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Dorsal PIP Joint Dislocations
1.2k Plays2 years ago
Dorsal joint dislocations account for 80% of PIP joint dislocations. This typically causes an injury to the volar plate which needs protection from a dorsal blocking orthosis.
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Transcript
Introduction to Dorsal PIP Joint Dislocations
00:00:06
Speaker
Hey guys, I'm Josh McDonald. And I'm Randi McMateri, and we're going to be talking about PIP joint dislocations, most specifically dorsal.
00:00:15
Speaker
Yeah, dorsal. Yeah. So there's dorsal. We're not doing folder today. We'll stay on track. We're going to do dorsal, which means we've got to talk about anatomy and what happens with dorsal. So to explain, it gets a little confusing which one's dorsal, which one's roller. We talk about what direction P2 goes. If P2 goes dorsally, that's a dorsal dislocation. But what gets damaged is damaged by the distal end of P1.
00:00:41
Speaker
So if the P2 goes dorsally, that means P1 then impacts or interferes with the volar plate, with the volar sides of that joint capsule, possibly down into FDS, FDP tendons, A1 polis, all that stuff on the volar side of the PIP joint. So it's a dorsal dislocation, but the volar side of the PIP joint is the one that's affected. Yeah. And I think for students imagining, they are always like, which part moves dorsally, right? So.
Clinical Priorities and Splinting Techniques
00:01:11
Speaker
I think you said a key point there we should highlight. It's that the direction that the distal aspect of P, or not the distal aspect of P2, but the distal joint that's involved. So if it's a PIP, it's P2, right, versus P1. And say if it was the DIP, it's P3 versus P2. So it's whatever direction that distal part goes.
00:01:33
Speaker
Yes, yeah, yeah. So if we have a dorsal dislocation, what's our walks in the clinic, someone with that injury, what's our first priority? What do we want to protect? So this is typically a dorsal PIP joint splint. So we're really protecting the volar plate, right, and the volar surface. And there is some controversy. Do we put them in neutral or do we put them in slight flexion? And I think this depends on how stable the fracture or the dislocation is. What are you primarily doing? Are you doing?
00:02:03
Speaker
extension are you doing slight flexion? I'm doing what's you know they say 30 degrees of flexion but there's some squish and pliability of all those tissues and any dorsal finger splint like a dorsal blocking has very small amount of purchase on that P1 so I feel like even when I put them at 30 degrees at picture perfect in the splint take a picture of it they still come out of that a little bit more
00:02:30
Speaker
And so they're really more like a minus 15 once they get moving and active with that hand. And so I feel like that kind of biases us a little bit more towards that neutral without hopefully getting that flexion contracture. If I'm only strapping P one, cause they're allowed to flex, but not a hyper-extend. So I'm putting the splint at 30, but their finger kind of really functions more like minus 15 give or take. Yeah. Cause the number one complication with these is usually a PIP joint flexion contracture, right? Yeah. Yeah. All the time.
00:02:59
Speaker
Right. And I always tell students and newbies, if you know what the number one problem with this type of injury is, then usually you can, you know, you can be watching for it and know when to adjust to your plan of care. So always knowing what the problems are with the specific injury, I think is key.
00:03:14
Speaker
Yeah, and knowing am I allowed to take them towards extension. So if it was a conservatively managed closed closed management and there was no repair and the doctor says, let's just be careful. I might be able to sneak a little bit further towards extension than if there was a repair that I'm worried about rupturing.
00:03:33
Speaker
if those sutures are at risk for rupturing and we want to make sure all those tissues stay approximated while they're healing, then I might really, really bias towards that, you know, let's limit that and hope we can get it back later. But yeah, that's a tough one to get back when they have that flexion contracture.
Pain Management Strategies
00:03:47
Speaker
And what about when your patient is just in so much pain, right? These tend to be very painful. So what if they're telling you, hey, it really, really hurts, I'm having a hard time.
00:03:58
Speaker
So pain is something that we need to really, really respect and have a good awareness of not causing this whole sympathetic pain response buildup that can cause a lot of other problems. So if I have a patient who's in a lot of pain, I'm going to do what I can to get them out of that pain. That doesn't mean I'm going to put them in 90 degrees of PIP flexion, but I'm not going to push that as much early on
00:04:20
Speaker
both to establish a rapport with a patient where they trust that I'm not gonna do things just that cause pain, but also to not ramp things up and make things more cyclical in this pain that they're living in. Yeah, and I always tell patients, too, at that beginning visit, these are painful injuries, right? So they kind of expect that there might be some pain with movement, because I feel like with this injury more than any other one, it tends to be quite painful, right? I would say this is one of our more painful
00:04:49
Speaker
um, diagnoses that we treat. Yeah, definitely. So you're right. They do need to understand that there's going to be some discomfort. Like it's if, if, if we just want to stay completely out of any pain, they're going to get stuck in a mobile. So you're right. We kind of balance that in with saying, let's, let's move as much as we can tolerate, understand that we got to challenge it a little bit, but nothing in that 10 out of 10 scale.
