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DIPJ arthritis

62 citationsUpdated Oct 2026
Illustration: DIPJ arthritis

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Distal interphalangeal joint (DIPJ) arthrodesis is indicated for persistently symptomatic, unstable DIP joints [4] and is the recommended immediate intervention for synovial chondromatosis [2]. For patients with severe painful osteoarthritis affecting both the PIP and DIP joints of the same digit, simultaneous surgical intervention is recommended [6]. While arthrodesis generally results in favourable bony union regardless of underlying medical condition or technical details [5], patient-reported outcomes, complications, and additional surgery rates for patients treated with screw fixation are comparable to those treated with hook or acrylic cement fixation [1].

Alternative motion-preserving strategies include Swanson hinge implant arthroplasty for patients desiring continued, albeit limited, mobility [16], and denervation with cheilectomy as a compelling alternative for symptomatic osteoarthritis [17]. Silicone interpositional arthroplasty is an acceptable alternative to arthrodesis, achieving excellent pain relief and 30–40 degrees of movement with a low overall complication rate of 5% [27]. In cases of failed DIPJ silicone arthroplasty, a customized structural bone graft addresses bone stock loss and medullary absence, achieving reliable union rates and high patient satisfaction [26].

Arthrodesis outcomes vary by technique; reamed percutaneous fusion achieves higher union rates in a shorter time with reduced postoperative pain compared to non-reamed techniques [7], and is advantageous in select patients over open fusion [8]. Specific approaches, such as the smile incision and reverse shotgun approach, are suitable when more volar joint preparation and implant insertion sites are necessary [10]. The X-fuse implant provides excellent stability with minimal hardware problems and a high union rate across a wide array of patients [12], while lateral approach and plate fixation yields results equivalent to traditional methods but with fewer major complications [13]. The NMSS technique is a feasible option, especially when a small finger is indicated and a significant flexion angle is required [50]. Given the lack of difference in biomechanical performance between K-wires and compression screws, implant selection should consider cost and complication profiles [119].

Anatomy & Pathophysiology

Osseous Anatomy

The hand skeleton comprises 27 bones, 19 of which are long bones [45]. It is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [45]. The thumb ray is the shortest, consisting of a metacarpal and two phalanges, whereas the other four digital rays consist of a metacarpal and three phalanges [45]. Among the metacarpals, the thumb metacarpal is the shortest and the index metacarpal is the longest [45]. The proximal and middle phalanges of the middle and ring fingers are longer than those of the index finger [45]. Epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, and at the distal ends of the other metacarpals [45]. An examination of 100 specimens of the terminal joints of human fingers has been described [109].

Extensor Mechanism

Distal interphalangeal joint extension is achieved through conjoined lateral bands composed of tendinous slips from extrinsic and intrinsic tendons [44]. The principal bony insertion of the extrinsic digital extensors is on the dorsal proximal aspect of the middle phalanx [44]. The deep head of each dorsal interosseous muscle forms a lateral band at the metacarpophalangeal joint level and extends the middle and distal phalanges [71]. Oblique fibers from the lateral bands insert onto the lateral tubercles at the base of the middle phalanx to extend the proximal interphalangeal joint [71]. The lateral bands join with the lateral slips of the extensor tendon to form the conjoined lateral band, which unites at the distal third of the middle phalanx to form the terminal tendon [71]. The terminal tendon inserts at the base of the distal phalanx to extend it [71]. The flexor digiti quinti brevis forms the ulnar lateral band of the little finger, while the volar interossei form the ulnar lateral band of the index finger and the radial lateral bands of the ring and little fingers [71]. In cadaveric index, middle, and ring fingers, the role of extrinsic and intrinsic muscles in distal interphalangeal joint extension strength was almost equal [106].

Flexor Mechanism

The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx and flexes the distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints [44]. The flexor digitorum superficialis inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx, with its primary function being digital flexion at the proximal interphalangeal joint [78]. The fifth annular pulley (A5) is located over the distal interphalangeal joint [78].

