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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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