Three hand surgeons from well-known centers for reconstructive hand surgery presented a lecture on complications following dislocations of the proximal interphalangeal (PIP) joint. The lecture was given at the 2013 annual meeting of the American Academy of Orthopaedic Surgeons. This article is a written record of that instructional lecture.
The proximal interphalangeal (PIP) joint is the middle joint of the finger. Dislocations of this joint can be very problematic. Every effort is made to prevent complications such as chronic swelling, stiffness, deformity, and loss of finger function. When the volar plate (restraining ligament) of the joint is damaged by the dislocation, redislocation can occur.
Damage to the cup-shaped joint along with injury to the ligaments can result in an unstable joint. The most successful treatment of these injuries involves limited immobilization with a finger splint and early motion of the finger. Keeping the gliding and sliding motion of the joint is very important -- even more so than fixing the dislocation.
Conservative (nonoperative) care is advised when the dislocation is considered "stable". Stability is determined by X-rays based on how much of the joint surface is damaged (fractured). The surgeon also looks at whether or not the joint partially or completely dislocates during motion.
The use of splinting during the early (acute) phase of healing is controversial. A balance is essential between maintaining the joint in a stable position while still allowing motion. These hand surgeons recommended the following:
Use a figure-of-eight splint keeping the finger in slight flexion (bent 10 degrees at the PIP joint).
Buddy taping (taping the damaged finger to the finger next to it or between two fingers) is an acceptable alternative.
When the joint dislocates but only near the end of full extension, then a figure-of-eight splint can be used. X-rays must show that the joint stays in place while the finger is in the splint. Any sign of redislocation is an indication that surgery is needed.
Splinting also immobilizes the distal interphalangeal (DIP) joint (tip of the finger). It is necessary to take this into consideration when preventing stiffness of the finger.
For patients who already have a flexion contracture (finger stuck in a bent position), splinting may help. Half of the motion can be regained in the first two weeks. If the patient doesn't improve as expected, then surgery may be needed. The surgeon would release scarring and adhesions and then release any tight ligaments until motion is restored.
Surgery is suggested when the joint is unstable, chronically dislocating, and/or if conservative care does not correct the contracture or deformity. The type of surgery performed is surgeon-determined and may include reconstruction of the cup-shaped contour of the joint, pinning the joint to block full extension (and thereby protect healing soft tissue structures), and/or fixation (internal or external) of the volar plate with mini-screws, pins, or wires. The authors provide a detailed discussion of the pros and cons of these treatment options.
Other points of discussion in this lecture include the use of autografting (to treat unstable fracture-dislocations), treatment of chronic dislocations, the use of salvage procedures, silicone implant arthroplasty (joint replacement), and fusion. The goal is always to eliminate pain, stabilize the joint, and improve hand function. With any surgical procedure, there can be complications, which are also presented and discussed.
The hand surgeons concluded by saying that fracture-dislocations of the PIP joint can be complex and challenging. Treatment is not always straightforward. Decisions are made based on the extent of damage, percentage of joint surface that is fractured, and presence of instability. The surgeon must rely on clinical judgment evaluating each and every patient individually.
Reference: John J. Mangelson, MD, et al. Complications Following Dislocations of the Proximal Interphalangeal Joint. In The Journal of Bone & Joint Surgery. July 17, 2013. Vol. 95A. No. 14. Pp. 1326-1332.