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The articular surface of the middle phalanx is biconcave with an inter-condylar ridge and is almost com-pletely congruent with the proximal phalangeal surface Fig.. subluxation are simil

The proximal interphalangeal (PIP)

joint has the largest arc of motion

(120 degrees) of the three joints in

each digit of the hand It is estimated

that this joint accounts for 85% of the

motion required to grasp an object.1

Unfortunately, the PIP joint is

unique-ly susceptible to injury and tends to

become stiff soon after trauma or

im-mobilization This tendency toward

stiffness has been attributed to the

pain and instability that may

accom-pany injury or to fibrosis of the joint

capsule and collateral ligaments

Early mobilization is essential to

minimize joint stiffness

Immobili-zation for longer than 3 weeks can

result in permanent loss of motion.2

It is essential for the treating

physi-cian to determine which treatment

can best achieve sufficient fracture

stability and when the fracture is

sta-ble enough to permit joint motion

Anatomy and Biomechanics

The articular surface of the proximal phalanx is bicondylar and broader volarly The condyles are slightly asymmetric, and for each individual finger the bone profiles and geome-try differ slightly Hyaline cartilage covers approximately 210 degrees

of the head of the proximal phalanx

The articular surface of the middle phalanx is biconcave with an inter-condylar ridge and is almost com-pletely congruent with the proximal phalangeal surface (Fig 1) This congruence confers stability to the joint, particularly in the axially loaded finger

The PIP joint functions primarily

as a hinge in the coronal plane

The asymmetry of the condyles of the proximal phalanx and the slight

incongruence of the articular sur-faces allows a gliding motion of the middle phalanx with a few degrees

of rotation and angulation The asymmetry of the condylar profiles produces rotation of the tip of the finger with flexion; the index finger supinates, and the ring and small fingers pronate.3

The central slip of the extensor mechanism inserts on a dorsal tuber-cle located just distal to the articular surface of the middle phalanx (Fig 2) The ligamentous structures of the PIP joint include the collateral liga-ments, the volar plate, the accessory collateral ligaments, and the joint capsule The collateral ligaments originate from concavities on the lat-eral aspects of the proximal phalanx They course volarly relative to the midaxis of the joint and insert on a tubercle at the palmar and lateral aspects of the middle phalanx The dorsal fibers tighten with joint flex-ion, and the palmar fibers tighten with extension The volarmost fibers blend with the distal volar plate

Dr Blazar is Assistant Professor of Ortho-paedic Surgery, University of Kentucky College

of Medicine, Lexington Dr Steinberg is Assistant Professor of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia.

Reprint requests: Dr Blazar, University of Kentucky, K401 Kentucky Clinic, 740 South Limestone, Lexington, KY 40536-0284.

Copyright 2000 by the American Academy of Orthopaedic Surgeons.

Abstract

Fractures of the proximal interphalangeal joint constitute a broad spectrum of

injuries An understanding of the anatomy, the potential for joint instability,

and the treatment options is essential to management of these fractures.

Commonly observed fracture patterns involve one or both condyles of the

proxi-mal phalanx or the base of the middle phalanx Fractures of the middle phalanx

may involve the palmar lip or the dorsal lip or may be a "pilon" type of injury

involving both the palmar and the dorsal lip with extensive intra-articular

com-minution Intra-articular injuries may lead to joint subluxation or dislocation

and must be identified in a timely manner to limit loss of motion, degenerative

changes, and impaired function These injuries range from those requiring

minimal intervention to obtain an excellent outcome to those that are

challeng-ing to the most experienced surgeon The treatment options include

extension-block splinting, percutaneous pinning, traction, external fixation, open

reduc-tion and internal fixareduc-tion, and volar-plate arthroplasty Prompt recognireduc-tion of

the complexity of the injury and appropriate management are essential for an

optimal functional outcome.

