PIP dislocations

1. High-Yield Summary

• The proximal interphalangeal (PIP) joint functions as a bicondylar hinge joint whose intrinsic structural stability depends on a three-sided box configuration composed of the thick fibrocartilaginous volar plate palmar-wise and the paired proper and accessory collateral ligament complexes bilaterally.
• Dorsal dislocations are the most prevalent (>85% of cases), resulting from hyperextension and axial compression that avulses the volar plate distally from the middle phalanx base; volar dislocations are rare (<5%) but clinically treacherous due to disruption of the extensor central slip, which induces a progressive Boutonniere deformity if unrecognized.
• Radiographic evaluation mandates a true, isolated orthogonal lateral view of the digit; persistent dorsal joint incongruity evidenced by dorsal divergence of the articular margins (the pathognomonic V-sign) indicates persistent subluxation requiring immediate corrective intervention.
• Stable, congruently reduced dislocations must avoid prolonged immobilization; rigid splinting must not exceed 7 to 10 days, followed by early protected active motion utilizing figure-of-8 orthoses or buddy taping to prevent permanent fibroblastic flexion contracture.
• Fracture-dislocations are triaged by the percentage of middle phalanx volar articular base involvement: fractures involving 50% demonstrate critical loss of collateral ligament support and require operative reconstruction (extension block pinning, dynamic external distraction, volar plate arthroplasty, or hemi-hamate osteochondral autograft).

2. Anatomy

The proximal interphalangeal (PIP) joint is a constrained ginglymus (hinge) articulation possessing a single primary degree of freedom in the sagittal plane (flexion-extension arc of 0° to 100°-110°). The bony architecture consists of the proximal phalanx bicondylar head, characterized by two asymmetric condyles separated by a shallow intercondylar groove, and the middle phalanx base, featuring two corresponding concave facets divided by a prominent median sagittal ridge. This tongue-in-groove osseous congruency provides significant intrinsic resistance against rotational torque and coronal plane translation throughout the range of motion.

Static ligamentous restraint is organized into a rigid three-sided structural box comprising the palmar fibrocartilaginous volar plate and the bilateral collateral ligament complexes:

• Volar Plate: A trapezoidal fibrocartilaginous structure that forms the floor of the joint capsule. Distally, it is thick (1.5 to 2.0 mm) and cartilaginous, anchoring into the subchondral bone of the volar lip of the middle phalanx base via dense Sharpey fibers. Proximally, it thins into a flexible membranous sheet that bifurcates into the paired check-rein ligaments. These check-rein ligaments insert into the ventrolateral periosteal margins of the proximal phalanx shaft, serving as static mechanical stops that arrest hyperextension beyond neutral.
• Proper Collateral Ligaments (PCL): Originating from the subcapital depressions and lateral tubercles of the proximal phalanx condyles, the PCLs course obliquely distally and volarly to insert onto the ventrolateral tubercles of the middle phalanx base. Because their origin lies dorsal to the axis of joint rotation, the proper collateral ligaments become progressively taut during flexion, serving as the primary restraints against varus and valgus stress.
• Accessory Collateral Ligaments (ACL): Originating immediately volar to the PCL origins, the ACLs fan out distally and volarly to insert directly into the lateral margins of the fibrocartilaginous volar plate. The accessory collateral ligaments remain taut in full extension, serving to suspend and stabilize the volar plate during joint motion.
• The Three-Sided Box: The rigid physical continuity between the volar plate, accessory collateral ligaments, and proper collateral ligaments forms an integrated U-shaped structural sleeve that resists multidirectional subluxation while maintaining articular congruency.

Dorsally, the extensor mechanism coordinates joint extension. The common extensor tendon trifurcates over the distal proximal phalanx into a central slip and paired lateral bands. The central slip inserts directly into the dorsal tubercle of the middle phalanx base to initiate and maintain active PIP joint extension. The lateral bands course dorsolaterally, stabilized by the transverse retinacular ligaments (which prevent excessive dorsal translation) and the triangular ligament on the dorsal aspect (which prevents volar descent below the joint axis of rotation). Fascial anchors—Cleland ligaments dorsal to the neurovascular bundles and Grayson ligaments palmar to them—anchor the skin envelope during digit flexion and extension.

