Choice of Treatment for Dislocation of Hand, Thumb and Fingers
- Conservative Treatment
- Physical Therapy
- Interventional Pain Therapy
- Close Reduction
- Surgical Treatment
1. Conservative Treatment for Dislocation of Hand, Thumb and Fingers
a. Restriction Of Hand And Finger Movement1-
Restriction is advised after reduction of dislocation to immobilize the joint. Joint restriction is achieved with following methods-
Ace Bandage for Dislocation of Fingers
- Ace bandage allows partial movement of the joint.
- Ace bandage is used to immobilize finger after reduction of PIP and DIP joint dislocation.
Finger and Hand Braces to Immobilize Dislocated Hand, Thumb and Fingers
- A brace restricts and supports fingers and wrist joint movements.
- Braces are useful to immobilize Inter-Phalangeal joint and Metacarpo-Phalangeal joint.
- Braces prevent most of the movement of wrist joint and finger.
- Braces are mostly prescribed for Metacarpo-Phalangeal joint.
Splints to Immobilize Finger
- Splints are made up of flexible metal or plastics covered by soft spongy synthetic material.
- Shape of the splint can be modified to cover the uneven surface of the finger and knuckle joint.
- Used following correction of dislocation of finger and hand.
Immobilize Finger And Hand By Cast
- Cast is used following close reduction of dislocated joint. Cast is prescribed for dislocation of hand (Metacarpo-Phalangeal joint) and finger (Inter –Phalangeal) joint.
- Cast is also used following open surgical reduction or joint reconstruction Surgery.
Advantages of Cast-
- Functions better than braces and splint in preventing re-dislocation.
- Prevents dislocation following close or open reduction.
- Functions better than braces and splint.
Disadvantages of Cast-
- Cast is applied for 6 to 10 weeks.
- Joint immobilization for 6 to 10 weeks caused tendon, ligament and muscle atrophy.
- Prolonged casting also causes muscle weakness.
- Frequent X-Ray examination is often necessary.
b. Heat And Infra Red Therapy for Dislocation of Hand, Thumb and Fingers
- Heat therapy is applied by using Infra Red light, hot water bag and heated coil.
- Heat therapy is useful to reduced soft tissue swelling often seen following close reduction of dislocation.
- Infra red light and heat therapy reduces stiffness in hand and finger.
- Infra red therapy also helps to reduce pain over dislocated joint.
c. Daily Exercises for Dislocation of Hand, Thumb and Fingers
- Normal finger and forearm muscle exercise is advised following close reduction of dislocation of hand, thumb and finger.
- Patient is advised to continue with exercise following surgery as well as following removal of cast and braces to prevent muscle weakness and atrophy.
- Exercise helps to maintain tone and power of muscles and tendon.
e. Cold Therapy for Dislocation of Hand, Thumb and Fingers
- Bag of ice is placed over dislocated joint of the finger and palm following close reduction.
- Cold therapy prevents tissue edema.
- Reduces hematoma and swelling of the tissue over fractured metacarpal (palm) bone and phalanges (finger).
2. Medications for Dislocation of Hand, Thumb and Fingers
- Anti-depressant Analgesics
- Anti-epileptic Analgesics
- Muscle Relaxants
A. NSAIDS (Non-Steroidal Anti-inflammatory Medications) for Dislocation of Hand, Thumb and Fingers
- NSAIDs are prescribed for inflammation and pain following close reduction of the dislocated joint.
- NSAIDS are ineffective immediately following dislocation since pain is very severe.
- NSAIDs are avoided following surgery since NSAIDs will interfere with normal healing of the wound.
Most Common NSAIDs Prescribed are Motrin, Naproxen and Celebrex.
- Ibuprofen (Motrin)- Tablets are available as 200 mg, 600 mg and 800 mg. Daily dosage is 1600 to 2400 mg per day.
- Naproxen- Tablets are available as 275 mg, 350 mg and 500 mg. Daily dosage- 750 to 1500 mg per day.
- Daypro- Tablet available as 600 mg. Daily Dosage- 600 to 1200 mg per day
- Celebrex- Tablet available as 100 mg and 200 mg. Daily dosage- 200 to 400 mg per day.
B. Opioids Therapy for Dislocation of Hand, Thumb and Fingers
Indications for opioids therapy is as follows-
- Severe pain immediately following injury.
- Severe pain following close reduction of dislocated finger or joints in hand.
- NSAIDs are not effective as an analgesic.
- NSAIDs are contraindicated because of side effects.
Opioids are prescribed for short-term pain relief or prolonged pain relief and are categorized as:
- Short Acting Opioids and
- Long Acting Opioids.
Short Acting Opioid Medications for Dislocation of Hand, Thumb and Fingers
Available in pills and known as Vicodin, Lortab and Norco.
Vicodin- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 650 mg of Tylenol.
Daily Dosage- 15 to 60 mg of hydrocodone.
Lortab- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 500 mg of Tylenol.
