Delayed Single Kirschner Wire Compression Technique for Mallet Fracture

An Evidence-Based Guide for Managing Phalangeal Fractures

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe treatment options for phalangeal fractures. 2. Choose an appropriate fracture management plan that optimizes patient goals and range of motion. 3. Describe closed and open reduction techniques of commonly encountered phalangeal fracture patterns.

SUMMARY

Phalangeal fractures are the second most common upper extremity fracture. Although many can be treated with splinting, operative intervention may be required for unstable fracture patterns and those involving the articular surface. Failure to appropriately treat these fractures can result in finger stiffness, loss in range of motion, and functional deficits. The type of fixation method can range from percutaneous pinning to open reduction and internal fixation. This article presents a series of cases to illustrate the appropriate management of phalangeal fractures using an evidence-based approach.

A Novel Hook Wire Tension Technique for the Treatment of Mallet Fractures: A Comparison with the Extension Block Pinning Technique

We developed a percutaneous surgical technique that allows early mobilization and compression for the treatment of mallet fractures. The aim of this study was to describe this novel technique called the hook wire tension technique (HWTT) and provide a clinical and radiological comparison between HWTT and the extension block pinning technique (EBT) in the treatment of mallet fractures. This retrospective study included 23 mallet fracture patients treated using HWTT and 25 patients treated using EBT. At the final follow-up visit, extension lag and flexion of the distal interphalangeal joint (DIPJ) were measured. DIPJ pain was assessed by the visual analogue scale (VAS) score, and the overall clinical outcomes were graded according to the Crawford criteria. Time to bone healing and osteoarthritis development were assessed radiologically. Complications, including skin necrosis, dorsal prominence and nail deformity, were also compared. The mean follow-up period was 18 months (range: 12-24) in the HWTT group and 19.2 months (range: 12-26) in the EBT group (p = 0.239). There was no statistically significant difference between the two groups in terms of mean extension lag of the DIPJ, mean VAS scores and mean time to bone healing (p > 0.405). The mean DIPJ flexion was greater in the HWTT group compared with the EBT group (p = 0.001). According to the Crawford criteria, outcomes were similar in both groups (p = 0.370). No statistically significant difference was found between the two groups when each complication was compared (p > 0.358). The short-term clinical and functional results of HWTT were found to be similar to those of EBT in the surgical treatment of mallet fractures.

Current methods, outcomes and challenges for the treatment of hand fractures

In treating hand fractures, we have to make a proper decision about conservative treatment versus surgical intervention and decide on individual surgical methods. This article reviews recent publications, technical advances, and outcome measures in treating metacarpal fractures, phalangeal fractures, complex fractures of the proximal interphalangeal joints, bony mallet fingers, and fractures of the thumb. My personal preferences and considerations are presented. At the end, the current challenges that hand surgeons are facing in treating frequent phalangeal and metacarpal fractures are discussed.

Mallet finger - A modified technique using the finger nail as a fixation point for the temporary immobilization of the distal interphalangeal joint - A biomechanical study

BACKGROUND

The aim of the current biomechanical study was to investigate a newly developed surgical technique for mallet fingers. The new method is based on the Ishiguro method which requires a K-wire through the distal interphalangeal joint for temporary fixation. The new technique avoids the joint trans fixation using a specially designed finger nail holder. This method was compared to the established Ishiguro's technique.

METHODS

For biomechanical testing, 32 paired, fresh-frozen human fingers (Digit II-V) of 4 donors (ages 60 to 71 years) were used. The paired fingers were assigned to either the new method or Ishiguro's technique. The biomechanical testing consisted of a cyclic cantilever bending (2000 cycles, 1-7N) followed by a load to failure test. The groups were evaluated for plastic deformation, stiffness, change in stiffness during cyclic loading, subluxation and failure load by analysing force-deflect data and fluoroscopic images.

FINDINGS

The nail fixation group showed significantly higher failure loads and stiffness than the trans fixation group. The values of plastic deformation were significantly lower in the nail fixation group. No differences were found in the change of stiffness. No subluxation was found in both groups.

INTERPRETATION

In the current biomechanical study, nail fixation performed at least as good as Ishiguro's trans fixation technique. The results and ease of implementation indicate that the newly developed nail fixation technique might be a useful treatment method in daily clinical practice without the need of temporary joint trans-fixation avoiding possible associated problems. To establish this method, clinical trials will be necessary.

