Patients › Hand
DIP Joint Fusion
DIP joint fusion stabilizes and reduces pain in the fingertip joint, often for arthritis or mallet finger.
Why this operation has been suggested¶
Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed to work out what is wrong.
This operation is a fusion of the end joint of a finger or thumb. The two bones on either side of the joint are joined so they heal into one solid bone. Once that has healed, the joint no longer bends, but it also no longer hurts.
We usually suggest this operation when the joint is worn out, badly damaged by injury, or unstable, and simpler measures such as activity change, hand therapy or splinting have not given enough relief. For some acute injuries, surgery may be the right choice straight away. The aim is a finger that is steady, comfortable and able to do its job when you pinch and grip.
Before the operation¶
In the weeks before surgery we confirm the plan with fresh X-rays of your finger. Most patients need nothing more than that. If you have other medical conditions, you may need blood tests or a review with the anaesthetist (the specialist doctor who keeps you safe and pain-free during the operation). You will be asked to stop eating and drinking for seven hours before surgery; we ask for a little longer than the usual six so your time can be brought forward if the theatre list runs early. Your surgeon will tell you which of your regular medicines to pause, so bring a written list of everything you take. Arrange a lift home, as you cannot drive afterwards. Wear loose, comfortable clothing that slides on easily over a bandaged hand.
On the day¶
You come to the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You then meet the anaesthetist (the specialist doctor who keeps you safe and pain-free during the operation). Most people choose local: recovery is quicker and you can go home soon after. If you'd prefer to be asleep, that's also a reasonable choice; discuss it with your surgeon and anaesthetist.
You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable, you either move to a ward or go home, depending on the procedure and how your recovery is going.
What the operation involves¶
Your surgeon makes a single cut over the end joint of your finger or thumb. Through this cut, they remove the worn-out joint surfaces so the raw bone on each side can meet.
The two bones are then held together while they heal into one solid bone. Small metal implants, such as a screw or a low-profile plate, keep the bones pressed together and in the right position. The joint is set at a bend that suits how you use your hand for pinch and grip, and the position can be fine-tuned before the implants are finally placed.
The cut is closed with stitches, and a dressing is applied over the top.
After the operation¶
Most patients stay one night in hospital after this operation, though some are able to go home the same day. You wake up in the recovery area, where nurses keep an eye on you while the anaesthetic wears off. Your hand will be bandaged, and the finger is usually supported with a splint (a firm cover that holds it still while it heals). Pain relief is planned with you before you leave theatre, and the nurses can top it up if you need more. Someone should stay with you for the first 24 hours. You can move around and use your hand gently as soon as you feel able. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you.
Recovery¶
For the first few days your finger will be sore and swollen, and the end joint may throb. Resting your hand raised on a pillow eases this, and your usual pain relief keeps you comfortable. The swelling settles gradually over the following weeks.
You will go home with a splint (a firm cover that holds the finger still while it heals) and a bandaged hand. Keep the dressing dry and leave it alone until we see you. Ruby Doolan, our hand therapist at Extend Rehabilitation, will direct your rehabilitation and make any splint you need. She will show you gentle exercises that keep the rest of your hand and fingers moving while the fused joint heals. Sustained, regular exercise supports the finger straightening as it recovers.
Day to day, you can use your other hand for most tasks. You can move around the house, dress yourself and prepare simple meals. Avoid heavy lifting, gripping hard or getting the dressing wet. Sleeping with your hand on a pillow or propped up can reduce night-time throbbing.
You will wear the splint until the bones have joined into one solid bone. Once it comes off and your surgeon clears you, driving becomes possible again, provided you can grip the wheel safely. See our page on Driving after upper-limb surgery.
Everyone heals at their own pace, so your timeline may differ. Your surgeon and hand therapist will guide you at each review.
What can go wrong¶
Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.
The main thing we watch for is the bones failing to join into one solid bone. If that happens, the finger may stay painful at the end joint, or you may notice a click, movement or grinding where there should be none. Tell us at your review if the pain does not settle or the joint feels loose. Sometimes the bones join in a slightly different position than planned. The finger may look twisted or lean to one side, which can make it harder to line up with your other fingers when you make a fist. Mention this at your next appointment.
The metal implants can also cause trouble. A screw or plate can loosen, back out or press on the skin, and you might feel a sharp edge under the skin or see the implant pushing through. If that happens, contact the clinic. Removing the implant is a small further operation, and we would talk it through with you.
Infection is uncommon but needs quick attention. Watch for pain that keeps getting worse rather than easing, redness spreading out from the wound, swelling that builds instead of settles, or fluid leaking from the cut. You may feel hot and generally unwell. Do not wait for your review: call the clinic straight away, or go to the emergency department if you cannot reach us.
Some conditions make problems more likely. Diabetes is one of them, so we take extra care planning surgery if you have it. Your overall health and the complexity of the operation play a part too, which is why we check carefully that this operation suits you before going ahead.
If any of these signs appear, do not put it down to normal healing. Call us, and we will see you sooner if needed.
The complications table on this page lists typical rates if you want the specifics.
