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https://upload.orthobullets.com/topic/6038/images/master pip.jpg
https://upload.orthobullets.com/topic/6038/images/pip dorsal.jpg
https://upload.orthobullets.com/topic/6038/images/Dorsal PIP dislocation_moved.jpg
https://upload.orthobullets.com/topic/6038/images/Volar approach_moved.jpg
https://upload.orthobullets.com/topic/6038/images/volar pip.jpg
Introduction
  • Common hand injuries can be broken into the following
    • PIP joint
      • dorsal dislocations
      • dorsal fracture-dislocations
      • volar dislocation
      • volar fracture-dislocation
      • rotatory dislocations
    • DIP joint
      • dorsal dislocations & fracture-dislocations
  • Associated conditions
    • swan neck deformity 
    • nail bed injuries 
      • associated with distal phalanx fractures
Imaging
  • Radiographs
    • finger xrays
      • must get true lateral of joint
    • hand xrays to rule out associated fractures
      • 30°pronated lateral to see 4th and 5th CMC x/dislocation
      • 30°supinated view to see 2nd and 3rd CMC fx/dislocation
Dorsal PIP Dislocations
  • Introduction
    • more common than volar dislocation
    • leads to injury to the volar plate and at least one collateral ligament, and if untreated a swan neck deformity will result 
  • Classification
    • simple
      • middle phalanx in contact with condyles of proximal phalanx
    • complex
      • base of middle phalanx not in contact with condyle of proximal phalanx, bayonet appearance
      • volar plate acts as block to reduction with longitudinal traction
  • Treatment
    • nonoperative
      • reduce and buddy tape to adjacent finger (3-6 weeks)
        • indications
          • dislocation is reducible
          • usually performed by patient
        • technique
          • if complex, reduce with hyperextension of middle phalanx followed by palmar force
        • complications
          • a PIP flexion contracture (pseudoboutonniere)
            • may develop but usually resolves with therapy
          • swan neck deformity
            • occurs secondary to a volar plate injury
    • operative
      • open reduction and extraction of the volar plate 
        • indication
          • failed reduction
        • technique
          • in closed injuries incomplete reduction usually due to volar plate interposition  
          • in open injuries incomplete reduction usually caused by dislocated FDP tendon
          • perform dorsal approach with incision between central slip and lateral band
Dorsal PIP Fracture-Dislocations
  • Classification
    • Hastings classification (based on amount of P2 articular surface involvement)
    • volar lip fractures are the most common fracture pattern 
      • Type I-Stable
        • <30%-treat with dorsally based extension block splint
      • Type II-Tenuous
        • 30-50%-if reducible in flexion, dorsally based extension block splint
      • Type III-Unstable
        • >50%-ORIF, hamate autograft, or volar plate arthroplasty
  • Treatment
    • nonoperative
      • dorsal extension block splinting 
        • indications
          • if < 40% joint involved and stable
        • outcome
          • regardless of treatment, must achieve adequate joint reduction for favorable long-term outcome
    • operative
      • ORIF or CRPP
        • indications
          • if  > 40% joint involved and unstable
        • 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
        • outcomes
          • articular surface reconstruction is desirable, but not necessary for a good clinical outcome
          • PIP subluxation inhibits the gliding arc of the joint and portends a poor clinical outcome 
      • dynamic distraction external fixation
        • indications
          • highly comminuted "pilon" fracture-dislocations
        • technique
          • follow with early mobilization
      • volar plate arthroplasty
        • indications
          • chronic injuries
      • arthrodesis
        • indications
          • chronic injuries
Volar PIP Dislocation & Fracture-dislocations
  • Introduction
    • less common than dorsal dislocation
    • leads to an injury to the central slip and at least one collateral ligament, and a failure to treat will lead to boutonneire deformity 
  • Treatment
    • dislocation only
      • nonoperative
        • splinting in extension for 6-8 weeks
          • indications
            • most PIP dislocations
    • fracture-dislocation
      • nonoperative
        • splinting in extension for 6-8 weeks
          • indications
            • if < 40% joint involved and stable
      • operative
        • ORIF  or CRPP
          • reduction of the middle phalanx on the condyles of the proximal phalanx is the primary goal 
          • if > 40% joint involvement
Rotatory PIP dislocation
  •  Introduction
    • one of phalangeal condyles is buttonholed between central slip and lateral band
  • Treatment
    • nonoperative
      • only if reduction is successful
      • reduce by applying traction to finger with MP and PIP joints in 90 degrees of flexion
        • flexion relaxes volarly displaced lateral band, allowing it to slip back dorsally
        • reduction is confirmed with post-reduction true lateral radiograph
    • operative
      • open reduction
        • indications
          • required in most cases
Dorsal DIP Dislocations & Fracture-Dislocations
  • Treatment
    • nonoperative
      • closed reduction, immobilization in slight flexion with a dorsal splint for 2 weeks
        • indications
          • first line of treatment
      • tuft fractures require no specific treatment
        • can consider temporary splinting
    • operative
      • open reduction
        • indications
          • if two reduction attempts fail
        • technique
          • volar plate interposition is most common block to reduction in irreducible closed DIP joint dislocation 
          • FDP may be blocking reduction if injury is open
          • may require percutaneous pinning to support nail bed repair
      • amputation
        • consider in highly comminuted injuries with significant soft tissue loss
 

