- Email: [email protected]
Use of a bivalve finger fracture orthosis for a new treatment protocol of a PIP comminuted fracture and dorsal dislocation
Journal of Hand Therapy xxx (2014) 1e4
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Practice Forum
Use of a bivalve finger fracture orthosis for a new treatment protocol of a PIP comminuted fracture and dorsal dislocation Marisol Monasterio MOT, OTR, CHT *, Kathleen A. Longsworth BS, Steven Viegas MD Advanced Orthopaedics and Sports Medicine, 13300 Hargrave #400, Houston, TX 77070, USA
As therapists and physicians, we often need to work with our patients to cater treatment accordingly. These authors describe how they modified a treatment protocol for a patient that sustained a proximal interphalangeal joint comminuted fracture and dorsal dislocation, but refused surgery. Their modification allowed the patient to return to full activities. e Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor. .
Introduction
Anatomy and classification
Injuries involving the combination of a proximal interphalangeal fracture and dorsal dislocation are puzzling to many, despite the currently known surgical repairs and orthosis methods. These types of fractures are typically treated with either a surgical or conservative approach. Surgical treatment is required if the fracture is unstable and involves more than 40% of the articular surface.1 Conservative therapy approaches include the use of an extension block orthosis and/or Buddy tapping if the fracture is stable and involves less that 30% of the articular surface.1 The main challenges in treating these patients include resolving pain, swelling, stiffness, and instability. Additional challenges include preventing degenerative arthritis and prolonged disability with damage in the osseous, articular and soft tissue components.2 The purpose of this report is to present a modification to the traditional comminuted fracture and dorsal dislocation protocol with the use of a bivalve finger fracture orthosis. The reason for the modification was because the patient that attended our clinic with this particular diagnosis chose not to have surgery as suggested by the surgeon and he agreed to follow a conservative protocol instead. Therapy goals involved with the use of this low profile orthosis included early motion, decrease edema, minimizing PIP flexion and extension contractions, diminishing tendon adhesion, minimizing secondary deformities, decreasing pain and increasing patient compliance to orthotic use.
Although the proximal interphalangeal joint (PIP) is a stable joint due to its articular and ligamentous structure, it is also one of the most commonly injured joints in hand. The PIP is surrounded by the joint capsule composed by the volar plate, true and accessory collateral ligaments, and the extensor mechanism. Stability is provided dorsally by the extensor tendon slip and lateral bands. Ulnarly and radially, the joint is statically stabilized by the accessory and true collateral ligaments, and conjoined lateral bands. Palmarly, the main static stabilizers are the volar plate, flexor tendons, and fibro-osseous flexor sheet. The articular congruency of the condyles, volar plate, and the accessory ligament act as dynamic restrains with hyperextension injuries; these structures contribute to lateral stability and prevention of dorsal dislocation. Proximal interphalangeal joint injuries range from ligament sprains to unstable irreducible fracture dislocations. The level of injury depends on the direction and force of the trauma, joint position, eccentric muscular contraction that affects the load on ligaments and tendons, and incongruence of bony fractures.3 Dorsally directed joint dislocations are the most common types of dislocations. These injuries result from PIP joint hyperextension that disrupts the volar plate, as well as one or both the true and accessory collateral ligaments from their insertion at the base of the middle phalanx. A more complex injury occurs from a fracture of the volar lip of the middle phalanx that may or not be reducible.4 There have been many classifications that summarize the effect of these injuries, but we will cite one in particular. Eaton and Littler5 categorized dorsal dislocation injuries into three types. Type I injuries, also known as hyperextension injuries, are defined by a partial volar plate avulsion with intact collateral ligaments. Type II injuries, or dorsal dislocation injuries, are characterized by total
This article was adapted from a Clinical Poster Presentation at the Chicago 2013 ASHT National Conference. * Corresponding author. Tel.: þ1 8327157043; fax: þ1 2819531104. E-mail addresses: [email protected], [email protected] (M. Monasterio).
