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PIPJ injuries are challenging to treat due the joint’s propensity for stiffness and late presentation, because it is not uncommon for these injuries to be dismissed at the initial presentation. With inadequate treatment, PIPJ injuries frequently lead to stiffness, deformity in the form of flexion contractures, and pain from premature degenerative arthritis. PIPJ injuries typically occur in young active individuals whose active lifestyles may be severely curtailed by a stiff and painful finger resulting in part from suboptimal treatment.
There are 3 main types of intra-articular fractures of the base of middle phalanx:
1.
Dorsal fracture subluxations or dislocations
2.
Volar fracture subluxations or dislocations
3.
Pilon fractures
Anatomy, biomechanics, and classification
The primary stability of the PIPJ is provided by its bony articular surface, the proper and accessory collateral ligaments, and the volar plate. Secondary stability is afforded by the flexor and extensor tendons.
The fracture pattern at the base of the middle phalanx depends on the direction of the force and position of the joint.
have suggested that the loss of bony restraint plays a much larger role compared with the collateral ligaments. As the debate continues regarding how much articular involvement leads to instability and how much flexion is required to keep the joint reduced, there is a general consensus that between 30% and 50% of articular involvement renders joint stability tenuous whereas more than 50% articular involvement indicates joint instability.
Initial assessment should include a thorough history, including chronicity and mechanism of injury. Physical examination should pay special attention to the stability of the PIPJ, with the use of local anesthesia if necessary. Lateral stability is tested in zero (for the proper collateral ligaments) and 30° of flexion (for the accessory collateral ligaments). Radiological assessment with anteroposterior and true lateral films is crucial to diagnosis of PIPJ injuries. When there is joint subluxation, a V sign is seen, which describes an asymmetric joint space seen on a true lateral radiograph
An estimate of the involved articular surface from plain radiographs enables classification of fractures according to their stability and serves as a guide to treatment. The degree of articular comminution
One possible reason suggested was that fractures entered the joint at varying angles that were difficult to assess with standard radiographs. Hence, oblique radiographs or advanced imaging may provide further insight into the severity of an injury. In pilon fractures, neither the initial degree of radiographic displacement nor any findings on CT help determine the need for surgery. Due to their configuration, pilon fractures are unstable and prone to collapse if not supported.
Goals of treatment
The main aim in treatment of PIPJ injuries is to achieve a stable joint for early mobilization.
Concentric joint reduction—this enables gliding motion of the joint without hinging, which occurs when there is joint subluxation.
2.
Restoration of stabilizers—this may include both bony and soft tissue stabilizers of the PIPJ.
Treatment of proximal interphalangeal joint collateral ligament injuries
Collateral ligament injuries of the PIPJ are common and may be classified into grades I, II and III injuries. More than 20° of deformity on the lateral stress test in extension indicates complete collateral ligament injury with involvement of at least 1 other secondary stabilizer, such as the volar plate, bony anatomy, or accessory collateral ligament.
Grades I and II injuries may be treated nonsurgically, with short-term immobilization in a splint followed by early buddy taping, whereas operative treatment may be considered for grade III injuries. This is still a topic of controversy, however, with some investigators advocating repair only if there is subluxation and closed reduction is not possible, whereas others report that surgical repair is necessary,
Collateral ligaments typically fail proximally. If there is enough substance of the collateral ligament on the condyle of the proximal phalanx, it may be repaired directly. Otherwise, a microsuture anchor may be used. Lee and colleagues
Clinical outcomes of operative repair of complete rupture of the proximal interphalangeal joint collateral ligament: comparison with non-operative treatment.
found that operative repair of grade II radial collateral ligament injuries resulted in lower pain score, more rapid recovery of finger motion, and better appearance of the PIPJ compared with nonsurgical treatment at short-term follow-up.
Although conservative treatment may achieve goals of joint stability and range of motion (ROM), operative treatment carries the advantage of allowing earlier ROM and decreased swelling. Surgical intervention should be balanced against a patient’s needs and risk of complications, such as skin irritation from the suture anchor knot.