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Questions (11)
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(OBQ06.120) A collegiate baseball player injures his left small finger sliding into third base. He complains of pain and swelling. The finger is ecchymotic, swollen throughout, and painful with attempted range of motion of the PIP joint. No sensory or vascular deficits are present. A radiograph is provided in Figure A. Which of the following interventions will provide the best outcome? Review Topic

QID: 306
FIGURES:
1

Buddy taping the small finger to the ring finger

1%

(24/1713)

2

Immobilization of the MCP in flexion and the PIP and DIP in extension with a custom splint

3%

(53/1713)

3

External fixation

2%

(26/1713)

4

Open reduction internal fixation

93%

(1593/1713)

5

PIP joint arthrodesis

0%

(1/1713)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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(OBQ07.218) A 27-year-old man falls on his hand at work. He notices an immediate deformity of his ring finger. Radiographs are provided in Figure A. Which of the following is the most appropriate initial treatment? Review Topic

QID: 879
FIGURES:
1

Closed reduction, buddy taping, and early motion to prevent stiffness

43%

(854/1991)

2

Closed reduction and full time extension splinting

45%

(902/1991)

3

Open reduction and repair of the central slip of the extensor tendon

7%

(138/1991)

4

Open reduction and repair of the volar plate

4%

(80/1991)

5

Amputation and immediate return to work

0%

(4/1991)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ09.194) What is the most frequently encountered form of osseous injury associated with dorsal proximal interphalangeal joint(PIP) fracture-dislocations? Review Topic

QID: 3007
1

Middle phalanx palmar lip fractures

81%

(2046/2517)

2

Proximal phalanx extraarticular fractures

1%

(27/2517)

3

Middle phalanx dorsal lip fractures

9%

(214/2517)

4

Middle phalanx dorsal and palmar lip fractures (pilon)

3%

(72/2517)

5

Proximal phalanx palmar lip fractures

5%

(134/2517)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ08.100) A 28-year-old professional baseball player injures his middle finger sliding into the catchers shin guard at home plate. He complains of pain and deformity of the middle finger. A radiograph is provided in figure A. All of the following are true EXCEPT: Review Topic

QID: 486
FIGURES:
1

Anatomic reconstruction of the articular surface is prognostic of clinical function

54%

(1332/2477)

2

Proximal interphalangeal joint subluxation precludes a normal gliding flexion arc

15%

(378/2477)

3

Hinging at the fracture site must be avoided

8%

(190/2477)

4

Early motion should be initiated in postoperative therapy

17%

(428/2477)

5

Early degenerative arthritis can be expected if the joint is not adequately reduced.

6%

(137/2477)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ07.24) A 20-year-old football player presents with a one week history of right index finger pain which started after his hand got caught in a face mask during a tackle. Physical exam shows swelling of the digit with no breaks in the skin, and no active flexion. AP, lateral, and oblique radiographs are provided in Figures A, B, and C respectively. Which of the following structures most often prevents closed reduction of this injury? Review Topic

QID: 685
FIGURES:
1

Volar plate

89%

(2363/2647)

2

Collateral ligaments

2%

(59/2647)

3

FDP tendon

4%

(101/2647)

4

Central slip

2%

(63/2647)

5

Dorsal capsule

2%

(49/2647)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ11.63) A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. Which of the following is true regarding open reduction and screw fixation of this injury? Review Topic

QID: 3486
FIGURES:
1

High risk of symptomatic implant

60%

(1680/2813)

2

Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively

5%

(151/2813)

3

High rates of post-operative infection are common

2%

(56/2813)

4

Open reduction via an approach through the nail bed leads to significant post-operative nail deformity

23%

(649/2813)

5

Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively

9%

(254/2813)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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