Proximal Interphalangeal Joint Ligament Injuries

Ligamentous injuries about the PIP joints are among the most common hand injuries in sports. Stability of the PIP joint is provided by the bicondylar articular anatomy, ligamentous support, extensor tendon apparatus, and the flexor tendon retinacular system.56 The key to stability is the relationship of the ulnar and radial collateral ligaments and volar plate. The lateral stabilizers of the joint include the accessory and proper RCLs and UCLs. The ligaments originate from the lateral aspect of each condyle. The proper and accessory collateral ligaments pass in an oblique manner to insert on the volar third of the MP and the volar plate, respectively. The volar plate serves as the floor of the joint and inserts into the palmar region of the MP. Check-rein ligaments are attached to the proximal region of the volar plate preventing hyperextension of the PIP joint. With the strong collateral ligament attachments on both sides of the volar plate, a three-sided box configuration is present to stabilize the PIP joint.

Collateral ligament injuries are frequently seen in athletes participating in ball-handling sports. RCLs are the most commonly injured. The majority of tears occur through the proximal region of the collateral ligament.57 The athlete may not recall the specific time of the injury and often will present in a delayed fashion. Patients complain of joint-line pain, swelling, and stiffness of the injured digit. Stability of the joint is assessed through a dynamic and passive examination. The ability to flex and extend the injured digit through a full arc ROM suggests adequate joint stability. Passive stability of the collateral ligaments should be assessed with the PIP joint in full extension and 30 degrees of flexion. Glickel et al37 have classified collateral ligament injuries of the PIP joint into three categories based on the degree of laxity. Athletes with grade I sprains have pain with stress of the ligament but no laxity. Clinical examination of grade II injuries demonstrates mild to moderate laxity on stress examination. A firm endpoint is noted on passive examination and no instability with active ROM is noted. Grade III injuries demonstrate significant laxity on stress examination. More than 20 degrees of angulation on lateral stress examination may indicate complete disruption of the proper collateral ligament57 (Fig. 41-19).

Grade I and II PIP joint collateral sprains are treated with early ROM and buddy taping. Most athletes may return to play with protective buddy taping. It is important to educate the athlete about the possibility of prolonged soreness, swelling, and stiffness in these types of injuries. The majority of grade III

Digit Pip Dislocation Partial

Figure 41-20 Lateral radiograph of a digit with a volar dislocation of the proximal interphalangeal joint.

Medial Collateral Lig Laxity

Figure 41-19 Stress examination of the ring finger proximal interphalangeal joint in a 25-year-old recreational flag football player demonstrates significant laxity (30 degrees) of the radial collateral ligament. This examination finding is suggestive of a grade III radial collateral ligament injury.

Figure 41-19 Stress examination of the ring finger proximal interphalangeal joint in a 25-year-old recreational flag football player demonstrates significant laxity (30 degrees) of the radial collateral ligament. This examination finding is suggestive of a grade III radial collateral ligament injury.

Figure 41-20 Lateral radiograph of a digit with a volar dislocation of the proximal interphalangeal joint.

injuries are managed with buddy taping, early ROM, and a short period of protection in a dorsal blocking splint with the PIP joint in 30 degrees of flexion. The indication for surgical repair of the ligament is instability on active ROM, nonanatomic joint reduction, or chronic pain. Consideration may be given to surgical repair of significant injuries to the RCL of the index finger because of the restraints required for lateral pinch.

PROXIMAL INTERPHALANGEAL JOINT DISLOCATION

There are three types of PIP joint dislocations: dorsal, lateral, and volar. Dorsal dislocations of the PIP joint are frequently seen in athletes playing ball-handling sports. The injuries often occur when a ball or object hits the tip of the digit. The mechanism of injury is an axial load with an associated hyperextension force. The majority of dorsal dislocations result in distal avulsion of the volar plate. Pure ligamentous dislocations usually have varying degrees of collateral ligament injuries. The injuries are often reduced by the player, coach, or trainer. Radiographs of the injured digit should be taken to evaluate for fracture and congruent joint reduction. If the joint is stable following reduction, early ROM is instituted with the injured digit buddy taped for 3 weeks. Return to play may be possible with protective buddy taping. If some instability exists and radiographs demonstrate congruent reduction, the patient may be placed into a dorsal blocking splint with the joint in 30 degrees of flexion for approximately 7 to 10 days.

