Volar Tilt as a Predictor in Dorsal Proximal Interphalangeal Joint Fracture–Dislocations

Background: Restoring the volar lip of the middle phalanx is key to regaining concentric joint gliding after dorsal proximal interphalangeal (PIP) joint fracture–dislocations, but no reliable radiographic assessment currently exists. This study introduces volar tilt as a new radiographic measure. Methods: We evaluated 27 dorsal PIP fracture–dislocations in 25 patients, analysing clinical outcomes, osteoarthritis (OA) and volar tilt on lateral radiographs at injury, after extension block pinning and at 16-year follow-up. Results: Initial volar tilt averaged 22°, improving to 12° after extension block pinning and 9° at follow-up, while adjacent uninjured fingers averaged −2°. Increased residual volar tilt was associated with pain and volar tilt ≥10° revealed significantly poorer Patient-Rated Wrist/Hand Evaluation scores and increased radiographic OA. Conclusions: Volar tilt reflects subluxation in both acute and chronic dorsal PIP joint fracture–dislocations and predicts better long-term outcomes and less radiological OA when properly restored. Level of Evidence: Level IV (Therapeutic)