- Email: [email protected]
Management of Proximal Interphalangeal Joint Hyperextension Injuries: A Randomized Controlled Trial
SCIENTIFIC ARTICLE
Management of Proximal Interphalangeal Joint Hyperextension Injuries: A Randomized Controlled Trial Nikolaos K. Paschos, MD, PhD, Khaled Abuhemoud, MD, Apostolos Gantsos, MD, Grigorios I. Mitsionis, MD, PhD, Anastasios D. Georgoulis, MD, PhD
Purpose To compare the effectiveness of buddy strapping and aluminum orthosis for treatment of proximal interphalangeal (PIP) joint hyperextension injuries. We also evaluated the effect of age on the outcome by comparing our results in adults and children. Methods One hundred twenty-one consecutive patients with a PIP joint hyperextension injury of the index, middle, ring, or little finger and without fracture were evaluated. Patients were randomly assigned into 2 groups. In the first group, treatment included buddy strapping of the injured finger to its neighbor noninjured finger for a week. In the second group, immobilization was secured with an aluminum extension blocking orthosis for a week in 15 flexion. Assessment of motion, edema, pain, and strength were performed weekly for the first month and then at 3, 6, and 12 months after injury. Results The patients treated with buddy strapping exhibited similar outcomes compared with those treated with aluminum orthoses. In patients with full recovery, buddy strapping allowed earlier recovery of motion and resolution of edema and pain compared with aluminum orthosis immobilization. Furthermore, PIP injuries appear to have better outcomes in children than in adults. Conclusions Buddy strapping is easy and effective treatment for PIP joint hyperextension injuries. (J Hand Surg Am. 2014;39(3):449e454. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic I. Key words Finger, hyperextension injury, proximal interphalangeal joint (PIP), randomized controlled trial (RCT), volar plate (VP).
H
proximal interphalangeal (PIP) joint represent one of the most common injuries of the hand, especially during sports. Despite their frequency, these YPEREXTENSION INJURIES TO THE
From the Department of Trauma and Orthopaedic Surgery, University of Ioannina, Greece; and the Department of Biomedical Engineering and Orthopaedic Surgery, University of California, Davis, California. Received for publication July 12, 2013; accepted in revised form November 19, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Nikolaos K. Paschos, MD, PhD, Department of Biomedical Engineering, University of California, Davis, CA; e-mail: [email protected]. 0363-5023/14/3903-0006$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.11.038
injuries are occasionally underestimated. This is mainly due to the negative x-ray findings, which do not exclude the presence of a major injury to the soft tissues stabilizing the joint including the volar plate (VP).1,2 Meticulous clinical examination and adequate knowledge of the soft tissue anatomy can identify these nonosseous injuries and prevent late complications, such as persistent pain and edema, loss of normal motion, deformity, and post-traumatic arthritis.3,4 Forced hyperextension of the joint may lead to various types of injury, ranging from a partial tear of the VP to an avulsion fracture of the phalanx. There is no consensus regarding the ideal treatment for these injuries, with some hand surgeons favoring
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
449
450
COMPARISON OF TREATMENT MODALITIES FOR PIP INJURIES
FIGURE 1: Eaton Classification for injuries of the volar plate and avulsion fractures.10 Type I: hyperextension injury to the volar plate and collateral ligaments, with no dislocation of the joint or presence of fracture. Type II: presence of dorsal dislocation of the PIP joint associated with volar plate and collateral ligament injury. Type III: presence of fracture (typically at the base of the middle phalanx), associated with the hyperextension injury.
immobilization whereas others suggest early active mobilization.5e7 A recent systematic review concluded that there was insufficient evidence regarding the efficiency of immobilization in treating hyperextension injuries.5,8,9 The literature does not differentiate among the various types of injuries sustained and proposes similar treatment irrespectively of the type of injury. Furthermore, most studies have been conducted in children, because in this age group, PIP joint hyperextension injuries occur frequently. In addition, hyperextension injuries are problematic in those who develop chronic stiffness, pain, and flexion contracture. It is unclear whether there is an association between the treatment approach and the risk for complications. Therefore, we evaluated whether the type of treatment was a factor that could be related to the complication rate or outcome. The primary purpose of this study was to compare the outcome of 2 commonly used treatment approaches in patients who sustained PIP joint hyperextension injury without fracture. We also evaluated the effect of age on the outcome by comparing our results in adults and children. We hypothesized that J Hand Surg Am.