Pathophysiology

Osteoarthritis occurs with the highest prevalence in the distal interphalangeal joint of the hand and is divided into erosive and nonerosive forms [23]. The pathogenesis of early-stage osteoarthritis is poorly understood, though considerable emphasis has been placed on the role of cartilage and subchondral bone [23]. Soft tissue structures, including collateral ligaments and tendons, also play a role in the pathogenesis of distal interphalangeal joint osteoarthritis [23]. Radiographic evaluation represents the most standardized method to quantify disease progression in this condition [23]. Posttraumatic arthritis is a common cause of joint disability, with repetitive injuries increasing the risk of development [46]. Athletes have a higher incidence of degenerative joint changes compared to the general population [46]. A swan neck deformity consists of hyperextension of the proximal interphalangeal joint, flexion of the distal interphalangeal joint, and sometimes flexion of the metacarpophalangeal joint [127]. Nontraumatic causes of swan neck deformity include rheumatoid arthritis and neurological disorders [127]. The most important factor in the development of finger deformities is changes occurring in the tendons and related structures, especially in early stages [100]. Understanding of distal interphalangeal joint morphology may lend insight into the biomechanics and disease progression within these joints [20].

Classification

Kellgren & Lawrence: The interrater reliability of the Kellgren & Lawrence classification system for post-traumatic osteoarthritis in the distal interphalangeal joint after mallet finger fractures is considerably lower than initially assumed [136].

OARSI: The interrater reliability of the OARSI classification system for post-traumatic osteoarthritis in the distal interphalangeal joint after mallet finger fractures is considerably lower than initially assumed [136].

Other Considerations: Classification of angular measurement according to tested systems does not reflect the patient's perspective, limits the precision of the measurement, and adds little value to the measurement itself [53].

Clinical Presentation

Chronic Arthropathy

Radiographic evaluation represents the most standardized method to quantify disease progression in the distal interphalangeal joint [23]. In a study of work-load and osteoarthritis development, Heberden's nodes were found in 85 women, while radiological osteoarthritis of the distal interphalangeal joint was present in 54 women [51]. Among those with radiological osteoarthritis, 46 women had bilateral disease, while only eight women in the high work-load group had unilateral disease [51]. The incidence of Heberden's nodes with radiological osteoarthritis was significantly higher in the high work-load group compared to lower work-load groups [51]. Additionally, 157 digits, including the thumb, showed radiological stage I disease in this cohort [51].

Swan neck deformity may progress significantly over time due to increasing distal interphalangeal joint flexion contracture [11]. Conversely, a finger with no active flexion did not develop erosive osteoarthritis at the time that it developed in the other active digits [130]. Primary synovial chondromatosis of the distal interphalangeal joint is an extremely rare entity that requires accurate diagnosis to distinguish from other arthropathies [118].

Acute Injury and Trauma

Radiological osteoarthritis after a mallet finger fracture is similar to the natural degenerative process in the distal interphalangeal joint [18]. This post-traumatic osteoarthritis is accompanied by a decrease in range of motion of the distal interphalangeal joint [18]. However, the decrease in range of motion following mallet finger fracture does not clinically affect patient-reported outcomes [18]. Inflammation seems to negatively impact the healing process of tendinous mallet finger [126]. Assessing if there is distal interphalangeal joint inflammation is suggested to anticipate the failure of treatment for tendinous mallet finger [126].

Palmar subluxation of a distal interphalangeal joint without preexisting arthritic deformity is expected when more than one half of the dorsal articular surface is injured [25]. Treatment delay greater than 8 hours of injury may develop significant distal interphalangeal joint stiffness [24]. A displaced intra-articular osteochondral fracture can cause irreducible dislocation of the distal interphalangeal joint [21]. Irreducible palmar fracture-dislocation of the distal interphalangeal joint in a child requires early open reduction due to mechanical obstruction by the displaced epiphysis and intact soft tissues [40]. Floating distal interphalangeal joint injuries can be misdiagnosed initially due to minimal deformity [38]. Osteoarthritis may develop following floating distal interphalangeal joint injuries [38].

Red-Flag Patterns

A malignant natural killer cell neoplasm can present as a mucous cyst on the distal interphalangeal joint [97]. In one case, a 66-year-old male patient presented with a tumorous lesion located on the dorsoulnar aspect of the distal interphalangeal joint of his right third digit [97]. The diameter of the lesion was about 8 mm, and its convexity reached a maximum of 3 mm [97]. Osteoarthritic changes were visible on the distal interphalangeal joint, and small osteophytes were visible on radiographs in this case [97].

Investigations

Plain radiography: Post-operative radiographs are obtained in PA and lateral projections at 1, 2, and 5 years for radiographic analysis [29]. Subsidence of the prosthesis in the proximal and middle phalanges is measured on PA images from the joint surface of the MCP or distal interphalangeal (DIP) joint to the end of the stem of the prosthesis [29]. In patients with arthrodesis of the DIP joint, this measurement is made from the end of the distal phalanx [29]. Subsidence is calculated as the ratio between the length of the prosthesis and the length of the phalanx, expressed as a percentage [29]. This ratio is translated into millimetres by using the known length of the prosthetic component used [29].