J Am Acad Orthop Surg 2000;8:383-390

Philip E Blazar, MD, and David R Steinberg, MD

The proximal portion of the

volar plate has a swallowtail shape

The slender proximal extensions

(checkrein ligaments) are somewhat

mobile from the underlying

proxi-mal phalanx Transverse branches

of the digital arteries course under

them to meet in the midline and

supply the joint and the vincula of

the flexor tendons The distal

por-tion of the volar plate inserts onto

the base of the middle phalanx

The attachments to the middle

pha-lanx blend with the periosteum of

the middle phalanx centrally and

are more substantial laterally, where

the volar-plate fibers blend with the

collateral ligaments

The accessory collateral

liga-ments originate just volar to the

proper collateral ligaments, but the

fibers of the former fan out volarly

to insert on the volar plate and the

flexor tendon sheath The

acces-sory collateral ligaments are tight

in extension and loose in flexion

The dorsal capsule is separate from

the overlying extensor mechanism

and consists of a minimal synovial

lining.3

The soft-tissue structures that surround the PIP joint contribute to its stability The volar plate resists joint hyperextension, while the col-lateral ligaments are the primary restraints to motion in the coronal plane.4 There are a number of sec-ondary stabilizers At terminal ex-tension, the volar plate and the accessory collateral ligaments as-sume a larger role In flexion, the proper collateral ligament is tight-ened over the flare of the condyle and becomes the primary stabilizer against lateral displacement Both the volar plate and at least one col-lateral ligament must be injured for dislocation of the PIP joint to occur.5

Clinical Evaluation

Specific features concerning the history of a PIP joint fracture, in-cluding time to presentation, mech-anism of injury, and occurrence of subluxation or dislocation, are im-portant The direction of any initial displacement should be noted

Examination of the digit begins with inspection for deformity, swelling, or laceration Local ten-derness of the affected digit, as well

as injury to the soft-tissue structures

of adjacent digits, should be evalu-ated If a reduction maneuver has been previously performed, radio-graphs should be reviewed before testing range of motion If the joint

is dislocated or subluxated, reduc-tion is attempted under digital block anesthesia, after which active and passive range of motion are assessed Fluoroscopic examination

is frequently helpful in evaluating fractudislocations that are re-ducible The position at which sub-luxation occurs is recorded A true lateral radiograph with the joint in full extension confirms posttion stability If initial closed reduc-tion is not successful, the surgeon must choose among the various other treatment options If initial closed reduction of a dislocation without a fracture is not successful,

a complex dislocation is likely to be present, requiring open reduction

Pathology

Fractures of the PIP joint can be divided into injuries with and without joint instability Treatment goals for fractures without joint

Volar view Lateral view

Figure 1 The bicondylar configuration of

the PIP joint provides intrinsic stability.

(Adapted with permission from Bowers

WH: The anatomy of the interphalangeal

joints, in Bowers WH [ed]: The

Inter-phalangeal Joints New York: Churchill

Livingstone, 1987, p 3.)

Figure 2 Sagittal view of the PIP joint illustrates the relative positions of the central slip, volar plate, collateral ligament, and accessory collateral ligament (Adapted with permis-sion from Bowers WH: The anatomy of the interphalangeal joints, in Bowers WH [ed]:

The Interphalangeal Joints New York: Churchill Livingstone, 1987, p 11.)