immediate mobilization of the injured joint would have a beneficial effect and that children would exhibit a better outcome compared with adults when a less restrictive treatment such as immediate mobilization would be applied. MATERIALS AND METHODS From January 2007 until December 2010, all consecutive patients who sustained a hyperextension injury without fracture (Eaton types I and II) to the PIP joint of any finger except the thumb were included in the study (Fig. 1).10 The criteria used for distinguishing between type I and type II injuries were either a history of dislocation that was reduced by the patient automatically, or the presence of dislocation at presentation to us. The study was approved by our institutional review board. All patients gave their informed consent to participate in the study. All patients had standard anteroposterior and lateral radiographs. The diagnostic criteria were a history of a hyperextension mechanism, edema, hematoma, or ecchymosis of the PIP joint and tenderness on its volar aspect. The exclusion criteria were r
Vol. 39, March 2014
451
COMPARISON OF TREATMENT MODALITIES FOR PIP INJURIES
TABLE 1. Study
Modification of the Incavo Scoring System Used for Scoring and Grading Outcome in the Present
SCORE
Pain
LOM
Edema
Strength
19e25
VAS 0e2
0 e10
100%e110%
80%e100%*
12e18
VAS 3e4
11 e20
111%e130%*
50%e79%*
6e11
VAS 5e7
21 e40
131%e150%*
30%e49%*
0e6
VAS 8e10
> 40
> 150%*
0%e29%
Maximum score
25
25
25
25
GRADING Excellent 75e100 Good 50e74 Fair 25e49 Poor 0e24 LOM, limitation of motion at PIP joint; VAS, visual analog scale. *Compared with the contralateral side. Modified with permission from Incavo SJ, Mogan JV, Hilfrank BC. Extension splinting of palmar plate avulsion injuries of the proximal interphalangeal joint. J Hand Surg Am. 1989;14(4):659e661.
comparison with the same finger on the other hand. A standard dynamometer (FEI, Irvington, NY) and a hydraulic pinch gauge (FEI, Irvington, NY) were used for assessment of grip and pinch strength, respectively, with the contralateral hand serving as a control. We assessed pain and tenderness over the VP with a visual analog scale. Return to daily activities and sports were monitored at every visit using the questionnaire of the Disabilities of the Arm, Shoulder, and Hand score.11 Patients with a score less that 5 were considered capable to return to their activities. Hand dominance, analgesic intake, and patient satisfaction were recorded at each visit. A modification of the Incavo scoring system6 was developed, which was used for scoring and grading outcome (Table 1). For nominal values, Fisher exact testing was used and a 1-way analysis of variance was used for comparing data between groups. Statistical significance was considered present at P < .05.
age younger than 2 years, presence of a middle phalanx volar lip fracture, instability implying a collateral ligament injury, presentation greater than a week after injury, presence of a tendon injury, and bilateral injuries. Diagnosis of instability was based on history and by testing for joint laxity in full flexion and in 30 of flexion, looking for subluxation during active motion, and noting incongruity or dislocation radiographically. Patients were randomly assigned into 2 groups using a computer-generated program where different treatment protocols were applied. In group A, treatment included buddy strapping of the injured finger to its neighbor noninjured finger for a week. The index and middle fingers were strapped together or the ring and little fingers were strapped together. In group B, immobilization was secured with an aluminum orthosis applied dorsally. The orthosis extended from the tip of the finger to the metacarpophalangeal joint at 15 of flexion for a week. After a week, unprotected mobilization was introduced in both groups. Orthopedic surgeons conducted the assessment at the time of presentation and evaluated the patients during the next several visits to the department. The surgeons were blinded to the treatment selected for each patient. This was ensured by the removal of the buddy strapping or orthosis prior to the evaluation. Assessment took place every week for the first month and then at 3, 6, and 12 months after injury. Range of motion (ROM) was evaluated with a digital goniometer. Edema was measured by evaluating the diameter of the finger at the level of the PIP joint in J Hand Surg Am.
RESULTS During the study period, 226 patients attended our department with a history of hyperextension injury to their index, middle, ring, or little finger. From these, fracture or instability was present in 94, 6 patients presented later than a week after injury, and 5 declined to participate. Therefore, 83 children with a mean age of 9 years (range, 3e16 y) and 38 adults with a mean age of 32 years (range, 16e51 y) were evaluated. Ten patients, (8 children and 2 adults) were lost in the follow up, which left group A with r
Vol. 39, March 2014
452
COMPARISON OF TREATMENT MODALITIES FOR PIP INJURIES
of patients between the 2 groups that demonstrated excellent results, good results, or excellent and good outcome grouped together. Patients with Eaton type II injuries demonstrated worse outcome in comparison with those with type I injuries irrespective of the treatment applied. Specifically, 87% of the patients with type I injury were graded as excellent, whereas 64% of the patients with type II injuries exhibited excellent outcome (P ¼ .02). Ninety-nine percent of patients with type I injuries demonstrated excellent and good outcomes compared with 80% with type II injuries (P ¼ .002). No type I injury resulted in poor outcome, whereas 3 type II injuries were graded as poor (P ¼ .01). There was no statistical difference in outcome between group A and group B in type I injuries. Similarly, no difference was detected between group A and group B patients in type II injuries. Excellent outcome was achieved in 89% of the children compared with 72% of the adults regardless of treatment (P < 0.05). The improved outcome in children was evident in both groups A and B (P ¼ .04 and P ¼ .02, respectively). There was no difference between the 2 treatment approaches in children. Three patients had poor outcomes, 2 adults in group A and 1 child, 11 years old, in group B. The poor outcomes were associated with limited motion, persistent edema, and severe pain. It was difficult to correlate these problems to the type of injury or treatment owing to the small number of patients. No other etiological factors were identified in these cases.