Extension block and direct pinning methods for mallet fracture: A comparative study

Background

Mallet fracture can easily occur during sports activities or in daily life; however, the principles and methods of treatment for such fractures remain debated. Among the surgical treatments, various methods of closed reduction have been proposed. We treated patients with the extension block method (EBM) and the direct pinning method (DPM), and then compared the results. We assessed differences in range of motion and measurements of finger movement after surgery.

Methods

A total of 41 patients who underwent surgery from August 2013 to September 2015 were evaluated retrospectively. Among them, 21 patients were treated with the EBM and 20 patients were treated with the DPM. We then compared extensor lag, range of motion, and outcomes according to Crawford’s criteria between before surgery and at 6 to 8 months postoperatively.

Results

The postoperative extensor lag improvement was 4.28° and 10.73°, and the postoperative arc of motion was 55.76° and 61.17° in the EBM and DPM groups, respectively. The Crawford assessment showed no statistically significant difference between the groups, although the score in the DPM group was higher than that in the EBM group (3.5 vs. 3.1).

Conclusions

As closed reduction methods for the treatment of mallet fracture, both the EBM and DPM showed good results. However, the DPM proved to be superior to the EBM in that it produced greater improvements in extensor lag and range of motion.

Patient satisfaction after hook plate treatment of bony avulsion fracture of the distal phalanges

BACKGROUND

Bony avulsion fractures of the distal phalanges can result in mallet finger deformity if not treated appropriately. Therefore, only minimally displaced fractures can be treated conservatively with a good outcome, as dislocation occurs very often. Several surgical treatment options have been developed during the past decades. Data concerning the recently developed hook plate are promising. So far, no data concerning the subjective satisfaction with this method have been published. Therefore, we have analyzed the outcome after hook plate implantation using a self-assessment score, which focuses also on subjective parameters and satisfaction.

METHODS

Standardized questionnaires (self-assessment scores and SF-36 questionnaire) were sent to each patient treated with a hook plate due to fracture of the distal phalanx, type Doyle IVb and IVc. Clinical data were evaluated according to the medical record. Scores given per question range from 0 to 10, 10 is the worst and 0 the best outcome.

RESULTS

From 69 patients treated, 38 (58%) were enrolled. The whole collective (n = 38) reached a score of 39.7 ± 28.7 points, while men had slightly better results. Men (n = 24) achieved 37.3 ± 27.9 points, women (n = 14) 43.9 ± 30.7 points. Women had significantly better results when analyzed later than 12 months after surgery (52.1 ± 27.9 vs. 29.1 ± 32.8), whereas no changes could be detected in the male group (37.1 ± 29.9 vs. 37.4 ± 27.6). Overall, men were slightly more satisfied than women. Most satisfaction was found regarding pain and fine motor skills (0-0.46 points). Esthetic aspect and nail deformities (3.65 points average) led to the highest dissatisfaction. No differences in the SF 36 score could be detected.

CONCLUSIONS

The hook plate is not only a convenient method but it also results in high patient satisfaction. Nail deformities are challenging; however, with increasing experience of the surgeon they decrease. SF 36 score is not an appropriate testing tool for this problem.

The Nonoperative Management of Hand Fractures in United Kingdom

Hand fractures (excluding small avulsion fractures and scaphoid fractures) almost always unite with bone. The role of the hand surgeon is not to achieve bone union but to achieve stability in an adequate position, often with some displacement, and maintenance of good soft tissue gliding. This article establishes that many fractures treated operatively do no better and often could not realistically do better than with good nonoperative treatment. Yet many are treated surgically to satisfy surgical egos, the desire to produce excellent radiographs, or just the mistaken belief that current surgical techniques can improve on nonoperative treatment.

The Diagnosis and Management of Mallet Finger Injuries

BACKGROUND

Mallet finger is a common injury of the extensor tendon insertion causing an extension lag of the distal interphalangeal joint.

METHODS

We reviewed the most current literature on the epidemiology, diagnosis, and management of mallet finger injuries focusing on the indications and outcomes of surgical intervention.

RESULTS

Nonoperative management has been advocated for almost all mallet finger injuries; however, complex injuries are usually treated surgically. There is still controversy regarding the absolute indications for surgical intervention.

CONCLUSIONS

Although surgery is generally indicated in the case of mallet fractures involving more than one-third of the articular surface as well as in all patients who develop volar subluxation of the distal phalanx, a significant advantage of surgical management even in those complicated cases has yet to be clearly proven.

