Simultaneous dislocation of both the proximal and distal interphalangeal joints of a little finger

Abstract

A 39-year-old man fell at work sustaining dislocation of both the proximal and distal interphalangeal joints of his left little finger. The injuries were assessed and treated with closed reduction and stabilised by buddy taping. Early active range of movement was encouraged and a referral to physiotherapy was made. At the final follow-up, 4 months after the injury, he lacked subtle end of range movement actively, but functionally he was coping well and had made a full return to work.

Background

Single dislocation of a finger joint is a common injury. However, simultaneous dislocation of both proximal (PIPJ) and distal (DIPJ) interphalangeal joints is rare. Each dislocation needs to be assessed for stability and urgent treatment is required in order to preserve a satisfactory range of movement (ROM), grip strength and functional ability. Closed reduction and early active mobilisation is the gold-standard treatment.

Case presentation

A fit and healthy 39-year-old man presented to the emergency department (ED) having slipped and fallen onto his left hand. As he fell, he put his outstretched left hand down and his whole body twisted around his hand. He presented with severe pain and reduced movement in his left little finger. There were no open wounds. On examination, there was obvious deformity of the little finger of his left hand which was tender to touch with reduced active and passive ROM. There was no distal neurovascular deficit.

Investigations

Initial radiographs demonstrated a dorsal dislocation of both the PIPJ and DIPJ of his left little finger. There was no associated fracture (figures 1 and 2).

Figure 1.

Lateral radiograph of the left hand demonstrating dorsal dislocation of both the proximal and distal interphalangeal joints. No associated bone fracture can be seen.

Figure 2.

Anteroposterior radiograph of the left hand demonstrating dorsal dislocation of both the proximal and distal interphalangeal joints. No associated bone fracture can be seen.

Treatment

The dislocations were reduced in the ED under a ring block (lignocaine 1%). Reduction of the DIPJ was achieved first by applying longitudinal traction and pressure over the dorsum of the base of the caudal phalanx. The PIPJ was then reduced in the same fashion. Satisfactory reduction was confirmed on check radiographs (figures 3 and 4). Both the little and ring fingers were buddy strapped and the patient was referred to the fracture clinic the following day.

Figure 3.

Lateral radiograph of the left hand following reduction of both the proximal and distal interphalangeal joints. Satisfactory reduction is achieved.

Figure 4.

Anteroposterior radiograph of the left hand following reduction of both the proximal and distal interphalangeal joints. Satisfactory reduction is achieved.

Outcome and follow-up

The patient was reviewed in the fracture clinic the following day. He was encouraged about early active mobilisation. He was later referred to physiotherapy. His pain settled down and his ROM gradually improved. He made full return to work and did not report any functional deficit.

On a final combined review by the treating surgeon and the physiotherapist 4 months later, he was noted to be lacking a very subtle end of range active movement. However, passive ROM was full, the joints were stable, and grip strength was normal. He was using his hand normally and made a full functional recovery (figures 5 and 6).

Figure 5.

Picture of the hand at the latest follow-up at 4 months.

Figure 6.

Picture of the hand at the latest follow-up at 4 months.

Discussion

Simultaneous dislocation of the PIPJ and DIPJ is a rare injury that was first described by Bartels.¹ The most common cause of injury reported in the literature is a sporting injury.² However, the patient in our case report presented following a simple fall at work. The mechanism of injury relates to a hyperextension with an element of rotatory force, first on the distal phalanx, causing a dorsal dislocation of the DIPJ, and then on the middle phalanx causing dislocation of the PIPJ.^{3 4} Bone avulsion and volar plate injuries have been reported.^{5 6} In our case report, there was no accompanying bone fracture.

Closed reduction is the treatment of choice, while open reduction is reserved for patients with delayed presentation.⁷ The patient's finger was buddy strapped to encourage early mobilisation. Seki⁸ noted that following 3 weeks of immobilisation in a patient with double interphalangeal joints dislocation, there was a slight residual contracture compared with a patient who was only immobilised for 1 week. Mangelson et al⁹ similarly recommends early supervised active ROM as permitted by stability to prevent stiffness and contracture. On the basis of the outcome of our case report, we also support early active mobilisation as the treatment of choice.

Learning points.

• Double interphalangeal joints dislocation in the same finger is not limited to sporting activities.

• Closed reduction with buddy strapping is the standard treatment method.

• Early active finger movements and physiotherapy input is important to reduce weakness, stiffness and contracture and early return to normal activities.

• Regular monitoring and physiotherapy input is important to ensure that there is no long-lasting functional disability.