PIPJ Dislocations - Strategic Management of Late Presentations.

PIPJ dislocations frequently present at a late stage - usually 3 months following the injury. The GP generally diagnoses a finger sprain and suggests that the patient buddy straps the finger to the adjacent finger. The generally do not mobilize the finger for a few weeks and at 1 month they have developed a pseudo Boutonniere deformity, often with reciprocal hyperextension of the DIP joint. These fixed flexion deformities usually have an associated collateral ligament injury. It is not possible to correct these deformities adequately with splinting alone, because the splint is removable and the patient does not permit adequate time spent in the splint to provide an adequate stress that will result in a change in tissue length and elasticity. This results in frustration as the result of treatment is poor. In the images below you can see that full digital flexion is achieved and the deformity does not limit functional use. However, it is not cosmetically pleasing and it prevents the patient from wearing a wedding ring. Every attempt must be made to regain PIPJ extension and reduce the swelling around the PIPJ. My treatment of choice is the application of a serial Plaster of Paris extension cast followed by a dorsal finger extension orthosis for use at night and an active re-direction orthosis for use during the day.