Proper collateral ligament

Central slip

Recess

Middle phalangeal attachment

of central 80% of volar plate

Accessory collateral ligament

Proximal lateral checkrein

subluxation are similar to those for

other articular fractures: reduction

and stability of the fracture

frag-ments, restoration of articular

con-gruity, and joint mobilization

There are no specific data relating

the amount of displacement of the

articular surface to clinical

out-come Patients must be specifically

informed by the surgeon regarding

the risks and benefits of surgical

intervention for fractures with

small amounts of displacement

Fractures accompanied by joint

subluxation are more difficult to

manage Joint subluxation or

dislo-cation must be reduced and must

not be allowed to recur during

treatment Maintenance of joint

reduction is a primary goal of

treat-ment and may dictate postinjury

management, such as limitation of

early mobilization of the digit

Other factors must be considered in

determining treatment in addition

to the presence or absence of

sub-luxation Fractures of the PIP joint

are frequently complicated by open

wounds and may be accompanied

by injury to tendons, nerves, blood

vessels, or skin The complexity of

the injury to the bone and adjacent

soft-tissue structures must be

con-sidered when selecting from among

the various treatment options For

example, a substantial soft-tissue

injury may limit the options

advis-able for a given fracture pattern

Proximal Phalanx

Fractures

Fractures of the articular surface of

the proximal phalanx can involve

one or both condyles The

mecha-nism of injury is usually a direct

blow and an axial load to the tip of

the digit, as from impact by a ball in

a sporting activity The digit must

be carefully inspected for the

pres-ence of rotational deformity

Dis-placement may be seen on an

ante-roposterior radiograph, but can be

confirmed only with a true lateral radiograph of the digit when the two condyles are not superimposed

Oblique radiographs may be neces-sary to observe displacement not apparent on anteroposterior and lat-eral films

Unicondylar injuries are poten-tially unstable even when nondis-placed The treatment options for these fractures are (1) immobiliza-tion, with frequent clinical and radiographic observation, and (2) operative stabilization with percu-taneous pinning and early mobi-lization Displaced or malrotated injuries require reduction and stabi-lization, which is often possible with indirect reduction and percu-taneous pinning If open reduction

is required, soft-tissue attachments must be maintained to preserve vascular supply At least two im-plants are recommended to obtain rotational stability of the fracture

Screw fixation for open reduction and internal fixation (ORIF) is pref-erable, as it can provide sufficient stability for early mobilization if the quality and size of the condylar fragment are adequate The combi-nation of one screw and one Kirsch-ner wire (K-wire) is acceptable if placement of two screws is techni-cally difficult Although screws may provide more stability, place-ment of screws is technically more challenging than insertion of K-wires Screw fixation requires more soft-tissue stripping and may result

in overcompression of a commi-nuted fracture

Surgical treatment predictably leads to union However, some loss

of motion is common Weiss and Hastings6 reported on 38 fractures treated by either operative or non-operative methods, with only a mean active range of PIP joint mo-tion of 71 degrees at a mean

follow-up interval of 3 years

Bicondylar fractures are usually unstable injuries and may be associ-ated with substantial comminution

of the articular surface Closed re-duction and pinning are occasionally acceptable, but open reduction is commonly required to reduce the condyles The choice of a dorsal or midlateral approach is dependent on the plan for fixation The dorsal approach affords better exposure of both condyles but necessitates more dissection of the extensor mechanism and therefore increases the likeli-hood of adhesions A midlateral incision is technically more demand-ing and places the digital neurovas-cular bundle at greater risk It pro-vides better exposure for lateral hardware placement and is not un-der any tension during postsurgical rehabilitation Mini-condylar blade-plate fixation is not commonly re-quired but may be utilized This technique provides adequate stabil-ity for early joint mobilization but requires more surgical exposure and technical precision The rate of com-plications associated with plate and/or screw fixation in the digits (e.g., stiffness, delayed union, and infection) is substantial.5 Fixation with K-wires and/or interfragmen-tary screws can be augmented with a mini–external fixator External fixa-tion devices are rarely used alone for proximal phalanx fractures but can function as adjunctive fixation if the surgeon remains concerned about joint or fracture stability after inter-nal fixation

