What is the treatment for a middle finger proximal interphalangeal (PIP) joint evulsion fracture?

Treatment of Middle Finger PIP Joint Avulsion Fracture

The treatment for a middle finger proximal interphalangeal (PIP) joint avulsion fracture depends primarily on the displacement of the fracture fragment, with conservative management indicated for minimally displaced fractures (<2-3mm) and surgical intervention necessary for fractures with displacement >3mm or involving more than one-third of the articular surface.

Initial Assessment and Imaging

• Radiography is essential as the initial imaging for suspected finger fractures, with at least 2 views recommended (PA and lateral), though adding an oblique view increases diagnostic yield 1
• For PIP joint fractures, radiographs should assess displacement of the fracture fragment (>3mm indicates need for surgery) and articular involvement (>1/3 of articular surface indicates need for surgery) 1

Treatment Algorithm

Conservative Management

• Rigid immobilization with a splint for 3-6 weeks is indicated for minimally displaced fractures (<2-3mm) 1, 2
• Follow-up radiographs should be obtained at 10-14 days to ensure the fracture position is maintained 1
• Active finger motion exercises should be performed following diagnosis to prevent stiffness, which is one of the most functionally disabling adverse effects 3
• A home exercise program is an option for patients prescribed therapy after fracture immobilization 3

Surgical Management

• Surgery should be considered when:
  • Fracture fragment displacement >3mm 1
  • Involvement of more than one-third of the articular surface 1
  • Conservative treatment has failed to provide pain relief or restore function 1
• Open reduction and internal fixation (ORIF) using mini-screws via a volar approach can be used to stabilize unstable dorsal fracture-dislocations of the PIP joint 4
• For dorsolateral dislocations with avulsion fractures, closed reduction often anatomically realigns the avulsed ligaments, allowing for non-operative management with a dorsal splint to prevent hyperextension and lateral stresses 5

Post-Treatment Management

• Hand stiffness is one of the most functionally disabling adverse effects following fracture treatment 3
• Instructing the patient to move the fingers regularly through a complete range of motion may help minimize the risk of stiffness complications 3
• Finger motion does not have adverse effects on an adequately stabilized fracture in regard to reduction or healing 3
• Patients do not need to begin early wrist motion routinely following stable fracture fixation 3

Outcomes and Prognosis

• For ORIF of unstable dorsal PIP joint fracture-dislocations using mini-screws, the average arc of motion for the involved PIP joint was found to be 70 degrees (range, 55-90 degrees) 4
• PIP joint range of motion is usually compromised after surgical fixation; in one study, 8 of 9 joints had a residual flexion contracture 4
• Most patients (7 of 9) had no pain after surgical treatment, while 2 had pain only with heavy activity 4

Common Pitfalls and Complications

• Failure to diagnose and properly treat PIP joint injuries can lead to prolonged or permanent impairment 6
• Overlooked extensor tendon injuries at the PIP joint can develop into a buttonhole/Boutonnière deformity within 1-2 weeks, characterized by an extension lag of the PIP joint and hyperextension at the distal interphalangeal joint 7
• Surgical treatment should be approached cautiously, especially in the presence of comminution 4
• Post-treatment monitoring should focus on pain relief and restoration of function 1