Updated: 10/14/2018

Phalanx Dislocations

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https://upload.orthobullets.com/topic/6038/images/pip_dorsal_dl_complex.jpg
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https://upload.orthobullets.com/topic/6038/images/master pip.jpg
Introduction
  • Common traumatic injury of the hand involving the proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP)
    • treatment is closed reduction and splinting unless volar plate entrapment blocks reduction or a concomitant fracture renders the joint unstable
  • Injuries patterns can be broken into
    • PIP joint 
      • dislocations
        • volar
        • dorsal
        • lateral
      • fracture-dislocations
    • DIP joint
      • dislocations
      • fracture-dislocations
  • 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
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
Type Amount of P2 articular surface involvement
Stability
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
        • 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 leads to a poor clinical outcome 
      • dynamic distraction external fixation 
        • indications
          • highly comminuted "pilon" fracture-dislocations
        • technique
          • follow with early mobilization
      • volar plate arthroplasty vs. arthrodesis
        • indications
          • chronic injuries
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
      • 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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Questions (12)
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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%

(29/2108)

2

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

3%

(63/2108)

3

External fixation

2%

(32/2108)

4

Open reduction internal fixation

93%

(1966/2108)

5

PIP joint arthrodesis

0%

(1/2108)

ML 1

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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%

(887/2054)

2

Closed reduction and full time extension splinting

45%

(926/2054)

3

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

7%

(139/2054)

4

Open reduction and repair of the volar plate

4%

(84/2054)

5

Amputation and immediate return to work

0%

(5/2054)

ML 4

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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%

(2097/2588)

2

Proximal phalanx extraarticular fractures

1%

(30/2588)

3

Middle phalanx dorsal lip fractures

9%

(223/2588)

4

Middle phalanx dorsal and palmar lip fractures (pilon)

3%

(73/2588)

5

Proximal phalanx palmar lip fractures

5%

(140/2588)

ML 2

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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

53%

(1360/2552)

2

Proximal interphalangeal joint subluxation precludes a normal gliding flexion arc

16%

(397/2552)

3

Hinging at the fracture site must be avoided

8%

(200/2552)

4

Early motion should be initiated in postoperative therapy

17%

(441/2552)

5

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

5%

(139/2552)

ML 3

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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%

(2489/2788)

2

Collateral ligaments

2%

(65/2788)

3

FDP tendon

4%

(106/2788)

4

Central slip

2%

(66/2788)

5

Dorsal capsule

2%

(50/2788)

ML 1

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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

59%

(1779/2998)

2

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

6%

(168/2998)

3

High rates of post-operative infection are common

2%

(57/2998)

4

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

23%

(698/2998)

5

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

9%

(272/2998)

ML 4

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PREFERRED RESPONSE 1
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