Implants are scored on lateral images according to Sweets and Stern (2011) to describe the migration of the prosthesis within the medullary canal [29]. Dorsal, palmar, and coronal migration of each implant within the medullary canal are defined using a four-point scale [29]. The Stern classification grades are defined as follows: * Grade 0: Well-aligned implant [29]. * Grade 1: Macroscopically evident migration [29]. * Grade 2: Severe migration with stem opposing cortex [29]. * Grade 3: Breach of cortex by stem [29].

MRI: MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing [86]. It may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas, which serves as an index of biologic activity [86]. The existence of a distinct collagen septum between the extensor tendon and skin at the DIP joint was confirmed using MRI and histology [143].

Other Considerations: An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences [86]. False-negatives are possible with 8-MHz Doppler tone assessment [86].

Treatment

Non-Operative

Splinting and anti-inflammatory medications constitute the mainstay of nonoperative treatment for DIP joint arthritis [46]. Short-term DIP joint splinting is a safe, simple, and inexpensive modality that reduces pain and improves joint extension [63]. In patients presenting with chronic soft tissue mallet fingers, a trial of full-time DIP joint extension splinting should be attempted [131].

Operative

Indications: Arthrodesis is the standard surgical treatment for DIPJ arthritis when conservative measures fail [39]. It provides stability, pain relief, and deformity correction [46]. A painless, stable joint in a functional position is prioritized over the ability to move the joint [46]. Arthrodesis is the only treatment that ensures a mucous cyst will not recur [62]. In cases of synovial chondromatosis, there is probably good reason to proceed to arthrodesis immediately [2].

Surgical Approach / Technique: A described technique for DIPJ arthrodesis is simple and reliable, yielding consistent clinical results with a very low non-union rate and an acceptable complication rate [139]. Lateral approach and plate fixation produce results equivalent to traditional methods but with fewer major complications [13]. Headless compression screw fusion allows a functional angle of up to 35° at the distal interphalangeal joint [32]. In a cohort of fifteen digits treated with headless compression screw fusion for osteoarthritis, all patients achieved successful radiographic union [32]. The mean preoperative Michigan Hand Questionnaire (MHQ) score was 47.22, improving to a postoperative score of 75.5 in this cohort [32]. For failed DIPJ silicone arthroplasty, a customized structural bone graft addresses bone stock loss and medullary absence, achieving reliable union rates and high patient satisfaction [26].

Motion-Preserving Options: Open DIP joint cheilectomy is a safe and effective alternative to arthrodesis for patients with symptomatic osteoarthritis who wish to preserve joint motion [41]. In a review of 78 patients, open cheilectomy and debridement resulted in a significant improvement in mean visual analog scale pain scores from 8 to 1 [41]. DIP joint range of motion improved by a mean of 20 degrees following this procedure [41]. Denervation with cheilectomy presents a compelling motion-preserving alternative to arthrodesis for symptomatic DIP joint osteoarthritis [17]. A surgical technique for symptomatic DIP joint arthritis reduces pain while preserving DIP joint motion [54].

Specific Etiologies and Salvage: Early thorough synovectomy may avoid complications and obtain favorable results in sea urchin spine arthritis of the hand, as neither antibiotics nor anti-inflammatory agents are effective [42]. Open reduction and internal fixation is a viable treatment option for chronic floating DIP joint injuries, though osteoarthritis may develop [38]. Irreducible palmar fracture-dislocation of the DIP joint in a child requires early open reduction due to mechanical obstruction by the displaced epiphysis and intact soft tissues [40].

Other Considerations: Osteoarthritis was the most common indication for arthrodesis in a retrospective cohort study of 149 cases, with postoperative complications occurring at a rate similar to that reported in existing literature [57].

Complications

Arthrodesis: DIP joint arthrodesis is frequently associated with postoperative complications [60]. In a large cohort of 209 fingers in 187 patients, 40 patients (21.4%) experienced a postoperative complication, and 30 patients (16.0%) required reoperation [52]. The primary indications for reoperation were hardware removal (n = 18) and revision fusion (n = 7) [52]. A retrospective cohort of 149 cases involving DIP and thumb IP joint arthrodesis reported complication rates similar to existing literature [57].