Treatment of proximal interphalangeal joint dislocations
PIPJ dislocations are classified as dorsal, volar, lateral, or rotatory, depending on the position of the middle phalanx relative to the proximal phalanx.
Dorsal and lateral dislocations are the most common and usually can be reduced in a closed fashion. Lateral dislocations frequently have a dorsal component.
Volar and rotatory dislocations are rare injuries and are irreducible usually by closed methods due to interposition of soft tissue, which requires open reduction.
Suspicion is required for patients who report rotatory traction injury.
Ultrasound or MRI facilitates assessment of the soft tissue injury involved.
Closed Reduction
Closed reduction is attempted under local anesthesia. Dorsal and dorsolateral dislocations are reduced with gentle longitudinal traction accompanied by pressure on the base of the middle phalanx. This prevents entrapment of the collateral ligament or volar plate. Reduction of volar and rotatory dislocations is attempted with the metacarpophalangeal joint and PIPJ flexed to relax the entrapped extensor apparatus.
Open reduction should be performed as soon as possible to avoid joint contracture, fibrosis, and adhesions. Dorsal dislocations commonly are dealt with via a volar or lateral approach. The volar plate may be interposed in the joint,
Irreducible volar subluxation of the proximal interphalangeal joint due to radial collateral ligament interposition: case report and review of literature.
An axial compression force with rotational element brings the lateral band of the extensor tendon on the volar side of the head of the proximal phalanx and remains entrapped in the joint.
Open reduction usually is via a dorsal or lateral approach.
Repair of ruptured collateral ligaments with microsuture anchors is beneficial for early ROM, whereas volar plate avulsions are treated more commonly with extension block splinting or buddy taping. Repair of the central slip should be performed routinely to prevent boutonniere deformity.
Treatment of proximal interphalangeal joint fracture dislocations
Stable PIPJ injuries are commonly treated nonsurgically, with extension block splinting or buddy taping. There is no universally accepted treatment, however, of unstable fracture dislocations of the PIPJ.
found that there was substantial agreement when deciding for operative versus nonoperative treatment, but there was variation regarding which surgical technique to use for the same fracture. Articular step or gap greater than 2 mm and joint subluxation or dislocation were associated most strongly with a decision for operative treatment.
Myriad surgical treatment options have been described for unstable PIPJ injuries. Mean PIPJ ROM using various approaches has been reported to be approximately 80°, and there is little difference between the efficacy of these methods.
If operative treatment is chosen, the outcomes of the chosen procedure should match or be better than that expected of conservative treatment. Table 1 summarizes the indications of current treatment options.
Table 1Current practices in treatment of proximal interphalangeal joint fracture dislocations
Method
Indications
Contraindications
Typically Used for Chronic Injuries
Percutaneous pinning
Extension block
Across the PIPJ
Can be used when a quick and simple method is desired or if soft tissue is unstable prohibiting an open approach
Fractures involving the dorsal cortex of the middle phalanx base
No
Interfragmentary screw
Large fragments
Severe comminution
No
Plate and screws
Volar plate
With raft screws
Buttress alone
Dorsal plate
Lateral plate
Large to comminuted fracture fragments Pilon fractures Comminuted fragments <50% of phalangeal base, which are too small for an interfragmentary screw Pilon fractures Volar fracture dislocations Pilon fractures
For a pure buttress volar plate, there should not be a fracture involving the dorsal cortex of the middle phalanx base
No
External fixation
Comminuted volar, dorsal lip or pilon fractures of the middle phalanx base Augmentation of other surgical methods
Concomitant fractures involving the proximal and middle phalanx
Yes
VPA
Large volar base defect Comminuted volar lip fractures (not amenable to fixation)
Fractures involving the dorsal cortex of the middle phalanx base or proximal phalangeal head fracture Preexisting PIPJ osteoarthritis
The treatment of dorsal fracture-dislocation of the proximal interphalangeal joint by closed reduction and Kirschner wire fixation: a 16-year follow up.
suggested that accurate anatomic reduction of the fracture itself is not required, provided a congruous and concentric reduction of the PIPJ is achieved—this is the main goal of percutaneous pinning. An anatomically imperfect joint surface associated with radiological degenerative changes may still have a good clinical outcome and may not always affect the ROM.