The paired digital neurovascular bundles (proper digital artery and nerve) run within the ventrolateral subcutaneous tissue directly adjacent to the flexor tendon sheath and palmar to Cleland ligaments. In acute dislocations, these bundles are vulnerable to traction stretch or direct compression against the displaced skeletal margins. Surgical approaches utilize structural tissue intervals: the midlateral (midaxial) approach enters dorsal to the digital neurovascular bundle along the line connecting the flexion crease apices, protecting the vessels while exposing the collateral ligaments and phalangeal base. The volar Bruner zig-zag approach elevates palmar flaps superficial to the flexor sheath, windows the C1/A3 annular pulley between the A2 and A4 pulleys, and retracts the flexor digitorum superficialis and profundus tendons to expose the volar plate and articular base.

3. Pathogenesis

The pathological cascade of proximal interphalangeal joint dislocations reflects specific mechanical vector forces, joint position, and tissue failure thresholds:

• Dorsal Dislocations: Initiated by an acute hyperextension moment combined with axial compression (e.g., a ball striking the tip of an extended finger). Tensile failure begins distally at the insertion of the fibrocartilaginous volar plate on the middle phalanx base, occurring either as a purely ligamentous avulsion or as an osseous avulsion fracture of the volar articular lip. As the hyperextension force continues, the accessory collateral ligaments tear, followed by partial or complete rupture of the proper collateral ligaments as the middle phalanx base translates dorsally over the condyles. When substantial axial compression accompanies hyperextension, the proximal phalanx condyle acts as a shearing wedge, generating impaction and shear fractures across the volar articular base.
• Volar Dislocations: Result from a direct anteriorly directed shear force applied to the dorsal base of the middle phalanx or sudden rotational torque on a semi-flexed digit. Tissue failure universally involves rupture or bony avulsion of the extensor central slip from the dorsal middle phalanx tubercle. In simple volar dislocations, both collateral ligaments and the volar plate check-reins may remain partially intact. In rotatory volar dislocations, one condyle buttonholes between the ruptured central slip and an intact lateral band, or the lateral band slips volar to the condyle and becomes locked in the intercondylar notch, blocking closed reduction.
• Lateral Dislocations: Occur when a violent varus or valgus angular force is applied to an extended or partially flexed joint. The primary lesion is complete rupture of the collateral ligament complex on the side of tension, with the radial collateral ligament disrupted in >75% of clinical cases due to the exposed position of the radial border during grasping. Collateral rupture is typically accompanied by tearing of the accessory collateral ligament and partial tearing of the lateral insertion of the volar plate.

4. Natural History

PIP joint dislocations represent the single most common ligamentous injury in the hand. The epidemiological distribution displays a prominent demographic peak in adolescents and young adults aged 15 to 35 years, heavily concentrated in athletic activities involving ball handling and contact sports (basketball, football, rugby, volleyball). A secondary peak occurs in manual industrial laborers and older adults following ground-level mechanical falls. The long and ring fingers are most frequently affected by dorsal dislocations, whereas the border digits (index and small fingers) sustain a disproportionate incidence of lateral and rotatory dislocations due to their unprotected peripheral positions.

When left untreated or managed with prolonged rigid immobilization, the natural history of PIP dislocations is marked by rapid functional deterioration:

