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

  • Review
  • Intervention

Authors


Abstract

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.

Résumé scientifique

Interventions conservatrices pour le traitement de blessures d'hyperextension des articulations interphalangiennes proximales des doigts

Contexte

L'immobilisation et le mouvement précoce (avec protection ou sans restriction) sont tous deux utilisés à la suite de blessures d'hyperextension à l'articulation interphalangienne proximale (PIP) du doigt.

Objectifs

Évaluer les effets des interventions conservatrices (prise en charge non chirurgicale) pour le traitement des blessures d'hyperextension des articulations interphalangiennes proximales des doigts.

Stratégie de recherche documentaire

Nous avons effectué une recherche dans le registre spécialisé du groupe Cochrane sur les traumatismes ostéo-articulaires et musculaires (janvier 2012), le registre Cochrane des essais contrôlés (CENTRAL) (dans The Cochrane Library 2012, numéro 1), MEDLINE (de 1946 à la 2ème semaine de janvier 2012), EMBASE (de 1980 à la 3ème semaine de l'année 2012), CINAHL (de 1950 au 24 janvier 2012), PEDro (de 1929 au mois de mars 2012), les registres d’essais cliniques et les bibliographies d'articles.

Critères de sélection

Les études randomisées et quasi-randomisés comparant l'immobilisation/la mobilisation avec protection/la mobilisation sans restriction chez des participants présentant des blessures d'hyperextension de l'articulation interphalangienne proximale (PIP) prises en charge de manière non chirurgicale.

Recueil et analyse des données

Deux auteurs ont, de manière indépendante, évalué les risques de biais et extrait les données. Nous n'avons effectué aucun regroupement de données.

Résultats principaux

Trois essais impliquant 366 participants ont été identifiés. Les trois essais, datant de plus 15 ans, étaient tous méthodologiquement défectueux avec un risque de biais incertain ou élevé. Aucune des études n'a rapporté la moindre auto-évaluation de la fonction par les participants. Un essai a comparé la mobilité sans restriction à l'immobilisation ; un essai a comparé la mobilisation avec protection à l'immobilisation ; et le dernier essai a comparé l'immobilisation pendant une semaine à trois semaines. Aucun de ces essais n'a identifié de différences statistiquement significatives entre leurs groupes avec intervention dans les différentes mesures de mauvais résultats, de la douleur et de l’amplitude du mouvement au bout de six mois de suivi. Cette absence de différence était observée au bout de trois années de suivi pour la comparaison entre la mobilité sans restriction et l'immobilisation.

Conclusions des auteurs

Les preuves issues des essais examinant la nécessité, ainsi que l'étendue et la durée, de l'immobilisation sont insuffisantes pour orienter les décisions pour la prise en charge conservatrice essentielle pour le traitement des blessures d'hyperextension des articulations interphalangiennes proximales.

Plain language summary

Splints and other non-surgical methods for treating common injuries of the middle joints of the fingers

Injury to the ligaments of the middle joint (proximal interphalangeal joint) of a finger may occur as a result of the finger being forced backwards. This is known as a hyperextension injury. Characteristically, this occurs in sporting accidents, such as where a football strikes an outstretched hand. These injuries are common and typically affect people of working age. Usually, these patients are treated without surgery using a combination of support (splinting/strapping to the adjacent finger) and exercise advice. Use of the hand is commonly encouraged but restricted to some degree by the severity of the injury. By examining the evidence from randomised controlled trials, this review aimed to assess which treatment for hyperextension injuries of the proximal interphalangeal joints of the fingers results in the best outcome for patients. The outcomes examined included function (including return to work), pain and joint movement.

Three small studies including a total of 366 patients met the inclusion criteria for the review. The studies, which were all over 15 years old, were prone to bias. None of the studies reported any self assessment of function by participants. One study compared unrestricted mobility with immobilisation. One trial compared protected mobilisation (using a removable support in combination with exercise) with immobilisation. The remaining study compared immobilisation for one week versus three weeks. None of these trials found important differences between their intervention groups in various measures of poor outcome, pain and range of movement at six months follow-up.

We concluded that there was a lack of robust evidence to inform on the need for, and the extent and duration of, immobilisation for these injuries.

Résumé simplifié

Attelles et autres méthodes non chirurgicales pour le traitement de blessures courantes des articulations moyennes des doigts

Les blessures aux ligaments de l'articulation moyenne (articulation interphalangienne proximale) d'un doigt peuvent survenir en résultat d'un mouvement forcé du doigt vers l'arrière. Ceci est connu sous le nom de blessure d'hyperextension. De façon caractéristique, ceci se produit lors d'accidents de sport, comme lorsqu'un ballon de foot frappe une main en extension. Ces blessures sont courantes et touchent généralement des personnes en âge de travailler. Habituellement, ces patients sont traités sans chirurgie en utilisant une combinaison de support (attelles/sangles au doigt adjacent) et de conseils en faveur de la pratique d'exercices physiques. L'utilisation de la main est couramment encouragée, mais limitée jusqu'à un certain degré par la gravité de la blessure. En examinant les preuves issues d'essais contrôlés randomisés, cette revue avait pour objectif d'établir quel traitement des blessures d'hyperextension des articulations interphalangiennes proximales des doigts aboutit au meilleur résultat pour les patients. Les critères de jugement examinés comprenaient la fonction (incluant la reprise du travail), la douleur et le mouvement de l'articulation.

Trois études de petite taille totalisant 366 patients répondaient aux critères d'inclusion de cette revue. Les études, qui dataient toutes de plus de 15 ans, étaient sujettes aux biais. Aucune des études n'a rapporté la moindre auto-évaluation de la fonction par les participants. Une étude a comparé la mobilité sans restriction à l'immobilisation. Un essai a comparé la mobilisation avec protection (en utilisant un support amovible en combinaison avec des exercices physiques) à l'immobilisation. La dernière étude a comparé l'immobilisation pendant une semaine à trois semaines. Aucun de ces essais n'a identifié de différences importantes entre leurs groupes avec intervention dans les différentes mesures de mauvais résultats, de la douleur et de l’amplitude du mouvement au bout de six mois de suivi.

Nous en avons conclu qu'il manquait des preuves probantes pour orienter la pratique sur la nécessité, ainsi que l'étendue et la durée, de l'immobilisation pour ces blessures.

Notes de traduction

Traduit par: French Cochrane Centre 1st March, 2013
Traduction financée par: Pour la France : Ministère de la Santé. Pour le Canada : Instituts de recherche en santé du Canada, ministère de la Santé du Québec, Fonds de recherche de Québec-Santé et Institut national d'excellence en santé et en services sociaux.

