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Irreducible dislocation of the distal interphalangeal joint
Irreducible Dislocation of the Distal Interphalangeal Joint Y. MURAKAMI From the Miki Orthopaedic Hospital, Imabari, Japan.
A case of irreducible dislocation of the distal interphalangeal joint of the finger caused by entrapment of the deep flexor tendon is reported. Dislocation at the distal interphalangeal joint of the finger is unusual because stability is provided by adjacent flexor and extensor tendon insertions, strong collateral ligaments and the relatively short lever arm of the distal phalanx (Eaton, 1971). Dislocation occurs most commonly dorsally and is frequently compound due to the tight, soft tissue envelope surrounding the joint. Most dislocations are reduced easily with simple longitudinal traction. But occasionally irreducible dislocations are encountered. This article reports another such case of irreducible dislocation caused by entrapment of the deep flexor tendon. Case Report A thirteen-year-old girl sustained an open dorsal dislocation of the distal interphalangeal joint of the right middle finger while trying to catch a softball. Soon after injury closed reduction was attempted at another hospital and failed. She was first seen on the day after the injury. Examination showed slight swelling and deformity of the distal interphalangeal joint. There was an oblique laceration on the volar aspect of the middle phalanx. She was unable to flex the joint actively, and any attempt to do so elicited severe pain. X-ray revealed a dorso-radial dislocation of the distal phalanx (Figure 1). No associated fracture was noted. Fig. 1
After a digital block was administered to the finger, several attempts at closed reduction were made without success. The patient was then brought to surgery where, under axillary block anaesthesia, the joint was explored through a dorsal incision. When the extensor tendon was split longitudinally and retracted to either side, the volar plate was found to be avulsed from its proximal attachment and was displaced dorsal to the head of the middle phalanx. The radial collateral ligament was ruptured. In addition, the deep flexor tendon was trapped dorsal to the radial condyle of the middle phalanx while still retaining its attachment to the distal phalanx (Figure 2). Reduction of dislocation was easily achieved only by palmar relocation of the deep flexor tendon. Neither the volar plate nor the radial collateral ligament were repaired because the joint was not unstable. The skin incision and volar wound were closed. Received for publication Y. Murakami, M.D., Ehime-ken 794, Japan.
July, 1984. Miki Orthopaedic
VOL. 10-B No. 2 JUNE 1985
Hospital,
Izumikawa-cho
1-3-45,
Imabari-shi,
X-rays show a dorso-radial dislocation of the distal phalanx.
The finger was immobilized in the functional position of semi-flexion for two weeks. Active exercises were then begun and a month postoperatively the patient had full extension and eighty degrees of flexion at the distal interphalangeal joint, with no instability. Discussion Irreducible dislocation of the distal interphaiangeal joint of the finger is a recognized but rare injury, as there are only fourteen cases reported in the literature. The majority of these patients were adolescents or young adults. Most dislocations occurred in ball games, such as baseball, softball, basketball, soccer, or football. The ring finger was the digit most frequently involved. Many different causes of irreducibility have been described, of which the most frequent is entrapment of the deep flexor tendon as seen in the present patient (Pohl, 1976; Nakaima, 1977; Takigawa, 1980; 231
Y. MURAKAMI
Irreducible dislocations caused by interposition of soft tissue structures can occur at the interphalangeal joint of the thumb which is basically identical to the distal interphalangeal joint of the finger. An open reduction was performed via a dorsal incision in the present case. This approach was simple and the main structure blocking reduction could easily be identified. These dislocations are usually stable after reduction despite serious soft tissue injuries. Repair of the volar plate or the collateral ligament should therefore be done only when the reduction is remarkably unstable. The functional result following open reduction is not always satisfactory. It depends on the extent of the soft tissue damage and the time interval between injury and operation. Good recovery of the injured joint was seen in only seven of the fourteen operated patients. References
Fig. 2
The deep flexor tendon (*) trapped condyle of the middle phalanx.
dorsal to the radial
Maruyama, 1980; Rayan, 1981 and Iftikhar, 1983). With hyperextension and rotation of the distal phalanx, the collateral ligament on one side and the volar plate are ruptured. At the same time the deep flexor tendon is displaced dorsally and wrapped around the radial or ulnar condyle of the middle phalanx precluding reduction. As Rayan (1981) and Iftikhar (1982) pointed out, entrapment of the flexor tendon was seen mostly in the open injuries. They postulated that the intact skin in closed dislocation prevents this displacement of the flexor tendon. Less frequently, irreducibility has resulted from the volar plate being interposed between the articular surfaces (Palmer, 1977; Phillips, 1981), a buttonhole tear in the volar plate or the deep flexor tendon with the head of the middle phalanx protruding through the rent (Selig, 1940; Takigawa, 1980) or the fracture fragment (Stripling, 1982; Zielinski, 1983).