• Fixed Flexion Contractures: The PIP joint capsule and retrocondylar recesses possess an unforgiving susceptibility to arthrofibrosis. Within 10 to 14 days of joint immobility, proliferative fibroblast activation causes dense collagen cross-linking, obliterating the retrocondylar pouches and shortening the collateral and check-rein ligaments.
• Chronic Subluxation and Post-Traumatic Arthritis: Persistent dorsal subluxation concentrates articular contact pressures onto the dorsal margin of the middle phalanx facets, leading to accelerated chondral wear, subchondral eburnation, marginal osteophyte formation, and painful post-traumatic osteoarthritis.
• Secondary Progressive Deformities: Unreconstructed volar plate attenuation following dorsal dislocations permits gradual hyperextension laxity, leading to dorsal migration of the lateral bands and a fixed Swan-Neck deformity. Conversely, unrecognized central slip disruptions in volar dislocations allow the lateral bands to displace volarly below the joint axis of rotation, converting them into primary flexors and establishing an intractable Boutonniere deformity with secondary DIP joint hyperextension contracture.
• Persistent Fusiform Joint Enlargement: Synovial hypertrophy, periarticular lymphatic stasis, and capsular thickening produce fusiform swelling that routinely persists for 12 to 18 months, frequently leaving permanent thickening of the knuckle perimeter.

5. Clinical Presentation

History

A structured, detailed history must establish the exact vector of injury forces, the position of the digit at impact (hyperextension, torsion, or axial load), and the immediate post-injury course. Specific inquiries should determine whether the joint was reduced at the scene (by the patient, coach, or athletic trainer) and whether reduction occurred spontaneously, with a notable pop, or required forceful manipulation. Clinicians must establish the precise chronicity (acute 6 weeks), the presence of mechanical symptoms (painful catching, clicking, or clunking during active motion), and any sensory complaints such as persistent numbness or paresthesias in the digital pulp distributions.

Physical Exam

Physical examination begins with visual inspection of the resting digital cascade. In uninjured hands, passive wrist extension (tenodesis) induces uniform progressive finger flexion; rotational malalignment or disruption of this cascade points to occult dislocation or collateral disruption. Neurovascular status must be documented prior to any digital block: static two-point discrimination (<6 mm normal) along both radial and ulnar pulp margins, along with digital capillary refill (<2 seconds). Step-by-step provocative examination maneuvers include:

• Active Extension Block Angle Test: With the digital nerve anesthetized, the examiner passively flexes the PIP joint to 90° and instructs the patient to slowly extend the digit actively. The exact angle at which the joint abruptly subluxates dorsally or exhibits a palpable clunk is recorded as the critical extension-block threshold -> Positive Finding: Dorsal subluxation or articular divergence occurring at a measurable flexion angle [Sensitivity 92%, Specificity 88%].
• Collateral Ligament Stability Stress Test in 30° Flexion: The PIP joint is placed in 30° of flexion to slacken the volar plate and accessory collateral ligaments. Gentle, controlled varus and valgus stresses are applied across the joint line -> Positive Finding: >15° to 20° of angular deviation or the absence of a firm, crisp mechanical endpoint indicating complete rupture of the proper collateral ligament [Sensitivity 94%, Specificity 91%].
• Collateral Stability Test in Full Extension (0°): Varus and valgus stresses are applied with the PIP joint maintained in absolute 0° extension -> Positive Finding: Palpable joint opening or instability indicating combined disruption of both the proper collateral ligament and the accessory collateral/volar plate complex [Sensitivity 89%, Specificity 95%].
• Elson Test for Central Slip Disruption: The injured PIP joint is flexed to 90° over the edge of a table or firm support. The patient attempts active PIP joint extension against firm examiner resistance while the distal interphalangeal (DIP) joint is palpated -> Positive Finding: Weak or absent active PIP extension accompanied by rigid, hyperactive extension of the DIP joint due to compensatory lateral band firing (in an intact central slip, PIP extension is powerful while the DIP joint remains completely flaccid) [Sensitivity 98%, Specificity 96%].
• Modified Boyes Test: The PIP joint is passively held in full extension while the examiner tests passive flexion of the DIP joint -> Positive Finding: Inability to passively flex the DIP joint indicates volar migration, contracture, or dorsal adherence of the lateral bands.

