Digit dislocation reduction

INTRODUCTION — The reduction of digit dislocations is reviewed here. The treatment of toe and finger fractures is discussed separately. (See "Metatarsal and toe fractures in children" and "Toe fractures in adults" and "Proximal phalanx fractures" and "Middle phalanx fractures" and "Distal phalanx fractures".)

BACKGROUND — Dislocation of a digit is common among skeletally mature adolescents and active young adults. Dorsal displacement of the proximal interphalangeal joint of the finger is the most frequent dislocation [1]. On the other hand, double dislocations of the finger interphalangeal and/or metacarpophalangeal joints are a rare entity [2].

ANATOMY — Finger function involves a complex interaction among multiple joints, flexor and extensor tendons, and supporting fascia and ligaments. Each of the digits, except the thumb, has three phalanges with three hinged joints: distal interphalangeal (DIP), proximal interphalangeal (PIP), and metacarpophalangeal (MCP) (figure 1). Joint stability is provided by the structure of the phalanges, joint capsule, radial and ulnar collateral ligaments, and dorsal and palmar ligaments. (See "Finger and thumb anatomy".)

Flexion and extension are the primary movements of the fingers. Abduction and adduction can be performed at the MCP joints. The thumb is capable of opposition, abduction, adduction, and retropulsion, in addition to flexion and extension.

At the metacarpophalangeal (MCP) joints, lateral motion is limited by the collateral ligaments, which are actually lateral oblique in position rather than true lateral. Triangular in shape, these ligaments arise from the lateral head of each metacarpal bone and attach to the base of the proximal phalanx distally. Because of these anatomical features, the MCP joint is more stable in flexion than in extension due to stabilization by the collateral ligaments (figure 2) [3]. The volar plate is part of the joint capsule that attaches only to the proximal phalanx, allowing hyperextension. The volar plate is the site of insertion for the intermetacarpal ligaments. The intermetacarpal ligaments restrict the separation of the metacarpal heads.

At the PIP and DIP joints, extension is limited by the volar plate, which attaches to the phalanges at each side of the joint and by the extensor hood (ligamentous) complex (figure 3). Radial and ulnar motion is restricted by collateral ligaments, which remain tight throughout the finger's range of motion.

By convention, toes and their respective metatarsals are numbered from one (great toe) through five (little toe). The second through fifth toes typically have three phalanges, while the great toe has two. Lesser toes, especially the fifth, may occasionally have only two phalanges (figure 4).

The ligamentous complexes of the metatarsal, PIP, and DIP joints are similar to the fingers; each joint is stabilized by collateral, extensor, and plantar ligaments [4]. In contrast to the MCP joint, the ligamentous anatomy of the metatarsal joint allows less abduction or adduction and opposition cannot occur [4]. Dislocations of the hallucal interphalangeal joint of the great toe are rare and frequently complicated by sesamoid and plantar ligament entrapment [5,6].

Fracture predisposition in children — In skeletally immature children, the digital growth plates are weaker than the supporting ligaments (figure 5). Thus, Salter-Harris digit fractures are more common than dislocations (image 1 and figure 6). When digit dislocations do occur, they are commonly accompanied by avulsion fractures because the collateral ligaments of the metatarsal, MCP, PIP, and DIP joints insert into the epiphyseal regions of the growth plate (image 2).

CLASSIFICATION — Dislocations of the digits are classified by the direction of dislocation as follows:

●Dorsal – Distal digit displacement is toward the back of the hand or the top of the foot.

●Volar – Distal digit displacement is toward the palm of the hand or the sole of the foot.

●Lateral – Distal digit displacement is in the ulnar or radial direction relative to the proximal digit in the hand or in the tibial or fibular direction in the foot.

Metacarpophalangeal (MCP) dislocations, other than thumb dislocations, are further classified as simple (volar plate is not interposed in the joint) and complex (volar plate is entrapped in the joint).

Thumb MCP dislocations are classified as follows (figure 7 and image 3):

●Incomplete – Volar plate ruptured, collateral ligament intact

●Simple – Volar plate and collateral ligament ruptured

●Complex – Dislocated phalanx is entrapped in the intrinsic hand muscles and volar plate is entrapped in the joint

Metatarsophalangeal (MTP) dislocations are typically multiple and associated with Lisfranc fractures of the foot. (See "Foot fractures (other than metatarsal or phalangeal) in children", section on 'Tarsometatarsal (Lisfranc) fractures'.)

