CASE 6 – IN A JAM

History:
A 19 year old girl presents with a sore PIP joint in her 3rd digit of her left hand.  She reports an injury 4 weeks prior where she was catching a football and the football “jammed” her finger.  Since she has been having difficulty straightening her finger and it has been persistently causing her pain.

Subsequently her friend a 24  year old male, also comes in the same day with the exact same injury but to the 3rd digit of his right hand.  His injury is 3 months old.

Examination:
D3 held in fixed flexion at the Proximal interphalangeal joint at about 20 degrees in both cases.  There is no apparent swelling.
You can passively extend beyond but with pain.
Neurovascular examination including 2-point discrimination is normal.
Both patients are point tender at the base of the middle phalanx of the affected digit.
They can both extend and flex versus resistance.

Differential Diagnosis:
Boutonniere Deformity/Central Slip disruption
PIP joint sprain
Volar-Plate fracture and dislocation

Xray: Figures 1 and 2 (D3 Right hand PIP – and injury hilighted)

Assessment:  Volar Plate Injury- non-displaced fractures of base of middle phalanx.
Plan: 
Buddy taping of fingers with gauze padding for 1-3 weeks depending on extent of injury and patient symptoms.
More significant injuries may require an extension block, blocking the PIP from extending beyond 30 degrees.  This can be done with either using a long finger splint and forming it into a C over the dorsum of the PIP joint and around into the palm. Or by taking two shorter finger splint sections and attaching them to the dorsum of the phalanges curling the meeting edges of both pieces up.1
Functional ROM exercises may beging early after 1 week.
Refer to Hand clinic for assessment if concern of greater injury or lack of progress.

Reference:

1.  Weisel, S  Operative techniques in orthopaedic surgery Lippincott Williams & Wilkins Philadelphia  2011

Dr. Neil Dilworth (Oct 23, 2014)