How to manage a stable flexion deformity at the PIP joint of the fifth finger?

Management of Stable Flexion Deformity at the PIP Joint of the Fifth Finger

For a stable flexion deformity at the PIP joint of the fifth finger, orthoses (splints) combined with physical therapy exercises should be the first-line treatment, with long-term use (at least 3 months) advocated for optimal outcomes. 1

Non-Pharmacological Management Options

Orthoses (Splinting)

• Custom-made orthoses are preferred over prefabricated ones to improve patient compliance and long-term use
• Evidence supports beneficial effects of orthoses, especially for pain relief and to a lesser extent for function improvement 1
• Long-term use (minimum 3 months) is necessary for effectiveness; short-term use shows minimal improvement 1
• Options include:
  • Custom-made thermoplast orthoses to be worn during daily activities
  • Custom-made neoprene orthoses to be worn at night

Physical Therapy

• Physical therapy is appropriate for this condition, as already prescribed in the case
• Should focus on:
  • Range of motion exercises
  • Strengthening exercises for intrinsic and extrinsic finger muscles
  • Joint mobilization techniques 1
• Exercise regimens have shown small beneficial effects on:
  • Self-reported pain and function
  • Joint stiffness
  • Grip strength 1

Specific Exercise Recommendations

• Progressive stretching of the PIP joint into extension
• Active and passive range of motion exercises
• Strengthening of extensor muscles
• Functional exercises to improve hand dexterity

Splinting Approaches for PIP Flexion Contractures

Two main custom-fabricated orthotic approaches have shown effectiveness 2:

1. Synthetic serial casting - provides maximal Total-End-Range-Time (TERT)
2. Static-progressive splinting - gradually increases extension while minimizing functional impediment

Pharmacological Management

Topical Treatments

• Topical NSAIDs should be considered as first-line pharmacological treatment if pain is present
• Offers favorable safety profile compared to oral medications 1
• Topical diclofenac gel has shown small improvements in pain and function 1

Oral Medications

• Paracetamol (up to 4g/day) is the oral analgesic of first choice if needed for pain 1
• Oral NSAIDs should be used only if patient responds inadequately to paracetamol, at lowest effective dose and shortest duration 1
• Note: The patient in this case denied pain when pain medications were offered

Follow-up Recommendations

• Regular clinical and functional assessments should be performed
• Reassessment after 12 months of treatment, or earlier if the deformity worsens 1
• Evaluate:
  • Range of motion
  • Pain levels
  • Functional improvement
  • Patient's ability to perform activities of daily living

Surgical Considerations

• Surgery should be considered only after conservative treatment has been maximized for at least 12 months 1
• Indications for surgical intervention:
  • Failure of conservative treatment
  • Severe functional limitation
  • Progressive deformity despite optimal non-surgical management
• Surgical options may include:
  • Soft tissue release 3
  • Tendon transfers 4, 5
  • Joint arthroplasty in severe cases

Common Pitfalls to Avoid

1. Inadequate duration of orthotic use (should be at least 3 months)
2. Improper fit of orthoses leading to poor compliance
3. Overly aggressive stretching causing pain and reduced compliance
4. Neglecting to address both extension and flexion range of motion
5. Premature consideration of surgical intervention before maximizing conservative treatment

In this case, the prescribed physical therapy is appropriate, and the patient's lack of pain is a positive prognostic factor. The treatment plan should focus on improving range of motion and function through consistent physical therapy and appropriate orthotic intervention.