PRESENTATION AND MECHANISM — The patient with a dislocated digit has pain, swelling, loss of continuity, and impaired range of motion of the affected joint.

Interphalangeal dislocation

●Dorsal dislocation – Patients with dorsal joint dislocation have displacement of the distal portion of the joint toward the back of the hand or the top of the foot (image 4 and image 5). Dorsal proximal interphalangeal (PIP) and distal interphalangeal (DIP) joint dislocations arise from a force that produces axial loading and hyperextension of the digit. Dorsal PIP dislocation is the most common articular injury of the hand in the skeletally mature patient. Dorsal DIP joint dislocations are frequently associated with a flexor digitorum profundus avulsion fracture called a jersey finger (figure 8). (See "Flexor tendon injury of the distal interphalangeal joint (jersey finger)".)

●Volar dislocation – Volar dislocations of the PIP and DIP joints occur due to a combination of dorsal, varus (medial), and valgus (lateral) forces that rupture the collateral ligaments and the volar plate while displacing the base of the dislocated phalanx towards the palm or sole [7]. In addition, rupture of the central slip of the extensor hood complex usually occurs, and an avulsion fracture is often present [8]. Lack of timely treatment of volar PIP finger dislocations may result in a boutonniere deformity (figure 9). Volar dislocations are rare and may be irreducible due to entrapment of the proximal phalangeal condyle between the central tendon and lateral band. Volar dislocations of the interphalangeal joint of the thumb may also present with rupture of the flexor pollicis longus tendon.

●Lateral joint dislocation – Isolated lateral dislocations of the PIP and DIP joints are rare and represent collateral ligament disruption caused by medial or lateral forces (image 6).

●Interphalangeal dislocation of the hallux (great toe) – Dislocations of the hallucal interphalangeal joint of the great toe are rare and frequently complicated by sesamoid and plantar ligament entrapment [5,6].

Metacarpophalangeal dislocation — Dorsal metacarpophalangeal (MCP) dislocation follows hyperextension of the affected joint with rupture of the volar plate. MCP dislocations, other than thumb dislocations, are classified as simple (no entrapment of the volar plate in the joint) or complex (interposition of the volar plate within the joint). Complex dislocations occur when the volar plate is ruptured, and the plate becomes lodged between the base of the proximal phalanx and the head of the metacarpal bone. Complex dislocation presents with skin dimpling, with less angulated deformities, or rotational deformity of the involved phalanges [9-13].

Thumb MCP dislocations are caused by the same mechanisms as other digit MCP dislocations but are far more common than at the digits because of mobility of the thumb. In addition, because of the greater physiologic range of motion, these types of dislocation are more complex. They are designated as follows:

●Incomplete – Volar plate ligament disruption with some preservation of collateral ligament function (image 7).

●Simple – Volar plate and collateral ligament disruption with 90 degree displacement of the thumb phalanx relative to the thumb MCP (figure 7 and image 3).

●Complex – The distal phalanx is positioned parallel to the metacarpal bone (figure 7). With these injuries, the metacarpal head may be trapped in the intrinsic muscles and the volar plate is interposed in the joint. On physical examination, puckering of skin near the affected joint that may be accompanied by volar ecchymosis suggests the possibility of volar entrapment. This finding is confirmed when plain radiographs show the sesamoid bones within the joint space [9].

Volar metacarpophalangeal joint dislocations are rare injuries that are typically entrapped and require operative repair [14,15].

Metatarsophalangeal dislocation — Dislocation at a single metatarsophalangeal joint frequently involves the fifth digit, which can be easily reduced. Multiple metatarsophalangeal (MTP) dislocations can be associated with Lisfranc fractures of the foot. These complex injuries require orthopedic or podiatric subspecialty care. (See "Tarsometatarsal (Lisfranc) joint complex injuries" and "Foot fractures (other than metatarsal or phalangeal) in children", section on 'Tarsometatarsal (Lisfranc) fractures'.)

Dislocation of the first MTP occurs rarely and should also prompt subspecialty consultation with an orthopedist or podiatrist [6,16].

DIFFERENTIAL DIAGNOSIS — Clinical evaluation and plain radiographs should differentiate the following injuries from digit dislocations.

