Acute open reduction and rigid internal fixation of proximal interphalangeal joint fracture dislocation

Management of Pediatric Volar Plate Avulsion Fractures of the Proximal Interphalangeal Joint: A Systematic Review

BACKGROUND

Sudden, forced hyperextension injuries to the proximal interphalangeal joint leading to volar plate avulsion fractures are common hand injuries in children. Suboptimal management of these fractures can lead to the development of long-term complications such as stiffness and flexion contracture.

METHODS

MEDLINE (PubMed), Scopus, Embase, Google Scholar, and Cochrane CENTRAL databases were systematically searched, and additional studies were found through reference of articles up to June 15, 2023. Identified articles were assessed using predetermined inclusion/exclusion criteria.

RESULTS

Twenty-five articles were included, involving 268 patients with ages from 3 to 17 years. Fractures with less than 30% joint involvement, classified as Eaton type I or II, or designated as "Stable" in the Keifhaber-Stern classification, were treated through nonsurgical means. Surgical interventions, encompassing open reduction and internal fixation, were reserved for fractures with more than 30% joint involvement and/or meeting criteria such as Eaton type IIIa or IIIb and Keifhaber-Stern "Tenuous" or "Unstable." Positive outcomes were seen in 99.5% of patients receiving nonsurgical treatment, compared with 85.7% in the surgical cohort.

CONCLUSIONS

The literature demonstrated positive outcomes for fractures presenting with less than 30% joint involvement that were managed nonsurgically. In fractures with more than 30% joint involvement, surgical interventions yielded positive results. To further substantiate these findings, larger prospective studies with uniform measures are needed to validate the results of this study.

Blocking Plate for Volar Proximal Interphalangeal Joint Fracture Dislocation

PURPOSE

To assess the use of a 2-mm miniplate as a dorsal blocking plate to stabilize the central avulsion fragment in a proximal interphalangeal joint (PIP) volar fracture dislocation.

METHODS

This was a case series comprising 8 patients with volar fracture dislocation of the PIP joint. The average age of the patients was 36 years. The patients were managed by this technique within an average of 11 days following the injury. The clinical outcome measurements included the assessment of pain and range of motion of the PIP and distal interphalangeal joints.

RESULTS

The average follow-up duration was 20 months. The mean visual analog scale pain score was 1.9. The average range of motion of the PIP joint was 82°, whereas the average range of motion of the distal interphalangeal joint was 43°. Reduction of the subluxation was achieved in all cases, with no articular step remaining.

CONCLUSIONS

A dorsal blocking plate is a simple technique, associated with a satisfactory outcome, for volar fracture dislocation injuries of the PIP joint.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Hand-Specific External Fixation for Treatment of Complex Proximal Interphalangeal Joint Injuries

Background Complex proximal interphalangeal joint (PIPJ) fractures are challenging injuries to treat. There are multiple established treatment methods available for these injuries, including dynamic external fixation. This study reports the outcomes of complex PIPJ fractures treated with a hand-specific external fixation device.

Methods Twenty-five fingers in 25 patients were treated with the DigiFix external fixator device for treatment of a PIPJ dorsal fracture dislocation (n = 16) or pilon fracture (n = 9). There were 16 males and 9 females with a mean age of 40 years (range: 14–75 years) at the time of injury. The median time from injury to surgery was 10 days (interquartile range [IQR]: 5; range: 3–49). Chart and radiographic data were reviewed retrospectively.

Results The average duration of external fixation was 41 days (range: 26–62 days). At a mean follow-up of 28 weeks (range: 12–105 weeks), the mean PIPJ flexion was 82 (range: 30–105 degrees), extension was −10° (range: −30 to 0 degrees), and flexion/extension arc of motion was 72 degrees (range: 30–95 degrees). Final mean Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score was 21.5 (range: 0–65.8). There were zero major complications and six (24%) minor complications, including superficial cellulitis (4) and stiffness (2).

Conclusion Dynamic external fixation for the treatment of complex PIPJ injuries allows for early range of motion and leads to favorable outcomes. This hand-specific external fixator has a reproducible technique which results in predictable and reliable PIPJ distraction.

Treatment for Acute Proximal Interphalangeal Joint Fractures and Fracture-Dislocations: A Systematic Review of the Literature

Proximal interphalangeal joint (PIPJ) fractures and fracture-dislocations are common hand injuries and recognition of this injury pattern is essential in the management of these fractures. Although a variety of treatment options have been reported in the literature, the optimal treatment remains controversial. MEDLINE, EMBASE, and The Cochrane Library Database were screened for treatment strategies of PIPJ fracture and fracture-dislocation. Demographic data and outcome data were collected and recorded. A total of 37 studies including 471 patients and 480 fingers were reviewed. PIPJ range of motion (ROM) was greatest postoperatively in patients who underwent volar plate arthroplasty at 90.6 degrees. Dynamic external fixation resulted in the lowest PIP joint ROM with an average of 79.7 degrees. Recurrent pain and osteoarthritis were most often reported in extension block pinning at 38.5 and 46.2%, respectively. Open reduction and internal fixation had the highest rate of revision at 19.7%. Overall, the outcomes of PIP fractures and fracture-dislocations are based on the severity of injury, and the necessary treatment required. Closed reduction with percutaneous pinning and volar plate arthroplasty had good clinical and functional outcomes, with the lowest complication rates. Hemi-hamate arthroplasty and dynamic external fixation were utilized in more complex injuries and resulted in the lowest PIPJ ROM. This is a therapeutic, Level III study.

The Importance of Restoring Anatomy of the Proximal Interphalangeal Joint in Dorsal Fracture Dislocations

The proximal interphalangeal joint (PIPJ) is a complex anatomical structure. In managing fracture dislocations about the PIPJ, the aim is to restore a congruent joint that allows for smooth gliding motion. Detailed knowledge of the anatomy and biomechanics of the PIPJ is necessary in managing these injuries with predictable success. The breadth of techniques previously described in the treatment of such injuries is testament to the difficulties faced in achieving optimal clinical and radiological outcomes. In this article we detail the anatomy and biomechanics of the PIPJ and summarize current literature and principles for the treatment of dorsal fracture dislocations.

