Proximal Inter-Phalangeal Joint Finger Dislocations

Buddy Strapping  Elevation of the Limb


Initial evaluation and definition of injury

  1. Consider this injury in the painful finger that is swollen proximally. This is commonly termed only a sprain but it may represent a dislocation that has been reduced. It should be treated as a dislocation.
  2. Dislocations are usually a spectrum of injuries involving the volar plate, collateral ligaments of the joint, joint capsule as well as the central slip.
  3. Dislocations should be described as dorsal or volar and also to which side the distal part has dislocated. For example dorso-radial.
  4. The key to diagnosis is a good lateral x-ray focussed on the PIPJ.
  5. Observe for congruent reduction, small avulsion fractures of the volar lip of the middle phalanx as well as the size of the dorsal fracture (relative to the joint) if present.
  6. Observe for rotational deformities.


Initial Management

  1. Reduce obvious dislocations and realign. An inter-metacarpal block works well for this purpose.
  2. Always send for a follow-up x-ray after reduction was done.
  3. Open wounds or irreducible dislocations must be prepared for surgery and should be treated as an open fracture.
  4. Test for stability of the collaterals and in a volar-dorsal plane after reduction while the finger is still blocked.
  5. The finger can be buddy strapped.
  6. All PIPJ dislocations, suspected dislocations and fracture dislocations must be reviewed within in a week by a hand surgeon.
  7. Please warn the patient that the rehabilitation period for these injuries is between 8-12 weeks and that neglect will result in a stiff and swollen finger.


Definitive Management

  1. Most dislocations will be treated conservatively, facilitated by a hand therapist.
  2. Subluxation of the joint or intra-articular fractures involving > 25% of the joint surface, instability or open dislocations are treated surgically.


Rehabilitation

  1. The time frame of rehabilitation is a minimum of 6 – 8 weeks. Early noncompliance can result in a stiff painful finger.
  2. The finger is initially splinted to provide stability and support to the injured structures. Buddy strapping or a shotgun sleeve provides collateral stability and facilitates mobilising the finger. A dorsal blocking splint in 20° flexion will prevent dorsal subluxation and facilitate healing of the volar structures.
  3. The therapist aids in reducing the swelling, which limits movement and increases the risk of fibrosis.
  4. Early active motion is encouraged by the therapist to prevent scarring, ensure good gliding of tendons and prevent tightness of the joint.
  5. It is critical to prevent deformities. The therapist will utilise different splints to prevent deformities like fixed flexion contracture of the PIPJ.