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The PIP Debate
858 Plays2 years ago
Josh and Miranda discuss best ways to treat PIP joint dislocations and what position they should be splinted in.
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Transcript
Introduction to Hand Therapy Academy
00:00:05
Speaker
I'm Josh McDonald and I'm random material and we are hand therapy Academy.
Lessons from ASHD Conference on PIP Joint Dislocations
00:00:11
Speaker
One of the take homes from the ASHD conference that I was at not too long ago was some tidbits about PIP joint dislocations and how to measure, how to splint, all that good stuff. They talked about the V sign on an x-ray, which may or may not be super applicable for us. But mostly, one of the big take homes was when we're doing a dorsal blocking splint for a dorsal dislocation of the PIP joint.
Creating Dorsal Blocking Splints for PIP Joints
00:00:39
Speaker
we're supposed to have 30 degrees of extension block. So they should be 30 degrees short of neutral. There's some variation on that, but when we're making that splint, chances are the PIP joint has some inflammation. So should we still be measuring dorsally? Miranda, do you measure dorsally when you're doing one of those? I usually do both. And honestly, I don't think this is
00:01:08
Speaker
my opinion. So it doesn't really matter if it's 25 degrees versus 30, or if it's 34 versus 30, like, how exact do we need to be, right? Because the research is never really that exact, especially for a PIP dorsal dislocation. So I'll do either and I try to get it where like, if they do have a lot of swelling, I would definitely do lateral, but for the most part,
00:01:32
Speaker
I think the only way to really tell is to put them in the split and then have them go back for x-rays and that would be accurate
Measuring Techniques for Splints with Edema Considerations
00:01:41
Speaker
then. But I don't think our measurements, even if you do it dorsal versus lateral, are going to be exact. And I would say that when I'm making that dorsal blocking, I don't pull out a goniometer.
00:01:54
Speaker
Like, sometimes you do this long enough and you kind of get a feel for what 30 degrees is, but my eye goes to the lateral side of that digit and looking at center axis of P1 and center axis of P2 and getting to that orientation. If you're a therapist that likes to pull out the goniometer, that's fine. Understand that when you're measuring dorsally, if you put them in that splint and you measure dorsally,
00:02:21
Speaker
you're measuring a swollen and a joint with edema in it, and that is raising the center axis of that goniometer and skewing it towards more flexion than it's actually in.
Research on PIP Joint Flexion Angles
00:02:34
Speaker
And so you should be measuring laterally. One option might be before you pull the splinting material out, take an ink pen, it's just a normal pen, and draw on the lateral side of their finger
00:02:45
Speaker
center axis of P2 and center axis of P1 so you can get a visual on what that looks like. And if you're going on or doesn't fit in that space or they're hesitant, take a little 3x5 card and cut out a 30 degree angle so you can hold that there, give yourself something that fits a little easier in there, but we shouldn't be using a dorsal reference point for that.
00:03:03
Speaker
Right. I think that's an interesting point. And if you're a new grad, right, you're probably not really too certain of what 30 degrees is either. So I'm not against pulling out the goniometer, but like you, I think when you've been doing it a long time, you kind of get an idea. But another point I think that we need to talk about is there are, there is some research and articles showing that you don't even need to put the
00:03:27
Speaker
PIP and 30 degrees flexion, right? There's some that show that it actually can be at neutral. And I think this makes sense, right?
Decision-Making in Splinting PIP Joint Dislocations
00:03:35
Speaker
It makes sense because oftentimes after a dorsal dislocation, one of the biggest complications is a PIP joint contracture. Well, we've just made it worse by holding it in 30 degrees flexion. So when do you decide, or I guess, or the surgeon, when do you decide to put it in 30 degrees versus neutral versus 10 degrees?
00:03:56
Speaker
And how do you make that decision? If I don't have clarity from the referring provider, if I can't reach out to him and ask or her if I can't, if I'm not looking at x-rays or op reports or an office visit note about the reduction and the severity of the injury, I'm probably going to default to that 30 degree block
00:04:18
Speaker
Just because it's kind of a cover your backside kind of thing to say like, listen, there's an awful lot of articles that say a 30 degree extension block is a safe plan of care and we'll deal with the flexion contraction later. But there is room for that full extension position. When do you think we would use that instead?
00:04:39
Speaker
Um, I think if you have your doctor, whoever sent the patient to you, if they're on board, I also think it depends on the severity of the severity of the dislocation. Like was there the boilerplate was involved? Is the, uh, anterior and proper ligaments involved? Like how extensive was that dislocation? How traumatic was it? And how much, um, flexion do we need to hold it in based on how traumatic it was? And.
00:05:05
Speaker
And how well does the person heal, right? Is it someone young that's gonna scar in fast or is it someone older that might have some healing complications and we need to hold them in a little bit more flexion with a little bit more protection?
