Hand and Wrist Surgery - part 5 ppsx

A simultaneous distal phalanx avulsion fracture with profundus tendon avulsion: a case report and review of the literature.. Dislocations: Phalanx and Metacarpals Volar Dislocations of t

Figure 36–4 (A) Lateral radiograph and (B) a radiograph of a type 3 avulsion secured with two cortical screws.

were placed with bicortical purchase (Fig 36–4) The fragment was seen to be stablewith a range of motion The tourniquet was deflated, hemostasis obtained, andsaline irrigation performed The skin was closed with 4–0 nylon simple sutures, abulky dressing applied, and a dorsal blocking splint applied with the wrist in 30 de-grees of flexion The fingers were splinted in the intrinsic-plus position to relax theFDP tendon and prevent postoperative stiffness

Type 1 and 2 injuries necessitate exploration at the level of the PIP joint, where

an additional palmar zigzag incision is used to expose the flexor sheath (Fig 36–3)

A transverse incision is made into the sheath just distal to the A2 pulley or throughthe C1 pulley If the FDP tendon is not found at this level, then an additional inci-sion is made in the palm and the flexor sheath is opened proximal to the A1 pulley

If the tendon is found at this level, it is classified a type 1 injury The long and shortvincula are ruptured, and the blood supply to the tendon is theoretically compromised.The tendon is retracted proximal to the flexor sheath, preventing this source of nutritionvia intrasynovial diffusion This necessitates earlier repair, within 7 to 10 days, to pre-vent possible necrosis and myostatic contracture that may develop A 4–0 Prolene suture

is placed as a core suture in the proximal tendon stump An infant feeding gastrostomytube or Swanson suture passer is placed in retrograde fashion from just distal to theA2 pulley (at the PIP level incision) through the flexor sheath Care is taken to placethe tube/suture passer through the flexor superficialis decussation and to exit proximal

to the A1 pulley The tube/suture passer is attached to the core suture, and the tendon ispulled distally to the level of the PIP joint Next the tube/suture passer is fed retrogradeunder A4 (from the DIP level incision) and the tendon is pulled distally to the level of

If the tendon was initially found at the level of the PIP joint upon exploration,

it is classified a type 2 injury The long vinculum is assumed to be intact, providing

a source of nutrition to the tendon and preventing further retraction of the tendoninto the palm The short vinculum from the distal end of the middle phalanx is rup-tured The tendon still lies within the flexor sheath and retains nutrition via in-trasynovial diffusion Due to these factors, the repairs have been reported more than

2 months after injury A 4–0 Prolene core suture is placed in the distal tendon end,and pulled underneath A4 as described before The suture is pulled through andtied to a button as described for a type 1 injury

If upon surgical exploration a type 4 injury is found, then reduction and fixation

of the bony fragment would be performed with screws, as described before Thetendon avulsion from this bony fragment would then be repaired to the distal pha-lanx, as described for a type 1 or 2 injury

Postoperative Management

This patient was seen the following week and started on a flexor tendon zone 1 sive range of motion protocol, as described by Evans A dorsal blocking splint wasplaced to keep the wrist in 30 degrees of flexion and the MP joints in 60 degrees

pas-of flexion A second dorsal splint was applied to the digit to maintain 45 degrees pas-offlexion at the DIP joint Passive flexion of the digit was allowed out of the splintseveral times daily A modified passive hook fist and passive PIP extension was al-lowed with the MP joints flexed Place and holds were performed for the FDS.Wrist extension to 10 degrees was allowed with the fingers flexed under therapist su-pervision Sutures were removed at 10 days and radiographs obtained at follow-upvisits to ensure reduction of the fragment and progression of healing

At 21 days, active range of motion was instituted with a full fist place and hold, andthe digital blocking splint was discontinued At 28 days the patient was started withtenodesis wrist exercises, gentle isolated FDS exercises, and hook fisting At 35 days, fullDIP active motion was allowed, including extension After bony union was confirmedradiographically and clinically, strengthening with resistance was started at 8 weeks; at

12 weeks the patient was allowed to return to full activity at work and in sports

Alternative Methods of Management

Alternatively, Bier block or local anesthesia can be used Care must be taken with localanesthesia, as the palm may also need to be blocked in case of a missed or convertedtype 1 injury A midlateral exposure can be used in the digit rather than a volar zigzag,depending on the surgeon’s preference

dis-Chronic (>3 months) untreated cases can be left alone if asymptomatic If there isbothersome instability or pain in the DIP joint, this can be treated by tenodesis orfusion If the remaining proximal stump of the profundus tendon is tender, this can

be excised from the palm Another somewhat laborious approach would be to form one- or two-stage tendon grafting through the superficialis, allowing active use

per-of the DIP joint

Complications

Rerupture of the tendon can occur early or late This should be repaired emergently

as with the initial injury Infection, skin slough, stiffness, and irritation at the woundand button site are infrequent A slight loss of extension at the DIP joint commonlyoccurs Nonunion or malunion of a bony fragment is a rare possibility, and can beprevented with careful attention to the bony reduction and fixation

Suggested Readings

Carroll RE, Match RM Avulsion of the flexor profundus tendon insertion J Trauma

1970;10:1109–1118

Eglseder WA, Russell JM Type IV flexor digitorum profundus avulsion J Hand

Surg [Am] 1990;15A:735–739.

Ehlert KJ, Gould JS, Black KP A simultaneous distal phalanx avulsion fracture with

profundus tendon avulsion: a case report and review of the literature Clin Orthop

1992;283:265–269

Evans RB A study of the zone I flexor tendon injury and implications for

treat-ment J Hand Ther 1990;133–148.

