Extension splinting of palmar plate avulsion injuries of the proximal interphalangeal joint

Management of Pediatric Volar Plate Avulsion Fractures of the Proximal Interphalangeal Joint: A Systematic Review

BACKGROUND

Sudden, forced hyperextension injuries to the proximal interphalangeal joint leading to volar plate avulsion fractures are common hand injuries in children. Suboptimal management of these fractures can lead to the development of long-term complications such as stiffness and flexion contracture.

METHODS

MEDLINE (PubMed), Scopus, Embase, Google Scholar, and Cochrane CENTRAL databases were systematically searched, and additional studies were found through reference of articles up to June 15, 2023. Identified articles were assessed using predetermined inclusion/exclusion criteria.

RESULTS

Twenty-five articles were included, involving 268 patients with ages from 3 to 17 years. Fractures with less than 30% joint involvement, classified as Eaton type I or II, or designated as "Stable" in the Keifhaber-Stern classification, were treated through nonsurgical means. Surgical interventions, encompassing open reduction and internal fixation, were reserved for fractures with more than 30% joint involvement and/or meeting criteria such as Eaton type IIIa or IIIb and Keifhaber-Stern "Tenuous" or "Unstable." Positive outcomes were seen in 99.5% of patients receiving nonsurgical treatment, compared with 85.7% in the surgical cohort.

CONCLUSIONS

The literature demonstrated positive outcomes for fractures presenting with less than 30% joint involvement that were managed nonsurgically. In fractures with more than 30% joint involvement, surgical interventions yielded positive results. To further substantiate these findings, larger prospective studies with uniform measures are needed to validate the results of this study.

The Effect of Kinesio Taping Versus Splint Techniques on Pain and Functional Scores in Children with Hand PIP Joint Sprain

Introduction: Due to the continual increase in the number of children engaging in sports today, physicians encounter finger injuries at an increasing frequency. This study sought to investigate the effectiveness of the method of Kinesio taping versus classic finger splint technique on pediatric patients with PIP (proximal interphalangeal) joint sprains of the fingers. Method: This is a retrospective cohort study. Forty-nine pediatric patients with PIP joint sprains were included in the study. The patients were divided into two groups, Group 1 being those treated with Kinesio taping and Group 2, those treated with splints. The area around the PIP joint was measured before and after treatment. Visual analog scale (VAS) evaluation: nighttime pain, numbness, pain at rest, and pain during activity were each separately evaluated before and after treatment. Also, flexion was measured at rest and in active motion before and after treatment. Results: The patients' periarticular measurements of the affected joint were statistically significant in both groups after treatment (p < 0.001). In the comparison between the groups, it was found that the group treated with Kinesio taping displayed a better outcome (p < 0.021). According to the VAS for PIP joint pain, it was observed that in both groups, pain at rest, pain during activity, nighttime pain, and numbness were statistically significant after treatment (p < 0.001). In the comparison of the groups, it was seen that the difference was statistically significant only in terms of nighttime pain (p < 0.013). Conclusions: The study conducted supported the literature that Kinesio taping method does not restrict the function of the extremity to which it is applied and also does not produce the complications reported in other treatment techniques. Kinesio taping was found to have a higher patient compliance and the outcomes were better in terms of edema and joint range of motion as well as night time pain when compared to the group treated with splint.

The Role of Dynamic Ultrasound in the Immediate Conservative Treatment of Volar Plate Injuries of the PIP Joint: A Series of 78 Patients

INTRODUCTION

The management of volar plate avulsion fractures in the context of a stable joint and a bony fragment of less than 30% has traditionally been conservative. This study was performed to assess volar plate healing with high-resolution ultrasound in order to provide early full mobilization.

MATERIAL AND METHODS

Between January 2012 and December 2013, 78 patients with volar plate injuries of the proximal interphalangeal (PIP) joints (42 distortions and 36 dislocations) were treated conservatively in our department for volar plate avulsion fracture associated with stable joint and bony fragment inferior to 30% of the intra-articular surface assessed both by radiography and ultrasound. Conservative treatment included extension stop splinting for the first 2 weeks and Coban bandage until 6 weeks postinjury. However, it may be possible to modify the duration of extension stop splinting based on clinical and ultrasound findings (with no additional X-ray) performed every 2 weeks for the first 3 months and then at 4 months postinjury. Only patients with residual contracture at the 4-month assessment had prolonged follow-up in order to ensure adequate dynamic splint therapy.

