DPTATC

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I am a PT ATC and was covering a local high school basketball game. In the 4th quarter our star player caught a ball directly on the end of his R (dominant) index finger and suffered an open dislocation of the 2nd PIP. I covered it with sterile gauze and put ice on it and sent him right to the ER with his parents. There was minimal bleeding, cap refill was good and he had normal sensation distal to the dislocation.

Our rural ER was staffed by a locum tenens FP doc who seems competent but doesn't/didn't dazzle with his management of ortho cases. (I have sent a wrestler there with intense back pain in the past that was ultimately diagnosed by a radiologist as a L4-5 spondlyolisthesis)

Plain films were negative for fracture but the middle phalanx was dislocated posteriorly and retracted about 1-1.5 cm. He contacted the nearest ortho group and they didn't have a hand surgeon so the nearest hand surgeon is 90 miles away. We spoke to two different hand surgeons by phone and they recommended reduction, irrigation, and closure of the skin along with a gram of Ancef IV.

This took about 2 hours before the first attempt at reduction took place. The FP was unable to reduce.

My questions: 1. Once there were no identified fractures, should an attempt at reduction happened immediately?
2. Since the FP was unable to reduce, should I have been more bold and asked if I could try? (He didn't seem to know the best way to do it which in my experience (only with closed dislocations BTW) is to apply posterior force on the middle phalanx then distract and try to reduce. He was simply pulling axially and pushing posteriorly on the proximal phalanx)

Reducing finger dislocations are on the fringes of my scope of practice. My professors in school all said that they reduced them but that we shouldn't. I have reduce probably half a dozen fingers and 3-4 shoulders in my 15 years of experience. It is well documented that rapid reduction vastly improves outcomes.

Did I do this right or should I have been more forward and asked to reduce earlier or myself after the FP had tried and failed.

The kid ended up having to drive 1.5 hours with his bone sticking out of his skin to a hand surgeon/orthopedist to have it reduced and closed.

Help me.
 

diabeticfootdr

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May 14, 2004
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Look up the Gustilo and Anderson classification of open fractures.

Open dislocations are treated the same way as open fractures. Within 6 hours of injury and in a relatively clean situation (like your was, I assume) it should be irrigated copiously and Gram + coverage with Ancef is fine. If treatment is delayed past 6 hours, then the wound is generally considered infected and admission with IV antibiotics is indicated.

The correct way to reduce a dislocation was described by Charnley in the late 1800's. There are 3 steps. 1. exaggerate the deformity 2. distract 3. reduce.

Many times with dislocated digits, tendons may be ruptured or their insertions avulsed, but almost always the ligamentous support to the joint has been lost. All of these things wouldn't be apparent on plain X-rays. This was likely the reason why you couldn't achieve proper reduction. Surgical management (with K-wire for stabilization) was probably necessary in your case.

I would definately seek the consult of a hand specialist. This could result in permanent disability to the joint and finger.

LCR
 
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DPTATC

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diabeticfootdr said:
Look up the Gustilo and Anderson classification of open fractures.

Open dislocations are treated the same way as open fractures. Within 6 hours of injury and in a relatively clean situation (like your was, I assume) it should be irrigated copiously and Gram + coverage with Ancef is fine. If treatment is delayed past 6 hours, then the wound is generally considered infected and admission with IV antibiotics is indicated.

The correct way to reduce a dislocation was described by Charnley in the late 1800's. There are 3 steps. 1. exaggerate the deformity 2. distract 3. reduce.

Many times with dislocated digits, tendons may be ruptured or their insertions avulsed, but almost always the ligamentous support to the joint has been lost. All of these things wouldn't be apparent on plain X-rays. This was likely the reason why you couldn't achieve proper reduction. Surgical management (with K-wire for stabilization) was probably necessary in your case.

I would definately seek the consult of a hand specialist. This could result in permanent disability to the joint and finger.

LCR
I spoke with the kid's mom this afternoon. They went to the hand surgeon and had to do an open reduction. But, fortunately, once reduced it was surprisingly stabile. Mom said he actually had decent ROM. I find that hard to believe but thats what she said. I understand how to reduce finger dislocations, my main questions is should I have pushed the FP to let me try. I do it as you described in your reply, but it didn't seem that the FP was exaggerating the deformity first, just distracting.
 

DocWagner

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Once you are in the ED, you are no longer covered by any malpractice coverage, therefore you CAN'T attempt the dislocation. Any risk sits squarely on the attending physicians shoulders.
As the outcome is OK, there really should be no more second guessing. If the outcome was poor...then there is concern.
The dislocation may have been aided by 1. conscious sedation 2. digital block

regardless, the treatment is relocation, irrigation, antibiotics, tetanus, splint
 
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DPTATC

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DocWagner said:
Once you are in the ED, you are no longer covered by any malpractice coverage, therefore you CAN'T attempt the dislocation. Any risk sits squarely on the attending physicians shoulders.
As the outcome is OK, there really should be no more second guessing. If the outcome was poor...then there is concern.
The dislocation may have been aided by 1. conscious sedation 2. digital block

regardless, the treatment is relocation, irrigation, antibiotics, tetanus, splint
Thanks Doc. I was just worried that the outcome might not be so good. His proximal phalanx was relatively exposed for about 4 hours. I am just trying to learn the best practice for if it should happen again. Would you say that the faster the reduction, the better the outcome? If so, once a fracture was ruled out, do you think that the locum's attempt to reduce would have been more likely to succeed if the attempt to reduce would have been within say, 30 minutes?

I'm not really second guessing, its just that out here, I am usually kind of the ortho guy, and some of the local FPs may ask me things in the future. I am just trying to contribute as much as I can within my scope.

I think you are right about the malpractice angle but it was at the hospital I work at so I might actually have been covered, not that it matters now anyway.

I'm glad that it turned out well though.

I just lost some sleep last night about if we could have done it better, thats all.
 

DocWagner

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Generally the quicker the reduction the better the outcome...but fingers are usually ok (always check neurovascular status).
As for you doing the reduction, likely a "wink wink" by the attending and he would dictate that he actually reduced the joint even if you did...but otherwise you would NOT be covered in the ED, your privleges don't extend that far, nor does the insurance cover you for adverse events in the ED...and without the attending physician performing the procedure, likely wouldn't recieve the payment for the procedure.

Likely a better outcome would have been achieved with better sedation or at least the digital block.
Don't lose sleep over it...unless you get a call within the next year that names you in a malpractice suit for permanent disability etc....kidding ;)
Seriously I am kidding...
Seriously.
 

homedum

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just for anyone that comes across this, the correct technique to reduce this is more difficult that your average reduction. the deformity must be wayyy overexaggerated in these. traction does not work, the distal joint must be bent dorsally over 90 degrees, then pull traction and roll back palmar and it should reduce. usually works well, if not the volar plate is probably caught in the joint and needs open reduction.