TABLE 2. Demographic Characteristics of the Patients Allocated in the 2 Groups GROUP A
GROUP B
Age, y (range)
22 (3e51)
23 (2e49)
Male:female
34:21
36:20
Children (n)
37
38
Hand dominance
Dominant 67%
Dominant 67%
Finger involved
Index 16%
Index 17%
Middle 32%
Middle 33%
Ring 31%
Ring 30%
Little 11%
Little 10%
55 patients and group B with 56. Table 2 describes the demographic characteristics of the patients allocated to the 2 groups. Buddy strapping resulted in better motion and less edema compared with splinting within the first 2 weeks (P < .05). Specifically, 65% of the patients in the group A had fully regained their motion by 1 week after injury. The percentage of patients in the second group with full restoration of motion at 1 week was 34% (P ¼ .001). After 2 weeks, 89% of patients in group A had full motion in contrast to 68% of the patients in group B (P ¼ .01). After 1 week, edema had resolved in 62% of patients in group A and 31% in group B (P ¼ .001). After 2 weeks, 91% of the patients in group A and 71% of patients in group B had no edema (P ¼ .01). Figure 2 shows the percentage of patients with full motion, edema reduction, strength recovery, and pain relief after 1 month. There was no difference between the groups in grip and pinch strength after 2 weeks (P > .05). Patients treated with immobilization had increased tenderness of the VP (P < .05). There was no significant difference in pain, as demonstrated in mean visual analog scale scores and mean analgesic intake between the 2 groups after 2 weeks. The percentage of patients without pain after 2 weeks was significantly greater in group A (84%) than in group B (63%) (P ¼ .02). After 3 weeks and at later follow-ups, there were no statistically significant differences between the 2 groups with respect to edema, motion, or pain. Adequate recovery that allowed return to daily and sport activities was achieved significantly earlier with buddy strapping compared with immobilization (2.1 wk vs 2.9 wk; P < .01). The outcome of the patients using a modification of the Incavo scoring system in both groups 1 year after injury is shown in Table 3.6 There was no difference in the percentage J Hand Surg Am.
DISCUSSION According to our results, protected mobilization of PIP joint hyperextension injuries represents a safe and effective management. Excellent results were achieved in more than 80% of the cases, whereas less than 10% of the patients experienced problems that affected their daily/sport activities. These results confirm similar findings that suggest that protected immediate mobilization of a stable VP injury is beneficial compared with immobilization.6,7 Specifically, excellent outcome is demonstrated in more than 90% of the patients in all protocols involving immediate protective mobilization.7,12 Conversely, immobilization of the PIP joint seems to be associated with slightly worse outcome.6,9,13 The propensity of the PIP joints to develop limited motion is also a factor that should be considered when dealing with hyperextension injuries. This is the reason why any injury in this area could potentially result in poor digit function.13 The literature r
Vol. 39, March 2014
COMPARISON OF TREATMENT MODALITIES FOR PIP INJURIES
453
FIGURE 2: Percentage of patients with full restoration of ROM*, edema*, pain, and strength* to normal values during the first month (*compared with the contralateral side).
immobilization. VP tenderness may be an indication of inadequate VP healing. Because almost all hyperextension injuries are associated with VP ruptures,1 full recovery could be linked to normal, uncomplicated healing of the VP. Our findings suggest that the type of treatment is associated with the time needed for achieving full recovery. Thus, a potential explanation could be that the type of treatment may interfere with the time needed for VP healing, as indicated by reduced tenderness, and with the time for overall recovery. Patients treated with buddy strapping were able to return to preinjury activity level much faster than the patients treated with immobilization. This is important when considering that these injuries occur to a young, active population. Despite the fact that there was no significant difference in the clinical outcome after 3 weeks between the 2 treatment approaches, the 6-day difference in recovery translates into less disability and decreased health care costs.14,15 The effect of age in wound and fracture healing is well established in the past. Children exhibit faster and significantly more effective healing potential than adults for wound and fracture healing.16,17 In the present study, children demonstrated uneventful recovery compared with adults. This is in accordance to several studies conducted in children in which early mobilization resulted in excellent outcome for the same type of injuries.12,18
TABLE 3. Clinical Outcome of Group A and Group B in Adults and Children Excellent
Good
Fair
Poor
GROUP A
12/18
4/18
0
2/18
Adults
(67%)
(22%)
(0%)
(11%)
GROUP B
11/18
6/18
1/18
0
Adults
(61%)
(33%)
(6%)
(0%)
GROUP A
34/37
2/37
1/37
0
Children
(92%)
(5%)
(3%)
(0%)
GROUP B
34/38
2/38
1/38
1/38
Children
(89%)
(5%)
(3%)
(3%)
GROUP A
46/55
6/55
1/55
2/55
TOTAL
(84%)
(11%)
(2%)
(4%)
GROUP B
45/56
8/56
2/56
1/56
TOTAL
(80%)
(14%)
(4%)
(2%)
does not provide strong evidence supporting 1 treatment option versus another,5 although most authors agree that prolonged immobilization results in stiffness and must be avoided.6,9 In the present study, both treatment protocols allowed PIP joint flexion, with buddy strapping being more aggressive. Patients treated with buddy strapping demonstrated improved motion and reduced edema at 2 weeks after injury. Furthermore, patients treated with buddy strapping had less VP tenderness than the patients treated with J Hand Surg Am.