Background

Description of the condition

The three bones in each finger are called, going from the palm of the hand towards the end of the fingers, the proximal, middle and distal phalanges. The proximal interphalangeal (PIP) joint is the articulation or joint between the proximal and middle phalanges of each finger. The PIP joint is primarily a stable hinge joint. It has a typical range of movement from zero degrees extension (finger is straightened out) up to 110 degrees of flexion (finger is bent) (Glickel 2005). Anatomically, the PIP joint is complex. The contours of the bony surfaces of the proximal and middle phalanges increase the stability of the PIP joint, allowing resistance to lateral (sideways) and rotational stress (Burton 1973; Glickel 2005; Kuczynski 1968). The soft tissue structures surrounding the PIP joint provide further joint stability (Burton 1973; Sprauge 1975). These structures include the volar (palmar) plate, the cord collateral and accessory collateral ligaments and the extensor expansion (Burton 1973; Freiberg 1999; Sprauge 1975). The volar plate, which is a strong soft tissue attachment to the base of the middle phalanx on the palm side, acts as a static ligament and limits hyperextension (thus preventing the finger from being bent backwards) of the PIP joint (Glickel 2005; Sprauge 1975). The other ligamentous structures combine with the volar plate to provide lateral and dorsal (back of the hand) stability (Freiberg 1999).

Injury to the proximal interphalangeal (PIP) joint of the fingers is one of the most common injuries of the hand (Eaton 1976; Sprauge 1975). The spectrum of injury to this joint can range from incomplete soft tissue disruption to unstable fracture-dislocations (Eaton 1976; Incavo 1989). Damage to the PIP joint is frequently the result of a hyperextension force resulting in soft tissue injury, with or without an associated fracture. Hyperextension is defined as a movement of the middle phalanx in a dorsal (backwards) direction beyond neutral, in respect to the proximal phalanx (Sprauge 1975). Any hyperextension injury to the PIP joint will result in some degree of disruption of the ligament complex. Many injuries are incomplete, with only partial damage to ligaments and soft tissue structures. In these cases joint stability is maintained; however, individuals will present with pain, swelling and limited movement (Bowers 1986; Burton 1973). In more severe cases there can be bony disruption and complete rupture of one or more of the supporting structures of the PIP joint (Eaton 1976; Glickel 2005). PIP joint injuries are generally classified into three main types of injury: type I (hyperextension injury); type II (dorsal dislocation); and type III (fracture - dislocation). Table 1 outlines the pathology of these injuries with respect to the damaged structures (Eaton 1976).

Table 1. Classification and pathology of hyperextension injuries of the PIP joint (Eaton 1976)
  1. PIP = proximal interphalangeal

Type I (hyperextension)These injuries are characterised by either partial or complete avulsion (pulling away) of the volar plate from the middle phalanx. This may be with or without a bone fragment, and/or minor tears in the collateral ligaments
Type II (dorsal dislocation) With complete dislocation, avulsion of the volar plate occurs, and includes a bilateral split in the collateral ligament system. The middle phalanx tends to adopt a resting position on the condyles of the proximal phalanx, yet there is no contact between the articular surfaces of the PIP joint. 
Type III (fracture - dislocation)In this type of injury the force is significant enough to avulse the volar plate from its insertion and create a disruption at the base of the middle phalanx on the volar surface. This result is a fracture dislocation. These injuries can be subdivided into stable and unstable fracture dislocations.

Sporting activities account for the majority of PIP joint hyperextension injuries. For example, Gaine 1998 reported that 92.8% of patients in their study received their injuries during sporting activities; 78% of these injuries being a direct result of ball games. Phair 1989 found that all 74 patients in their study reported a hyperextension mechanism of injury, and 51 patients (69%) had sustained an injury to the PIP joint from a sporting activity.

Description of the intervention

Type I (hyperextension) or type II (dislocation) injuries of the PIP joint are generally treated by either a period of immobilisation or by protected mobilisation (or a combination of the two) of the finger with range of motion exercises. Dislocated PIP joints without fractures are reduced (put back into place) using gentle manipulation beforehand. Unstable injuries, usually involving bony disruption, are generally managed surgically (Burton 1973; Eaton 1976). 

The PIP joint is often immobilised using plaster of Paris or a rigid plastic or metal splint, secured with tape or Velcro to one side of the finger. In most cases only the PIP joint is kept still or supported and the joints above and below are free to move.

Common types of protected mobilisation are buddy strapping, where the injured finger is strapped to a neighbouring finger, and dorsal block splinting. Dorsal block splinting involves securing a metal or plastic splint to the back of the finger and allowing the patient to loosen the tape to bend the PIP joint for exercises whilst preventing unwanted straightening.

Time frames for either of these forms of treatment vary from one to six weeks. It is anticipated that usual function is resumed between six and eight weeks post injury (Eaton 1976; Freiberg 1999; Incavo 1989; Sprauge 1975).

How the intervention might work

Sprauge 1975 suggested that immobilising the injured PIP joint in a position of flexion for a period of time is favourable for soft tissue healing and for preventing further dorsal or lateral dislocation of the finger. However, other authors report that immobilisation of the PIP joint results in less positive outcomes with individuals taking a greater amount of time to regain range of movement and function of their affected finger (Phair 1989).

Immediate protected mobilisation of the PIP joint, within the individuals' pain tolerance, has been advocated to prevent finger stiffness (Phair 1989). It is considered that mobilisation enhances cartilage and soft tissue healing while movement assists in minimising the formation of tendon adhesions and PIP joint contractures (Freiberg 1999; Kiefhaber 1998). Protective splinting in the form of buddy strapping is considered to prevent lateral and dorsal disruption of the PIP joint and to minimise pain on extension (Bowers 1986; Freiberg 1999; Gaine 1998).

Why it is important to do this review

These injuries may result in chronic pain, stiffness, deformity or premature degenerative arthritis (Freiberg 1999). Because the hand is so vital to everyday activities and work, a poor outcome can be disproportionately disabling. Currently there is uncertainty on what is the best approach to take for these injuries in terms of the extent, type and duration of immobilisation. These point to the need for this systematic review in order to inform practice.

Objectives

To assess the effects (benefits and harms) of conservative interventions for treating hyperextension injuries of the proximal interphalangeal joints of the fingers presenting within one month of injury. Comparisons included:

  • PIP joint unrestricted mobilisation (e.g. no splint) versus immobilisation

  • PIP joint protected mobilisation (e.g. dorsal blocking splinting, buddy strapping) versus immobilisation

  • PIP joint unrestricted mobilisation versus protected mobilisation

Methods

Criteria for considering studies for this review

Types of studies

We considered any randomised controlled and quasi-randomised (method of allocating participants to a treatment which is not strictly random: e.g. by date of birth, hospital record number, alternation) trials of conservative management for hyperextension injuries of the PIP joint in the hand.

Types of participants

We included trials with participants that had an acute (less than one month), conservatively-managed hyperextension injury to the PIP joint. Injury was defined through: history of dislocation, history of hyperextension injury, diagnosis of volar plate/collateral ligament fracture avulsion via x-ray, joint laxity or pain in the PIP joint following trauma to the finger.

We excluded trials focusing on participants presenting with open hyperextension injuries, concomitant tendon injury, fracture (with the exception of ligamentous avulsion fractures) or hyperextension injuries requiring surgical treatment. Trials focusing on participants with underlying rheumatological, neurological or congenital conditions were also excluded.

