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Dorsal Fracture Dislocation of the Proximal Interphalangeal Joint
Dorsal Fracture Dislocation of the Proximal Interphalangeal Joint John A. McAuliffe, MD THE PATIENT A 26-year-old man jammed his nondominant right ring finger into the ground attempting a diving catch while playing softball. He initially applied ice and a homemade splint, but pain, swelling, and limited motion of the proximal interphalangeal (PIP) joint persisted. A week after injury, he presented to his primary care physician who obtained radiographs (Fig. 1) that demonstrated a dorsal fracture dislocation (DFD) of the PIP joint. Hand surgery consultation was obtained for definitive management. THE QUESTIONS What is the best treatment for an unstable DFD of the PIP joint? Is there a guiding principle that should direct our treatment of these injuries? CURRENT OPINION There is broad agreement that the difficulties involved in the treatment of unstable DFDs of the PIP joint are proportional to the size and complexity (fragmentation/ impaction) of the fracture of the palmar articular surface of the base of the middle phalanx. The generally accepted classification of the palmar lip injury is that of Hastings and Carroll1 and is based on the percentage of middle phalanx articular surface that is injured. When 30% or less of the articular surface is disrupted, the injury is likely to be stable; 30% to 50% of injuries exhibit tenuous stability; and injuries that involve more than 50% of the joint are unstable. Although these numbers are useful guidelines, the stability of a given joint must always be assessed clinically at the time of treatment.2,3 FromtheSectionofHandSurgery,BrowardHealthOrthopaedicsandSportsMedicine,Ft.Lauderdale, FL. Received for publication August 21, 2008; accepted August 22, 2008. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: John A. McAuliffe, MD, Section of Hand Surgery, Broward Health Orthopaedics and Sports Medicine, 300 S.E. 17th Street, Fort Lauderdale, FL 33316; e-mail: [email protected]. 0363-5023/08/33A10-0032$34.00/0 doi:10.1016/j.jhsa.2008.08.017
FIGURE 1: Lateral radiograph of the injured PIP joint demonstrates a DFD.
Stable injuries are successfully treated closed, using some method of digital protection as motion and function are regained.4 There is no agreement regarding the treatment of tenuous or unstable injuries, prompting Glickel to opine that this is “one of the unanswered and, perhaps, unanswerable questions in hand surgery.”5 Many different treatment techniques have been proposed, including the following: ● ● ●
● ● ● ●
Extension block techniques (splinting3,6 or pinning7,8) Transarticular fixation9,10 Traction methods, including outrigger traction,11,12 force couple devices,13 and dynamic intradigital traction (so-called pins and rubbers constructs)14 –17 Static18 and dynamic external fixation19,20 Percutaneous21 or open reduction and internal fixation (ORIF)22–26 Palmar plate arthroplasty27–29 Osteochondral bone grafting30,31
Transarticular pinning and the various traction and external fixation methods have, at times, been combined with other techniques, including ORIF and palmar plate arthroplasty.19,20,22,23,27,32 Advocacy for the various techniques and combinations thereof has waxed and waned over time. In the absence of comparative studies assessing the different methods, treatment decisions are often based on the preference and experience of the individual surgeon.