0894-1130/$ e see front matter Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jht.2014.08.002
2
M. Monasterio et al. / Journal of Hand Therapy xxx (2014) 1e4
Fig. 1. Orthosis applied on patient, allowing therapist to check for motion, sensation and circulation.
volar plate and complete collateral ligament rupture. Type III injuries, or fracture dislocation injuries, include a fracture of the volar lip of the middle phalanx and complete ligament disruption. Treatment is chosen based on the categories listed. Eaton and Littler type I and II usually involve closed treatment with dorsal block pinning or a dorsal blocking orthosis with a Buddy tape use to the adjacent digits for 4e6 weeks. Type III usually require extension block orthosis, extension block pinning, traction orthosis, the “S” Quatro technique, force coupled methods, external fixators, volar plate advancement arthroplasties, or ORIF procedures.3 A 51 y/o right-hand-dominant gentleman who worked in construction and real estate sales, as well as #1 ranked tennis player in a mayor metropolitan city was playing baseball with his son at his yard when the baseball struck his left ring finger into hyperextension. The patient was seen in our clinic and was diagnosed by the hand surgeon with an impacted comminuted fracture of the volar half of the base of the middle phalanx of the left ring finger with dorsal subluxation of the middle phalanx. There was no instability to stress of the radial or ulnar collateral ligament with
Fig. 2. Materials.
Fig. 3. Thermoplastic material wrapped dorsally from ulnar to radial side overlapping at the top.
the PIP joint in slight flexion. The patient showed an Eaton and Littler type III injury. Bivalve finger fracture orthosis Because our patient opted to not have surgery, we modified the protocol using a bivalve finger fracture orthosis, which is a finger based circumferential orthosis that allows DIP and MP motion while providing static reduction of the middle phalanx volar fracture lip, as well as allowing ligamentous healing (Fig. 1). The surgeon determined the exact degree of PIP flexion while evaluating the anatomic reduction and stabilization of the fracture fragment using fluoroscopy. After the fabrication of the orthosis, the finger position was evaluated under X-ray to ensure joint stability. The orthosis was constructed around the digit overlapping at the dorsal side. Constant pressure was provided by the use of rivets and straps over the first and second phalanges. This compression around the digit decreased edema and ensured bone stability and healing (similar to a cast).
Fig. 4. Orthosis finished with 2 straps that wrap around the middle first and second phalanges from dorsal to radial side.
M. Monasterio et al. / Journal of Hand Therapy xxx (2014) 1e4
3
Fig. 5. Extension blocking orthosis at 30 .
The orthosis is low profile compared to the ones listed in the literature, including the arcuate dynamic traction method by Schenck,6 the James traction orthosis used within the Army hand community,7 and the lateral hinge traction orthosis cited by Dennys et al,8 among others. Excluding the distal joint allowed for motion at the DIP in order to prevent ORL tightness. Likewise, not including the MP joint allowed for motion and decreased hyperextension posture of the MCP joint and attenuation of the sagittal band (as a kinematic mechanical imbalance due to PIP flexion contracture3). The orthosis’s adaptable pressure around the fracture site was controlled by the amount of pull the patient applied using the rivets and straps. Rivets were used instead of Velcro to act as a “D ring”
Fig. 7. X-rays taken after injury and then at discharge.
progressive pull (as seen on humeral fracture braces) that started dorsally and surrounded the digit. It was inferred that the rivets would be more durable and the patient could avoid further visits for orthosis refurbishing. Supplies needed for fabrication of the orthosis (Fig. 2): 7 cm 6 cm 1/16 in perforated thermoplastic material Two 6 cm ¼ in straps Two large size rivets Two 1 cm 1 cm adhesive Velcro pieces Moleskin 23 cm
Fig. 6. Elastic band to decrease intrinsic tightness.
