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climbing injuries of the hand:Finger dislocation

Writer's picture: Becca CatlinBecca Catlin

Updated: Sep 15, 2024

The plan was to spend a week in Squamish, BC, a haven for outdoor sports enthusiasts from across Canadas and the US. Granite walls rise straight up from the Howe Sound lined with cracks perfect for gear. I was there to attend a conference on rock climbing and sports medicine and then spend the rest of the week climbing. The first day was full of the latest research associated with climbing injures followed by several lines of single pitch trad until we lost daylight. It provided enough stoke to fuel the imagination on all the routes that were to come. Day two was another great day at presentations. But climbing was out, as rain blanked the region and we opted for a hike. A trail near the Chief (the iconic granite massif in the middle of town) should be simple to do in drizzle. A couple miles into the hike I took an innocuous slip and landed on my butt. Not a big deal, however, my finger took the initial impact against a rock. The initial sensation was a like a “jammed finger” I had as a kid playing basketball. To my horror I looked down and saw my ring finger pointing toward my pinky finger at 30-degree angle.

I yelled, “I broke my finger! I think I am going to cry, not because it hurts but because I'm not going to be able to climb!” I pulled the finger out distracting it and gently guided it back to center, with an audible pop it settled back in its correct position. This was not super painful. It had been dislocated but hopefully not fractured. I had decent range of motion able to bend my fingers back and forth with minimal to no pain. I knew with a dislocation there had to be soft tissue damage.  At least the collateral ligament and the joint capsule. The faint bruise starting to show told me there was bleeding confirming damaged tissue.

 

The lucky part of this unlucky situation was that I was at attending a climbing sports medicine conference with many experts on climbing injuries of the hand. One of the docs had their diagnostic ultrasound available and we determined that I had not sustained a fracture, but I had torn the volar plate.


Initial treatment of a dislocated finger; do I need imaging



If you are unfortunate to experince climbing injuries of the hand, a dislocation is not as bad as it may appear. It is ok to try and relocate it immediately. Do so by pulling the dislocated section straight out hold that gentle traction as your pull it back into the correct position. Once the joint is relocated you will likely be able to move it signaling its back where it belongs. If you cannot relocate it easily or it is painful, do not force it and go to urgent care sports medicine clinic or the ER. If you are able to relocate it but extensive loss of motion persists, referral to a hand specialist is recommended inside a few days. If the joint is dislocated to where 30 percent intra-articular surface is involved, or if subluxation or instability of the PIP joint is detected, get imaging. My finger was bent sideways at about a 30-degree angle, I was able to relocate it immediately, had nearly full ROM upon relocation, and pain was low.  These are all signs of a good prognosis for not needing surgery. However, still wanted imaging to know the extent of soft tissue injury and rule avulsion fracture. If a piece of bone is pulled off (avulsion fracture), that might require a surgery to pin the fragment back in place. For those requiring operative intervention, range-of-motion outcomes appear better if surgery is performed within 4 weeks of injury. injuries left untreated or poorly managed may result in chronic dysfunction at that joint including loss of range of motion, subluxation, and swan neck deformities, leading to weakness of grip and poor function.


Anatomy of a finger dislocation


It is most common to have a hyperextension dislocation and most occur at the PIP (proximal interphalangeal joint), the middle of the three joints in the finger. The finger can be dislocated laterally (sideways) or palmary (into flexion). If you dislocate your finger into hyperextension, you likely have partial or complete volar plate and collateral ligament rapture and possible fracture. Clinical sings of volar plate injury include tenderness over the volar plate which is on the palm side of the finger right between the creases of the joint. Pain in that same area with passive extension of the injured finger, possible instability, and loss of pinch power. 

The volar plate is a fibrocartilaginous tissue lying between the flexor tendons and the joint capsule of the PIP joint. The volar plate on one side of the joint attaches to the bone and is reinforced by checkrein ligaments, it has attachments to the A2 pulley and accessory collateral ligaments. On the other side



of the joint, it attaches to bone with fewer ligamentous connections at this is the end of the volar plate that usually will avulse when the finger is dislocated. The function of the volar plate is to protect the finger from hyperextension. It is fibrocartilage rather than bone to allow our fingers to flex up to 110 degrees. The volar plate is a soft tissue structure allowing mobility while give us some stability limiting hyperextension. Uncheck extension results in a swan neck deformity.


