Houston Methodist. Leading Medicine

Hand FAQ

Question:

My wife and I were away over the weekend on a snowmobiling trip. Unfortunately, she was flipped off the snowmobile and got a badly broken and dislocated middle joint of the middle finger. We were out of town at the time. She had surgery there at the regional medical center and now sent home (we live about 200 miles from where she was treated). We have a referral to the hand center in our area. But what should we expect? Like what happens next?

Answer:

A broken finger is not something trivial. 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. And the "middle" joint of the finger (called the proximal interphalangeal (PIP) joint is important because of the tendons that attach there allowing for finger motion. 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. So, it sounds like you've crossed the first important hurdle: early evaluation and treatment. 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. Treatment depends on what type of PIP fracture your wife has. 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 requiring surgery right away. 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. But if and when the fracture-dislocation cannot be held stable with taping or splinting, then surgery is necessary. It sounds like this is where your wife ended up. 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. Now that you have been sent home with a referral to the hand center, your focus will be 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 based on the type of fracture and surgery that was done. 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. Your hand therapist will guide you and your wife through each phase of treatment. Finger joints are small but mighty. It can take a long time to heal and recover fully. It can take several months to work through stiffness, swelling, and loss of smooth motion before she regains full function. But with steady rehab and following the hand therapist and surgeon's instructions, full recovery is possible. 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.

*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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