●Open dislocations – The clinician should suspect open dislocations in patients with a wound near the dislocated joint (picture 1). These injuries require antibiotic treatment, tetanus prophylaxis, urgent orthopedic or hand surgery consultation, meticulous operative debridement, and repair of the collateral ligaments and volar plate [17].

●Fracture-dislocations – Fracture-dislocations commonly occur in skeletally mature patients when the extended finger is struck in such a manner that longitudinal compression occurs along with hyperextension. A typical mechanism involves a ball striking the extended finger [18]. This mechanism typically causes a fracture through the volar lip of the proximal interphalangeal (PIP) joint with dorsal displacement [19].

In children, the growth plates are typically weaker than the surrounding ligaments. Thus, dislocations are commonly accompanied by Salter-Harris fractures because the collateral ligaments of the MCP, PIP, and DIP joints insert into the epiphyseal regions of the growth plate (image 2 and figure 5). (See 'Fracture predisposition in children' above.)

●Complex thumb dislocation – Volar and complex dorsal MCP joint dislocations should be evaluated and treated by a hand surgeon or orthopedist with appropriate expertise [1]. (See 'Metacarpophalangeal dislocation' above.)

●Gamekeeper's thumb – Gamekeeper's thumb describes ulnar collateral ligament injury with lateral thumb metacarpophalangeal (MCP) instability. It is commonly seen in skiers when the ski pole forcefully abducts the thumb at the MCP joint during a fall. Physical findings include tenderness on the ulnar aspect of the thumb and a weak pinch. Valgus stress testing determines the integrity of the ulnar collateral ligament (picture 2). The diagnostic approach and treatment of gamekeeper's thumb is discussed in greater detail separately. (See "Ulnar collateral ligament injury (gamekeeper's or skier's thumb)", section on 'Clinical features' and "Ulnar collateral ligament injury (gamekeeper's or skier's thumb)".)

●Jammed finger – "Jammed finger" refers to prolonged swelling of the proximal interphalangeal joint after an axial loading force (eg, basketball striking the end of an extended finger) [20]. Diagnostic criteria include lack of radiographic changes, complete functional stability of the joint, and no evidence of extensor tendon avulsion. Symptoms may arise from cartilage bruising and chondromalacia or chronic synovitis. The usual treatment for jammed finger involves therapeutic heat, passive and active range of motion exercises, and control of swelling. Aggressive, early range of motion in a supervised therapy program is useful to prevent stiffening [21]. Occasionally, corticosteroid injection into the joint is used to reduce synovitis.

●Mallet finger – Mallet finger occurs most commonly during collision sports, such as American football and rugby, or ball-handling sports, such as basketball and baseball. The injury is usually caused by a direct blow to the tip of the finger, as when a ball strikes the fingertip or the fingertip strikes a rigid surface (figure 10 and picture 3). The axial load from the blow causes sudden, forceful flexion of the distal phalanx. This flexion damages the extensor tendon where it attaches to the proximal portion of the distal phalanx. Less frequently, a mallet finger may occur as part of finger injuries involving lacerations or crushing mechanisms. Physical examination findings and treatment of mallet finger are discussed in more detail separately. (See "Extensor tendon injury of the distal interphalangeal joint (mallet finger)", section on 'Symptoms and examination findings' and "Extensor tendon injury of the distal interphalangeal joint (mallet finger)", section on 'Treatment'.)

INDICATIONS — The clinician may proceed with reduction of a digit dislocation once the presence of a simple dislocation is confirmed and an open joint, associated fracture, or entrapped volar plate are excluded.

CONTRAINDICATIONS AND PRECAUTIONS — The clinician should not attempt dislocation reduction prior to radiographic evaluation, especially in skeletally immature children.

