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Updated: Feb 26 2023

Phalanx Dislocations

Images
https://upload.orthobullets.com/topic/6038/images/pip_dorsal_dl_complex.jpg
https://upload.orthobullets.com/topic/6038/images/pip_volar_dl_simple.jpg
https://upload.orthobullets.com/topic/6038/images/pip_lateral_dl..jpg
https://upload.orthobullets.com/topic/6038/images/pip_volar_dl_rotatory.jpg
https://upload.orthobullets.com/topic/6038/images/master pip.jpg
  • Summary
    • Phalanx Dislocations are common traumatic injury of the hand involving the proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP).
    • Diagnosis can be made clinically and are confirmed with orthogonal radiographs.
    • Treatment is closed reduction and splinting unless volar plate entrapment blocks reduction or a concomitant fracture renders the joint unstable.
  • Epidemiology
    • Incidence
      • common injury, especially in athletes
    • Anatomic location
      • PIP joint
        • dislocations
          • volar
          • dorsal 
          • lateral
        • fracture-dislocations
      • DIP joint
        • dislocations
        • fracture-dislocations
  • Etiology
    • Mechanism of injury
      • Generally due to direct blow
      • Fracture dislocations due to
        • avulsion
        • impaction shear
    • Associated conditions
      • swan neck deformity
      • nail bed injuries
        • usually associated with distal phalanx fractures
  • Anatomy
    • Distal Interphalangeal Joint
      • osteology
        • hinge joints
      • stabilized by
        • collateral ligaments
          • comprised of proper and accessory collateral ligaments
          • both originate from middle phalanx condyles
          • proper collateral ligament inserts on volar base of distal phalanx
          • accessory collateral ligament inserts on volar plate
          • act as restraint against radial and ulnar deviation
        • terminal extensor tendon
          • inserts on dorsal base of distal phalanx
        • FDP
          • inserts on volar base of distal phalanx
        • volar plate
          • inserts on volar base of distal phalanx
          • does not form checkrein ligaments
          • acts as restraint against hyperextension
    • Proximal Interphalangeal Joint
      • osteology
        • a hinge joint
      • is stabilized by
        • collateral ligaments
          • comprised of proper and accessory collateral ligaments
          • both originate from proximal phalanx condyles
          • proper collateral ligament inserts on volar base of middle phalanx
          • accessory collateral ligament inserts on volar plate
          • act as restraint against radial and ulnar deviation
        • central slip
          • inserts on dorsal base of middle phalanx
        • FDS
          • inserts on volar shaft of middle phalanx
        • volar plate
          • inserts on volar base of middle phalanx
          • forms 2 checkrein ligaments proximally that attach to proximal phalanx
          • acts as restraint against hyperextension
  • Presentation
    • Physical exam
      • inspection
        • pain and deformity of the affected digit
        • skin puckering may indicate interposition of soft tissues within the joint
      • motion
        • important to assess stability of the joint after reduction
        • passive stability
          • lateral stress
            • perform with joint in full extension and in 30° of flexion
            • assesses competency of collateral ligaments when stressed in flexion
              • collateral ligament injury can be classified into 3 grades
                • grade I - pain with no laxity
                • grade II - laxity with firm endpoint and stable arc of motion
                • grade III - gross instability with no endpoint
            • assesses competency of secondary stabilizers (bony anatomy, accessory collateral ligaments, volar plate) when stressed in extension
          • hyperextension
            • assesses competency of volar plate
          • elson test
            • assesses integrity of central slip
        • active stability
          • flexion/extension
            • ability to achieve full ROM indicates stable joint
      • neurovascular
        • evaluate sensation in adjacent digits
          • traction neuropraxia may occur due to stretching of adjacent digital nerves
  • Imaging
    • Radiographs
      • recommended views
        • AP
        • lateral
        • oblique
      • findings
        • V sign
          • results from dorsal joint widening
          • indicates subtle subluxation
  • Diagnosis
    • Clinical and radiographic
      • diagnosis confirmed by history, physical exam, and radiographs
  • PIP Dislocations
    • Introduction
      • dorsal dislocations are more common than volar dislocations
      • dorsal dislocations can lead to a swan neck deformity
      • volar dislocations can lead to a boutonniere deformity
    • Epidemiology
      • incidence
        • most commonly injured joint in the hand
    • Classification
      • dorsal dislocations
        • results from PIPJ hyperextension with longitudinal compression (i.e. ball striking fingertip)
        • leads to tearing of the collateral ligaments and shearing of the volar plate off of the base of middle phalanx
        • commonly seen with small avulsion fracture of the base of the middle phalanx
        • simple
          • hyperextension deformity
          • middle phalanx remains in contact with condyles of proximal phalanx
        • complex
          • bayonet deformity
          • base of middle phalanx not in contact with condyle of proximal phalanx
          • volar plate can act as block to reduction with longitudinal traction
      • volar dislocations
        • simple
          • dislocation without rotation
          • results from rupture of central slip
        • rotatory
          • dislocation with rotation
          • results from rupture of one collateral ligament, with the other remaining intact
          • one of proximal phalangeal condyles buttonholes between the central slip and lateral band
      • lateral dislocations 
        • results from rupture of one collateral ligament and at least partial avulsion of volar plate from middle phalanx
    • Treatment
      • nonoperative
        • closed reduction and buddy taping (or splinting)
          • indications
            • simple dorsal dislocation
              • usually performed by patient
            • simple volar dislocation
            • lateral dislocation
        • technique
          • reduction
            • if simple dorsal dislocation, reduce with force directed volarly and in flexion