232
EATON, R. G. Joint Injuries of the Hand, Springfield, Charles C. Thomas, 1971 p. 18. IFTIKHAR, T. B. (1982). Long Flexor Tendon Entrapment Causing Open Irreducible Dorsoradial Dislocation of Distal Interphalangeal Joint of the Finger, Orthopaedic Review, 1l(2): 117-l 19. MARUYAMA, .I., IIDA, Y. and SHIRASU, H. (1980). Irreducible Dorsal Dislocation of the Distal Interphalangeal Joint of the Right Ring Finger, Kanto Journal of Orthopedics and Traumatology, 11: 114-115. (In Japanese) NAKAIMA, N., KISHI, Y. and FUJIYAMA, T. (1977). Two Cases of Irreducible Dorsal Dislocation of the Distal Interphalangeal Joint and the Proximal Interphalangeal Joint of the Fingers, Central Japan Journal of Orthopaedic and Traumatic Surgery, 20: 206-207. (In Japanese) PALMER, A. K. and LINSCHEID, R. L. (1977). Irreducible Dorsal Dislocation of the Distal Interphalangeal Joint of the Finger, The Journal of Hand Surgery, 2: 406-408. PHILLIPS, J. H. (1981). Irreducible Dislocation of a Distal Interphalangeal Joint: Case Renort and Review of Literature. Clinical Orthouaedics and Related Research, 154: 188-190. POHL, A. L. (1976). Irreducible Dislocation of a Distal Interphalangeal Joint. British Journal of Plastic Surgery, 29: 227-229. RAYAN, G. M. and ELIAS, L. S. (1981). Irreducible Dislocation of the Distal Interphalangeal Joint Caused by Long Flexor Tendon Entrapment, Orthopedics, 4: 35-37. SELIG, S. and SCHEIN, A. (1940). Irreducible Buttonhole Dislocations of the Fingers, The Journal of Bone and Joint Surgery, 22: 436-441. STRIPLING, W. D. (1982). Displaced Intra-articular Osteochondral FractureCause for Irreducible Dislocation of the Distal Interphalangeal Joint, The Journal of Hand Surgery, 7: 11-78. TAKIGAWA, S., FUJIMAKI, E., OHMURA, K., HIRANUMA, A., MONMA, M., KOBAYASHI, N. and OGIUCHI, M. (1980). Dorsal Dislocation of the Distal Interphalangeal Joint of the Finger. Report of Four Cases, Kanto Journal of Orthopedics and Traumatology, 11: 57-63. (In Japanese) ZIELINSKI, C. J. (1983). Irreducible Fracture-dislocation of the Distal Interphalangeal Joint. A Case Report, The Journal of Bone and Joint Surgery, 65A: 109-l 10.
THE JOURNAL OF HAND SURGERY
A case of irreducible dislocation of the distal interphalangeal joint of the finger caused by entrapment of the deep flexor tendon is reported. Dislocation at the distal interphalangeal joint of the finger is unusual because stability is provided by adjacent flexor and extensor tendon insertions, strong collateral ligaments and the relatively short lever arm of the distal phalanx (Eaton, 1971). Dislocation occurs most commonly dorsally and is frequently compound due to the tight, soft tissue envelope surrounding the joint. Most dislocations are reduced easily with simple longitudinal traction. But occasionally irreducible dislocations are encountered. This article reports another such case of irreducible dislocation caused by entrapment of the deep flexor tendon. Case Report A thirteen-year-old girl sustained an open dorsal dislocation of the distal interphalangeal joint of the right middle finger while trying to catch a softball. Soon after injury closed reduction was attempted at another hospital and failed. She was first seen on the day after the injury. Examination showed slight swelling and deformity of the distal interphalangeal joint. There was an oblique laceration on the volar aspect of the middle phalanx. She was unable to flex the joint actively, and any attempt to do so elicited severe pain. X-ray revealed a dorso-radial dislocation of the distal phalanx (Figure 1). No associated fracture was noted. Fig. 1
After a digital block was administered to the finger, several attempts at closed reduction were made without success. The patient was then brought to surgery where, under axillary block anaesthesia, the joint was explored through a dorsal incision. When the extensor tendon was split longitudinally and retracted to either side, the volar plate was found to be avulsed from its proximal attachment and was displaced dorsal to the head of the middle phalanx. The radial collateral ligament was ruptured. In addition, the deep flexor tendon was trapped dorsal to the radial condyle of the middle phalanx while still retaining its attachment to the distal phalanx (Figure 2). Reduction of dislocation was easily achieved only by palmar relocation of the deep flexor tendon. Neither the volar plate nor the radial collateral ligament were repaired because the joint was not unstable. The skin incision and volar wound were closed. Received for publication Y. Murakami, M.D., Ehime-ken 794, Japan.
July, 1984. Miki Orthopaedic
VOL. 10-B No. 2 JUNE 1985
Hospital,
Izumikawa-cho
1-3-45,
Imabari-shi,
X-rays show a dorso-radial dislocation of the distal phalanx.