Leddy JP Avulsions of the flexor digitorum profundus Hand Clin 1985;1:77–83.

Leddy JP, Bechler J Flexor tendon avulsion from the distal phalanx In: Blair WF, ed

Techniques in Hand Surgery Baltimore: Williams & Wilkins; 1996:120–128.

Leddy JP, Packer JW Avulsion of the profundus tendon insertion in athletes J Hand

Surg [Am] 1977;2A:66–69.

Schneider LH Fractures of the distal phalanx Hand Clin 1988;4:537–547.

Smith JH Avulsion of a profundus tendon with simultaneous intraarticular fracture

of the distal phalanx–Case report J Hand Surg [Am] 1981;6A:600–601.

Strickland JW Flexor tendons–acute injuries In: Green DP, Hotchkiss RN,

Peder-son WC, eds Operative Hand Surgery, 4th ed Philadelphia: Churchill Livingstone;

1999:1877–1883

Trumble TE, Vedder NB, Benirschke SK Misleading fractures after profundus

ten-don avulsions: A report of six cases J Hand Surg [Am] 1992;17A:902–906.

Section VIII

Fractures and Dislocations

of the Hand

Distal Phalangeal Fractures

and Thomas R Kiefhaber

Metacarpal Shaft Fractures

Robert J Goitz, Sokratis Varitimidis,

and Dean G Sotereanos

Metacarpophalangeal

Joint Injuries: Fractures

(Intraarticular) at the Base of

the Proximal Phalanx, An

Arthroscopic Technique

Joseph F Slade III and John D Mahoney

Metacarpal Head Fractures

Paul R Greenlaw and Mark R Belsky

C Dislocations: Phalanx

and Metacarpals

Volar Dislocations of the Proximal

Interphalangeal Joint

Lisa L Lattanza and Steven Z Glickel

Lateral Dislocations of the Proximal

Interphalangeal Joint

Christopher H Martin and Steven Z Glickel

Proximal Interphalangeal Joint

Rosa L Dell’Oca and Amy Ladd

Distal Interphalangeal Joint Dislocations

John D Wyrick

Dorsal Metacarpophalangeal Dislocations (Irreducible)

Benjamin Chang and Mark Katz

Volar Metacarpophalangeal Dislocations (Irreducible)

Benjamin Chang and Mark Katz

D Thumb and Carpometacarpal Joint Ulnar Collateral Ligament Injuries: “Skier’s Thumb”

Kevin D Plancher

Carpometacarpal Joint Injuries: Bennett’s Fractures (Arthroscopic and Percutaneous

Screw Technique)

Joseph F Slade III and John D Mahoney

Carpometacarpal Joint Injuries: Bennett’s Fractures

D I S T A L P H A L A N G E A L F R A C T U R E S

227

PEARLS

• Expect patients 50% of the

time to have cold

intoler-ance, hypersensitivity, and

paresthesias

• Sew these flaps with chromic

or catgut sutures Suture to the

nail should be absorbable to

avoid painful removal in the

office

PITFALLS

• Attention to detail in lifting

the V-Y flap in the

subcuta-neous tissue will provide

sur-vival of the tissues

• Adequate incision and

drain-age with antibiotics will avoid

infection in most cases

37

Distal Phalangeal Fractures

Kevin D Plancher

History and Clinical Presentation

A 35 year old carpenter was on the job using a table saw He forgot to engage thesafety and cut the tip of his finger He presents to the emergency room with exposedbone at the tip of his finger after a transverse cut to his fingertip

ob-Differential Diagnosis

Distal phalanx fractureVascular injuryNerve injuryMallet fractureDistal phalanx (P3) dislocations

Diagnosis

Open Distal Phalanx Fracture with Soft Tissue Loss

The type of injury, the functional goal, and possible complications often determinethe treatment of fingertip injuries Factors to consider include finger sensitivity, anontender finger, maximum length, nail appearance, normal joint movement, andcosmesis On initial diagnosis, the viability of the tissues should be assessed to deter-mine which tissue is unlikely to survive It must also be determined what can be sac-rificed and what must be preserved to maintain function

Transverse amputations are the easiest to repair Treatment is determined by thecoverage of the bone The amount of nail following injury is also important in de-termining treatment Depending on the level of amputation, blood vessel and nervestatus must also be determined In oblique dorsal amputations, if the nail is onlypartially injured, an attempt must be made to preserve it The condition of the nailmatrix is also important Oblique palmar amputations are difficult to treat Thenarflaps are an option The goal of treatment in a palmar amputation is to provide a re-constructed pulp, which is sensitive and well cushioned

Surgical Treatment

For this patient the volar V-Y flap or Atasoy technique was used to provide coverage

of exposed bone with adequate padding The patient was most concerned with gertip tenderness and function of the finger

fin-The finger was prepared and a lidocaine metacarpal block supplemented withbupivacaine provided anesthesia A Penrose drain was placed on the digit to act as atourniquet The wound was irrigated and surgically cleaned, and debridement ofthe skin edges was performed A pattern of the defect was transferred onto the pal-mar skin proximal to the defect The skin pattern was made ~1 mm larger The pal-mar skin incisions were marked from the lateral edges of the defect site to enclosethe skin pattern and continued proximally and obliquely to meet in the midline ofthe finger at the distal crease (Fig 37–1) The skin was incised through the dermissharply and the flap was dissected from the periosteum and the flexor sheath TheGrayson’s and Cleland’s ligaments that surround the neurovascular bundles andconnect the flap to surrounding tissues were bluntly dissected and divided withdissection scissors (Fig 37–2) The flap was mobilized to allow advancement ofthe flap without tension (Fig 37–3) Hemostasis was maintained with a bipolarcautery

The flap was then sutured to the nail with nonabsorbable sutures (Fig 37–4).The apex of the V was closed with interrupted sutures, which were kept close to the

Figure 37–1 The palmar skin incisions are marked from the

lat-eral edges of the defect site to enclose the skin pattern and continue

proximally and obliquely to meet in the midline of the finger at the

distal crease.