Fabrication steps: 1. Heat thermoplastic material until soft. Wrap the material starting dorsally from ulnar to radial side overlapping at the top of the digit. Place finger in desired degree of PIP flexion (Fig. 3). 2. Separate the edges carefully to remove the orthosis from the patient in a proximal to distal motion to avoid PIP extension. Secure the finger in the allowed amount of PIP flexion (90 in this case) while the orthosis is constructed. 3. Cut and flare proximally and distally to allow MP and DIP flexion. Pad the edges close to the skin area using Moleskin. This will help to prevent pressure sores and ensure skin integrity. 4. Perforate 1/8 in holes using a hole punching device over the dorsal site of the middle first and second phalanges. Attach the two ¼ in straps respectively in each hole, pressing the large size rivets together using pliers. 5. Apply 1 cm by 1 cm adhesive hooked Velcro pieces to the radial side of the rivet over the thermoplastic material to secure the straps after they wrap around the first and second phalanges (Fig. 4).
4
M. Monasterio et al. / Journal of Hand Therapy xxx (2014) 1e4
Fig. 8. Patient achieved full AROM in flexion and extension.
6. Place the orthosis on the patient’s finger by separating the edges (avoiding PIP extension) and sliding the orthosis onto the finger in a distal to proximal motion. Apply a steady, but comfortable pressure using the straps. Check for skin sensation and circulation at the tip of the finger, as well as DIP and MP motion. Protocol The patient was instructed to use the custom made bivalve finger fracture orthosis at the allowed degrees of flexion (90 in this case) at all times, and to not attempt to remove it for 2 weeks. The patient was encouraged to call the therapist if he felt discomfort. After 2 weeks of immobilization in the bivalve finger fracture orthosis, the patient started AROM as recommended by the physician. The extension block was fabricated at 30 of PIP flexion. The patient’s arc of motion was changed from 90 to 30 of PIP flexion in the extension blocking orthosis in order to avoid volar plate tightness (Fig. 5). The orthosis was modified by 10 every week for a total of 2 weeks in order to advance PIP extension. Four weeks after starting the protocol, the patient began light strengthening per therapist preference. In order to achieve the remaining degrees of PIP extension and avoid extension lag, a LMB orthosis was used at night. An elastic band for intrinsic minus stretch was utilized during the day for 5 min intervals 4 times a day (Fig. 6). The patient was discharged from therapy at 8 weeks after beginning of the protocol and was allowed to return to sports since he demonstrated functional AROM and strength. Conclusions and Precautions This method avoided some of the complications seen in the use of dynamic traction orthoses, including flexion contraction, hyperextension posture of the MCP, PIP extension lag, pain, stiffness, patient’s noncompliance to orthosis use, pin tract infection, and skin irritation.8,9 While using the bivalve orthosis, the therapist and patient must remember to check for circulation and sensation. Skin integrity was not compromised due to the use of thin perforated thermoplastic material in the orthosis fabrication; this material was also strong enough to conform and stabilize the digit. Moleskin padding was used on the edges of the orthosis where the skin was exposed, but not around the whole orthosis (since it would increase volume and create pressure areas). When removing the orthosis for fabrication, separate the edges and then slide the orthosis in a proximal to distal motion in order to avoid PIP extension and maintain the allowed PIP flexion. In this case, the patient wore the
orthosis continuously at all times for 2 weeks in order to allow for ligamentous healing and anatomical reduction. The use of this orthosis, demonstrated an alternative approach to surgical treatment for PIP fracture dislocation injuries. When choosing to pursue a conservative approach to treating a combined proximal interphalangeal fracture with dorsal dislocation, the use of a bivalve finger fracture orthosis has proven, in the case of this particular patient that attended our clinic, to be very successful in reducing the challenges associated with this injury (Fig. 7). The conservative static bivalve finger fracture orthosis can be utilized (instead of the dynamic traction orthosis) if there is correct alignment and reduction of the articular congruence of the middle phalanx volar lip