Middle Phalanx Fractures

Intra-articular fractures of the mid-dle phalanx require careful atten-tion because apparently benign injuries can lead to joint instability and severe functional problems These injuries have been grouped according to the anatomic location

of the fracture and the presence of joint instability The common frac-ture patterns are those affecting the dorsal lip, the palmar lip, or both surfaces (pilon type) By definition,

fracture-dislocations include a

liga-mentous injury or ligaliga-mentous

insufficiency resulting from the

fracture

Dorsal Lip

Fractures of the dorsal lip of the

middle phalanx occur as a result of

hyperflexion of the PIP joint

Usu-ally 25% of the articular surface or

less is involved Characteristically,

comminution of the articular surface

is limited, and articular depression

and joint instability are infrequent

A dorsal lip fracture can be an

avul-sion of the insertion of the central

slip of the extensor mechanism If

the fracture is nondisplaced, the

joint surface is congruent, and the

joint is reduced, the digit can be

splinted in extension Active motion

of the distal interphalangeal (DIP)

joint is permitted Gentle

mobiliza-tion of the PIP joint can begin 3 to 4

weeks after injury; however,

splint-ing should be continued for 6 to 8

weeks after injury If the digit lacks

motion at 8 weeks, more aggressive

modalities to regain motion may

begin (e.g., dynamic flexion

splint-ing or progressive static splintsplint-ing)

Displaced fractures require

op-erative intervention The central

slip is reattached to avoid a

bou-tonnière deformity.7 The goal is

stable fixation for immediate

mobi-lization These injuries are

typical-ly approached dorsaltypical-ly, and the

options include mini-screw fixation

if the fragment is adequate in size

and tension-band or K-wire

fixa-tion for smaller fragments

Palmar Lip

Fractures of the palmar lip are

more common than injuries to the

dorsal lip and may be caused by

either hyperextension or axial

load-ing Radiographically, injuries

resulting from either of these

mech-anisms can be deceptively similar

Hyperextension injuries are

avul-sions of the joint surface by the

volar plate, which usually involve

less than 30% of the joint surface and have little articular comminu-tion In contrast, injuries from lon-gitudinal impaction are character-ized by articular comminution, which may involve the entire artic-ular surface

Treatment of palmar lip fractures can be one of the most challenging problems faced by orthopaedic sur-geons These injuries frequently result in unstable joints with persis-tent joint subluxation, and delay in diagnosis is associated with a poor outcome There is a direct relation-ship between the amount of the surface that has been fractured and the stability of the joint Fractures involving 30% or less of the articu-lar surface are typically stable after reduction Fractures involving 50%

or more of the articular surface tend

to be unstable These numbers are only guidelines, however, and sta-bility must be tested after reduction

The primary goal of treatment is

to restore joint stability; restoration

of the articular surface is some-times difficult and is less critical to the outcome.8-10 Imperfect reduc-tion of the articular surface has a less significant effect on functional outcome than a delay in achieving

a stable reduction

It is important to check for subtle signs of instability on postreduction lateral radiographs of the digit A true lateral radiograph should show a congruent joint space with two parallel surfaces Divergence

of the posterior articular surfaces from the central portion of the joint (a “V” sign) indicates incomplete re-duction (Fig 3).11

A small volar-plate avulsion may present acutely or subacutely, with the patient complaining of persistent stiffness and swelling weeks or months after a “jammed”

finger Mechanically, the joint is typically stable; however, patients are likely to experience some swelling and stiffness for as long as

6 months For comfort, the digit

may be splinted in 20 degrees of flexion, but for no more than 7 days Active motion should be started early: buddy taping for several weeks allows active motion

as well as protection and support

by the adjacent finger This tech-nique is particularly helpful in ath-letes, who are likely to subject the injured digit to a second episode of trauma Overtreating these injuries with prolonged splinting may result in a stiff joint Patients with difficulty regaining motion may need supervised therapy for pas-sive manipulation, edema control, and dynamic splinting

In the unstable joint, dorsal sub-luxation typically occurs at less than full extension and is usually managed with an extension-block splint set at 10 to 20 degrees less extension than the stable point The patient is encouraged to

active-ly flex the finger in the splint There are many types of extension-block splints,12 which a therapist can fabricate from heat-sensitive plastic The plastic can be reheated and molded to the degree of flexion required over the course of treat-ment The allowed range of mo-tion is increased to full extension over 3 to 8 weeks, depending on the stability of the injury Frequent

Figure 3 Light 11 described a dorsal “V” sign on a lateral radiograph that indicates PIP joint subluxation, illustrating that the articular surfaces are neither congruent nor parallel.