Pins and rubbers traction system for fractures of the proximal interphalangeal joint

PURPOSE

We aimed to evaluate the clinical results using the pins and rubbers traction system (PRTS) as described by Suzuki et al. for unstable intra-articular fractures of the proximal interphalangeal (PIP) joint and to assess the efficacy and the indication of the technique of the PRTS.

METHODS

Thirty-nine fingers in 39 patients (mean age 46.0 years) with unstable fractures of the PIP joint were treated by the PRTS. The mean interval between injury and surgery was 30.8 days. Active and passive exercise of range of motion of all fingers was started immediately after surgery. Radiographic and clinical results were evaluated at the final examination.

RESULTS

The mean period the PRTS was applied was 6.4 weeks. The mean follow-up period was 8.9 months. Anatomical union was obtained in all patients. No joint instability, no malunion, nor osteomyelitis was observed. At the final examination, the average active range of motion of the PIP joint was 74.6°. The average Visual Analogue Scale for pain and Quick Disability of Arm, Shoulder, and Hand score were 1.2 and 3.2, respectively.

CONCLUSIONS

The current study demonstrated good results of the PRTS for unstable intra-articular fractures of the PIP joint. Furthermore, satisfactory results were obtained in cases of an incomplete amputation at the PIP joint, a pathological fracture due to bone tumor, and an osteochondral defect due to comminuted fracture of the proximal phalangeal head, where costal osteochondral bone was transplanted. From this study, the PRTS is recommended as a useful treatment because it is widely effective for various unstable fractures of the PIP joint.

Modified Hemihamate Arthroplasty With Oblique Osteotomy of the Middle Phalanx Base to Reconstruct Proper Contour of the Articular Surface

Treatments of unstable dorsal fracture dislocations of the proximal interphalangeal (PIP) joint are very challenging. The authors performed modified hemihamate arthroplasty for these injuries in 13 patients (13 fingers). Our surgical technique was unique in the point that we put volarly oblique osteotomy in the coronal plane at the recipient site to create an adequate reconstruction of the volar lip of the articular surface of the middle phalanx. Affected fingers are index in 2, middle in 4, ring in 3, and little in 3, and the mean duration of follow-up was 14 months. Hemihamate arthroplasty was indicated if >30% to 50% of the volar articular surface of the middle phalangeal base showed comminuted fracture which was not large enough to allow open reduction and internal fixation. The average range of motion of the PIP joint was 17.7 degrees preoperatively, which was improved significantly to 71.3 degrees at final follow-up. Radiographically, all grafts were united but 1 showed mild graft absorption. Ten patients demonstrated normal joint space and other 3 showed mild degenerative change of PIP joints. Eleven patients showed good congruency of the PIP joint and other 2 demonstrated slight dorsal subluxation. Four patients complained of mild pain in flexion, but other 9 had no pain at all. The modified hemihamate arthroplasty is a reliable technique to treat comminuted dorsal fracture dislocations of the PIP joint.

Injuries Around the Proximal Interphalangeal Joint

Proximal interphalangeal joint (PIPJ) injuries are common and challenging to treat, involving a spectrum of conditions ranging from isolated ligamentous injuries to severe fracture dislocations. The main goal of treatment is to achieve a congruent, stable joint, which is key to achieving early range of motion and a favorable outcome. Injuries that do not compromise the stability of the joint may be treated nonsurgically, whereas those that render the joint unstable may be managed with one of many surgical strategies available. This article focuses on the current practices of treatment of injuries around the PIPJ.

Joint distraction and early mobilization using a new dynamic external finger fixator for the treatment of fracture-dislocations of the proximal interphalangeal joint

BACKGROUND

Dynamic external fixation is a useful treatment option for unstable fracture-dislocations of the proximal interphalangeal (PIP) joint, because it simultaneously reduces axial pressure load on the joint surface, maintains congruent joint reduction, and permits early joint motion. However, most current devices are large, hindering finger movement, and unstable. To address these problems, we developed a dynamic external finger fixator, named the Micro Ortho Fixator^®. The purpose of this study was to review the results of using the new external finger fixator to treat unstable fracture-dislocations of the PIP joint.

MATERIALS AND METHODS

Nine patients who sustained unstable fracture-dislocation injuries of the PIP joint were treated with the Micro Ortho Fixator^®. Seven fractures were accompanied by depressed bony fragments at the base of the middle phalanx. All patients were evaluated for pain and range of PIP motion at the final follow-up. Radiographs of the affected fingers were evaluated for PIP congruity and reduction. The mean follow-up duration was 11.1 months (range: 6-33 months).

RESULTS

At the final follow-up, pain averaged 0.3 (range: 0-2) on the Numeric Pain Rating Scale, and the total arc of motion at the PIP joint averaged 91.2° (range: 50-110°). All fractures had healed, and the intra-articular step-off improved from 1.9 mm (SD: 1.0) before surgery to 0.2 mm (SD: 0.4) at the final follow-up. The patients who sustained sports injuries returned to competition after an average of 3.5 months (range: 2.5-4 months).

CONCLUSION

The external fixator is compact and facilitates range-of-motion (ROM) exercises, has high stability, and achieves good joint congruity and an ROM equivalent to the healthy joint of the patient.

STUDY DESIGN/LEVEL OF EVIDENCE

Therapeutic/IV.

Biomechanics of Internal Fixation Modalities for Middle Phalangeal Base Fracture Dislocation

BACKGROUND

Internal fixation modalities of unstable (>50 percent articular involvement) middle phalangeal volar lip fracture-dislocations include interfragmentary screw and volar buttress plating. This study investigates the mechanical properties (yield strength, ultimate tensile strength, and stiffness) of interfragmentary screw (IS), simple buttress plating (BP) and buttress plating with subchondral screw (BP+S).

METHODS

Fifteen cadaveric digits (5 index, 5 middle, and 5 ring) were prepared by excising its skin envelope and flexor tendons while preserving the structures around the proximal interphalangeal joint. An oblique osteotomy involving 50 percent of the articular surface was performed, and this was fixed with based on its study group: interfragmentary screw (IS), simple buttress plating (BP) and buttress plating with subchondral screw (BP+S). These specimens were then loaded to failure.

