Hand Surgery Source

DISLOCATION, FINGER PROXIMAL INTERPHALANGEAL (PIP) JOINT

Introduction

Proximal interphalangeal (PIP) joint dislocations are the most common injuries of the hand.1  These injuries are frequently secondary to athletic injuries and are sometimes referred to as the “coach’s finger,” “finger sprains,” or “jammed fingers.”2,3,7,8  Acute PIP dislocations present with finger deformity, swelling, and PIP tenderness.1,3  When the PIP dislocates dorsally, the volar plate insertion is torn off the base of the middle phalanx and usually the collateral ligaments remain intact, but the proper collateral separates longitudinally from the accessory collateral.4,5,8  Near complete dorsal separation of the articular surface occurs with the hyperextension-type dorsal dislocation and complete separation of surface occurs in the bayonet-type closed dislocation.5,6  Similar degree of separation can occur with the lateral and volar PIP dislocations.

Definitions

  • A PIP joint dislocation occurs when the articular surface of the base of the middle phalanx is displaced off the articular surface of the head of the proximal phalanx.

Hand Surgery Resource’s Dislocation Description and Characterization Acronym

D O C S

D – Direction of displacement

O – Open vs closed dislocation

C – Complex vs simple

S – Stability post reduction

D – Direction of displacement

  • The primary description and characterization of PIP joint dislocations are done by noting the direction of the displacement of the middle phalanx relative to the head of the proximal phalanx. The three possible directions of displacement are dorsal, lateral and volar.6 Dorsal PIP dislocations are the most common. 
  • Dorsal dislocations are further divided into two sub-types: the hyperextension sub-type where the volar base of the middle phalanx catches on the dorsal edge of the proximal phalanx condyles in an extended position and the bayonet sub-type where the base of the middle phalanx is displaced on top of the neck of the proximal phalanx in a position parallel to the longitudinal axis of the proximal phalanx neck.
  • The degree of displacement of the middle phalanx further characterizes the PIP dislocations.  In a true complete dislocation, the articular surface of the middle phalanx is no longer in contact with the articular cartilage of the head of the proximal phalanx.  If there is partial contact of the cartilaginous surface, then this is not a true dislocation but rather a joint subluxation.6,7,8

O – Open vs closed

  • Open PIP joint dislocations are extremely rare but urgent irrigation, debridement, open reduction and ligament repair is indicated.
  • The majority of PIP dislocations are closed; the skin is intact, and there is no route for bacteria to contaminate the joint space.

C – Complex vs simple

  • Almost all PIP joint dislocations are simple, meaning that reduction is easily achieved under digital anesthetic block and is not blocked by soft tissue being interposed in the joint between the middle and proximal phalanx joint surfaces.
  • Complex PIP joint dislocations do occur, but are rare.
    • For example, a volar dislocation with intact central slip that has separated from the lateral bands and has a complete collateral ligament rupture can become irreducible (complex) when the lateral band and/or collateral ligament becomes locked in the joint and blocks a closed reduction.7,8,9

S – Stability

  • A stable PIP joint dislocation can be reduced and then put through an active range of motion (ROM) test under a local anesthetic block without re-dislocating.
  • Furthermore, a stable PIP joint dislocation is stable to stress testing of the collateral ligaments in the radial/ulnar plane after reduction.

PIP dislocation with special and complex features other than fractures

Complex (irreducible) PIP dislocation6,7,8,9

  • Complex PIP joint dislocations are very rare.
  • Mechanism of injury involves PIP flexion and torsional stresses.
  • Majority of complex PIP joint dislocations are closed injuries, but a few are open injuries.
  • These dislocations are irreducible because the head of the proximal phalanx becomes trapped between the lateral band and central slip, which may also be torn in some cases
    • Trapped between the flexor tendons and lateral band with an in-folded collateral ligament, or
    • Trapped between the flexor digitorum profundus and a slip of the flexor digitorum sublimis
    • Closed reduction always fails in these injuries

Imaging

  • X-ray
  • MRI

Treatment

  • Early diagnosis of complex PIP joint dislocations is very important.
  • Ideally, this is followed by open reduction and surgical anatomic repair of the collateral and tendon injuries.
  • Postoperatively, early motion with dynamic extension splint helps improve the post-injury function.

Complications

  • Stiffness
  • PIP joint pain
  • Persistent deformity

Outcome

  • Early diagnosis, surgical repair, and therapy will give a functional outcome, but some limited ROM is to be expected.

Related anatomy4,5

  • Extensor tendon – central slip and lateral bands
  • Flexor tendons – FDP and FDS
  • Dorsal capsule
  • Proper collateral ligament
  • Accessory collateral ligament
  • Volar plate
  • Osteology of the head of the proximal phalanx and the base of the middle phalanx

Overall incidence

  • PIP joint dislocation is the most common injury in the hand, especially in young athletic individuals.
  • Complex PIP joint dislocations are very rare.