Contraindications to closed reduction of digit dislocations include:

●Open dislocation

●Complex dislocation

●Chronic dislocation (dislocation of more than three weeks duration)

●Joint instability

INDICATION FOR SPECIALTY CONSULTATION OR REFERRAL — The clinician should defer care to the appropriate specialist (orthopedist, hand surgeon or podiatrist), if available, in patients with the following conditions:

●Associated digit fracture

●Open joint dislocation (picture 1)

●Digital neurovascular compromise (unless emergency orthopedic or hand surgery consultation is not available)

●Interphalangeal joint dislocation of the great toe (hallux)

●Multiple metatarsophalangeal dislocations

Prompt subspecialty consultation is also appropriate in the following situations:

●Volar proximal interphalangeal joint dislocation, because entrapment of the lateral band around the head of the proximal phalanx often prevents a successful closed reduction (figure 3)

●Volar, lateral, or complex dorsal metacarpophalangeal joint dislocation, because open reduction is typically required

●Any joint dislocation with tendon rupture

●Digit dislocation that is irreducible

●Unstable joint after attempted dislocation reduction

●Multiple failed reduction attempts (which can convert a simple dislocation into a complex dislocation)

●Patients who remain in a significant amount of discomfort after reduction for whom an occult fracture (at any age) or growth plate injury (pediatric age) is suspected

PREPARATION

Evaluation — Proper management of digit dislocation requires careful evaluation, including plain radiographs, prior to attempting closed reduction. This assessment should identify conditions not amenable to closed reduction or those that require prompt referral to a hand surgeon, orthopedic surgeon, or podiatrist.

●History/physical examination – The clinician should obtain history and fully evaluate the site of injury prior to reduction. Key historical elements include:

•Age and skeletal maturity

•Mechanism and time of injury

•Digit position during injury (flexed versus extended)

•Dominant hand

•Occupation

•Prior hand conditions, injuries, or interventions

•Important physical examination features include:

-Site of injury (eg, maximal pain and swelling)

-Neurovascular examination, especially distal to the injury

-Presence of open wounds adjacent to the injury

-Range of motion

●Radiographic studies – AP, oblique, and, most importantly, true lateral plain radiographs are necessary before the procedure to exclude associated fractures and to assist in identifying complex dislocations or other digit conditions that warrant referral to an orthopedist, hand surgeon, or podiatrist [22]. (See 'Differential diagnosis' above and 'Contraindications and precautions' above.)

Patient counseling/informed consent — The patient with digit dislocation is typically anxious and in pain. The patient and family/caregiver(s) should receive an explanation of the problem and the procedural approach.

The benefits of the joint reduction procedure usually outweigh the risks. Appropriate expectations regarding the outcome of any injury should be discussed with the patient and family/caregiver(s). Prior to initiation of reduction attempts, the potential adverse effects of the procedure should be disclosed, including [1,23-29]:

●Inadequate or delayed reduction may cause an unstable, deformed, or stiff joint

●Reduction attempts may lead to fracture

●The joint may become dislocated again if immobilization is not maintained

●Swelling of the affected joint with stiffness may be present for several months despite appropriate treatment

●Permanent joint enlargement may occur

Analgesia and sedation — Appropriate analgesia, anesthesia, and, especially in children, distraction by a child life specialist or other personnel, may help to decrease the anxiety and pain of the procedure and promote successful reduction. A digital block often provides adequate analgesia in older adolescents and adults. In younger children, procedural sedation is frequently warranted. (See "Digital nerve block" and "Procedural sedation in children: Approach".)

In most instances, the clinician should provide analgesia before attempting reduction of the digit. Rarely, an older adolescent or adult with a very recent dislocation (less than one hour old) and minimal swelling may tolerate reduction without analgesia.

Equipment

●Latex-free gloves

●1 percent buffered lidocaine without epinephrine (one part of 1 mEq/mL [8.4 percent] sodium bicarbonate to 9 or 10 parts of 1 percent lidocaine)

●Syringes (3 mL or 5 mL) and needles (25 or 27 gauge)

●Povidone iodine solution (eg, Betadine) and alcohol

●Scissors

●White surgical tape

●Splinting materials depend on the affected joint:

•Finger interphalangeal dislocations: padded, malleable, aluminum digital splint

•Metacarpal (thumb) dislocations: water, bucket, prefabricated splinting material (eg, plaster of Paris or fiberglass) OR Webril, plaster of Paris, and stockinette to fashion a thumb spica splint (figure 11). (See "Basic techniques for splinting of musculoskeletal injuries", section on 'Thumb spica splint'.)

PROCEDURE

Interphalangeal dislocation — The procedure for proximal interphalangeal (PIP) or distal interphalangeal (DIP) dislocation reduction is summarized in the table (table 1) and consists of the following steps [30,31]:

●Assure no fracture or open joint is present on AP, true lateral, and oblique plain radiographs.