fracture before and after the fabrication of the orthosis. More complex intra-articular fractures, such as Pilon fractures that extend to both volar and palmar cortices at the base of the middle phalanx,9,10 as well as unicondylar or bicondylar fractures, should be excluded from this conservative treatment option since they might require more advanced surgical intervention. Further results on the use of this orthosis should be documented on a larger number of participants. The patient that used the bivalve finger fracture orthosis was a healthy and compliant individual, extremely motivated to return to sports activities (Fig. 8). The use of the therapeutic and orthosis protocol may vary based on the patient’s healing rate and physician recommendations. References 1. Feldscher SB, Blank JE. Management of a proximal interphalangeal joint fracture dislocation with a compass proximal interphalangeal joint hinge and therapy: a case report. J Hand Ther. 2002;15:266e273. 2. Badia A, Riano F, Ravikoff J, Khouri R, Gonzalez-Hernandez E, Orbay JL. Dynamic intradigital external fixation for proximal interphalangeal joint fracture dislocations. J Hand Surg. 2005;30A:154e160. 3. Chinchalkar SJ, Gan BS. Management of proximal interphalangeal joint fractures and dislocations. J Hand Ther. 2003;16:117e128. 4. Freiberg A, Pollard b, Macdonald M, Duncan MJ. Management of proximal interphalangeal joint injuries. Hand Clin. 2006;22(3):235e242. 5. Eaton RG, Littler JW. Joint injuries and their sequelae. Clin Plast Surg. 1976;3:85e98. 6. Schenck RR. Dynamic traction and early passive movement for fractures at the proximal interphalangeal joint. J Hand Surg. 1986;11A(6):850e858. 7. Goldman SB, Amaker RJ, Espinosa RA. James traction splinting for PIP fractures. J Hand Ther. 2008;21:209e215. 8. Dennys LJ, Hurst LN, Cox J. Management of proximal interphalangeal joint fractures using a new dynamic traction splint and early active movement. J Hand Ther. 1992;5:16e24. 9. Viegas SF. Extension block pinning for proximal interphalangeal joint fracture dislocations: preliminary report of a new technique. J Hand Ther. 1992;17: 896e901. 10. Baratz M, Bauman J. Simple hand fractures that aren’t. Hand Clin. 2006;22: 243e251.
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Practice Forum
Use of a bivalve finger fracture orthosis for a new treatment protocol of a PIP comminuted fracture and dorsal dislocation Marisol Monasterio MOT, OTR, CHT *, Kathleen A. Longsworth BS, Steven Viegas MD Advanced Orthopaedics and Sports Medicine, 13300 Hargrave #400, Houston, TX 77070, USA
As therapists and physicians, we often need to work with our patients to cater treatment accordingly. These authors describe how they modified a treatment protocol for a patient that sustained a proximal interphalangeal joint comminuted fracture and dorsal dislocation, but refused surgery. Their modification allowed the patient to return to full activities. e Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor. .
Introduction
Anatomy and classification
Injuries involving the combination of a proximal interphalangeal fracture and dorsal dislocation are puzzling to many, despite the currently known surgical repairs and orthosis methods. These types of fractures are typically treated with either a surgical or conservative approach. Surgical treatment is required if the fracture is unstable and involves more than 40% of the articular surface.1 Conservative therapy approaches include the use of an extension block orthosis and/or Buddy tapping if the fracture is stable and involves less that 30% of the articular surface.1 The main challenges in treating these patients include resolving pain, swelling, stiffness, and instability. Additional challenges include preventing degenerative arthritis and prolonged disability with damage in the osseous, articular and soft tissue components.2 The purpose of this report is to present a modification to the traditional comminuted fracture and dorsal dislocation protocol with the use of a bivalve finger fracture orthosis. The reason for the modification was because the patient that attended our clinic with this particular diagnosis chose not to have surgery as suggested by the surgeon and he agreed to follow a conservative protocol instead. Therapy goals involved with the use of this low profile orthosis included early motion, decrease edema, minimizing PIP flexion and extension contractions, diminishing tendon adhesion, minimizing secondary deformities, decreasing pain and increasing patient compliance to orthotic use.