RESULTS

Yield strength was as follows: BP+S (33.5±9.76 N), IS (13.6±5.46 N), and BP (8.1±3.84 N). Ultimate tensile strength was as follows: BP+S (49.1±21.4 N), IS (15.6±5.19 N), and BP (8.86±3.99 N). Stiffness was as follows: BP+S (4.77±1.32 N/mm), IS (2.44±0.86 N/mm), and BP (1.84±0.71 N/mm).

CONCLUSIONS

A buttress plate and screw construct confers significantly more stability than either interfragmentary screw or buttress plate only fixation in an experimental model.

Lessons Learned from the Management of Complex Intra-Articular Fractures at the Base of the Middle Phalanges of Fingers

The use of dynamic traction splintage is established in the treatment of complex intra-articular phalangeal fractures. Several different systems have been used and we report our experience with one of these, the Pins and Rubber Traction System. A cohort of 14 patients with complex intra-articular fractures at the base of the middle phalanges of the fingers were treated and assessed prospectively over a 2.5-year period (mean, 20 months; range, 7–28 months). The mean active range of motion regained, at the proximal interphalangeal joint, was 74° (range, 0–100°). The mean total active motion of the injured digit was 196° (range, 40–275°). Refinements in the regime are suggested as a result of this investigation.

Internal Fixation of Unstable Fracture Dislocations of the Proximal Interphalangeal Joint

We report a group of 14 patients with fracture dislocations of the proximal interphalangeal joint with fracture fragments of adequate size to allow reduction of the proximal interphalangeal joint and internal mini screw fixation of the bone fragment attached to the palmar plate to the base of the middle phalanx. Three years after surgery, (range 25–52 months) the average total active range of motion of the proximal interphalangeal joint was 100° (range 65–115°) for the acute group (operation within 14 days of injury, n = 7) and 86° (range 60–110°) for the chronic group (operation on average 46 days after injury, range 21–120 days, n = 7). Longer delay from injury was associated with a decreased total range of motion ( P = 0.028). Further subluxation occurred in three chronic group patients, one required further surgery. The key to successful treatment of this injury is the re-establishment of joint congruity and early mobilization. With appropriate patient selection, pain free, satisfactory range of motion can be achieved. There is a risk of persistent subluxation or dislocation, particularly if treatment is delayed.

Dorsal Fracture Dislocations of the Proximal Interphalangeal Joint Treated by Open Reduction and Interfragmentary Screw Fixation: Indications, Approaches and Results

Many operative and non-operative treatments of dorsal fracture dislocations of the proximal interphalageal (PIP) joint have been described. Return of good joint function requires anatomical reduction of the articular fragments and restoration of joint congruity and a stable functional arc of motion, with the fixation construct stable enough for early mobilization. To prevent recurrent dorsal subluxation, the attachments of the ligamentous palmar restraints and the bony buttress provided by the palmar lip of the middle phalanx base must be restored. Open reduction and internal interfragmentary screw fixation using 1.5 or 1.3 mm screws was employed in 12 fingers in 10 patients with unstable dorsal fracture dislocations of the PIP joints of Schenck grades III and IV. At an average follow-up of 8.7 months, all patients in this series achieved good to excellent results and an average total active interphalangeal motion of 132° (range 105°–165°). Additional benefits over non-operative techniques included improved patient comfort and simplified nursing care and therapy supervision.

Factors affecting the functional results of open reduction and internal fixation for fracture-dislocations of the proximal interphalangeal joint

To clarify the factors affecting functional results of fracture-dislocations of the proximal interphalangeal (PIP) joint treated by open reduction and internal fixation (ORIF), 60 patients, including 38 patients with a dorsal fracture-dislocation and 22 with a pilon fracture, were analysed. The mean ratio of articular surface involvement was 48.5% and a depressed central fragment existed in 75.3% of the cases. ORIF was performed in 47 patients through a lateral approach using Kirschner wires and in 13 through a palmar approach using a plate or screws. The mean flexion, extension and range of motion (ROM) of the PIP joint was 89.5°, 11.5° and 78.0°, respectively. Stepwise regression analysis revealed that a delayed start of active motion exercise after surgery, elderly age and ulnar ray digit were factors affecting functional outcomes. Although ORIF allows accurate restoration of the articular surfaces, an early start of motion exercise is essential for good results.

Current concepts in treatment of fracture-dislocations of the proximal interphalangeal joint

BACKGROUND

Proximal interphalangeal joint fracture-dislocations are common injuries that require expedient and attentive treatment for the best outcomes. Management can range from protective splinting and early mobilization to complex surgery. In this review, the current concepts surrounding the management of these injuries are reviewed.

METHODS

A literature review was performed of all recent articles pertaining to proximal interphalangeal joint fracture-dislocation, with specific focus on middle phalangeal base fractures. Where appropriate, older articles or articles on closely related injury types were included for completeness. The methodology and outcomes of each study were analyzed.

RESULTS

When small avulsion fractures are present, good results are routinely obtained with reduction and early mobilization of stable injuries. Strategies for management of the unstable dorsal fracture-dislocation have evolved over time. To provide early stability, a variety of techniques have evolved, including closed, percutaneous, external, and internal fixation methods. Although each of these techniques can be successful in skilled hands, none has been subjected to rigorous, prospective, comparative trials. Volar dislocations fare less well, with significant loss of motion in many studies. Pilon fractures represent the most complicated injuries, and return of normal motion is not expected.

CONCLUSIONS

The best outcomes can be achieved by (1) establishing enough stability to allow early motion, (2) restoring gliding joint motion rather than noncongruent motion, and (3) restoring the articular surface congruity when possible. Although the majority of literature on this topic consists of expert opinion and retrospective case series, the consensus appears to favor less invasive techniques whenever possible.

