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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.

Overview

• In select patients, percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques [1].
• Swan neck deformity can progress significantly over time due to increasing DIPJ flexion contracture [2].
• Simultaneous surgical intervention is recommended for severe painful osteoarthritis of the PIP and DIP joints of the same digit [3].
• Denervation with cheilectomy presents a motion-preserving alternative to arthrodesis for symptomatic DIP joint osteoarthritis [4].
• A lateral approach and plate fixation for DIP joint arthrodesis yields results equivalent to traditional methods but with fewer major complications [5].
• The combination of DIP arthrodesis and PIP Swanson arthroplasty results in a favourable outcome regarding simultaneous bony union and flexibility [7].
• 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% [8].
• The smile incision and reverse shotgun approach is a surgical option for DIPJ arthrodesis when more volar part joint preparation and more volar implant insertion sites are necessary [9].
• The nonaxial multiple small screws (NMSS) technique is a feasible option for DIPJ and thumb IPJ arthrodesis, especially when a small finger is indicated and a significant flexion angle is required [11].
• A customized structural bone graft addresses issues of bone stock loss and medullary absence in failed DIPJ silicone arthroplasty, achieving reliable union rates and high patient satisfaction [14].
• There is no difference in biomechanical performance between K-wires and compression screws for DIPJ arthrodesis, so cost and complication profiles should be considered when choosing an implant [26].

Anatomy & Pathophysiology

Bony Anatomy & Dimensions

• A substantial number of distal phalanges are too small to accommodate commonly available headless compression screws, particularly in females and the small finger [25].
• The dorsal integument of the distal phalanx is characterized by the presence of the nail bed with its matrix [28].
• The hand consists of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand [27].

Soft Tissue Anatomy

• The terminal tendon of the extensor mechanism inserts at the base of the distal phalanx to extend it [29].
• The dorsal covering of the interphalangeal articulations of the digits forms a unique cutaneous unit characterized by a considerable excess of skin when the digits are in extension [28].
• The fine tight skin of the dorsal aspect of the middle phalanx forms a distinct functional cutaneous unit [28].

Pathophysiology & Biomechanics

• Osteoarthritis occurs with the highest prevalence in the distal interphalangeal joint of the hand and has been divided into an erosive and a nonerosive form [12].
• The pathogenesis of the early stages of osteoarthritis is poorly understood, but considerable emphasis has been placed on the role of cartilage and subchondral bone as well as soft tissue structures such as collateral ligaments and tendons [12].
• Palmar subluxation of a DIP joint without preexisting arthritic deformity is expected when more than one half of the dorsal articular surface is injured [6].
• Fracture fragments that are less than 43% of the distal phalanx articular surface usually do not allow volar subluxation, whereas fragments involving larger than 52% of the joint surface consistently allow subluxation [48].
• Mallet fractures associated with large fragments may result in volar subluxation of the distal phalanx as the collateral ligaments remain attached to the fracture fragment [48].
• If left untreated, mallet fractures with volar subluxation may lead to a secondary swan neck deformity of the finger, premature osteoarthritis, pain, or stiffness [48].
• Immobilization of the distal interphalangeal joint of any finger reduces the overall grip strength of the hand, with the effect becoming progressively more pronounced from the index to the little fingers [19].
• Positioning the middle finger DIP joint in either extension or 20° of flexion did not significantly affect grip strength or dexterity [38].
• Irreducibility was more commonly seen in dorsal than in volar dislocations of the distal interphalangeal joint [49].
• Volar dislocations of the distal interphalangeal joint carried a higher risk of instability immediately after reduction compared to dorsal dislocations [49].

Classification

• Osteoarthritis of the distal interphalangeal joint has been divided into an erosive and a nonerosive form [12].
• 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 [50].