How and when to Immobilize the finger


Once the finger is relocated and you have determined conservative treatment is appropriate, you will need to get splint that blocks extension and keeps the finger bent 20-30 degrees. Look for a splint that sits on the back of the finger stopping you from straightening it. If you cannot find one over the counter, consult a Physical therapist or Occupational therapist who makes finger splints. I made one out of material I had for making pulley splints. You will wear you splint most of the time the first 7-10 days. Without the splint, my finger was sore trying to brush my teeth, cut food, grip and doing manual therapy on patients without the splint.  I also wore it to bed to make sure I did not catch it on the covers. As activates became pain free, I stopped using the splint. I was able to eat and brush my teeth without the splint before I stopped using it when doing manual treatments on patients. By the end of 3 weeks, I was not using the splint very often during normal daily living. From the begining, I had my finger out of the splint 5-6 times at least to work active range of motion. I simply curled my fingers back and forth in a pain free range repetedly to pump out edema and keep the joint mobile. Studies do show increased range of motion and intrinsic muscle strength following four weeks of splinting with daily active exercise compared with immobilization alone (1,2). I did not do any static stretching. My finger was mildly limited in range of motion but the early weeks of healing for this injury is



not the time to passively stretch it. I intentionally avoided passive extension mobilization and stretching the first 6 weeks. I wanted the tissue to heal and adhere to reduce the chances of developing an unstable joint.


Easing into training and getting back on the rocks


I used pain as a guide if it hurt, I did not do it. As the swelling resolved and my range increased, after 2 week I added light resistance, such as gripping a spongy ball. By 4 weeks I was able to do finger curls with a few pounds using rock rings.



I progressively increased the load on rock rings from 6-8 weeks. I continued to keep the reps relatively high but as was increasingly able to tolerate more loads as I started at 2lbs. I had my rock rings at work and did a set 3-5 times during work. Loads were always pain free and used a weight that allowed 25-30 reps per set prior to fatigue and I did not go to failure. The lows, high reps increase local circulation for tissue healing and allows the tissue time to gain back integrity through repeated loading with the intent of avoiding heavy loads that might exceed the integrity of the healing tissue. Adding sets and overall reps is the first progression before increasing to heavy loads where fatigue is <10 reps.  Initially I did one set of 25 3-4 times a day and over 10-14 days progressed to 2-3 sets of 25 3 times a day. If any point I was sore during, experienced increased swelling, I backed off and reduced my sets or frequency or took a day off. By four weeks, I was tolerating heavy gripping and was training with pull-ups and tolerated any dumbbell/kettle bell training. Though I might have been able to return to the climbing gym at 6 weeks, it takes some discipline to climb easier routes and the temptation to push it is ever looming. I chose to train with my rock rings up until 8 wks. When I went back to gym, I did tape my finger.


Some suggest buddy taping, I chose to tape the single finger in a way that protected extension. I climbed on big holds and used the spray wall to test out different holds at a low level of include. After a week of regaining stamina and building confidence that my finger was


stable, I was back to climbing without limitations. I discontinued the taping after a couple of weeks. At three or four months, I was still lacking a bit of full extension. I had a colleague mobilize the joint for me over a few sessions to restore that last bit of motion. If you need help restoring full mobility, look for a physical therapist with specific manual therapy certifications. If you are unsure of how to progress your training, when to get back on the wall or have unique circumstances, reach out with your questions!



Refernces

Arora R, Lutz M, Fritz D, Zimmermann R, Gabl M, Pechlaner S. Dorsolateral dislocation of the proximal interphalangeal joint: closed reduction and early active motion or static splinting; a retrospective study. Arch Orthop Trauma Surg. 2004;124(7):486-488.


Dislocation of the Interphalangeal (IP) Joint. In: Bytomski JR, Moorman CT, MacAuley D, eds. Oxford American Handbook of Sports Medicine. New York, NY: Oxford University Press; 2010:181.


Borchers JR, Best TM. Common finger fractures and dislocations. Am Fam Physician. 2012 Apr 15;85(8):805-10. PMID: 22534390.


Pang, Eric Quan, and Jeffrey Yao. "Anatomy and biomechanics of the finger proximal interphalangeal joint." Hand clinics 34.2 (2018): 121-126.


Pattni A, Jones M, Gujral S. Volar Plate Avulsion Injury. Eplasty. 2016 Jun 1;16:ic22. PMID: 27313814; PMCID: PMC4894366.


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