Sideline Management of PIP Dislocation

Introduction

The most commonly diagnosed finger dislocation is a dorsal dislocation of the PIP joint. There are three types of PIP joint dislocation which are volar, dorsal, and lateral dislocation (1). The PIP joint is includes the proximal and middle phalanx and is supported by multiple soft tissue structures (2). These include the collateral ligament, central slip of the extensor tendon, flexor tendon sheath, and also the volar plate (2). The volar plate is a fibrocartilaginous structure that is located on the palmar surface connecting the proximal to the middle phalanx (2). Proper relocation of a dislocated PIP is important because a neglected or improperly treated PIP dislocation can lead to joint contracture and figure stiffness (9).

Case Vignette

A 17 year old high school soccer play fell and notice their middle finger was dislocated dorsally. They are diagnosed with a dorsal dislocation of the proximal interphalangeal joint. Which structure can be damaged with a dorsal PIP dislocation?

A) Volar plate

B) Central extensor hood

C) Palmar fascia

D) Ulnar nerve

Image 1. Volar plate ultrasound image (2)

Diagnosis

Diagnosis of a dorsal dislocation is typically made clinically based on the visible deformity seen. The patient will also have a decrease in their range of motion (9). Soft tissue structures should be assessed, as a dorsal dislocation of the PIP joint can injure the volar plate (1). If the joint is already relocated prior to evaluation, then checking for joint stability is necessary (9). Radiographs are also taken to rule out concomitant fracture after reduction. 

Image 2. Soft tissue support of the PIP joint (5)

Video. Ultrasound video demonstrating PIPJ dislocation status post reduction. Note the small avulsion fracture seen dorsally.

Treatment

Relocation of a dorsal PIP dislocation should be done at the time of the injury (1).

  1. Grasp dislocated finger with both hands (3)
  2. Initially extend the digit while one hand applies longitudinal traction and the other provides a relocating volar pressure (9)
  3. Then flex at the PIP joint

Image 3. Dorsal PIP dislocation treatment steps (3)

Post reduction treatment of a dorsal dislocation of the PIP joint includes splinting in 30 degrees of flexion and allowing for early range of motion as pain improves (1). A study published in the Archives of Orthopedic Trauma Surgery compared the treatment of dorsolateral dislocations with either finger splinting with PIP flexion of 20-30 degrees verses early active motion with a dorsal block splint (4). The early range of motion group was found to be superior, as it avoided the development of a flexion contracture, which is commonly seen in hyperextension injuries (4).  The early range of motion group also regained their full range of motion quicker than the immobilization group (4). Another study that looked at immobilization after reduction compared one group splinted with an aluminum orthosis with 15 degrees of flexion verses early buddy taping of the digit. This study showed that the buddy taped group showed quicker improvement in pain and range of motion (6).

Volar dislocations are less commonly seen than dorsal dislocations. The volar displacement can lead to injury to the central slip extensor mechanism (4). These dislocations require 6 weeks of immobilization in extension (1). Volar dislocations may need open reduction (8).

Conclusion

Dorsal dislocation of the proximal interphalangeal joint is the most commonly seen dislocation of the hand. Prompt relocation on the sideline is typically attempted. Early range of motion with buddy taping will lead to improved outcomes. Most athletes with a stable PIP joint after reduction can immediately return to play (9).

Case Conclusion

Answer: Volar Plate. A dorsal PIP dislocation is the most commonly seen finger dislocation. The volar plate can be injured with a dorsal dislocation. The volar plate is a band of fibrocartilaginous structure that is located on the palmar surface connecting the proximal to the middle phalanx.
Yoong, P., et al. “Phalangeal Fractures of the Hand.” Clinical Radiology, vol. 65, no. 10, Oct. 2010, pp. 773–80. PubMed, https://doi.org/10.1016/j.crad.2010.04.008.

By Gregory Rubin, DO

rubinsportsmed.com

– More Hand Pain @ Sports Med Review: https://www.sportsmedreview.com/by-joint/hand/

– Read More: https://wikism.org/Proximal_Interphalangeal_Joint_Dislocation

References

  1. Borchers, James R., and Thomas M. Best. “Common Finger Fractures and Dislocations.” American Family Physician, vol. 85, no. 8, Apr. 2012, pp. 805–10.
  2. Yoong, P., et al. “Phalangeal Fractures of the Hand.” Clinical Radiology, vol. 65, no. 10, Oct. 2010, pp. 773–80. PubMed, https://doi.org/10.1016/j.crad.2010.04.008.
  3. Buttaravoli, Philip, and Stephen Leffler. Minor Emergencies. Elsevier.
  4. Arora, R., et al. “Dorsolateral Dislocation of the Proximal Interphalangeal Joint: Closed Reduction and Early Active Motion or Static Splinting; a Retrospective Study.” Archives of Orthopaedic and Trauma Surgery, vol. 124, no. 7, Sept. 2004, pp. 486–88. PubMed, https://doi.org/10.1007/s00402-004-0707-0.
  5. Miller, Erin A., and Jeffrey B. Friedrich. “Management of Finger Joint Dislocation and Fracture-Dislocations in Athletes.” Clinics in Sports Medicine, vol. 39, no. 2, Apr. 2020, pp. 423–42. PubMed, https://doi.org/10.1016/j.csm.2019.10.006.
  6. Paschos, Nikolaos K., et al. “Management of Proximal Interphalangeal Joint Hyperextension Injuries: A Randomized Controlled Trial.” The Journal of Hand Surgery, vol. 39, no. 3, Mar. 2014, pp. 449–54. PubMed, https://doi.org/10.1016/j.jhsa.2013.11.038.
  7. Chinchalkar, Shrikant J., and Bing Siang Gan. “Management of Proximal Interphalangeal Joint Fractures and Dislocations.” Journal of Hand Therapy: Official Journal of the American Society of Hand Therapists, vol. 16, no. 2, June 2003, pp. 117–28. PubMed, https://doi.org/10.1016/s0894-1130(03)80007-8.
  8. Calandruccio, James. Campbell’s Operative Orthopaedics. Elsevier.
  9. Prucz, Roni B., and Jeffrey B. Friedrich. “Finger Joint Injuries.” Clinics in Sports Medicine, vol. 34, no. 1, Jan. 2015, pp. 99–116. PubMed, https://doi.org/10.1016/j.csm.2014.09.002.
  10. Saitta, Bradley Hart, and Jennifer Moriatis Wolf. “Treating Proximal Interphalangeal Joint Dislocations.” Hand Clinics, vol. 34, no. 2, May 2018, pp. 139–48. PubMed, https://doi.org/10.1016/j.hcl.2017.12.004.