Types of interventions

Randomised comparisons for the conservative management of PIP joint hyperextension injuries included any two or more of the following interventions: unrestricted movement, buddy strapping, protective splinting, and immobilisation. We also aimed to include trials comparing different time frames for treatment.

We excluded trials that compared management after surgical intervention or different exercise regimens. Comparisons of different exercise regimens were excluded due to the high variation possible between studies, for example, frequency and duration of exercises, as well as active versus passive versus resisted motion.

Types of outcome measures

Primary outcomes
  1. Self-reported, preferably validated, functional questionnaires such as the Disability of the Arm, Shoulder and Hand (DASH) and the Michigan Hand questionnaires

  2. Poor outcome: finger stiffness, joint laxity, joint deformity (cosmetic or clinically assessed), subsequent surgery

Secondary outcomes
  1. Pain (visual analogue scale, ordinal scale, pain questionnaire)

  2. Range of motion

  3. Return to work/sport/previous activity

  4. Number of follow-up appointments

Timing of outcome assessment

Our focus is on primary outcomes at final follow-up in the individual studies. Ideally, follow-up should be at least six months for type I injuries and at least 12 months for type II injuries.

Search methods for identification of studies

Electronic searches

We searched the Cochrane Bone, Joint, Muscle Trauma Group Specialised Register (January 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 1), MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE Daily Update (1946 to January Week 2 2012), EMBASE (1980 to 2012 Week 03), CINAHL (1950 to 24 January 2012) and PEDro - the Physiotherapy Evidence Database (1929 to March 2012) (see Appendix 1 for details of the search strategies). The subject-specific search has not been combined with a trial filter due to the small number of trials in this area.

We searched the WHO International Clinical Trials Registry Platform (to 8 March 2012) to identify ongoing and recently completed trials, and also Zetoc (1993 to 8 March 2012) to identify additional trials reported in conference proceedings.

Trials were included regardless of language and publication status.

Searching other resources

We also searched reference lists of articles, reviews and relevant textbooks.

Data collection and analysis

Selection of studies

Two review authors (MB and ZA) independently screened the titles, abstracts and descriptors of identified studies for possible inclusion. We obtained full text versions of all studies that were considered potentially eligible by either author, and independently assessed these for inclusion. Any disagreement was resolved by discussion with a third author (JC). Where uncertainty remained about eligibility, we contacted trial authors for clarification. Translations for potential studies published in languages other than English were obtained where possible.

Data extraction and management

Two review authors (JC and ZA) independently extracted trial details and data using a standardised data collection form. The form was tested for consistency on two studies prior to the commencement of the review. Any disagreement was resolved by discussion with a third review author (MB).

Assessment of risk of bias in included studies

Two review authors (JC and ZA) independently assessed the risk of bias in each included study using The Cochrane Collaboration's 'Risk of bias' tool. We assessed generation of allocation sequence, allocation concealment, blinding (of trial participants, care providers and assessors), incomplete outcome data, selective outcome reporting, and other sources of bias. The risk of bias was rated for each domain and was expressed as 'Yes', implying a low risk of bias; 'No', implying a high risk of bias; or 'Unclear', implying the risk of bias is unclear. Any disagreement was resolved by discussion with a third review author (MB) when required. Journal titles, authors and supporting institutions were not be masked at any time.

Measures of treatment effect

Risk ratios and 95% confidence intervals were calculated for dichotomous data. We planned to calculate mean differences or, where different scales or tools were used to measure the same outcome, standardised mean differences and 95% confidence intervals for continuous data.

Unit of analysis issues

A possible unit of analysis issue may arise if an individual had more than one injured finger and the individual (or both or more digits) is randomised rather than the individual digits. When such an issue arose and appropriate corrections were not made, we presented the data for such trials where the disparity between the units of analysis and randomisation is small. Should data pooling be possible, we planned to perform a sensitivity analysis to examine the effects of excluding incorrectly reported trials from the analysis.

Dealing with missing data

We contacted authors of individual studies for missing data and clarification. Where possible, we performed intention-to-treat analyses. We stated beforehand that we would not impute missing standard deviations.

Assessment of heterogeneity

We planned the following approach for assessing study heterogeneity, which we determined from both clinical and statistical perspectives. Clinical heterogeneity was assessed in terms of important differences between trials in the study populations, interventions and outcome measures. Statistical heterogeneity between pooled trials was to be assessed using a combination of visual inspection of the graphs along with consideration of the chi² test (with statistical significance set at P < 0.10), and the I² statistic.

Assessment of reporting biases

We attempted to reduce reporting biases, particularly publication bias, through our comprehensive search of the literature. This extended across multiple databases using a sensitive search strategy, include clinical trial registers, and a search of Zetoc that identified trials reported at conferences but never published in full. Thus, searches were not constrained by language or publication status.

Data synthesis

Where considered appropriate from a clinical perspective, we planned to pool data from comparable trials. Initially we planned to use the fixed-effect model and 95% confidence intervals. We also would have considered using the random-effects model, especially where there was unexplained heterogeneity.

Subgroup analysis and investigation of heterogeneity

Should sufficient data become available in future versions of this review, our planned subgroup analyses are based on age (those younger than 16, those aged between 17 and 64 and those aged older than 65), the type of injury (see Table 1), and time elapsed between injury and medical intervention (treatment started within two weeks versus after two weeks) where possible and appropriate.

Sensitivity analysis

We planned to perform sensitivity analyses to examine the effects of missing data and of the inclusion of trials at high risk of bias (such as from lack of allocation concealment). However, it was not possible to perform these analyses in this version of the review.

Results

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

Results of the search

The search strategy found 520 references, of which 480 were excluded through initial screening of reference titles and abstracts. Of those excluded, 155 were duplicates and 325 were not considered relevant. Of the 40 remaining potentially relevant studies, for which full reports were obtained, 35 were excluded as they were clearly not randomised or quasi-randomised controlled trials. Three studies were included (Norregaard 1987 (3 reports of study); Thomsen 1979; Thomsen 1995) and one (Arora 2004) was excluded. No ongoing trials were identified.

Included studies

All three included studies were reported in medical journals. Norregaard 1987 was reported in a conference abstract (Norregaard 1986), an English language report (Norregaard 1987) and a Danish language report (Norregaard 1988). A translation from Danish were obtained for Thomsen 1979.

Details of the three individual trials can be found in the Characteristics of included studies. A summary of these is presented below.

Design

Norregaard 1987 was a quasi-randomised trial with two intervention groups. Thomsen 1979 and Thomsen 1995 were randomised trials with four and two intervention groups respectively.

Sample sizes

In total, there were 366 participants with proximal interphalangeal joint hyperextension injuries randomised into the three trials. Norregaard 1987 included 126 participants (as reported in Norregaard 1986 and Norregaard 1988). However, we based our analysis of this trial on the English language report that reported on 112 participants only, 87 of whom were followed up at six months. Thomsen 1979 randomised 200 patients of which 181 were followed up. This study included participants with multiple finger injuries and follow-up analysis was based on the number of treated fingers (191) rather than participants. Thomsen 1995 included 40 participants of whom 39 were followed up at six months. Overall, 307 participants and 317 fingers were included in the six months follow-up results for the three trials.

