Hand Surgery Source

SPRAIN, PIP JOINT

Introduction

The proximal interphalangeal (PIP) joint is the most frequently injured of all the joints in the fingers, with injuries ranging from mild sprains to complete ligament ruptures and joint dislocations. PIP joint sprains are fairly common, and the mechanism of injury is usually either hyperextension or a laterally deviating force to the fingertip. These injuries typically have an excellent prognosis, but prolonged immobilization of the PIP joint can cause stiffness and may result in irreversible loss of motion in the digit. This highlights the need for a timely and accurate diagnosis and appropriate treatment to prevent long-term complications.1-3

Pathophysiology

  • The PIP joint accounts for approximately 85% of the motion required in a functional grip, and as a hinge joint, it is extremely stable in the sagittal plane. Despite this stability, the PIP joint has limited tolerance to angular, axial, and rotational stress. This, combined with the PIP joint’s unprotected position in the digit and long moment arm, makes it one of the most susceptible joints to injury.1
  • Volar plate sprains occur due to hyperextension of the PIP joint or from rotational longitudinal compression, which are common in ball-handling sports. On the other hand, any laterally deviating force to the fingertip will affect stress distribution over the collateral ligaments and may cause injury within these structures.
    • With enough force, this force can cause the true collateral ligament to tear from its insertion at the middle phalanx. This disruption may also progress to the accessory collateral ligament and the attachment of volar plate at the middle phalanx.1,4
    • A disruption of any of the important PIP joint structures will impact the coordinated gliding motion of tendons and ligaments and impair the range of motion (ROM) of the joint.5

Related Anatomy6,7

  • Ulnar collateral ligament (UCL): proper and accessory
  • Radial collateral ligament (RCL): proper and accessory
  • Dorsal capsule
  • Volar plate
  • The PIP joint is a bicondylar hinge joint primarily stabilized on the radial and ulnar sides by a collateral ligament complex composed of proper and accessory portions.
    • The proper collateral ligament originates from a crescent-shaped area just dorsal and proximal to the concavity on either side of the head of the proximal phalanx. 
    • The accessory collateral ligament is a thin structure lying volar to the proper portion that inserts on the volar plate.
    • The volar plate forms the floor of the joint and limits passive hyperextension.
    • In addition to the 3 primary stabilizers, the PIP joint is further supported by the central slip, lateral bands, and flexor tendons, which collectively serve as the secondary dynamic stabilizers.1,8,9
  • The PIP joint is designed to undergo 100-110° of motion in flexion and extension, and it must do so while maintaining near-maximum resistance to radial-ulnar deviation stresses in all angles of flexion. This stability is critical to the normal functioning of the PIP joint.10
  • Ligamentous injuries of the PIP joint are typically categorized into one of the following three groups:
    • Grade 1: involves asymmetric swelling and tenderness over the collateral ligament without instability on the lateral stress test
    • Grade 2: involves partial disruption of the collateral ligament, but the volar plate remains intact. There is some instability, but stress testing reveals a definite soft tissue endpoint indicating that the collateral is not completely torn.
    • Grade 3: involves total collateral ligament disruption and volar plate rupture, with clinical examination depicting evidence of potential subluxation or dislocation on active extension.1,10 Stress testing reveals no soft tissue endpoint indicating that the collateral is completely torn.

Incidence and Related Conditions

  • One study found that finger injuries accounted for 38% of 3.5 million upper extremity injuries in the U.S. About 16% of these injuries were sprains and strains, while dislocations accounted for ~5%.11
  • The incidence of finger sprains is 37.3 per 100,000 persons/year, and the PIP joint is the most commonly injured joint of the hand, followed by the thumb metacarpophalangeal (MP) joint and MP joint of the fingers. Due to their infrequency, statistics are lacking on the specific occurrence rates of sprains to the distal interphalangeal (DIP) joint of the fingers and thumb interphalangeal (IP) joint.11
  • In one study of 50 patients with PIP joint sprains, the majority occurred in the ring and long fingers, followed by the index and finally the little finger, in which rates were significantly lower. This study also found the RCL to be injured twice as frequently as the UCL.12

Differential Diagnosis

  • Collateral ligament tear
  • Volar plate tear
  • Extensor tendon avulsion
  • PIP joint dislocation
  • Middle phalanx fracture
  • Proximal phalanx fracture
ICD-10 Codes