●Remove all rings from the affected hand or foot.

●Assemble all necessary materials. (See 'Equipment' above.)

●Provide appropriate analgesia as determined by the patient's age and degree of pain. (See 'Analgesia and sedation' above.)

Interphalangeal reduction

●Have an assistant brace the hand or foot.

●Reduce the dislocation using one of the following methods:

•Dorsal dislocation – Provide longitudinal traction; gently hyperextend the joint while pushing the base of the dislocated phalanx into place [32].

•Volar dislocation – Provide longitudinal traction; gently hyperflex while pushing the base of the dislocated phalanx into place.

•Lateral dislocation – Provide longitudinal traction; gently hyperextend the joint while correcting the ulnar or radial deformity [32].

●After reduction, test joint stability throughout the full range of motion of the digit to ensure that the joint will recover well with splinting alone [33].

●Obtain a post-reduction plain radiograph, including a true lateral view of the digit.

Interphalangeal immobilization

●Immobilize the digit based on the location and type of dislocation:

•DIP dorsal or lateral finger dislocation – Splint the DIP in full extension while allowing full range of motion of the PIP joint.

•PIP dorsal or lateral finger dislocation – Apply a dorsal splint with the PIP in 20 to 30 degrees of flexion.

•Volar finger dislocation – Splint the PIP and DIP in full extension.

•DIP or PIP toe dislocation – Buddy tape the affected digit to its neighbor (picture 4).

Simple metacarpophalangeal or metatarsophalangeal dislocation — The procedure for simple metacarpophalangeal (MCP) dislocation reduction is summarized in the table (table 1) and consists of the following steps [30,31]:

●Assure no fracture or open joint is present on AP, true lateral, and oblique plain radiographs.

●Remove all rings from the affected hand or foot.

●Assemble all necessary materials. (See 'Equipment' above.)

●Provide appropriate analgesia as determined by the patient's age and degree of pain. (See 'Analgesia and sedation' above.)

Reduction

●Have an assistant brace the hand and flex the wrist.

●Avoid excessive hyperextension or distraction that can convert a simple dislocation into a complex dislocation [34].

●Gently distract the affected thumb or digit and apply volar pressure to the base of the dislocated proximal phalanx.

●Test joint stability throughout the full range of thumb motions to ensure that the joint will recover well with splinting alone [33].

Immobilization

●Finger dislocation – Splint the digit in 90 degrees of flexion at the MCP joint.

●Thumb dislocation – Apply a thumb spica splint with the MCP joint in 20 degrees of flexion (figure 11).

FOLLOW-UP CARE — All patients with digit dislocations should be seen within seven days to assess degree of pain, compliance with splinting, and joint stability. Unless the clinician has appropriate experience and comfort in the management of simple digit dislocations, referral to an orthopedist, hand surgeon, or podiatrist (toe dislocations) is warranted.

Range of motion exercises should commence as soon as the splint can be removed. Duration of splinting depends on the type of dislocation [30]:

●Dorsal finger proximal interphalangeal (PIP) – Three to five days as needed for comfort, then buddy tape

●Dorsal finger distal interphalangeal (DIP) – Two to three weeks

●Volar PIP – Four weeks

●Simple finger metacarpophalangeal (MCP) – Three to five days

●Simple thumb MCP – Three to four weeks

●Toe dislocations – Buddy tape for two weeks

Return to play

●Dorsal dislocations of the PIP or DIP joint – Patients with these injuries can immediately return to play with proper splinting (finger dislocations) or buddy taping (toe dislocations) if a stable reduction is achieved, if their position does not place unusual demands on the digit (eg, quarterbacks, pitchers with an injury to the dominant hand or toe of foot used to push off), and if pain is tolerable.

●MCP joint dislocations – Patients may return to play after clearance by a hand or orthopedic surgeon. Typical timing is six to eight weeks [23].

COMPLICATIONS — Most simple digit dislocations will have full return of function as long as successful reductions are properly splinted and early range of motion occurs [34]. However, early referral of irreducible dislocations, avoidance of an excessive duration of splinting, and careful testing of joint stability after reduction are essential to avoid poor outcomes.