Subluxated Normal

clinical and radiographic follow-up

is required for the first 3 weeks to

assess whether subluxation has

re-curred

As the size of the volar fragment

increases, the degree of instability

usually increases If the entire

col-lateral ligament is attached to the

palmar fragment, the joint will be

unstable The criteria for

extension-block splinting utilized with smaller

fragments can be employed The

practical use of extension-block

splinting is limited by the degree of

flexion required to maintain

reduc-tion If flexion beyond 60 degrees is

required, the active arc of motion is

minimal, and other options should

be considered

For unstable fractures,

immobi-lization in a reduced position with

external support or with a

transar-ticular K-wire can be used

How-ever, immobilization is likely to

lead to permanent joint

contrac-ture, especially if maintained for

more than 3 weeks

Extension-block pinning with K-wires (Fig 4)

requires less postoperative

supervi-sion to maintain reduction than

extension-block splinting The joint

is reduced, and a K-wire is inserted

percutaneously into the head of the

proximal phalanx, parallel to the

shaft The wire is placed with the

joint in full flexion to prevent

re-striction of flexion by the extensor

mechanism (which is transfixed by

the wire).13 Early active motion is encouraged

If the joint can be reduced but not practically maintained by closed means, several open tech-niques can be used to maintain reduction If the volar fragment is not comminuted, open reduction and fixation with one or more K-wires or mini-screws or a tension band is possible If the fragments are comminuted, open reduction can be technically challenging or impractical because of inability to achieve adequate fixation sufficient for early motion A number of techniques use ligamentotaxis to maintain general joint reduction

These methods utilize traction by means of a pin placed percuta-neously through the middle pha-lanx or a hinged external fixation device Traction apparatuses have been reported by several authors.8

Complications reported with trac-tion techniques include pin-track infection, pin loosening, residual joint depression, loss of PIP and DIP joint motion, and pain

Agee14 has published a method

of maintaining reduction by pro-ducing a force couple with three K-wires and a rubber band The force couple is arranged to pull the head

of the proximal phalanx dorsally and the base of the middle phalanx volarly to maintain joint reduction (Fig 5) This technique requires a

stable dorsal shelf of intact middle phalanx to resist axial displacement The method has been criticized for being technically difficult.15 Com-plications include resubluxation, loss of DIP and PIP joint motion, and pyarthrosis

Use of hinged external-fixation devices mobilizes the injured joint while maintaining reduction These devices are designed to approxi-mate PIP joint motion about a point

in the head of the proximal phalanx and can be employed with or with-out internal fixation This tech-nique allows early mobilization while maintaining joint and frac-ture reduction through ligamento-taxis There are currently few pub-lications that describe indications, outcome, and complications in de-tail Complications include pin-track drainage, pin loosening, deep infection, recurrent subluxation, and arthritic changes.9,16,17

Fractures of the volar lip that in-volve more than 50% of the articular surface are almost universally un-stable and require an open proce-dure to recreate volar support and prevent redislocation Although traction or external fixation can be used to maintain joint reduction, these techniques rarely achieve reduction of the articular surface Because of the degree of comminu-tion and instability, a combinacomminu-tion

of ORIF and external fixation or

Figure 4 A, Radiograph of a patient with a dorsal fracture-subluxation of the PIP joint involving 40% of the articular surface

B, Intraoperative radiograph shows extension-block pin in place and reduction of the PIP joint.