Modified hemihamate arthroplasty technique for treatment of acute proximal interphalangeal joint fracture-dislocations

We retrospectively reviewed 11 patients who underwent modified hemihamate arthroplasty for the treatment of comminuted dorsal fracture-dislocation of the proximal interphalangeal (PIP) joint. This technique was used to minimize the potential risk of complications at the recipient site by volarly oblique osteotomy in the coronal plane at graft harvesting and anatomical repair of the detached flexor sheath. The average joint involvement of the fracture was 58.4%, and the mean duration of follow-up was 38 months. The active range of motion of the distal interphalangeal, PIP, and metacarpophalangeal joint was 80.4, 85.4, and 91.8 degrees, respectively. The mean disabilities of the arm, shoulder, and hand score was 4.8, and all patients achieved bony union at final follow-up. One patient showed radiographic signs of graft absorption, but this did not limit their daily activities. The modified hemihamate arthroplasty technique is safe and reliable and reduces the risk of iatrogenic damage when used to treat comminuted dorsal fracture-dislocations of the PIP joint.

Surgical exposures of the hand

Surgical approaches to the hand are commonly executed in the treatment of fractures, ligament injuries, and less commonly in the resection of bony tumors. Careful design and execution of these surgical approaches translates into superior functional and aesthetic outcomes. We have provided a thorough review of commonly used approaches to the hand by evaluating each of these approaches in the context of core principles including safety, versatility, preservation of stability, and aesthetic outcomes.

Pins and rubber band traction for treatment of comminuted intra-articular fractures in the hand

PURPOSE

To determine the efficacy of pins and rubber band traction for treatment of comminuted intra-articular fractures in the hand.

METHODS

We performed a retrospective study from 1994 to 2013 to evaluate 33 patients in whom pins and rubber band traction was employed. We clinically evaluated the active range of motion of the affected fingers after surgery. Eleven of the 33 fractures were at the proximal interphalangeal joint, 10 at the distal interphalangeal joint, 5 at the thumb interphalangeal joint, and 2 at the metacarpophalangeal joint of the thumb. The remaining 5 patients had complex fracture-dislocation of the proximal interphalangeal joints.

RESULTS

The mean follow-up period was 24 months. The average active motion of the metacarpophalangeal joints of the fingers was 91° (range, extension 0°-10°/flexion 85°-90°), proximal interphalangeal joints was 92° (range, extension/flexion 0°-10°/85°-100°), and distal interphalangeal joints was 73° (range, extension/flexion 0°-10°/60°-80°). The overall average of all active motion of the injured fingers except thumbs was 255° (range, 240°-270°). The average active motion of the of the thumb metacarpophalangeal joint was 56° (range, extension 5°-10°/flexion 50°-55°), and interphalangeal joint was 74° (range, extension 0°-10°/flexion 75°-80°). The average of active motion of the injured thumb metacarpal and interphalangeal joints combined was 130° (range, 125°-135°).

CONCLUSIONS

Pins and rubber band traction is a treatment option for comminuted displaced intra-articular fractures of the digits that offers satisfactory clinical results.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Current trends in the management of proximal interphalangeal joint injuries of the hand

Injuries to the proximal interphalangeal joint are commonly encountered by the hand surgeon. Proper diagnosis and treatment are vital for optimal outcomes. Proper treatment of these injuries requires a working knowledge of the anatomy of the joint and an appreciation for principles for reduction, stabilization, and early rehabilitation to provide the best outcomes possible. Injuries can include fractures of the head of the proximal phalanx, dislocations, fracture dislocations, and fractures of the base of the middle phalanx. Similar to other aspects of plastic surgery, there is little high-level evidence guiding treatment and thus most treatment is based on level III or IV evidence. The goal for treatment of any injury around the proximal interphalangeal joint is to establish a congruent joint and allow for early motion. Stiffness and posttraumatic arthritis are common following these injuries. Salvage procedures are limited to arthrodesis and arthroplasty, neither of which can restore the normal function of the hand.

Extension-block pinning for fracture-dislocation of the proximal interphalangeal joint

INTRODUCTION

Dorsal fracture-dislocation of the proximal interphalangeal joint is an unstable fracture that associates the anterior marginal fracture of the second phalangeal base and the dorsal dislocation of the proximal interphalangeal joint under the influence of the median band traction of the extensor apparatus. Stiffness and residual pain are frequent sequelae. Treatment involves choosing between the various methods with the objective of providing stable reduction allowing early mobilization.

HYPOTHESIS

We relate our experience concerning treatment by proximal interphalangeal extension-block pinning. It consists in reduction by external manipulation and stabilization by extension-block pinning.

MATERIALS AND METHODS

This technique was used in 22 Trojan-type fractures. The average age of our patients was 36 years, with a predominance of males. In half of the cases, the fracture involved more than 40% of the second phalangeal articular surface.

RESULTS

The mean follow-up in this series was 2 years and 7 months. Assessed based on functional, clinical, and radiological criteria, the results were good in 82% of the cases. The proximal interphalangeal joint was painless and the active mobility sector mean was greater than 85°.

DISCUSSION

The dorsal dislocation fracture of the proximal interphalangeal joint is an unstable lesion. Its treatment must provide stable reduction allowing early mobilization. Various therapeutic means are described. We opted for extension-block pinning, a simple and reproducible technique with encouraging results.

LEVEL OF EVIDENCE

Level IV retrospective study.

Nail hooks and elastic bands external dynamic traction for fractures of the proximal interphalangeal joint

Intra-articular fractures of the proximal interphalangeal joint remain a treatment challenge for hand specialists. The purpose of this investigation was to review the results of 12 patients, 6 men and 6 women (average age, 21 y), who were treated using the nail hooks and elastic bands external dynamic traction technique for their intra-articular proximal interphalangeal joint fractures. Of the total 12 fractures, 6 involved the proximal phalanx and 6 involved the middle phalanx. The final arc of motion at the proximal interphalangeal joint averaged 89 degrees (range, 25 to 111 degrees). At the conclusion of treatment: 1 patient developed a radial deviation and 1 developed a slight ulnar deviation. All patients were able to return to their preinjury level of functioning. Nail hooks and elastic bands external dynamic traction provides an effective treatment for intra-articular proximal interphalangeal joint fractures. It is an inexpensive, easily applied, nonoperative method of treatment.