Figure 37–2 The Grayson’s and Cleland’s ligaments that surround the neurovascular bundles and connect the flap to surrounding tissues are bluntly dissected and divided with dissection scissors.

skin edge to avoid interference with the vascular supply The tourniquet was flated and blood supply to the flap was verified The finger was treated with Xero-form, a light dressing, and a protective tip splint The patient was instructed to keepthe finger elevated for 2 days The dressing was changed 5 days postoperatively andthe patient was prescribed active exercises of the proximal interphalangeal (PIP)joint Sutures were removed at 14 days postoperatively and the patient was in-structed to keep the protective splint on for 4 to 6 weeks postoperatively

de-Alternative Techniques

The lateral V-Y flap technique uses flaps from the lateral side of the digit to closefingertip defects Digital anesthesia is obtained with metacarpal block The bone isdebrided and the wound is irrigated The dorsal incision is made from the amputa-tion site to 2 mm lateral to the nail fold and continued proximally midway betweenthe palmar and dorsal surfaces of the bone The incision length is twice the width

of the flap The oblique incision is made from the palmar edge of the defect tointersect with the dorsal incision (Fig 37–5) Advancement of the flaps requirescomplete release of the dorsal-lateral fibrous bands (Fig 37–6) With tension on thedistal aspect of the flap, the fibrous septum is dissected The two flaps are advanced

Figure 37–5 The oblique incision is made from the palmar edge of the defect

to intersect with the dorsal incision.

Figure 37–6 Advancement

of the flaps requires complete release of the dorsal-lateral fibrous bands.

Complications include infection, fingertip pain or stiffness, scar formation, and

loss of motion Most complications can be avoided with meticulous

intraopera-tive technique, adequate postoperaintraopera-tive care of the flap site, and early motion of thefinger

Suggested Readings

Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE Reconstruction of the

am-putated fingertip with triangular volar flap J Bone Joint Surg [Am] 1970;52A:921–926 Fisher RH The Kulter method of repair of fingertip amputations J Bone Joint Surg

[Am] 1967;49A:317–321.

Martin C, Gonzalez Del Pino J Controversies in the treatment of fingertip

amputa-tions Conservative versus surgical reconstruction Clin Orthop 1998;353:63–73.

Shepard GH The use of lateral V-Y advancement flaps for fingertip reconstruction

J Hand Surg [Am] 1983;8A:254–259.

Tupper J, Miller G Sensitivity following volar V-Y plasty for fingertip amputations

J Hand Surg [Br] 1985;10B:183–184.

Figure 37–7 The two flaps are advanced toward each other and sutured together and to the nail bed.

Figure 38–2 Radiograph, splay lateral, demonstrating a mallet of the ring finger of a different patient.

Figure 38–1 Attitude of a finger with the inability to extend the

tip sitting at 45 degrees.

38

Mallet Fractures

Kevin D Plancher

History and Clinical Presentation

A 45-year-old left hand dominant professional squash player was lunging for a shotand fell, landing on his hand He had sudden pain in his long finger with the inabil-ity to extend the tip of his finger The patient reported no other injuries He has nohistory of arthritis

Physical Examination

The patient is unable to extend the tip of his finger There is swelling around the jury The tip of the fingers is sitting at a 45-degree dropped position (Fig 38–1).The finger has full vascular flow

in-Diagnostic Studies

Anteroposterior (AP), splay lateral, and oblique radiographs of the injured digitwere obtained The joint was assessed for joint dislocation, subluxation, and frac-tures (Fig 38–2)

Differential Diagnosis

Soft tissue malletDislocated distal interphalangeal (DIP) joint

to tell patient that half the

“droop” will be a goal

• Do not underestimate the

cosmetic emotional effect of

a mallet finger on individual

personalities.

PITFALLS

• ORIF of a distal phalanx (P3)

mallet is a technically

demand-ing exercise One drill hole is

permitted with one pass only to

avoid infection and damage

to the articular surface.

• Nonoperative treatment may

lead to a splint that is too tight

Dorsal skin ulceration and

maceration

Figure 38–3 A type A mallet finger.

Diagnosis

Mallet Fracture with Subluxation

Mallet finger injuries range from pure tendon rupture to tendon rupture with afracture of the base of the distal phalanx A type A mallet finger is a tendon rupture(Fig 38–3), a type B is a chip fracture, a type C is an avulsion fracture without dis-placement, a type D is an avulsion fracture with displacement of the fragment (Fig.38–4), and a type E has displacement of the avulsion fracture with subluxation ofthe distal phalanx Type E fractures often require operative intervention Forcefulhyperflexion usually results in pure tendon ruptures or tendon ruptures with a smallbone fracture

In fractures involving articular surfaces, accurate anatomic reduction by surgery

is usually required For mallet fractures, satisfactory finger function may be regaineddespite mild arthrosis

more than one third to one half of the joint space with volar subluxation present,open reduction and internal fixation (ORIF) have obtained good results

