Palmar dislocation of the proximal interphalangeal joint

A Review on Volar Fracture-Dislocations of the Proximal Interphalangeal Joint

Volar fracture-dislocations of the proximal interphalangeal joint are rare injuries caused by an axial force on a flexed digit resulting in an avulsion fracture of the dorsal lip of the middle phalanx with volar dislocation of the joint. This volar subtype is analogous to the more common dorsal subtype with a mirror image fracture on the dorsal lip of the middle phalanx. The main significance in this type of injury lies in the disruption of the extensor mechanism at the central slip. The goals of treatment, apart from restoring a congruent and stable joint, is to restore the extensor mechanism to prevent a boutonnière deformity. In this article, we summarise the current literature and discuss the principles for treatment of this uncommon injury. Level of Evidence: Level V (Therapeutic).

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.

Proximal interphalangeal joint dislocations and fracture-dislocations

Although proximal interphalangeal joint dislocations are generally straightforward to treat, fracture-dislocations are among the most difficult hand injuries to manage. Fracture patterns range from simple to treat palmar plate avulsion fractures to complex, unstable pilon fractures of the base of the middle phalanx, where achieving adequate reduction and fixation can be extremely difficult. Moreover, these fractures may present sub-acutely or chronically, which greatly adds to the complexity of the case. It is therefore no surprise that clinical results vary and are often difficult to predict. We will discuss the clinical presentations, the various dislocation and fracture-dislocation patterns, treatment options and the complications of these injuries.

Reverse Hemi-Hamate Autograft for Volar Proximal Interphalangeal Joint Fracture-Dislocations

Volar proximal interphalangeal joint fracture-dislocations are rare injuries. Treatment is challenging when they are not identified acutely, with poor outcomes reported. We report a surgical technique to treat chronic volar proximal interphalangeal joint fracture-dislocations: a reverse hemi-hamate autograft.

Open Reduction of Neglected Dislocations of the Proximal Interphalangeal Joint

Chronic unreduced dislocations of the proximal interphalangeal joint are uncommon and management principles for these injuries have not been defined. The dislocation can be volar or dorsal and closed reduction is rarely successful owing to soft tissue contractures. We describe an extensile midaxial approach to the proximal interphalangeal joint for release of contractures, open reduction, and repair of critical structures. A smaller contralateral incision can be made if needed for additional soft tissue release. Using illustrative cases, we discuss technical points that are essential for a successful outcome and common pitfalls that could lead to complications. A functional range of motion with a stable joint can be achieved as long as articular cartilage is relatively preserved.

Dorsal Plating for Intra-articular Middle Phalangeal Base Fractures With Volar Instability

Background: Intra-articular middle phalangeal base fractures with volar instability are rare injuries with scant literature on optimal management. Our purpose is to describe our method of dorsal plating and report postoperative outcomes. Methods: This study is a retrospective case review of 5 patients with intra-articular middle phalangeal base fractures with volar proximal interphalangeal joint instability, measuring subjective, clinical, and radiographic outcomes. Results: Patient age averaged 38.2 years (range, 23-56 years), and 80% were male. Sporting injuries were the most common mechanism (80%). Time to surgery averaged 7 days, and postoperative follow-up duration averaged 19.6 months (median 8 months). All fractures were intra-articular at the proximal interphalangeal joint with volar instability. There were no complications and no patients required secondary surgery. Grip strength was maintained and range of motion was good, based on the American Society for Surgery of the Hand Total Active Motion score. Average Quick Disability of the Arm, Shoulder and Hand was 0.5 (range, 0-2.3), 100% of patients were satisfied, and average visual analog pain score was 1.2. Patients returned to work at a median of 4 days. There was radiographic union at an average of 6.6 weeks (range, 6-7 weeks) in all fractures. Conclusions: Dorsal plating using a 1.5-mm modular hand plate is a viable option for rigid fixation of intra-articular middle phalangeal base fractures with volar instability. This fixation method allows for early range of motion without complications in this case series. All fractures united, and patients had minimal functional deficits and were able to maintain good range of motion.

Injuries Around the Proximal Interphalangeal Joint

Proximal interphalangeal joint (PIPJ) injuries are common and challenging to treat, involving a spectrum of conditions ranging from isolated ligamentous injuries to severe fracture dislocations. The main goal of treatment is to achieve a congruent, stable joint, which is key to achieving early range of motion and a favorable outcome. Injuries that do not compromise the stability of the joint may be treated nonsurgically, whereas those that render the joint unstable may be managed with one of many surgical strategies available. This article focuses on the current practices of treatment of injuries around the PIPJ.

Irreducible Dislocations of the Proximal Interphalangeal Joint: Algorithm for Open Reduction and Soft-tissue Repair

Supplemental Digital Content is available in the text.

