Courtesy Dr. Hemant Patankar, Dr Ashok Shyam, Ortho TV

Introduction

PIP joint injuries are among the most common hand injuries.

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Common Causes

• Sports injuries (especially cricket ball injuries)
• Twisting injuries
• Motorbike accidents

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Why These Injuries Are Missed

• Inadequate history taking
• Improper imaging
• Initially appear trivial

 Early diagnosis is critical to prevent long-term complications

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Clinical Evaluation

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History

• Mechanism of injury
• Type of trauma

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Examination Findings

• Swelling
• Bruising
• Pain
• Restricted finger motion

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Radiological Evaluation

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Essential Imaging

• Plain X-ray

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Recommended Views

• AP view
• True lateral (dead lateral) view
• Oblique view

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Important Principle

 Always take X-ray of the individual finger, not the whole hand

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Role of Lateral View

• Critical for detecting:
  • Subluxations
  • Fracture-dislocations
  • Articular involvement

Two lateral views may be useful (medial & lateral sides)

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CT Scan

• Usually not required if proper X-rays are taken

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PIP Joint Fracture-Dislocations

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Key Factors Affecting Treatment

• Time since injury
• Articular surface involvement
• Joint stability

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Management Based on Timing

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1. Acute Presentation (Early)

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Indications

• Stable joint in flexion
• Minimal articular disruption

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Treatment

• Closed reduction
• Immobilization in flexion (~2 weeks)

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Rationale

• Volar plate heals best in flexion

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Follow-Up

• Start active extension exercises after 2 weeks

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Expected Outcome

• Mild flexion contracture initially

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2. Follow-Up at 6 Weeks

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Assessment

• X-ray in flexion and extension
• Evaluate:
  • Stability
  • Residual subluxation

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If Contracture Persists

 Use Capener spring splint

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Capener Splint Protocol

• Gradual extension
• Initially intermittent ? later night splint

 Monitor vascular status

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3. Methods to Maintain Reduction

• Finger traction
• Splints
• Strapping
• Extension block pinning

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Extension Block Pinning

Indication

• Reduction achieved but not maintained

Technique

• K-wire blocks extension

Outcome

• Good functional recovery

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4. Intermediate Presentation (10–15 Days)

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Management

• If joint congruent:
  • Attempt closed reduction
  • Maintain traction

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Preferred Method

• Finger taping with traction

Advantages

• Comfortable
• Allows vascular monitoring

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Duration

• ~2 weeks

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5. Late Presentation (3 Weeks)

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Treatment

External fixation with ligamentotaxis

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Technique

• K-wires in proximal and middle phalanx
• External distractor applied

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Principle

• Ligamentotaxis realigns fragments

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Outcome

• Good functional recovery

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6. Delayed Presentation (6 Weeks)

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Management

• External fixation with distraction

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Duration

• ~4 weeks

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Note

Even partially healed fractures may still be corrected

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7. Very Late Presentation (6 Months)

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Surgical Options

• Volar plate arthroplasty
• Hemi-hamate arthroplasty
• ORIF

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Open Reduction Technique

Approach

• Shotgun approach

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Steps

• Identify volar fragment
• Perform osteotomy (if required)
• Reduce and fix with small screw (~1 mm)
• Add extension block pin

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Outcome

• Restoration of articular congruity

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Blunt PIP Joint Injuries

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Characteristics

• Normal X-rays
• Significant soft tissue injury

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Common Issue

• Often neglected due to preserved flexion

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Flexion Contracture

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Causes

• Hemarthrosis
• Capsular injury
• Extensor weakness

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Early Management

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Treatment

• Ice
• NSAIDs
• Dorsal gutter splint

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Position

• Finger in extension

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Duration

• ~2 weeks

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Additional Exercise

• Encourage DIP joint movement

 Prevents tendon adhesions

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Low-Cost Splint Option

• Modified syringe barrel
• Padded dorsal splint

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Late Flexion Contracture

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Presentation

• Severe contracture
• Cosmetic deformity
• Functional limitation

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Clinical Test

• Passive extension:

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Surgical Release

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Procedure

• Flexor sheath release
• ± Volar capsular release

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Common Cause

• Tight flexor sheath

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Outcome

• Immediate correction often achieved

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PIP Joint Dislocations

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Features

• Obvious deformity
• Severe pain
• Easily diagnosed

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Treatment

• Closed reduction
• Immobilization in slight flexion
• Avoid hyperextension (~2 weeks)

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Complications

• Flexion contracture
• Joint stiffness
• Residual subluxation
• Tendon adhesions

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Prevention of Contracture

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Essential Splints

• Dorsal gutter splint
• Capener spring splint

 Proper use prevents most complications

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Key Take-Home Messages

• Always X-ray the individual finger
• True lateral view is critical
• PIP injuries are stable in flexion
• Early flexion immobilization improves outcomes
• External fixation (ligamentotaxis) helps in delayed cases
• Early splinting prevents long-term stiffness