traction may be required The

indi-cations for ORIF include

involve-ment of 25% or more of the joint

surface, displacement of the

articu-lar surface, and joint instability.18

The approach is through a volar

zigzag incision, opening the flexor

tendon sheath between the A2 and

A4 pulleys Exposure of the

frac-ture may require release of the

col-lateral ligaments and volar plate

The joint can be hyperextended to

improve visualization of the

articu-lar surface Depressed articuarticu-lar

fragments are elevated to restore the

articular surface Bone grafting of

defects under impacted fragments

will increase stability Screw

fixa-tion is used for large fragments, and

K-wire or cerclage fixation is used

for smaller comminuted fractures

Although ORIF is the best option

for restoring the articular surface,

high complication rates have been

reported In the only published

series comparing ORIF with

trac-tion or immobilizatrac-tion,19 ORIF did

not result in superior motion or

de-crease arthritic changes Reported

complications include pyarthrosis,

loss of fixation and reduction,

arthritic changes, pain, DIP and PIP

joint contracture, and loss of grip

strength

Volar-plate arthroplasty as

de-scribed by Eaton is also an option if

the articular surface cannot be

re-paired.20 The indications for this procedure differ among surgeons

Some authors primarily use the tech-nique to salvage late dislocations;

others prefer this procedure for many acute fracture-dislocations.10,21

The joint is exposed by using the approach described for ORIF The volar plate is incised along its lateral margins, freeing it from the collat-eral ligaments The distal end of the volar plate is freed from any bone fragments A shallow transverse trough is created across the entire middle phalanx at or near the junc-ture between the intact articular sur-face and the fracture defect The trough must be symmetrical in the coronal plane The volar plate is ad-vanced into the defect and held in place with sutures or pull-out wires through bone These can be secured over a dorsal button or on the dor-sum of the middle phalanx beneath the extensor mechanism The ad-vanced volar plate resurfaces the palmar portion of the middle pha-lanx and assists in joint stabilization (Fig 6) A congruent reduction must

be achieved; a K-wire is frequently placed with the joint in slight flexion

to maintain the reduction for several weeks

The most common complication

is a flexion contracture of the PIP joint Other complications of this procedure include redisplacement,

angular deformity, and loss of motion at the PIP and/or DIP joint

Dorsal and Palmar Lip

Injuries caused by axial loading, which involve both the palmar and dorsal cortices, have been referred

to as pilon-type fractures The artic-ular surface has been described as exploding from the axial forces, causing these injuries to exhibit the greatest amount of joint disruption These fractures include components

of central depression with com-minution and displacement of the articular surface, as well as the volar and dorsal cortices Techniques for treatment of these injuries include immobilization, traction, external fixation, and ORIF It is difficult to compare the results of treatment from one published series to another because the fracture classifications and indications are not uniform Because of the technical complex-ity and poor outcomes associated with ORIF, many surgeons prefer either traction or external fixation The joint surface is not exposed, and reduction is achieved through liga-mentotaxis Reduction of the articu-lar surface is always imperfect.22

Traction is exerted by attaching a rubber band to a pin placed in the middle phalanx distal to the articu-lar surface (Fig 7) The rubber band

is connected to an external splint that is fabricated to allow motion Early motion reduces contracture of the soft-tissue envelope.23,24 Trac-tion is maintained for about 6 weeks The joint is initially mobi-lized within a limited range, which

is based on fluoroscopic examina-tion of joint stability After 2 to 3 weeks, the range is increased Proponents of this technique emphasize the articular remodeling that can occur with passive motion Therapy is often required after re-moval of the traction splint; how-ever, substantial motion is gained after removal of the external de-vice Schenck8 reported an active

Figure 5 A, Representation of the Agee force-couple technique The force couple is

con-structed from three K-wires and a rubber band B, Use of the Agee force-couple technique

in the treatment of a subacute fracture-dislocation.