Related Injuries/Conditions

  • Fractures of the proximal phalanx
  • Fractures of the middle phalanx, especially chip fractures of the middle phalanx base at the volar or dorsal lip
  • Collateral ligament injuries
  • Volar plate injuries
  • Central slip ruptures
ICD-10 Codes

DISLOCATION, FINGER PROXIMAL INTERPHALANGEAL (PIP) JOINT

Diagnostic Guide Name

DISLOCATION, FINGER PROXIMAL INTERPHALANGEAL (PIP) JOINT

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
DISLOCATION FINGER: PIP Joint        
- INDEX   S63.281_ S63.280_  
- MIDDLE   S63.283_ S63.282_  
- RING   S63.285_ S63.284_  
- LITTLE   S63.287_ S63.0286_  

Instructions (ICD 10 CM 2020, U.S. Version)

THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S63, S64, S65 AND S69
A - Initial Encounter
D - Subsequent Routine Healing
S - Sequela

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Dislocation PIP Joint
  • Dorsal PIP Dislocation Bayonet Type
    Dorsal PIP Dislocation Bayonet Type
  • Dorsal PIP Dislocation Bayonet Type Mechanism: Volar plate ruptured off base of middle phalanx; proper collateral (blue) separated from accessory collateral (not shown).
    Dorsal PIP Dislocation Bayonet Type Mechanism: Volar plate ruptured off base of middle phalanx; proper collateral (blue) separated from accessory collateral (not shown).
  • Dorsal PIP Dislocation Hyperextension Type
    Dorsal PIP Dislocation Hyperextension Type
  • Volar PIP Dislocation
    Volar PIP Dislocation
  • Lateral PIP Dislocation
    Lateral PIP Dislocation
  • Lateral Chronic PIP Dislocation left fifth finger
    Lateral Chronic PIP Dislocation left fifth finger
Pathoanatomy Photos and Related Diagrams
Complex PIP Dislocations
  • Complex Dislocation left long finger - Closed reduction not possible. These rare complex (irreducible by closed methods) PIP dislocations usually occur in the ring and little fingers. The mechanism of the volar complex PIP dislocations involves deviation, flexion and torsion. Approximately 1/5 of the reported complex dislocations are open. Delayed presentation is common.
    Complex Dislocation left long finger - Closed reduction not possible. These rare complex (irreducible by closed methods) PIP dislocations usually occur in the ring and little fingers. The mechanism of the volar complex PIP dislocations involves deviation, flexion and torsion. Approximately 1/5 of the reported complex dislocations are open. Delayed presentation is common.
  • Complex Dislocation ring - Closed reduction not possible
    Complex Dislocation ring - Closed reduction not possible
  • Complex Dislocation ring little - Closed reduction not possible
    Complex Dislocation ring little - Closed reduction not possible
  • The first stage of a complex PIP dislocation is a deviation force which ruptures the collateral ligament. This is followed by flexion and torsion which splits the lateral band off the central slip, forces the band over the proximal phalanx condyle and into the PIP joint.
    The first stage of a complex PIP dislocation is a deviation force which ruptures the collateral ligament. This is followed by flexion and torsion which splits the lateral band off the central slip, forces the band over the proximal phalanx condyle and into the PIP joint.
  • Complex PIP Dislocation by Collateral Ligament: the mechanism of injury stops after the collateral (blue) ruptures off the middle phalanx and folds itself into the PIP joint and thus blocks a closed reduction without tear or displacement of the lateral band.
    Complex PIP Dislocation by Collateral Ligament: the mechanism of injury stops after the collateral (blue) ruptures off the middle phalanx and folds itself into the PIP joint and thus blocks a closed reduction without tear or displacement of the lateral band.
  • Complex PIP Dislocation by Lateral Band: the mechanism of injury involves flexion and torsion which splits the lateral band off the central slip, forces the band over the proximal phalanx condyle and into the PIP joint with the central slip remaining intact.
    Complex PIP Dislocation by Lateral Band: the mechanism of injury involves flexion and torsion which splits the lateral band off the central slip, forces the band over the proximal phalanx condyle and into the PIP joint with the central slip remaining intact.
  • Complex PIP Dislocation by Lateral Band & Ruptured Central Slip: the mechanism of injury involves flexion and torsion which splits the lateral band off the central slip, forces the band over the proximal phalanx condyle and into the PIP joint with a ruptured central slip.
    Complex PIP Dislocation by Lateral Band & Ruptured Central Slip: the mechanism of injury involves flexion and torsion which splits the lateral band off the central slip, forces the band over the proximal phalanx condyle and into the PIP joint with a ruptured central slip.
  • Complex Open PIP Dislocation by Flexor Tendons: In this very rare open injury the volar plate ruptures off the neck of the proximal phalanx and goes dorsal with the middle phalanx. The collateral ligament ruptures and the head of the proximal phalanx gets caught in a noose formed by one slip of the FDS on one side and the FDS slip & FDP on the other. 1-volar plate; 2-FDS Slips; 3-FDP; 4-collateral ligament; 5-FDS Slip; 6-FDP; 7-Other FDS Slip; 7- A-4 pulley
    Complex Open PIP Dislocation by Flexor Tendons: In this very rare open injury the volar plate ruptures off the neck of the proximal phalanx and goes dorsal with the middle phalanx. The collateral ligament ruptures and the head of the proximal phalanx gets caught in a noose formed by one slip of the FDS on one side and the FDS slip & FDP on the other. 1-volar plate; 2-FDS Slips; 3-FDP; 4-collateral ligament; 5-FDS Slip; 6-FDP; 7-Other FDS Slip; 7- A-4 pulley
Symptoms
History of trauma with finger deformity or ecchymosis
Finger pain and swelling localized at the PIP joint
Typical History

