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require closed reduction prior to immobilization. Displaced intra-articular
fractures require operative management. Early hand specialist referral is
appropriate.

DISLOCATIONS
CLINICAL PEARLS AND PITFALLS
MCP dislocations can be difficult to identify on radiograph and may
simply appear hyperextended.
Avoid longitudinal traction with MCP joint reductions.

Clinical Considerations
Dislocations of the IP and metacarpophalangeal (MCP) joints are generally
uncommon in younger patients, although adolescents tend to have incidence
similar to adults, particularly when involved in contact sports.
Initial Assessment and Management
IP dislocations most often occur with the distal bone placed dorsal to the
proximal. After management of pain with either systemic analgesics or a digital
block, prompt relocation is performed with inline distraction and hyperextension
in the IP joints.
MCP joint dislocations most frequently involve the thumb ( Fig. 109.12 ).
These dislocations occur most often with the proximal phalanx dorsal to the
metacarpal and the metacarpal head palpable in the palm. In the immature patient,
these dislocations may be difficult to clarify on radiographs because of the joint
consisting mainly of cartilage or in the case of lesser digits, adjacent digit overlap
on imaging that makes diagnosis challenging. Therefore, the digit may simply
appear to be hyperextended. Reduction attempts should maintain or exaggerate
the hyperextension while applying pressure toward the palm on the base of the
phalanx. In general, straight longitudinal traction is not recommended in MCP
dislocations, to avoid soft tissue interposition and converting a reducible injury
into an irreducible dislocation. If the joint is not easily relocated, hand specialist
involvement is required for likely open reduction. In these cases, the tendons and

volar plate involved may prevent reduction with inline traction.