© Published by Elsevier, Inc. on behalf of the ASSH. 䉬 1885
Evidence-Based Medicine
EVIDENCE-BASED MEDICINE
1886
DORSAL PIP FRACTURE DISLOCATION
Evidence-Based Medicine
THE EVIDENCE Unstable injuries are usually associated with fracture of 30% or more of the palmar base of the middle phalanx and are produced not by hyperextension but by axial loading in some degree of flexion.1,2,28,29 The fractures are generally comminuted and the joint subluxated at rest by the proximal and dorsal pull of the central slip insertion on the intact dorsal base of the middle phalanx. In the subluxated position, attempts at flexion of the PIP joint result in hinging of the middle phalanx about the fracture margin, in lieu of the normal gliding motion of the base of the middle phalanx around the head of the proximal phalanx.2 It is generally accepted that accurate restoration of the joint surface is an important objective in the treatment of articular fractures; however, in the case of DFD of the PIP joint, the available evidence would suggest that meeting this goal may not be of major clinical importance. For instance, advocates of the dynamic traction techniques make no particular effort to reestablish joint contour. Regardless of treatment technique, although inaccuracy of joint surface restoration (residual articular stepoff or gap, or central fragment depression) is sometimes associated with the presence of degenerative changes on radiographs, it does not seem to adversely affect range of motion, pain, or patient satisfaction, nor do results in these joints seem to deteriorate over time.9,16,17,27,33 Early motion of the injured joint is also felt to be an important determinant of success, and it is cited as an explanation for the good results of the dynamic traction methods.11,14 There are, however, numerous series describing the treatment of DFDs of the PIP joint that would seem to dispute the importance of early motion. Joints that have been statically fixated or pinned for 3 to 4 weeks following treatment have recovered motion similar to those that are allowed to move early.7,9,10,22–24 The one consistent finding is that recurrent subluxation following treatment of DFDs almost universally leads to a poor result; many authors emphasize the importance of maintaining concentric joint reduction.1,24,28,29,33 It seems increasingly clear that restoration of the palmar lip of the middle phalanx is the critical step in restoring joint stability and maintaining concentric reduction.1,20,23,30,34 A recent, unpublished cadaver study has demonstrated that restoration of the osseous anatomy of the base of the middle phalanx is the necessary and sufficient determinant of PIP joint stability, even in the absence of the collateral ligaments and palmar plate (Hamlet WP, Hastings H. 2nd. Critical assessment of PIP joint stability after palmar lip fracture dislocations. Presented at the 56th Annual Meeting of
the American Society for Surgery of the Hand, Baltimore, MD, October 4, 2001). These findings prompted the senior author of that study to develop a technique in which the comminuted palmar lip of the middle phalanx is replaced with an osteochondral bone graft from the distal hamate. A cadaver study has demonstrated that this bone graft is an excellent anatomic match with similar contours to the base of the middle phalanx and that the hemicondylar hamate replacement arthroplasty procedure was capable of restoring PIP joint stability with no tendency to subluxate.34 A clinical series including 13 patients achieved union of the hamate bone graft in all and restored an average arc of PIP motion of 85°. Two patients demonstrated asymptomatic mild residual subluxation of the joint, probably related to minor malposition of the bone graft. Donor site morbidity was minimal.30 Careful examination of the radiographs of PIP joints that have done well following treatment will sometimes reveal slight residual dorsal subluxation (the central axis of the middle phalanx is dorsal to that of the proximal phalanx on the lateral radiograph).11,27,28 In these cases, the middle phalanx fracture has healed in a position that has restored the concavity of the phalangeal base on the lateral view, although it is often expanded in the dorsal– palmar plane or deepened. Restoration of the palmar buttress of the base of the middle phalanx allows for restoration of the normal gliding motion of the joint, producing a successful result. When the palmar fracture fragments are allowed to heal in a distally displaced position such that the palmar surface is flat and the buttress is not restored, the PIP joint will hinge in flexion, resulting in treatment failure.20,29,33 Restoration of joint gliding seems to be the determinant of success, and restoration of the palmar buttress is the anatomic prerequisite which allows this to occur. Critical evaluation of the case series that report on the numerous alternatives for the treatment of unstable DFDs of the PIP joint reveals no consistent differences among the techniques in terms of joint range of motion, flexion contracture, radiographic joint degeneration, or pain at final follow-up.1,3,7–24,26 –30,33,35 Failure of the index procedure resulting in recurrence of subluxation or the need for revision surgery, and other complications, including infection or pin track issues, are also remarkably similar in the vast majority of reported series.1,3,7–24,26 –30,33,35 Occasionally authors report less favorable results or higher complication rates with a given technique, but these are often in small series that are not consistent with the preponderance of findings reported elsewhere.10,35 It is also common that the originator of a given procedure reports results that are
