Treatment is closed reduction unless soft tissue interposition blocks reduction, in which case open reduction is needed. Fracture at the neck of the fifth metacarpal bone (boxer’s fracture), often caused by a missed punch during a boxing match, is the most common metacarpal bone fracture. Anesthesia may be necessary to facilitate reduction. Eiff MP, Hatch RL, Calmbach WL. Rehabilitation exercises are explained in the accompanying patient information handout. A physician can treat middle phalanx fractures if proper alignment is achieved through reduction. UCL injury (skier’s thumb). Reduction of a lateral PIP joint dislocation is accomplished by applying reducing pressure to the deviated distal portion (middle phalanx) while stabilizing the proximal portion (proximal phalanx). The metacarpophalangeal (MCP) joint most commonly dislocated is that of the thumb. 3. Montgomery K. Detecting rotation in middle phalanx fractures. Emergent evaluation. If successful, further treatment focuses on the concomitant soft tissue injury. Treatment is closed reduction and immobilization with unstable injuries requiring surgical stabilization. Palmer RE. afpserv@aafp.org for copyright questions and/or permission requests. 1995;11:373–86. Pointers for acute and late-phase management. Avulsion fracture involving more than one third of the joint or irreducible injury, Metacarpal bone fracture (boxer’s fracture; most common above the fifth digit). Statius Muller MG, ), Stable UCL injuries are treated with splinting using a thumb spica cast or splint (Figure 9) for six weeks. Am Fam Physician. Referral is needed for irreducible dislocations. Reprints are not available from the authors. The direction of dislocation is usually dorsal, but lateral and volar dislocations sometimes occur. Rosen’s emergency medicine: concepts and clinical practice. Acute finger injuries: part I. Tendons and ligaments. Boxer fractures are an impaction injury that almost always is a consequence of a direct blow with a clenched fist against a solid surface which causes axial loading of the 5 th metacarpal. Epidemiology. Salam GA. McDevitt ER. Rheumatoid Arthritis - MCP swelling, Swan neck deformities, Ulnar deviation at MCP joints, Nodules along tendon sheaths. Antosia RE, Lyn E. The hand. Regional anesthesia for office procedures: Part II. Normally the UCL is underneath the adductor aponeurosis. If no fracture is present, the joint should be stressed in full flexion to maximally isolate the ligament. 6. It also supplies the dorsum of the fingers as far distal as the proximal interphalangeal (PIP) joint and as far medial as the middle of the ring finger. Am Fam Physician. Part I1of this two-part article covers tendon and ligament injuries of the finger. Sesamoid bones. Athletic injuries of the adult hand. If a fracture is present, consultation with an orthopedic or hand surgeon is appropriate.10,14 Generally, nondisplaced fractures can be treated closed, whereas displaced fractures require surgery. Fingertip injuries. To accomplish an ulnar block, inject 5 to 7 mL of anesthetic, 1 to 2 cm deep between the flexor carpi ulnaris tendon and the ulnar artery to block the palmar branch of the ulnar nerve. Philadelphia, Pa.: Saunders, 2003:1381–1430. 13. 7. Sesamoid bones are small round or oval shaped nodules that are located within certain tendons. (UCL = ulnar collateral ligament; MCP = metacarpophalangeal.). 73/No. Statius Muller MG, If a Stener lesion is suspected, consultation with an orthopedic or hand surgeon is necessary. Athletic hand injuries. : Mosby, 2002:493–534. In: Roberts JR, Hedges JR, eds. If successful, the joint should be splinted in full extension for six weeks. Typically there are five sesamoid bones in each hand; two at the metacarpophalangeal (MCP) joint of the thumb, one at the interphalangeal (IP) joint of the thumb, one at the MCP … This content is owned by the AAFP. 2nd ed. Follow up with radiography to ensure proper healing. Çiğdem Ayhan, Egemen Ayhan, in Comparative Kinesiology of the Human Body, 2020. General Leonard Wood Army Community Hospital, Fort Leonard Wood, Missouri; Womack Army Medical Center, Fort Bragg, North Carolina, A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. In: DeLee JC, Drez D Jr, Miller MD, eds. Copyright © 2021 Lineage Medical, Inc. All rights reserved. Disruption of the ulnar collateral ligament (UCL), also known as skier’s thumb, is usually caused by forced abduction of the MCP joint. Lynch JM. Lynch JM. The largest joint of each finger lies between the finger and the hand. Orthop Clin North Am. 11. Zook EG, Do not perform this procedure in patients with grossly contaminated skin (because of osteomyelitis risk) or open fractures, or in small children. Wang QC, Thumb Spica Splint ... st-AROM – PIP and MCP 1 6wks **No DIP bending allowed – not even one time. 1. Extremity and inguinal area surgeries. Extensor and flexor tendon injuries in the hand, wrist, and foot. A “glove” cast (i.e., a cast starting slightly distal to the palmar crease and ending just proximal to the MCP joint) can create some immobilization and protection while maximizing function.4, A randomized trial11 compared outcomes of metacarpal bone fractures after reduction and ulnar gutter splinting with no reduction and splinting. (B) Rotation. Flexion (2-5 MCP) 90° Extension (MP) 40° Abduction 20° Adduction 20° PIP joint. Dorsal PIP joint dislocation can injure the volar plate or cause an avulsion fracture of the middle phalanx (Figure 1). ACR appropriateness criteria. 5. / Each finger is made up of 3 phalanges; the thumb is made up of 2. Eiff MP, Hatch RL, Calmbach WL. 8. The thumb metacarpal can bend and extend the thumb, move the thumb away from and toward the hand, and spin the thumb on the trapezium. Incidence. Clinical procedures in emergency medicine. For information about the SORT evidence rating system, see page 755 or, PIP = proximal interphalangeal; UCL = ulnar collateral ligament, Reduction may be attempted during an athletic event without radiography; however, follow-up evaluation including radiography is necessary. Poolman RW, Athletic hand injuries. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Philadelphia, Pa.: Saunders, 2004: 927–45. Am Fam Physician. Reducing a fifth metacarpal bone fracture (boxer’s fracture). / afp Administer ulnar or hematoma block and attempt reduction. Want to use this article elsewhere? Patient information: See related handout on rehabilitation exercises after finger injuries, written by the authors of this article. Reduction technique for proximal interphalangeal joint dislocations. 2nd ed. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large. To accomplish a hematoma block, clean the area and inject 5 to 10 mL of 1 to 2% lidocaine without epinephrine directly into the fracture site. A metacarpophalangeal dislocation, or MCP dislocation, is a dislocation of the metacarpophalangeal joint, usually dorsal, caused by a fall and hyperextension of the MCP joint. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. Antosia RE, Lyn E. The hand. Regional anesthesia for office procedures: Part II. If reduction is unsuccessful, or if avulsion involves more than one third of the joint, referral to an orthopedic or hand surgeon is needed. The opposite is true for a volar dislocation; there will be injured dorsal structures, and splinting should be initiated to maintain extension. Graham TJ, Mullen DJ. Am Fam Physician. Montgomery K. 2006 Mar 1;73(5):827-834. Bach AW. The adductor pollicis helps move the thumb toward the hand. Choose a single article, issue, or full-access subscription. Handbook of sports medicine: a symptom-oriented approach. Splinting depends on the direction of the dislocation. A simple dislocation involves no soft tissue obstruction, and reduction should be attempted. In: Marx JA, Hockberger RS, Walls RM, Adams J, eds. This may be difficult because of the tension created by the extensor and flexor tendons. Hand and wrist injuries: Part II. Emergent evaluation. MCP dislocation (especially in the thumb) Attempt reduction. In: Lillegard WA, Butcher JD, Rucker KS, eds. Clin Sports Med. The physician may attempt reduction by hyperflexing the distal segment (middle phalanx) to “unlock” the joint and then applying traction. Wang QC, An orthopedic or hand surgeon should treat finger injuries that are unstable or that have rotation. Examination includes radiography (oblique, anteroposterior, and true lateral views) and physical examination to detect fractures. The MCP joint can become dislocated in accidents involving the hands, requiring casting and/or surgical intervention. This article discusses the evaluation, diagnosis, and treatment of common finger fractures and dislocations and thumb injuries. Immediate mobilization gives good results in boxer’s fractures with volar angulation up to 70 degrees: a prospective randomized trial comparing immediate mobilization with cast immobilization. Accessed online November 2, 2005, at: http://acr.org/s_acr/bin.asp?CID=1206&DID=11792&DOC=FILE.PDF. 2002;33:547–54. Volar dislocation of the PIP joint is rare. The metacarpophalangeal (MCP) joint most commonly dislocated is that of the thumb. Fractures, Dislocations, and Thumb Injuries. Johnson BA. Rubin DA, Dalinka MK, Daffner RH, De Smet AA, El-Khoury GY, Kneeland JB, et al, for the Expert Panel on Musculoskeletal Imaging. Graham TJ, Mullen DJ. Although not truly a finger fracture, this injury is included in this article because of its prevalence. St. Pierre P. Hand injuries. Fingertip injuries. Complications from excessive