The treatment of dorsal fracture-dislocation of the proximal interphalangeal joint by closed reduction and Kirschner wire fixation: a 16-year follow up.
extension block pinning involves closed reduction of the dorsal fracture dislocation and drilling of a Kirschner (K) wire into the distal, dorsal aspect of the proximal phalanx to block the terminal extension and prevent dorsal dislocation
(Fig. 2). Typically, a 1.2-mm or 1.4-mm K wire is inserted at an angle dorsal to the coronal plane through or beside the central slip into the distal dorsal aspect of the proximal phalanx.
may be performed together with extension block pinning. Postoperatively, flexion of the PIPJ is allowed with extension limited by the K wire. The K wire is removed after an average of 3 weeks.
Fig. 2PA (left) and lateral (right) radiographs of a patient who sustained a PIPJ dorsal fracture subluxation of the index finger and volar fracture dislocation of the middle finger (A) who underwent fixation of index finger with an extension block K wire, and fixation of middle finger with a K wire transfixing the PIPJ and percutaneous pinning of the dorsal lip fragment (B). The left and right panels show the PA and lateral radiographs respectively.
Another method of pinning involves transfixing of the PIPJ (see Fig. 2), using a K wire inserted from the dorsum of the base of the middle phalanx just distal to the central slip insertion and then passed proximally across the PIPJ joint into the proximal phalanx head with the PIPJ in 30° to 60° of flexion.
The treatment of dorsal fracture-dislocation of the proximal interphalangeal joint by closed reduction and Kirschner wire fixation: a 16-year follow up.
Dorsal fracture-dislocation of the proximal interphalangeal joint: a comparative study of percutaneous Kirschner wire fixation versus open reduction and internal fixation.
Satisfactory outcomes have been reported despite the PIPJ being in slight dorsal subluxation, especially when the middle phalanx heals in a position that restores the concavity of the phalangeal base.
Dorsal fracture-dislocation of the proximal interphalangeal joint: a comparative study of percutaneous Kirschner wire fixation versus open reduction and internal fixation.
If the palmar fragment does not heal, the joint is more likely to hinge and not glide normally.
Open Reduction and Internal Fixation
Open reduction and internal fixation (ORIF) ideally allows for anatomic reduction of the joint and articular fragments, while restoring stability with the crucial volar lip buttress and allowing early ROM. Reducing the articular surface (for example, a central depressed fragment) may prevent secondary osteoarthrosis
but is less crucial. Factors influencing the results after ORIF include patient age, size of palmar fragment, chronic cases, period of immobilization after surgery, and recurrence of subluxation. The most significant factor influencing PIPJ joint ROM after surgery is postoperative early motion, with a second factor patient age.
Dorsal fracture-dislocation of the proximal interphalangeal joint: a comparative study of percutaneous Kirschner wire fixation versus open reduction and internal fixation.
Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results.
Percutaneous reduction and Kirschner-wire fixation of impacted intra-articular fractures and volar lip fractures of the proximal interphalangeal joint.
Fig. 3PA and lateral radiographs on the right and left pane respectively of a patient with unstable PIPJ dorsal fracture subluxation with a centrally depressed fragment. (B) PA and lateral radiographs shown in the right and left panel respectively of the same patient underwent ORIR with combination of miniscrew fixation and volar plating.
The proximal part of the plate can be fashioned into a hook and wrapped around the small fragments that remain attached to the volar plate, which reduces comminuted fragments (Fig. 4).
Placement of screws in the diaphysis of the middle phalanx distally adds to stability without affecting the viability of the fracture fragments; the subchondral screws provide structural support for centrally depressed fragments, which have been reduced.
demonstrated that a plate and screw construct showed the greater resistance to displacement and implant failure compared with interfragmentary screws or a buttress plate alone. Flexion contracture due to flexor tendon adhesion after palmar plating can occur
Dynamic distraction external fixation makes use of ligamentotaxis through distraction to obtain and maintain fracture reduction. Static external fixators have fallen out of fashion in favor of dynamic ones that allowed early active motion to achieve better clinical outcomes.