SPRAIN

Diagnostic Guide Name

SPRAIN

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

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
- WRIST        
 - CARPAL JOINT   S63.512_ S63.511_  
 - RADIOCARPAL JOINT   S63.522_ S63.521_  
 - OTHER SPECIFIED SPRAIN OF WRIST   S63.592_ S63.591_  
- METACARPOPHALANGEAL (MCP)        
 - INDEX   S63.651_ S63.650_  
 - MIDDLE   S63.653_ S63.652_  
 - RING   S63.655_ S63.654_  
 - LITTLE   S63.657_ S63.656_  
 - THUMB   S63.642_ S63.641_  
- INTERPHALANGEAL (DIP, PIP)        
 - INDEX   S63.631_ S63.630_  
 - MIDDLE   S63.633_ S63.632_  
 - RING   S63.635_ S63.634_  
 - LITTLE   S63.637_ S63.636_  
- CARPOMETACARPAL OF THUMB (CMC)   S63.8X2_ S63.8X1_  

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

THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S63
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
Collateral Ligament Sprains
  • Right ring finger PIP joint grade 3 sprain (arrow) in 17 y.o. male basketball player.
    Right ring finger PIP joint grade 3 sprain (arrow) in 17 y.o. male basketball player.
  • Left long finger PIP joint grade 2 sprain
    Left long finger PIP joint grade 2 sprain
  • Right ring finger PIP joint grade 3 sprain of the radial collateral ligament
    Right ring finger PIP joint grade 3 sprain of the radial collateral ligament
Basic Science Photos and Related Diagrams
Collateral Ligament Sprain Exam
  • Right index finger PIP joint radial collateral ligament (arrow) exam.
    Right index finger PIP joint radial collateral ligament (arrow) exam.
  • Right index finger PIP joint ulnar collateral ligament (arrow) exam
    Right index finger PIP joint ulnar collateral ligament (arrow) exam
Symptoms
History of finger trauma with PIP joint instability and/or deformity
Pain, swelling and ecchymosis over the PIP joint
Decreased finger motion
Typical History

A typical patient is a 15-year-old, right-handed female basketball player, who injured her finger during a recent game. The girl was not paying attention when another player quickly passed her the ball, and when she moved her hands to catch it, her fingers were not positioned correctly, as they were pointing perpendicularly to the direction of the ball as it moved towards her. This positioning resulted in the ball connecting with the tip of the ring finger in her right hand and hyperextending its PIP joint. The force caused a mild-to-moderate sprain of the PIP joint’s volar plate and led to pain, swelling, and ecchymosis over the joint, and the girl had to be taken out of the game for treatment.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
X-ray of PIP Joint Sprain
  • X-ray of PIP joint sprain. Note tiny collateral avulsion fractures (arrows) and soft tissue swelling around the PIP joint.
    X-ray of PIP joint sprain. Note tiny collateral avulsion fractures (arrows) and soft tissue swelling around the PIP joint.
Treatment Options
Treatment Goals
  • The goal of injury management for PIP joint sprains is to obtain a strong, stable, and pain-free joint with an near normal range of motion.5
Conservative
  • Treatment decisions should be based on the injury pattern, joint stability and level of chronicity, but the majority of PIP sprains can be effectively managed conservatively with a brief period of immobilization followed by early return to active range of motion exercises with buddy taping.4 Most authors recommend buddy taping and/or a sustained extension splint of the injured digit.9 A dorsal-blocking or figure-of-eight splint may also be used, with the figure-of-eight splint being most effective for volar plate and collateral ligament injuries when there is no associated central slip injury.5 Initial splinting should be done in mild flexion, and the splint should be used until the acute pain and swelling have subsided. If full extension is not possible at first, then dynamic PIP extension splinting may be needed.12 Immobilization typically should not extend 2- 3 weeks, as doing so may lead to permanent stiffness.4
  • Nonsteroidal anti-inflammatory drugs should only be used cautiously and for short period of time.10
  • Steroid injections may reduce pain and inflammation, but injections can be detrimental to healing. Most experts therefore caution against their use for acute PIP joint sprains.10
Operative
  • Ligamentous injuries of the PIP joint rarely require surgical intervention unless a ligament is completely ruptured. Most grade 3 injuries need to be treated surgically because they rarely respond to conservative measures, and failure to effectively manage these cases can lead to chronic pain, swelling, joint instability, and dysfunction.10
  • Many types of repairs and reconstructions have been described for ligamentous ruptures of the PIP joint, in which sutures, bone anchors, tendon weaves, and various muscle-tendon advancements may be utilized.10
  • PIP collateral ligament reconstruction
    • Indications include chronic, symptomatic instability of any finger PIP joint resulting from collateral ligament deficiency that has otherwise failed conservative management.
    • Contraindications include advanced arthrosis, fixed joint deformity, instability from articular or bony deformity, or instability from inflammatory conditions. In these situations, arthrodesis is a viable alternative.8
  • After surgery, the finger should be immobilized for up to 3-4 weeks, and continued physical therapy with active ROM exercises will be necessary to ensure a proper return of function.8  The sooner the active range of motion exercises are begun the better as long as the active range of motion exercises do not disrupt the collateral ligament repair. Observing the arc of motion at surgery that does not put excessive tension on the repair at surgery may help guide the post-operative exercise program.
CPT Codes for Treatment Options

