DPTATC

solve the problem
10+ Year Member
Nov 20, 2004
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minnesota
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management of an open PIP dislocation

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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.
 

volkl7

Junior Member
10+ Year Member
5+ Year Member
Oct 23, 2004
18
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you need to determine whether it is a simple or a complex dislocation.
 
OP
D

DPTATC

solve the problem
10+ Year Member
Nov 20, 2004
32
0
minnesota
Status
volkl7 said:
you need to determine whether it is a simple or a complex dislocation.
How do you determine that? I spoke with the kid's mom this afternoon. They had to do an open reduction. But once reduced, it was found to be stabile and he actually had decent ROM.
 

volkl7

Junior Member
10+ Year Member
5+ Year Member
Oct 23, 2004
18
1
Status
DPTATC said:
How do you determine that? I spoke with the kid's mom this afternoon. They had to do an open reduction. But once reduced, it was found to be stabile and he actually had decent ROM.

a complex dislocation is one where the volar plate is interposed in the joint or the metacarpal head is button-holed through the lumbricals. it actually looks less deformed and angulated on radiograph. a close reduction is essentially impossible.
if they had to reduce it openly, then it was likely a complex dislocation.