Surgical Management

Kirschner Wire Technique

Regional or digital block anesthesia may be used If digital block is used, 2% caine is introduced either dorsally between the metacarpal heads or via a palmarapproach The anesthetic is injected on the radial and ulnar sides of each digit di-rectly over the neurovascular bundle It is very important to confirm that the injec-tion has successfully anesthetized the dorsal cutaneous because it supplies the area ofthe incision

lido-Using an H-shaped incision, dissection is made through the dorsal subcutaneoustissue Most of the dorsal veins are sacrificed, although most of the radial and ulnarones may be saved Skin flaps are mobilized deep to the epitenon of the extensormechanism to help avoid skin sloughing The flaps are held by stay sutures and keptmoist throughout the procedure using copious amounts of saline or lactated Ringer’ssolution The dorsal 30% of the radial ulnar collateral ligaments of the DIP joint can

be taken down to mobilize the distal phalanx Loupe or other magnification devicemay be used to adequately visualize the injury

The key to successful restoration of fracture and successful return to function inthe long run rests on leaving the extensor mechanism intact and attached to thefracture fragment The joint is copiously irrigated Next, fracture fragment and anyhematoma present are evacuated

Reduction is obtained by anatomic realignment of the dorsal cortex of the distalphalanx Small instruments such as a dental probe, Freer elevator, and fine-toothforceps are helpful in holding the reduction in place A 0.028-inch Kirschner wire(K wire) is passed retrograde through the dorsal third of the fracture surface in thedistal phalanx in such a way that the wire passes through the distal phalanx just be-low the sterile matrix of the nail bed and avoids the undersurface of the nail.Next, the dorsal fragment is anatomically reduced with the DIP joint in neutralposition, and the pin is driven back across the fracture site This secures both thefragment and the DIP joint The second pin is passed through the fragment into thedistal phalanx as an added stabilization force This should be accomplished withextreme care because multiple attempts at fixation often result in comminution

of the fracture and further compromises the possibility of achieving stabilization Ifthe fragment seems large for a K wire of the size suggested, a second wire may beadded instead of using a larger wire The additional wire adds torsional stability and

is less likely to further break up the fragment

Figure 38–5 (A) Lateral radiograph of middle phalanx with no volar subluxation present (B) Mallet splint used for this type of fracture.

M A L L E T F R A C T U R E S

235

Anatomic reduction of the fragment is then confirmed by posteroanterior andsplay lateral radiographs The skin is then closed with nylon, and a bulky dressingand plaster splint are applied The splint should immobilize the DIP joint and ex-tend across the wrist to neutralize the flexor muscles

At 4 to 6 weeks local tenderness at the site of the fracture should be assessed

If fracture healing has begun (as shown by minimal tenderness), the transarticular

K wire should be removed Active DIP joint flexion should then be instituted withblocking of the joint When 2 or 3 additional weeks have passed, the remaining

K wire is removed At this time, more active motion with resistance can be started.Splinting may be reinstated if displacement is noted or discomfort begins To avoidrefracture, splinting should continue at night or during strenuous activity for atleast 6 more weeks Any wire at anytime that can be moved by gentle manipulationshould always be removed to avoid the risk of infection secondary to a loose wire

Alternative Technique

Surgical Technique for Percutaneous Open Reduction

and Internal Fixation (ORIF)

After suitable antibiotics, the right arm is prepped and draped in the usual sterilefashion A well-padded tourniquet is placed on the right upper arm and followedwith exsanguinations and tourniquet up to 250 mm Hg

A mini C-arm is brought into the field and a small transverse incision, the size of

a screw head, is made over the distal phalanx The skin is cut through to the minal tendon Under fluoroscopy, use a reduction tool to verify that anatomic re-duction is achieved (Fig 38–6), and then again, using the C-arm, a spinal needle is

ter-Figure 38–6 C-arm utilized operatively to verify the anatomic reduction.

radi-M A L L E T F R A C T U R E S

237

placed to match an appropriate angle to place the screw into P3 (distal phalanx).Meticulous technique is used with a 1.1 mm drill bit while an assistant holds thehand, and then a self-tapping screw is usually used (8 mm) to transfix the fracture(Fig 38–7) A longitudinal 0.35-inch K wire may be placed to allow screw protec-tion while healing in the first 3 weeks (Fig 38–8) Gentle active assisted range-of-motion exercises are begun at 8 weeks with a protective splint (Fig 38–9) Fullpassive and active exercises without restrictions can be performed at 12 weeks

Complications

Complications seen following mallet fracture surgery include deep joint infection,joint incongruity, and nail deformity

Suggested Readings

Casscells SW, Strange TH Intramedullary wire fixation of mallet finger J Bone

Joint Surg [Am] 1983;65B:606–607.

Darder-Prats A, Fernanadex-Garcia E, Fernanadex-Gabarda R, Darder-Garcia A

Treatment of mallet finger fractures by the extension-block K-wire technique J Hand

Surg [Br] 1998;23B:802–805.

Gaberman SF, Diao E, Peimer CA Mallet finger: results of early versus delayed

closed treatment J Hand Surg [Am] 1994;19A:850–852.

Inoue G Closed reduction of mallet fractures using extension-block Kirschner wire

J Orthop Trauma 1992;6:413–415.

King HJ, Shin SJ, Kang ES Complications of operative treatment for mallet

frac-tures of the distal phalanx J Hand Surg [Br] 2001;26B:28–31.

Lubahn JD Mallet finger fractures: a comparison of open and closed technique

J Hand Surg [Am] 1989;14A:394–396.

