PURPOSE: Complex metacarpophalangeal (MCP) dislocations require open surgical reduction, but surgeons disagree about the best surgical approach. We hypothesized that a dorsal approach would require less operative time than would a volar approach and result in a decreased need for a secondary approach. METHODS: We performed a retrospective chart review of all isolated irreducible dorsal MCP dislocations treated at 2 level 1 trauma centers between 2005 and 2015. We recorded the initial surgical approach (volar or dorsal), total operative time, and whether the surgeon used a second surgical approach. Operative times for initial volar approach versus initial dorsal approach, hand surgeon versus non-hand surgeon, and thumb versus other digits were compared using the 2-tailed Student t test. We used Fisher exact test to compare the need for a second approach between the volar and dorsal approach groups. RESULTS: A total of 21 patients (22 digits) with MCP dislocations required surgical reduction. Average operative time was longer for the 14 patients who underwent the initial volar approach (70 minutes) than for the 7 who underwent an initial dorsal approach (45 minutes). Six of the 14 MCP joints approached volarly (42%) required a second dorsal approach. None of the 7 patients in the dorsal group required a second approach. CONCLUSIONS: Using a dorsal approach to reduce complex MCP dislocations reduces operative time and decreases the need for a secondary approach.