Daily Dosage- 15 to 60 mg of hydrocodone.
Norco- Hydrocodone of quantity 5 mg, 7.5 mg and 10 mg is mixed with 350 mg of Tylenol.
Daily Dosage- 15 to 60 mg of hydrocodone.
Norco is preferred if higher dosage like 30 to 60 mg of hydrocodone is prescribed for pain treatment so Tylenol dosage is kept below 2 grams.
Available in pill form known as Oxy IR and percocet
- Oxy-IR- Strength of pills- 5 mg, 7.5 mg and 10 mg, Daily dosage- 15 to 60 mg.
- Percocet- Pills contain Oxycodone and Tylenol.
- Strength of Oxycodone- 5 mg, 7.5 mg and 10 mg.
- Strength of Tylenol- 325 mg, 500 mg and 650 mg.
- Maximum allowed dosage of Tylenol is 4 gm.
- MS IR(Morphine Sulphate Immediate Release)
- Available as liquid and pills.
- Liquid strength- 20 mg/mL
- Pill strength- 15 and 30 mg
- Daily dosage 60 mg to 120 mg.
Long Acting Opioid Medications for Dislocation of Hand, Thumb and Fingers
- Pills available as 10 mg, 20 mg, 40 mg and 80 mg.
- Suggested safe dosage par day- 40 mg to 160 mg.
Morphine- MS Contin
- Pills available as 15 mg, 30 mg, 60 mg, 100 mg and 200 mg.
- Suggested safe dosage per day- 90 mg to 200 mg.
- Pills available as 10 mg
- Suggested safe dosage per day- 40 to 80 mg.
C. Muscle Relaxants for Dislocation of Hand, Thumb and Fingers
Muscle relaxants are prescribed for muscle spasm and joint stiffness
- Pills available as 5 mg, 10 mg, 15 mg and 20 mg.
- Suggested safe dosage per day- 30 to 60 mg
- Pills available as 5 mg and 10 mg
- Suggested safe dosage per day- 20 to 30 mg
- Pills available as 800 mg
- Suggested safe dosage per day- 2400 to 3200 mg
- Pills available as 500 mg and 750 mg
- Suggested safe dosage per day- 1500 to 2150 mg
3. Physical Therapy (PT) For Dislocation of Hand, Thumb and Fingers
Goal of Physical Therapy (PT)
- Improve joint movements.
- Improve muscle strengthening.
- Maintain normal muscle tone.
- Improve muscle co-ordination.
Techniques of Physical Therapy (PT)
- Ultrasound therapy
- Infrared or Heat Therapy
- Cold Therapy
- Massage Therapy
4. Interventional Pain Therapy for Dislocation of Hand, Thumb and Fingers
Interventional pain therapy is rarely indicated following treatment of dislocation of hand and fingers. Interventional pain therapy includes injection of corticosteroid or local anesthesia in the joint.
Cortisone Injection for Dislocation of Hand, Thumb and Fingers
Cortisone Injection to Treat Inflammation-
Cortisone injection is performed to reduced inflammation following close reduction if pain continues.
Cortisone Injection to Treat Severe Pain-
Severe pain if not responding to NSAIDs and opioids, then the chronic pain is treated with frequent cortisone injections. Injections are repeated between 3 to 6 months.
Local Anesthetic Injection for Dislocation of Hand, Thumb and Fingers
Therapeutic value of just local anesthetic injection is very limited.
Local Anesthetic Injection to Treat Severe Chronic Pain
- Joint is injected with local anesthesia when chronic pain not responding to opioids and NSAIDs.
- Local anesthesia is injected in joint when opioid and NSAIDs are contraindicated.
Local Anesthetic Injection to Assist Physical Therapy
- Procedure is performed prior to physical therapy so as to achieve optimum pain relief
- Prior to aggressive physical therapy.
- Median Nerve block is often performed prior to physical therapy every 2 weeks. For 6 to 8 weeks.
When to Avoid Interventional Pain Therapy or Injections-
- Dislocation associated with compound fracture.
- Osteomyelitis or bone infection of dislocated bones.
- Skin Infection
- Allergies to local anesthetics
5. Close Reduction for Dislocation of Hand, Thumb and Fingers
Close reduction is performed in physician office or ER.2
Indications for Close Reduction To Treat Dislocation of Hand, Thumb, and Fingers-
- Isolated dislocation- Dislocation not associated with fracture of the hand, thumb or finger.
- Dislocation associated with fracture- Close reduction is tried if dislocation is associated with fracture. Procedure is considered as successful if fracture and dislocation is reduced simultaneously and position is maintained with cast or splint.
- Close reduction is performed under local anesthesia and sedations.
- Close reduction is performed by pulling wrist and finger in opposite directions under x-ray guidance.
- Finger and hand movements are restricted with splint or cast for 6 to 8 weeks.
Advantages of Close Reduction-
- Procedure is performed under local anesthesia.
- Skin incision or exposure of joint is avoided.