RESULTS

The amount of soft tissue oedema and the mobility of the volar plate were factors used to determine return to full mobilization. Mean extension-stop-splint wear was 16 ± 2 days. During the first 2 follow-up assessments, 4 patients were excluded from the study because of the instability of the PIP joint. One patient required refixation of a large fragment of 30%, 2 patients required superficial flexor tendon (FDS) tenodesis of the unstable volar plate in hyperextension and 1 other patient required arthrodesis of the PIP joint. In 51 patients, the postoperative follow-up was free of complications at 4 months. In 18 patients, flexion contracture of 20° (range 11°-40°) and oedema during follow-up required dynamic extension splints for 3 to 5 months. After this time, 5 patients had a residual contracture of 10° to 15°.

CONCLUSION

Avulsion fractures of the volar plate at the PIP joint are common. In general, they have a good outcome using the conservative treatment with extension block splints. Flexion contracture is a common complication and may be reduced by immediate splints in full extension at night and Coban bandage during the day. High-resolution sonography is a convenient tool to evaluate palmar plate stability, to assess reduction of oedema, and thus to guide safe return to full range of movement.

Results of conservative treatment of volar plate sprains of the proximal interphalangeal joint with and without avulsion fracture

The prognosis of isolated volar plate sprains of the proximal interphalangeal (PIP) joint is related to the extension deficit. Some consider an associated avulsion fracture as a sign of severity. The goal of this study was to find out whether the outcomes of conservative treatment in PIP volar plate injury was impacted by the presence of an avulsion fracture. Our series included 75 patients, 27 years old on average, of which 58 were men. All sprains were stable. The X-rays were normal in 52 cases (group 1); an avulsion fracture was found in 23 cases (group 2). The patients were treated by buddy taping during the day and a straight finger splint at night for 3 weeks. At the last follow-up, no significant difference was found between the two groups regarding pain, extension/flexion range of motion or edema. The results of this study show that the prognosis of conservative treatment of PIP volar plate injuries does not depend on the presence of an avulsion fracture.

Management of proximal interphalangeal joint hyperextension injuries: a randomized controlled trial

PURPOSE

To compare the effectiveness of buddy strapping and aluminum orthosis for treatment of proximal interphalangeal (PIP) joint hyperextension injuries. We also evaluated the effect of age on the outcome by comparing our results in adults and children.

METHODS

One hundred twenty-one consecutive patients with a PIP joint hyperextension injury of the index, middle, ring, or little finger and without fracture were evaluated. Patients were randomly assigned into 2 groups. In the first group, treatment included buddy strapping of the injured finger to its neighbor noninjured finger for a week. In the second group, immobilization was secured with an aluminum extension blocking orthosis for a week in 15° flexion. Assessment of motion, edema, pain, and strength were performed weekly for the first month and then at 3, 6, and 12 months after injury.

RESULTS

The patients treated with buddy strapping exhibited similar outcomes compared with those treated with aluminum orthoses. In patients with full recovery, buddy strapping allowed earlier recovery of motion and resolution of edema and pain compared with aluminum orthosis immobilization. Furthermore, PIP injuries appear to have better outcomes in children than in adults.

CONCLUSIONS

Buddy strapping is easy and effective treatment for PIP joint hyperextension injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Open Reduction of Proximal Interphalangeal Fracture-Dislocation through a Midlateral Incision Using Absorbable Suture Materials

BACKGROUND

Fracture-dislocation of the proximal interphalangeal (PIP) joint is a relatively common injury. Various treatments for fracture-dislocation of the PIP joint have been reported. In the present study, we performed open reduction through a midlateral incision using absorbable sutures to reduce the small bone fragments and performed volar plate repair.

METHODS

We treated nine patients with fracture-dislocation of the PIP joint with small fractured bone fragments too small for pinning or screw fixation. Patients with volar plate injury were treated with open reduction and volar plate repair at the periosteum of the middle phalangeal bone base by the modified Kessler method using absorbable sutures. All patients were placed in a dorsal aluminum extension block splint, which maintained the PIP joint in approximately 30 degrees of flexion to avoid excessive tension on the sutured volar plate.