Risk Factors: In the 209-finger cohort, the use of autograft was significantly associated with a decreased risk of reoperation (P = .003) [52]. Autograft use was also associated with a decreased risk of complication (P = .005), although this finding did not cross the threshold of significance after Bonferroni correction [52]. Neither smoking nor the presence of diabetes mellitus had a significant effect on complications or reoperations in bivariate analysis [52]. The type of implant used was not significantly associated with increased complications or reoperation [52]. Furthermore, no difference in complications was observed based on laterality, number of digits, or diagnosis [52].

Arthroplasty: Silicone interpositional arthroplasty of the DIP joint carries a low overall complication rate of 5% [27]. For failed DIPJ silicone arthroplasty, a customized structural bone graft technique achieves reliable union rates and high patient satisfaction [26].

Debridement: In a review of 78 patients undergoing open cheilectomy and debridement of the DIP joint, no postoperative infections or other complications were noted [41]. No reoperations were required or performed during the follow-up period in this cohort [41].

Other Considerations: The Mini-Acutrak screw is suitable for DIPJ fusion in all fingers with the exception of the small finger [28].

Recovery

Light activity (weeks): The evidence does not specify a distinct timeline for light activities such as desk work or driving. However, bony union was present in 10 weeks or less in 86% of the digits [154]. In the author's experience of 20 joints, solid bony union was obtained in 19 and stable fibrous union in one [155].

Full activity (months): The provided evidence does not define a specific month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The provided evidence does not define a specific month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: Treatment delay of more than 8 hours after injury may develop significant DIP joint stiffness [24]. In the DIP joint, there is probably good reason to proceed to arthrodesis immediately [2]. Although bony union of the joint was delayed, firm bone union was ultimately obtained in all joints [151].

Functional milestones: The patient's function was good, despite limited flexion of the DIP joint to 30 degrees [9]. Radiological OA after an MFF is similar to the natural degenerative process in the DIP joint and is accompanied by a decrease in range of motion of the DIP joint, which does not clinically affect PROMs [18].

Other Considerations: The swan neck deformity in this individual progressed significantly with time because of increasing DIPJ flexion contracture [11]. DIPJ arthrodesis is the standard surgical treatment for DIPJ arthritis if conservative measures fail [39]. Intramedullary screw fixation preceded by DIPJ arthrotomy for cartilage and subchondral bone resection is commonly used [39]. Inclusion criteria for the percutaneous reamed arthrodesis study were DIPJ arthropathy of the long fingers for primary or post-traumatic osteoarthritis or inflammatory disease refractory to at least 6 months of conservative treatment [39]. Exclusion criteria for the percutaneous reamed arthrodesis study were revision procedures, severe angular deformity (> 35°) and infection [39]. Procedures were performed under local anaesthesia with 1% lidocaine digital block and part of a sterile glove used as a finger tourniquet [39]. A 5 mm mid-lateral incision was made under fluoroscopic guidance to access the DIPJ [39]. An ulnar approach was used for the index finger and a radial approach for the ring and little fingers [39]. There was no preference for the middle finger regarding approach [39]. In patients with arthrodesis of the DIP joint, the measurement was made from the end of the distal phalanx [29]. All implants were scored on lateral images according to Sweets and Stern (2011) to describe the migration of the prosthesis within the medullary canal [29]. Dorsal, palmar, and coronal migration of each implant within the medullary canal were defined using a fourpoint scale [29]. Grade 0 is defined as a well-aligned implant [29]. Grade 1 is defined as macroscopically evident migration [29]. Grade 2 is defined as severe migration with stem opposing cortex [29]. Grade 3 is defined as breach of cortex by stem [29].