The “jammed finger” is among the most common hand injuries and may include simple sprains, dislocations, fractures, and fracture-dislocations. In contrast, irreducible dislocations of the proximal interphalangeal joint are rare injuries. However, they must not be overlooked in the primary assessment, because persistent subluxation may lead to joint contracture, severely compromising hand function. Irreducible dislocations are challenging injuries with interposed soft tissues, preventing closed reduction. Thorough preoperative diagnosis and soft-tissue imaging guide the approach to open reduction and repair of injured periarticular structures. We introduce a systematic algorithm with considerations on classification and management of irreducible proximal interphalangeal joint dislocations. The algorithm is useful for the primary assessment and for hand surgeons responsible for open reduction and rehabilitation.

Treating Proximal Interphalangeal Joint Dislocations

Proximal interphalangeal (PIP) joint dislocation a common injury. Usually, concentric stable reduction can be achieved with closed reduction. Occasionally, PIP joint dislocations are irreducible and open reduction is necessary. Complications include prolonged splinting and delay in presentation with subluxation or persistent dislocation. Surgery is often recommended for contracture or joint reduction. Surgical techniques focus on contracture release, joint reduction, and range of motion. Techniques have evolved from primary repair to tenodesis and suture anchor reconstruction. Most studies on PIP joint dislocations are retrospective case reports with good outcomes but chronic mild contracture and deformity are consistent in the literature.

Irreducible Volar Rotatory Subluxation of the Proximal Interphalangeal Joint of the Finger

We describe 4 cases of irreducible volar rotatory subluxation of the proximal interphalangeal (PIP) joint of the finger that required open reduction. All of the patients had radiographically proven (in lateral-view radiographs) volar rotatory subluxation of the PIP joint, without fracture. The causes of irreducibility were interposition of the lateral band about the condyle of the middle phalanx in 2 cases, interposition of the collateral ligament in 1 case, and scarring of the injured central slip in 1 case. Rupture of the collateral ligament of one side was found in all cases. Acceptable results were provided with all cases after restoration of the collateral ligaments and the damaged parts. Accurate early diagnosis by careful physical examination and obtaining true lateral radiographs of the PIP joint is important.

Volar fracture-dislocation of the proximal interphalangeal joint: Four cases at an average follow-up of 3 years

Volar dislocation of the proximal interphalangeal joint associated with dorsal fracture of the base of the middle phalanx is a rare injury, with only 38 cases published. We report here four such cases: three treated surgically and one conservatively. Patients had a mean age of 19.5 years. At an average follow-up of 3 years, pulp-to-palm contact was obtained and no pain was reported with regular daily activities. All patients considered themselves cured and were very satisfied with the result. Incomplete reduction of the dorsal fragment or the presence of localized articular impaction warrant surgical treatment.

Current concepts in treatment of fracture-dislocations of the proximal interphalangeal joint

BACKGROUND

Proximal interphalangeal joint fracture-dislocations are common injuries that require expedient and attentive treatment for the best outcomes. Management can range from protective splinting and early mobilization to complex surgery. In this review, the current concepts surrounding the management of these injuries are reviewed.

METHODS

A literature review was performed of all recent articles pertaining to proximal interphalangeal joint fracture-dislocation, with specific focus on middle phalangeal base fractures. Where appropriate, older articles or articles on closely related injury types were included for completeness. The methodology and outcomes of each study were analyzed.

RESULTS

When small avulsion fractures are present, good results are routinely obtained with reduction and early mobilization of stable injuries. Strategies for management of the unstable dorsal fracture-dislocation have evolved over time. To provide early stability, a variety of techniques have evolved, including closed, percutaneous, external, and internal fixation methods. Although each of these techniques can be successful in skilled hands, none has been subjected to rigorous, prospective, comparative trials. Volar dislocations fare less well, with significant loss of motion in many studies. Pilon fractures represent the most complicated injuries, and return of normal motion is not expected.

CONCLUSIONS

The best outcomes can be achieved by (1) establishing enough stability to allow early motion, (2) restoring gliding joint motion rather than noncongruent motion, and (3) restoring the articular surface congruity when possible. Although the majority of literature on this topic consists of expert opinion and retrospective case series, the consensus appears to favor less invasive techniques whenever possible.

IRREDUCIBLE VOLAR SUBLUXATION OF THE PROXIMAL INTERPHALANGEAL JOINT DUE TO RADIAL COLLATERAL LIGAMENT INTERPOSITION: CASE REPORT AND REVIEW OF LITERATURE

Irreducible volar subluxation should be considered when assessing a patient with flexion deformity of the proximal interphalangeal finger joint (PIPJ). Primary assessment requires careful examination of the collateral ligaments and extensor tendon. Preoperative imaging such as ultrasound and MRI can help identify the interposed structures and plan the subsequent operation. Although rare, irreducible volar subluxation due to radial collateral ligament interposition is an important entity to be aware of. Prompt and appropriate management can prevent joint stiffness and loss of function.