r
Vol. 39, March 2014
454
COMPARISON OF TREATMENT MODALITIES FOR PIP INJURIES
The strengths of our study include that it was a randomized controlled trial evaluating a homogenous population and included evaluations in the early postinjury period. The present study has some limitations. First, only stable hyperextension injuries without fracture were included in the study, so our findings may not be applicable to unstable injuries, although conservative treatment appears to be the suggested treatment approach for these injuries too.19 It is among our future goals to also evaluate unstable PIP joint injuries, because intervention is more likely to have a major impact in these injuries. Another limitation is that the current practice in our hospital is to perform only anteroposterior and lateral views for finger injuries. The oblique view was obtained only when there was suspicion of a VP avulsion fracture in the initial views. Further, the present study had difficulty in quantifying tenderness. For this reason, a visual analog scale measurement was used. In conclusion, both buddy strapping and aluminum orthosis represent safe and effective treatment methods for hyperextension injuries to the PIP joint without fracture. Regardless of treatment, most injuries healed with return of full ROM and return of full function in the long term, demonstrating that both approaches are acceptable. Buddy strapping allowed full restoration of ROM, edema, and pain significantly earlier compared with aluminum splint immobilization, resulting in a higher percentage of patients achieving full recovery at the early post-traumatic period. Furthermore, PIP injuries appear to be more forgiving in children than in adults.
3. Chinchalkar SJ, Gan BS. Management of proximal interphalangeal joint fractures and dislocations. J Hand Ther. 2003;16(2):117e128. 4. Leggit JC, Meko CJ. Acute finger injuries: part I. Tendons and ligaments. Am Fam Physician. 2006;73(5):810e816. 5. Chalmer J, Blakeway M, Adams Z, Milan SJ. Conservative interventions for treating hyperextension injuries of the proximal interphalangeal joints of the fingers. Cochrane Database Syst Rev. 2013;2:CD009030. 6. Incavo SJ, Mogan JV, Hilfrank BC. Extension splinting of palmar plate avulsion injuries of the proximal interphalangeal joint. J Hand Surg Am. 1989;14(4):659e661. 7. Gaine WJ, Beardsmore J, Fahmy N. Early active mobilisation of volar plate avulsion fractures. Injury. 1998;29(8):589e591. 8. Norregaard O, Jakobsen J, Nielsen KK. Hyperextension injuries of the PIP finger joint. Comparison of early motion and immobilization. Acta Orthop Scand. 1987;58(3):239e240. 9. Thomsen NO, Petersen MS, Hovgaard C. Treatment of hyperextension injuries to the PIP joint. J Hand Surg Br. 1995;20(3):383e384. 10. Eaton RG, Littler JW. Joint injuries and their sequelae. Clin Plast Surg. 1976;3(1):85e98. 11. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29(6):602e608. 12. Weber DM, Kellenberger CJ, Meuli M. Conservative treatment of stable volar plate injuries of the proximal interphalangeal joint in children and adolescents: a prospective study. Pediatr Emerg Care. 2009;25(9):547e549. 13. Phair IC, Quinton DN, Allen MJ. The conservative management of volar avulsion fractures of the P.I.P. joint. J Hand Surg Br. 1989;14(2):168e170. 14. Rosberg H-E, Carlsson KS, Dahlin LB. Prospective study of patients with injuries to the hand and forearm: costs, function, and general health. Scand J Plast Reconstr Surg Hand Surg. 2005;39(6): 360e369. 15. Picavet HSJ, Schouten JSAG. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC3study. Pain. 2003;102(1e2):167e178. 16. Holt DR, Kirk SJ, Regan MC, Hurson M, Lindblad WJ, Barbul A. Effect of age on wound healing in healthy human beings. Surgery. 1992;112(2):293e297; discussion 297e298. 17. Ekeland A, Engesoeter LB, Langeland N. Influence of age on mechanical properties of healing fractures and intact bones in rats. Acta Orthop Scand. 1982;53(4):527e534. 18. Rimmer CS, Burke D. Proximal interphalangeal joint hyperextension injuries in children. Emerg Med J. 2009;26(12):854e856. 19. Werlinrud JC, Petersen K, Lauritsen J, Larsen S, Schroder H. A prospective randomized study of conservative versus surgical treatment of unstable palmar plate disruption in the proximal interphalangeal finger joint. Strategies Trauma Limb Reconstr. 2013;8(1): 21e24.
REFERENCES 1. Bowers WH. The proximal interphalangeal joint volar plate. II: a clinical study of hyperextension injury. J Hand Surg Am. 1981;6(1):77e81. 2. Palmer RE. Joint injuries of the hand in athletes. Clin Sports Med. 1998;17(3):513e531.