Open reduction and internal fixation for dorsal fracture dislocations of the proximal interphalangeal joint using a miniplate

Various operative techniques have been described for unstable dorsal fracture dislocations of the proximal interphalangeal (PIP) joint with articular involvement. However, this injury still remains a therapeutic challenge for hand surgeons because no single technique guarantees successful outcomes. We performed a novel procedure using a low-profile miniplate, which allows for anatomic reduction, rigid internal fixation, and early finger joint motion. Between March 2003 and May 2009, 18 consecutive patients who suffered from 19 dorsal fracture dislocations of the PIP joint with volar articular fracture of the middle phalanx involving more than 40% of the articular surface were treated using this technique. The postoperative follow-up period averaged 16.6 months (range, 12-18 mo). Bony union was obtained in all cases. No patient showed residual dorsal subluxation. Active motion of the PIP joint averaged 85.0 degrees (range, 62-105 degrees), flexion contracture averaged 5.4 degrees (range, 0-17 degrees), and percent total active interphalangeal joint motion averaged 89.0% (range, 60%-100%). Two patients had restricted active distal interphalangeal joint flexion owing to tendon adhesion resulting from the use of a relatively long plate in the first few cases of this series. No major complications were reported for the other 16 patients. We describe the surgical technique, indications, complications, and postoperative management for this technique.

A percutaneous technique to treat unstable dorsal fracture-dislocations of the proximal interphalangeal joint

PURPOSE

Unstable dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint are complex injuries that are difficult to treat and usually require operative fixation. There are a number of surgical techniques for treating these injuries but none has emerged as superior. The purposes of this study were to describe a simple percutaneous technique to treat unstable dorsal fracture-dislocations of the PIP joint and to report short-term postoperative results.

METHODS

We treated 6 patients with unstable dorsal fracture-dislocations of the PIP joint with the technique of closed reduction, percutaneous fracture reduction, and pinning via a volar approach and also with dorsal block pinning. We collected information on postoperative stability, range of motion at the PIP and distal interphalangeal joints, and radiographic outcomes. We also administered the Disabilities of the Arm, Shoulder, and Hand and visual analog pain scale questionnaires.

RESULTS

At a mean follow-up of 18 months (range, 6-57 mo), there were no subluxation or dislocation events. The mean range of motion was from 4° of extension to 93° of flexion at the PIP joint and from 1° of extension to 73° of flexion at the distal interphalangeal joint. Radiographic analysis revealed a concentric reduction and union in all cases. The mean Disabilities of the Arm, Shoulder, and Hand score was 8 and the mean visual analog pain score was 1.4 out of 10. There were no minor or major complications.

CONCLUSIONS

This percutaneous technique reliably restored stability to the PIP joint, allowed for concentric reduction of the joint, and produced excellent radiographic and clinical outcomes. The postoperative management course with this technique is critical to the outcome.

Interphalangeal traction for comminuted fracture of middle phalanx fingers: case report

We report an interphalangeal traction system through capsuloligamentotaxis for the treatment of comminuted fracture of the middle phalanx. The interphalangeal (IP) traction system inserts a K-wire at the proximal and distal phalanx. The difference between our IP traction system compared with the modified Suzuki frame method is that distal IP and proximal IP joints are synchronously distracted in the fixator, and bony continuity and articular integrity are restored.

Percutaneous pinning of the displaced volar plate avulsion fracture of the PIP joint

The use of operative or non-operative techniques in the treatment of a volar plate avulsion fracture of the PIP joint has remained controversial. In this study, we describe the use of percutaneous K-wire fixation in 15 patients with a displaced and rotated large fragment of this injury. All processes of the technique, including reduction and interfragmental fixation, were performed with percutaneous K-wires. Mean follow-up was 14.2 months. All patients achieved bony union. Mean active motion was -1.3 degrees /86.2 degrees for the PIP joint and 0 degrees /77.5 degrees for the DIP joint and mean %TAIM was 94.6%. There were no complications. No patients complained of pain and all were able to return to their previous activity. Although this procedure is technically demanding, it reconstructs a rotated or displaced large volar plate avulsion with a low level of invasion, and achieves a satisfactory functional recovery.

Fractures of the proximal interphalangeal joints of the fingers

Fractures of the proximal interphalangeal joint include a wide spectrum of injuries, from stable avulsion fractures to complex fracture-dislocations. Stability of the joint is paramount in determining the appropriate treatment, which should aim to facilitate early mobilisation and restoration of function.

Surgical outcome of volar plate arthroplasty of the proximal interphalangeal joint using the Mitek micro GII suture anchor

BACKGROUND

The mechanism of injury in dorsal dislocation is usually a hyperextensive stress simultaneous with some degree of longitudinal compression. Operative treatment is indicated for those unstable and reduction is not achieved. We report the surgical outcome of volar plate arthroplasty of the proximal interphalangeal (PIP) joint using the Mitek Micro GII suture anchor.

METHODS

We reviewed the medical records of 20 patients with acute or chronic dorsal dislocation or subluxation of the PIP joint who were managed using the Mitek Micro GII suture anchor over the past 5 years by the same surgeon (J.T.S.). Fourteen patients had acute injuries (<4 weeks before surgery) and six patients had chronic injuries (average interval of 4.1 week from injury to surgery; range, 1-8 weeks). The patients had persistent pain and loss of range of motion after trauma, and the reductions were still unstable.

RESULTS

All patients were evaluated an average of 25 months postoperatively (range, 12-30 months). The average arc of motion of the PIP joints of the fingers was 82 degrees . There were no obvious perioperative complications, and no patient reported pain at rest or with activity.

CONCLUSION

Volar plate arthroplasty using the Mitek Micro GII suture anchor is an effective treatment choice for acute or chronic PIP joint dorsal dislocation or subluxation.

Hemicondylar hamate replacement arthroplasty for proximal interphalangeal joint fracture dislocations: an assessment of graft suitability

PURPOSE

Proximal interphalangeal (PIP) joint fracture-dislocations are complex injuries, and successful surgical treatment can be challenging. The hamate appears to be an appropriate graft based on its general shape and dimensions. The purpose of this study was to evaluate the rationale and suitability of the hamate as an autograft for proximal interphalangeal joint fracture-dislocations and to determine the inherent stability of the donor site after graft harvesting.