Setting

All three trials were conducted in Denmark with participants presenting to hospital emergency departments or orthopaedic clinics. All trials are over 15 years old: Norregaard 1987 was completed in 1983; Thomsen 1979 in 1978; and Thomsen 1995 in 1993.

Participants

All participants in the three trials had sustained a hyperextension injury to the proximal interphalangeal joint. Diagnostic criteria varied across the studies and were reported to various levels. Norregaard 1987 included participants with hyperextension trauma presenting with four signs of injury (volar tenderness, pain at maximal flexion, relief from pain in the intermediate position and recurrence of pain at maximal extension). In contrast, Thomsen 1995 did not describe inclusion criteria beyond that of lesions to the volar plate of the proximal interphalangeal joint. Thomsen 1979 admitted participants who sustained hyperextension trauma and volar pain at maximal flexion, pain relief in semi-flexion and pain increasing at maximal extension. Participant demographics of gender and age were not reported in Norregaard 1987. The participants of Thomsen 1979 were aged between 7 and 76 years, and 41% were male. Thomsen 1995 reported an age range of 18 to 79 years and that 49% of participants were male.

Interventions

The three trials evaluated four different comparisons in all.

Norregaard 1987 compared unrestricted mobilisation of the affected PIP joint versus immobilisation of the affected PIP joint in 15 degrees of flexion, the metacarpophalangeal joint in 80 to 90 degrees flexion and the wrist in 30 degrees of extension for three weeks using an aluminium splint.

Thomsen 1995 investigated limitation of PIP joint protected motion through the application of a double finger elastic bandage (motion ranging between neutral and 25 to 30 degrees of flexion) versus immobilisation with an aluminium splint applied to the dorsum of the finger prohibiting PIP joint movement. The splint was designed to position the finger in 15 degrees of flexion at the PIP joint. These interventions were instituted for an initial two week period, after which the elastic bandage or aluminium splint was removed and normal hand movement was encouraged.

In Thomsen 1979, patients were randomised into four groups: group one, aluminium splint for one week; group two, aluminium splint for three weeks; group three, plaster of Paris cast for one week; group four, plaster of Paris cast for three weeks. The authors describe positioning the PIP joint in semi-flexion but do not report the angle of measurement. Active range of motion was commenced for all groups once the aluminium splint or plaster of Paris had been removed, at either one or three weeks. Thomsen 1979 made two comparisons: immobilisation of the affected PIP joint for one week versus three weeks; and aluminium splint versus plaster of Paris cast. However, results were provided for the first comparison only.

Outcomes

Two trials (Norregaard 1987; Thomsen 1995) reported outcomes by participant, while Thomsen 1979 reported on outcome by injured finger.

Follow-up assessment ranged from two weeks (Thomsen 1995) to three years (Norregaard 1987); however, all three trials investigated outcome at six months.

Norregaard 1987 reviewed joint stiffness, laxity and deformity at both six months and three years post injury. However, the authors do not clearly report the methods by which they determined and measured these sequelae. Secondary outcomes of pain and range of movement were acknowledged. Pain was rated using the Moller scale (Moller 1974). The origin, method, validity and reliability of this scale is not reported in the literature. Range of movement was described in terms of an extension or flexion deficit. It is not clear if goniometry was used to assess for deficit or what parameters the authors use to define a range of movement deficit.

Thomsen 1979 presented pooled results for the two groups immobilised for one week and the two groups immobilised for three weeks. They commented on stiffness and deformity but did not report the methods by which they measured these outcomes. Secondary outcomes of pain and deficits in extension and flexion were reported. This trial also monitored discomfort from use of a splint or plaster and recorded sick leave. As with Norregaard 1987, pain was rated using the Moller scale (Moller 1974). The parameters of defining an extension/flexion deficit were not described.

Norregaard 1987 and Thomsen 1979 both appeared to use the same assessment tool that considered pain (during movement, work and hobby activities), volar plate tenderness, stiffness and coldness, thickened joint, extension and flexion deficits, swan neck deformity and button-hole deformity. This assessment tool is not referenced by either study.

Thomsen 1995 assessed range of motion, volar stability and return to work at two weeks. The authors also used an assessment of results scale originally developed by Benke 1979 that is based on movement, symptoms, stability and function. Outcome was rated as excellent, good or poor. The authors used this scale to comment on the primary outcome measure of 'poor outcome'. The only secondary outcome reported in this study is range of movement. This is discussed in terms of achieving PIP joint range of motion 0 to 90 degrees. There was no information provided on how these deficits were measured and if goniometry was used.

Excluded studies

One study (Arora 2004) was excluded after contact with the authors established that participants were not randomised to treatment group (see the Characteristics of excluded studies).

Risk of bias in included studies

See Figure 1 and Figure 2. All three trials included in this review were methodologically flawed. Many items described in the 'Risk of bias' tool were judged to be at high risk of bias. Others were judged as being unclear because of insufficient information. More details about the sources of bias in each study can be found in the Characteristics of included studies.

Figure 1.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 2.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Allocation

Norregaard 1987, which was a quasi-randomised trial, based on the date of patient trauma, was at a high risk of selection bias. Thomsen 1979 used a random numbers table for sequence generation but Thomsen 1995 did not describe their method of sequence generation. There was no details to determine whether allocation was concealed in either trial.

Blinding

The nature of these trials make it impossible for participants to be blinded to their treatment. It is also not possible to blind those delivering treatment. However, it is unclear if there was any blinding of assessors at follow-up in any of the included studies.

Incomplete outcome data

Participants were lost to follow-up in all three trials. The reporting of loss to follow-up was inconsistent in Norregaard 1987, which was judged at high risk of attrition bias based on the inconsistent reporting and the high loss to follow-up (22% at six months using data from Table 1 of the trial report; see the Characteristics of included studies). Nine per cent of patients randomised to treatment with immobilisation for one week were lost compared with 10% immobilised for three weeks in Thomsen 1979. One participant was lost to follow-up in Thomsen 1995 from the protection motion group.

Selective reporting

It is difficult to determine the presence of selective reporting as protocols are not available for any of the trials.

Other potential sources of bias

All three studies failed to provide sufficient information regarding the baseline characteristics of their treatment groups. Two of the three studies (Thomsen 1979; Thomsen 1995) reported an inadequate length of follow-up (six months). Although outcome measures reported in each of the studies are appropriate to these injuries, the methods of assessment vary and it is not clear if these were undertaken in a validated and reliable fashion, if these are subjective or objective measures, nor the parameters for determining the presence of a particular outcome. For example, Thomsen 1979 and Norregaard 1987 both report pain using the Moller scale, but do not describe the nature of this scale. Similarly, all three trials report range of movement as an outcome without reporting how this was assessed (e.g. goniometry). Further bias may have been introduced in the assessment process by the involvement of multiple assessors. Thomsen 1995 reports the involvement of three assessors whilst the other two studies do not provide any information as to the number of assessors.