Clinical Presentation

• Osteoarthritis occurs with the highest prevalence in the distal interphalangeal joint of the hand [12].
• The pathogenesis of the early stages of osteoarthritis is poorly understood [12].
• Considerable emphasis has been placed on the role of cartilage and subchondral bone in the pathogenesis of distal interphalangeal joint osteoarthritis [12].
• Soft tissue structures such as collateral ligaments and tendons play a role in the pathogenesis of distal interphalangeal joint osteoarthritis [12].
• Radiographic evaluation represents the most standardized method to quantify disease progression in distal interphalangeal joint osteoarthritis [12].
• Different systems have been developed for defining and grading radiographic features of distal interphalangeal joint osteoarthritis [12].
• Osteoarthritis at the distal interphalangeal joint often results in pain and deformity [15].
• Swan neck deformity can progress significantly with time due to increasing distal interphalangeal joint flexion contracture [2].
• 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 [6].
• Radiological osteoarthritis after a mallet finger fracture is similar to the natural degenerative process in the distal interphalangeal joint [13].
• Radiological osteoarthritis after a mallet finger fracture is accompanied by a decrease in range of motion of the distal interphalangeal joint [13].
• The decrease in range of motion following mallet finger fracture does not clinically affect patient-reported outcome measures [13].
• Primary synovial chondromatosis of the distal interphalangeal joint is an extremely rare entity [43].
• Primary synovial chondromatosis of the distal interphalangeal joint requires accurate diagnosis to distinguish from other arthropathies [43].
• Floating distal interphalangeal joint injuries can be misdiagnosed initially due to minimal deformity [21].

Investigations

• A distinct collagen septum exists between the extensor tendon and skin at the DIP joint, confirmed using MRI and histology [55].
• The curvatures of the DIP joints may lend insight into the biomechanics and disease progression within the DIP joints [10].

Treatment

Non-Operative

• DIP joint splinting reduces pain and improves extension at the joint [17].
• DIP joint splinting does not result in non-compliance, increased stiffness, or restriction of range of motion [17].
• Collagenase Clostridium histolyticum injection is an option for treating DIP joint contractures in Dupuytren disease [54].
• The potential risk for recurrence must be carefully weighed prior to using Collagenase Clostridium histolyticum for DIP joint contractures [54].

Operative

• Arthrodesis is generally the most accepted surgical option for treatment of degenerative and traumatic conditions involving the DIP joint of the fingers or the IP joint of the thumb [20].
• The ideal position for DIP joint arthrodesis is slightly flexed to improve power, fine pinch, and grip [20].
• Most surgeons use straight intramedullary implants for DIP joint arthrodesis, which obligates the joint to be positioned in neutral extension [20].
• Dorsal plate fixation allows for DIP joint arthrodesis in slight flexion [20].
• Indications for DIP joint fusion include rheumatoid arthritis, posttraumatic arthritis, and chronic conditions [20].
• Percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques in select patients [1].
• A lateral approach with plate fixation for DIP joint arthrodesis yields results equivalent to traditional methods but with fewer major complications [5].
• Diabetes and surgeon experience are factors that increase the risk of postoperative complications in DIP/thumb IP joint arthrodeses [16].
• Open cheilectomy and debridement of the DIP joint is a safe and effective alternative to DIP joint arthrodesis in patients with symptomatic osteoarthritis who wish to preserve joint motion [15].
• In a review of 78 patients, open DIP joint cheilectomy resulted in a significant improvement in mean visual analog scale pain scores from 8 to 1 [15].
• In a review of 78 patients, open DIP joint cheilectomy improved DIP joint flexion contracture by a mean of 6 degrees and DIP joint range of motion by a mean of 20 degrees [15].
• No postoperative infections or other complications were noted in a review of 78 patients undergoing open DIP joint cheilectomy [15].
• No reoperations were required during the follow-up period in a review of 78 patients undergoing open DIP joint cheilectomy [15].
• Denervation with cheilectomy presents a compelling motion-preserving alternative to arthrodesis for symptomatic DIP joint osteoarthritis [4].
• For patients prioritizing hand aesthetics or with unstable joints, DIP joint arthrodesis is preferable to silicone arthroplasty [18].
• The combination of DIP arthrodesis and PIP Swanson arthroplasty resulted in a favourable outcome in terms of simultaneous bony union and flexibility [7].
• The authors recommend simultaneous surgical intervention in case of severe painful OA of the PIP and DIP joints of the same digit [3].
• Open reduction and internal fixation is a viable treatment option for chronic floating DIP joint injuries, though osteoarthritis may develop [21].

