DISLOCATIONS AND FRACTURE DISLOCATIONS OF THE THUMB AND FINGER JOINTS

The hand is one of the most flexible and useful parts of our body. Because of overuse in various activities, the hands are more prone to injuries, such as sprains and strains, fractures and dislocations, lacerations and amputations while operating machinery, bracing against a fall and sports-related injuries.

Dislocation

A dislocation is when 2 bones articulating in a joint go out of alignment, which occurs when force greater than the bearable limit is applied against a joint or if there is an associated fracture. The most common symptoms of any dislocation include severe pain, swelling, bruising or bleeding, deformity, discolouration of the skin and limited mobility of the hand or finger.

Finger dislocation

Fingers are fine structures of the human body that assist in daily routine activities through coordinated movements. Any abnormality affecting the fingers can have a huge impact on the quality of life. A finger dislocation is not a minor injury, and if left untreated can lead to stiffness, pain, disruption of the alignment of the whole hand and interference with specialised functions such as grasping or manipulating objects. Finger dislocation commonly occurs during sports activities, when you break a fall or while operating machinery.

Diagnosis

The diagnosis of a thumb or finger dislocation is based on history, physical examinations and X-ray imaging to determine the direction and severity of the dislocation. X-rays are the most widely used diagnostic tools for the evaluation of associated fractures. Stress x-rays may be used in some cases of dislocation of the middle joint of the thumb where a ligament has been injured or not healed properly. Sometimes an ultrasound or an MRI may be needed if a joint is irreducible or has some soft tissue structure interposed preventing closed reduction.

 

Non operative treatment

The objective of early dislocation management is to provide pain relief, prevent ischemic injury and splint the affected finger. The next step in dislocation management is the early and accurate reduction of the joint by closed means and its maintenance with a splint. This is followed by aggressive physiotherapy after 4-6 weeks when the ligament is assumed to be healed.

Surgical

Open reduction of a finger dislocation may be required if closed reduction is not achievable or fails to maintain due to an associated fracture. This may involve either sedation or general anaesthesia and may require removal of the obstructing structure. The associated fracture may need concomitant fixation. The maintenance of a reduced joint may need stabilisation with either an external splint or with wires. Dr Bala uses special magnification loupes to visualize and protect individual blood vessels and nerves in this region to minimize complications.

A common ligament injury in the thumb is the inner ligament in the middle joint of the thumb. This ligament is called the Ulnar Collateral Ligament (UCL) of the thumb. The injury is called skiers thumb as it commonly occurs during skiing. Chronic insufficiency of the ligament is called gamekeeper’s thumb. It is diagnosed by stress x-rays and ultrasound or an MRI.

If the UCL has not healed after a trial of conservative treatment or is unable to heal due to displacement and interposition of a muscle surgery is indicated. The thumb is approached from the inside usually under general anaesthesia. The torn ligament is identified and the blood vessels and nerves to the thumb are protected. Dr Bala uses special magnification loupes to visualize and protect individual blood vessels and nerves in this region to minimize complications. If the ligament can be repaired it is fixed back to the bone with strong suture material fixed to a device called a bone anchor. This may be augmented with a strong artificial suture called the internal brace. If the ligament is not repairable a new ligament is made from tendon harvested from the forearm and fixed above and below with suture anchors. A plaster or splint is given for 2 to 4 weeks after UCL reconstruction after which gentle hand therapy is initiated to improve movement and strength.

Other ligaments that are injured and need a similar repair are the Radial Collateral Ligament (RCL) of the thumb or the medial or lateral collateral ligaments of any of the other fingers.

Rehabilitation

It is important to ensure that the involved part of the hand/ finger returns to its function after the joint is reduced by early controlled mobilisation and involvement of a dedicated hand therapist. Rehabilitation program involves exercises and gradual increase in activity levels to strengthen the muscles and improve range of movement.

Dr Bala also deals with complications of this surgery such as stiffness and can give you a second opinion if you haven’t gotten better from surgery elsewhere.