Effects of interventions

No immobilisation versus immobilisation

Norregaard 1987 found no statistically significant differences between the no immobilisation (unrestricted motion) group and the splint immobilisation group in the reported outcomes at either six months or three years. The risk of attrition bias, in particular relating to the high loss to follow-up and inconsistencies in the reporting of the losses to follow-up raises some questions over the reliability of the results from this quasi-randomised trial. The following analyses use the data from the main publication of this study only. At six months after injury there were no statistically significant differences between the two groups for poor outcome, a primary outcome measure, particularly joint stiffness and coldness (6/43 versus 11/44; RR 0.56, 95% CI 0.23 to 1.37) or thickened joints (8/43 versus 7/44; RR 1.17, 95% CI 0.46 to 2.94) (see Analysis 1.1). One participant in the splint group developed a swan neck deformity. Similar findings applied at three years (see Analysis 1.2): stiffness and coldness (3/34 versus 5/34; RR 0.60, 95% CI 0.16 to 2.31) and thickened joint (8/34 versus 4/34; RR 2.00, 95% CI 0.66 to 6.02). No participant had swan neck or button hole deformity at this time. Similar numbers in each group had 'sequelae', which were mainly 'mild' involving 'minor pain': 9/34 versus 7/34; RR 1.29, 95% CI 0.54 to 3.06). While there were some differences across the three papers for this trial, none of these changed the overall findings: the results for 'sequelae' at two to three years are given in Analysis 1.2.

There was also no difference between the two groups for secondary outcomes of pain and tenderness at six months (see Analysis 1.3): pain during movement (7/43 versus 5/44; RR 1.43, 95% CI 0.49 to 4.17); pain during work (5/43 versus 5/44; RR 1.02, 95% CI 0.32 to 3.28); pain during hobby activities (4/43 versus 4/44; RR 1.02, 95% CI 0.27 to 3.83); and volar plate tenderness (5/43 versus 8/44; RR 0.64, 95% CI 0.23 to 1.80). Similar findings applied at three years for pain and tenderness (see Analysis 1.4): pain during movement (3/34 versus 2/34; RR 1.50, 95% CI 0.27 to 8.42); pain during work (5/34 versus 2/34; RR 2.50, 95% CI 0.52 to 12.01); pain during hobby activities (4/34 versus 1/34; RR 4.00, 95% CI 0.47 to 33.97); and volar plate tenderness (6/34 versus 6/34; RR 1.00, 95% CI 0.36 to 2.79). There were no differences between groups at six months for extension deficit (5/43 versus 3/44; RR 1.71, 95% CI 0.43 to 6.70) or flexion deficit (7/43 versus 8/44; RR 0.90, 95% CI 0.36 to 2.25) (see Analysis 1.5). The same lack of statistically significant differences between two groups applied at three years in both extension deficit (1/34 versus 2/34; RR 0.50, 95% CI 0.05 to 5.26) or flexion deficit (2/34 versus 3/34; RR 0.67, 95% CI 0.12 to 3.74) (see Analysis 1.6).

Protected mobilisation versus immobilisation

Thomsen 1995 found no statistically significant differences in reported outcomes between protected mobilisation versus immobilisation in an aluminium splint at two weeks following injury, nor at six months. There was no formal measure of functional outcome. At two weeks, fewer participants in the protection mobilisation group had instability (3/19 versus 7/20; RR 0.45, 95% CI 0.14 to 1.49; see Analysis 2.1) and more were able to bend their finger (11/19 versus 6/20; RR 1.93, 95% CI 0.89 to 4.17; see Analysis 2.2); neither result reached statistical significance.

At six months, there was no difference between groups in the number of participants who were considered to have had an excellent outcome (16/19 versus 16/20; RR 1.05, 95% CI 0.79 to 1.41; see Analysis 2.3). The remaining participants (3 versus 4) had a good outcome and thus none of the participants were considered to have had a poor outcome.

The authors reported that all participants were able to return to their normal job within two to three weeks post injury.

Immobilisation 1 week versus 3 weeks

Thomsen 1979 used two methods of immobilisation (plaster cast and aluminium splint) to restrict movement for one week or for three weeks. They presented "complaints and findings" results for 191 fingers (181 participants) split according to the period of immobilisation: one week versus three weeks. Thomsen 1979 did not provide details of the distribution of the participants with multiple injuries to their PIP joints: but these were equally distributed with five extra fingers in each duration-of-immobilisation group. There were no statistically significant differences in the reported outcomes between the two duration of immobilisation groups at six month follow-up. Similar results were found for poor outcome (see Analysis 3.1) as represented by complaints of joint stiffness and coldness (23/96 versus 28/95 fingers; RR 0.81, 95% CI 0.51 to 1.30) and joint thickening (19/96 versus 15/95 fingers; RR 1.25, 95% CI 0.68 to 2.32). Likewise, there was little difference between the two groups in pain or tenderness (see Analysis 3.2): pain during movement (20/96 versus 16/95 fingers; RR 1.24, 95% CI 0.68 to 2.24; pain during work (17/96 versus 13/95 fingers; RR 1.29, 95% CI 0.67 to 2.51); pain during hobby activities (19/96 versus 15/95 fingers; RR 1.25, 95% CI 0.68 to 2.32); and volar plate tenderness (1/96 versus 3/95; RR 0.33, 95% CI 0.03 to 3.12). Few people in each group had decreased range of motion at six months (decreased extension: 3/96 versus 1/95 fingers; RR 2.97, 95% CI 0.31 to 28.04; decreased flexion: 3/96 versus 3/95 fingers; RR 0.99, 95% CI 0.20 to 4.78) (see Analysis 3.3). The authors reviewed the number of sick days taken by participants, regardless of immobilisation method, and concluded that number of sick days increased when the PIP joint was immobilised for a longer period of time. 

Aluminium splint versus plaster of Paris

Thomsen 1979 restricted movement for one or three weeks using either an aluminium splint or a plaster cast. The authors reported there was no difference between two methods of splinting and presented pooled data according to the duration of immobilisation. However, they reported the cost of application of an aluminium splint to be less than the cost of a plaster cast (9.53 Danish kroner versus 33.73 Danish kroner), mainly reflecting differences in staffing time involved.

Discussion

Despite a comprehensive search for appropriate trials, we were only able to identify three trials that adequately met our selection criteria for inclusion in this review.

Summary of main results

Three trials of 366 participants with hyperextension injuries to the proximal interphalangeal joints of the hand managed with conservative interventions were identified.

Norregaard 1987, which compared unrestricted mobility with splint immobilisation, found no statistically significant differences in outcome between the two groups at six months or three years post injury. Reported outcomes included finger movement, pain, joint tenderness and stiffness.

Thomsen 1995 found no statistically significant differences in reported outcomes between protected mobilisation versus immobilisation in an aluminium splint at two weeks following injury, nor at six months. Reported outcomes included finger movement, instability, and overall outcome.