J Hand Surg Am.
r
Vol. 39, March 2014
Management of Proximal Interphalangeal Joint Hyperextension Injuries: A Randomized Controlled Trial Nikolaos K. Paschos, MD, PhD, Khaled Abuhemoud, MD, Apostolos Gantsos, MD, Grigorios I. Mitsionis, MD, PhD, Anastasios D. Georgoulis, MD, PhD
Purpose To compare the effectiveness of buddy strapping and aluminum orthosis for treatment of proximal interphalangeal (PIP) joint hyperextension injuries. We also evaluated the effect of age on the outcome by comparing our results in adults and children. Methods One hundred twenty-one consecutive patients with a PIP joint hyperextension injury of the index, middle, ring, or little finger and without fracture were evaluated. Patients were randomly assigned into 2 groups. In the first group, treatment included buddy strapping of the injured finger to its neighbor noninjured finger for a week. In the second group, immobilization was secured with an aluminum extension blocking orthosis for a week in 15 flexion. Assessment of motion, edema, pain, and strength were performed weekly for the first month and then at 3, 6, and 12 months after injury. Results The patients treated with buddy strapping exhibited similar outcomes compared with those treated with aluminum orthoses. In patients with full recovery, buddy strapping allowed earlier recovery of motion and resolution of edema and pain compared with aluminum orthosis immobilization. Furthermore, PIP injuries appear to have better outcomes in children than in adults. Conclusions Buddy strapping is easy and effective treatment for PIP joint hyperextension injuries. (J Hand Surg Am. 2014;39(3):449e454. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic I. Key words Finger, hyperextension injury, proximal interphalangeal joint (PIP), randomized controlled trial (RCT), volar plate (VP).
H
proximal interphalangeal (PIP) joint represent one of the most common injuries of the hand, especially during sports. Despite their frequency, these YPEREXTENSION INJURIES TO THE
From the Department of Trauma and Orthopaedic Surgery, University of Ioannina, Greece; and the Department of Biomedical Engineering and Orthopaedic Surgery, University of California, Davis, California. Received for publication July 12, 2013; accepted in revised form November 19, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Nikolaos K. Paschos, MD, PhD, Department of Biomedical Engineering, University of California, Davis, CA; e-mail: [email protected]. 0363-5023/14/3903-0006$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.11.038
injuries are occasionally underestimated. This is mainly due to the negative x-ray findings, which do not exclude the presence of a major injury to the soft tissues stabilizing the joint including the volar plate (VP).1,2 Meticulous clinical examination and adequate knowledge of the soft tissue anatomy can identify these nonosseous injuries and prevent late complications, such as persistent pain and edema, loss of normal motion, deformity, and post-traumatic arthritis.3,4 Forced hyperextension of the joint may lead to various types of injury, ranging from a partial tear of the VP to an avulsion fracture of the phalanx. There is no consensus regarding the ideal treatment for these injuries, with some hand surgeons favoring
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
449
450
COMPARISON OF TREATMENT MODALITIES FOR PIP INJURIES
FIGURE 1: Eaton Classification for injuries of the volar plate and avulsion fractures.10 Type I: hyperextension injury to the volar plate and collateral ligaments, with no dislocation of the joint or presence of fracture. Type II: presence of dorsal dislocation of the PIP joint associated with volar plate and collateral ligament injury. Type III: presence of fracture (typically at the base of the middle phalanx), associated with the hyperextension injury.
immobilization whereas others suggest early active mobilization.5e7 A recent systematic review concluded that there was insufficient evidence regarding the efficiency of immobilization in treating hyperextension injuries.5,8,9 The literature does not differentiate among the various types of injuries sustained and proposes similar treatment irrespectively of the type of injury. Furthermore, most studies have been conducted in children, because in this age group, PIP joint hyperextension injuries occur frequently. In addition, hyperextension injuries are problematic in those who develop chronic stiffness, pain, and flexion contracture. It is unclear whether there is an association between the treatment approach and the risk for complications. Therefore, we evaluated whether the type of treatment was a factor that could be related to the complication rate or outcome. The primary purpose of this study was to compare the outcome of 2 commonly used treatment approaches in patients who sustained PIP joint hyperextension injury without fracture. We also evaluated the effect of age on the outcome by comparing our results in adults and children. We hypothesized that J Hand Surg Am.