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Common Procedure Name
PIP joint release (capsulotomy)
CPT Description
Capsulectomy or capsulotomy; interphalangeal joint, each joint
CPT Code Number
26525
Common Procedure Name
Ulnar collateral ligament repair
CPT Description
Repair of collateral ligament, metacarpophalangeal or interphalangeal joint
CPT Code Number
26540
Common Procedure Name
Volar plate repair/reconstruction
CPT Description
Repair and reconstruction finger, volar plate, interphalangeal joint
CPT Code Number
26548
Common Procedure Name
Flexor digitorum superficialis tenodesis PIP joint
CPT Description
Tenodesis; of proximal interphalangeal joint, each joint
CPT Code Number
26471
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Complications
  • Infection
  • Stiffness that is far more common than joint instability in PIP sprains
  • PIP flexion contracture 
  • Osteoarthritis
  • Swan neck deformity 
  • Pseudo-boutonniere deformity
  • According to some authors, most complications are due to over-treatment—such as extended periods of immobilization—rather than the absence of treatment.9
Outcomes
  • PIP joint sprains typically have an excellent prognosis, and most patients will eventually regain full finger ROM; however, some patients will continue to experience pain, stiffness, and disability up to 3 months after the injury.2,3,9 Even partial-thickness ligament tears and minimally displaced full-thickness tears have been found to experience favorable results with conservative treatment.2The prognosis depends of the promptness of treatment, as injuries managed early are typically associated with more positive outcomes.9
  • In one randomized study of 221 patients with hyperextension injuries of the PIP joint, buddy taping alone was found to lead to faster and better results than a splint in terms of pain and edema.13 Another similar study of patients with PIP joint volar plate injuries found 98% good results after using a splint for 10 days followed by buddy taping for 3 weeks.14 An active range of motion test at the time of the initial PIP joint examination should help identify the safe arc of motion that can be performed  before the motion overly stresses the collateral ligament injury.
Key Educational Points
  • Many patients present several weeks or months after injury, at which point they still experience pain, swelling, and stiffness. This can lead some patients to protect the finger excessively, which results in additional stiffness and hinders their recovery.3
  • Patients must be advised to work on active range of motion exercises despite some joint discomfort.  A “No Pain No Gain” approach should be emphasized. Explaining the typically prolonged recovery associated with these seemingly simple injuries must be part of the patient education.  Finally, the patient must understand that even after a year, the PIP collaterals will undoubtedly be larger on the injured side than the collaterals at the PIP joint of the opposite normal finger.
  • Patients, athletic trainers, and coaches often overlook PIP joint injuries, and delayed or improper treatment often occurs as a result, which can lead to permanent deformities of the affected digit.1
  • Over the past 10 years, there have been many advances in the understanding of the anatomy, physiology, and biomechanics of the ligamentous joint capsule of the finger joints, which may help to better deliver effective treatments to patients.10
  • Lateral stress test - used to evaluate the status of the collateral ligaments.  A 15-20° “opening” of the PIP joint may be detected during stress testing in PIP joint sprains.12
  • Ultrasound - has become increasingly effective at imaging the articular surface and associated soft tissues of the fingers, in part because it allows for dynamic evaluation.4  Sprains appear as a diffusely swollen hypoechoic ligament with loss of normal ligament fibrous structure.10  Other findings for ligamentous injuries include frank ligament discontinuity or detachment, ligament thickening with intrasubstance fissurations or hyperintensity in fluid sensitive sequences, and extracapsular leakage of joint fluid.4
  • MRI - imaging modality of choice for collateral ligament injuries, when indicated.4
    • May be useful for detecting torn ligaments, but may not detect ligaments that are lax or stretched.10
  • One study found that psychological factors accounted for about half the variation in disability in patients with PIP joint sprains, making them the strongest predictors of pain intensity and finger stiffness. Recovery from PIP sprains therefore appears to be mediated largely by mindset and coping strategies, both of which can be learned and practiced.3
References