Thomsen 1979 found no statistically significant differences between immobilisation for one week versus three weeks in the reported outcomes, relating to poor outcome, pain and tenderness and range of motion at six months follow-up. Thomsen 1979 reported, without providing data, no difference in outcome at six months post intervention between aluminium splint versus plaster of Paris aside from greater application (mainly staffing) costs for plaster of Paris.

There was no statistically significant difference in outcomes reported by any of the three studies included in this review and it is therefore not possible to determine if one form of treatment (unrestricted mobilisation, protected mobilisation, immobilisation) is better than any other when deciding how to conservatively manage PIP joint hyperextension injuries.

Overall completeness and applicability of evidence

All studies report on one of this review's primary outcome measures: 'poor outcome', including finger stiffness, joint laxity and joint deformity. The other primary outcome measure, self-reported functional outcomes, was not acknowledged in any of the three studies.

All three studies adequately reported the inclusion and exclusion criteria. While it is likely that these trial populations are representative, the lack of detailed information on the baseline characteristics of the trial participants on all three trials reduces the confidence on the applicability of their findings.

Despite the age of these trials, being more than 15 years since publication, these methods of conservative management continue to be applicable in clinical practice. Trials report participants presenting to emergency departments and orthopaedic clinics, as is commonly the case. However none of the three trials describe the methods used to evaluate the outcome measures on which the authors base their results. Additionally, the studies did not report information on exercise prescription. It is therefore difficult to extrapolate these outcomes to clinical practice and makes it almost impossible to replicate the studies in order to compare results.

Quality of the evidence

The quality of evidence available for the purpose of this review is very low. As well as being quasi-randomised, Norregaard 1987 was inconsistently reported and was at high risk of attrition bias. Thomsen 1979 was the only study to report an adequate method of sequence generation, but neither this trial nor Thomsen 1995 provided information on allocation concealment. Whilst we recognise that for the three included trials it was not possible to blind treatment providers or the patients to the interventions included, blinded assessors could have been used to review and record clinical outcomes.

Potential biases in the review process

In an attempt to reduce the possibility of bias in the review process, we undertook a comprehensive search of electronic databases. We acknowledge that all three studies are more than 15 years old. Although we found more recent publications on management of PIP joint hyperextension injuries, none were randomised controlled trials. There may be unpublished trials that have been reported in abstracts only. For future updates, we will attempt to identify non-published studies by liaising with content area specialists and search conference proceedings. As part of this review, contact was made with two authors to establish both the suitability of the trial for inclusion in the review and for clarification on the randomisation process.

Agreements and disagreements with other studies or reviews

We did not find any other reviews that looked at conservative management of hyperextension injuries.

Authors' conclusions

Implications for practice

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.

Implications for research

Hyperextension injuries of the proximal interphalangeal joints are a common presentation in hand clinics (Eaton 1976; Sprauge 1975). Currently, there is no consensus on optimum management. Further randomised trials comparing intervention options, exercise prescription and outcomes would be useful in determining the appropriate level of intervention for these injuries. Outcomes should include self-reported functional ability and pain, and objective measures of deformity, motion, grip strength.

A randomised controlled trial comparing thermoplastic splinting and early active mobilisation versus buddy strapping and early active mobilisation is recommended. As well as short term follow-up at three and six months to monitor recovery and capture time to return to function and employment, longer term follow-up at 12 and 24 months post injury is needed. Direct and indirect costs should also be included in the study to determine the cost-effectiveness of each intervention. Such trials should meet the CONSORT criteria for design and reporting of non-pharmacological studies (Boutron 2008).

Acknowledgements

The authors would like to thank Roma Bhopal, Lesley Gillespie, Nigel Hanchard, Helen Handoll and Adam Watts for helpful comments about the protocol and the review, as well as acknowledging the assistance of Lindsey Elstub and Amy Kavanagh of the Cochrane Bone, Joint and Muscle Trauma Group in preparing drafts of both the protocol and the review.

We would like to thank Anne Moseley at The George Institute for Public Health for running searches through PEDro.

We would like to thank Steve Powell, Clinical Effectiveness Department, St George's Healthcare NHS Trust for his assistance in obtaining full text articles.

We would also like to thank Dr Annette Bluemle and Jeppe Schroll for their assistance in translating articles.

We thank Mr John Jakobsen for providing further details of his trial.

Our thanks also to the Therapies Department, St George's Healthcare NHS Trust and to the staff of St George's University Library for their support and assistance.

Data and analyses

Download statistical data

Comparison 1. No immobilisation (analgesics only) versus Aluminium splint
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Poor outcome (6 months)1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
1.1 Stiffness and coldness1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
1.2 Thickened joint1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
1.3 Swan neck deformity1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
1.4 Button hole deformity1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2 Poor outcome (3 years)1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
2.1 Stiffness and coldness1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.2 Thickened joint1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.3 Swan neck deformity1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.4 Button hole deformity1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.5 "Sequelae" (mainly mild pain)1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.6 "Sequelae" (mainly mild pain) - alternative report data1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
3 Pain and tenderness (6 months)1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
3.1 Pain during movement1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
3.2 Pain during work1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
3.3 Pain during hobby-activities1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
3.4 Volar-plate tenderness1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
4 Pain and tenderness (3 years)1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
4.1 Pain during movement1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
4.2 Pain during work1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
4.3 Pain during hobby-activities1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
4.4 Volar-plate tenderness1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
5 Range of motion defect (6 months)1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
5.1 Extension defect1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
5.2 Flexion defect1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
6 Range of motion defect (3 years)1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
6.1 Extension defect1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
6.2 Flexion defect1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
Analysis 1.1.

Comparison 1 No immobilisation (analgesics only) versus Aluminium splint, Outcome 1 Poor outcome (6 months).

Analysis 1.2.

Comparison 1 No immobilisation (analgesics only) versus Aluminium splint, Outcome 2 Poor outcome (3 years).

Analysis 1.3.

Comparison 1 No immobilisation (analgesics only) versus Aluminium splint, Outcome 3 Pain and tenderness (6 months).

Analysis 1.4.

Comparison 1 No immobilisation (analgesics only) versus Aluminium splint, Outcome 4 Pain and tenderness (3 years).

Analysis 1.5.

Comparison 1 No immobilisation (analgesics only) versus Aluminium splint, Outcome 5 Range of motion defect (6 months).

Analysis 1.6.

Comparison 1 No immobilisation (analgesics only) versus Aluminium splint, Outcome 6 Range of motion defect (3 years).

Comparison 2. Elastic double finger bandage versus aluminium splint
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Instability (2 weeks: post intervention)1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
2 Range of movement 0 to 90 degrees (2 weeks: post intervention)1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
3 Excellent outcome (6 months)1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
Analysis 2.1.

Comparison 2 Elastic double finger bandage versus aluminium splint, Outcome 1 Instability (2 weeks: post intervention).

Analysis 2.2.

Comparison 2 Elastic double finger bandage versus aluminium splint, Outcome 2 Range of movement 0 to 90 degrees (2 weeks: post intervention).

Analysis 2.3.

Comparison 2 Elastic double finger bandage versus aluminium splint, Outcome 3 Excellent outcome (6 months).