Lateral dislocations usually indicate complete disruption of the collateral ligament and portions of the volar plate. These injuries are most often amenable to nonsurgical management similar to dorsal dislocations of the PIP joint.

Volar dislocations of the PIP joint are rare injuries (Fig. 4120). The mechanism of injury is a longitudinal compression load across a partially flexed MP. This injury may result in a straight volar dislocation or one with a rotatory component. Straight volar dislocations are more likely to have a severe injury to the central slip.58 With rotatory volar dislocation, the middle pha-langeal condyle may become entrapped between the central slip and the lateral band as it displaces palmarly. This results in only partial tearing of the central slip along with disruption of the collateral ligament. The majority of these injuries can be reduced by closed methods. With both the MCP and PIP joints flexed, gentle traction is applied.59 In the case of volar rotatory dislocation, avoidance of straight longitudinal traction is important because of the buttonhole entrapment of the MP. After congruent reduction of a rotatory dislocation, athletes who demonstrate full active extension may return to play with buddy taping and ROM as tolerated. Straight volar dislocations and extensor lag after reduction of a volar rotatory dislocation should be managed as an acute boutonniere injury (see "Closed Tendon Injuries").

PROXIMAL INTERPHALANGEAL JOINT FRACTURE DISLOCATIONS

Injuries to the PIP joint, especially those that involve a fracture, require a true lateral view of the joint to assess this area. This is necessary to ensure concentric reduction of the joint. If the volar fragment of the MP is greater than 30% to 40% of the articular surface, the joint is often rendered unstable. Treatment varies from dorsal block splinting to closed reduction, open reduction to external fixation. No splinting is necessary in nondisplaced fractures. Dorsal block splinting is used in a displaced fracture that reduces concentrically with the finger in a flexed position.60 If concentric reduction is not obtained, then closed reduction and pinning of the PIP joint for 10 to 14 days, followed by dorsal block splinting, may be necessary.61 If the fracture fragment is large, open reduction and internal fixation may be beneficial.62,63 Comminuted fractures involving the PIP joint often require external fixation. Return to sports after operative fixation generally occurs in 6 to 8 weeks with protective splinting.

LIGAMENT INJURIES OF THE DISTAL INTERPHALANGEAL JOINT OF THE DIGITS AND INTERPHALANGEAL JOINT OF THE THUMB

The distal joints of the thumb and fingers have ligamentous anatomy similar to that of the PIP joint. Dislocations within these joints are less common in part because of the adjacent insertions of the extensor mechanism and flexor tendon. However, there is a higher propensity for open injuries because of the relationship of the soft-tissue envelope to the joint. These injuries are most commonly seen in ball-handling sports. Athletes may present in a delayed fashion with pain and stiffness of the digit after self-reducing the dislocation. Subluxations or dislocations usually occur dorsally or lateral. Closed reduction is usually possible after placement of a digital block. The dislocation is reduced by applying longitudinal traction and flexing the joint. After reduction, anteroposterior and lateral radiographs are taken. If congruent reduction is obtained, the collateral ligaments are assessed. If the joint is stable, a dorsal blocking splint is applied to the injured joint in 20 degrees of flexion for approximately 2 weeks. Because instability of these injuries is rare, athletes may return to play with a protective splint. Irreducible dislocations are rare and are usually secondary to interposition of the volar plate or flexor tendons.64 Open injuries should be managed with irrigation, debridement, and administration of antibiotics.

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Responses

  • lemlem aman
    How to test colateral lighment of pip joint?
    11 months ago
  • frodo
    How does a kisal interphalangeal joint injury to a 2 Pulley look?
    6 months ago

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