            • if complex dorsal dislocation, reduce with hyperextension of middle phalanx followed by palmar force
            • if rotatory volar dislocation, reduce by applying traction to finger with MCP and PIP joints in 90° of flexion
              • flexion relaxes volarly displaced lateral band, allowing it to slip back dorsally
          • assess stability after reduction
          • buddy taping to adjacent finger for 3-6 weeks if
            • dorsal dislocation that is stable after reduction
            • lateral dislocation
          • extension block splinting if dorsal dislocation that is unstable after reduction
          • extension splinting for 6-8 weeks if volar dislocation
      • operative
        • open reduction
          • indication
            • failed closed reduction
              • in closed dorsal dislocations, reduction is usually prevented by volar plate interposition
              • in open dorsal dislocations, reduction is usually prevented by dislocated FDP tendon
              • in lateral dislocations, reduction is usually prevented by lateral band interposition
          • technique
            • dorsal dislocations
              • perform dorsal approach with incision between central slip and lateral band
            • rotatory volar dislocations
              • perform dorsolateral approach
    • Complications
      • PIP flexion contracture (pseudoboutonniere)
        • may develop but usually resolves with therapy
        • more commonly seen in volar dislocations
      • swan neck deformity
        • occurs secondary to a volar plate injury
        • seen in dorsal dislocations
      • extensor lag
        • seen in volar dislocations
  • PIP Fracture-Dislocations
    • Introduction
      • PIPJ fracture-dislocations can be volar or dorsal
      • volar lip fractures are the most common fracture pattern seen with dorsal dislocations
      • highly comminuted fracture may occur, known as "pilon"
    • Pathophysiology
      • mechanism of injury
        • avulsion
          • in dorsal PIPJ fracture-dislocations, hyperextension leads to failure of the volar plate resulting in rupture or avulsion of the middle phalangeal volar lip
          • in volar PIPJ fracture-dislocations, hyperflexion leads to failure of the central slip resulting in rupture or avulsion of the middle phalangeal dorsal lip
        • impaction shear
          • axial loading of the finger with the PIPJ in flexion or extension leads to dorsal and volar fracture-dislocations, respectively
    • Classification
      • Hastings Classification (based on amount of P2 articular surface involvement)
      • Type I
      • < 30% (stable)
      • Type II
      • 30-50% (tenuous)
      • Type III
      • > 50% (unstable)
    • Treatment
      • nonoperative
        • closed reduction and splinting
          • indications
            • if < 40% joint involved and stable
          • technique
            • extension block splinting if dorsal fracture-dislocation
            • extension splinting if volar fracture-dislocation
          • outcome
            • regardless of treatment, must achieve adequate joint reduction for favorable long-term outcome
      • operative
        • CRPP vs. ORIF
          • indications
            • if > 40% joint involved and unstable
          • outcomes
            • articular surface reconstruction is desirable, but not necessary for a good clinical outcome
            • PIP subluxation inhibits the gliding arc of the joint and leads to a poor clinical outcome
        • dynamic distraction external fixation
          • indications
            • highly comminuted "pilon" fracture-dislocations
        • volar plate arthroplasty vs. arthrodesis
          • indications
            • chronic injuries
        • hemi-hamate arthroplasty
          • indications
            • younger patients with significant (~50%) middle phalanx joint involvement not amenable to ORIF
    • Technique
      • reduction of the middle phalanx on the condyles of the proximal phalanx is the primary goal
        • adequate volar exposure of the volar plate requires resection of
          • proximal portion of C2 pulley
          • entire A3 pulley
          • distal C1 pulley
  • DIP Dislocations & Fracture-Dislocations
    • Introduction
      • DIPJ dislocations are usually dorsal or lateral
        • volar dislocations are rare
      • often associated with open wounds due to tight soft tissue envelope
    • Classification
      • DIPJ dislocations
        • dorsal
        • volar
          • rare
        • lateral
      • DIPJ fracture-dislocations
        • volar
          • associated with avulsion of dorsal lip/terminal tendon
        • dorsal
          • associated with avulsion of volar lip/FDP
    • Treatment
      • nonoperative
        • closed reduction +/- splinting
          • indications
            • first line of treatment
          • technique
            • if dorsal DIPJ dislocation, reduce with longitudinal traction, direct pressure on dorsal aspect of distal phalanx, and DIPJ flexion
            • perform thorough irrigation and debridement if open
            • dorsal splinting in slight flexion for 2-3 weeks if dorsal dislocation that is unstable after reduction
            • extension splinting for 6 weeks if volar dislocation
            • tuft fractures require no specific treatment
              • can consider temporary splinting, and rarely may require pinning
      • operative
        • open reduction +/- FDP repair
          • indications
            • if two reduction attempts fail
              • in closed dorsal DIPJ dislocation, volar plate interposition is most common block to reduction
                • FDP may be blocking reduction if injury is open
              • in volar DIPJ dislocation, terminal tendon interposition can prevent reduction
          • technique
            • perform FDP repair if dorsal fracture-dislocation where FDP is attached to volar fragment
            • may require percutaneous pinning to support nail bed repair
        • volar plate arthroplasty
          • indications
            • if > 40% joint involved and unstable
        • arthrodesis
          • indications
            • highly community injuries without significant soft tissue loss or vascular injury
        • amputation
          • indications
            • highly comminuted injuries with significant soft tissue loss or neurovascular injury
    • Complications
      • DIPJ stiffness
      • mallet finger deformity
        • seen with volar dislocations
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