Comparison 3. One week splinting versus three week splinting
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Poor outcome1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
1.1 Stiffness and coldness1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
1.2 Thickened joint1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2 Pain and tenderness1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
2.1 Pain at movement1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.2 Pain at work1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.3 Pain at hobbywork1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
2.4 Volar plate tenderness1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
3 Decreased range of motion1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
3.1 Decreased extension1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
3.2 Decreased flexion1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
Analysis 3.1.

Comparison 3 One week splinting versus three week splinting, Outcome 1 Poor outcome.

Analysis 3.2.

Comparison 3 One week splinting versus three week splinting, Outcome 2 Pain and tenderness.

Analysis 3.3.

Comparison 3 One week splinting versus three week splinting, Outcome 3 Decreased range of motion.

Appendices

Appendix 1. Search strategies

The Cochrane Library (Wiley Online Library)

#1 (proximal interphalangeal):ti,ab (77)
#2 (PIPs OR PIPj* OR PIP joint*):ti,ab (307)
#3 (#1 OR #2) (358)
#4 MeSH descriptor Dislocations, this term only (179)
#5 MeSH descriptor Fractures, Bone, this term only (976)
#6 MeSH descriptor Finger Injuries, this term only (82)
#7 (fracture* OR dislocat* OR injur*):ti (8773)
#8 ((injur* OR fracture* OR dislocat*) NEAR/3 (ligament* OR volar plate OR interphalangeal OR proximal)):ti,ab (431)
#9 (hyperexten* OR sublux*):ti,ab (175)
#10 (#4 OR #5 OR #6 OR #7 OR #8 OR #9) (9589)
#11 (#3 AND #10) (25)

MEDLINE (Ovid Online)

1 "proximal interphalangeal".ti,ab. (1910)
2  (PIPs or PIPj* or "PIP joint*").ti,ab. (1323)
3  VOLAR PLATE/in (11)
4  1 or 2 or 3 (2796)
5  DISLOCATIONS/th (3101)
6  FRACTURES, BONE/th (6275)
7  FINGER INJURIES/th (812)
8  (fracture* or dislocat* or injur*).ti. (277899)
9  ((injur* or fracture* or dislocat*) adj3 (ligament* or "volar plate" or interphalangeal or proximal)).ti,ab. (10489)
10 (hyperexten* or sublux*).ti,ab. (9309)
11 5 or 6 or 7 or 8 or 9 or 10 (290636)
12 4 and 11 (579)
13 IMMOBILIZATION/ (10879)
14 ("early motion" or "early active motion" or mobili*).ti,ab. (135541)
15 exp EXERCISE THERAPY/ (24123)
16 exercis*.ti,ab. (170086)
17 ((buddy or neighbour* or adjacent) adj2 (strap* or tape* or taping or wrap*)).ti,ab. (46)
18 SPLINTS/ (7069)
19 BANDAGES/ (12730)
20 splint*.ti,ab. (9851)
21 14 or 15 or 16 or 17 or 18 or 19 or 20 (337734)
22 12 and 21 (202)

EMBASE (Ovid Online)

1 PROXIMAL INTERPHALANGEAL JOINT/ (1128)
2 "proximal interphalangeal joint*".ti,ab. (1517)
3 (PIPs or PIPj* or "PIP joint*").ti,ab. (1493)
4 1 or 2 or 3 (3189)
5 DISLOCATION/th or FINGER DISLOCATION/ (1706)
6 FINGER FRACTURE/ (603)
7 JOINT INJURY/th or JOINT FRACTURE/th (130)
8 FINGER INJURY/th (471)
9 ((injur* or fracture* or dislocat*) adj3 (ligament* or "volar plate" or interphalangeal or proximal)).ti,ab. (11783)
10 (fracture* or dislocat* or injur*).ti. (306032)
11 (hyperexten* or sublux*).ti,ab. (9870)
12 5 or 6 or 7 or 8 or 9 or 10 or 11 (318155)
13 4 and 12 (603)
14 MOBILIZATION/ (12918)
15 ("early motion" or "early active motion" or mobili*).ti,ab. (148937)
16 exp EXERCISE/ or MOVEMENT THERAPY/ (164981)
17 exercis*.ti,ab. (199501)
18 ((buddy or neighbour* or adjacent) adj2 (strap* or tape* or taping or wrap*)).ti,ab. (49)
19  SPLINTS/ or SPLINTING/ or BANDAGE/ (17806)
20  splint*.ti,ab. (10286)
21  14 or 15 or 16 or 17 or 18 or 19 or 20 (434718)
22  13 and 21 (206)

CINAHL (Ebsco Interface)

1.   TX (proximal N3 interphalangeal N3 joint*)   (220)
2.   TX (PIP or PIPj*)  (315)
3.   TX (PIP N3 joint*) (82)
4.   TX (volar N1 plate*) (81)
5.   S1 or S2 or S3 or S4  (544)
6.   (MH "Finger Dislocation") (240)
7.   (MH "Finger Injuries")  (26)
8.   MH "Hand Fractures") (29)
9.   TI (fractur* or dislocat* or injur*) (62074)
10. TX (injur* or fracture* or dislocat*) N3 (ligament* or interphalanageal or proximal) (6336)
11. TX (hyperexten* OR sublux*)  (2823)
12. S6 or S7 or S8 or S9 or S10 or S11 (68529)
13. S5 and S12 (164)
14. (MH "Joint Mobilization")  (1)
15. TX ("early motion"or "early active motion" or mobili*)  (21335)
16. (MH "Therapeutic Exercise+") (30452)
17. TX (exercis*)  (89288)
18. TX (buddy or neighbour or adjacent) N2 (strap* or tape* or taping or wrap*) (13)
19. (MH "Splints") (429)
20. (MH "Taping and Strapping")  (1539)
21. S14 or S15 or S16 or S17 or S18 or S19 or S20  (138485)
22. S13 and S21   (32)

Footnotes

/in: injuries subheading
/th: therapy subheading
.ti: textword in title
.ti,ab: textword in title and abstract 

Contributions of authors

All authors were involved in the preparation of the protocol, the conception of which was based on previous work undertaken by MB. All authors contributed to the work and writing involved in the review. Data entry and analysis were completed by SM. JC, MB and ZA completed the first draft of the review with feedback from SM.

Declarations of interest

None known.

Sources of support

Internal sources

  • St George's NHS Healthcare Trust, UK.

External sources

  • No sources of support supplied

Differences between protocol and review

In our risk of bias assessment, we did not assess patient reported and clinician rated outcome measures separately in our assessment of assessor blinding and completeness of outcome data. Another difference was that we also assessed risk of performance bias associated with blinding of participants and care providers.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Norregaard 1987

MethodsQuasi-randomised trial. Patients randomised to group 1 on even dates of trauma and to group 2 on odd dates of trauma
Participants

126 patients with hyperextension injuries to the PIP joint (mean age at time of injury: 24 years) were randomised (stated in two reports of the trial). However, 112 were reported in the 1987 English language publication, which is treated as the main publication in this review.