JHS 䉬 Vol A, December
somewhat more favorable than those of later adopters, but again, there are no consistent trends in the available data.10,27,28,35 Analysis of the cases of recurrent subluxation following treatment or those that go on to additional surgery also yields little consistent information of potentially predictive value. Failure of the index procedure is generally not related to fragment size or central fragment depression.6,11,17,27,33 Although it has been suggested that larger fracture fragments or marked comminution may predispose to recurrent subluxation following palmar plate arthroplasty, this contention is based on a handful of failures,1,33,35 and it is not corroborated in other series.27–29 I am aware of only 1 attempt at a randomized controlled trial regarding the treatment of these injuries, which was terminated early because of the authors’ concerns regarding the morbidity and complications associated with ORIF, and the awareness that satisfactory results were being achieved with closed reduction and pin fixation.10 The limited range of motion achieved in this series using 2 different methods of ORIF is contrary to the experience of many other authors.22–26 There are no reports that allow legitimate comparison between different treatment techniques in similar groups of patients. Deitch and coauthors report their results in patients treated with ORIF or palmar plate arthroplasty, but they do not describe the methods by which a specific treatment was chosen for a given patient, and they specifically state that their study was not designed to compare the 2 techniques.33 Other authors have reported results using numerous techniques as their appreciation of the difficulties involved in the treatment of DFDs evolved over time.1 In these series, patient groups are often markedly dissimilar in terms of magnitude of injury and delay in treatment.35 SHORTCOMINGS OF THE EVIDENCE AND DIRECTIONS FOR FUTURE RESEARCH Definitive conclusions regarding the best treatment for DFDs of the PIP joint are difficult to make, as virtually all of the evidence is limited to case series (level IV) and expert opinion (level V). The vast majority of the currently available studies provide short-term or, at best, intermediate-term follow-up. Many of the studies include both acute and chronic injuries and some include other types of injury, including palmar fracture dislocations and pilon fractures, making it difficult to determine the results specific to acute DFDs. Finally, none of these studies contain patient-reported health
1887
status data as measured by validated outcome instruments. Prospective randomized clinical trials (level I evidence) of adequate sample size and with a minimum of intermediate-term (2- to 5-year) follow-up would be of great benefit in decision making regarding the treatment of DFDs of the PIP joint but may be difficult to perform due to the relative infrequency of this injury. These studies should include patient-reported measures of function and disability measured by validated outcome questionnaires. An examination of the relative advantages and disadvantages of temporary immobilization (static pinning or external fixation) in the treatment of these injuries would be helpful in guiding and perhaps simplifying treatment. It would also be helpful to determine more precisely the time after injury when attempts at reparative treatment of these joints should be abandoned in favor of procedures that may be considered more reconstructive in nature, such as palmar plate arthroplasty or osteochondral bone grafting. More precise recommendations regarding the need for reconstitution of bone defects during the performance of palmar plate arthroplasty are also needed. CURRENT CONCEPTS Evaluation of the available evidence reveals that there is no clearly superior treatment method for acute unstable DFDs of the PIP joint. My preference is to perform ORIF when this is feasible. Using a palmar approach, mini-screw fixation, and supplemental cerclage wiring as needed,26 I would agree with others that half or more of these injuries can be successfully treated in this fashion.24 If fracture fragmentation precludes ORIF, I would proceed with fragment excision and osteochondral bone grafting using the hemi-hamate replacement arthroplasty technique. Although technically demanding, this structural bone graft provides immediate joint stability and has shown promising results in short-term follow-up.30 Equivalent success has been reported with extension block splinting, static pin fixation, external fixation, and dynamic traction techniques, and at this time all of these can be considered equally reasonable alternatives. It can be argued that the relative simplicity of some of these methods could make them preferable in certain circumstances. It may be wise to exercise caution in using palmar plate arthroplasty for the treatment of acute injuries with large middle phalangeal bony defects, because a tendency to recurrent subluxation has been suggested in this setting.