RESULTS

At a mean final follow-up of postoperative 9 months, all patients were evaluated radiographically and had adequate alignment of the PIP joint and reduction of the displaced bone fragments. Range of motion was improved and there were no complications.

CONCLUSIONS

This technique is an excellent alternative to the current method of treating patients with fracture-dislocations that include small fragments that are too small for pinning or screw fixation. It is a less invasive surgical method and enables stable reduction and early exercise without noticeable complications.

Conservative interventions for treating hyperextension injuries of the proximal interphalangeal joints of the fingers

BACKGROUND

Immobilisation and early motion (protected or unrestricted) are both used following hyperextension injuries to the proximal interphalangeal (PIP) joint of the finger.

OBJECTIVES

To assess the effects of conservative interventions (non-surgical management) for treating hyperextension injuries of the proximal interphalangeal joints of the fingers.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2012), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2012, Issue 1), MEDLINE (1946 to January Week 2 2012), EMBASE (1980 to 2012 Week 03), CINAHL (1950 to 24 January 2012), PEDro (1929 to March 2012), trial registers and reference lists of articles.

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing immobilisation/protected mobilisation/unrestricted mobilisation in participants with PIP joint hyperextension injuries managed non-surgically.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. There was no pooling of data.

MAIN RESULTS

Three trials involving 366 people were identified. All three trials, which were over 15 years old, were methodologically flawed with unclear or high risk of bias. None of the studies reported on self assessment of function. One trial compared unrestricted mobility with immobilisation; one trial compared protected mobilisation with immobilisation; and the remaining trial compared immobilisation for one week versus three weeks. None of these trials found statistically significant differences between their intervention groups in various measures of poor outcome, pain and range of movement at six months follow-up. This lack of difference applied at three years for the comparison between unrestricted mobility with immobilisation.

AUTHORS' CONCLUSIONS

There is insufficient evidence from trials testing the need for, and the extent and duration of, immobilisation to inform on the key conservative management decisions for treating hyperextension injuries of the proximal interphalangeal joints.

A prospective randomized study of conservative versus surgical treatment of unstable palmar plate disruption in the proximal interphalangeal finger joint

The aim of this study was to assess the effect of conservative versus operative treatment for unstable palmar plate disruption in the proximal interphalangeal (PIP) joint of the fingers with respect to preservation of joint stability, mobility, and pain. The study was conducted as a prospective study in which 83 patients were randomly assigned into 2 groups: (1) conservative treatment with a rigid splint for 2 weeks, (2) surgical reattachment of the palmar plate in local anesthesia followed by 2 weeks of immobilization in a plaster cast. Both groups were thereafter treated by taping to the neighboring finger for 3 weeks. With regard to hyperextension instability, stiffness, and pain, there is no significant difference in outcome between patients with traumatic palmar plate lesions and hyperextension instability treated with surgical repair and patients treated conservatively with a splint. We do not recommend primary surgical repair of unstable isolated palmar plate lesions in the proximal interphalangeal joints of the 4 ulnar fingers.

Type of study/level of evidence Therapeutic, Level II.

Percutaneous pinning of the displaced volar plate avulsion fracture of the PIP joint

The use of operative or non-operative techniques in the treatment of a volar plate avulsion fracture of the PIP joint has remained controversial. In this study, we describe the use of percutaneous K-wire fixation in 15 patients with a displaced and rotated large fragment of this injury. All processes of the technique, including reduction and interfragmental fixation, were performed with percutaneous K-wires. Mean follow-up was 14.2 months. All patients achieved bony union. Mean active motion was -1.3 degrees /86.2 degrees for the PIP joint and 0 degrees /77.5 degrees for the DIP joint and mean %TAIM was 94.6%. There were no complications. No patients complained of pain and all were able to return to their previous activity. Although this procedure is technically demanding, it reconstructs a rotated or displaced large volar plate avulsion with a low level of invasion, and achieves a satisfactory functional recovery.