The typical patient with a PIP joint dislocation is a young male football player who “jammed” his finger against an opposing player as he attempted a tackle. He experienced sudden PIP joint pain and swelling. He immediately noticed that his left long finger was crooked. On the sideline, his coach snapped the finger back in place and sent the player back into the game.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Dislocation PIP Joint X-rays
  • X-ray chronic lateral PIP dislocation left fifth finger
    X-ray chronic lateral PIP dislocation left fifth finger
  • X-ray dorsal hyperextension type PIP dislocation right fifth finger
    X-ray dorsal hyperextension type PIP dislocation right fifth finger
  • Complex dislocations frequently have a rotational component, therefore the lateral X-ray may look half like an oblique view and half like a true lateral view.
    Complex dislocations frequently have a rotational component, therefore the lateral X-ray may look half like an oblique view and half like a true lateral view.
  • Complex dislocations AP X-ray views often show a widened joint space (arrow).
    Complex dislocations AP X-ray views often show a widened joint space (arrow).
  • Dorsal lateral PIP dislocation
    Dorsal lateral PIP dislocation
Treatment Options
Treatment Goals
  • Reduce the dislocation
  • Analyze the PIP joint’s stability
  • Rehabilitate the finger to regain ROM and normal finger and hand function
Conservative

Conservative1-8

  • Ideally, PIP joint dislocations are treated early with a closed reduction under local anesthesia, which should be a finger block or wrist block. Anesthesia allows a gentle reduction with minimal pain.
  • After reduction, performing an active ROM test and stress testing of the collateral ligaments is very important. This should be done before splinting. If the patient can actively extend and flex the finger almost normally without the finger re-dislocating, and if the collateral ligaments are stable to stress testing, then splinting the finger in mild flexion for comfort is indicated.
  • This static splinting can be discontinued quickly (7-10 days) and a buddy tape splint used. Buddy taping the injured finger to an adjacent finger allows early active ROM exercising which should provide the best opportunity for obtaining normal ROM and finger function.
Operative

Operative1-9

  • PIP joint dislocations without fractures rarely need operative treatment.
  • Operative treatment is indicated for open PIP joint dislocations, complex (irreducible) dislocations, and lateral dislocations in young individuals with completely torn and unstable collateral ligament tears.
Treatment Photos and Diagrams
Dislocation PIP Joint Treatment
  • The closed reduction maneuver for the dorsal PIP joint dorsal dislocation involves hyperextending the PIP joint (1), while applying pressure to push the base of the middle phalanx distally until it is beyond the head of the proximal phalanx and can fall back into the reduced position. Once the joint starts to relocate, then the middle phalanx is flexed while the traction is maintained on the distal part of the finger.
    The closed reduction maneuver for the dorsal PIP joint dorsal dislocation involves hyperextending the PIP joint (1), while applying pressure to push the base of the middle phalanx distally until it is beyond the head of the proximal phalanx and can fall back into the reduced position. Once the joint starts to relocate, then the middle phalanx is flexed while the traction is maintained on the distal part of the finger.
  • Always take a post-reduction X-ray to verify and document the reduction and rule out any missed fractures.
    Always take a post-reduction X-ray to verify and document the reduction and rule out any missed fractures.
  • Testing ulnar collateral ligament (UCL) stability after closed reduction right long finger PIP dislocation under local block.
    Testing ulnar collateral ligament (UCL) stability after closed reduction right long finger PIP dislocation under local block.
  • Testing volar plate stability after closed reduction right little finger hypertension type dorsal PIP dislocation under local block.
    Testing volar plate stability after closed reduction right little finger hypertension type dorsal PIP dislocation under local block.
  • For stable and anatomically reduced PIP dislocations, buddy tape splinting and early active ROM may be the only treatment needed.
    For stable and anatomically reduced PIP dislocations, buddy tape splinting and early active ROM may be the only treatment needed.
  • Neglected Complex PIP dislocation with 1 - edge of the central extensor tendon; 2 - lateral band heading into the PIP joint; G - granulation tissue over ruptured collateral ligament and in split between lateral band and central extensor.
    Neglected Complex PIP dislocation with 1 - edge of the central extensor tendon; 2 - lateral band heading into the PIP joint; G - granulation tissue over ruptured collateral ligament and in split between lateral band and central extensor.
  • Complex PIP dislocation with 1 - lateral band displaced into the PIP joint; 2 -edge of the central slip ; 3 - ruptured collateral ligament .
    Complex PIP dislocation with 1 - lateral band displaced into the PIP joint; 2 -edge of the central slip ; 3 - ruptured collateral ligament .
  • Complex PIP dislocation with repaired lateral band and central slip.
    Complex PIP dislocation with repaired lateral band and central slip.
  • Static PIP extension splint to protect central slip and extensor hood repairs after open reduction and repair of complex volar PIP dislocation.
    Static PIP extension splint to protect central slip and extensor hood repairs after open reduction and repair of complex volar PIP dislocation.
  • Dynamic extensor splint to allow mobilization of extensor hood repair.
    Dynamic extensor splint to allow mobilization of extensor hood repair.
Hand Therapy

