PIPJ dislocations

PIPJ Dislocations

 

Types

- Dorsal

- Lateral

- Volar

 

Stabilisers

 

Proper collateral ligaments

- primary stabilisers

- insert volar third of the base of PP

 

Accessory collateral ligaments

- inserts on and stabilises lateral margin of volar plate

 

Volar plate

- thick distally

- thin proximally, allowing collapse during flexion

 

Dorsal dislocations PIPJ

 

Most common joint injury of the hand

- hinge joint permitting 110^o ROM

- volar plate fails distally

- collateral ligaments may be intact

- may be a fracture

 

Mechanism

- hyperextension

- axial loading of the flexed fingertip

 

Examination

 

 

Stability

- dependant on integrity of the collateral ligaments

- if fragment is > 40 – 50%, the attachment of the true collateral ligament is lost

- unstable

 

Eaton Classification

 

I Simple hyperextension

- buddy strap, early ROM

 

II Dorsal dislocation

- reduced and assess stability

- buddy strap if stable

- extension splint 10^o further than instability

- each week extend further by 10^o

- early aggressive ROM program

 

 

IIIA  fracture < 40% volar articular surface

- closed treatment with extension block

 

 

IIIB fracture > 40% + Pilon fractures

- inherently unstable

- extension blocking requires extreme flexion for stability, so risk of flexion contracture is high

- aim for congruent articular surface and early ROM

 

 

IIIB Treatment Options

 

1.  Dorsal Blocking K wire

2.  Slade Dynamic Distraction External Fixator

3.  Compass Hinge

4.  Volar Plate Arthroplasty

 

Dorsal Blocking K wire

 

Technique

- flexion P2

- dorsal entry into P1

- 40^o flexion

- early removal at 3/52

- Improvement compared to extension blocking

 

Suzuki / Slade Dynamic Distraction external fixator

 

Concept

- closed reduction through ligamentotaxis

- early motion of PIPJ

 

Technique

- transverse K wire in rotational centre / head P1

- transverse K wire distal P2

- attached by rubber bands

- third K wire mid-diaphysis P2,  prevents dorsal translation of MP

 

Deshmuhk S etal JBJS Br July 2004

- 12 patients complex fracture dislocations PIPJ

- treated with modified pin / rubber band system

- average 84^o ROM

- nil radiological osteolysis or clinical osteomyelitis

- all returned to occupation

 

Hotchkiss designed PIP compass hinge

 

Technique

- K wire to centre head of P1 to set centre rotation

- 2 x  K wires each in P1 / P2

- barrel over centre of rotation

- options of active motion, passive ROM, locked

 

Bain I JBJS Br 1998

- 12 patients

- mean range of motion 12 – 86^o

- only half presented within 2 week of injury

- combined operation with ORIF and volar plate arthroplasty

- nil osteomyelitis

- hinge on for 6 weeks

 

Volar plate arthroplasty / Volar plate advancement

 

Technique

- incise accessory collaterals to release volar plate

- excise bony fragment

- suture proximal volar plate into defect

- pass sutures through drill holes in base P2

- tie over button dorsally

- dorsal blocking splint 4 - 6 / 52

 

 

Volar PIPJ dislocations

 

 

A.  Straight volar dislocation

 

Assessment of central slip post reduction critical

- if can active extend to within 30^o, splint extended

- if nil active, surgical repair to prevent boutonniere

 

B.  Volar rotary subluxation

- condyle button holes between central slip and lateral band

- irreducible dislocation

 

Lateral PIPJ dislocations

 

Rupture of one collateral ligament and volar plate

- may be bony avulsion

 

Management

- reduce and hold in extension 2/52, then protected ROM

- can perform primary repair or reconstruct