Complications

• Arthrodesis of the distal interphalangeal joint often leads to complications [22].
• Diabetes and surgeon experience were identified as factors increasing the risk of postoperative complications in DIP and thumb IP joint arthrodeses [16].
• The complication rate for DIP joint arthrodesis using the AcuTwist headless compression screw was 9% [56].
• In a series of 48 primary arthrodeses using the AcuTwist device, three arthrodeses failed to fuse, including two asymptomatic nonunions and one fixation loss requiring revision with autograft [56].
• There were no cases of nail deformity, wound complications, tip hypersensitivity, or clinically notable malalignment in a series of 48 primary arthrodeses using the AcuTwist device [56].
• The overall complication rate for silicone interpositional arthroplasty of the DIP joint was 5% [8].
• No postoperative infections or other complications were noted in a review of 78 patients undergoing open cheilectomy and debridement of the DIP joint [15].
• No reoperations were required or performed during the follow-up period for patients undergoing open cheilectomy and debridement of the DIP joint [15].
• Swan neck deformity can progress significantly with time due to increasing DIPJ flexion contracture [2].

Recovery

Operative

• The results of lateral approach and plate fixation for DIP joint arthrodesis are equivalent to traditional methods but with fewer major complications [5].
• 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 [14].
• Diabetes and surgeon experience were identified as factors increasing the risk of postoperative complications in DIP/thumb IP joint arthrodeses [16].

Non-Operative

• Splinting of the DIP joint does not give rise to non-compliance, increased stiffness or restriction of range of motion [17].