6. Imaging and Diagnostic Studies

Radiographic assessment begins with standard 3-view radiographs of the hand (anteroposterior, oblique, and lateral). However, standard hand views are inadequate for definitive joint evaluation due to phalangeal overlap. The absolute gold standard is a dedicated, true orthogonal lateral view of the isolated digit:

• True Lateral View Technique: The adjacent uninjured digits are actively flexed into the palm or extended out of the radiographic beam so that the target digit lies directly against the cassette. On an acceptable true lateral projection, the subcapital condylar outlines of the proximal phalanx superimpose perfectly as a single, concentric circular profile without double condylar shadows.
• The V-Sign (Articular Incongruity): In a congruent joint, the joint space between the proximal phalanx condyle and the middle phalanx base is completely parallel and uniform. When subtle dorsal subluxation persists, the dorsal joint space widens while the volar margin narrows, forming a triangular V-shaped divergence. The presence of the V-sign is pathognomonic for joint incongruity and ongoing instability.
• Fracture Fragment Sizing: Measured on the true lateral view as the vertical height of the volar fracture fragment relative to the total vertical articular base height of the middle phalanx. Fractures are stratified into 50% (unstable).
• Post-Reduction Radiographs: Mandatory immediate true lateral and AP radiographs must be obtained following any closed reduction to verify absolute concentric articular seating and rule out iatrogenic fracture displacement.

Advanced cross-sectional imaging provides critical anatomical resolution when plain radiography leaves clinical ambiguity:

• Computed Tomography (CT) with 2D Multiplanar and 3D Reconstructions: Thin-slice (0.5 to 1.0 mm) CT is indicated for fracture-dislocations involving >30% of the middle phalanx articular base, comminuted pilon fracture configurations, central impacted chondral depressions (die-punch fragments), or when joint incongruity persists on plain radiographs despite closed reduction. CT accurately delineates fragment size, dorsal cortical buttress integrity, and articular comminution to direct surgical planning.
• Magnetic Resonance Imaging (MRI): Rarely indicated in acute management. Reserved for subacute or chronic presentations with persistent joint pain, suspected occult collateral ligament avulsions, or rotatory volar dislocations where soft-tissue interposition (volar plate, lateral band, or flexor tendon) impedes closed reduction.
• High-Resolution Ultrasound: Offers dynamic, point-of-care assessment of collateral ligament continuity, volar plate retraction, and real-time joint congruency during gentle active flexion arcs.

7. Classification

Validated classification systems stratify PIP joint dislocations by the anatomical direction of displacement and the degree of articular base destruction, dictating nonoperative versus operative pathways:

8. Treatment

Medical / Nonoperative

Acute closed reduction is the foundational intervention for all simple dislocations and reducible fracture-dislocations:

• Digital Anesthesia: Administer a digital block using 3 to 5 mL of 1% plain lidocaine or 0.5% plain bupivacaine via a volar subcutaneous flexor sheath injection or dual dorsal-web-space digital nerve blocks. Vasoconstrictors (epinephrine) are strictly avoided in digital nerve blocks.
• Closed Reduction Technique: For dorsal dislocations, apply gentle longitudinal axial traction while exaggerating the hyperextension deformity slightly to unlock the middle phalanx base from behind the condyles. Once unhooked, apply direct palmar-directed translation onto the middle phalanx base while maintaining dorsal counter-pressure over the proximal phalanx neck. For volar dislocations, apply axial traction and apply direct dorsal-directed pressure onto the middle phalanx base.
• Post-Reduction Dynamic Stability Testing: Following reduction, the joint is put through an active and passive arc of motion. The clinician verifies concentric seating and determines the critical extension-block angle at which dorsal subluxation recurs.
• Nonoperative Immobilization Regimens:
  • Stable Simple Dorsal Dislocation: Immediate buddy taping to the adjacent uninjured digit with unrestricted active motion, or a dorsal extension-block splint set at 20° to 30° of flexion for 7 to 10 days, followed by buddy taping during sports and labor.
  • Figure-of-8 Orthosis: Controls hyperextension while permitting immediate, unrestricted active flexion. Highly effective for stable volar plate avulsions, achieving equivalent joint stability with superior early active motion and lower flexion contracture rates compared to rigid splints.
  • Tenuous Fracture-Dislocation (<40% base fracture): Dorsal extension-block splint positioned 10° more flexed than the critical subluxation threshold. The extension block is progressively advanced into greater extension by 10° to 15° each week over a 3- to 4-week window.
  • Volar Dislocation with Central Slip Injury: Requires rigid splinting of the PIP joint in absolute 0° extension for 4 to 6 weeks, while actively encouraging unrestricted active DIP joint flexion exercises to prevent lateral band adherence.
• Maximum Safe Immobilization Window: Rigid immobilization of the PIP joint must never exceed 7 to 10 days (absolute maximum 14 days) in dorsal dislocations. Prolonged cast or splint immobilization leads directly to intractable capsular contracture and permanent loss of composite finger flexion.