JHS 䉬 Vol A, December
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DORSAL PIP FRACTURE DISLOCATION
1888
DORSAL PIP FRACTURE DISLOCATION
REFERENCES Evidence-Based Medicine
1. Hastings H 2nd, Carroll C 4th. Treatment of closed articular fractures of the metacarpophalangeal and proximal interphalangeal joints. Hand Clin 1988;4:503–527. 2. Kiefhaber TR, Stern PJ. Fracture dislocations of the proximal interphalangeal joint. J Hand Surg 1998;23A:368 –380. 3. McElfresh EC, Dobyns JH, O’Brien ET. Management of fracturedislocation of the proximal interphalangeal joints by extension-block splinting. J Bone Joint Surg 1972;54A:1705–1711. 4. Phair IC, Quinton DN, Allen MJ. The conservative management of volar avulsion fractures of the P.I.P. joint. J Hand Surg 1989;14B: 168 –170. 5. Glickel SZ, Barron OA. Proximal interphalangeal joint fracture dislocations. Hand Clin 2000;16:333–344. 6. Hamer DW, Quinton DN. Dorsal fracture subluxation of the proximal interphalangeal joints treated by extension block splintage. J Hand Surg 1992;17B:586 –590. 7. Inoue G, Tamura Y. Treatment of fracture-dislocation of the proximal interphalangeal joint using extension-block Kirschner wire. Ann Chir Main Memb Super 1991;10:564 –568. 8. Viegas SF. Extension block pinning for proximal interphalangeal joint fracture dislocations: preliminary report of a new technique. J Hand Surg 1992;17A:896 –901. 9. Newington DP, Davis TR, Barton NJ. The treatment of dorsal fracture-dislocation of the proximal interphalangeal joint by closed reduction and Kirschner wire fixation: a 16-year follow up. J Hand Surg 2001;26B:537–540. 10. Aladin A, Davis TR. Dorsal fracture-dislocation of the proximal interphalangeal joint: a comparative study of percutaneous Kirschner wire fixation versus open reduction and internal fixation. J Hand Surg 2005;30B:120 –128. 11. Schenck RR. Dynamic traction and early passive movement for fractures of the proximal interphalangeal joint. J Hand Surg 1986; 11A:850 – 858. 12. Morgan JP, Gordon DA, Klug MS, Perry PE, Barre PS. Dynamic digital traction for unstable comminuted intra-articular fracture-dislocations of the proximal interphalangeal joint. J Hand Surg 1995; 20A:565–573. 13. Agee JM. Unstable fracture dislocations of the proximal interphalangeal joint. Treatment with the force couple splint. Clin Orthop Relat Res 1987;214:101–112. 14. Ruland RT, Hogan CJ, Cannon DL, Slade JF. Use of dynamic distraction external fixation for unstable fracture-dislocations of the proximal interphalangeal joint. J Hand Surg 2008;33A:19 –25. 15. Ellis SJ, Cheng R, Prokopis P, Chetboun A, Wolfe SW, Athanasian EA, et al. Treatment of proximal interphalangeal dorsal fracturedislocation injuries with dynamic external fixation: a pins and rubber and system. J Hand Surg 2007;32A:1242–1250. 16. Duteille F, Pasquier P, Lim A, Dautel G. Treatment of complex interphalangeal joint fractures with dynamic external traction: a series of 20 cases. Plast Reconstr Surg 2003;111:1623–1629. 17. Majumder S, Peck F, Watson JS, Lees VC. Lessons learned from the management of complex intra-articular fractures at the base of the middle phalanges of fingers. J Hand Surg 2003;28B:559 –565.