Key Evidence

  • [L5] In the DIP joint there is probably good reason to proceed to arthrodesis immediately. [2] (10.1016/s0363-5023(09)91115-7)
  • [L4] For persistently symptomatic, unstable DIP joints, arthrodesis should be considered. [4] (10.1016/j.jhsb.2005.09.003)
  • [L3] In our cohort finger DIP and thumb IP joint arthrodesis generally resulted in favourable outcome in terms of bony union regardless of the underlying medical condition or technical details of the surgical operation. [5] (10.1142/s2424835520500216)
  • [L3] The authors recommend simultaneous surgical intervention in case of severe painful OA of the PIP and DIP joints of the same digit. [6] (10.1177/17531934231191255)
  • [L3] Reamed percutaneous DIPJ arthrodesis is associated with higher union rates achieved in a shorter time and reduced postoperative pain compared with the non-reamed percutaneous technique. [7] (10.1177/15589447261487482)
  • [L4] In select patients, this percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques. [8] (10.1007/s11552-010-9265-9)
  • [L5] The patient's function was good, despite limited flexion of the DIP joint to 30 degrees. [9] (10.1016/s0020-1383(97)00121-6)
  • [L4] This technique may be a good surgical option for DIPJ arthrodesis when more volar part joint preparation and more volar implant insertion sites are necessary. [10] (10.1186/s12891-024-08016-6)
  • [L5] The swan neck deformity in this individual progressed significantly with time because of increasing DIPJ flexion contracture. [11] (10.1016/j.jht.2009.11.005)
  • [L4] The X-fuse implant seems to provide excellent stability with minimal hardware problems with a high rate of union in a wide array of patients with finger DIPJ and thumb IPJ arthritis. [12] (10.1097/bth.0b013e31829ba688)
  • [L4] The results obtained in this small series are equivalent to the traditional methods of DIP joint arthrodesis but with fewer major complications. [13] (10.1016/j.jhsa.2007.09.004)
  • [L5] Swanson hinge implant arthroplasty can be the surgical treatment of choice for the patient who desires continued mobility, albeit limited, of the involved osteoarthritic DIP joint. [16] (10.1016/s0894-1130(98)80061-6)
  • [L4] It presents a compelling motion-preserving alternative to arthrodesis for symptomatic DIP joint osteoarthritis. [17] (10.1016/j.jhsa.2026.01.027)
  • [L4] Radiological OA after an MFF is similar to the natural degenerative process in the DIP joint and is accompanied by a decrease in range of motion of the DIP joint, which does not clinically affect PROMs. [18] (10.1016/j.jhsa.2023.03.027)
  • [L5] Our understanding of morphology may lend insight into the biomechanics and disease progression within the DIP joints. [20] (10.1007/s11552-014-9605-2)
  • [L5] A cause for irreducible dislocation of a DIP joint is described. [21] (10.1016/s0363-5023(82)80018-x)
  • [L5] [23] (10.1016/j.jhsa.2010.09.003)
  • [L4] Treatment delay > 8 hours of injury may develop significant DIP joint stiffness. [24] (10.1016/j.otsr.2021.102852)
  • [L5] Palmar subluxation of a DIP joint without preexisting arthritic deformity is expected when more than one half of the dorsal articular surface is injured. [25] (10.1016/j.jhsa.2007.09.006)
  • [L4] A customized structural bone graft using the described technique addresses issues of bone stock loss and medullary absence in failed DIPJ silicone arthroplasty, achieving reliable union rates and high patient satisfaction. [26] (10.1177/17531934231151217)
  • [L4] The study confirms that silicone interpositional arthroplasty of the DIP joint is an acceptable alternative to arthrodesis, achieving excellent pain relief and a range of movement of 30–40 degrees with a low overall complication rate of 5%. [27] (10.1177/1753193411422679)
  • [L4] The authors conclude that the Mini-Acutrak screw is suitable for DIPJ fusion in all fingers with the exception of the small finger. [28] (10.1016/j.jhsa.2005.09.009)
  • [L4] [29] (10.1177/1753193413479527)
  • [L4] [32] (10.1142/s2424835518500406)
  • [L4] The combination of DIP arthrodesis and PIP Swanson arthroplasty resulted in a favourable outcome in terms of simultaneous bony union and flexibility. [36] (10.1177/17531934231215790)
  • [Case_report] Floating DIP joint injuries can be misdiagnosed initially due to minimal deformity; open reduction and internal fixation is a viable treatment option for chronic cases, though osteoarthritis may develop. [38] (10.1016/j.jhsa.2010.05.025)