Operative

The primary goals of operative intervention are to restore concentric, congruent joint reduction, reconstruct the articular surface (achieving <1 mm articular step-off), preserve collateral ligament integrity, and establish rigid skeletal stability that permits immediate or early active rehabilitation within 7 to 10 days postoperatively.

• Closed Reduction and Percutaneous Extension-Block Pinning (Ishiguro Technique): Indicated for dorsal fracture-dislocations involving 30% to 50% of the volar articular base that reduce congruently in flexion. Under fluoroscopic guidance, the PIP joint is flexed 30° to 45°, and a 1.0 mm to 1.2 mm K-wire is driven obliquely into the dorsal condylar bone of the proximal phalanx immediately dorsal to the middle phalanx base. The wire acts as a rigid dorsal mechanical buttress preventing dorsal translation while allowing the patient to actively flex the joint. The pin is maintained for 3 to 4 weeks and removed in clinic.
• Dynamic External Distraction Fixation (Suzuki Frame / Ligamentotaxis): Indicated for comminuted Eaton Type IIIB or Type IV pilon fractures. Percutaneous K-wires placed transfixion-style through the rotation center of the proximal phalanx head and the middle phalanx shaft are coupled with curved spring wires and elastic traction bands. This provides continuous longitudinal joint distraction (ligamentotaxis) to pull comminuted articular fragments out of impaction while permitting immediate active PIP flexion exercises. The frame is maintained for 4 to 6 weeks.
• Open Reduction and Internal Fixation (ORIF): Indicated for large, non-comminuted volar fragments (>35% to 50% articular surface). Through a midlateral or volar Bruner approach, the fracture fragment is reduced anatomically under direct visualization and stabilized using 1.0 mm to 1.3 mm mini-fragment cortical screws, headless compression screws, or pull-out transosseous sutures.
• Volar Plate Arthroplasty (Eaton-Malerich Technique): Indicated for comminuted, non-reconstructible volar fractures involving >40% to 50% of the middle phalanx base or chronic subluxations (>6 weeks post-injury). Through a volar Bruner exposure, the comminuted bony fragments are excised, and the detached distal margin of the volar plate is advanced into the base defect and anchored to the dorsal cortex with transosseous pull-out sutures tied over a dorsal button, resurfacing the defect with a stable fibrocartilaginous shelf.
• Hemi-Hamate Osteochondral Autograft: Indicated for extensive, comminuted dorsal fracture-dislocations with >50% articular destruction of the middle phalanx base, especially in younger, high-demand patients. The dorsal articular lip of the hamate matches the bicondylar radius of curvature and central median ridge of the middle phalanx base. The osteochondral graft is harvested from the dorsal carpus between the fourth and fifth metacarpal bases and rigidly secured to the middle phalanx base using 1.0 mm to 1.3 mm mini-screws, creating an anatomically contoured, vascularizable articular buttress.

Indications & Contraindications

Operative intervention is governed by strict anatomical and stability criteria:

• Absolute Indications for Surgery:
  • Irreducible acute dislocation (soft tissue entrapment such as volar plate interposition, flexor tendon trapping, or lateral band buttonholing).
  • Persistent joint subluxation or articular incongruity (dorsal V-sign) following closed reduction maneuvers.
  • Articular fracture fragment involving >40% to 50% of the middle phalanx base.
  • Joint instability requiring >30° of flexion to maintain concentric reduction.
  • Residual articular step-off > 1 mm after reduction.
  • Open dislocation or associated acute neurovascular compromise.
• Contraindications to Surgery:
  • Concentric, stable joint reduction maintained through a full active motion arc in <30° of flexion.
  • Severe systemic medical comorbidities precluding regional or general anesthesia.
  • Active localized soft-tissue infection or contaminated soft-tissue envelope.
  • Pre-existing end-stage degenerative joint disease (where primary arthrodesis or silicone arthroplasty is indicated rather than joint preservation).

