How should I splint a laterally dislocated proximal interphalangeal joint with a visible bone fragment on radiograph?

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Management of Laterally Dislocated PIP Joint with Bone Fragment

For a laterally dislocated PIP joint with a visible bone fragment on radiograph, immediately reduce the joint and splint in 10-15 degrees of flexion using a dorsal blocking splint, but only if the fracture involves less than one-third of the articular surface and the joint is stable after reduction—otherwise, refer urgently for surgical fixation. 1, 2

Immediate Assessment and Decision-Making

Determine Surgical vs. Conservative Management

Critical radiographic criteria that mandate immediate surgical referral:

  • Bone fragment involving ≥33% of the articular surface of the middle phalanx base 3, 1
  • Volar (palmar) subluxation of the middle phalanx on lateral view, even with small fragments 3, 4
  • Articular step-off or gap ≥2 mm after attempted closed reduction 4
  • Interfragmentary gap >3 mm 3
  • Joint instability after closed reduction (redislocates with gentle range of motion testing) 1, 2

If none of these criteria are present, proceed with conservative management. 1, 5

Conservative Splinting Technique (For Stable Injuries)

Splint Configuration

Apply a dorsal blocking splint that:

  • Holds the PIP joint in 10-15 degrees of flexion (not full extension) 5, 2
  • Blocks hyperextension and lateral deviation while allowing controlled flexion 5
  • Leaves the DIP joint completely free for immediate active motion 3
  • Extends from the fingertip to mid-palm on the dorsal surface 1

Critical Splinting Principles

The splint must remain in place continuously for 3-6 weeks without removal, as even brief interruptions restart the healing timeline. 3, 1

Begin active flexion exercises of the PIP joint immediately within the protective arc of the splint (flexion allowed, extension blocked at 10-15 degrees). 3, 1

Start active DIP and MCP joint motion exercises immediately while the PIP remains splinted to prevent stiffness in adjacent joints. 3

Initial Management Steps

Before Splinting

  • Apply ice-water mixture for 10-20 minutes with a thin towel barrier to reduce swelling 3
  • Never attempt to straighten the finger forcefully or apply heat 3
  • Perform gentle closed reduction by applying longitudinal traction with the MCP joint flexed to 90 degrees, then directing the middle phalanx volarly while maintaining traction 5, 2

Post-Reduction Verification

After reduction, test stability by:

  • Gently flexing and extending the PIP joint through a small arc 2
  • Applying gentle lateral stress 5
  • If the joint redislocates or subluxates with these maneuvers, surgical referral is mandatory 1, 2

Common Pitfalls to Avoid

Do not splint in full extension—this places excessive tension on the healing volar structures and increases risk of redislocation. 5, 2

Do not immobilize the DIP or MCP joints—this causes unnecessary stiffness without improving PIP stability. 3, 1

Do not delay radiographs—attempting to splint before obtaining imaging can miss surgical indications and lead to poor outcomes. 3, 4

Do not underestimate lateral dislocations—these injuries disrupt both the collateral ligament and accessory collateral ligament, and the bone fragment indicates significant instability. 5, 6

Follow-Up Protocol

Re-evaluate immediately if unremitting pain develops during immobilization, as this may indicate loss of reduction or compartment syndrome. 3

Obtain repeat radiographs at 7-10 days to confirm maintained reduction, as late subluxation can occur even in initially stable injuries. 1, 2

Buddy-tape to adjacent finger after splint removal (typically 3-6 weeks) and continue for an additional 3-4 weeks during activities. 4, 1

Special Considerations for Lateral Dislocations

Lateral (radial or ulnar) dislocations with bone fragments represent disruption of the proper collateral ligament at its attachment to the proximal phalanx head AND avulsion of the volar plate from the middle phalanx base. 5, 6

These injuries are inherently less stable than pure dorsal dislocations because the collateral ligament system is completely disrupted on one side. 5, 6

After closed reduction in cadaver studies, the collateral ligament returns to its anatomic position without interposition only when the joint is held in slight flexion. 5

References

3
Guideline

Mallet Finger Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Guideline

Management of Intra‑articular Middle Phalanx Fractures

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

6
Research

Proximal interphalangeal joint dislocations and fracture-dislocations.

The Journal of hand surgery, European volume, 2023

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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