sign in sign up
<<
Home , Joint dislocation

IJAccid Emerg Med 1999;16:431-432 431

SHORT REPORT

Palmar dislocation of the proximal interphalangeal -an not to be missed

P P Tekkis, N Kessaris, M Enchill-Yawson, G V Mani, M Gavalas

Abstract unrecognised, misdiagnosed, or only casually Palmar dislocations ofthe proximal inter- treated may lead to residual long term disabil- phalangeal (PIP) joint are associated with ity and disfigurement (chronic boutonniere long term complications if suboptimally deformity). Even when promptly recognised treated. Six cases ofpalmar dislocation of and effectively treated, some permanent im- the PIP joint are presented and a system- pairment of mobility may still occur.' atic approach in the diagnosis and man- agement of such in the accident Patients and methods and is described. Six patients presented to our two A&E depart- Department of (JAccid Emerg Med 1999;16:431-432) ments between April 1996 and April 1997 with Orthopaedic Surgery, palmar dislocation ofthe PIP joint. There were Queen Mary's Keywords: proximal interphalangeal joint; dislocation Hospital, Sidcup, Kent five male and one female patients with a mean P P Tekkis age of 42.6 years (range 19-56). The mech- M Enchill-Yawson Injuries to the proximal interphalangeal (PIP) anism of injury was forced hyperflexion of the G V Mani joint are common in the accident and emer- PIP joint resulting from a fall (three cases) and gency (A&E) department. Such injuries vary as a result offighting (three cases). All six cases Departnent of presented to the A&E department within 24 Accident and from soft tissue and ligamentous injuries to Emergency, University joint , dislocations, and fracture hours oftheir injury. Diagnosis was made upon College Hospital, dislocations. Whereas posterior (dorsal) PIP clinical examination and radiological findings London WClE 6AU joint dislocations have been traditionally man- on before and after reduction radiographs N Kessaris aged in the A&E department by closed reduc- (figl). All six cases were treated in the A&E M Gavalas tion and neighbour strapping, palmar disloca- department by closed reduction under digital block and neighbour strapping for an Correspondence to: tions and fracture dislocations of the PIP joint Mr Gavalas, Consultant are less common and constitute entirely differ- average period of two weeks, followed by (e-mail: dynamic extensor splintage for a further two to [email protected]). ent injuries that do not usually respond to con- servative treatment. In this report we three weeks. Passive and active motion of the empha- distal was to Accepted 20 March 1999 sise the interphalangeal joint encouraged importance of identifying which if prevent of the lateral bands and joint stiffness. Upon one year follow up all six patients presented with a residual 42°-45° fixed flexion deformity at the PIP joint and a range of flexion up to 1 100 (fig 2).

Classification Palmar dislocation of the PIP joint is present when the middle phalanx is displaced anterior to the proximal phalanx at the level of the PIP joint. Historically three types of palmar PIP joint dislocations have been described by vari- sf_ . ous authors,2" but more recently it has been Figure I True lateral radiograph of a palmar dislocation of the PIPjoint. Note the suggested that these injuries form a subgroup position ofthe middle phalanx in relation with the proximal phalanx. of acute boutonniere deformities.5 (1) Simple palmar dislocation of the PIP joint: this usually results in disruption of at least one collateral joint and avulsion of the central slip of the extensor .2 (2) Rotatory palmar dislocation of the PIP joint in which the condyle of the head of the proximal phalanx is buttonholed between the lateral band and the central slip of the extensor Figure 2 Lateral radiograph ofthe same patient displaying a typical chronic boutonniere tendon, both of which remain intact often ren- deformity resultingfrom a previous palmar dislocation of the PIPjoint. dering the joint irreducible.3 432 Tekkis, Kessaris, Enchill-Yawson, et al