[Complex fracture-dislocation of the proximal interphalangeal joint. A case report and focus on palmar proximal interphalangeal fractures-dislocations]

The palmar fracture-dislocation of the proximal interphalangeal (PIP) joint of fingers is an uncommon injury. We report a complex form in a 16-year old teenager, associating a palmar fracture-dislocation and a fracture of the base of the middle phalanx with the dorsal fragment dislocated between the neck of the proximal phalange and the palmar plate. The management was surgical with open reduction and fixation of the fragments by K-wires and temporary PIP arthrorisis. The result at 6months of follow- up after removal of the wires and physiotherapy was satisfactory. The patient was painless with a range of motion of 115°. Clinically, the sagittal and frontal stability of the joint both in flexion and extension was maintained. Osseous healing was obtained on X-ray control. The patient went back to his usual activities. A focus on palmar fracture-dislocations of PIP joint is presented through incidence, mechanism and treatment.

Fracture-dislocations of the proximal interphalangeal joint

Fracture-dislocations of the proximal interphalangeal joint encompass a spectrum of injury severity, ranging from injuries that require little intervention to those that require advanced reconstructive surgery for optimal outcome. Three fracture-dislocation patterns are recognized: dorsal, volar, and pilon. Acceptable outcome is dependent on achieving and maintaining a well-aligned and well-reduced joint, re-establishing normal joint kinematics, and restoring motion. Anatomic articular surface reduction is desirable but not absolutely necessary for a good outcome. Treatment depends on both the type of injury and patient-dependent factors. Optimal outcome for a specific injury is predicated on expedient diagnosis and recognition of injury severity, which enables initiation of appropriate management.

IRREDUCIBLE PALMAR DISLOCATION OF THE PROXIMAL INTERPHALANGEAL JOINT OF A FINGER EVALUATED BY MAGNETIC RESONANCE IMAGING: A CASE REPORT

The irreducible palmar dislocation of the proximal interphalangeal joint (PIPJ) of a finger is rare and central slip rupture with the interposition of the lateral band in the PIPJ is extremely rare. In our present case, magnetic resonance imaging (MRI) enabled a very effective and detailed evaluation of soft tissue damage.

Irreducible volar dislocation of the proximal interphalangeal finger joint

Volar dislocation of the proximal interphalangeal finger joint is rare. The trauma that causes this injury consists in a rotation mechanism in almost all cases. It may be initially missed and diagnosed at a late sequel stage. Closed reduction should always be attempted first but this procedure may result in failure, necessitating a surgical intervention. In irreducible cases, the surgical investigation shows a longitudinal split which separates one of the lateral bands (ulnar or radial) from the central slip of the terminal extensor tendon. In addition, the lateral band is displaced to the volar aspect of the head of the first phalanx, and partially entrapped into the proximal interphalangeal joint, the head of the first phalanx being trapped between the central slip and the displaced lateral band. Surgical relocation of the displaced lateral band gives an immediate reduction of the dislocated joint. We present a case of irreducible dislocation of the proximal interphalangeal joint of the right index finger in a 42-year-old female patient who required a surgical treatment. We present the diagnostic, anatomic and therapeutic aspects of this rare injury, together with a review of the literature.

Management of proximal interphalangeal joint injuries

Injuries about the PIP joint of the finger are commonly encountered by primary care physicians and are associated with significant morbidity, including pain, stiffness, instability, premature degenerative arthritis, and residual deformities. An accurate understanding of the regional anatomy and appreciation of the mechanism of injury allows for classification so that a treatment protocol can be formulated for each injury pattern. Emphasis on careful consideration of the implications of open reduction, rational splinting, and early, active, protected motion provides for the most favorable outcome.

Irreducible palmar dislocation of the proximal interphalangeal joint caused by a fracture fragment: a case report

We present a case of irreducible palmar dislocation of the proximal interphalangeal joint of the little finger caused by entrapment of a fracture fragment attached to the collateral ligament. The bony fragment was trapped between the radial condyle of the proximal phalanx and the volar plate. Reduction was easily accomplished by hooking out the fragment.

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.

Palmar dislocation of the proximal interphalangeal joint--an injury not to be missed

Palmar dislocations of the proximal interphalangeal (PIP) joint are associated with long term complications if suboptimally treated. Six cases of palmar dislocation of the PIP joint are presented and a systematic approach in the diagnosis and management of such injuries in the accident and emergency department is described.

