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Volar PIP Joint Dislocation
995 Plays2 years ago
Volar PIP joint dislocations can cause damage to the central slip. Josh and Mirand cover the quick facts about this type of injury form splnting to therapy.
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Transcript
Introduction to Hosts and Topic
00:00:06
Speaker
Hi guys, I'm Josh McDonald. And I'm Miranda Materi, and we are Hand Therapy Academy. All right, today we're talking... Go for it. Today we're talking about Volar PIP dislocations and what happens in anatomy, treatment, splints, all that stuff. Yeah, so Volar is slightly different and does not occur very often, right? I think these occur 10% of the time with PIP joint dislocations, it's something like 10 to 20
Complexity of Volar PIP Dislocations
00:00:31
Speaker
% of the time. So most commonly what you're seeing in your clinic is dorsal.
00:00:35
Speaker
And volar I think is much, much harder to treat or much, I wouldn't say harder to treat, but has more complications. Like if I had to choose one, I'd rather have a dorsal dislocation versus a volar dislocation. And the reason for that is because of the central slip, right? So oftentimes the central slip is involved with these and sometimes you can't reduce them. So, you know, it's not where you're on the field, you know, they try to pop it back in place. They're not able to just easily pop it back in.
00:01:04
Speaker
And so let's talk a little bit of anatomy first to know what we're talking about. A volar dislocation means P2, the distal end of that articulation, our particular surface goes volarly.
Central Slip Issues in Dislocations
00:01:16
Speaker
And then the distal end of P1 impacts or interfaces with the central slip. Could be just an attenuation, could be a frang, could be a full-on rupture, that central slip. So we end up with all the things that come with a lack of extensor tendon connection to that PAP joint.
00:01:33
Speaker
Yeah, that's something that if you're out in the field and you get a volar dislocation and someone like pops up and says, oh, my finger. And then you just like reset it. You haven't done anything with that central slip. And so you end up with this developing near deformity extension lag. All these are the complications because you feel like, oh, I fixed it. I've got a patient right now that was a hockey player and pulled his hand out of his glove and thought, oh, I'll take care of it. And now we're three months later and he's got this massive stiff finger.
00:02:01
Speaker
Yeah. And so it was a volar dislocation. Yes. Yeah. Ruptured the central slip, had a lag and didn't get better for a couple of months. And so two, three months later went to the doctor. Doctor said, let's just manage it conservatively because that thing scarred in. And so now he's at us getting as much progress as we can away from a boutonniere deformity. Yeah.
Diagnosing Central Slip Rupture
00:02:25
Speaker
So how would you know, so say you have a volar PIP joint dislocation, how are you knowing or
00:02:30
Speaker
What do you do to know if the central slip is intact? So one possibility is an Ellison's test and that's the, you know, you bend the PIP joint with MCP straight. So whether you're hanging over the edge of the table or a book, but that concept where that's straight. And then if that DIP joint is rigid,
00:02:49
Speaker
That's a bad thing. That's a positive ELSEN's test. And that means lateral bands are now retracting unbalanced by a central slip intact. So without that central slip, DIP pulls tight and it's not loose and floppy. You want a loose floppy DIP joint on an ELSEN's test. So that would tell me if the central slip is ruptured. And these we don't often know, right? I've seen these in the clinic too where
00:03:13
Speaker
you're like, I don't even think your central slip's intact, and the doctor doesn't know either, right? So it's not like you see it on an x-ray. You're just kind of watching for it, right? You know if they had an OLPIP joint dislocation, there could be a central slip problem. So you're doing the typical things that you would do. Are they able to actively extend their finger, do the Elson's test? But sometimes they're so stiff, you can't get them into the position for an Elson's test.
00:03:38
Speaker
And sometimes they don't know what happened on the field. You know, they come in a, you know, a couple of weeks, a month to later and they say, I jammed my finger and it was out of place and I put it back, which direction? I don't remember. So a lot of times you're working with incomplete information. You just know that they can't extend that finger, um, extend that PIP joint. And so you're working under that folder dislocation pretext. So what type of splint you are you making initially for these patients?
00:04:04
Speaker
So I'm trying to get them into like an anti-buteneer, kind of our burrito style thing that wraps around, trying to get that finger extended.
Splinting Techniques and Protocols
00:04:12
Speaker
If it's a standard presentation and we're just protecting the central slip, I want DIP moving for ORL lengthening exercises, but I want to maintain that approximation of the central slip edges so they can scar back in again. If it's further down the road, then it's a whole different thing, but yeah.
00:04:31
Speaker
Yeah, and then so with these patients since they have the joint dislocation, are you starting more of an early active protocol when they have their central slip involved or are you just holding them for the typical six weeks with like you would for a typical boutonniere deformity or typical central slip injury? Yeah, if it's
00:04:51
Speaker
If it's someone that I think understands the concepts, maybe I'll say in the clinic, we're going to do some early short arc, 20 degree, 40 degree, 60 degree with a, with a volar block to go to. If it's someone I think understands the concepts and can be diligent and understand at home, then I may send them home with that little exercise splint and they bring it in and we adjust it every time.
