Closed reduction and percutaneous "periarticular" single K-wire fixation for displaced unstable transverse fractures of the proximal phalanx in elderly osteoporotic women: A case series of five patients

A Novel Technique With Buttress Plating for Comminuted Base Fractures of the Proximal Phalanx

BACKGROUND

Extra-articular but severely comminuted distal basal fractures of the proximal phalanx (PP) are rarely reported. Therefore, the aim of this study was to achieve proper union and desirable outcomes using low-profile locking plates/screws. We introduced our own surgical approach and reported the clinical/radiographic outcomes via retrospective case series.

METHODS

Thirty-eight patients diagnosed with comminuted basal fracture of the PP were admitted between January 2014 and December 2020. Nineteen of these patients met the inclusion/exclusion criteria and were investigated in this retrospective study. Focusing only on preventing the volar tilt/collapse of the articular cartilage from the vertical position due to comminuted metaphysis, such as the "buttress concept by locking plate," the defect was filled with bone grafts. Meticulous repair of the incised central tendon effectively stabilized it by tightening the sagittal band and capsule of the metacarpophalangeal joint. It also acted as an envelope with proper sealing to minimize the loss of grafted bone materials.

RESULTS

Among the 19 patients, the mean patient age was 58.94 years, and the male/female ratio was 6:13. The mean follow-up period was 3.15 years, and the mean BMD was -0.15. Complete union was achieved after a mean of 9.63 weeks, without complications requiring secondary intervention. Two patients complained of skin lesion associated with PDS suture material, but this material spontaneously resolved by 4 weeks postoperatively. The mean extension lag at the proximal interphalangeal joint was 3.68 degrees, and the total active range of motion (TAM) was 256.38 degrees. Among the 19 patients, 6 were categorized as having a "good" modified Belsky classification, and the other patients all had an "excellent" classification. The mean articular-dorsal cortex angle was 85 ± 3.33 degrees at the final follow-up, which was slightly less than the normal value with statistical difference ( P < 0.05); however, it did not correlate with the TAM statistically ( r = 0.126, P = 0.608). Clinical outcomes were also satisfactorily evaluated using the VAS and DASH scores.

CONCLUSIONS

A low-profile locking plate is an effective option for extra-articular, severely comminuted basal fractures of the PP using the buttress concept in terms of clinical outcomes, such as finger movement and proper union.

Extra-Articular Base Fractures of the Proximal Phalanx in Adults: A Systematic Review

Background: Extra-articular proximal phalanx base fractures are common in adults and can lead to permanent finger stiffness and joint contractures. The purpose of this review is to summarise the evidence for operative and non-operative management of this fracture type. Methods: The MedLine, Embase, PubMed, Scopus and Cochrane Library databases were searched using the following key terms: 'proximal phalanx', 'base', 'fracture', 'repair' and 'fixation'. A total of 2,889 unique records were extracted. All studies with primary data on the management of extra-articular proximal phalangeal base fractures in adults were included for initial review. Results: Eleven studies met inclusion criteria with a total of 441 extra-articular proximal phalanx base fractures. Outcomes were determined by final total active range of motion. 182 extra-articular proximal phalangeal base fractures were treated non-operatively, with excellent or good outcomes attained in 80% of cases. Another 259 extra-articular proximal phalangeal base fractures were treated operatively, including 236 with Kirschner wires (K-wires), 18 with plates, and five with intramedullary screws. Case-level data were available in 186 fractures managed by K-wire fixation, with excellent or good outcomes achieved in 79% of cases. Excellent or good outcomes were achieved in 35% of cases treated by plates, and 80% of five cases treated by intramedullary screw fixation. Three (1.6%) patients managed conservatively required surgery after reduction loss. No patients managed with K-wires required re-operation for reduction loss; tenolysis/capsulotomy was required in 11 (4.5%) cases for stiffness, and pin site infections occurred in eight (3.5%) cases. Complex regional pain syndrome occurred in five cases (28%) of plate fixation. Conclusions: In summary, excellent or good results may be achieved by K-wire pinning or conservative management. Current evidence is limited for plate or intramedullary screw fixation. Prospective trials and outcomes standardisation are needed to improve the evidence base. Level of Evidence: Level III (Therapeutic).