Post-treatment Management

  • Many patients with PIP joint dislocations that are closed and reduced early can potentially exercise their finger on their own.
  • However, patients with marked swelling and pain will need hand therapy to help reduce swelling and improve ROM and strength.
  • Surgically repaired PIP joint complex dislocations, repaired collateral ligaments, and unstable PIP dislocations will definitely need hand therapy, custom splinting, and dynamic extension splints.  
Complications
  • Pain
  • Stiffness
  • Residual deformity
  • Weak grip
Outcomes
  • Simple PIP joint dislocations that are treated early typically have an excellent outcome.
  • However, all patients with PIP joint dislocations should be warned that the PIP joint on the injured side will likely remain slightly larger than the opposite PIP joint because the stretched collateral ligaments are likely to heal with a little extra bulk (collagen).
Key Educational Points
  • Simple closed PIP joint dislocations can be mobilized early and should get a good outcome with minimal loss of ROM and residual deformity.
  • Unstable PIP joint dislocations require prolonged extension block splinting with continuous monitoring by hand therapy for splint adjustment, etc.
  • Open and complex PIP joint dislocations require urgent surgical treatment.
References

New and Cited Articles

  1. Palmer AK, Linscheid RL. Chronic recurrent dislocations of the proximal interphalangeal joint of the hand. J Hand Surg Am1978;3(1):95-7. PMID: 621373
  2. McCue FC, Honner R, Johnson MC, Gieck JH. Athletic injuries of the proximal interphalangeal joint requiring surgical treatment.  J Bone Joint Surg Am1970;52:937-56. PMID: 5479483
  3. Leggit JC, Meko CJ. Acute finger injuries: Part II fractures, dislocations, and thumb injuries.  Am FamPhysician2006;73(5):827-34. PMID: 16529090
  4. Bowers WH, Wolf JW Jr, Nehil JL, Bittinger S. The proximal interphalangeal joint volar plate. I. An anatomic and biomechanical study. J Hand Surg Am1980;5(1):79-88. PMID: 7365222
  5. Bowers WH. The proximal interphalangeal joint volar plate. II: A clinical study of hyperextension injury. J Hand Surg Am1981;6(1):77-81. PMID: 7204922
  6. Merrell G, Slade JF. Dislocations and ligament injuries in the digits. In: Wolfe, SW, Hotchkiss RN, Pederson WC, Kozin SH (eds): Green’s Operative Hand Surgery.  Philadelphia 2011: Elsevier Churchill Livingstone, pp. 291-332.
  7. Chinchalkar SJ, Gan BS. Management of proximal interphalangeal joint fractures and dislocations.  J Hand Ther2003;16:117-28. PMID: 12755163
  8. Bindra RR, Foster BJ. Management of proximal interphalangeal joint dislocations in athletes. Hand Clin2009;25:423-35. PMID: 19643341
  9. Garroway RY, Hurst LC, Leppard J, Dick HM. Complex dislocations of the proximal interphalangeal joint, a pathoanatomic classification of the injury. Ortho Review1984;13(9):490-7.

Classic

  1. McCue FC, Honner R, Johnson MC, Gieck JH. Athletic injuries of the proximal interphalangeal joint requiring surgical treatment.  J Bone Joint Surg Am1970;52:937-56. PMID: 5479483