An ideal external fixator maintains congruent joint surfaces, reduces the fracture by ligamentotaxis, is low profile, prevents compression forces, and allows immediate active motion.
Importantly, the investigators found that with the PIPJ in full extension, no amount of force could keep the joint reduced in unstable dorsal fracture dislocations. Hence, an optimal PIPJ flexion angle of 20° was suggested to maintain joint reduction while minimizing risk of flexion contracture. For unstable dorsal fracture dislocations, modalities that do not restore the bony volar lip (such as splint and external fixation) need to have an element of dorsal blocking in their design. Otherwise, there is persistent subluxation when the PIPJ is in full extension. In contrast, when internal fixation restores the bony volar lip of the middle phalanx, extension blocking is not required because the bony buttress maintains reduction of the joint.
in 1980 for treatment of acute and chronic PIPJ dorsal fracture dislocations up to 2 years after injury, volar plate arthroplasty (VPA) aims to resurface the fractured surface of the middle phalanx base with the volar plate while providing a restraint to dorsal subluxation. Interposition of other types of soft tissue into the PIPJ has been described, including fat, tendon, and periosteum.
The PIPJ is exposed via a shotgun approach after mobilization of the neurovascular bundles. The volar plate is incised along its most lateral (from the collaterals) and distal margins (from the base of the middle phalanx), creating a flap that is as broad and long as possible.
The volar plate is attached to the most dorsal part of the articular defect after fashioning of a trough. This trough should be perpendicular to the long axis of the middle phalanx to prevent angular deformity and asymmetric collapse.
Sutures are attached to radial and ulnar sides of the volar plate and passed as a pull-out suture over the dorsum of the middle phalanx. There should be smooth articular contour from the base of the middle phalanx to the volar plate.
VPA has a tendency for flexion deformity, which increases with an increasing defect in the middle phalanx palmar base as the volar plate is advanced further into the joint.
Biomechanical characteristics of hemi-hamate reconstruction versus volar plate arthroplasty in the treatment of dorsal fracture dislocations of the proximal interphalangeal joint.
Mild flexion contractures of the DIPJ 10° to 20° are common and expected, but more severe flexion contractures can occur if the joint is immobilized in excessive flexion or if the volar plate is insufficiently mobilized.
Biomechanical characteristics of hemi-hamate reconstruction versus volar plate arthroplasty in the treatment of dorsal fracture dislocations of the proximal interphalangeal joint.
Biomechanical characteristics of hemi-hamate reconstruction versus volar plate arthroplasty in the treatment of dorsal fracture dislocations of the proximal interphalangeal joint.
in 1999, with clinical results published in 2003, the hemi-hamate autograft reconstruction of the middle phalanx base is a technically challenging procedure that aims to restore joint congruity by replacing the damaged volar lip of the middle phalanx. The configuration of the hamate (dimensions, central ridge, and bicondylar facets) mimics the base of the middle phalanx volar lip. Reconstruction of the articular surface can be difficult in comminuted fractures, hence the usefulness of a graft.
It is more technically demanding than ORIF. Consequently, it may be reasonable to first attempt ORIF and then proceed to HHA when excessive comminution precludes ORIF.
Radiographs of a young patient with a malunited right middle finger PIPJ dorsal fracture dislocation are shown in Fig. 6. After shot-gunning the joint with the PIPJ hyperextended, the extent of volar lip involvement is assessed (Fig. 7) and removed to create a recipient site for the hemi-hamate graft (Fig. 8). The size of the graft required is measured in 3 planes. An incision is made over the fourth and fifth carpometacarpal joints in the same hand (Fig. 9) and a graft of appropriate size is harvested from the dorsal distal part of the hamate (Fig. 10). After harvesting, the graft is further contoured to match the recipient site accurately. The graft then is fixed with at least 2 lag screws (Figs. 11 and 12). The volar plate is repaired.
