Case Study: PIP joint injury

20th August 2012 Thuy Tran

Outline

• Anatomy

• Mechanism of Injuries

• Treatment Protocols

• Case Study- “Jack”

• Possible Complications

• Discussion

• Summary

Anatomy- PIP joint

PP- Proximal Phalanx FT- Flexor Tendon

MP- Metacarpal Phalanx ACL- Accessory Collateral Ligament

ECS- Extensor Central Slip VP- Volar Plate

PCL- Proper Collateral Ligament

Anatomy- PIP joint

Volar plate injury

Forced

Hyperextension

Axial

Loading

Swan Neck Deformity

Central slip injury

Forced Hyper-flexion

Boutonniere’s Deformity

Treatment Protocols

Primary Goal

To restore joint stability, manage pain, swelling and maintain functional range

of movement.

Volar Avulsion Rx

Progressive extension splint with protected active motion:

- Week 1: 30 degrees

- Week 2: 20 degrees

- Week 3: 10 degrees

- Week 4: Full extension

- Buddy strapping for two weeks (Leggit & Meko, 2006)

Dorsal Avulsion Rx

1. Large Fragment (>30 %)

• Open reduction and fixation followed by early active motion

• Splint PIP joint in extension for 3- 6 weeks (Leggit & Meko, 2006)

2. Insignificant Fragment or none

• Splint PIP joint in extension for 6 weeks

- Followed by buddy tape for 2 weeks (Frieberg et al,2006)

“Jack”

“Jack”

Occupational Goal:

To return to playing

football for the rest of the

season.

Person

• 18 years old

• Football injury

• “… avulsion fractures to the volar

and dorsal lips of the left ring finger

base of the middle phalanx”

• “Marked surrounding soft tissue

thickening”

• Motivated to return to football

ASAP

• Non-dominant hand

Occupation

• Engineer student

• Plays football twice

weekly

Environment

•Referred by GP

•Presented 2 days post

injury date

•Exam period

• Football season

• Weekly sessions

“Jack”

Initial Assessment

Pain

Oedema

AROM

Elson’s Test

Possible complications to consider • Pain

• Reduced AROM

• Ongoing swelling

• Stiffness

• Instability

• Fixed flexion deformity

• Premature degenerative arthritis

• Swan necking

• Boutonniere's Deformity

How would you splint Jack?

Jack’s Rehabilitation

Initial Assessment Problems • Joint instability

• Pain

• Moderate/ severe swelling

Goals • Protect PIP joint, manage pain and reduce swelling

Solutions • Finger dorsal blocking splint with PIP joint in 15

degrees flexion, DIPJ 0 degrees

• Lycra finger stall

• No exercises

Week 2

Problems • Pain

• Mild swelling

• DIP joint stiffness

Goals • Protect PIP joint, manage pain, reduce swelling, reduce

stiffness of DIP joint

Solutions • Continue with finger dorsal blocking splint with PIP joint

in 15 degrees flexion, DIPJ 0 degrees

• Continue with lycra finger stall

• DIP joint blocking exercises

Week 3

Problems • Pain

• Stiff PIP and DIP joints

Goals • Protect PIP joint, manage pain and stiffness of the

DIP and PIP joints

Solutions • Finger volar blocking splint with PIP joint in 10

degrees flexion, DIPJ 0 degrees

• Continue with DIP joint blocking exercises , gentle passive PIP joint exercises

Week 4 Problems • Increased pain

• Stiff PIP and DIP joints

Goals • Protect PIP joint, manage pain and maintain AROM

Solutions • Finger barrel splint, with PIP joint in 0 degrees and

DIP joint free

• Active extension and flexion of DIP joint

• Stopped passive PIP joint exercises

Week 5 Problems • Pain

• Stiff PIP joint

Goals • Protect PIP joint, manage pain and maintain AROM

Solutions • Lycra buddy socks

Week 6 Problems • Avulsion fractures still healing

• Achy pain

Goals • Protect PIP joint, manage pain and maintain

AROM

• Return to football

Solutions • Full finger barrel splint for football

• Continue with lycra buddy stall

Week 8 Problems • Mild discomfort

• Reduced strength

Goals • Protect PIP joint, manage pain and grip strength

Solutions • Gentle strengthening program

Week 10 AROM:

Week 12

Stable joint Reduced swelling Full AROM Reduced pain Good strength

Week 12

ACHIEVED FOOTBALL GOAL!!!

Summary

• PIP joint injuries can be complex

• Possible complications

• Clinical Reasoning

• Holistic approach

Reference List Bindra, R., Foster, B. (2009). Management of Proximal Interphalangeal Joint Dislocations in Athletes. Hand Clinic, 25, 423-435. Blazar, P., Steinberg, D. (2000). Fractures of the Proximal Interphalangeal Joint. Journal of the American Academy of Orthopaedic Surgeons, 8(6), 383-390 Claude, S., Williams, IV. (2012). Proximal Interphalangeal Joint Fracture Dislocations. Hand Clinic, 1-8. Cooper, S. (2006). Volar Plate Avulsion Fractures. Journal of the Accident and Medical Practitioners Association 3(1), 2-8. Freiberg, A., Pollard, B., Macdonald, M., Duncan, M. (2006). Management of Proximal Interphalangeal Joint Injuries. Hand Clinic, 22, 235-242.

Reference List Leggit, J., Meko, C. (2006). Acute Finger Injuries: Part I. Tendons and Ligaments. American Family Physician, 73(5), 810-816. Lo, I., Richards, R.S. (1995). Combined Central Slip and Volar Plate Injuries at the PIP joint. Journal of Hand Surgery, 20(3), 390-391. Ng, C. Y., Oliver, C.W. (2009). Fractures of the Proximal Interphalangeal Joints of the Fingers. The Journal of Bone and Joint Surgery, 91-B(6), 706-712. Pratt, Burr and Grobbelaar (2002) A prospective review of open central slip laceration repair and rehabilitation. Journal of Hand Surgery 27B (6):530-534. Saito, S., Yoshihisu, S. (2011). Biomechanics of the Volar Plate of the Proximal Interphalangeal Joint: A Dynamic Ultrasonographic Study. Journal of Hand Surgery, 36A, 265-271.

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