Participants were recruited on presentation to an Emergency Department in Denmark between 1 November 1982 and 1 November 1983.

Interventions

Analgesics and commencement of unrestricted motion within days of the initial trauma (56 patients)

versus

3 weeks of immobilisation with 15 to 20 cm foam rubber covered aluminium splint applied to volar surface with the injured joint flexed to 15 degrees, the MP joint 80 to 90 degrees, and the wrist extended 30 degrees (56 patients)

Outcomes

Pain (during movement, during work, during hobby activities), volar plate tenderness, stiffness and coldness, thickened joint, extension deficit, flexion deficit, swan neck deformity, button-hold deformity, other.

Pain was graded according to the Moller 1974 scale.

Follow-up at six months and three years.

Notes

Diagnostic inclusion criteria was the presence of a volar plate lesion, indicated by the presence of all of:

1. local volar tenderness

2. pain at maximal flexion

3. relief from pain in intermediate position

4. recurrence of pain at maximal extension.

Six months after injury: In the text of the report: 78 patients (34 in group 1 and 44 in group 2) were re-examined. In table 1 of the main report, it is 87 (44 versus 43).

A further follow-up of 77 (text: 34 in group 1 and 43 in group 2; table 1 68 in all: 34 versus 34) patients was performed about 3 years after the injury. Given the pattern of the loss to follow-up was similar in the other reports of the trial to that given in table 1, we have used these data in the results.

Sequelae were graded according to Moller (1974):

+ mild pain from forceful loading or cold water

++ moderate pain from tapping or performing normal work

+++ considerable daily pain, symptomatic restriction of movement, dystrophic appearance

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskDate of trauma
Allocation concealment (selection bias)High riskQuasi-randomised by date of trauma
Blinding of participants and personnel (performance bias)
All outcomes
High riskAuthor contacted - unable to recall relevant details of assessment procedure and blinding of personnel is not reported. Not possible to blind participants
Blinding of outcome assessment (detection bias)
All outcomes
High riskAs above.
Incomplete outcome data (attrition bias)
All outcomes
High riskIrregularities in reported loss to follow-up both within trial report (results in the text vary from the results table) and between trial reports. In the text of the main report: 39% were lost from the no immobilisation group and 21% from the immobilisation group at 6 months; but table 1 of the report shows more similar losses in the two groups 23% versus 21%. There is no indication as to how the incomplete outcome data was managed
Selective reporting (reporting bias)Unclear riskUnable to assess this as no protocol for the trial was located
Other biasUnclear riskNo indication of baseline demographics of groups. Assessment procedures for outcome measures is unclear nor is the number of assessors reported. There are inconsistencies in the results text and the table of results

Thomsen 1979

MethodsParallel group randomised controlled trial
Participants200 patients (181 patients followed up; 191 fingers) with hyperextension lesions of the volar fibrocartilage in the PIP joint (age range 7 to 76 years; 75 males and 106 females) were randomised. Participants were recruited on presentation to an Emergency Department in Denmark between 1 September 1977 to 1 September 1978.
Interventions

1 week of immobilisation with an aluminium splint (46 participants)

versus

3 weeks of immobilisation with an aluminium splint (39 participants)

versus

1 week of immobilisation with plaster of Paris cast (45 participants)

versus

3 weeks of immobilisation with plaster of Paris cast (51 participants).

Outcomes

Pain, decreased flexion or extension, stiffness and coldness, tenderness and thickened joint at 6 months. Any sick leave. Discomfort from splint or plaster at week 1 or week 3.

Application costs of aluminium splint versus plaster of Paris.

Follow-up at 6 months (3 patients with severe complications were seen again at 12 months).

Notes

Inclusion criteria: hyperextension trauma and

1. volar pain at maximal flexion of the PIP joint

2. pain relief at semiflexion

3. pain increase at maximal extension.

Exclusion criteria: larger fractures, abnormal hyperextension and lateral laxity

The authors report no difference between immobilisation method therefore they pooled all subjects immobilised for one week and all subjects immobilised for three weeks.

Results are presented in terms of injured fingers rather than participants.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskUsed randomised table
Allocation concealment (selection bias)Unclear riskNot specified
Blinding of participants and personnel (performance bias)
All outcomes
High riskNot possible to blind participants and no report of personnel blinding
Blinding of outcome assessment (detection bias)
All outcomes
High riskAs above
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo indication of how lost data was managed. Nine per cent of participants immobilised for one week and 10% of participants immobilised for three weeks were lost to follow-up or excluded. Exclusion criteria were applied after randomisation
Selective reporting (reporting bias)Unclear riskUnable to assess this as no protocol for the trial was located
Other biasUnclear riskUnclear homogeneity of groups and unclear procedures of assessment. Inadequate follow-up period (6 months except for 3 patients) and no comment as to the number of assessors involved

Thomsen 1995

MethodsRandomised controlled trial
Participants40 patients with hyperextension injuries to the PIP joint (age range 18 to 79; 19 males and 20 females). One patient (gender unknown) withdrew after removal of bandage, not wishing to participate in trial. The study was conducted in Denmark, between August 1992 and September 1993 (setting unclear).
Interventions

2 weeks of elastic double finger bandage allowing the PIP joint to be flexed 25 to 30 degrees (19 patients)

versus

2 weeks of aluminium splint applied to dorsal surface of finger holding PIP joint in 15 degrees of flexion (20 patients)

Outcomes

Two weeks: range of movement, volar instability, return to work.

Six months: Assessment of outcome using the Benke and Stableforth (1979) criteria based on movement, symptoms, stability and function, rated as excellent / good / poor.

Notes

Inclusion criteria: type 1 lesions of the volar plate - volar plate avulsion or minor avulsion fracture and minor split in collateral ligaments (Eaton 1976)

Exclusion criteria: patients with previous injuries to the joint

Two weeks and six months after injury 39 patients were re-examined (20 in group 1 and 19 in group).

Outcome was graded according to Benke and Stableforth (1979):

Excellent: Movement 0 to 90°+, no symptoms, stable, normal function

Good: Fixed flexion of 20 or less, flexion of 90°+, minimal symptoms, stable, good function

Poor: Fixed flexion > 20, flexion < 90, significant symptoms, instability, poor function

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskProspective randomised trial - sequence generation not reported
Allocation concealment (selection bias)Unclear riskNot reported
Blinding of participants and personnel (performance bias)
All outcomes
High riskNot possible for participants to be blinded and no report of personnel blinding
Blinding of outcome assessment (detection bias)
All outcomes
High riskNot reported. However, it was reported that authors performed all assessments at follow-up
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo indication of incomplete outcome data. However, one patient withdrew after removal of the elastic bandage
Selective reporting (reporting bias)Unclear riskUnable to assess this as no protocol for the trial was located
Other biasUnclear riskNo report on homogeneity of the two groups. Outcomes were assessed by three examiners, who were the authors. Unclear assessment procedures and inadequate length of follow-up (3 months)

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Arora 2004This trial reported two different types of management options for hyperextension injuries. Communication with the author confirmed this study was not a randomised or a quasi-randomised controlled trial.