[Intraarticular fractures of the proximal interphalangeal joint: dynamic early functional therapy with an external fixation system]

The results of treating fracture dislocations of the proximal interphalangeal joint are often unsatisfactory for the patient because conservative methods cannot prevent stiffness of the joint. Thus, early functional treatment with external fixation systems is increasingly favoured. This therapy combines the principles of ligamentotaxis and the possibility of early movement of the injured joint. The frequently modified pins and rubbers traction system is especially effective. It is cheap, easy to apply, and well accepted by patients due to its light weight and small size. This paper gives an overview of the therapeutic options and the clinical results of treating fractures of the proximal interphalangeal joint.

Conservative treatment of stable volar plate injuries of the proximal interphalangeal joint in children and adolescents: a prospective study

OBJECTIVES

The purpose of this study was to assess a standard conservative management for stable volar plate injuries of the proximal interphalangeal joint in children and adolescents. No study is available regarding this subject for this age group.

METHODS

A prospective study was performed on 37 consecutive patients (aged between 9 and 15 years; mean, 13 years) with stable acute volar plate injuries of the proximal interphalangeal joints, including 22 avulsion fractures without dislocation. All patients had a standardized conservative treatment consisting of a dorsal aluminum extension block splinting at a 15-degree flexion for 10 days, followed by a spontaneous mobilization and taping to adjacent fingers for sports only. At follow-up visits, active and passive ranges of motion, swelling of the affected joints, analgesic intake, and pain perception by the patient were recorded. Regular follow-up consisted of standardized assessments at 2, 6, and 12 weeks, with additional consultations if symptoms persisted.

RESULTS

Healing was uneventful, and hand therapy was not necessary to regain full range of motion in 32 of 33 children with a regular follow-up. The only flexion contracture observed responded well to splinting. Of the 33 patients, 31 had an excellent outcome and 2 had a good outcome.

CONCLUSIONS

Dorsal extension block splinting was an efficient, simple, well-tolerated treatment for stable volar plate injuries of the proximal interphalangeal joint in a preliminary series of patients younger 16 years. Flexion contractures were rare and responded well to dynamic splinting.

Management of proximal interphalangeal joint fractures and dislocations

Proximal interphalangeal joint (PIP) injuries are among the most common in the hand and their severity is often underestimated. These injuries often lead to prolonged disability, pain, and stiffness. Appropriate treatment includes a thorough assessment, physical examination, and directed imaging. Such an approach should lead to a rational treatment plan that focuses on the rehabilitation of all damaged components, including osseous, articular, and soft tissue structures. This article reviews all elements in the management of PIP injuries and introduces an assessment method for PIP injuries based on the mechanism of injury rather than primarily on the basis of radiographic findings.

Large volar plate avulsion fracture of the base of the middle phalanx with rotational displacement: a report of three cases

Three cases of large volar plate avulsion fracture at the base of the middle phalanx with significant displacement are reported. In each case, the fracture fragment involved about 30% of the articular surface and was rotated 90 degrees. The proximal interphalangeal (PIP) joint showed loss of volar stability with hyperextension stress. This unusual variant of volar plate injury is thought to be caused by subluxation of the PIP joint. All patients underwent open reduction and internal fixation. The fracture healed in anatomic alignment without articular incongruity or instability in all cases.

Dynamic digital traction for unstable comminuted intra-articular fracture-dislocations of the proximal interphalangeal joint

Unstable intra-articular fracture-dislocations about the proximal interphalangeal joint present a formidable management dilemma. Fourteen patients with comminuted injuries of the proximal interphalangeal joint were treated with dynamic digital traction and followed for an average of 24 months. Dorsal fracture-dislocation and pilon-type injuries made up the majority of cases. Average proximal interphalangeal joint articular surface involvement was 80%. Immediate motion was instituted after traction application. The device was applied in the office with readily available materials. At final follow-up examination, active arc of motion averaged 89 degrees at the proximal interphalangeal joint and 95 degrees for patients sustaining isolated injuries. X-ray films revealed fracture union, joint remodeling, and preservation of joint space. Patient satisfaction was high, with return to previous levels of activity and excellent functional joint restoration. Dynamic digital traction is recommended for unstable proximal interphalangeal joint fractures with comminution, including those associated with subluxation or dislocation.

Treatment of hyperextension injuries to the PIP joint

A prospective randomized trial of type 1 hyperextension injuries to the PIP joint treated conservatively by an elastic double-finger bandage or an aluminium splint for 2 weeks showed no differences in the clinical outcome after 6 months.