immediate mobilization of the injured joint would have a beneficial effect and that children would exhibit a better outcome compared with adults when a less restrictive treatment such as immediate mobilization would be applied. MATERIALS AND METHODS From January 2007 until December 2010, all consecutive patients who sustained a hyperextension injury without fracture (Eaton types I and II) to the PIP joint of any finger except the thumb were included in the study (Fig. 1).10 The criteria used for distinguishing between type I and type II injuries were either a history of dislocation that was reduced by the patient automatically, or the presence of dislocation at presentation to us. The study was approved by our institutional review board. All patients gave their informed consent to participate in the study. All patients had standard anteroposterior and lateral radiographs. The diagnostic criteria were a history of a hyperextension mechanism, edema, hematoma, or ecchymosis of the PIP joint and tenderness on its volar aspect. The exclusion criteria were r
Vol. 39, March 2014
451
COMPARISON OF TREATMENT MODALITIES FOR PIP INJURIES
TABLE 1. Study
Modification of the Incavo Scoring System Used for Scoring and Grading Outcome in the Present
SCORE
Pain
LOM
Edema
Strength
19e25
VAS 0e2
0 e10
100%e110%
80%e100%*
12e18
VAS 3e4
11 e20
111%e130%*
50%e79%*
6e11
VAS 5e7
21 e40
131%e150%*
30%e49%*
0e6
VAS 8e10
> 40
> 150%*
0%e29%
Maximum score
25
25
25
25
GRADING Excellent 75e100 Good 50e74 Fair 25e49 Poor 0e24 LOM, limitation of motion at PIP joint; VAS, visual analog scale. *Compared with the contralateral side. Modified with permission from Incavo SJ, Mogan JV, Hilfrank BC. Extension splinting of palmar plate avulsion injuries of the proximal interphalangeal joint. J Hand Surg Am. 1989;14(4):659e661.
comparison with the same finger on the other hand. A standard dynamometer (FEI, Irvington, NY) and a hydraulic pinch gauge (FEI, Irvington, NY) were used for assessment of grip and pinch strength, respectively, with the contralateral hand serving as a control. We assessed pain and tenderness over the VP with a visual analog scale. Return to daily activities and sports were monitored at every visit using the questionnaire of the Disabilities of the Arm, Shoulder, and Hand score.11 Patients with a score less that 5 were considered capable to return to their activities. Hand dominance, analgesic intake, and patient satisfaction were recorded at each visit. A modification of the Incavo scoring system6 was developed, which was used for scoring and grading outcome (Table 1). For nominal values, Fisher exact testing was used and a 1-way analysis of variance was used for comparing data between groups. Statistical significance was considered present at P < .05.
age younger than 2 years, presence of a middle phalanx volar lip fracture, instability implying a collateral ligament injury, presentation greater than a week after injury, presence of a tendon injury, and bilateral injuries. Diagnosis of instability was based on history and by testing for joint laxity in full flexion and in 30 of flexion, looking for subluxation during active motion, and noting incongruity or dislocation radiographically. Patients were randomly assigned into 2 groups using a computer-generated program where different treatment protocols were applied. In group A, treatment included buddy strapping of the injured finger to its neighbor noninjured finger for a week. The index and middle fingers were strapped together or the ring and little fingers were strapped together. In group B, immobilization was secured with an aluminum orthosis applied dorsally. The orthosis extended from the tip of the finger to the metacarpophalangeal joint at 15 of flexion for a week. After a week, unprotected mobilization was introduced in both groups. Orthopedic surgeons conducted the assessment at the time of presentation and evaluated the patients during the next several visits to the department. The surgeons were blinded to the treatment selected for each patient. This was ensured by the removal of the buddy strapping or orthosis prior to the evaluation. Assessment took place every week for the first month and then at 3, 6, and 12 months after injury. Range of motion (ROM) was evaluated with a digital goniometer. Edema was measured by evaluating the diameter of the finger at the level of the PIP joint in J Hand Surg Am.
RESULTS During the study period, 226 patients attended our department with a history of hyperextension injury to their index, middle, ring, or little finger. From these, fracture or instability was present in 94, 6 patients presented later than a week after injury, and 5 declined to participate. Therefore, 83 children with a mean age of 9 years (range, 3e16 y) and 38 adults with a mean age of 32 years (range, 16e51 y) were evaluated. Ten patients, (8 children and 2 adults) were lost in the follow up, which left group A with r
Vol. 39, March 2014
452
COMPARISON OF TREATMENT MODALITIES FOR PIP INJURIES
of patients between the 2 groups that demonstrated excellent results, good results, or excellent and good outcome grouped together. Patients with Eaton type II injuries demonstrated worse outcome in comparison with those with type I injuries irrespective of the treatment applied. Specifically, 87% of the patients with type I injury were graded as excellent, whereas 64% of the patients with type II injuries exhibited excellent outcome (P ¼ .02). Ninety-nine percent of patients with type I injuries demonstrated excellent and good outcomes compared with 80% with type II injuries (P ¼ .002). No type I injury resulted in poor outcome, whereas 3 type II injuries were graded as poor (P ¼ .01). There was no statistical difference in outcome between group A and group B in type I injuries. Similarly, no difference was detected between group A and group B patients in type II injuries. Excellent outcome was achieved in 89% of the children compared with 72% of the adults regardless of treatment (P < 0.05). The improved outcome in children was evident in both groups A and B (P ¼ .04 and P ¼ .02, respectively). There was no difference between the 2 treatment approaches in children. Three patients had poor outcomes, 2 adults in group A and 1 child, 11 years old, in group B. The poor outcomes were associated with limited motion, persistent edema, and severe pain. It was difficult to correlate these problems to the type of injury or treatment owing to the small number of patients. No other etiological factors were identified in these cases.
