Management of Acute Lateral PIP Joint Dislocation with Small Bone Fragment
In this 30-year-old man with a lateral PIP joint dislocation and a bone fragment involving less than 33% of the articular surface, perform immediate closed reduction followed by buddy taping with early controlled mobilization, as fractures involving less than 30% of the volar articular surface are unlikely to cause gross instability and can be managed non-operatively.
Immediate Management
Reduction Technique
- Perform prompt closed reduction of the lateral dislocation, as finger dislocations should be reduced immediately to optimize outcomes 1.
- Apply longitudinal traction while applying pressure to relocate the displaced middle phalanx base back into anatomic alignment 1.
- Confirm successful reduction with post-reduction radiographs (anteroposterior, lateral, and oblique views) to verify joint congruity and fragment position 1.
Post-Reduction Stability Assessment
- Test joint stability through active range of motion immediately after reduction 2.
- Fractures involving less than 30% of the volar articular surface are biomechanically stable and unlikely to result in gross instability, even with associated collateral ligament and volar plate injuries 3.
- Your patient's fragment (<33% of joint surface) falls within this stable category and does not require surgical fixation 3.
Definitive Non-Operative Management
Immobilization Strategy
- Use buddy taping with a figure-of-eight splint to allow early controlled mobilization rather than rigid immobilization 4.
- The figure-of-eight splint technique produces significantly greater range of motion compared to complete immobilization methods and requires fewer follow-up visits 4.
- Avoid immobilization in more than 20° of flexion or transfixation with K-wires, as these contribute to poor outcomes including persistent swelling, instability, and limited motion 5.
Early Mobilization Protocol
- Begin active finger motion exercises of the PIP joint within the first few days, protected by buddy taping 4.
- Early controlled mobilization is critical to prevent stiffness and optimize functional recovery 5, 4.
- Continue buddy taping for 3-4 weeks during activities while encouraging progressive active motion 2.
Surgical Indications (Not Applicable to This Case)
The following would require orthopedic hand surgery referral, but none apply to your patient 6, 5, 2:
- Bony avulsion fractures involving ≥33% (one-third) of the articular surface 6
- Volar subluxation of the middle phalanx that cannot be reduced or maintained 6, 2
- Interfragmentary gap >3mm 6
- Failed closed reduction 1
- Joint instability after reduction attempts 1
Critical Pitfalls to Avoid
- Do not immobilize completely for extended periods, as unnecessary immobilization is a major contributor to poor outcomes in PIP joint injuries 5.
- Do not immobilize in excessive flexion (>20°), which leads to flexion contractures 5.
- Ensure the patient understands that even small PIP joint injuries are frequently underestimated and require diligent adherence to the mobilization protocol to prevent long-term stiffness 5.
- If the joint demonstrates instability during post-reduction testing or if closed reduction fails, immediate referral to a hand specialist is mandatory 1.