Although the proximal interphalangeal joint (PIP) is a stable joint due to its articular and ligamentous structure, it is also one of the most commonly injured joints in hand. The PIP is surrounded by the joint capsule composed by the volar plate, true and accessory collateral ligaments, and the extensor mechanism. Stability is provided dorsally by the extensor tendon slip and lateral bands. Ulnarly and radially, the joint is statically stabilized by the accessory and true collateral ligaments, and conjoined lateral bands. Palmarly, the main static stabilizers are the volar plate, flexor tendons, and fibro-osseous flexor sheet. The articular congruency of the condyles, volar plate, and the accessory ligament act as dynamic restrains with hyperextension injuries; these structures contribute to lateral stability and prevention of dorsal dislocation. Proximal interphalangeal joint injuries range from ligament sprains to unstable irreducible fracture dislocations. The level of injury depends on the direction and force of the trauma, joint position, eccentric muscular contraction that affects the load on ligaments and tendons, and incongruence of bony fractures.3 Dorsally directed joint dislocations are the most common types of dislocations. These injuries result from PIP joint hyperextension that disrupts the volar plate, as well as one or both the true and accessory collateral ligaments from their insertion at the base of the middle phalanx. A more complex injury occurs from a fracture of the volar lip of the middle phalanx that may or not be reducible.4 There have been many classifications that summarize the effect of these injuries, but we will cite one in particular. Eaton and Littler5 categorized dorsal dislocation injuries into three types. Type I injuries, also known as hyperextension injuries, are defined by a partial volar plate avulsion with intact collateral ligaments. Type II injuries, or dorsal dislocation injuries, are characterized by total
This article was adapted from a Clinical Poster Presentation at the Chicago 2013 ASHT National Conference. * Corresponding author. Tel.: þ1 8327157043; fax: þ1 2819531104. E-mail addresses: [email protected], [email protected] (M. Monasterio).
0894-1130/$ e see front matter Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jht.2014.08.002
2
M. Monasterio et al. / Journal of Hand Therapy xxx (2014) 1e4
Fig. 1. Orthosis applied on patient, allowing therapist to check for motion, sensation and circulation.
volar plate and complete collateral ligament rupture. Type III injuries, or fracture dislocation injuries, include a fracture of the volar lip of the middle phalanx and complete ligament disruption. Treatment is chosen based on the categories listed. Eaton and Littler type I and II usually involve closed treatment with dorsal block pinning or a dorsal blocking orthosis with a Buddy tape use to the adjacent digits for 4e6 weeks. Type III usually require extension block orthosis, extension block pinning, traction orthosis, the “S” Quatro technique, force coupled methods, external fixators, volar plate advancement arthroplasties, or ORIF procedures.3 A 51 y/o right-hand-dominant gentleman who worked in construction and real estate sales, as well as #1 ranked tennis player in a mayor metropolitan city was playing baseball with his son at his yard when the baseball struck his left ring finger into hyperextension. The patient was seen in our clinic and was diagnosed by the hand surgeon with an impacted comminuted fracture of the volar half of the base of the middle phalanx of the left ring finger with dorsal subluxation of the middle phalanx. There was no instability to stress of the radial or ulnar collateral ligament with
Fig. 2. Materials.
Fig. 3. Thermoplastic material wrapped dorsally from ulnar to radial side overlapping at the top.
the PIP joint in slight flexion. The patient showed an Eaton and Littler type III injury. Bivalve finger fracture orthosis Because our patient opted to not have surgery, we modified the protocol using a bivalve finger fracture orthosis, which is a finger based circumferential orthosis that allows DIP and MP motion while providing static reduction of the middle phalanx volar fracture lip, as well as allowing ligamentous healing (Fig. 1). The surgeon determined the exact degree of PIP flexion while evaluating the anatomic reduction and stabilization of the fracture fragment using fluoroscopy. After the fabrication of the orthosis, the finger position was evaluated under X-ray to ensure joint stability. The orthosis was constructed around the digit overlapping at the dorsal side. Constant pressure was provided by the use of rivets and straps over the first and second phalanges. This compression around the digit decreased edema and ensured bone stability and healing (similar to a cast).
