Nonsurgical Management

It is extremely uncommon for these injuries to require surgery. After obtaining the appropriate radiographs and the diagnosis is made, the next step is administering an anesthetic. Lidocaine 1% without epinephrine is injected as a metacarpal block to anesthetize the radial and ulnar digital nerves and then injected dorsally subcutaneous at the base of the finger to block the dorsal sensory nerves. Usually only ~4 to 5 cc are required. Once the patient is anesthetized, the reduction can usually be obtained with longitudinal traction and flexion of the DIP joint for dorsal dislocations. Sometimes an exaggeration of injury (e.g., hyperextension of the joint) may be necessary to reduce it. For the volarly displaced injuries, traction and extension are used for reduction.

Once the reduction is completed, the joint is first tested for stability, both passively and actively. Most important is to actively test the extension and flexion of the DIP joint. An extensor lag can be indicative of a mallet injury and needs to be splinted appropriately (see Case 38, Mallet Fractures). A mallet injury would be more likely with a volar dislocation. Ifthe patient cannot actively flex the DIP joint, he or she may have an FDP avulsion, which needs urgent treatment like any flexor tendon injury.

After stability testing, AP and lateral radiographs need to be obtained (1) to confirm a concentric reduction and (2) to make sure no fractures have been missed.

These injuries are rarely unstable and thus need no splinting. If the patient is uncomfortable, then a removable splint can be applied for approximately 1 week. If there is instability, a splint should be fashioned to keep the joint in slight flexion. This should not be necessary for more than 3 weeks.

In the case presented here, attempted reduction under metacarpal block was unsuccessful. After a reduction attempt and splinting, radiographs appeared as in Figure 48—1.

Incision

Extensor tendon

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