require closed reduction prior to immobilization Displaced intra-articular fractures require operative management Early hand specialist referral is appropriate DISLOCATIONS CLINICAL PEARLS AND PITFALLS MCP dislocations can be difficult to identify on radiograph and may simply appear hyperextended Avoid longitudinal traction with MCP joint reductions Clinical Considerations Dislocations of the IP and metacarpophalangeal (MCP) joints are generally uncommon in younger patients, although adolescents tend to have incidence similar to adults, particularly when involved in contact sports Initial Assessment and Management IP dislocations most often occur with the distal bone placed dorsal to the proximal After management of pain with either systemic analgesics or a digital block, prompt relocation is performed with inline distraction and hyperextension in the IP joints MCP joint dislocations most frequently involve the thumb ( Fig 109.12 ) These dislocations occur most often with the proximal phalanx dorsal to the metacarpal and the metacarpal head palpable in the palm In the immature patient, these dislocations may be difficult to clarify on radiographs because of the joint consisting mainly of cartilage or in the case of lesser digits, adjacent digit overlap on imaging that makes diagnosis challenging Therefore, the digit may simply appear to be hyperextended Reduction attempts should maintain or exaggerate the hyperextension while applying pressure toward the palm on the base of the phalanx In general, straight longitudinal traction is not recommended in MCP dislocations, to avoid soft tissue interposition and converting a reducible injury into an irreducible dislocation If the joint is not easily relocated, hand specialist involvement is required for likely open reduction In these cases, the tendons and volar plate involved may prevent reduction with inline traction