Liability and Standard Care in Hand Therapy
00:05:20
Speaker
And so many of the decisions we make on a daily basis with our patients in plan of care and protocols is based on what's safe and protects me from liability. That's why six weeks is when we discharge the flexor tendon splint.
00:05:35
Speaker
because that's what research says is six weeks. At five weeks and six days, were they probably okay to discharge that splint? What about five weeks and five days? But because that's the established norm, that's the gold standard, that's what we do. But there's certainly room for flexing around with this a little bit. And if you have a surgeon that says, it was a little dislocation, volar plate's fine, we don't want that volar plate to get stiff,
00:06:00
Speaker
go ahead and put them in full extension. Articles support that that's a reasonable plan of care. I think that's a good, perfectly fine option to do. Just you need a little bit of corroboration before you make the decision out there on your own island. Yeah, definitely. And make sure you have all the facts, right?
Handling Dislocations in Public: Knowledge vs. Liability
00:06:16
Speaker
Do you have the imaging that was done? Do you have the reports that were done? Do you have access to the doctor to ask those questions? And
00:06:25
Speaker
And as a side note, and so I think we've covered some of that. Well, I'm curious, something popped into my head here. I've had therapists ask me this, employees ask me this, and I'm curious what your answer is. If you're out at one of your kids' basketball games, I was going to say, if you're playing basketball, but you and I are old enough, we don't go out and play basketball. Oh, it's you, actually. Okay, fantastic. Maybe it's just me. Last night in the driveway, yeah. Oh, great, okay. Hoping I didn't injure myself. Right? Yeah. So if you're out playing basketball and you dislocate a finger,
00:06:54
Speaker
Would you reduce it yourself? If you saw someone else, would you reduce it? Would you go to an ER or an urgent care? What would you do if you saw a dislocated PIP joint? I would reduce my own. I would reduce my child's. Anybody that couldn't sue me, I would probably reduce it. If it's someone else, like a neighbor kid, which could very well be right, I'm not going to reduce it. I'm sending them to their parent or to an urgent care or the emergency room.
00:07:24
Speaker
How about you? I have a similar answer. It's much about protecting myself from liability. I know that I know more about that joint than certainly the urgent care PA that's there working on a Saturday night.
00:07:40
Speaker
probably more than the ER doctor or PA that says, ooh, I saw this on a course I went to, let me give it a try. I know more about what needs to be done. I'd be more likely to reduce a dorsal dislocation than I would be a volar dislocation, because volar dislocation is more likely to be central split rupture.
00:08:00
Speaker
But if I'm not gonna reduce it, if I'm not comfortable, I'm gonna say, go to the ER and ask for the on-call hand surgeon or ask for this hand surgeon specifically. Don't just walk in, have an ER doc reduce it and walk out with an aluma foam splint on there. That's insufficient care. But that's what most of our patients get. And then six weeks later, when they're joint stiff, they go to the hand surgeon. Right, or they end up having a, like you said, a central slip rupture and nobody knows. It's been missed because it was a fuller dislocation, like you said.
00:08:30
Speaker
Yeah, yeah, but I'm way less likely to do it if I'm walking by the park and some stranger over there has it happen and he wants my business card. Like, you don't need to know my name if I'm gonna, but it's unfortunate that that's how we have to think about liability instead of just helping this person and then giving them the information to say, go get this looked at beyond, certainly not urgent care. They're good at a couple of stitches and some sniffles, but even an ER doc, they're not finger specialists. They don't know how to reduce
00:08:58
Speaker
maybe a shoulder dislocation, but PIP, they don't understand central slit and folded plates. And they're going to say, follow up with your primary care doctor in a couple weeks.
Specialized Knowledge in Hand Therapy
00:09:08
Speaker
And maybe some of them do, right? It's not all of them. It's just, you know, whatever their experience level might be. But you're right. I think we are so afraid of being sued.
00:09:18
Speaker
Yeah, yeah, but we as hand therapists, no more than almost anyone else are gonna go have to reduce that. So maybe you reduce it, lock it in if it's a volar, say, I want you to, I'm gonna tape a stick to your finger, now go to the hand surgeon. Something like that, but yeah, trying to do no harm, but not get sued too. Yeah, that's true. I guess you gotta know you're reducing.
00:09:40
Speaker
Right. Right. Right. A lot of this information, maybe not what to do to get, not get sued is in our PIP course that's out. And if you have any thoughts on all this Volar dorsal dislocation stuff is a little unclear, you're not sure. We have a course that covers that specifically. All of our courses are free in our pro and CHT prep membership tier.
Hand Therapy Academy Resources and Courses
00:10:02
Speaker
So if you have interest in all of that stuff, check it out on handtherapyacademy.com.
00:10:06
Speaker
or you can shoot us an email at info at handtherapy.com and we'd love to answer any questions and help you out any way we can.