When to call us¶
Most problems show up in the first few weeks. Call us if your pain keeps getting worse instead of easing, if redness spreads from the wound, or if fluid leaks from it. Call us if you feel hot and generally unwell, or if the finger becomes numb, cold or changes colour. Go to emergency if you cannot reach us, or if the swelling is severe and comes on suddenly. Trust your instincts: if something feels wrong, call us.
Where to read more about the condition¶
This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the DIPJ arthritis page.
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Anatomy & Pathophysiology¶
Bony and Articular Anatomy¶
- The hand consists of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand [2].
- Each finger ray is a polyarticular chain composed of a metacarpal and three phalanges [2].
- The distal interphalangeal (DIP) joint is the most distal articulation in the finger ray [2].
- The dorsal integument of the distal phalanx is characterized by the presence of the nail bed and its matrix [3].
- The MCP joint contributes 77% of the total arc of finger flexion [18].
- Studies indicate that 5 to 10 degrees of flexion and 30 to 35 degrees of extension are needed for most activities of daily living [18].
Soft Tissue Anatomy¶
- The terminal tendon inserts at the base of the distal phalanx to extend it [4].
- The two conjoined lateral bands to each finger unite at the distal third of the middle phalanx to form the terminal tendon [4].
- The dorsal covering of the interphalangeal articulations forms a unique cutaneous unit characterized by a considerable excess of skin when the digits are in extension [3].
- The fine tight skin of the dorsal aspect of the middle phalanx forms a distinct functional cutaneous unit [3].
- The skin covering each finger is 7 cm by 10 cm on both the palmar and dorsal aspects [6].
- The necessary skin to cover the thumb distal to the metacarpophalangeal joint is about 9 cm wide and 8 cm long [6].
Extensor Mechanism and Pathomechanics¶
- The deep head of each dorsal interosseous muscle extends the middle and distal phalanges [4].
- The superficial head of the dorsal interosseous muscle has no direct effect on the middle or distal phalanges [4].
- Boutonnière deformities primarily arise at the PIP joint when stretching of the extensor tendon over the joint induces hyperextension of the DIP and MCP joints [17].
- Acute boutonnière deformity results from central slip disruption and volar subluxation of the lateral bands, resulting in DIP hyperextension [15].
- In boutonnière deformity, attenuation of the central slip results in unopposed flexion at the PIP joint [16].
- With PIP joint flexion in boutonnière deformity, the lateral bands drift volar to the axis of rotation at the PIP joint [16].
- The lateral bands stay in the volar position owing to loss of dorsal support from the attenuated triangular ligament and contracture of the transverse retinacular ligament [16].
- Swan neck deformities can occur at the DIP, PIP, and MCP joints as a result of multiple etiologies [13].
- Synovitis can cause a flexion deformity at the DIP joint [13].
- A zigzag deformity propagates proximally because there is stretching of the terminal tendon [13].
- In type I swan neck deformity, the deformity can originate at the DIP joint with stretching or rupture of the terminal extensor tendon attachment, resulting in a mallet deformity [14].
- Imbalance of the extensor mechanism secondary to DIP joint flexion coupled with laxity of the PIP joint volar plate allows the PIP joint to assume a posture of hyperextension [14].
Functional Considerations¶
- DIP fusion of the digits is generally tolerated well with limited loss of function [18].
- PIP joint motion is much more important to preserve than DIP joint motion [18].
- Fingers with fused PIP joints are of little use for grip or grasp and frequently get in the way [18].
- The quadriga effect can occur when profundus excursion is impaired with arthrodesis [18].
- Even with a successful DIP fusion, the fine motor skills of a finger may be compromised [14].
Clinical Presentation¶
Physical Examination¶
- Inspection of the dorsal and palmar surfaces of the hand is the initial step in physical examination [19].
- Swelling and volar subluxation may be present at the metacarpophalangeal (MCP) joints in osteoarthritis [19].
- Flexion contracture or extension lag may be associated with MCP joint swelling and volar subluxation [19].
- Proximal interphalangeal (PIP) joints may display flexion contractures in osteoarthritis [19].
- The Bouchard node is a distinguishing characteristic of osteoarthritic PIP joints [19].
- The presence of Heberden nodes heralds inspection of the osteoarthritic distal interphalangeal (DIP) joint [19].
- Heberden nodes signify swelling and periarticular osteophyte formation at the DIP joint [19].
- Mucous cyst formation may occur in relation to an osteoarthritic DIP joint [19].
- Palpation of an acutely inflamed osteoarthritic DIP joint elicits tenderness [19].
- Palpation of an acutely inflamed osteoarthritic DIP joint elicits a sensation of fullness about the joint [19].
- Palpation of an acutely inflamed osteoarthritic DIP joint reveals loss of the normal bony contour of the joint [19].
- The examiner can detect tenderness and synovitis by applying small pressure while holding the joint between the dominant thumb and index finger [19].
- Range of motion of each joint may be limited due to a superimposed flexion contracture [19].
- Digital range of motion is often expressed in terms of total active range of motion, approximately 250 degrees [19].