Yamanaka K, Sasaki T Treatment of mallet fractures using compression fixation

pins J Hand Surg [Br] 1999;24B:358–360.

Proximal Phalangeal Shaft Fractures

Kevin D Plancher

History and Clinical Presentation

A 37-year-old right hand dominant high school teacher and coach of the footballteam comes to the office because he got his finger caught in a football helmetduring a drill He said that he felt a crack and looked down and noticed his longfinger on his right hand was pointing toward his thumb He reports taking hold

of it and pulling back straight and had the team trainer tape it to the index ger He has no history of diabetes or vascular disease, and is presently not on anymedications

fin-Physical Examination

The tips of all fingers have good capillary refill and the patient’s two-point sensory crimination, as determined by the Weber two-point discrimination test, using a dullpointed eye caliper applied in the longitudinal axis of the digit without blanching theskin, is within normal limits of all fingers The hand and fingers show no sign of vas-cular compromise Fingers are noted to be swollen with no obvious deformity and noopen wounds Patient was able to actively flex and extend all other fingers but felt pain

dis-in the little fdis-inger between the metacarpophalangeal (MP) and proximal dis-langeal (PIP) joints and was limited on his motion He was sent for radiographs

interpha-Diagnostic Studies

Diagnostic studies include anteroposterior, splay lateral, and oblique radiographs ofthe hand Oblique splay films are especially helpful in assessing intraarticular frac-tures and in removing the overlap from adjacent digits

Differential Diagnosis

Fracture of the phalanxIntraarticularExtraarticularComminutedTumor of proximal phalanx

Diagnosis

Extraarticular Oblique Proximal Phalanx Fracture

Many types of phalangeal fractures are seen, and the examining physician must notethe resting posture of the injured hand in each case When the fingers of the handare flexed, a line should be drawn from the dorsal aspect of the PIP joint to the fin-gernail This line should converge, not to a single fixed point, but rather directly

238

PEARLS

Interosseous Wiring

STABLEFRACTUREPATTERNS(TRANSVERSE)

• Treat stable fracture pattern

conservatively

• When a stable fracture pattern

becomes unstable it needs to

be surgically stabilized

• A K wire is utilized to stabilize

the fracture after the

inter-osseous wire is placed

• Preserve periosteum for closure

• Leave the twisted wire on the

noncontact side of the finger

(Start wire from that side.)

• Leave at least 5 mm bone

bridge from fracture line to

wire.

PITFALLS

• Do not treat an unstable

frac-ture pattern conservatively

(spiral oblique)

• If you leave prominent the

twisted interosseous wire there

will be soft tissue irritation

• Do not stabilize the fracture

with K wire prior to tightening

the stainless-steel wire when

using the interosseous wire

technique

to the area of the scaphoid from the radial artery to the palmaris longus One of themost common causes of malunion is a malrotation of a phalangeal fracture, and it isdiagnosed by physical examination, not by x-ray (Fig 39–1).

Proximal phalanx fractures are often obvious, and local swelling along with thedeformity are easy to identify Recognition of rotational malalignment is essential Acomplete sensory and motor evaluation should always be done, and the integrity ofthe dermis should be examined The vascular integrity needs to be documented, andpatency of collateral circulation should always be tested with an Allen’s test of thewrist and digit Satisfactory physical examination may not be possible without localanesthetic, but the block should be provided only after a careful two-point sensoryexamination has been completed

Indications for operative intervention for phalangeal fractures are based on cerns about shortening or malrotation Spiral and short oblique fractures are usuallymore susceptible to instability, and a few millimeters of shortening, although ac-ceptable in the metacarpal, is not acceptable in the phalanx Malrotation is neveracceptable, and operative intervention is required for intraarticular fractures, openfractures, fractures with bone loss, and multiple phalangeal fractures that are associ-ated with a neurovascular or tendon injury Extensive soft tissue injury may requirestable fixation to allow early mobilization and skin loss with hand fractures associ-ated with polytrauma needs operative repair

con-Many factors determine the selection of treatment, including fracture location,intraarticular or extraarticular deformity, angulation, rotation, shortening, open orclosed injury, associated neurovascular and soft tissue injuries, and the nature of thefracture (i.e., transverse, spiral, comminuted, or oblique) Additional considerationsfor operative reduction or internal fixation include the surgeon’s skill with the fixa-tion device, the patient’s ability to work postoperatively with an appropriate plan,and the patient’s occupation

The operative goal is always to avoid prolonged immobilization because of the risk of permanent deformity and stiffness However, soft tissue damage, infection, the need

for a second procedure, and technique failure can occur when moving the fractures

aggressively if fixation is not rigid Operative fixation must ultimately have a

bet-ter outcome than nonoperative management, and the risks and benefits must always be explained to the patient.

P R O X I M A L P H A L A N G E A L S H A F T F R A C T U R E S

239

PEARLS

Screw Fixation

• Fracture edges are inspected

and the optimal position for

screw fixation (perpendicular)

is selected

• Anatomic reduction is ideal for

maximal compression

• Ensure the fracture fragment

is at least three times the

thread diameter of the screw

for fixation.

• Long oblique and spiral

frac-ture patterns may be fixed

with 1.5-mm screws if the

frac-ture is two to three times

diam-eter of the phalanx

• Loupe magnification is helpful

when using 1.1- or 1.5-mm

screws.

PITFALLS

Screw Fixation

• Failure to clean and free

fracture edges of soft tissue

or hematoma will not allow

anatomic reduction

• The screw head many irritate

the soft tissues when prominent

• Early range-of-motion exercises

without stable, rigid fixation will

cause the loss of anatomic

re-duction and possible

malalign-ment or malunion.