angulation after a metacarpal bone fracture include a stiff MCP joint, a prominent metacarpal head in the palm, pain, and pseudoclawing. Finger joint injuries in active patients. Joint dislocations (dorsal PIP joint dislocation is most common), Tenderness at volar plate with an obvious deformity. Address correspondence to Jeffrey C. Leggit, LTC, MC, USA, 107 Sawmill Rd., St. Robert, MO 65584 (e-mail: Leggit JC, 2003;123:534–7. This first joint at the base of the finger is called the metacarpophalangeal joint (MCP). PIP = proximal interphalangeal; UCL = ulnar collateral ligament. Most data7 suggest referral to an orthopedic or hand surgeon if there is 35 to 40 degrees of joint opening or if there is no clear endpoint. Flexion 100° Extension 0° DIP joint. ACR appropriateness criteria. In most cases, the neck fracture is … Hand and wrist injuries: Part II. 2nd ed. If reduction is successful, the finger should be splinted in 70 to 90 degrees of flexion for six weeks to avoid significant stiffness using an ulnar gutter splint or cast or a ready-made orthotic splint. 12. Commercial splints are an alternative to casting if patient compliance can be ensured. 2004;69:896–900. Determine extent of angulation and evaluate for rotation. Extensor tendon injuries at the distal interphalangeal joint. Collateral ligament injuries of the thumb should be examined with radiography before physical examination. If tenderness is present at the UCL, radiography should be performed to rule out fracture before further evaluation. The dislocated middle phalanx is dorsal to the line bisecting the proximal phalanx; therefore, it is a dorsal dislocation. He received his medical degree from Dartmouth Medical School, Hanover, N.H., and completed a family practice residency at Dewitt Army Community Hospital. Poolman RW, 16. For information about the SORT evidence rating system, see page 755 orhttps://www.aafp.org/afpsort.xml. … Johnson BA. The UCL may be partially or completely torn with or without an avulsion fracture. An ulnar collateral ligament injury should be considered when a patient presents with traumatic thumb pain, and fracture should be ruled out with radiography before a stress test is performed. Schneider LH. *—Reduction may be attempted during an athletic event without radiography; however, follow-up evaluation including radiography is necessary. Physicians can treat most finger fractures and dislocations, although knowing when to refer a patient to an orthopedic or hand surgeon is important to ensure maximal future functionality. Meko CJ. 5(March 1, 2006) Acute hand or wrist trauma. A partial dislocation is referred to as a subluxation.Dislocations are often caused by sudden trauma on the joint like an impact or fall. Two very important ligaments are the dorsoradial and the volar beak ligaments. MCP Joint Dislocation. Chronic instability of the 1ste MCP joint: Injuries to the two main supporting ligaments traversing the metacarpophalangeal (MCP) joint of the thumb can lead to symptomatic joint … handlebar driven into a motorcyclist’s thumb on impact), used to evaluate for base of thumb fractures, persistent/recurrent instability after reduction, diagnosis confirmed by history, physical exam, and radiographs, stable on reduction (implying the AOL is intact), grossly unstable joint (AOL possibly torn as well), better abduction and pinch strength than closed reduction and pinning, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). In: Lillegard WA, Butcher JD, Rucker KS, eds. Table 1 summarizes the evaluation and treatment of common dislocation and fracture injuries of the finger and ulnar collateral ligament injuries of the thumb. All rights Reserved. If reduction is performed immediately, anesthesia is not needed. Hold the proximal phalanx in place while applying counterpressure. Finger Joints (Knuckles) Each finger contains 3 joints, more commonly known as knuckles. 14. This is part II of a two-part article on finger injuries. A simple dislocation involves no soft tissue obstruction, and reduction should be attempted. Treatment depends on rotation and extent of the fracture fragment. Leggit JC, The trial showed that the treatments are equally effective if the fracture is not angulated more than 70 degrees.11 This result should not dissuade physicians from attempting reduction; it should provide reassurance that the fracture should heal well unless severely angulated or rotated. Get Permissions, Access the latest issue of American Family Physician. Diagnosis is clinical and can be confirmed by orthogonal radiographs. Treat soft tissue injury (e.g., volar plate injury). 4. The most commonly dislocated joint in the body is the proximal interphalangeal (PIP) joint of the finger (“coach’s finger”).4 The severity of this injury often is underestimated and improper treatment can cause long-term morbidity. 