00:05:11
Speaker
But I'm cautious about that because I don't want a patient thinking, well, if I can bend a little, then more is better. So I'm only going to do that short arc motion early active if I feel like the patient really understands the restrictions put on that. Yeah, definitely. And then so typically immobilizing for six weeks. And then what's your treatment look like after the mobilization period?
Post-Splint Treatment Approaches
00:05:34
Speaker
So again, it depends if they are stuck or if they're doing okay. If they come out of that immobilization and they've got likely they're going to be a little bit stiff into extension if we haven't been doing the early arc stuff. So I'll work on getting back to that mobility and deflection without doing passive range of motion to possibly re-rupture. If they're lagging again, we might extend that precaution a little bit more. Or if they come to me late and they're stuck, maybe we look at some serial casting.
00:06:02
Speaker
Yeah. And so I think for these two, are you doing any relative motion splinting? That's usually one of my favorites. Yeah. Yeah. You're right. And I'll use that if they're safe and secure and doing okay. And, um, and, and we know that that, that is healing and intact, but if they're continuing to droop, that's something I may not do right away. How about you? When do you decide to do it?
00:06:24
Speaker
So if they're really stiff, I might start with it a little bit earlier. I think there was a paper that came out using relative motion splinting for boutonniere deformities, and it had a decent outcome. So I think for the right patient, it's ideal. And I think we have an article review coming out about it soon. So I won't spill the tea on that one too early.
Advancements in Hand Therapy
00:06:44
Speaker
And in a Wendell Merritt course recently at Surgeon's Conference, he talked about doing that like right out of the gate.
00:06:51
Speaker
like a yoke orthosis or a relative motion orthosis right out of the gate instead of immobilization. And I didn't get a chance to ask him afterwards, but I want to see that in a journal article sense. So we had some good structure to say like, hey, if we don't have to immobilize, they're going to get way less stiff. That'd be great. Yeah, definitely. And I know you've referred to Wendell Merritt a few times. Why don't you tell everybody who Wendell Merritt is? Yeah.
00:07:19
Speaker
He's a surgeon that has done an amazing amount of research and put stuff out there. A lot of it's kind of open source stuff, but he does all kinds of work on the Wide Awake. Oh, I'm going to forget what it stands for. We'll launch W-A-L-A-N-T. It's Wide Awake Surgeries, where he's doing these repairs on patients while they're awake, and he can do movement, and he's doing research on patients with progressing that protocol towards
00:07:43
Speaker
yolk orthosis instead of long term immobilization, it gets them more active. So lots of good potentials with some of the work he's done. And he is just a really nice guy too. Easy to talk to and good to answer questions for anyone after. Do you ever get a chance to go to a course of his? Go to it. And then if you have a question, go up and ask him afterwards.
00:08:01
Speaker
Yeah, I think he's really supportive of the community of hand surgery and hand therapy. And when I think of Wendell Merritt, I always think about all the work he's done on extensor tendon stuff. So I feel like he's really changed the game for us in doing relative motion splinting, even for those zone five, zone six injuries. So he's really been a pioneer with the extensor tendon stuff.
00:08:22
Speaker
Yeah, so quick clarification, when you're doing a yoke splint, let's say it's a long finger affected, are you putting that MCP into flexion relatively or extension relatively? So when, I'm sorry, I was kind of tuning you out. That happens all the time with us. That happens all the time. I'm talking and everyone's like, say that again. I don't know what you're talking about.
00:08:44
Speaker
When do you do a yolk orthosis for this kind of dislocation on a PIP joint to predict the central slip? Are you relative flexion or relative extension? Yeah, so I am putting them in relative flexion.
00:08:57
Speaker
Because if you're putting them in relative extension, you're going to really be loading that central slip because they're going to be allowing them a lot of flexion versus if it's in relative flexion, then you're really making that extensor tendon work. You're making that central slip work, and you're really working to pull them into full extension. So I think it's a great option for that, but definitely more relative flexion.
00:09:18
Speaker
which is the opposite of what we'd normally do if it's a zone four or proximal. So key point there, it's a different direction on that extensor loading that we wanna pursue, but yeah. Yeah, I think that's key for everyone to know, right? It depends on what you're really working on and what, yeah. So you can't just put any relative motion. You gotta make sure it's an extension or flexion. And then if you just think about what structure you're trying to protect, I think it's helpful.
00:09:43
Speaker
Yeah.
Engagement with Listeners
00:09:44
Speaker
All right. So we covered a bunch of stuff. There's always more we could cover. But if you guys have ideas on topics you'd like us to cover, let us know. Shoot us an email at info at handtherapyacademy.com.