Fig. 6PA and lateral radiographs in the left and right panes respectively of a patient with malunited PIPJ dorsal fracture dislocation.
Fig. 12PA and lateral radiographs shown in the right and left panels respectively demonstrating union of the hemi-hamate autograft and restoration of the PIPJ joint surface.
with an extension block splint to prevent tendon adhesion and joint contracture. Subsequently, patients are allowed full active ROM of the joint after radiographic graft union. It has been recommended to wait 4 months before active loads are placed on joint.
proposed a vascularized hemi-hamate free flap. Other complications include PIPJ joint contracture (present in up to 10% of patients) and graft resorption. Donor site morbidity generally is low.
Volar Fracture Dislocations
Volar fracture dislocations are associated with a dorsal lip or central slip fracture, with or without disrupting of the central slip and/or collateral ligaments. They are far less common than dorsal fracture dislocations and usually have worse outcomes with a delay to treatment due to failure of early diagnosis.
These injuries can range from complete dislocation of the PIPJ with disruption of the intra-articular surface to mild subluxation with a small dorsal lip fragment. With attenuation of the central slip, these injuries can progress to a boutonniere deformity.
Although there currently is no classification to describe or guide treatment, strategies follow the same principles as dorsal fracture dislocations with focus on early ROM. These include splinting in extension, closed reduction, and percutaneous pinning,
Treatment may be delayed if a patient does not seek immediate medical attention. These injuries are difficult to treat because malunion at the articular surface may have already set in and can impair outcomes. In general, fracture dislocations more than 3 weeks to 6 weeks old
VPA, HHA, dynamic distraction external fixator, and silicon or pyrocarbon arthroplasties may be used for treatment of chronic injuries. VPA and HHA, however, require an intact dorsal base of middle phalanx and may not be used for pilon fractures.
reported treatment outcomes of DFD in 10 patients treated with dynamic distraction external fixation—performed at least 21 days after injury with good outcomes. Remodeling of the fracture occurs resulting in a concentric PIPJ articular surface with good function and painless ROM. Incomplete remodeling also may occur but does not impair function or cause pain. The key is early active ROM and edema control.
The volar approach shown in this cadaveric dissection commonly is used for ORIF and also used for hemi-hamate arthroplasty and VVA. The skin incision is commonly a Bruner type, Bruner midlateral hybrid, or zigzag incision. A Bruner-type incision is demonstrated. The flexor sheath is exposed while protecting the digital neurovascular bundles. The flexor tendons are encountered after the A3 pulley of the flexor sheath is incised and raised as a laterally based flap (the A2 and A4 pulley can be partially vented to increase the exposure). The volar plate of the PIPJ is then approached by going in-between the 2 slips of flexor digitorum superficialis and retracting the flexor digitorum profundus to 1 side. Alternatively, the flexor tendons also may be all retracted to 1 side. The surgical steps after this point are determined by which procedure the surgeon has planned.
References
Williams C.S.
Proximal interphalangeal joint fracture dislocations: stable and unstable.
Clinical outcomes of operative repair of complete rupture of the proximal interphalangeal joint collateral ligament: comparison with non-operative treatment.
Irreducible volar subluxation of the proximal interphalangeal joint due to radial collateral ligament interposition: case report and review of literature.
The treatment of dorsal fracture-dislocation of the proximal interphalangeal joint by closed reduction and Kirschner wire fixation: a 16-year follow up.
Dorsal fracture-dislocation of the proximal interphalangeal joint: a comparative study of percutaneous Kirschner wire fixation versus open reduction and internal fixation.
Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results.
Percutaneous reduction and Kirschner-wire fixation of impacted intra-articular fractures and volar lip fractures of the proximal interphalangeal joint.
Biomechanical characteristics of hemi-hamate reconstruction versus volar plate arthroplasty in the treatment of dorsal fracture dislocations of the proximal interphalangeal joint.
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