Figure 39–1 Intraoperative photo of malalignment

of a fractured little finger (a different patient).

Nonsurgical Treatment

There are so many ways to treat phalangeal fractures that the choice of approach pends on the experience, expertise, and personal preference of the physician No singlemethod of treatment can be applied to all fractures of the phalanx, and a surgeon must

de-be comfortable with multiple techniques Fracture healing takes the same amount oftime no matter which method is chosen, if treatment is performed correctly

Many fractures of the phalanges can be treated by closed reduction and cast mobilization If the fracture pattern is stable (transverse), it can be treated nonsur-gically Fracture patterns that are inherently unstable (spiral oblique) will fall out ofalignment and will usually require surgical stabilization Soft tissue conditions withany neurovascular compromise or swelling may prevent nonoperative treatment.The position for immobilization is the intrinsic-plus position, with the MP joint in

im-at least 70 degrees, if not 90 degrees, of flexion and the PIP and distal langeal (DIP) joints in extension

interpha-A proximal phalanx dorsal blocking cast with an adjacent finger held in the castcan be applied when the hand is in the intrinsic-plus position, contracture is avoided,and the intrinsics are maintained in a relaxed position This position also effectivelyimmobilizes stable fractures of the proximal phalanx (Fig 39–2)

the surgeon while preserving soft tissue gliding planes and minimizing surgical sult to the surrounding tendons Exposure of the phalanges for fracture fixation isdone primarily from a dorsal or lateral approach Palmar exposures are discouraged,except when the PIP joint exposure is necessary for a volar plate arthroplasty.Exposure of the proximal and middle phalanx is accomplished through a dorsallongitudinal incision or a midaxial incision, with the terminal aspects of the incisioncurving toward the midline of the digit The ends of the incision are incorporatedinto the dorsal skin creases allowing for adequate cosmesis This extensile exposureallows access to the extensor hood, as well as access in the midaxial line.

in-The extensor tendon must be retracted for exposure of the fracture when access tothe middle phalanx is necessary The periosteum should be incised at the midaxialline and raised as a flap, thereby preserving the gliding surface between the perios-teum and the extensor tendon Proximal phalanx fractures exposed through a dorsallongitudinal split in the extensor tendon have adequate exposure The periosteumshould be raised as a flap to allow exposure to the fracture and preservation of a glid-ing surface between the fracture plane and the extensor tendon

Long Oblique Fracture: Open Reduction and Internal Fixation (ORIF)

Screw fixation is used in the management of long oblique fractures To manage tures with screws alone, it is recommended that the length of the fracture be at leastthree times the width of the shaft The choice of implant depends on skeletal sizeand fracture location Low-profile implants are widely available now In general,fractures of the phalanges are fixed with 1.0 mm to 2.0 mm screws Self-tappingscrews diminish the technical complexity of this technique

frac-The technique of compression-screw fixation is usually done in a reproducible quence of steps Once the fracture has been opened, the fracture line is identified,and the fracture is anatomically reduced and held with either pointed reductionclamps or a small, smooth Kirschner wire (K wire) Ideally, the surgeon should try

se-to minimize exposure of the skelese-ton, thereby limiting the devascularization First,drill the near cortex with a 1.5-mm drill bit because this allows the screw to dynam-ically compress the fracture site The technical point of this technique is to drill onlythe near cortex with this larger 1.5-mm drill bit Then use a countersink to the nearcortex to increase the contact pressure of the screw head Place the drill guide intothis near cortex drill hole and then drill the far cortex with a 1.1-mm drill bit Thedrill sleeve is designed to fit in the near cortex and align the drilling of the far cor-tex Measure the depth of the hole on the volar aspect to get the correct length screwand then tap with a 1.5-mm tap Using a tap sleeve protects the surrounding softtissues Place the appropriate screw and follow with the second screw, and, if neces-sary, the third screw should be placed accordingly (Fig 39–3)

Transverse Fracture: Interosseous Wiring

The surgeon may choose from wrist blocks, intravenous regional or brachial block,

or general anesthesia The patient is placed supine, and, using a hand table, the armand hand are extended onto the field

Using a dorsal longitudinal incision over the long proximal phalanx we make

a lateral approach We elevate the periosteum, and preserve it for later closure Thefracture site is exposed and the fracture hematoma is debrided

The cleaned two fracture ends are exposed, and a drill hole is made with a0.035-inch K wire parallel to the transverse fracture, leaving a bridge of at least

P R O X I M A L P H A L A N G E A L S H A F T F R A C T U R E S

241

frac-5 mm from the fracture line A 26-gauge (No 0) stainless-steel wire is thenpassed through the holes Keep in mind that the side you want to leave thetwisted wire on is the side you start on This is usually best when left on the non-contact side Load a smooth 0.035-inch K wire into your driver and place itobliquely out through the dorsal cortex until the tip protrudes slightly at thefracture site Now reduce the fracture anatomically and then advance the wireinto the proximal fragment and achieve cortical contact The wires are thentwisted around each other, and using the appropriate device (surgeon choice),are tightened Secure the loop onto the bone The twisted end is bent so that it isnot prominent, to prevent soft tissue irritation.

