What is the best treatment for a proximal interphalangeal (PIP) joint injury with loss of range of motion?

Treatment of PIP Joint Injury with Loss of Range of Motion

For PIP joint injuries with loss of range of motion, initiate conservative management with range of motion exercises and orthotic intervention, reserving surgery (arthrodesis or arthroplasty) only for cases with structural abnormalities that fail conservative treatment.

Initial Conservative Management

Range of Motion Exercises

• Begin active, active-assisted, or passive range of motion exercises immediately to prevent further stiffness and complications like Complex Regional Pain Syndrome (CRPS) 1.
• Combine range of motion exercises with joint protection education to optimize functional outcomes 1.
• Exercise provides substantial benefit with an effect size of 0.32 for both pain relief and functional improvement in joint conditions 1.

Orthotic Intervention for Extension Deficits

For fixed flexion deformities following traumatic PIP injury, extension orthoses are significantly more effective than hand therapy alone (mean improvement of 16.7° greater than therapy alone) 2.

Orthosis Selection:

• Custom-fabricated synthetic serial casting or static-progressive splinting are the preferred approaches for resistant PIP flexion contractures, as they maximize Total-End-Range-Time while minimizing functional hand impairment 3.
• For acute hyperextension injuries without fracture, buddy strapping is equally effective as aluminum orthoses and allows earlier recovery of motion, edema resolution, and pain relief 4.
• For volar plate injuries, dorsal blocking orthoses positioned in neutral require fewer therapy appointments (approximately one less session) compared to 25-30° flexion positioning, with no significant difference in outcomes 5.

Critical caveat: Avoid splinting that increases attention to the affected area, promotes compensatory movements, causes muscle deconditioning, or leads to learned non-use, as these can worsen outcomes 1.

Pain Management

• Use analgesics (acetaminophen or ibuprofen) if no contraindications exist 1.
• Intra-articular glucocorticoid injections may be considered specifically for painful interphalangeal joints with evidence of inflammation, as they demonstrate efficacy for pain during movement and joint swelling 1.
• However, glucocorticoids should not be used routinely, only when clear joint inflammation is present 1.

Adjunctive Therapies

• Local heat application (paraffin wax, hot packs) before exercise may provide benefit, though evidence is limited 1.
• Gentle stretching and mobilization techniques should be performed gradually, restoring alignment while strengthening weak muscles 1.

Surgical Intervention

Surgery should be considered only when conservative treatments fail to adequately relieve pain in patients with structural abnormalities 1.

Surgical Options for PIP Joint:

• Arthroplasty (typically silicone implants) is the preferred technique for PIP joints, except for the index finger (PIP-2), where arthrodesis may be considered 1.
• Even neglected extensor tendon injuries (>1 year old) can achieve satisfactory outcomes with primary repair using modified Kessler technique when proper balance between central slip and lateral bands is maintained 6.

Essential post-surgical requirement: Patients must receive rehabilitation postoperatively to optimize outcomes 1.

Treatment Algorithm Based on Injury Type

For Acute Hyperextension Injuries:

1. Buddy strapping for 1 week (preferred for ease and equivalent outcomes) 4
2. Weekly assessment of motion, edema, pain, and strength for first month 4
3. Follow-up at 3,6, and 12 months 4

For Fixed Flexion Deformities:

1. Extension orthosis (serial casting or static-progressive splinting) 3, 2
2. Maximize Total-End-Range-Time with orthosis 3
3. Continue until maximal passive and active extension achieved 3

For Volar Plate Injuries:

1. Dorsal blocking orthosis in neutral position 5
2. Flexion exercises as tolerated 5
3. Monitor for fixed flexion deformity development 5

Common Pitfalls to Avoid

• Do not use overhead pulley exercises, as they may cause harm to the complex PIP joint structure 1.
• Avoid aggressive passive range of motion if performed improperly, as this can cause more harm than benefit 1.
• Do not immobilize for prolonged periods without concurrent exercise, as this leads to muscle deconditioning and learned non-use 1.
• Serial casting for fixed functional dystonia has been associated with worsening symptoms and onset of CRPS 1.

Prognostic Factors

• Children have better outcomes than adults with PIP injuries 4.
• Patients achieving full recovery with buddy strapping demonstrate earlier resolution of symptoms compared to rigid immobilization 4.