●Irreducible dislocations – Dislocations that are irreducible by closed reduction are uncommon but may occur when soft tissue or bony fragments (eg, the volar plate) become interposed in the joint space [35,36]. This is likely to be the situation if one or two attempts at reduction prove unsuccessful. These patients usually require open reduction to extract and repair the interposed ligament, tendon, or volar plate [5,6,16,34-38]. The clinician should avoid multiple forceful attempts at reduction in these patients. Such excessive force may cause a fracture or convert a dislocation that is amenable to closed reduction to one that requires open reduction.

●Stiffness – Stiffness and joint thickening is a common complication, especially with PIP dislocations [37]. As soon as the appropriate duration of splinting has passed, early initiation of range of motion exercises helps to decrease stiffness. (See 'Follow-up care' above.)

However, in some patients, stiffness and soreness may last as long as 12 to 18 months, and result in permanent residual enlargement of the joint despite appropriate treatment [38].

●Recurrent dislocation – Recurrent dislocation may arise from improper splint position, inadequate duration of splinting, or inappropriate return to play. This complication is most common with metacarpophalangeal dislocations.

●Boutonniere deformity – Boutonniere deformity (hyperextension at the distal interphalangeal joint with fixed flexion at the proximal interphalangeal joint) is a potential complication in patients with volar PIP finger dislocations (figure 9). Such patients are at risk for boutonniere deformity if their dislocation is not splinted in extension or if immobilization is not maintained for at least six weeks.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Finger dislocation (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Anatomy of the injury – Dislocation of a digit occurs commonly among skeletally mature adolescents and active young adults. Dorsal displacement of the proximal interphalangeal joint of the finger is the most frequent dislocation. In children, digit dislocation is often associated with a growth plate fracture. (See 'Anatomy' above and 'Fracture predisposition in children' above.)

●Clinical presentation and evaluation – The patient with a dislocated digit has pain, swelling, loss of continuity, and impaired range of motion of the affected joint. Proper management of digit dislocation requires careful examination for an open fracture or neurovascular compromise. Plain radiographs to exclude a fracture, should be performed prior to attempting closed reduction. (See 'Presentation and mechanism' above and 'Indications' above.)

●Indication for specialty consultation (complex or complicated dislocations) – The clinician should defer care to the appropriate specialist (orthopedist, hand surgeon or podiatrist), whenever available, in patients with the following conditions (see 'Indication for specialty consultation or referral' above):

•Associated digit fracture

•Open joint dislocation (picture 1)

•Digital neurovascular compromise (unless orthopedic or hand surgery consultation is not emergently available)

•Interphalangeal joint dislocation of the great toe (hallux)

•Multiple metatarsophalangeal dislocations

•Volar proximal interphalangeal joint dislocation, because entrapment of the lateral band around the head of the proximal phalanx often prevents a successful closed reduction (figure 3)

•Volar, lateral, or complex dorsal metacarpophalangeal joint dislocation, because open reduction is typically required

•Any joint dislocation with tendon rupture

•Digit dislocation that is irreducible

•Unstable joint after attempted dislocation reduction

•Patients who remain in a significant amount of discomfort after reduction for whom an occult fracture (at any age) or growth plate injury (pediatric age) is suspected

●Simple dislocations – Simple dislocations may be reduced by clinicians other than surgical specialists. Patient counseling and informed consent should include the risks of the procedure, including the potential for closed reduction causing a fracture or need for surgical intervention, as described above. (See 'Patient counseling/informed consent' above.)

Appropriate analgesia, anesthesia, and (especially in children) distraction by a child life specialist or other personnel may help to decrease the anxiety and pain of the procedure and promote successful reduction. A digital block often provides adequate analgesia in older adolescents and adults. (See 'Analgesia and sedation' above.)

The type and location of digit dislocation determine the reduction technique and splinting method (table 1). (See 'Equipment' above and 'Procedure' above.)

●Postprocedure evaluation and immobilization – After reduction, careful clinical and radiographic assessment is necessary to assure complete reduction; immobilization is performed according to the specific location. (See 'Interphalangeal immobilization' above and 'Immobilization' above.)

●Follow-up care – All patients with digit dislocations should be seen within seven days to assess degree of pain, compliance with splinting, and joint stability. Unless the clinician has appropriate experience and comfort in the management of simple digit dislocations, referral to an orthopedist, hand surgeon, or podiatrist (toe dislocations) for this follow-up is warranted. (See 'Follow-up care' above.)