Bain GI, Mehta JS Proximal interphalangeal joint: surgical and mobilisation options. Br J Hand Ther. 1999; 3:(4)13-18

Borchers JR, Best TM Common finger fractures and dislocations. Am Fam Physician. 2011; 85:(8)805-810

Brzezienski MA, Schneider LH Extensor tendon injuries at the distal interphalangeal joint. Hand Clin. 1995; 11:(3)373-386

Cannon B, Chan L, Rowlinson JS, Baker M, Clancy M Digital anaesthesia: one injection or two?. Emerg Med J. 2010; 27:(7)533-536

Caroline NL, Elling B, Smith M Nancy Caroline's Emergency Care in the Streets, 6th edn. Sudbury, MA: Jones and Bartlett Publishers; 2009

Coel RA Hand injuries in young athletes. Athl Ther Today. 2010; 15:(4)42-45

College of Paramedics. Paramedic Post-Graduate Curriculum Guidance [Internet]. 2017. https// (cited 2017 Aug 31)

Eddy M Hands, fingers, thumbs - assessment and management of common hand injuries in general practice. Aust Fam Physician. 2012; 41:(4)202-209

Finger sprains and dislocations. Musculoskeletal Medicine for Medical Students. 2013. http//

Freiberg A, Pollard BA, Macdonald MR, Duncan MJ Management of proximal interphalangeal joint injuries. Hand Clin. 2006; 22:(3)235-242

HCPC (Health and Care Professions Council. Standards of Education and training [Internet]. 2017. http// (cited 2017 Aug 31)

Jensen J, Croskerry P, Travers A Paramedic Clinical Decision Making.Edmonton: Canadian Patient Safety Institute; 2010

Johnson D Advanced techniques for dislocation management. Emerg Med Serv. 1999; 28:(8)60-63

UK Ambulance Services Clinical Practice Guidelines 2016.London: The Association of Ambulance Chief Executives; 2016

Hand Injuries and their Assessment [Internet]. 2011. http//

Kovacs G, Croskerry P Clinical decision making: an emergency medicine perspective. Acad Emerg Med. 1999; 6:(9)947-952

Lang J, Counselman F Common orthopedic hand and wrist injuries. Emerg Med. 2003; 35:20-38

Leggit JC, Meko CJ Acute finger injuries: part II. Fractures, dislocations, and thumb injuries. Am Fam Physician. 2006; 73:(5)827-834

McDevitt ER On-Site Treatment of PIP Joint Dislocations. Phys Sports Med. 1998; 26:(8)85-86

O'Donnell J, Wilson K, Leonard PA An avoidable complication of digital nerve block. Emerg Med J. 2001; 18:(4)

Parsons V, O'Brien L Paramedic clinical decision making in mental health care: a new theoretical approach. J Paramedic Practice. 2011; 3:(10)572-579

Rehak D Finger Injuries in Basketball Players. Hughston Health Alert. 2004; 16:(4)3-4

Rettig AC Athletic injuries of the wrist and hand: part II: overuse injuries of the wrist and traumatic injuries to the hand. Am J Sports Med. 2004; 32:(1)262-273

Robson AK, Bloom PA Suturing of digital lacerations: digital block or local infiltration?. Ann R Coll Surg Engl. 1990; 72:(6)360-361

Sanders MJ Mosby's Paramedic Textbook.St Louis: Mosby; 2005

Simpson PM, McCabe B, Bendall JC, Cone DC, Middleton PM Paramedic-performed digital nerve block to facilitate field reduction of a dislocated finger. Prehosp Emerg Care. 2012; 16:(3)415-417

Souryal J, Counselman F Dealing with Dislocation, part 1: Shoulder and Finger Emerg Med. 1998; 42-75

Williams JG, Lalonde DH Randomized comparison of the single-injection volar subcutaneous block and the two-injection dorsal block for digital anesthesia. Plast Reconstr Surg. 2006; 118:(5)1195-1200

Woodford P The Decision is yours. J Paramedic Practice. 2015; 7:(2)90-94

Reduction of a finger in the out-of-hospital arena?

02 September 2017
Volume 9 · Issue 9



Paramedics can find themselves called to digit dislocations. This is challenging as a dislocation can present in various ways, bringing residual damage to tissue and underlying structures from prolonged displacement. The aim is to limit impact on the welfare of the patient and the paramedic's objective is always to get the dislocation reduced as soon as a possible in a quick and safe manner.


The most common dislocation of the digit is at the proximal interphalangeal joint (PIPJ), also known as the ‘coach's finger’. PIPJ injuries are commonly seen in ball sports; the dislocation is mainly dorsal in presentation, and normally closed and stable. It is vital that the paramedic undertakes an in-depth digit assessment in order to be equipped with an appropriate treatment plan for the presentation, which can manage the dislocated digit.

Discussion—pain relief:

While there has been extensive study of systemic analgesia in emergency medical services (EMS), there is little out-of-hospital research on digit ring blocks and the use of regional anesthetics by paramedics in the pre-hospital setting.


The evidence is contradictory as some insist that X-ray must be carried out pre-reduction, where other authors state that reduction first is acceptable, but only after a thorough assessment.


There is a distinct lack of evidence for out-of-hospital digit reduction, too sparse for any robust argument to be built.


The suggestion is that reduction of the PIPJ dislocation in the out-of-hospital arena is not supported, owing to a lack of evidence. Until more studies are carried out and patient follow-up is proved to be negative with no ongoing digit impact, this skill needs to be undertaken in appropriate locations supported by X-ray.

Paramedics find themselves called to digit dislocations, which is challenging as they can present in various ways. Digit dislocations bring residual damage to tissue and underlying structures from prolonged displacement owing to misaligned bones. The paramedic's objective is always to get the dislocation reduced as soon as a possible, which was eluded to by Simpson et al. (2012) who identified that quick and safe out-of-hospital reduction was a far better option than transport to an accident and emergency (A&E) department.

It can be advantageous to reduce discomfort and pain for the patient more quickly, thus reducing anxiety and emotional stress, and at the same time limiting further tissue damage. The specialist or advanced practitioner needs a good understanding of the anatomy and techniques required to undertake a detailed evaluation and assessment of the injury, and identify any complications that could unfold (Freiberg et al. 2006). With various specialist and advanced practitioners now working across a variety of clinical environments bringing additional knowledge and skill, they are able to recognise and treat a number minor injuries, which includes in-depth assessment of digits and soft-tissue damage. Specialist or advanced practitioners undertake accurate and informed clinical decisions, underpinned by specialist knowledge and education, and taking into account the patient's wishes and concerns. This allows for a patient-centred approach and appropriate patient consultation. Specialist or advanced practitioners must be transparent about the available choices, reducing poorly informed decisions, and making way for their patients (who must clearly demonstrate capacity) to make good choices. This article will look at the evidence for out-of-hospital digit reduction, namely the proximal interphalangeal joint (PIPJ) in a dorsal presentation. After reviewing the evidence, the author will determine if the procedure is safe and effective in this new and emerging arena.

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