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

Abstract

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.

Figure 1

This lateral schematic of the proximal interphalangeal joint (PIPJ) emphasizes the structures important for stability, specifically the proper collateral ligaments, the volar plate, and the central slip of the extensor mechanism. P1 = proximal phalanx. P2 = middle phalanx.

Figure 2

PIPJ stability depends on the amount of intact joint surface. Fractures involving 30% or less of the joint surface are almost always stable, whereas fractures of more than 50% of the joint surface are likely to be unstable. Fractures of between 30-50% of the joint surface are more variable, and stability may be tenuous. P1 = proximal phalanx. P2 = middle phalanx.

Figure 3

Lateral radiograph showing dorsal PIPJ dislocation.

Figure 4

Lateral radiograph showing volar PIPJ dislocation.

Figure 5

Lateral radiograph showing dorsal PIPJ fracture-dislocation with small volar lip avulsion fracture.

Figure 6

(A) This lateral schematic of the PIPJ shows a volar lip avulsion fracture and dorsal subluxation of the joint. The V-shaped gap shown in blue emphasizes the non-congruency of the dorsal portion of the joint, often referred to as a “V-sign.” P1 = proximal phalanx. P2 = middle phalanx. (B) This lateral radiograph demonstrates the “V-sign” due to PIPJ subluxation.

Figure 7

This lateral schematic illustrates what can occur with PIPJ flexion after volar lip fracture. (A) Normal gliding motion of the joint, with maintenance of congruity. (B) Abnormal “hinging” of the joint, as the middle phalanx pivots on the fracture line, rather than maintaining congruity. P1 = proximal phalanx. P2 = middle phalanx.

Figure 8

This schematic shows the step-by-step technique to achieve percutaneous reduction of central articular fragments in PIPJ fracture-dislocations, with K-wire stabilization of the articular surface. (A) K-wire inserted dorsally, distal to impacted articular fragment, (B) K-wire used as a lever to reduce the articular fragment, (C) Articular surface can be stabilized with multiple K-wires placed just distal and parallel to the articular surface.

Figure 9

Evolution of dynamic traction devices for comminuted PIPJ fractures and fracture-dislocations. From Agarwal et al. Ann Plast Surg 2007;58: 489–495, used with permission.

Figure 10

Technique for design of hemi-hamate arthroplasty for the PIPJ. The dimensions A, B, and C, are measured from the defect in the middle phalanx (P2) and carefully plotted out on the dorsal, distal hamate to obtain a graft of the appropriate size. MC = metacarpal. CMC = carpometacarpal joint. PIP = Proximal interphalangeal joint.

Figure 11

Lateral radiograph showing dorsal lip fracture with minimal volar subluxation.

Figure 12

Lateral radiograph showing pilon fracture of the PIPJ (as well as an incidental mallet fracture of the distal interphalangeal joint).