The finger was immobilized in the functional position of semi-flexion for two weeks. Active exercises were then begun and a month postoperatively the patient had full extension and eighty degrees of flexion at the distal interphalangeal joint, with no instability. Discussion Irreducible dislocation of the distal interphaiangeal joint of the finger is a recognized but rare injury, as there are only fourteen cases reported in the literature. The majority of these patients were adolescents or young adults. Most dislocations occurred in ball games, such as baseball, softball, basketball, soccer, or football. The ring finger was the digit most frequently involved. Many different causes of irreducibility have been described, of which the most frequent is entrapment of the deep flexor tendon as seen in the present patient (Pohl, 1976; Nakaima, 1977; Takigawa, 1980; 231
Y. MURAKAMI
Irreducible dislocations caused by interposition of soft tissue structures can occur at the interphalangeal joint of the thumb which is basically identical to the distal interphalangeal joint of the finger. An open reduction was performed via a dorsal incision in the present case. This approach was simple and the main structure blocking reduction could easily be identified. These dislocations are usually stable after reduction despite serious soft tissue injuries. Repair of the volar plate or the collateral ligament should therefore be done only when the reduction is remarkably unstable. The functional result following open reduction is not always satisfactory. It depends on the extent of the soft tissue damage and the time interval between injury and operation. Good recovery of the injured joint was seen in only seven of the fourteen operated patients. References
Fig. 2
The deep flexor tendon (*) trapped condyle of the middle phalanx.
dorsal to the radial
Maruyama, 1980; Rayan, 1981 and Iftikhar, 1983). With hyperextension and rotation of the distal phalanx, the collateral ligament on one side and the volar plate are ruptured. At the same time the deep flexor tendon is displaced dorsally and wrapped around the radial or ulnar condyle of the middle phalanx precluding reduction. As Rayan (1981) and Iftikhar (1982) pointed out, entrapment of the flexor tendon was seen mostly in the open injuries. They postulated that the intact skin in closed dislocation prevents this displacement of the flexor tendon. Less frequently, irreducibility has resulted from the volar plate being interposed between the articular surfaces (Palmer, 1977; Phillips, 1981), a buttonhole tear in the volar plate or the deep flexor tendon with the head of the middle phalanx protruding through the rent (Selig, 1940; Takigawa, 1980) or the fracture fragment (Stripling, 1982; Zielinski, 1983).
232
EATON, R. G. Joint Injuries of the Hand, Springfield, Charles C. Thomas, 1971 p. 18. IFTIKHAR, T. B. (1982). Long Flexor Tendon Entrapment Causing Open Irreducible Dorsoradial Dislocation of Distal Interphalangeal Joint of the Finger, Orthopaedic Review, 1l(2): 117-l 19. MARUYAMA, .I., IIDA, Y. and SHIRASU, H. (1980). Irreducible Dorsal Dislocation of the Distal Interphalangeal Joint of the Right Ring Finger, Kanto Journal of Orthopedics and Traumatology, 11: 114-115. (In Japanese) NAKAIMA, N., KISHI, Y. and FUJIYAMA, T. (1977). Two Cases of Irreducible Dorsal Dislocation of the Distal Interphalangeal Joint and the Proximal Interphalangeal Joint of the Fingers, Central Japan Journal of Orthopaedic and Traumatic Surgery, 20: 206-207. (In Japanese) PALMER, A. K. and LINSCHEID, R. L. (1977). Irreducible Dorsal Dislocation of the Distal Interphalangeal Joint of the Finger, The Journal of Hand Surgery, 2: 406-408. PHILLIPS, J. H. (1981). Irreducible Dislocation of a Distal Interphalangeal Joint: Case Renort and Review of Literature. Clinical Orthouaedics and Related Research, 154: 188-190. POHL, A. L. (1976). Irreducible Dislocation of a Distal Interphalangeal Joint. British Journal of Plastic Surgery, 29: 227-229. RAYAN, G. M. and ELIAS, L. S. (1981). Irreducible Dislocation of the Distal Interphalangeal Joint Caused by Long Flexor Tendon Entrapment, Orthopedics, 4: 35-37. SELIG, S. and SCHEIN, A. (1940). Irreducible Buttonhole Dislocations of the Fingers, The Journal of Bone and Joint Surgery, 22: 436-441. STRIPLING, W. D. (1982). Displaced Intra-articular Osteochondral FractureCause for Irreducible Dislocation of the Distal Interphalangeal Joint, The Journal of Hand Surgery, 7: 11-78. TAKIGAWA, S., FUJIMAKI, E., OHMURA, K., HIRANUMA, A., MONMA, M., KOBAYASHI, N. and OGIUCHI, M. (1980). Dorsal Dislocation of the Distal Interphalangeal Joint of the Finger. Report of Four Cases, Kanto Journal of Orthopedics and Traumatology, 11: 57-63. (In Japanese) ZIELINSKI, C. J. (1983). Irreducible Fracture-dislocation of the Distal Interphalangeal Joint. A Case Report, The Journal of Bone and Joint Surgery, 65A: 109-l 10.
THE JOURNAL OF HAND SURGERY