METHODS

Fresh-frozen cadaveric hand specimens were used to evaluate the hamate as a suitable graft source for defects of the middle phalanx based on macroscopic, radiographic, and biomechanical properties. Radiographic measurements were made of the articular contours of the hamate and the base of middle phalanx of digits 2 through 5. Hemicondylar hamate replacement arthroplasty (HHRA) was performed in cadavers for defects created in the middle phalanges. Biomechanical stability testing of the hamate-metacarpal joint was then assessed in additional specimens before and after HHRA. Fluoroscopic examination with a 22.2-N load applied in a 45 degrees dorsal-proximal direction was used to assess stability of the carpometacarpal joints. A servohydraulic testing machine was then used to determine the amount of translation induced with a similarly directed force before and after harvesting of the hamate graft.

RESULTS

The cadaveric HHRA reconstructions restored joint stability with no tendency to subluxate. Radiographic measurement showed that the hamate has a central ridge and bicondylar facet with articular contours that are similar to the base of the middle phalanx. The removal of a central portion of the hamate did not induce dislocation or create obvious clinical instability of the carpometacarpal joint.

CONCLUSIONS

The HHRA technique is used for treatment of fracture-dislocations of the proximal interphalangeal joint. This study demonstrated the suitability of using the dorsal portion of the hamate as an osteochondral autograft for middle phalangeal base fractures; the technique creates minimal donor site morbidity.

Treatment of proximal interphalangeal dorsal fracture-dislocation injuries with dynamic external fixation: a pins and rubber band system

PURPOSE

Unstable, dorsal, intra-articular, fracture-dislocations of the proximal interphalangeal (PIP) joint can be difficult to treat and often lead to long-term pain, stiffness, and functional deficit. We present the outcomes of patients sustaining such injuries that were treated by a novel dynamic external fixator. This fixator uses a system of K-wires and rubber bands that maintains a concentrically reduced PIP joint while allowing for early motion.

METHODS

Fourteen patients with unstable, dorsal fracture-dislocation injuries of the PIP joint were treated between September 2001 and January 2006. Eight were available for follow-up evaluation at an average of 26 months. We measured PIP range of motion and grip strength, and assessed pain on a visual analog scale. Demographic information about the original injury was recorded. New radiographs were obtained to assess joint congruency and the presence of arthritis or articular step-off deformity.

RESULTS

In the 8 patients available for follow-up evaluation, the average motion of the affected PIP joint was from 1 degrees (range 0 degrees to 5 degrees) to 89 degrees (range 75 degrees to 110 degrees). Grip strength was 92% (range 71% to 110%) of the unaffected hand. The average score on the visual analog pain scale was 0.6 (range 0-1.5). There were few complications. Radiographs at follow-up evaluation showed a concentric reduction in all joints, but with evidence of a small step-off deformity or arthritis in 5 patients.

CONCLUSIONS

The dynamic external fixator studied is an effective method of treating unstable, dorsal fracture-dislocation injuries. Outcomes compared favorably with those of other similar devices studied in the literature.

The Suzuki frame for complex intra-articular fractures of the proximal interphalangeal joint of the fingers

In 1994, Suzuki et al proposed the pins-and-rubbers traction system, a new dynamic distraction technique for difficult complex intra-articular fractures of the digits of the hand. From February 1999 to April 2003, we used the Suzuki frame for 15 complex fractures of the proximal interphalangeal joint of the fingers. The mean follow-up period was 18 months. Four patients missed their follow-up. In the remaining 11 patients, the mean active range of motion achieved following treatment was 84 degrees in the proximal interphalangeal joint finger injuries.

Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations

PURPOSE

Surgical intervention may be necessary to treat unstable dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint of the hand. One method of stabilization is open reduction and internal fixation (ORIF). The purpose of this study was to assess the outcomes of ORIF for unstable dorsal fracture-dislocations of the PIP joint using mini-screws via a volar approach.

METHODS

A retrospective chart review with clinical follow-up evaluation was performed on 9 patients who had ORIF for unstable dorsal fracture-dislocations of the PIP joint. The fracture fragment(s) from the middle phalangeal base were reduced and secured using mini-screws.

RESULTS

A clinical evaluation was performed at an average of 42 months after surgery. The average arc of motion for the involved PIP joint was 70 degrees (range, 55 degrees -90 degrees ). The average PIP joint motion in the 2 patients with 1 fracture fragment was 85 degrees , and the average PIP joint motion for the remaining 7 patients was 65 degrees . One joint was subluxated with an intra-articular screw. Nine patients had an average flexion contracture of 14 degrees . Seven patients had no pain, and 2 had pain only with heavy activity.

CONCLUSIONS

Open reduction and internal fixation of unstable dorsal PIP joint fracture-dislocations using mini-screws can be considered if the fracture fragment(s) can accommodate the screws. The procedure attempts to restore the concave contour of the middle phalangeal base and permits early protected range of motion. The procedure should be approached cautiously, especially in the presence of comminution. Proximal interphalangeal joint range of motion is usually compromised; 8 of our 9 joints had a residual flexion contracture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Double-strand suturing fixation technique for treatment of acute volar plate avulsion fracture of the base of the middle phalanx

A new suturing technique for treatment of acute volar plate avulsion fracture of the proximal interphalangeal joint is reported. Because this technique that consists of double-strand suture is rigid enough and never obstructs joint motion, early motion exercise can be allowed. This technique only demands simple skill like conventional K-wire fixation. Furthermore, removal of fixation material is not necessary.

The Suzuki Frame for Complex Intraarticular Fractures of the Thumb

BACKGROUND

Suzuki et al. in 1994 described the pins and rubber traction system for comminuted intraarticular fractures and fracture-dislocations of the proximal interphalangeal joint of the hand. The authors used the pins and rubber traction system to treat five complex fractures of the thumb.

METHODS

From February of 1999 to April of 2003, five patients, four men and one woman, had a pins and rubber traction system applied for complex fractures of the interphalangeal joint (two patients) and metacarpophalangeal joint (three patients) of the thumb. The mean age of the patients was 35.4 years (range, 28 to 50 years). The system was applied for 4 weeks in all cases.