  • [L4] [39] (10.1177/17531934251409628)
  • [L4] Irreducible palmar fracture-dislocation of the DIP joint in a child requires early open reduction due to mechanical obstruction by the displaced epiphysis and intact soft tissues. [40] (10.1007/bf00571488)
  • [L4] [41] (10.1016/j.jhsa.2017.07.006)
  • [L4] Neither antibiotics nor anti-inflammatory agents are effective, but early thorough synovectomy may avoid complications and obtain favorable results. [42] (10.1016/j.jhsa.2007.11.016)
  • [L4] [46] (10.1142/s0218810417500149)
  • [L4] Thus, the NMSS technique could be used as a feasible option in DIPJ and thumb IPJ arthrodesis, especially when a small finger is indicated and a significant flexion angle is required. [50] (10.1186/s12891-022-05473-9)
  • [L4] [51] (10.1016/0266-7681(93)90167-e)
  • [L3] [52] (10.1177/15589447251334671)
  • [L4] Classification of angular measurement according to the tested systems does not reflect the patient's perspective; it limits the precision of the measurement and adds little value to the measurement itself. [53] (10.1016/j.jhsa.2018.06.010)
  • [L4] This surgical technique reduces pain while preserving DIP joint motion. [54] (10.1177/1558944716660555i)
  • [L3] Osteoarthritis was the most common indication for arthrodesis and postoperative complications occurred at a rate similar to that reported in the existing literature. [57] (10.1186/s12891-024-07361-w)
  • [L3] Arthrodesis of the distal interphalangeal joint often leads to complications. [60] (10.1177/17531934221111641)
  • [L4] The only treatment that can ensure a cyst will not recur is DIP joint arthrodesis. [62] (10.1016/j.jhsa.2010.01.029)
  • [L2] Short-term DIP joint splinting is a safe, simple, inexpensive treatment modality which reduces DIP joint pain and improves joint extension. [63] (10.1016/j.jht.2013.08.004)
  • [L5] [97] (10.1007/s00402-008-0794-4)
  • [L4] The most important factor in the development of finger deformities is the changes occurring in the tendons and related structures, especially in early stages. [100] (10.2106/00004623-195739030-00006)
  • [L5] The role of these muscles was almost equal in cadaveric index, middle, and ring fingers. [106] (10.1002/jor.22021)
  • [L5] An examination of 100 specimens of the terminal joints of human fingers is described. [109] (10.1016/s0363-5023(82)80084-1)
  • [Case_report] Primary synovial chondromatosis of the distal interphalangeal joint is an extremely rare entity that requires accurate diagnosis to distinguish from other arthropathies. [118] (10.1177/15589447211049520)
  • [L5] Given the lack of difference in biomechanical performance between K-wires and compression screws, consideration should be given to other factors such as cost and complication profiles when choosing an implant for DIPJ fusion. [119] (10.1177/1558944715627211)
  • [L4] Inflammation seems to negatively impact the healing process, and we suggest assessing if there is DIP joint inflammation to anticipate the failure of treatment, which will require a longer treatment. [126] (10.1016/j.hansur.2021.01.009)
  • [L5] [127] (10.1016/j.hansur.2021.03.021)
  • [L5] A case is reported in which a finger with no active flexion did not develop erosive osteoarthritis at the time that it developed in the other active digits. [130] (10.1016/s0363-5023(84)80119-7)
  • [L4] [131] (10.1097/bth.0b013e31812f5714)
  • [L4] The interrater reliability of the Kellgren & Lawrence and OARSI classification systems for post-traumatic osteoarthritis in the distal interphalangeal joint after mallet finger fractures is considerably lower than initially assumed. [136] (10.1016/j.jhsa.2024.03.012)
  • [L4] The technique is simple and reliable giving consistent clinical results with a very low non-union rate and an acceptable complication rate. [139] (10.1007/s00402-007-0457-x)
  • [L5] We confirmed the existence of a distinct collagen septum between the extensor tendon and skin at the DIP joint using MRI and histology. [143] (10.1016/j.jhsa.2008.11.030)
  • [L4] Although bony union of the joint was delayed, firm bone union was ultimately obtained in all joints. [151] (10.1097/00130911-200212000-00008)
  • [L4] Bony union was present in 10 weeks or less in 86% of the digits. [154] (10.1016/s0363-5023(88)80104-7)
  • [L5] In the author's experience of 20 joints, solid bony union was obtained in 19 and stable fibrous union in one. [155] (10.1097/00130911-199906000-00008)