New and Cited Articles

  1. Kamnerdnakta, S, Huetteman, HE and Chung, KC. Complications of Proximal Interphalangeal Joint Injuries: Prevention and Treatment. Hand Clin 2018;34(2):267-288.PMID: 29625645
  2. Draghi, F, Gitto, S and Bianchi, S. Injuries to the Collateral Ligaments of the Metacarpophalangeal and Interphalangeal Joints: Sonographic Appearance. J Ultrasound Med 2018;37(9):2117-2133. PMID: 29480577
  3. Bot, AG, Bekkers, S, Herndon, JH, et al. Determinants of disability after proximal interphalangeal joint sprain or dislocation. Psychosomatics 2014;55(6):595-601. PMID: 25034813
  4. Prucz, RB and Friedrich, JB. Finger joint injuries. Clin Sports Med 2015;34(1):99-116. PMID: 25455398
  5. Joyce, KM, Joyce, CW, Conroy, F, et al. Proximal interphalangeal joint dislocations and treatment: an evolutionary process. Arch Plast Surg 2014;41(4):394-7. PMID: 25075363
  6. Bowers WH, Wolf JW Jr, Nehil JL, Bittinger S. The proximal interphalangeal joint volar plate. I. An anatomic and biomechanical study. J Hand Surg Am 1980;5(1):79-88. PMID: 7365222
  7. Bowers WH. The proximal interphalangeal joint volar plate. II: A clinical study of hyperextension injury. J Hand Surg Am 1981;6(1):77-81. PMID: 7204922
  8. Carlo, J, Dell, PC, Matthias, R, et al. Collateral Ligament Reconstruction of the Proximal Interphalangeal Joint. J Hand Surg Am 2016;41(1):129-32. PMID: 26614593
  9. Adi, M, Hidalgo Diaz, JJ, Salazar Botero, S, et al. Results of conservative treatment of volar plate sprains of the proximal interphalangeal joint with and without avulsion fracture. Hand Surg Rehabil 2017;36(1):44-47.PMID: 28137442
  10. Rozmaryn, LM. The Collateral Ligament of the Digits of the Hand: Anatomy, Physiology, Biomechanics, Injury, and Treatment. J Hand Surg Am 2017;42(11):904-915. PMID: 29101974
  11. Ootes, D, Lambers, KT and Ring, DC. The epidemiology of upper extremity injuries presenting to the emergency department in the United States. Hand (N Y) 2012;7(1):18-22. PMID: 23449400
  12. Wray, RC, Young, VL and Holtman, B. Proximal interphalangeal joint sprains. Plast Reconstr Surg 1984;74(1):101-7. PMID: 6739583
  13. Paschos, NK, Abuhemoud, K, Gantsos, A, et al. Management of proximal interphalangeal joint hyperextension injuries: a randomized controlled trial. J Hand Surg Am 2014;39(3):449-54. PMID: 24503231
  14. Incavo, SJ, Mogan, JV and Hilfrank, BC. Extension splinting of palmar plate avulsion injuries of the proximal interphalangeal joint. J Hand Surg Am 1989;14(4):659-61. PMID: 2754199

Reviews

  1. Rozmaryn, LM. The Collateral Ligament of the Digits of the Hand: Anatomy, Physiology, Biomechanics, Injury, and Treatment. J Hand Surg Am 2017;42(11):904-915. PMID: 29101974
  2. Prucz, RB and Friedrich, JB. Finger joint injuries. Clin Sports Med 2015;34(1):99-116. PMID: 25455398

Classics

  1. London PS. Sprains and fractures involving the interphalangeal joints. Hand1971;3(2):155-8. PMID: 5127923
  2. Sprague BL. Proximal interphalangeal joint injuries and their initial treatment. J Trauma1975;15(5):380-5. PMID: 1127765
  3. Bowers WH, Wolf JW Jr, Nehil JL, Bittinger S. The proximal interphalangeal joint volar plate. I. An anatomic and biomechanical study. J Hand Surg Am 1980;5(1):79-88. PMID: 7365222
  4. Bowers WH. The proximal interphalangeal joint volar plate. II: A clinical study of hyperextension injury. J Hand Surg Am 1981;6(1):77-81. PMID: 7204922