction attempts

Post-procedure care

Check X-ray, circulation and limb function:

Reassess neurovascular status (sensation and capillary refill)

Assess joint stability with movement of joint (hyperextension, ulnar and radial stress)

Assess rotational deformity with movement of joint (no digital overlap, nailbeds point to thenar eminence)

Obtain post-reduction finger X-ray and confirm satisfactory reduction

Digital immobilisation:

Volar dislocation: dorsal splint in mild flexion

Dorsal dislocation: volar splint in extension

Lateral dislocation: buddy strapping

MCP dislocation: POSI splint

Thumb dislocation: thumb spica splint

Ongoing care:

Tetanus (ADT) and antibiotic cover (cefazolin 2g IV) for open wounds

Discuss follow-up and length of immobilisation with orthopaedic or hands team

Document procedure, neurovascular assessments, X-ray findings and management plan

Tips

Search for other fractures and serious injuries when treating a dislocated joint

Always perform a neurovascular exam before and after a relocation attempt

Reassurance, verbal distraction, and effective pain relief all aid successful joint relocation

Slight traction distal to the dislocation is often enough to relocate the joint

Orthopaedic consultation prior to reduction for associated fractures, open dislocations, thumb dislocations

Discussion

This guide has been simplified for general application to all digital dislocations. Difficult reduction should always prompt orthopaedic discussion and only experienced providers should attempt thumb reduction without orthopaedic discussion.

Thumb dislocations are often associated with complications. Carpometacarpal thumb dislocations are associated with unstable fractures, metacarpophalangeal thumb dislocations may be irreducible due to volar plate entrapment which can lead to fracture if reduction is attempted.

Most digital dislocations with require local anaesthetic for reduction but some will reduce easily, producing immediate relief of discomfort and resolution of the deformity. We suggest reduction may be attempted without anaesthesia at time of injury or initial assessment. If pain impedes reduction, local anaesthetic ring block should be applied, and an X-ray performed before further attempts.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

In: UpToDate. Waltham (MA): UpToDate. (2019): Digit dislocation reduction

Skinner H. Current diagnosis & treatment in orthopaedics. 5th ed. New York: McGraw-Hill Medical; 2013.

Borchers JR, Best TM. Common finger fractures and dislocations. Am Fam Physician. 2012;85(8):805-810.

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