1999;27:89–104. Dislocation reduction is accomplished with careful traction. St Louis, Mo. McDevitt ER. Dislocation of 1st MCP joint: A dislocation is an injury to a joint — a place where two or more of your bones come together — in which the ends of your bones are forced from their normal positions. Immediate, unlimited access to all AFP content. The injuries are treated similarly, but there is no risk of Stener lesion with radial collateral ligament injuries. Finger injuries should be evaluated with radiography (oblique, anteroposterior, and true lateral views). Inability to maintain proper alignment or irreducible injury, Disruption of UCL at the thumb (skier’s thumb). Philadelphia, Pa.: Saunders, 2003:63–79. Immobilization of the said joint should not be prolonged; otherwise, the functionality of the hand will be affected. Philadelphia, Pa.: Saunders, 2003:1381–1430. Note the normal joint congruity (arrow). A patient with a dorsally dislocated PIP joint will have tenderness at the volar plate and an obvious deformity. Proximal phalanx and articular surface fractures involving more than 30 percent of the joint should be managed in consultation with an orthopedic or hand surgeon. A joint dislocation can cause damage to the surrounding ligaments, tendons, muscles, and nerves. Stener lesions usually present as joint instability and a tender mass. In: DeLee JC, Drez D Jr, Miller MD, eds. Dorsal PIP joint dislocation. If reduction is successful, the PIP joint should be splinted (e.g., buddy taping the injured PIP joint in slight flexion) and the patient may continue to participate in the athletic event.5 The injury must be reevaluated in the office, including radiography. Unless severe angulation or displacement is present, these fractures should be reduced, treated by splinting the DIP joint in full extension using a stack or aluminum splint for four to six weeks, and reevaluated. Patients may continue to participate in athletic events during the splinting period depending on their sports and positions. Fifth metacarpal bone fracture (boxer’s fracture). Pathology Mechanism. Joint injuries of the hand in athletes. : Butterworth-Heinemann, 1999:183. Daniels JM II, Sokolove PE. (B) The proximal phalanx or (C) the proximal interphalangeal joint can be used as a lever arm to move the metacarpal head upward while applying counterpressure to the proximal fracture fragment. Steller EP. Apply distal tension on the injured finger while applying volarly directed pressure to the middle phalanx. Accessed online November 2, 2005, at: http://acr.org/s_acr/bin.asp?CID=1206&DID=11792&DOC=FILE.PDF. Lee SJ, Evaluate the stability of the ligament by applying abducting pressure to one side of the UCL while applying counterpressure to the other side. Brzezienski MA, Steller EP. capsulorrhaphy The tightening of a torn joint capsule by suturing or, in the case of joint hyperlaxity, by thermal shrinking with a laser to prevent recurring joint dislocation, which is of particular use for shoulder joint instability. 5th ed. Arch Orthop Trauma Surg. Am Fam Physician. If no rotation is present, all of the fingernails will be on the same plane and will be pointing towards the scaphoid bone9 (Figure 4). Don't miss a single issue. Reduction is obvious when it occurs. Fracture management for primary care. 2nd ed. Zook EG, To see the full article, log in or purchase access. JEFFREY C. LEGGIT, LTC, MC, USA, General Leonard Wood Army Community Hospital, Fort Leonard Wood, Missouri; CHRISTIAN J. MEKO, CAPT, MC, USA, Womack Army Medical Center, Fort Bragg, North Carolina. Boston, Mass. Phys Sportsmed. Fractures should be reduced and then assessed using radiography. Thumb CMC dislocation are rare injuries that occur due to axial force on a flexed thumb. Therefore, a splint that does not allow full extension is necessary, as it is with a PIP dislocation. Reduction of a dorsal PIP joint dislocation may be achieved by gently applying distal traction to the injured finger while applying volarly directed pressure to the middle phalanx (Figure 2). UCL injuries may cause Stener lesions. Fifth metacarpal bone fracture (boxer’s fracture) with angulations of 70 degrees or less heal with or without reduction and splinting. Physicians may provide local anesthesia or a digital block to facilitate the stress examination if needed. A digital or hematoma block should be used to facilitate reduction. Contact However, a digital block is usually needed for pain if presentation is delayed for more than one hour.6 For a digital block, 1 to 2% lidocaine (Xylocaine) without epinephrine is placed along both sides of the affected digit just distal to the MCP joint.

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