18. Stark RH. Treatment of difficult PIP joint fractures with a miniexternal fixation device. Orthop Rev 1993;22:609 – 615. 19. Bain GI, Mehta JA, Heptinstall RJ, Bria M. Dynamic external fixation for injuries of the proximal interphalangeal joint. J Bone Joint Surg 1998;80B:1014 –1019. 20. Krakauer JD, Stern PJ. Hinged device for fractures involving the proximal interphalangeal joint. Clin Orthop Relat Res 1996;327:29 – 37. 21. Lahav A, Teplitz GA, McCormack RR. Percutaneous reduction and Kirschner-wire fixation of impacted intra-articular fractures and volar lip fractures of the proximal interphalangeal joint. Am J Orthop 2005;34:62– 65. 22. McCue FC, Honner R, Johnson MC, Gieck JH. Athletic injuries of the proximal interphalangeal joint requiring surgical treatment. J Bone Joint Surg 1970;52A:937–956. 23. Wilson JN, Rowland SA. Fracture-dislocation of the proximal interphalangeal joint of the finger. J Bone Joint Surg 1966;48A:493–502. 24. Grant I, Berger AC, Tham SK. Internal fixation of unstable fracture dislocations of the proximal interphalangeal joint. J Hand Surg 2005;30B:492– 498. 25. Lee JY, Teoh LC. Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results. J Hand Surg 2006;31B:138 –146. 26. Weiss AP. Cerclage fixation for fracture dislocation of the proximal interphalangeal joint. Clin Orthop Relat Res 1996;327:21–28. 27. Dionysian E, Eaton RG. The long-term outcome of volar plate arthroplasty of the proximal interphalangeal joint. J Hand Surg 2000;25A:429 – 437. 28. Eaton RG, Malerich MM. Volar plate arthroplasty of the proximal interphalangeal joint: a review of ten years’ experience. J Hand Surg 1980;5:260 –268. 29. Durham-Smith G, McCarten GM. Volar plate arthroplasty for closed proximal interphalangeal joint injuries. J Hand Surg 1992;17B:422– 428. 30. Williams RM, Kiefhaber TR, Sommerkamp TG, Stern PJ. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg 2003;28A:856 – 865. 31. Ishida O, Ikuta Y, Kuroki H. Ipsilateral osteochondral grafting for finger joint repair. J Hand Surg 1994;19A:372–377. 32. Hamilton SC, Stern PJ, Fassler PR, Kiefhaber TR. Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations. J Hand Surg 2006;31A:1349 –1354. 33. Deitch MA, Kiefhaber TR, Comisar BR, Stern PJ. Dorsal fracture dislocations of the proximal interphalangeal joint: surgical complications and long-term results. J Hand Surg 1999;24A:914 –923. 34. Capo JT, Hastings H 2nd, Choung E, Kinchelow T, Rossy W, Steinberg B. Hemicondylar hamate replacement arthroplasty for proximal interphalangeal joint fracture dislocations: an assessment of graft suitability. J Hand Surg 2008;33A:733–739. 35. Ishida O, Ikuta Y. Results of treatment of chronic dorsal fracturedislocations of the proximal interphalangeal joints of the fingers. J Hand Surg 1998;23B:798 – 801.
JHS 䉬 Vol A, December
FIGURE 1: Lateral radiograph of the injured PIP joint demonstrates a DFD.
Stable injuries are successfully treated closed, using some method of digital protection as motion and function are regained.4 There is no agreement regarding the treatment of tenuous or unstable injuries, prompting Glickel to opine that this is “one of the unanswered and, perhaps, unanswerable questions in hand surgery.”5 Many different treatment techniques have been proposed, including the following: ● ● ●
● ● ● ●
Extension block techniques (splinting3,6 or pinning7,8) Transarticular fixation9,10 Traction methods, including outrigger traction,11,12 force couple devices,13 and dynamic intradigital traction (so-called pins and rubbers constructs)14 –17 Static18 and dynamic external fixation19,20 Percutaneous21 or open reduction and internal fixation (ORIF)22–26 Palmar plate arthroplasty27–29 Osteochondral bone grafting30,31
Transarticular pinning and the various traction and external fixation methods have, at times, been combined with other techniques, including ORIF and palmar plate arthroplasty.19,20,22,23,27,32 Advocacy for the various techniques and combinations thereof has waxed and waned over time. In the absence of comparative studies assessing the different methods, treatment decisions are often based on the preference and experience of the individual surgeon.