Fig. 4. Orthosis finished with 2 straps that wrap around the middle first and second phalanges from dorsal to radial side.
M. Monasterio et al. / Journal of Hand Therapy xxx (2014) 1e4
3
Fig. 5. Extension blocking orthosis at 30 .
The orthosis is low profile compared to the ones listed in the literature, including the arcuate dynamic traction method by Schenck,6 the James traction orthosis used within the Army hand community,7 and the lateral hinge traction orthosis cited by Dennys et al,8 among others. Excluding the distal joint allowed for motion at the DIP in order to prevent ORL tightness. Likewise, not including the MP joint allowed for motion and decreased hyperextension posture of the MCP joint and attenuation of the sagittal band (as a kinematic mechanical imbalance due to PIP flexion contracture3). The orthosis’s adaptable pressure around the fracture site was controlled by the amount of pull the patient applied using the rivets and straps. Rivets were used instead of Velcro to act as a “D ring”
Fig. 7. X-rays taken after injury and then at discharge.
progressive pull (as seen on humeral fracture braces) that started dorsally and surrounded the digit. It was inferred that the rivets would be more durable and the patient could avoid further visits for orthosis refurbishing. Supplies needed for fabrication of the orthosis (Fig. 2): 7 cm 6 cm 1/16 in perforated thermoplastic material Two 6 cm ¼ in straps Two large size rivets Two 1 cm 1 cm adhesive Velcro pieces Moleskin 23 cm
Fig. 6. Elastic band to decrease intrinsic tightness.
Fabrication steps: 1. Heat thermoplastic material until soft. Wrap the material starting dorsally from ulnar to radial side overlapping at the top of the digit. Place finger in desired degree of PIP flexion (Fig. 3). 2. Separate the edges carefully to remove the orthosis from the patient in a proximal to distal motion to avoid PIP extension. Secure the finger in the allowed amount of PIP flexion (90 in this case) while the orthosis is constructed. 3. Cut and flare proximally and distally to allow MP and DIP flexion. Pad the edges close to the skin area using Moleskin. This will help to prevent pressure sores and ensure skin integrity. 4. Perforate 1/8 in holes using a hole punching device over the dorsal site of the middle first and second phalanges. Attach the two ¼ in straps respectively in each hole, pressing the large size rivets together using pliers. 5. Apply 1 cm by 1 cm adhesive hooked Velcro pieces to the radial side of the rivet over the thermoplastic material to secure the straps after they wrap around the first and second phalanges (Fig. 4).
4
M. Monasterio et al. / Journal of Hand Therapy xxx (2014) 1e4
Fig. 8. Patient achieved full AROM in flexion and extension.