9. Outcome

Functional outcomes following proximal interphalangeal joint dislocations correlate directly with joint congruency, extent of initial articular destruction, and avoidance of prolonged rigid immobilization:

• Active Range of Motion Arcs:
  • Simple Dislocations: Patients treated with early protected mobilization consistently achieve a functional PIP active arc of motion of 95° to 105° (normal active motion 0° to 100°-110°).
  • Unstable Fracture-Dislocations: Patients treated with dynamic external fixation or percutaneous extension-block pinning achieve mean active arcs of 75° to 85°, typically with an average residual extension lag of 5° to 15°.
  • Hemi-Hamate Arthroplasty / Volar Plate Arthroplasty: Reconstructive procedures for comminuted defects restore active motion arcs averaging 70° to 80°, with reliable maintenance of joint stability and pain relief.
• Patient-Reported Outcome Measures (PROMs): Validated instruments demonstrate excellent functional recovery. Long-term QuickDASH scores range from 5 to 14 points, reflecting minimal functional limitation in activities of daily living. Visual Analog Scale (VAS) pain scores average <1.5 out of 10 at final follow-up, though mild weather-sensitive aching or cold intolerance is reported in 20% to 30% of patients.
• Grip Strength Recovery: Average digital grip strength recovers to 85% to 95% of the contralateral uninjured extremity by 6 to 12 months post-injury.
• Permanent Fusiform Swelling Counseling: Clinicians must educate patients at the initial consultation that periarticular fusiform thickening of the knuckle will persist for at least 12 to 18 months, and in up to 40% to 50% of individuals, the joint permanently remains 1 to 2 ring sizes larger than baseline despite excellent motion and painless stability.

10. Complications

Complications following PIP joint dislocations range from common nuisance stiffness to catastrophic recurrent instability and joint degeneration, categorized by post-injury timeline:

11. Pearls and Pitfalls

• The True Lateral View is Non-Negotiable: Never accept an oblique or rotational view of the hand when evaluating a suspected PIP joint injury. An isolated true lateral of the digit—demonstrating complete condylar superimposition into a single circular contour—is the only projection that reveals the subtle dorsal V-sign of joint subluxation.
• Mandatory Elson Testing on Every Volar Dislocation: Never assume the extensor mechanism is intact after reducing a volar dislocation, even if the patient can passively extend the digit. Perform the Elson test immediately; missing an occult central slip rupture guarantees a fixed, difficult-to-treat Boutonniere deformity within weeks.
• Set the Extension Block 10° Ahead of Instability: In extension-block splinting or pinning, establish the exact flexion angle where the joint begins to subluxate under fluoroscopy or exam, and block the joint at least 10° more flexed than that threshold to provide a safe mechanical buffer.
• Beware the Irreducible Rotatory Volar Dislocation: If a volar dislocation resists gentle closed reduction under adequate anesthesia, stop immediately. Repeated forceful manipulation will lacerate buttonholed lateral bands or cause digital vessel occlusion. Convert promptly to open reduction.
• Rigid Immobilization Beyond 10 Days is a Clinical Error: Prolonged casting or splinting does not improve ligamentous healing; it directly creates intractable capsular contracture. Transition stable injuries to early active motion using figure-of-8 orthoses or buddy taping within the first 7 to 10 days.
• Do Not Mislabel Fracture-Dislocations as Sprains: A small avulsion fleck on the volar lip on plain radiography often represents the tip of an impacted, depressed articular fracture involving 30% to 50% of the joint surface. Always measure the defect on a pristine lateral view and assess dynamic stability.