© Published by Elsevier, Inc. on behalf of the ASSH. 䉬 1885
Evidence-Based Medicine
EVIDENCE-BASED MEDICINE
1886
DORSAL PIP FRACTURE DISLOCATION
Evidence-Based Medicine
THE EVIDENCE Unstable injuries are usually associated with fracture of 30% or more of the palmar base of the middle phalanx and are produced not by hyperextension but by axial loading in some degree of flexion.1,2,28,29 The fractures are generally comminuted and the joint subluxated at rest by the proximal and dorsal pull of the central slip insertion on the intact dorsal base of the middle phalanx. In the subluxated position, attempts at flexion of the PIP joint result in hinging of the middle phalanx about the fracture margin, in lieu of the normal gliding motion of the base of the middle phalanx around the head of the proximal phalanx.2 It is generally accepted that accurate restoration of the joint surface is an important objective in the treatment of articular fractures; however, in the case of DFD of the PIP joint, the available evidence would suggest that meeting this goal may not be of major clinical importance. For instance, advocates of the dynamic traction techniques make no particular effort to reestablish joint contour. Regardless of treatment technique, although inaccuracy of joint surface restoration (residual articular stepoff or gap, or central fragment depression) is sometimes associated with the presence of degenerative changes on radiographs, it does not seem to adversely affect range of motion, pain, or patient satisfaction, nor do results in these joints seem to deteriorate over time.9,16,17,27,33 Early motion of the injured joint is also felt to be an important determinant of success, and it is cited as an explanation for the good results of the dynamic traction methods.11,14 There are, however, numerous series describing the treatment of DFDs of the PIP joint that would seem to dispute the importance of early motion. Joints that have been statically fixated or pinned for 3 to 4 weeks following treatment have recovered motion similar to those that are allowed to move early.7,9,10,22–24 The one consistent finding is that recurrent subluxation following treatment of DFDs almost universally leads to a poor result; many authors emphasize the importance of maintaining concentric joint reduction.1,24,28,29,33 It seems increasingly clear that restoration of the palmar lip of the middle phalanx is the critical step in restoring joint stability and maintaining concentric reduction.1,20,23,30,34 A recent, unpublished cadaver study has demonstrated that restoration of the osseous anatomy of the base of the middle phalanx is the necessary and sufficient determinant of PIP joint stability, even in the absence of the collateral ligaments and palmar plate (Hamlet WP, Hastings H. 2nd. Critical assessment of PIP joint stability after palmar lip fracture dislocations. Presented at the 56th Annual Meeting of
the American Society for Surgery of the Hand, Baltimore, MD, October 4, 2001). These findings prompted the senior author of that study to develop a technique in which the comminuted palmar lip of the middle phalanx is replaced with an osteochondral bone graft from the distal hamate. A cadaver study has demonstrated that this bone graft is an excellent anatomic match with similar contours to the base of the middle phalanx and that the hemicondylar hamate replacement arthroplasty procedure was capable of restoring PIP joint stability with no tendency to subluxate.34 A clinical series including 13 patients achieved union of the hamate bone graft in all and restored an average arc of PIP motion of 85°. Two patients demonstrated asymptomatic mild residual subluxation of the joint, probably related to minor malposition of the bone graft. Donor site morbidity was minimal.30 Careful examination of the radiographs of PIP joints that have done well following treatment will sometimes reveal slight residual dorsal subluxation (the central axis of the middle phalanx is dorsal to that of the proximal phalanx on the lateral radiograph).11,27,28 In these cases, the middle phalanx fracture has healed in a position that has restored the concavity of the phalangeal base on the lateral view, although it is often expanded in the dorsal– palmar plane or deepened. Restoration of the palmar buttress of the base of the middle phalanx allows for restoration of the normal gliding motion of the joint, producing a successful result. When the palmar fracture fragments are allowed to heal in a distally displaced position such that the palmar surface is flat and the buttress is not restored, the PIP joint will hinge in flexion, resulting in treatment failure.20,29,33 Restoration of joint gliding seems to be the determinant of success, and restoration of the palmar buttress is the anatomic prerequisite which allows this to occur. Critical evaluation of the case series that report on the numerous alternatives for the treatment of unstable DFDs of the PIP joint reveals no consistent differences among the techniques in terms of joint range of motion, flexion contracture, radiographic joint degeneration, or pain at final follow-up.1,3,7–24,26 –30,33,35 Failure of the index procedure resulting in recurrence of subluxation or the need for revision surgery, and other complications, including infection or pin track issues, are also remarkably similar in the vast majority of reported series.1,3,7–24,26 –30,33,35 Occasionally authors report less favorable results or higher complication rates with a given technique, but these are often in small series that are not consistent with the preponderance of findings reported elsewhere.10,35 It is also common that the originator of a given procedure reports results that are