See Also

References

[1] 10.1177-15589447261447515. n.d..

[2] Synovial chondromatosis in the distal interphalangeal joint. The Journal of Hand Surgery. 1990. DOI: 10.1016/s0363-5023(09)91115-7

[4] Management of Tophaceous Gout of the Distal Interphalangeal Joint. Journal of Hand Surgery. 2006. DOI: 10.1016/j.jhsb.2005.09.003

[5] Factors Influencing Bone Union in Finger Distal Interphalangeal and Thumb Interphalangeal Joint Arthrodesis. The Journal of Hand Surgery (Asian-Pacific Volume). 2020. DOI: 10.1142/s2424835520500216

[6] Does distal interphalangeal joint arthrodesis affect proximal interphalangeal joint arthroplasty outcomes in the same finger?. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231191255

[7] Reamed Percutaneous Arthrodesis for Distal Interphalangeal Joint Arthritis Improves Bone Fusion and Pain Compared With a Non-Reamed Technique. HAND. 2026. DOI: 10.1177/15589447261487482

[8] Treatment of Symptomatic Distal Interphalangeal Joint Arthritis with Percutaneous Arthrodesis: A Novel Technique in Select Patients. HAND. 2010. DOI: 10.1007/s11552-010-9265-9

[9] Dorsal dislocation of the distal interphalangeal joint with fracture of the volar base: an unusual type. Injury. 1997. DOI: 10.1016/s0020-1383(97)00121-6

[10] Smile incision and reverse shotgun approach in distal interphalangeal joint arthrodesis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-08016-6

[11] Swan Neck Deformity after Distal Interphalangeal Joint Flexion Contractures: A Biomechanical Analysis. Journal of Hand Therapy. 2010. DOI: 10.1016/j.jht.2009.11.005

[12] Distal Interphalangeal Joint Arthrodesis Using Nitinol Intramedullary Fixation Implants. Techniques in Hand & Upper Extremity Surgery. 2013. DOI: 10.1097/bth.0b013e31829ba688

[13] Alternative to the Distal Interphalangeal Joint Arthrodesis: Lateral Approach and Plate Fixation. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.09.004

[16] Distal interphalangeal joint implant arthroplasty in a musician. Journal of Hand Therapy. 1998. DOI: 10.1016/s0894-1130(98)80061-6

[17] Denervation with Cheilectomy of the Distal Interphalangeal Joint: Technique and Medium-Term Results. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2026.01.027

[18] Posttraumatic Osteoarthritis of the Distal Interphalangeal Joint: A Follow-Up Study of 12 Years After Nonsurgical Treatment of Mallet Finger Fractures. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2023.03.027

[20] Curvatures of the DIP Joints of the Hand. HAND. 2014. DOI: 10.1007/s11552-014-9605-2

[21] Displaced intra-articular osteochondral fracture—Cause for irreducible dislocation of the distal interphalangeal joint. The Journal of Hand Surgery. 1982. DOI: 10.1016/s0363-5023(82)80018-x

[23] Osteoarthritis of the Distal Interphalangeal Joint. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.09.003

[24] Open dorsal distal interphalangeal joint dislocations: A report of 20 cases. Orthopaedics & Traumatology: Surgery & Research. 2021. DOI: 10.1016/j.otsr.2021.102852

[25] A Biomechanical Study of Distal Interphalangeal Joint Subluxation After Mallet Fracture Injury. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.09.006

[26] Salvage of failed Swanson’s arthroplasty of the distal interphalangeal joint. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231151217

[27] Joint replacement in 131 painful osteoarthritic and post-traumatic distal interphalangeal joints. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411422679

[28] Use of a Headless Compressive Screw for Distal Interphalangeal Joint Arthrodesis in Digits: Clinical Outcome and Review of Complications. The Journal of Hand Surgery. 2006. DOI: 10.1016/j.jhsa.2005.09.009

[29] Ten years’ experience with a pyrocarbon prosthesis replacing the proximal interphalangeal joint. A prospective clinical and radiographic follow-up. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413479527

[32] A Functional Angle of Up to 35° at the Distal Interphalangeal Joint Can Be Achieved with Headless Compression Screw Fusion. The Journal of Hand Surgery (Asian-Pacific Volume). 2018. DOI: 10.1142/s2424835518500406

[36] Simultaneous anterograde screw arthrodesis of distal interphalangeal joint and silastic proximal interphalangeal joint replacement for osteoarthritis. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231215790

[38] Floating Distal Interphalangeal Joint Injury: Case Report. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.05.025

[39] Percutaneous reamed arthrodesis for distal interphalangeal joint arthritis: surgical technique and case series. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934251409628

[40] Irreducible palmar epiphyseal fracture-dislocation of the distal interphalangeal joint of a finger. Archives of Orthopaedic and Trauma Surgery. 1992. DOI: 10.1007/bf00571488

[41] Cheilectomy for Treatment of Symptomatic Distal Interphalangeal Joint Osteoarthritis: A Review of 78 Patients. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.07.006

[42] Sea Urchin Spine Arthritis of the Hand. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.11.016

[44] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > Image DISORDERS OF THE MUSCULATURE OF THE HAND.

[45] Exam Of The Hand Wrist 2Ed. 1.1 SKELETON OF THE HAND > The osseous skeleton.