6. Place the orthosis on the patient’s finger by separating the edges (avoiding PIP extension) and sliding the orthosis onto the finger in a distal to proximal motion. Apply a steady, but comfortable pressure using the straps. Check for skin sensation and circulation at the tip of the finger, as well as DIP and MP motion. Protocol The patient was instructed to use the custom made bivalve finger fracture orthosis at the allowed degrees of flexion (90 in this case) at all times, and to not attempt to remove it for 2 weeks. The patient was encouraged to call the therapist if he felt discomfort. After 2 weeks of immobilization in the bivalve finger fracture orthosis, the patient started AROM as recommended by the physician. The extension block was fabricated at 30 of PIP flexion. The patient’s arc of motion was changed from 90 to 30 of PIP flexion in the extension blocking orthosis in order to avoid volar plate tightness (Fig. 5). The orthosis was modified by 10 every week for a total of 2 weeks in order to advance PIP extension. Four weeks after starting the protocol, the patient began light strengthening per therapist preference. In order to achieve the remaining degrees of PIP extension and avoid extension lag, a LMB orthosis was used at night. An elastic band for intrinsic minus stretch was utilized during the day for 5 min intervals 4 times a day (Fig. 6). The patient was discharged from therapy at 8 weeks after beginning of the protocol and was allowed to return to sports since he demonstrated functional AROM and strength. Conclusions and Precautions This method avoided some of the complications seen in the use of dynamic traction orthoses, including flexion contraction, hyperextension posture of the MCP, PIP extension lag, pain, stiffness, patient’s noncompliance to orthosis use, pin tract infection, and skin irritation.8,9 While using the bivalve orthosis, the therapist and patient must remember to check for circulation and sensation. Skin integrity was not compromised due to the use of thin perforated thermoplastic material in the orthosis fabrication; this material was also strong enough to conform and stabilize the digit. Moleskin padding was used on the edges of the orthosis where the skin was exposed, but not around the whole orthosis (since it would increase volume and create pressure areas). When removing the orthosis for fabrication, separate the edges and then slide the orthosis in a proximal to distal motion in order to avoid PIP extension and maintain the allowed PIP flexion. In this case, the patient wore the
orthosis continuously at all times for 2 weeks in order to allow for ligamentous healing and anatomical reduction. The use of this orthosis, demonstrated an alternative approach to surgical treatment for PIP fracture dislocation injuries. When choosing to pursue a conservative approach to treating a combined proximal interphalangeal fracture with dorsal dislocation, the use of a bivalve finger fracture orthosis has proven, in the case of this particular patient that attended our clinic, to be very successful in reducing the challenges associated with this injury (Fig. 7). The conservative static bivalve finger fracture orthosis can be utilized (instead of the dynamic traction orthosis) if there is correct alignment and reduction of the articular congruence of the middle phalanx volar lip fracture before and after the fabrication of the orthosis. More complex intra-articular fractures, such as Pilon fractures that extend to both volar and palmar cortices at the base of the middle phalanx,9,10 as well as unicondylar or bicondylar fractures, should be excluded from this conservative treatment option since they might require more advanced surgical intervention. Further results on the use of this orthosis should be documented on a larger number of participants. The patient that used the bivalve finger fracture orthosis was a healthy and compliant individual, extremely motivated to return to sports activities (Fig. 8). The use of the therapeutic and orthosis protocol may vary based on the patient’s healing rate and physician recommendations. References 1. Feldscher SB, Blank JE. Management of a proximal interphalangeal joint fracture dislocation with a compass proximal interphalangeal joint hinge and therapy: a case report. J Hand Ther. 2002;15:266e273. 2. Badia A, Riano F, Ravikoff J, Khouri R, Gonzalez-Hernandez E, Orbay JL. Dynamic intradigital external fixation for proximal interphalangeal joint fracture dislocations. J Hand Surg. 2005;30A:154e160. 3. Chinchalkar SJ, Gan BS. Management of proximal interphalangeal joint fractures and dislocations. J Hand Ther. 2003;16:117e128. 4. Freiberg A, Pollard b, Macdonald M, Duncan MJ. Management of proximal interphalangeal joint injuries. Hand Clin. 2006;22(3):235e242. 5. Eaton RG, Littler JW. Joint injuries and their sequelae. Clin Plast Surg. 1976;3:85e98. 6. Schenck RR. Dynamic traction and early passive movement for fractures at the proximal interphalangeal joint. J Hand Surg. 1986;11A(6):850e858. 7. Goldman SB, Amaker RJ, Espinosa RA. James traction splinting for PIP fractures. J Hand Ther. 2008;21:209e215. 8. Dennys LJ, Hurst LN, Cox J. Management of proximal interphalangeal joint fractures using a new dynamic traction splint and early active movement. J Hand Ther. 1992;5:16e24. 9. Viegas SF. Extension block pinning for proximal interphalangeal joint fracture dislocations: preliminary report of a new technique. J Hand Ther. 1992;17: 896e901. 10. Baratz M, Bauman J. Simple hand fractures that aren’t. Hand Clin. 2006;22: 243e251.