JHS 䉬 Vol A, December
somewhat more favorable than those of later adopters, but again, there are no consistent trends in the available data.10,27,28,35 Analysis of the cases of recurrent subluxation following treatment or those that go on to additional surgery also yields little consistent information of potentially predictive value. Failure of the index procedure is generally not related to fragment size or central fragment depression.6,11,17,27,33 Although it has been suggested that larger fracture fragments or marked comminution may predispose to recurrent subluxation following palmar plate arthroplasty, this contention is based on a handful of failures,1,33,35 and it is not corroborated in other series.27–29 I am aware of only 1 attempt at a randomized controlled trial regarding the treatment of these injuries, which was terminated early because of the authors’ concerns regarding the morbidity and complications associated with ORIF, and the awareness that satisfactory results were being achieved with closed reduction and pin fixation.10 The limited range of motion achieved in this series using 2 different methods of ORIF is contrary to the experience of many other authors.22–26 There are no reports that allow legitimate comparison between different treatment techniques in similar groups of patients. Deitch and coauthors report their results in patients treated with ORIF or palmar plate arthroplasty, but they do not describe the methods by which a specific treatment was chosen for a given patient, and they specifically state that their study was not designed to compare the 2 techniques.33 Other authors have reported results using numerous techniques as their appreciation of the difficulties involved in the treatment of DFDs evolved over time.1 In these series, patient groups are often markedly dissimilar in terms of magnitude of injury and delay in treatment.35 SHORTCOMINGS OF THE EVIDENCE AND DIRECTIONS FOR FUTURE RESEARCH Definitive conclusions regarding the best treatment for DFDs of the PIP joint are difficult to make, as virtually all of the evidence is limited to case series (level IV) and expert opinion (level V). The vast majority of the currently available studies provide short-term or, at best, intermediate-term follow-up. Many of the studies include both acute and chronic injuries and some include other types of injury, including palmar fracture dislocations and pilon fractures, making it difficult to determine the results specific to acute DFDs. Finally, none of these studies contain patient-reported health
1887
status data as measured by validated outcome instruments. Prospective randomized clinical trials (level I evidence) of adequate sample size and with a minimum of intermediate-term (2- to 5-year) follow-up would be of great benefit in decision making regarding the treatment of DFDs of the PIP joint but may be difficult to perform due to the relative infrequency of this injury. These studies should include patient-reported measures of function and disability measured by validated outcome questionnaires. An examination of the relative advantages and disadvantages of temporary immobilization (static pinning or external fixation) in the treatment of these injuries would be helpful in guiding and perhaps simplifying treatment. It would also be helpful to determine more precisely the time after injury when attempts at reparative treatment of these joints should be abandoned in favor of procedures that may be considered more reconstructive in nature, such as palmar plate arthroplasty or osteochondral bone grafting. More precise recommendations regarding the need for reconstitution of bone defects during the performance of palmar plate arthroplasty are also needed. CURRENT CONCEPTS Evaluation of the available evidence reveals that there is no clearly superior treatment method for acute unstable DFDs of the PIP joint. My preference is to perform ORIF when this is feasible. Using a palmar approach, mini-screw fixation, and supplemental cerclage wiring as needed,26 I would agree with others that half or more of these injuries can be successfully treated in this fashion.24 If fracture fragmentation precludes ORIF, I would proceed with fragment excision and osteochondral bone grafting using the hemi-hamate replacement arthroplasty technique. Although technically demanding, this structural bone graft provides immediate joint stability and has shown promising results in short-term follow-up.30 Equivalent success has been reported with extension block splinting, static pin fixation, external fixation, and dynamic traction techniques, and at this time all of these can be considered equally reasonable alternatives. It can be argued that the relative simplicity of some of these methods could make them preferable in certain circumstances. It may be wise to exercise caution in using palmar plate arthroplasty for the treatment of acute injuries with large middle phalangeal bony defects, because a tendency to recurrent subluxation has been suggested in this setting.
JHS 䉬 Vol A, December
Evidence-Based Medicine
DORSAL PIP FRACTURE DISLOCATION
1888
DORSAL PIP FRACTURE DISLOCATION
REFERENCES Evidence-Based Medicine
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JHS 䉬 Vol A, December