case study: pip joint injury - hand works … · case study: pip joint injury 20th august 2012 ......
TRANSCRIPT
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Case Study: PIP joint injury
20th August 2012 Thuy Tran
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Outline
• Anatomy
• Mechanism of Injuries
• Treatment Protocols
• Case Study- “Jack”
• Possible Complications
• Discussion
• Summary
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Anatomy- PIP joint
PP- Proximal Phalanx FT- Flexor Tendon
MP- Metacarpal Phalanx ACL- Accessory Collateral Ligament
ECS- Extensor Central Slip VP- Volar Plate
PCL- Proper Collateral Ligament
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Anatomy- PIP joint
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Volar plate injury
Forced
Hyperextension
Axial
Loading
Swan Neck Deformity
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Central slip injury
Forced Hyper-flexion
Boutonniere’s Deformity
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Treatment Protocols
Primary Goal
To restore joint stability, manage pain, swelling and maintain functional range
of movement.
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Volar Avulsion Rx
Progressive extension splint with protected active motion:
- Week 1: 30 degrees
- Week 2: 20 degrees
- Week 3: 10 degrees
- Week 4: Full extension
- Buddy strapping for two weeks (Leggit & Meko, 2006)
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Dorsal Avulsion Rx
1. Large Fragment (>30 %)
• Open reduction and fixation followed by early active motion
• Splint PIP joint in extension for 3- 6 weeks (Leggit & Meko, 2006)
2. Insignificant Fragment or none
• Splint PIP joint in extension for 6 weeks
- Followed by buddy tape for 2 weeks (Frieberg et al,2006)
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“Jack”
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“Jack”
Occupational Goal:
To return to playing
football for the rest of the
season.
Person
• 18 years old
• Football injury
• “… avulsion fractures to the volar
and dorsal lips of the left ring finger
base of the middle phalanx”
• “Marked surrounding soft tissue
thickening”
• Motivated to return to football
ASAP
• Non-dominant hand
Occupation
• Engineer student
• Plays football twice
weekly
Environment
•Referred by GP
•Presented 2 days post
injury date
•Exam period
• Football season
• Weekly sessions
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“Jack”
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Initial Assessment
Pain
Oedema
AROM
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Elson’s Test
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Possible complications to consider • Pain
• Reduced AROM
• Ongoing swelling
• Stiffness
• Instability
• Fixed flexion deformity
• Premature degenerative arthritis
• Swan necking
• Boutonniere's Deformity
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How would you splint Jack?
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Jack’s Rehabilitation
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Initial Assessment Problems • Joint instability
• Pain
• Moderate/ severe swelling
Goals • Protect PIP joint, manage pain and reduce swelling
Solutions • Finger dorsal blocking splint with PIP joint in 15
degrees flexion, DIPJ 0 degrees
• Lycra finger stall
• No exercises
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Week 2
Problems • Pain
• Mild swelling
• DIP joint stiffness
Goals • Protect PIP joint, manage pain, reduce swelling, reduce
stiffness of DIP joint
Solutions • Continue with finger dorsal blocking splint with PIP joint
in 15 degrees flexion, DIPJ 0 degrees
• Continue with lycra finger stall
• DIP joint blocking exercises
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Week 3
Problems • Pain
• Stiff PIP and DIP joints
Goals • Protect PIP joint, manage pain and stiffness of the
DIP and PIP joints
Solutions • Finger volar blocking splint with PIP joint in 10
degrees flexion, DIPJ 0 degrees
• Continue with DIP joint blocking exercises , gentle passive PIP joint exercises
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Week 4 Problems • Increased pain
• Stiff PIP and DIP joints
Goals • Protect PIP joint, manage pain and maintain AROM
Solutions • Finger barrel splint, with PIP joint in 0 degrees and
DIP joint free
• Active extension and flexion of DIP joint
• Stopped passive PIP joint exercises
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Week 5 Problems • Pain
• Stiff PIP joint
Goals • Protect PIP joint, manage pain and maintain AROM
Solutions • Lycra buddy socks
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Week 6 Problems • Avulsion fractures still healing
• Achy pain
Goals • Protect PIP joint, manage pain and maintain
AROM
• Return to football
Solutions • Full finger barrel splint for football
• Continue with lycra buddy stall
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Week 8 Problems • Mild discomfort
• Reduced strength
Goals • Protect PIP joint, manage pain and grip strength
Solutions • Gentle strengthening program
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Week 10 AROM:
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Week 12
Stable joint Reduced swelling Full AROM Reduced pain Good strength
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Week 12
ACHIEVED FOOTBALL GOAL!!!
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Summary
• PIP joint injuries can be complex
• Possible complications
• Clinical Reasoning
• Holistic approach
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Reference List Bindra, R., Foster, B. (2009). Management of Proximal Interphalangeal Joint Dislocations in Athletes. Hand Clinic, 25, 423-435. Blazar, P., Steinberg, D. (2000). Fractures of the Proximal Interphalangeal Joint. Journal of the American Academy of Orthopaedic Surgeons, 8(6), 383-390 Claude, S., Williams, IV. (2012). Proximal Interphalangeal Joint Fracture Dislocations. Hand Clinic, 1-8. Cooper, S. (2006). Volar Plate Avulsion Fractures. Journal of the Accident and Medical Practitioners Association 3(1), 2-8. Freiberg, A., Pollard, B., Macdonald, M., Duncan, M. (2006). Management of Proximal Interphalangeal Joint Injuries. Hand Clinic, 22, 235-242.
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Reference List Leggit, J., Meko, C. (2006). Acute Finger Injuries: Part I. Tendons and Ligaments. American Family Physician, 73(5), 810-816. Lo, I., Richards, R.S. (1995). Combined Central Slip and Volar Plate Injuries at the PIP joint. Journal of Hand Surgery, 20(3), 390-391. Ng, C. Y., Oliver, C.W. (2009). Fractures of the Proximal Interphalangeal Joints of the Fingers. The Journal of Bone and Joint Surgery, 91-B(6), 706-712. Pratt, Burr and Grobbelaar (2002) A prospective review of open central slip laceration repair and rehabilitation. Journal of Hand Surgery 27B (6):530-534. Saito, S., Yoshihisu, S. (2011). Biomechanics of the Volar Plate of the Proximal Interphalangeal Joint: A Dynamic Ultrasonographic Study. Journal of Hand Surgery, 36A, 265-271.
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Any Questions or Comments?