tendons on the ulnar side and the lumbrical muscle on the radial aspect which trap the metacarpal head in a ''button-hole'' (Kaplan, 1957). The round, regularly shaped head of the second metacarpal stretches and puckers the palmar skin overlying it. Kaplan identified this puckering, describing it as similar to ''dimpling of the skin in carcinoma of the breast'' and stated that this sign was pathognomonic of a dislocation which could not be reduced by a closed method. He recommended that closed reduction should not be attempted when this sign was seen.An 8 year-old girl presented with a complex dorsal dislocation of the metacarpophalangeal joint of the right index finger following a forced extension injury (Fig 1). An attempt at closed reduction under general anaesthesia was unsuccessful. Note was made of a ''dimple'' on the palmar aspect of the dislocated joint and this was used to guide placement of a skin hook and provide traction to the volar structures obstructing the joint. Following this manoeuvre, closed reduction was achieved at first attempt with minimal effort. Stable reduction was confirmed through a full range of passive movement. The hand was splinted in a dorsal blocking splint for 3 weeks. The child made a full recovery.Regardless of whether the dorsal or the palmar approach is used to reduce this dislocation, there is an operative risk of digital nerve injury (Bohart et al., 1982). The technique described above is a sensible and safe procedure to try, if a dimple is present, before going on to open surgery. The longitudinal pre-tendinous band, along with the transverse fibres, of the palmar fascia are intimately connected with the palmar skin. Displacement of these structures around the metacarpal head is responsible for the dimple. A skin hook may be placed, under local or general anaesthesia, in the skin of the dimple. Traction away from the joint lifts the obstructing palmar structures forward and allows gentle reduction of the joint.

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