- Recovery is quick and patient is discharged home same day from ER.
- Infection is not observed following treatment.
Disadvantage of Close Reduction Procedure-
- Recurrence of dislocation occurs in few cases
- Healing is delayed in few cases, which results in need to immobilize joint for prolong period.
- Prolong casting may result in muscle wasting, muscle atrophy and severe joint stiffness.
6. Surgery for Dislocation of Hand, Thumb and Fingers
External Fixation Following Close Reduction To Treat Dislocated Hand and Fingers
Indication for External Fixation-
- Unstable or repeated dislocation after close reduction.
- Dislocation of finger, thumb and hand associated with fracture of metacarpal bone or phalanges.
- Most of the close reductions are done in doctor office or ER under local anesthesia.
- Occasionally following close reduction, patient may need external fixation surgery to prevent dislocation.
- Surgery is performed in surgical center. External fixator is connected to dislocated bones under sedation.
- Fixator is used to align and link the dislocated bones in normal anatomical position and maintain the position until joint is healed.
Metacarpo-Phalangeal Joint (Knuckle Joint) Dislocation-
- Proximal pin is inserted in metacarpal bone and distal pin is inserted in proximal phalange.
- Dislocation of Inter-Phalangeal Joint- Proximal pin is inserted in proximal phalange and distal pin is inserted in distal phalange.
- External Fixator is connected to proximal and distal pin.
- Two pins are pulled away from each using external fixator.
- Two ends of the dislocated bones are maintained against each other in anatomical position.
- In few cases cast is applied over hand, wrist and forearm to prevent wrist joint and finger movements.
Advantages of Percutaneous External Fixation
- Open surgery avoided
- Repeat dislocation following close reduction is avoided.
- Joint stability is achieved than close reduction.
- Cast placement is not necessary.
- Permanent placement of hardware is avoided
- Minimum soft tissue injury
- Less painful procedure than open fixation
- Scarring and surgical trauma is avoided
Disadvantage of Percutaneous External Fixation
- Bulky instruments and frame around hand and fingers.
- Unable to use injured hand and arm
Complications of Percutaneous External Fixation
- Fail to reduce or maintained dislocated or fractured wrist joint in place.
- Infection cause by internal pins.
- Nerve injury while placing pins.
- Bleeding and hematoma resulting from laceration of blood vessels while placing pins in fracture segments.
- Laceration or tear of ligaments and tendon by pin.
Internal Fixation (Plate and Screws)3 for Dislocation of Hand, Thumb and Fingers
- Skin incision is taken over the dislocated joint following local anesthesia and sedation.
- Dislocated bones are brought together manually through open wound and linked in anatomical position.
- Plastic or metal plate is placed over Plate.
- Plate is anchored to bone with screws.
- Patient is discharged home with cast.
- Unstable metacarpal and phalangeal dislocation.
- Displace dislocation with fracture of metacarpal bone or phalanges.
- Dislocation associated with comminuted fracture of metacarpal bone or phalanges.
- Dislocation with compound fracture of metacarpal bone and phalanges.
- Failed close reduction and external fixation treatment.
Advantage Of Open Reduction And Internal Fixation Procedure-
- Internal fixation prevents nerve and vascular injury.
- Cast can be removed in 2 to 3 weeks,
- Early physical therapy prevents long-term muscle atrophy and joint stiffness.
- Increase joint stability
Disadvantage Of Open Reduction And Internal Fixation Procedure-
- Incision may cause soft tissue, tendon, ligament or muscle damage.
- Surgery may be cause infection of surgical wound.
- Infection follows prolong recovery and wound healing.
- Infection may need long-term antibiotic treatment.
- Plates and screw may have to be removed if surgery is followed by wound infection.
Arthrodesis of MP and IP Joint4 for Dislocation of Hand, Thumb and Fingers
Indication for Arthrodesis-
- Continuous pain not responding to conservative treatment
- Joint instability
- Joint deformity
- Loss of "Motor Control".
- Joint is surgically exposed.
- Joint cartilage is removed.
- Two end of the align bone shaved or re-shaped to lie against each other.
- Metal pin is passed through center of both the bone.
- Bones are aligned in angle to achieve optimum function.
- Joint is allowed to fuse in 6 to 8 weeks.
The soft tissues over the joint are sewn back together. The forearm and hand are then placed in a cast until the bones completely fuse together. This takes about six weeks.
Prognosis Following Treatment for Dislocation of Hand, Thumb and Fingers
- Healing of the Metacarpo-Phalangeal and Inter-Phalangeal joint may follow joint arthritis.
- Arthritis causes cartilage and tendon damage.
Joint Infection or Septic Arthritis-
- Surgical treatment of dislocation may result in joint infection and septic arthritis.
- Septic arthritis may be associated with infection of the bone or osteomyelitis.
- Osteomyelitis is an infection of the bone.
Healing of joint dislocation may be associated with visible and palpable deformity.
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