What is the standard management for minimal dorsal subluxation of the DIPJ?

Management of Minimal Dorsal Subluxation of the Distal Interphalangeal Joint (DIPJ)

Minimal dorsal subluxation of the DIPJ can be managed conservatively with extension block splinting as the first-line treatment, provided there is no significant articular involvement or instability.

Assessment and Diagnosis

• Radiographic evaluation is essential to determine:

  • Percentage of articular surface involvement
  • Presence of associated fractures
  • Degree of subluxation
  • Joint stability

• MRI may be considered for evaluation of associated soft tissue injuries, particularly when:

  • Ligamentous injury is suspected
  • Persistent pain or instability exists despite appropriate treatment
  • Unclear diagnosis on plain radiographs 1

Treatment Algorithm

Conservative Management (First-Line)

1. Extension block splinting:

   • Indicated for stable subluxations with minimal articular involvement (less than 30% of articular surface)
   • Provides excellent outcomes with good to excellent results in most cases 2
   • Splint should be applied with the DIPJ in slight flexion to prevent redislocation
   • Duration: 4-6 weeks followed by protected mobilization

2. Monitoring parameters:

   • Joint reduction maintenance
   • Pain control
   • Progressive range of motion
   • Development of any instability

Surgical Management (Second-Line)

Indicated when:

• Failed closed reduction
• Unstable reduction
• Articular surface involvement >30%
• Persistent subluxation after conservative treatment

Surgical options:

1. Open Reduction Internal Fixation (ORIF):

   • Interfragmentary screw fixation is preferred when technically feasible
     • Results in better DIP joint range of motion
     • Lower incidence of hardware removal 3
   • Small buttress plate fixation as alternative
     • May cause limited DIP flexion
     • Higher rate of hardware removal requirement 3

2. Post-surgical rehabilitation:

   • Early protected range of motion exercises
   • Gradual return to activities
   • Hardware removal if symptomatic (more common with plate fixation)

Expected Outcomes and Prognosis

• Conservative treatment with extension block splinting provides good to excellent results in most cases with minimal articular involvement 2
• Some loss of motion should be expected even with optimal treatment:
  • Potential for extension lag of approximately 10 degrees
  • Possible limitation in flexion range 4
• Pain-free function is achievable in most cases with appropriate treatment

Complications and Management

• Joint stiffness: Address with supervised physical therapy and stretching exercises
• Persistent subluxation: Consider surgical intervention if conservative management fails
• Post-traumatic arthritis: May develop despite appropriate treatment; manage symptomatically
• Hardware-related issues: Remove symptomatic hardware, particularly with plate fixation 3

Special Considerations

• Irreducible dorsal DIPJ dislocations may require open reduction via volar approach to address:

  • Volar plate interposition
  • Entrapped flexor digitorum profundus tendon
  • Buttonholing of middle phalanx through volar plate 5

• For chronic cases with persistent instability, reconstructive procedures may be considered, though these are more commonly described for proximal joints 6

The key to successful management is early appropriate treatment based on the stability of the joint and degree of articular involvement, with conservative management being the preferred initial approach for minimal dorsal subluxation.