Key Evidence

• [L4] In select patients, this percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques. [1] (10.1007/s11552-010-9265-9)
• [L5] The swan neck deformity in this individual progressed significantly with time because of increasing DIPJ flexion contracture. [2] (10.1016/j.jht.2009.11.005)
• [L3] The authors recommend simultaneous surgical intervention in case of severe painful OA of the PIP and DIP joints of the same digit. [3] (10.1177/17531934231191255)
• [L4] It presents a compelling motion-preserving alternative to arthrodesis for symptomatic DIP joint osteoarthritis. [4] (10.1016/j.jhsa.2026.01.027)
• [L4] The results obtained in this small series are equivalent to the traditional methods of DIP joint arthrodesis but with fewer major complications. [5] (10.1016/j.jhsa.2007.09.004)
• [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. [6] (10.1016/j.jhsa.2007.09.006)
• [L4] The combination of DIP arthrodesis and PIP Swanson arthroplasty resulted in a favourable outcome in terms of simultaneous bony union and flexibility. [7] (10.1177/17531934231215790)
• [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%. [8] (10.1177/1753193411422679)
• [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. [9] (10.1186/s12891-024-08016-6)
• [L5] Our understanding of morphology may lend insight into the biomechanics and disease progression within the DIP joints. [10] (10.1007/s11552-014-9605-2)
• [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. [11] (10.1186/s12891-022-05473-9)
• [L5] [12] (10.1016/j.jhsa.2010.09.003)
• [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. [13] (10.1016/j.jhsa.2023.03.027)
• [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. [14] (10.1177/17531934231151217)
• [L4] [15] (10.1016/j.jhsa.2017.07.006)
• [L3] Diabetes and surgeon experience were identified as factors increasing the risk of postoperative complications in these DIP/thumb IP joint arthrodeses. [16] (10.1186/s12891-024-07361-w)
• [L2] It does not give rise to non-compliance, increased stiffness or restriction of range of motion. [17] (10.1016/j.jht.2013.08.004)
• [L3] For patients prioritizing hand aesthetics or with unstable joints, distal interphalangeal joint arthrodesis is preferable. [18] (10.1177/1753193420917818)
• [L4] Immobilization of the distal interphalangeal joint of any finger reduces the overall grip strength of the hand, with the effect becoming progressively more pronounced from the index to the little fingers. [19] (10.1177/1753193418765068)
• [L4] [20] (10.1016/j.jhsa.2018.03.049)
• [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. [21] (10.1016/j.jhsa.2010.05.025)
• [L3] Arthrodesis of the distal interphalangeal joint often leads to complications. [22] (10.1177/17531934221111641)
• [L4] A substantial number of distal phalanges are too small to accommodate commonly available headless compression screws, particularly in females and the small finger. [25] (10.1007/s11552-014-9679-x)
• [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. [26] (10.1177/1558944715627211)
• [L2] Positioning the middle finger DIP joint in either extension or 20° of flexion did not significantly affect grip strength or dexterity, allowing other considerations such as appearance to be prioritized. [38] (10.1016/j.jhsa.2014.06.021)
• [Case_report] Primary synovial chondromatosis of the distal interphalangeal joint is an extremely rare entity that requires accurate diagnosis to distinguish from other arthropathies. [43] (10.1177/15589447211049520)
• [L5] [48] (10.1177/1753193414554772)
• [L4] Irreducibility was more commonly seen in dorsal than in volar dislocations, while volar dislocations carried a higher risk of instability immediately after reduction. [49] (10.1177/1753193415616957)
• [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. [50] (10.1016/j.jhsa.2024.03.012)
• [L4] Injection with CCH is an option for the treatment of DIP joint contractures in Dupuytren disease, though the potential risk for recurrence should be carefully weighed prior to its use. [54] (10.1016/j.jhsa.2018.07.004)
• [L5] We confirmed the existence of a distinct collagen septum between the extensor tendon and skin at the DIP joint using MRI and histology. [55] (10.1016/j.jhsa.2008.11.030)
• [L4] [56] (10.1016/j.jhsa.2013.09.040)

References

[1] 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

[2] 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

[3] 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

[4] 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

[5] 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

[6] 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

[7] 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

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

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

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

[11] 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

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

[13] 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

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

[15] 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

[16] 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

[17] 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

[18] Silicone arthroplasty versus screw arthrodesis in distal interphalangeal joint osteoarthritis. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420917818

[19] Effect of immobilization of the distal interphalangeal joint of fingers on grip strength. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418765068

[20] Dorsal Plate Fixation for Distal Interphalangeal Joint Arthrodesis of the Fingers and Thumb. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.03.049

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

[22] 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

[25] Dimensional Analysis of the Distal Phalanx with Consideration of Distal Interphalangeal Joint Arthrodesis Using a Headless Compression Screw. HAND. 2014. DOI: 10.1007/s11552-014-9679-x

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

[27] Exam Of The Hand Wrist 2Ed. INTRODUCTION.

[28] Exam Of The Hand Wrist 2Ed. Functional cutaneous units.

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

[38] Simulated Distal Interphalangeal Joint Fusion of the Index and Middle Fingers in 0° and 20° of Flexion: A Comparison of Grip Strength and Dexterity. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.021

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

[48] Mallet fingers with bone avulsion and DIP joint subluxation. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414554772

[49] Differences between dorsal and volar dislocations of the distal interphalangeal joint of fingers: a report of 30 cases. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193415616957

[50] 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

[54] Collagenase Clostridium histolyticum for the Treatment of Distal Interphalangeal Joint Contractures in Dupuytren Disease. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.07.004

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

[56] Arthrodesis of the Thumb Interphalangeal Joint and Finger Distal Interphalangeal Joints With a Headless Compression Screw. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.09.040