Boutonniere Deformities: Pseudo vs. Real
00:05:12
Speaker
And then, so one of the complications for our dorsal PIP joint dislocation is a pseudo boot in here.
00:05:17
Speaker
And how do you tell your students and people what's the difference between a pseudo and a real boutonniere? So I've seen a couple of descriptions, one that basically just says if the DIP is not affected and just a PIP contracture, that's a pseudo boutonniere. And then I've seen other descriptions in articles that say it has to do with central slip involvement. So basically I take it functionally as if the PIP is contracted into flexion, but I don't have hyperextension of
00:05:47
Speaker
the DIP because of a redistribution of the balance of the tendon pulls. So it's just a standard will save PIP joint flexion contracture without PIP or excuse me, without DIP involvement.
00:06:00
Speaker
Yeah. Yeah. And so what are some of your go-to treatments? Let's say we're out of the precautionary stage. We're trying to get early active movement, but watching protection, what kind of comes after that when you say, okay, we're, we're out of the danger zone here. What are some things we do to get that thing moving?
Rehabilitation and Movement Importance
00:06:18
Speaker
Yeah. So I think initially it's, you know, managing the swelling, make sure there's not a lot of extra gunk in that joint, right? So it moves a little bit easier, but then we're starting with, you know, kind of the typical tendon glides, joint blocking,
00:06:30
Speaker
I'll have them come out of the split more and use their hand functionally, right? So I'll tell them, I want you to pick up light things. We might do some towel walking and non-functional things in the clinic too, just to give them confidence in the movement. But then I really want them to use it. I want you to brush your teeth with that hand and I want you to grab your hand around the steering wheel and try to bend that middle joint. So just doing, trying to integrate real functional things so that way they're doing it constantly throughout the day as opposed to sitting down and doing
00:07:00
Speaker
The exercises, the exercises are still important, but I think the more chances you get at moving it, the better. What's kind of your go-to approach? First of all, the steering wheel is like a universal therapy tool. Excuse me, everyone says, oh, I use the steering wheel all the time and that makes it better. So it's kind of a funny thing.
Advanced Treatment Options
00:07:18
Speaker
Once they're out of the precautionary stage, I like to use a relative motion orthosis and kind of bias that MCP into flexion so that it, that EDC drives extension of the PIP a little bit. Again, once they're safe and protected, I like to do like some home stuff. So maybe I do like a volar gutter splint for nighttime.
00:07:36
Speaker
And we do kind of a serial progressive where I'm slowly gaining more extension with that. That may be an option. I don't like to throw too many tools at people because it's something that may not be compliant with, but you cover the bases on a lot of the use it, move it, be active with it. So maybe an LMB, if they're a little bit further out, that's something that can be really potent and significant discomfort. So I'm hesitant to give that to patients early.
00:08:01
Speaker
and just kind of say like, let's just go for it and they get kind of the wrong idea. Movement is better, function is better. But if we're getting kind of stuck, those are some of the extra things I may come up with to throw at for a patient. So what is your, so you're talking about some, you know, static progressive type or dynamic extension splits. When do you decide if you're going to use one of those? Is there a formula you have or kind of how do you decide when or when not to do that?
00:08:28
Speaker
Um, kind of a judgment call thing, but I'm not going to do it before they're out of that safe zone. So I'm kind of waiting until well after six weeks. Um, and if they're moving and progressing well, I don't feel the need for it. If they're like, we're headed the right direction, we can see the end of the woods, no need to throw new stuff at you until we get
Post-Treatment PIP Joint Contracture
00:08:44
Speaker
stuck. And it's when a patient's kind of stuck that that's when I say, okay, what are we going to do to kind of step this up a little bit? And it depends on their tolerance to an LMB as we trial it in the clinic.
00:08:54
Speaker
maybe a nighttime extension so that we can get a little bit of stretch if that's a good option. So kind of this, what's the best fit for that patient's life if they're stuck and the conservative, you know, the normal clinic stuff and home stuff isn't progressing them along. And is there an acceptable leg for these patients or is there an acceptable degree of PIP joint contracture? So a course at AHS was super, super thorough and Dr. Merritt said a
00:09:21
Speaker
He's comfortable, if he's got a patient, he says something like 20, maybe 30 degrees of extension lag. He's like, that's a reasonable outcome. That kind of surprised me. Yeah, me too. That would not. I know, I see 30 and I think, oh, we messed up. But I've got surgeons that are saying, if you've got 20 degree lag, I'm not going to touch it because they could only maybe make it worse. So 20, I think is a reasonable lag to expect and the patients need to know that going in.
00:09:48
Speaker
Yeah. And especially I think if it's like a grade three, grade four injury where those are more complicated. But then I think, you know, you're having problems reaching in between your car seats, putting your hand in your pocket. Like that would be kind of a bummer. But yeah, yeah. 20 degrees is not fun. It's not fun to deal with. But if the alternative to surgery and you get worse out of that, that's no better. Right. Definitely. All right. I think that wraps up dorsal PIP joint dislocations. All right, guys. Talk to you later.