TABLE 2. Demographic Characteristics of the Patients Allocated in the 2 Groups GROUP A
GROUP B
Age, y (range)
22 (3e51)
23 (2e49)
Male:female
34:21
36:20
Children (n)
37
38
Hand dominance
Dominant 67%
Dominant 67%
Finger involved
Index 16%
Index 17%
Middle 32%
Middle 33%
Ring 31%
Ring 30%
Little 11%
Little 10%
55 patients and group B with 56. Table 2 describes the demographic characteristics of the patients allocated to the 2 groups. Buddy strapping resulted in better motion and less edema compared with splinting within the first 2 weeks (P < .05). Specifically, 65% of the patients in the group A had fully regained their motion by 1 week after injury. The percentage of patients in the second group with full restoration of motion at 1 week was 34% (P ¼ .001). After 2 weeks, 89% of patients in group A had full motion in contrast to 68% of the patients in group B (P ¼ .01). After 1 week, edema had resolved in 62% of patients in group A and 31% in group B (P ¼ .001). After 2 weeks, 91% of the patients in group A and 71% of patients in group B had no edema (P ¼ .01). Figure 2 shows the percentage of patients with full motion, edema reduction, strength recovery, and pain relief after 1 month. There was no difference between the groups in grip and pinch strength after 2 weeks (P > .05). Patients treated with immobilization had increased tenderness of the VP (P < .05). There was no significant difference in pain, as demonstrated in mean visual analog scale scores and mean analgesic intake between the 2 groups after 2 weeks. The percentage of patients without pain after 2 weeks was significantly greater in group A (84%) than in group B (63%) (P ¼ .02). After 3 weeks and at later follow-ups, there were no statistically significant differences between the 2 groups with respect to edema, motion, or pain. Adequate recovery that allowed return to daily and sport activities was achieved significantly earlier with buddy strapping compared with immobilization (2.1 wk vs 2.9 wk; P < .01). The outcome of the patients using a modification of the Incavo scoring system in both groups 1 year after injury is shown in Table 3.6 There was no difference in the percentage J Hand Surg Am.
DISCUSSION According to our results, protected mobilization of PIP joint hyperextension injuries represents a safe and effective management. Excellent results were achieved in more than 80% of the cases, whereas less than 10% of the patients experienced problems that affected their daily/sport activities. These results confirm similar findings that suggest that protected immediate mobilization of a stable VP injury is beneficial compared with immobilization.6,7 Specifically, excellent outcome is demonstrated in more than 90% of the patients in all protocols involving immediate protective mobilization.7,12 Conversely, immobilization of the PIP joint seems to be associated with slightly worse outcome.6,9,13 The propensity of the PIP joints to develop limited motion is also a factor that should be considered when dealing with hyperextension injuries. This is the reason why any injury in this area could potentially result in poor digit function.13 The literature r
Vol. 39, March 2014
COMPARISON OF TREATMENT MODALITIES FOR PIP INJURIES
453
FIGURE 2: Percentage of patients with full restoration of ROM*, edema*, pain, and strength* to normal values during the first month (*compared with the contralateral side).
immobilization. VP tenderness may be an indication of inadequate VP healing. Because almost all hyperextension injuries are associated with VP ruptures,1 full recovery could be linked to normal, uncomplicated healing of the VP. Our findings suggest that the type of treatment is associated with the time needed for achieving full recovery. Thus, a potential explanation could be that the type of treatment may interfere with the time needed for VP healing, as indicated by reduced tenderness, and with the time for overall recovery. Patients treated with buddy strapping were able to return to preinjury activity level much faster than the patients treated with immobilization. This is important when considering that these injuries occur to a young, active population. Despite the fact that there was no significant difference in the clinical outcome after 3 weeks between the 2 treatment approaches, the 6-day difference in recovery translates into less disability and decreased health care costs.14,15 The effect of age in wound and fracture healing is well established in the past. Children exhibit faster and significantly more effective healing potential than adults for wound and fracture healing.16,17 In the present study, children demonstrated uneventful recovery compared with adults. This is in accordance to several studies conducted in children in which early mobilization resulted in excellent outcome for the same type of injuries.12,18
TABLE 3. Clinical Outcome of Group A and Group B in Adults and Children Excellent
Good
Fair
Poor
GROUP A
12/18
4/18
0
2/18
Adults
(67%)
(22%)
(0%)
(11%)
GROUP B
11/18
6/18
1/18
0
Adults
(61%)
(33%)
(6%)
(0%)
GROUP A
34/37
2/37
1/37
0
Children
(92%)
(5%)
(3%)
(0%)
GROUP B
34/38
2/38
1/38
1/38
Children
(89%)
(5%)
(3%)
(3%)
GROUP A
46/55
6/55
1/55
2/55
TOTAL
(84%)
(11%)
(2%)
(4%)
GROUP B
45/56
8/56
2/56
1/56
TOTAL
(80%)
(14%)
(4%)
(2%)
does not provide strong evidence supporting 1 treatment option versus another,5 although most authors agree that prolonged immobilization results in stiffness and must be avoided.6,9 In the present study, both treatment protocols allowed PIP joint flexion, with buddy strapping being more aggressive. Patients treated with buddy strapping demonstrated improved motion and reduced edema at 2 weeks after injury. Furthermore, patients treated with buddy strapping had less VP tenderness than the patients treated with J Hand Surg Am.