(3) Palmar dislocation of the PIP joint in tion of the volar dislocation of the PIP joint,6 association with central slip attachment frac- other authors advocate prompt open reduc- ture, which represents a spectrum of injuries, tion, primary reconstitution of the ruptured ranging from a traumatic boutonniere deform- structures, and fixation of the PIP joint soon ity to the anterior fracture dislocation of the after injury to prevent the development of joint PIP joint that can be grossly unstable.4 .5 89 As there are no randomised prospective studies that describe the ideal Discussion method of treatment of palmar dislocations of A systematic approach to the examination of the PIP joint, the final decision whether to treat the PIP joint with inspection, , and surgically or non-surgically depends on the movement is essential to establish the diagnosis hand surgeon and the patient involved. An and instigate optimum treatment. Pre- important point to be emphasised is that all reduction radiographic investigations are man- cases of palmar dislocation of the PIP joint datory in differentiating volar from dorsal PIP after reduction in the A&E department should joint injuries. Two at right angle views of the be followed up by a hand surgeon within a few PIP joint are necessary, but ideally a true days to expertly assess central slip function. lateral film should be aimed for.6 A central slip attachment fracture of the dorsal third of the articular surface of the middle phalanx may be Conclusion visible on the lateral radiograph.7 Re- Volar PIP joint dislocations are associated with examination after reducing the dislocation serious and disabling soft tissue injuries, which under digital block is also vital but often not are not commonly recognised as such and are undertaken in the A&E department. A radio- often treated inadequately. Careful clinical graph of the finger after reduction should also assessment as well as before and after reduc- be taken to ensure that joint congruity is main- tion radiographs of the involved finger is the tained. key to recognition of palmar PIP joint injuries. It is our belief that it is safe A&E practice to Such injuries can be safely treated in the A&E treat palmar PIP joint dislocations by closed by closed reduction and extensor splintage reduction under digital block anaesthesia until a definite treatment plan is made by an followed by extensor splintage. Extensor orthopaedic hand surgeon. splints position the PIP joint in full extension, Conflict of interest: none. reducing the separation of the ends of the cen- Funding: none. tral slip of the extensor tendon and allowing 1 Postner MA, Kapila D. Chronic palmar dislocation ofproxi- repair of the structure at the tendon's normal mal interphalangeal . J Hand Surg [Am] length. Early mobilisation as well as passive or 1986;11:253-8. 2 Peimer CA, Sullivan DJ, Wild DR. Plamar dislocation ofthe active exercises of the distal interphalangeal proximal interphalangeal joint. J Hand Surg [Am] 1984;9: joint should be encouraged to prevent joint 39-48. 3 Auquit-Auckbur I, Duparc F, Milliez PY, et al. Recent stiffness and late development of a boutonniere palmar dislocations of the proximal interphalangeal joint. deformity. Whereby closed reduction is not Rev Chir Orthop Reparatrice Appar Mot 1997;83:60-4. 4 Imatami J, Hashizume H, Wake H, et al. The central slip possible due to soft tissue interposition in the attachment fracture. Jf Hand Surg [Br] 1997;22: 107-9. PIP joint, as in the case of rotational PIP joint 5 Doyle JR. Boutonniere deformity. In: Strickland JW, ed. The hand. Master techniques in orthopaedic surgery. Lippincott- dislocation, formal exploration and open re- Raven, 1998: 539-54. duction of the joint may be necessary. Simi- 6 Rockwood CA, Green DP, Bucholz RW, et al. Fractures and dislocations in the hand. In: Rockwood CA, eds. Rockwood larly, open reduction may be necessary when and Green's fractures in adults. Lippincott-Raven, 1996: there is gross displacement of a large dorsal 678-86. 7 Rosenstadt BE, Glickel SZ, Lane LB, et al. Palmar fracture fragment rendering the joint unstable as in the dislocation of the proximal interphalangeal joint. J Hand case of anterior fracture dislocation of the PIP Surg [Am] 1998;23:811-20. 8 Baugher WH, MacCue FC. Anterior fracture-dislocation of joint.' the proximal interphalangeal joint. J Bone joint Surg Am Although an argument can be made for 1979;61:779-80. 9 Spinner M, Choi BY Anterior dislocation of the proximal splinting the PIP joint in full extension without interphalangeal joint. J Bone joint Surg Am 1970;52: 1329- surgical repair of the central slip after reduc- 36.