- Normal DIP joint range of motion is 0 to 60 degrees [19].
- Tendon integrity may be compromised in the osteoarthritic hand [19].
- Chronic tenosynovitis of the flexor tendon uncommonly coexists with a zone 2 flexor digitorum superficialis (FDS) or flexor digitorum profundus (FDP) tendon rupture [19].
- Extensor tendons are more commonly involved in osteoarthritic hands [19].
- Ulnar subluxation of extensor tendons at the level of the MCP joints occurs secondary to failure of the sagittal bands [19].
- Ulnar drift and flexion positioning of the digits at the level of the MCP joints result from extensor tendon subluxation [19].
- In the acute phase, extensor tendon subluxation and ulnar drift/MCP flexion may be passively correctable [19].
- In the acute phase, extensor tendon subluxation and ulnar drift/MCP flexion are amenable to individual MCP extension splinting for 3 weeks [19].
- In the chronic situation, the only treatment option is surgical release of the tight sagittal bands [19].
- Surgical release of tight sagittal bands in chronic cases may be performed with or without intrinsic releases [19].
- Surgical release of tight sagittal bands in chronic cases may be performed with extensor tendon realignment [19].
Erosive or Inflammatory Osteoarthritis¶
- Erosive or inflammatory osteoarthritis is an uncommon variant of osteoarthritis first described in 1966 by Peter and coworkers [19].
- Erosive or inflammatory osteoarthritis is more common in women [19].
- Symptoms of erosive or inflammatory osteoarthritis appear abruptly [19].
- Erosive or inflammatory osteoarthritis involves the joints on the radial aspect of the hand [19].
- Erosive or inflammatory osteoarthritis spares the joints on the ulnar side [19].
- The DIP joint is the most commonly affected joint in erosive or inflammatory osteoarthritis [19].
- The PIP joint is the most commonly symptomatic joint in erosive or inflammatory osteoarthritis [19].
- In some patients, erosive osteoarthritis will seroconvert to rheumatoid arthritis at a later time [19].
Diagnostic Imaging¶
- Plain posteroanterior (PA), lateral, and oblique radiographic views can adequately image the osteoarthritic hand [19].
- Further detail can be obtained by directly imaging the individual digit [19].
- Direct imaging of the individual digit involves an attempt to center the radiograph beam over the joint in question [19].
Investigations¶
- Clinical evaluation of the injured or dysfunctional hand and wrist requires combining patient history with a careful physical examination to pinpoint or narrow the scope of possible pathologic processes [1].
- Diagnostic tests such as imaging and serum laboratory studies are useful in determining pathology but can be expensive, time consuming, and often nonspecific [1].
- A careful physical examination is essential to direct care and future testing if indicated [1].
- The skeleton of the hand and wrist consists of 27 bones, of which 19 are long bones [12].
- The skeleton is divided into five rays, each ray making up a polyarticulated chain comprising the metacarpals and phalanges [12].
- The base of each metacarpal articulates with the distal row of the carpus [12].
- The carpus articulates with the skeleton of the forearm through its proximal row [12].
- The radioulnocarpal articulation has two axes of movement to which is added a third—pronation and supination from the forearm [12].
- The wrist has three axes of movement, permitting the hand to be positioned in any spatial configuration and allowing it to be placed as needed for grasping [12].
- The radial ray or first ray is the shortest and is made up of only three bones—a metacarpal and two phalanges [12].
- The other four digital rays are formed by four skeletal segments—a metacarpal and three phalanges [12].
- The thumb metacarpal is the shortest, the index finger metacarpal is the longest, and the others decrease in length from the third to the fifth digits [12].
- The proximal and particularly the middle phalanges of the middle and ring fingers are longer than those of the index finger [12].
- The long finger, and usually the ring finger, are longer than the index finger [12].
- The epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal [12].
- The epiphyseal plates are located at the distal ends of the other metacarpals [12].
References¶
[1] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.
[2] Exam Of The Hand Wrist 2Ed. INTRODUCTION.
[3] Exam Of The Hand Wrist 2Ed. Functional cutaneous units.
[4] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.
[6] Exam Of The Hand Wrist 2Ed. Planning skin cover of the hand and forearm.
[12] Exam Of The Hand Wrist 2Ed. 1.1 SKELETON OF THE HAND > The osseous skeleton.
[13] Green S Operative Hand Surgery. Swan Neck Deformities.
[14] Green S Operative Hand Surgery. Swan Neck Deformities > Postoperative Care.
[15] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > TENDON INJURIES AND OVERUSE SYNDROMES > Zone III injury (boutonnière).
[16] Miller S Review Of Orthopaedics. TENDON INJURIES AND OVERUSE SYNDROMES > Zone III injury (boutonnière).
[17] Green S Operative Hand Surgery. Boutonnière Deformities.
[18] Green S Operative Hand Surgery. EVOLUTION IN THE TREATMENT OF MANGLING INJURIES > Joints.
[19] Green S Operative Hand Surgery. Treatment of the Osteoarthritic Hand and Thumb > OSTEOARTHRITIS OF THE SMALL JOINTS OF THE HAND.