Rubber band

Middle phalanx

Proximal

phalanx

Smooth

0.045-inch

K-wires Tape

Threaded 0.062-inch K-wire

range of motion of 50 degrees at

splint removal, with 50% of

pa-tients having active motion of 40

degrees or less at traction removal

At long-term follow-up, the

aver-age arc of active motion was 87

de-grees Articular impaction cannot

be reduced by traction; therefore,

some authors have questioned

whether results will deteriorate

over the long term

Stern et al19 compared different

treatments, including

immobiliza-tion, tracimmobiliza-tion, and ORIF All three

methods resulted in some loss of

DIP and PIP joint motion

Extension-block splinting led to loss of motion

and a high likelihood of

symptom-atic arthritis A higher rate of

com-plications was associated with ORIF,

including the inability to achieve

adequate fixation to begin early

mobilization in several cases The

authors concluded that skeletal

traction provided motion

compara-ble to that obtained with ORIF with

a lower complication rate

Regardless of the treatment

selected, careful follow-up and

su-pervision of rehabilitation are

essen-tial Radiographs should be

ob-tained at least weekly for several

weeks, as early loss of reduction can

occur with all methods, particularly

those utilizing early motion

Recur-rent subluxation is the result of

in-adequate treatment or poor patient

compliance and should be treated

operatively when discovered, as the results of salvage surgery are ac-ceptable but worse than the results

of treatment of the acute injury

Rehabilitation

Loss of finger motion can be ex-pected if mobilization is not insti-tuted early; however, some loss will occur regardless of treatment and rehabilitation The goal of sur-gical or nonsursur-gical treatment is to initiate motion as soon as stability can be verified In adults, immobi-lization for a period of 4 weeks or longer is likely to produce a sub-stantial contracture, which will be difficult to overcome with rehabili-tation Rehabilitation must be tai-lored to the individual and the

injury In general, however, active motion is usually initiated early, while use of active assisted and passive modalities is delayed until the fracture has healed

In fractures that have been

treat-ed in a clostreat-ed manner, active mo-tion is initiated by 3 to 4 weeks after injury, but splinting continues until fracture healing has occurred Typi-cally, healing occurs by 6 weeks Passive motion and dynamic splint-ing may begin around that time if indicated

The time course is similar for fractures treated with closed re-duction and percutaneous pinning

In some instances, active motion is initiated with the pins in place Pin sites must be carefully fol-lowed, as pin complications may

be higher if the digit is mobilized

Figure 6 A, Volar-plate arthroplasty technique B, Radiograph shows a chronic

fracture-dislocation of the PIP joint C, Radiograph obtained after treatment with volar-plate

arthroplasty and a hinged external fixator.

Volar view

Lateral

view

Volar plate

Volar plate

Pull-out suture button Middle phalanx

Proximal phalanx

Figure 7 Range of motion 4 weeks after application of a traction device.

A

In the setting of stable fixation, the

digit is protected with an external

splint, but active range of motion is

begun within 1 week Passive

mo-tion and dynamic splinting are

de-layed until fracture healing, which

lags several weeks behind healing

of fractures treated in a closed

manner

With an articulated fixator,

ac-tive or passive motion may be

initi-ated within the first week The

fix-ator is removed at 4 to 6 weeks,

and rehabilitation is progressed

according to fracture healing and

joint stability Strengthening mo-dalities are usually limited or avoided until solid union has occurred and range of motion has been regained

Summary

Early recognition of joint instability

is essential for adequate treatment

of injuries of the PIP joint These in-juries are often misdiagnosed as being merely a “jammed finger,” re-sulting in treatment delays

Reduc-tion of the joint is the primary goal

of treatment, followed by recon-struction of the articular surface, if technically feasible The surgeon should be facile with a number of techniques, which need to be care-fully selected for the individual patient and injury In general, treat-ment options that require more than

3 to 4 weeks of immobilization should be avoided Loss of some motion should be expected, especi-ally in the case of more severe in-juries; however, functional motion can often be achieved

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