RESULTS

The mean follow-up period was 23.6 months. The mean range of total movement for the metacarpophalangeal joint was 55 degrees (45 degrees of flexion and 10 degrees of extension). The two patients with the interphalangeal joint fractures achieved flexion of 0 to 65 degrees and 0 to 55 degrees, respectively. Joint space narrowing was observed in three cases. One patient had persistent swelling of the metacarpophalangeal joint 14 months after the initial treatment but had no functional deficit or pain. No pin track infection was observed in this series.

CONCLUSIONS

Previous reports regarding the application of the pins and rubber traction system have focused on pilon fractures and dorsal fracture-dislocation of the proximal interphalangeal joint. In the present study, the authors described their experience with application of the Suzuki frame for complex intraarticular fractures of the thumb. The authors believe that the pins and rubber traction system can be used to treat difficult intraarticular fractures of the thumb, with very good functional results.

Dynamic intradigital external fixation for proximal interphalangeal joint fracture dislocations

PURPOSE

Many skeletal traction devices have been described to treat fracture dislocations of the proximal interphalangeal (PIP) joint. Most of these techniques are technically challenging or involve cumbersome frames. We present a design modification that enhances the stability of a simple dynamic fixation system described previously and report our results with this technique.

METHODS

A previously described simple dynamic fixator with no rubber bands was applied to 6 patients who sustained fracture dislocations of the PIP joint. The middle finger was involved in 3 patients, the ring finger in 1 patient, and the small finger in 2 patients. The average age of the patients was 27 years (range, 21-42 y). The average involvement of the base of the middle phalanx was 48% (range, 35% to 60%). The average time from the injury to the surgery was 6 days (range, 1-14 d). The average follow-up period was 24 months (range, 7-43 mo). Immediate active flexion extension was allowed and the fixator was removed after 3 to 4 weeks.

RESULTS

The average range of motion of the PIP joint at the final follow-up evaluation was 5 degrees to 89 degrees (range, 0 degrees to 100 degrees ). Two patients developed pin track infection that resolved with oral antibiotics. Only one patient complained of mild pain with extreme flexion. Proper reduction and congruency of the joint was noted on final anteroposterior and lateral radiographs.

CONCLUSIONS

A simple dynamic fixator for the treatment of unstable PIP joint fracture dislocations was used successfully in 6 digits to maintain reduction and restore digital range of motion. The addition of modifications to the original technique not only improves the solidity of the construct but also provides satisfactory functional results. Based on our experience we recommend this easy technique to treat fracture dislocations of the PIP joint.

Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft

PURPOSE

This retrospective study was designed to evaluate the clinical and radiographic results of a hemi-hamate autograft for the treatment of comminuted dorsal proximal interphalangeal (PIP) joint fracture/dislocations.

METHODS

Thirteen consecutive patients underwent hemi-hamate autograft for the treatment of an unstable dorsal PIP fracture dislocation. The fractured middle phalangeal base was debrided and the defect was replaced using a size-matched portion of the dorsal/distal hamate osteoarticular surface and was secured with miniscrews. The average middle phalangeal volar lip involvement on initial radiographs was 60% (range, 40% to 80%). The average time to surgery was 45 days (range, 2-175 d). Range of motion, stability, and grip strength were measured at a mean follow-up evaluation of 16 months. Radiographs were evaluated for union, graft incorporation, and/or collapse. Subjective data, satisfaction, and return to work were obtained on 12 of the 13 patients at a mean follow-up evaluation of 17 months.

RESULTS

The average arc of motion at the PIP joint was 85 degrees (range, 65 degrees to 100 degrees ). The distal interphalangeal (DIP) joint average arc of motion was 60 degrees (range, 35 degrees to 80 degrees ). Average grip strength was 80% of the uninjured side. Bony union was achieved in all patients. One graft showed ulnar collapse but graft resorption was not noted. Except for 2 patients with recurrent dorsal subluxation there were no complications. The average pain level was 1.3 (as rated on a visual analog scale of 0-10). Eleven of 12 patients were very satisfied with their function and one was somewhat satisfied; one patient was lost to follow-up.

CONCLUSIONS

When greater than 50% of the volar base of the middle phalanx is fractured in a PIP fracture/dislocation or the joint remains unstable despite a lesser degree of involvement, a hemi-hamate autograft should be considered. This procedure reconstructs the cup-shaped contour of the middle phalangeal articular surface and facilitates a stable, functional arc of motion at the PIP joint. Additionally, in our experience the procedure renders minimal disability and has a low complication rate.

Treatment of complex interphalangeal joint fractures with dynamic external traction: a series of 20 cases

Data are reported for a series of 20 patients who were treated with the pins and rubbers traction system for fractures of the proximal interphalangeal joints of the long fingers. This technique allows fracture reduction with external dynamic traction and immediate active mobilization. Two patients in the series were lost to follow-up monitoring. For two others, the pins and rubbers traction system needed to be removed early (during the first week) because of intolerance or infection. Sixteen patients who were reexamined after minimal follow-up periods of 1 year demonstrated a mean active range of motion of 85.9 degrees for the injured joint; only one patient experienced intermittent pain.

PIP Fracture/Dislocation Treatment Technique: Use of a Hemi-Hamate Resurfacing Arthroplasty

The nature of injury following a PIP fracture dislocation is determined by the direction of force transmission and the position of the joint at the time of impact. Dorsal dislocations with palmar lip fractures are the most frequently encountered and can be classified based on stability. The degree of stability is directly determined by the amount of middle phalangeal palmar lip involvement; the larger the palmar lip fracture, the more unstable the joint becomes. When there is persistent instability or greater than 30 degrees of flexion is required to maintain reduction, treatment must be aimed at reconstituting the cup shaped geometry and buttressing effect of the volar lip of the middle phalanx if stability is to be restored. The use of a hemi-hamate autograft to reconstruct the base of the middle phalanx is a new technique that restores joint congruity and stability while allowing for early motion. This operative technique replaces the damaged palmar lip of the middle phalanx with a size-matched portion of the hamate obtained from its distal dorsal articular surface between the 4th and 5th metacarpals. By restoring both articular congruity and osseous stability the advantage of this procedure is that it allows more immediate rehabilitation with a potential for earlier motion, less stiffness and possibly less post-traumatic arthritis.

