Hyperextension injuries of the PIP finger joint. Comparison of early motion and immobilization

A randomised clinical trial comparing outcomes of a single digit volar plate injury - Buddy loops versus dorsal thermoplastic orthosis in a neutral position: study protocol

BACKGROUND

Volar plate injuries are a common hand injury and complications associated with this injury such as a fixed flexion deformity, persistent pain and oedema can have a significant impact on a person's function. The literature reports these injuries are treated using various splinting materials such as thermoplastic, in varying degrees of proximal interphalangeal joint flexion or buddy loops. Despite volar plate injuries being reported as common, optimal non-surgical treatment of these injuries remains unclear. This study aims to investigate whether a dorsal blocking orthosis in a neutral position (0⁰) is more effective than buddy loops for a volar plate injury to the proximal interphalangeal joint in preventing a fixed flexion deformity, reducing pain, managing oedema, and promoting function.

METHODS

This study is a single-centre, prospective parallel-group, single blinded (assessor), randomised clinical trial. Patients between 18-65 years, who have sustained a volar plate injury to a single digit, have adequate cognitive functioning and give written informed consent will be invited to participate in this study. Patients will be randomised to either the control group where they will be fitted with buddy loops and commence early active motion exercises or the experimental group where they will receive a dorsal thermoplastic orthosis in a neutral position and commence early active motion exercises. The primary outcome measure is passive proximal interphalangeal joint extension and secondary outcome measures include passive range of motion, total passive motion, active range of motion, total active motion, grip strength, oedema, pain, function and adherence to treatment. Assessments will be completed until 8 weeks following commencement of treatment. The sample size calculation indicates that 23 patients is required in each group. With an expected dropout rate of 25% a total of 32 patients will be enrolled in each group.

DISCUSSION

This study will assist in trying to improve treatment of volar plate injuries and assist in reducing complications associated with volar plate injuries, potentially reducing the need for prolonged hand therapy.

TRIAL REGISTRATION

This trial has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622001425785p). Ethical approval has been granted by the South Eastern Sydney Local Health District ethical committee (2022/ETH01697).

Types of Fibrocartilage

Fibrocartilage is a transitional tissue that derives from mesenchymal tissue that lacks a perichondrium and has structural and functional properties between that of dense fibrous connective tissue and hyaline cartilage. It is comprised of densely braided collagen fibers with a low number of chondrocytes that make the tissue highly resistant to compression. It contains high levels of Type I Collagen in addition to Type II Collagen and a small component of ground substance. It is dynamic in that its composition can change over time as it responds to local mechanical stresses and exposure to various cytologic chemicals. There are 4 main categories of fibrocartilage. The first is intra-articular whereby flexion and extension occur with gliding. The second is connecting fibrocartilage to disperse pressure across a joint. The third is stratiform which is a thin layer over a bone whereby tendon glides. The fourth is circumferential which is ring shaped. Various examples are discussed within this article.

Management of proximal interphalangeal joint hyperextension injuries: a randomized controlled trial

PURPOSE

To compare the effectiveness of buddy strapping and aluminum orthosis for treatment of proximal interphalangeal (PIP) joint hyperextension injuries. We also evaluated the effect of age on the outcome by comparing our results in adults and children.

METHODS

One hundred twenty-one consecutive patients with a PIP joint hyperextension injury of the index, middle, ring, or little finger and without fracture were evaluated. Patients were randomly assigned into 2 groups. In the first group, treatment included buddy strapping of the injured finger to its neighbor noninjured finger for a week. In the second group, immobilization was secured with an aluminum extension blocking orthosis for a week in 15° flexion. Assessment of motion, edema, pain, and strength were performed weekly for the first month and then at 3, 6, and 12 months after injury.

RESULTS

The patients treated with buddy strapping exhibited similar outcomes compared with those treated with aluminum orthoses. In patients with full recovery, buddy strapping allowed earlier recovery of motion and resolution of edema and pain compared with aluminum orthosis immobilization. Furthermore, PIP injuries appear to have better outcomes in children than in adults.

CONCLUSIONS

Buddy strapping is easy and effective treatment for PIP joint hyperextension injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Conservative interventions for treating hyperextension injuries of the proximal interphalangeal joints of the fingers

BACKGROUND

Immobilisation and early motion (protected or unrestricted) are both used following hyperextension injuries to the proximal interphalangeal (PIP) joint of the finger.

OBJECTIVES

To assess the effects of conservative interventions (non-surgical management) for treating hyperextension injuries of the proximal interphalangeal joints of the fingers.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2012), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2012, Issue 1), MEDLINE (1946 to January Week 2 2012), EMBASE (1980 to 2012 Week 03), CINAHL (1950 to 24 January 2012), PEDro (1929 to March 2012), trial registers and reference lists of articles.

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing immobilisation/protected mobilisation/unrestricted mobilisation in participants with PIP joint hyperextension injuries managed non-surgically.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. There was no pooling of data.

MAIN RESULTS

Three trials involving 366 people were identified. All three trials, which were over 15 years old, were methodologically flawed with unclear or high risk of bias. None of the studies reported on self assessment of function. One trial compared unrestricted mobility with immobilisation; one trial compared protected mobilisation with immobilisation; and the remaining trial compared immobilisation for one week versus three weeks. None of these trials found statistically significant differences between their intervention groups in various measures of poor outcome, pain and range of movement at six months follow-up. This lack of difference applied at three years for the comparison between unrestricted mobility with immobilisation.

AUTHORS' CONCLUSIONS

There is insufficient evidence from trials testing the need for, and the extent and duration of, immobilisation to inform on the key conservative management decisions for treating hyperextension injuries of the proximal interphalangeal joints.

Outcome of late presentation of injuries of the volar plate of the proximal interphalangeal joint

Early recognition and treatment of volar plate injuries within two weeks is reported to give a good outcome, but there is no published information about the consequences of delayed presentation. We present a series of 14 patients with 16 injuries, who presented more than two weeks after the initial injury. All patients were referred to a specialist hand trauma clinic over a 10 months period and were evaluated prospectively and treated with immediate mobilisation by a specialist hand therapist. Mean time to presentation was 27 days (range 14-79) and mean improvement in range of movement was 25 degrees (range 2-52) with mean residual extension lag 10 degrees (range -4-56). All patients returned to their previous levels of function by the time of discharge. We conclude that it is possible to achieve good outcome without surgical intervention even when the presentation time is four weeks if experienced hand therapists manage the rehabilitation.