[46] Arthrodesis of Little Finger Distal Interphalangeal Joint in Flexion to Regain Sporting Ability. The Journal of Hand Surgery (Asian-Pacific Volume). 2017. DOI: 10.1142/s0218810417500149

[50] Distal interphalangeal joint arthrodesis with nonaxial multiple small screws: a biomechanical analysis with axial headless compression screw and clinical result of 15 consecutive cases. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05473-9

[51] The Aetiological Significance of Work-Load in the Development of Osteoarthritis of the Distal Interphalangeal Joint. Journal of Hand Surgery. 1993. DOI: 10.1016/0266-7681(93)90167-e

[52] Factors Associated With Complications and Reoperations in Distal Interphalangeal Joint Fusion. HAND. 2025. DOI: 10.1177/15589447251334671

[53] Correlations Among Objectively Measured Impairment, Outcome Classification Systems, and Subjectively Perceived Disability After Flexor Tendon Repair. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.06.010

[54] Treatment of Symptomatic Distal Interphalangeal Joint Arthritis. HAND. 2016. DOI: 10.1177/1558944716660555i

[57] Arthrodesis of distal interphalangeal and thumb interphalangeal joint: a retrospective cohort study of 149 cases. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07361-w

[60] Risk factors in distal interphalangeal joint arthrodesis in the hand: a retrospective study of 173 cases. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221111641

[62] Mucous Cysts. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.01.029

[63] Splinting of the Distal Interphalangeal Joint Reduces Pain and Improves Extension at the Joint; Results Front the Splint-OA Study. Journal of Hand Therapy. 2014. DOI: 10.1016/j.jht.2013.08.004

[71] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.

[78] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > FLEXOR TENDON INJURY.

[86] Dupuytren S Disease And Related Hyperproliferative Disorders. 54. The Future of Dupuytren’s Research and Treatment > 54.4 Mechanical Measurements and Procedures > 54.4.4 Imaging.

[97] Malignant Natural-Killer cell neoplasm presenting as a mucous cyst on the distal interphalangeal joint of the finger. Archives of Orthopaedic and Trauma Surgery. 2008. DOI: 10.1007/s00402-008-0794-4

[100] Finger Deformities Caused by Rheumatoid Arthritis. The Journal of Bone & Joint Surgery. 1957. DOI: 10.2106/00004623-195739030-00006

[106] Combinatorial roles of extrinsic and intrinsic muscles in extension strength of the distal interphalangeal joint. Journal of Orthopaedic Research. 2011. DOI: 10.1002/jor.22021

[109] The distal interphalangeal joints of human fingers. The Journal of Hand Surgery. 1982. DOI: 10.1016/s0363-5023(82)80084-1

[118] Primary Distal Interphalangeal Joint Tenosynovial Chondromatosis of the Small Finger: A Case Report With Literature Review. HAND. 2022. DOI: 10.1177/15589447211049520

[119] Biomechanical Analysis of Internal Fixation Methods for Distal Interphalangeal Joint Arthrodesis. HAND. 2016. DOI: 10.1177/1558944715627211

[126] When should splint treatment start for a tendinous mallet finger? A retrospective review of 319 fingers. Hand Surgery and Rehabilitation. 2021. DOI: 10.1016/j.hansur.2021.01.009

[127] Percutaneous management of swan neck deformity using WALANT: case report featuring a new surgical technique. Hand Surgery and Rehabilitation. 2021. DOI: 10.1016/j.hansur.2021.03.021

[130] Sparing effect of tendon injury on osteoarthritis. The Journal of Hand Surgery. 1984. DOI: 10.1016/s0363-5023(84)80119-7

[131] Tenodermodesis for Chronic Mallet Finger Deformities in Children. Techniques in Hand & Upper Extremity Surgery. 2007. DOI: 10.1097/bth.0b013e31812f5714

[136] Rater Agreement of Post-Traumatic Osteoarthritis of the Distal Interphalangeal Joint 12 Years After a Mallet Finger Fracture. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2024.03.012

[139] Arthrodesis of the distal interphalangeal joint: description of a new technique and clinical follow-up at 2 years. Archives of Orthopaedic and Trauma Surgery. 2007. DOI: 10.1007/s00402-007-0457-x

[143] Dorsal Digital Septum of the Distal Interphalangeal Joint. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.11.030

[151] Distal Interphalangeal Joint Arthrodesis Using a Minimally Invasive Technique with the Herbert Screw. Techniques in Hand and Upper Extremity Surgery. 2002. DOI: 10.1097/00130911-200212000-00008

[154] Arthrodesis of small joint of the hand: A rapid and effective technique. The Journal of Hand Surgery. 1988. DOI: 10.1016/s0363-5023(88)80104-7

[155] Arthrodesis of Digital Joints for Congenital Hand Condition. Techniques in Hand & Upper Extremity Surgery. 1999. DOI: 10.1097/00130911-199906000-00008

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