Treatment and Rehab Vital to Finger Fractures
A broken finger is not something to ignore. Even though the individual bones that make up each finger are small, a fracture (and especially a fracture with dislocation) can result in a painful, unstable, nonfunctional finger. Studies show that early treatment (within the first six weeks of injury) is advised for the best outcomes. Waiting too long (until the injury becomes "chronic") is never a good idea.

Surgeons treating fracture injuries of the proximal interphalangeal (PIP) joints (the middle bone of the three bones of each finger) will find this review article helpful. Three types of fracture-dislocations of the PIP joint and goals of treatment are presented. Readers are given an anatomical understanding of the forces and mechanism of injury. Nonsurgical and surgical treatments are discussed along with some pointers on the rehabilitation process.

Proximal interphalangeal (PIP) joint fracture-dislocation injuries are named according to the location of the damage. There is the dorsal fracture pattern, the volar fracture pattern, and the pilon injury. Drawings are provided to illustrate each one.

In simple terms, a dorsal fracture occurs along the bottom (palm side) of the finger. The tendon that helps flex or bend the finger is torn away from the bone allowing the joint to dislocate. A volar fracture affects the top (back of the hand side) of the bone. In this case, the extensor tendon is torn (the one that straightens the finger) with joint dislocation. And a pilon fracture involves multiple fractures on both sides of the bone and ruptures of both the flexor and extensor tendons. With a pilon injury, the joint is very unstable.

The authors provide an easy-to-read table to give the reader an overall view of each fracture classification. Range-of-motion, amount of joint involvement, and whether the fracture/dislocation is stable or unstable can be seen at a glance. The dividing point between a stable versus unstable fracture-dislocation is based on the amount of joint involvement.

Less than one-third of the joint surface disruption will likely be a stable joint. More than half of the joint surface involvement is predictive of an unstable joint. Anyone with 30 to 50 per cent joint surface damage falls into the gray area (not as easy to predict stability). Of course, with a pilon injury, the entire joint is compromised and there's no question it will be severely unstable.

The goals of treatment are fairly simple and straightforward but not always so easy to achieve: realign the joint, restore range-of-motion, and return patient to full finger/hand function. The plan of care and treatment decisions depend on severity of injury and amount of tendon retraction (pulling away from the bone).

Sometimes it is possible to treat these injuries (even when there is a fracture and dislocation) nonsurgically. This is possible when the fracture-dislocation is stable (not likely to separate or shift). You have probably seen someone with two (or sometimes three) fingers taped together. This is called buddy taping. It can be used for one to three weeks and has the advantage of allowing some early range-of-motion.

A second approach to conservative (nonsurgical) care is the use of splinting. One type of block splinting is especially helpful when motion in one direction is okay but movement in the other direction is unstable (results in the bones shifting or the joint dislocating).

But if and when the fracture-dislocation cannot be held stable with buddy taping or splinting, then surgery is necessary. The surgeon has a wide variety of surgical techniques to choose from. Sometimes the bone and joint can be realigned and held together with pins and/or wires without making an incision to open the finger. This is called closed reduction and pinning.

If closed reduction is not possible, then open incision may be needed to realign the bones and hold them together with hardware. This procedure is called open reduction and fixation (ORIF). ORIF is necessary when the surgeon must repair or reconstruct the torn tendons and/or when there is hinging at the fracture site. Hinging refers to motion that occurs between the two ends of the broken bone (rather than at the actual joint).

Pilon fractures can be treated with ORIF but sometimes require a special surgical treatment referred to as dynamic distraction and external fixation or DDEF. The joint is "distracted" or pulled apart and as many of the pieces of bone as possible are put back together. Then the surgeon applies a special device made of wires and rubber bands to achieve stability. The authors comment that restoring normal joint structure and function may not be possible with either the ORIF or the DDEF.

The final section of this review article is focused on rehabilitation, which is considered "vital" to the successful treatment of proximal interphalangeal joint fracture-dislocations. A hand therapist working with the surgeon will provide the treatment.

Early passive range-of-motion is a key to recovery. Passive means the therapist (and eventually the patient) moves the joint. Motion is only allowed through the stable arc of motion. Too much movement too early can disrupt the healing bone and soft tissues.

Gradually, the therapist will advance the motion to active-assisted (patient is allowed to move the finger through partial range-of-motion with help). In the case of dynamic distraction and external fixation (DDEF), active motion can be started right away since everything is stabilized with hardware.

In summary, the results of treatment for fracture-dislocations of proximal interphalangeal (PIP) joints vary depending on the severity of the injury, stability, and approach (surgical versus nonsurgical). There is no set way to deal with these injuries that will always produce the best results. That's why these surgeons put together this review article with as much information as is available through published studies and their own experience. Hand surgeons will find the detail and thoroughness of the article helpful.
John Elfar, MD, and Tobias Mann, MD, MSc. Fracture-Dislocations of the Proximal Interphalangeal Joint. In Journal of the American Academy of Orthopaedic Surgeons. February 2013. Vol. 21. No. 2. Pp. 88-98.