My journey in hand surgery: combining patient care, clinical and basic science research

This review is about my clinical and research journey in hand surgery. The journey has been a worthwhile and meaningful one, especially when I felt there were areas I could influence management, whether this be rare cases, common conditions or where a suggested algorithm may be helpful. I also had the unique privilege of working with geneticists, which has resulted in clinical-pathological publications that could influence patient management, as shared from a clinician's perspective. It is hoped this article will inspire young clinician scientists to pursue a journey of collaboration with other researchers.

[Percutaneous, antegrade Pinning of proximal phalangeal Fractures: Comparison of Early Active Motion vs. Immobilization by Splinting]

PURPOSE

This retrospective study compares the functional outcome after early active postoperative motion with the outcome after 6 weeks of immobilization by splinting in patients with proximal phalangeal fractures treated by percutaneous, antegrade pinning.

PATIENTS AND METHODS

46 out of 90 patients treated by closed reduction and percutaneous antegrade pinning of isolated fractures of the proximal phalanges were re-evaluated on average after 18.5 months. There were 17 women and 29 men with a mean age of 42.8 years. 28 patients underwent early active postoperative motion and 18 patients were immobilized by splinting for 6 weeks postoperatively. The two groups were statistically comparable with respect to age, gender, fracture localisation and morphology, mechanism of injury and operative time. Follow-up examination included measurement of active and passive range of motion (TAM; TPM) of the injured finger and the uninjured finger of the opposite side as well as grip strength of both hands. In addition, postoperative complications, the DASH-score and time interval between surgery and return to work were registered.

RESULTS

There were no significant differences between the two groups regarding rate of complication, number or required revisions, finger motion and grip strenght. Patients with early active motion returned earlier back to work than patients treated by postoperative splinting (2.5 vs. 9.0 weeks; p = 0.035). With 1.7 the DASH-score in the group with early active motion was better than in the splinting group with 2.5 (p = .269).

CONCLUSION

Patients with early active postoperative motion returned earlier back to work. There was no significant difference between both groups respecting global finger function.Compliant patients with a fracture of the proximal phalanx treated by closed reduction and percutaneous pinning can be treated with early active motion postoperatively.

"Bi-cortical" periarticular K-wire fixation for displaced unstable transverse extra-articular fractures of the base of the proximal phalanx of the fingers

INTRODUCTION

Management of unstable fractures of the proximal phalanx is a challenge.

OBJECTIVE

The purpose of this study is to introduce to the literature the use of "bi-cortical" periarticular K-wire fixation for displaced unstable transverse extra-articular fractures of the base of the proximal phalanx of the fingers.

PATIENTS AND METHODS

This is a retrospective study of 30 patients with such fractures treated by the author over the last 10 years. Demographic data were collected and surgical complications were documented. The outcome was considered excellent, good, fair and poor if the total active motion of the finger was >260^o, 250^o-259^o, 210^o - 249^o, and <210^o; respectively.

RESULTS

The worst outcome was seen in an elderly patient who sustained multiple fractures and concurrent flexor tendon injury. The remaining 29 patients were relatively young (mean age of 29 years, range = 19 - 42 years) and sustained an isolated single fracture from a fall or a fight. Out of these 29 patients, the outcome was excellent in 27 patients and good in the remaining 2 patients.

CONCLUSIONS

The "bi-cortical" periarticular k-wire fixation is best suited for transverse extra-articular fractures of the base of the proximal phalanx. The wire avoids all joints and hence, early post-operative mobilization is feasible. The technique is simple and obtains a favorable outcome in most patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Joint sparing Kirschner-wire fixation for displaced proximal phalangeal neck fractures: randomized prospective comparative study

The aim of this study was to compare two joint sparing Kirschner-wire fixation techniques for displaced proximal phalangeal neck fractures. Forty-six patients with proximal phalangeal neck fractures managed by either percutaneous antegrade flexible intramedullary nailing (Group I) or crossed Kirschner-wires (Group II) were recruited for a randomized prospective comparative study. Clinical and radiological assessment of all patients was done in addition to the Kang scoring system, Disability of Arm, Shoulder and Hand score and total active motion. The mean time for radiological union for both groups was 5.8 weeks. The mean postoperative total active motion, Kang and the Disability of Arm, Shoulder and Hand scores were better in Group I patients, but without any statistically significant differences. Closed reduction and percutaneous Kirschner-wire fixation by a joint sparing approach will yield good functional results with no or minimal complications in proximal phalangeal neck fractures. Level of evidence: II.