The periosteum is then restored and closed, followed by simple closure of theskin The K wire remains in place and is trimmed to the appropriate length, and thetip protector is attached (Fig 39–4)

Alternative Technique

Plate fixation in the hand skeleton should be infrequent and should be reservedprimarily for the metacarpals Use of plates in the fingers is discouraged because ofthe frequent need for removal of hardware and tenolysis However, highly commin-uted fractures may require fixation with plates to allow adequate stability for earlymotion For the phalanges, 1.5- and 2.0-mm plates are recommended Their appli-cation requires an extensive exposure of the joint and precise placement of the im-plants (Fig 39–5)

Postoperatively, have the patient try to achieve joint motion above and below thephalangeal fracture Many factors determine the patient’s ability to proceed withearly range of motion: the fracture geometry, the extent of soft tissue injury, and pa-tient ability and reliability A general rule with pins is that they should be removed

no later than 4 weeks in phalangeal fractures In stable and minimally displaced ture patterns, the pin can safely be removed in 3 weeks to allow early active motion.Pins left in longer than 4 weeks are associated with permanent stiffness of the digit.Range of motion when plate or screw fixation is performed can be initiated after

frac-4 to 5 days of soft tissue rest Plate and screw fixation of the hand skeleton withoutthe incorporation of a supervised early active range-of-motion program results inpermanent stiffness of the hand ORIF should be avoided in any patient who is un-able to comply with an early active motion program

Complications

When malunion presents a functional problem, corrective osteotomies are effective

in restoring motion Nonunion is associated with percutaneous pinning of the ture in distraction, and if this occurs, it is best managed with ORIF

frac-Loss of motion is the most frequent complication when working with

pha-langeal fracture fixation A supervised comprehensive hand therapy program, ing active and passive range-of-motion exercises combined with dynamic splinting

includ-or progressive static splinting, is always recommended After 3 to 4 months, tenolysisand capsulotomy of stiff joints are often helpful when supervised hand therapy hasfailed to restore acceptable motion

Infection is a frequent complication when working with the percutaneous

pin-ning technique of phalangeal fractures Most cases are self-limiting and respondrapidly to antibiotics and pin removal Osteomyelitis secondary to complex openfractures can be particularly difficult to eradicate

Flexor or extensor tendon adhesions, with phalangeal fractures, may result from

closed or operative treatment A supervised progressive therapy program should beinitiated If supervised hand therapy for 3 months does not restore or improve mo-tion, then a tenolysis may be indicated

Suggested Readings

Jupiter JB, Axelrod TS, Belsky MR Fractures and dislocations of the hand In:

Browner BD, ed Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries 2nd

ed Philadelphia: WB Saunders, 1998:1294

Jupiter JF, Winters S Open reduction internal fixation: phalangeal fractures In:

Strickland JW, ed Master Techniques in Orthopaedic Surgery, The Hand Philadelphia:

Lippincott-Raven; 1998:41–48

McCue FC, Honner R, Johnson MC Jr, et al Athletic injuries of the proximal

in-terphalangeal joint requiring surgical treatment J Bone Joint Surg [Am] 1970;54A:

937–956

McElfresh EC, Dobyns JH, O’Brien ET Management of fracture-dislocation of the

proximal interphalangeal joints with extension-block splinting J Bone Joint Surg [Am]

1970;54A:1705–1711

244

Miller MD, Howard RF, Plancher KD Treatment of Fractures of the Phalanges and

Metacarpals Surgical Atlas of Sports Medicine Philadelphia: WB Saunders; 2003:

497–509

Stern PJ Fractures of the metacarpals and phalanges In: Green DP, Hotchkiss RN,

Pederson WC, eds Green’s Operative Hand Surgery, 4th ed New York: Churchill

Proximal Phalangeal Condylar Fractures

Carrie R Swigart

History and Clinical Presentation

A 53-year-old right hand dominant man slipped and fell, striking his left fifth digit

He initially thought little of it, and it was not until later that day, while he wasworking with some tires and caught his left small finger, that he noticed pain andswelling of the digit After initial consultation with an orthopedic surgeon, he wasreferred to a hand surgeon 6 days after injury

Physical Examination

There was circumferential swelling of the digit The finger angulated dorsally atthe level of the distal portion of the proximal phalanx No rotation deformity wasnoted, although the patient was unable to completely flex the digit Profundus andsublimis tendon function was intact, as was the neurovascular status The patientwas otherwise in good health He had had cardiac bypass surgery, but had no cur-rent complaints of exertional angina His only medication was Dilantin

Diagnostic Studies

Radiographs of the left small finger showed a comminuted fracture of the distal tion of the proximal phalanx The fracture was slightly shortened and angulated dor-sally ~35 degrees There was no apparent intraarticular involvement (Fig 40–1)

• Careful preparation and

plan-ning are mandatory for

suc-cessful use of the minicondylar

plate

• If rigid fixation is not likely to

be attainable, closed or

per-cutaneous methods must be

considered

PITFALLS

• Careful attention to rotation

alignment is critical

• The initial condylar K-wire

placement has little to no

margin for error.