Treatment of fracture-dislocation of the proximal interphalangeal joint using the Suzuki external fixator

We describe a simple technique for fracture-dislocations of the proximal interphalangeal joint. Eight fingers with a fracture-dislocation were treated with a self-manufactured dynamic external fixator, allowing early mobilization. The fixator consists of pins and rubbers. The clinical and radiographic outcome was evaluated and recorded. A near-normal function was obtained in four patients. The average total active motion was 82 degrees. Radiographic reduction was maintained. This external fixator is an inexpensive and simple technique for these difficult fracture-dislocations. Early intervention (before two weeks post-trauma) is recommended.

Volar plate arthroplasty of the distal interphalangeal joint

Ten patients with chronic dorsal fracture subluxation of the distal interphalangeal joint were managed over 5 years with volar plate advancement arthroplasty. The mean time from injury to definitive surgical treatment was 8 weeks (range, 2 weeks to 4 months). All injuries were characterized by volar comminution and impaction of the distal phalanx, with associated dorsal subluxation. Surgical treatment included volar plate advancement arthroplasty and K-wire fixation of the reduced joint for 4 weeks. All patients were evaluated at an average postoperative duration of 25 months (range, 10-60 months). The average arc of motion of the distal interphalangeal joint of the 4 fingers (6) was 42 degrees and of the interphalangeal joint of the thumb (4) was 51 degrees. All patients had a residual flexion contracture averaging 12 degrees (range, 6 degrees to 25 degrees ). Volar plate advancement arthroplasty is an effective treatment for chronic distal interphalangeal joint dorsal fracture subluxation.

Osteosynthesis of intra-articular fractures in the proximal interphalangeal joint with Kirschner wires

Twenty-eight consecutive patients, aged 4-68 years, who had had an intra-articular fracture of the proximal interphalangeal (PIP) joint were reviewed retrospectively in 1996. All patients were operated on within a median of three days (range 0-26). Only three patients had open injuries while 11 had fracture-dislocations. A median of half the articular surfaces were involved, and dislocations ranged from 1-4 mm. Twelve patients had their fractures anatomically reduced and 13 had postoperative dislocations of less than 1 mm. Eighteen patients were reviewed after 10-49 months, and four were interviewed by telephone. The median reduction in range of movement in the PIP joint at follow-up was 15 degrees (range 0-90 degrees). Nine patients had subjectively slightly reduced movements, and only three of 17 patients stated that they had limited movement. Ten patients had occasional pain, which eight described as mild and two as moderate. Two patients had ulnar instability less than 5 degrees, and the remainder were stable. Twelve patients had a cold sensation in the affected finger joint in cold weather. No patients had changed occupation as a result of their injury, and only two patients said that they were limited in any way in any activity at work or at home. Open and precise reduction and osteosynthesis with Kirschner (K) wires seems to be an effective treatment for most intra-articular fractures of PIP joints.

The Bone Tie. A new device for interfragmentary fixation

A new method of bone fixation is described, using a small stainless steel device to provide compression between fragments with a single drill hole. The Bone Tie uses an old architectural principle to hold bone fragments together with minimal surgical dissection for access. The technique has been used in 14 cases, and the results are presented. In ten cases the outcome was good. Complications were encountered in four, mostly through technical error, although the final outcomes were acceptable.

Large volar plate avulsion fracture of the base of the middle phalanx with rotational displacement: a report of three cases

Three cases of large volar plate avulsion fracture at the base of the middle phalanx with significant displacement are reported. In each case, the fracture fragment involved about 30% of the articular surface and was rotated 90 degrees. The proximal interphalangeal (PIP) joint showed loss of volar stability with hyperextension stress. This unusual variant of volar plate injury is thought to be caused by subluxation of the PIP joint. All patients underwent open reduction and internal fixation. The fracture healed in anatomic alignment without articular incongruity or instability in all cases.

Hinged device for fractures involving the proximal interphalangeal joint

Well known complications of proximal interphalangeal joint fractures and fracture dislocations are stiffness, chronic instability, and degenerative arthritis. The Compass PIP Hinge is a dynamic external fixator that allows protected proximal interphalangeal mobilization after closed reduction, open reduction and internal fixation, volar plate arthroplasty, or other salvage procedures. To help avoid these problems, 20 patients, 12 treated within 2 weeks of injury (Group I) and 8 treated more than 4 weeks after injury (Group II), are reported. Articular surface involvement among Group I cases averaged 66% (range, 50%-90%), and postoperative proximal interphalangeal motion for this group averaged 9 degrees to 82 degrees. Mild pain with heavy use was present in 3 patients, and 9 patients were pain free. Postoperative proximal interphalangeal motion for Group II averaged 21 degrees to 77 degrees. Pain was moderate to severe in 2 patients, mild with heavy use in 1 patient, and none in 5 patients. One patient from Group II underwent surgery to convert to a silicone proximal interphalangeal arthroplasty because of painful degenerative arthritis. It is concluded that there is a role for hinged external fixation in treating unstable proximal interphalangeal fracture dislocations. Outcomes in acute injuries are superior to those in chronic or salvage cases.

Intra-articular impaction fractures of the phalanges

Six patients with acute impacted fractures of the base of the proximal or middle phalanges were treated with open reduction and internal fixation. Two of three patients who presented with chronic injuries also underwent surgical reconstruction. Contiguous 1.5-mm sagittal computed tomographic imaging was performed on each proximal interphalangeal joint fracture; the imaging documented an average impaction of 30% of the articular surface area. Metaphyseal bone grafting was necessary to support the articular surface in three acute and both late patients. Rigid internal fixation, most frequently employing a composite wire tension band technique, allowed immediate postoperative range of motion exercises. At an average follow-up period of 21 months, all six acute patients had restoration of an excellent painless range of motion. There was no loss of articular congruency on final x-ray films. Late or conservative treatment of these injuries was uniformly less successful.