12. Controversy

Two primary areas of ongoing clinical debate characterize modern management of proximal interphalangeal joint injuries:

• Rigid Splinting versus Early Functional Mobilization with Figure-of-8 Orthoses: Traditional management of stable volar plate avulsion injuries mandated 2 to 3 weeks of dorsal rigid splinting. However, contemporary randomized controlled trials demonstrate that early protected motion using figure-of-8 orthoses achieves equivalent joint stability and radiographic healing, while providing significantly superior early active flexion arcs and lower rates of permanent flexion contracture compared to rigid splinting. Consensus increasingly favors immediate or early (by day 7) functional mobilization for all stable injuries.
• Management of 30% to 50% Unstable Articular Fracture-Dislocations: The management of the borderline 30% to 50% articular fracture remains intensely contested. Proponents of closed reduction and percutaneous extension-block pinning (Ishiguro technique) highlight its minimal invasiveness, low surgical morbidity, and avoidance of periarticular devascularization. Conversely, advocates of dynamic external distraction fixation (Suzuki frame) argue that continuous ligamentotaxis restores comminuted fragments while permitting immediate active motion. Meanwhile, proponents of open anatomical reconstruction (ORIF or hemi-hamate autograft) maintain that restoring anatomical articular congruency with <1 mm step-off is essential to prevent long-term post-traumatic osteoarthritis in younger, active patients.

13. Evidence-Based Synthesis

Modern clinical decision-making is grounded in high-quality randomized controlled trials and prospective registry analyses, corroborated by seminal biomechanical and anatomical descriptions.

14. References

• Grange M, Carra K, Barrett S et al. Management of stable proximal interphalangeal joint volar plate injuries with figure-of-8 orthoses: A parallel-group randomized controlled trial. J Hand Ther. 2024. doi:10.1016/j.jht.2023.11.001 [Level I: Randomized Controlled Trial]
• Breahna A, Mishra A, Arrowsmith J et al. The management of acute fracture dislocations of proximal interphalangeal joints: a systematic review. J Plast Surg Hand Surg. 2020. doi:10.1080/2000656X.2020.1788041 [Level I: Systematic Review / Meta-Analysis]
• Kiefhaber TR, Stern PJ. Fracture dislocations of the proximal interphalangeal joint. J Hand Surg Am. 1998. doi:10.1016/S0363-5023(05)80454-X [Level IV: Clinical Case Series / Cohort Study]
• Deitch MA, Kiefhaber TR, Comisar BR et al. Dorsal fracture dislocations of the proximal interphalangeal joint: surgical complications and long-term results. J Hand Surg Am. 1999. doi:10.1053/jhsu.1999.0914 [Level IV: Clinical Case Series / Cohort Study]
• Eaton RG, Malerich MM. Volar plate arthroplasty of the proximal interphalangeal joint: a review of ten years’ experience. J Hand Surg Am. 1980. doi:10.1016/s0363-5023(80)80011-6 [Level IV: Clinical Case Series / Cohort Study]

15. Master Class Pro-Tip

The cardinal sin in managing proximal interphalangeal joint dislocations is accepting prolonged immobilization in a well-intentioned effort to ensure ligamentous healing. The PIP joint has an unforgiving tolerance for stiffness: retrocondylar recesses scar within 10 days, and collateral ligaments contract rapidly. For stable dislocations, transition immediately or within 7 days to protected active motion using a figure-of-8 orthosis or buddy taping. For unstable fracture-dislocations, true concentric joint reduction must be validated on an isolated, orthogonal lateral radiograph. Look relentlessly for the subtle dorsal ‘V-sign’; any loss of concentric parallelism between the middle phalanx base and proximal phalanx condyles dictates immediate mechanical stabilization. If surgical reconstruction is required, choose a technique—whether extension-block pinning, dynamic distraction, or hemi-hamate autograft—that achieves rigid skeletal stability and permits active rehabilitation within the first postoperative week.

Master Class Surgical Pearl: Joint Congruency and Early Controlled Motion in PIP Dislocations