• Additional soft tissue disruption

complicated by insufficient

stability can be disastrous

11 days after sustaining the fracture A Bier block anesthetic was used as a ripheral adjunct to general anesthesia The patient was placed in the supine posi-tion with the left upper extremity on a hand table The tourniquet, used for boththe Bier block and hemostasis, was placed on the upper arm It was inflated to

pe-250 mm Hg

An ulnar straight midaxial incision, ~4 cm in length, was made Careful section directly to the level of the bone was performed, achieving hemostasis withelectrocautery The dorsal sensory branches of the ulnar digital nerve were identi-fied and preserved The extensor apparatus was left intact and carefully elevated toexpose the fracture beneath Soft tissue and hematoma were removed using smallcurettes, and the fracture site was irrigated copiously

dis-Due to the intercondylar fracture pattern, a minicondylar blade plate was lected as the implant Because of the size of the phalanx, a 1.5-mm plate was cho-sen (Fig 40–2) The first step in applying the plate was to pass a 0.045-inchKirschner wire (K wire) distally across the condyles in the location of the futurecondylar screw (Fig 40–3A) Its position was carefully checked in the antero-posterior (AP) and lateral planes with a minifluoroscopy unit A preliminary re-duction of the fracture was performed so that the appropriate length for theminicondylar plate could be assessed This plate was then bent to match the lat-eral contour of the phalanx and trimmed to size The blade of the plate was alsotrimmed to fit the AP dimension of the condyles The blade of the plate was then

inserted by first drilling a 1.5-mm hole adjacent and parallel to the K wire(Fig 40–3B) The blade of the plate was then inserted, slipping the previouslyplaced K wire through the hole for the condylar screw (Fig 40–3C) The adjacentcondylar screw was then placed, obtaining bicortical purchase (Fig 40–3D) Oncethe condylar fragment was attached to the plate, the fracture was reduced Due

to the high degree of comminution, an anatomically keyed reduction could not

be obtained The fragments were aligned with maximal apposition of the fracturedsurfaces Rotation was carefully checked during fragment alignment The mostproximal 1.5-mm screw was placed next, thus holding the fracture aligned and re-duced with appropriate length of the proximal phalanx The subsequent threescrews were then carefully placed to rigidly stabilize the fracture (Fig 40–3E).The wound was irrigated and closed with interrupted 5-0 nylon and 5-0 plaincatgut sutures Final radiographs were obtained, and a well-padded hand dressingwas applied The hand was immobilized with volar and dorsal plaster splints

Postoperative Management

A therapist saw the patient on the third postoperative day and the splint anddressing were removed A custom-molded Orthoplast splint with the metacar-pophalangeal (MP) joints flexed 40 degrees and the interphalangeal (IP) jointsstraight was fabricated to immobilize the affected and neighboring digit Activerange-of-motion exercises were begun out of the splint several times a day Thefracture healed uneventfully, and showed solid union on radiographs at 6 weeks

248

Figure 40–2 A 1.5-mm titanium minicondylar blade plate.

Figure 40–3 Application of the minicondylar blade plate begins with placement of a Kirschner wire across the condyles (A), followed by a drill hole parallel to this wire to position the blade (B) The blade is then inserted across the condyles (C), and they are further stabilized with the condylar screw (D) The fracture of the shaft is then reduced and the proximal screws placed (E).

(Fig 40–4) Despite initiation of early range-of-motion exercises, the digit tion at last follow-up examination, 3 months postoperatively, showed a 20-degreeactive extension lag at the PIP joint and a 15-degree extension lag at the distal in-terphalangeal (DIP) joint PIP and DIP joint flexion were 70 and 75 degrees, re-spectively The patient had returned to all activities without limitation and had nocomplaints of pain.

mo-Alternative Methods of Management

Alternative methods of management for this case are open reduction and fixationwith another type of plate or with screws alone, or closed reduction and K-wire fix-ation (Table 40–1)

Alternative plates would include any of the 1.5- or 2.0-mm minifragment platesystems Because they are usually applied dorsally, these plates may be more bulkyand can cause more problems with tendon gliding Another disadvantage of theseplates is that they lack the torsional stability afforded by the blade Finally, it is diffi-cult to attain rigid fixation of small condylar fragments with a simple dorsal plate.The principles of their application would be the same as for the blade plate, that is,fixation of the condyles first, followed by reduction and fixation of the shaft to thecondyles

Either 1.5- or 2.0-mm screws can be used in isolation for selected fractures of theproximal and middle phalanges Their use requires a fracture with minimal com-minution and a long oblique or spiral pattern (i.e., in length at least 1.5 to 2 timesthe width of the base).

Fixation with K wires, although perhaps technically easier, may lead to timal results due to the inability to secure the fracture rigidly enough to allow forimmediate motion of the digits This method should be reserved for the case of themultiple digit injured hand when time allotted for fracture fixation is limited, or in

subop-a relsubop-atively simple frsubop-acture where minimsubop-al fixsubop-ation is required

Complications

Plate fixation of phalanx fractures is associated with multiple potential tions These include stiffness, malunion, nonunion, infection, and tendon rupture.Stiffness is the most common complication and is associated with complex frac-ture patterns requiring extensive soft tissue mobilization for fixation, and the failure

complica-to begin early poscomplica-toperative motion With certain fracture patterns, some amount

of residual stiffness is inevitable, but this can be minimized by rigid fixation andearly motion protocols

Malunion becomes significant when it interferes with hand function The mostcommon deformity is rotational, as this is the most difficult to judge clinically with-out being able to take the digit through a full range of motion If the resulting rota-tional or angular malunion is sufficient to hinder hand function, osteotomy afterfracture healing can be performed secondarily

Nonunion is associated with highly comminuted fractures resulting in bone loss,crush injuries, and open fractures Nonunions can be treated effectively in mostcases with internal fixation and bone graft

Infection may be classified as superficial and deep Superficial infections may besuccessfully treated initially with oral antibiotics and local wound care Deep infec-tion must be addressed with aggressive debridement and irrigation and intravenousantibiotics Occasionally, removal of the implant may be required and the digit can

be stabilized temporarily with pins or a small external fixator

Lag screw fixation Interfragmentary compression Useful only in select fracture patterns

(1.5 or 2.0 mm)

Kirschner wire fixation Technically easier, closed method Does not allow for early active motion