Dynamic External Fixation of the Proximal Interphalangeal (PIP) Joint

Chapter 23 Dynamic External Fixation of the Proximal Interphalangeal (PIP) Joint



Emily Altman, PT, DPT, CHT


Injury to the proximal interphalangeal (PIP) joint is frequently the result of a fall or participation in sports. Many injuries are managed with closed reduction, open reduction and internal fixation (ORIF), or splinting. However, complex, unstable fracture dislocations are very difficult to successfully treat. Poor results include severely limited joint range of motion (ROM), chronic joint pain, posttraumatic arthritis, and chronic joint instability. ROM impairments affect the patient’s ability to grasp objects. Severe PIP joint flexion contractures make it very difficult to open the hand enough to get around objects, don a glove, slip a hand in a garment pocket, or shake another person’s hand.


Use of the Compass PIP joint hinge (Smith & Nephew, Orthopedic Division, Memphis, TN) can be an effective way to treat complex PIP joint injuries. The Compass PIP joint hinge (hereafter referred to as “hinge”) is an external fixation device composed of a unilateral external hinge that attaches with skeletal fixation to either side of the joint. The design permits controlled passive motion of the joint when the gear is engaged and protected active motion when the gear is not engaged. Indications for use of the hinge include acute fracture dislocations with comminution, volar plate arthroplasty, contracture release of the PIP joint, and chronic boutonnière reconstruction.



Surgical Overview



• The PIP joint is a ginglymus, or hinge joint, whose instant center of rotation moves only slightly as the joint moves through its arc of motion. This kinematic fact permits the use of this hinged external fixator whose axis of rotation is fixed.

• For the hinged external fixator to work effectively, its axis of rotation must be aligned perfectly with the joint’s axis of rotation.
1 The hinge is attached to the skeleton by two pins in the proximal phalanx and two pins in the middle phalanx.

2 Exactly four pins are necessary to handle the mechanical requirements of maintaining joint stability (two pins), applying distraction, if needed (one pin), and controlling joint rotation (one pin).

3 Distraction creates tension in the ligaments and capsule, which maintains reduction (the principle of ligamentotaxis).

• The hinge is often used in conjunction with other surgical procedures, such as volar plate arthroplasty, internal fracture fixation, extensor tendon reconstruction, or tenolysis.

• The hinge is usually removed after 5 to 6 weeks. It can be removed as early as 3 weeks, depending on the specifics of the injury and surgery.


Rehabilitation Overview



• Because the hinged external fixator can be used in the surgical management of several different diagnoses (e.g., fracture dislocations, volar plate arthroplasties, contracture releases), postoperative rehabilitation guidelines will vary widely.
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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Dynamic External Fixation of the Proximal Interphalangeal (PIP) Joint

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