r
Vol. 39, March 2014
454
COMPARISON OF TREATMENT MODALITIES FOR PIP INJURIES
The strengths of our study include that it was a randomized controlled trial evaluating a homogenous population and included evaluations in the early postinjury period. The present study has some limitations. First, only stable hyperextension injuries without fracture were included in the study, so our findings may not be applicable to unstable injuries, although conservative treatment appears to be the suggested treatment approach for these injuries too.19 It is among our future goals to also evaluate unstable PIP joint injuries, because intervention is more likely to have a major impact in these injuries. Another limitation is that the current practice in our hospital is to perform only anteroposterior and lateral views for finger injuries. The oblique view was obtained only when there was suspicion of a VP avulsion fracture in the initial views. Further, the present study had difficulty in quantifying tenderness. For this reason, a visual analog scale measurement was used. In conclusion, both buddy strapping and aluminum orthosis represent safe and effective treatment methods for hyperextension injuries to the PIP joint without fracture. Regardless of treatment, most injuries healed with return of full ROM and return of full function in the long term, demonstrating that both approaches are acceptable. Buddy strapping allowed full restoration of ROM, edema, and pain significantly earlier compared with aluminum splint immobilization, resulting in a higher percentage of patients achieving full recovery at the early post-traumatic period. Furthermore, PIP injuries appear to be more forgiving in children than in adults.
3. Chinchalkar SJ, Gan BS. Management of proximal interphalangeal joint fractures and dislocations. J Hand Ther. 2003;16(2):117e128. 4. Leggit JC, Meko CJ. Acute finger injuries: part I. Tendons and ligaments. Am Fam Physician. 2006;73(5):810e816. 5. Chalmer J, Blakeway M, Adams Z, Milan SJ. Conservative interventions for treating hyperextension injuries of the proximal interphalangeal joints of the fingers. Cochrane Database Syst Rev. 2013;2:CD009030. 6. Incavo SJ, Mogan JV, Hilfrank BC. Extension splinting of palmar plate avulsion injuries of the proximal interphalangeal joint. J Hand Surg Am. 1989;14(4):659e661. 7. Gaine WJ, Beardsmore J, Fahmy N. Early active mobilisation of volar plate avulsion fractures. Injury. 1998;29(8):589e591. 8. Norregaard O, Jakobsen J, Nielsen KK. Hyperextension injuries of the PIP finger joint. Comparison of early motion and immobilization. Acta Orthop Scand. 1987;58(3):239e240. 9. Thomsen NO, Petersen MS, Hovgaard C. Treatment of hyperextension injuries to the PIP joint. J Hand Surg Br. 1995;20(3):383e384. 10. Eaton RG, Littler JW. Joint injuries and their sequelae. Clin Plast Surg. 1976;3(1):85e98. 11. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29(6):602e608. 12. Weber DM, Kellenberger CJ, Meuli M. Conservative treatment of stable volar plate injuries of the proximal interphalangeal joint in children and adolescents: a prospective study. Pediatr Emerg Care. 2009;25(9):547e549. 13. Phair IC, Quinton DN, Allen MJ. The conservative management of volar avulsion fractures of the P.I.P. joint. J Hand Surg Br. 1989;14(2):168e170. 14. Rosberg H-E, Carlsson KS, Dahlin LB. Prospective study of patients with injuries to the hand and forearm: costs, function, and general health. Scand J Plast Reconstr Surg Hand Surg. 2005;39(6): 360e369. 15. Picavet HSJ, Schouten JSAG. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC3study. Pain. 2003;102(1e2):167e178. 16. Holt DR, Kirk SJ, Regan MC, Hurson M, Lindblad WJ, Barbul A. Effect of age on wound healing in healthy human beings. Surgery. 1992;112(2):293e297; discussion 297e298. 17. Ekeland A, Engesoeter LB, Langeland N. Influence of age on mechanical properties of healing fractures and intact bones in rats. Acta Orthop Scand. 1982;53(4):527e534. 18. Rimmer CS, Burke D. Proximal interphalangeal joint hyperextension injuries in children. Emerg Med J. 2009;26(12):854e856. 19. Werlinrud JC, Petersen K, Lauritsen J, Larsen S, Schroder H. A prospective randomized study of conservative versus surgical treatment of unstable palmar plate disruption in the proximal interphalangeal finger joint. Strategies Trauma Limb Reconstr. 2013;8(1): 21e24.
REFERENCES 1. Bowers WH. The proximal interphalangeal joint volar plate. II: a clinical study of hyperextension injury. J Hand Surg Am. 1981;6(1):77e81. 2. Palmer RE. Joint injuries of the hand in athletes. Clin Sports Med. 1998;17(3):513e531.
J Hand Surg Am.
r
Vol. 39, March 2014