Palmar fracture dislocation of the proximal interphalangeal joint

Palmar fracture dislocation of the proximal interphalangeal joint is uncommon. Thirteen patients treated for this injury were retrospectively reviewed. There were 9 acute injuries. Seven were treated by closed reduction and percutaneous pin fixation and 2 were treated by open reduction and internal fixation. The 4 chronic injuries (more than 1 month after injury) were treated with open reduction and soft tissue reconstruction. The length of follow-up averaged 55 months. Eight patients were free from pain. Postoperative proximal interphalangeal motion averaged 91 for the acute injuries and 70 degrees for the chronic injuries. Follow-up radiographic findings were notable for an increased height of the middle phalangeal base in 6 patients, articular irregularity in 4, and residual subluxation in 2; however, these changes did not correlate with the clinical results. Complications included loss of reduction in 1 patient, progressive swan neck deformity in 1, and development of an average 25 degrees extension lag of the distal interphalangeal joint in 5.

The central slip attachment fracture

Eight displaced central slip attachment fractures were treated by open reduction and internal fixation to avoid boutonniere deformity, to reduce the fracture anatomically and to allow early mobilization of the joint. This injury should be recognized as a disruption of the dynamic extensor mechanism associated with an intraarticular fracture, fracture-dislocation or soft tissue injury of the PIP joint. We have grouped central slip attachment fractures into three types according to the mechanism of injury, with suggested methods of treatment.

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.

Combined central slip and volar plate injuries at the PIP joint

PIP joint injuries are common. We describe an unusual injury in which an apparent volar plate avulsion injury was associated with a dorsal, central slip avulsion fracture. We postulate that the mechanism of injury would appear to have been forced flexion with the central slip being avulsed and the volar plate fracture occurring as a secondary impingement fracture. Our two cases were treated with full extension splinting with satisfactory results.

Irreducible rotational anterior dislocation of the proximal interphalangeal joint. A spin drier injury

Two cases are described of anterior dislocation of the proximal interphalangeal joint which could not be reduced because of interposition of the central slip of the extensor mechanism. In common with previously reported cases the injuries were sustained in a spin drier. The literature on anterior dislocation of the proximal interphalangeal joint is reviewed. Three distinct patterns of dislocation are recognised and their management is discussed.

Hand Injuries in Football Players

In brief Football players have a fairly high brief risk of injury to the soft tissues of the hand; among the most common problems are thumb sprains and proximal interphalangeal joint dislocations. Stable ligament injuries can be treated with splints and casts, but more severe sprains may require surgical intervention. Closed tendon injuries must be followed carefully to prevent boutonniere deformity or mallet finger. Athletes with these injuries often can return quickly to play with protective splinting, but more recovery time may be necessary for ball handlers and for players who have injuries that require open reduction.

Irreducible palmar dislocation of the proximal interphalangeal joint with bilateral avulsion fractures

An unusual case of an irreducible anterior fracture dislocation of the proximal interphalangeal joint in a child with open epiphyses is described. Bilateral intraarticular avulsion fractures at the proximal attachment of the collateral ligaments were present, and the phalangeal head was locked through a tear in the central slip.

Irreducible palmar dislocation of the proximal interphalangeal joint of the finger

Three patients with palmar dislocations of the proximal interphalangeal joints are described. The causes of irreducibility were the interposition of one lateral band about the condyle of the middle phalangeal head in two patients and the interposition of the central slip in one patient.

Chronic anterior dislocation of the proximal interphalangeal joint

Anterior dislocation of the proximal interphalangeal joint is a complex injury involving specific pathomechanics. Progression of this injury to a chronic stage is associated with considerable morbidity in the form of pain, instability, and loss of motion in the involved joint. Surgical reconstruction is complicated and results of delayed intervention are compromised. Two cases of anteriorly dislocated interphalangeal joints, unrecognized as such early and allowed to progress to a chronic stage, presented to us as boutonniere deformities. Descriptions of clinical presentation, surgical findings, and treatment results in these cases attest to the disabling potential of this injury. Emphasis is therefore placed on early recognition of the anteriorly dislocated proximal interphalangeal joint so that appropriate treatment can be initiated and progression to a chronic stage prevented.

Irreducible palmar dislocation of the proximal interphalangeal joint associated with an epiphyseal fracture of the middle phalanx

A palmar dislocation of the proximal interphalangeal joint that became irreducible because of a Salter-Harris type I fracture of the epiphysis of the middle phalanx is described. The anatomic mechanisms of irreducible palmar dislocations are discussed.

Irreducible palmar dislocation of the proximal interphalangeal joint. A case report

Irreducible palmar dislocation of the proximal interphalangeal joint in which the central slip remains intact is a rare injury. A noose formed by the extensor mechanism traps the condyle of the proximal phalanx. The collateral ligament is avulsed and the volar plate is disrupted. Closed reduction was unsuccessful in this case. Open reduction achieved a good result.