Percutaneous Fixation of Mallet Fractures By the “Umbrella Handle” Technique

Over a period of 8 years, 48 fingers with mallet fractures of Wehbé and Schneider Types 1 and 2, subtypes B and C, were treated in 31 men and 17 women of mean age 42 (range 17–61) years. The fractures included 5 Type 1 subtype B, 2 Type 1 subtype C, 23 Type 2 subtype B and 18 Type 2 subtype C fractures. The technique used consisted in passing a K-wire percutaneously from dorsal to volar and pinning the fracture fragment while leaving the distal interphalangeal joint free to allow immediate postoperative mobilisation. Fracture splintage was removed at 6 weeks. The results at 8 weeks, which remained unchanged at 12 months in 46 fingers, were assessed as excellent in 11, good in 35 and fair in two cases by the Crawford rating system. One case of pin track infection required early removal of the pin.

Clinical comparison of hook plate fixation versus extension block pinning for bony mallet finger: a retrospective comparison study

The aim of this retrospective study was to determine whether traumatic mallet fractures had better outcomes when treated by hook plate fixation (13 patients) or extension block pinning (19 patients). We assessed outcomes using Crawford's criteria; distal interphalangeal joint range of motion; the DASH score; and a visual analogue scale score for pain. We measured radiological parameters. No significant differences were observed in functional and clinical outcomes and in complications. Whereas the operative time was longer in the hook plate group, intraoperative fluoroscopy use, time to bone union and time to return to work were greater in the extension block group. Although the hook plate method is more technically demanding, it provides good stable reduction, earlier mobilization and an earlier return to work. The extension block pinning technique is easier and as effective but it requires greater peri-operative fluoroscopy. Level of evidence: Level III.

PBNR: Percutaneous Blunt Needle Reduction of Bony Mallet Injuries

Mallet finger injuries are common; treatment goals include achieving joint stability, preventing extensor lag, and subsequent swan-neck deformity. We describe a simple technique for improving intraoperative bony mallet reduction, which may avoid the requirement for closed Ishiguro extension blocking wires or open fixation, and present a prospective case series (n=12). Intraoperative percutaneous blunt needle reduction (PBNR) is achieved under image intensifier guidance. Using artery forceps, a blunt fill needle tip is manipulated onto the proximal avulsed fragment; this is then guided into a reduced position and maintained using a well-formed Zimmer splint across the distal interphalangeal joint in 15- to 30-degree extension. There were 5 injuries involving >1/3 of the articular surface (Doyle's classification IVb) and 7 injuries involving >1/2 of the articular surface (Doyle's classification IVc). Mean hand therapy follow-up was 10.6±1.0 weeks, extensor lag was 4.6±1.7 degrees, and all patients achieved full functional recovery with return to normal daily activity. No complications were reported. Closed techniques, for example, Ishiguro extension blocking wires, may reduce the risks associated with open reduction, but do not avoid further articular surface damage. PBNR offers the surgeon a useful adjunct to the treatment options for bony mallet injuries, without excluding progression to surgical fixation if required. PBNR represents a less-invasive management option for bony mallet injures where surgical fixation may also be indicated.

[Treatment of phalangeal fractures using the mini-hook plate. An alternative for surgical fixation of small phalangeal bone fragments?]

BACKGROUND

Fixation of the small bony fragments of the phalanges is often difficult. In this study a clinical and radiological evaluation was carried out after operative treatment using the mini-hook plate.

PATIENTS AND METHODS

Between 2003 and 2006 a total of 36 fractures were treated operatively using the mini-hook plate. Of the patients 24 had an basal avulsion fracture of the distal phalanx and 11 patients (12 fractures) had other bony avulsion fractures of the phalanges. The patients were evaluated clinically and radiologically as well as using the disabilities of the arm, shoulder and hand (DASH) questionnaire.

RESULTS

A total of 29 patients with 30 fractures were examined. The mean follow-up was 13.6 months. The mean range of motion in the affected finger joint was 60.3 ° and the mean DASH score was 2.8 points. Postoperatively five nail growth defects, one infection and one secondary dislocation of the implant were observed.

CONCLUSION

Using the mini-hook plate, preservation of the joint and stable internal fixation with no need for temporary arthrodesis is possible; however, prerequisites are experience and skill of the surgeon with a difficult surgical technique.

The non-operative management of hand fractures

Most hand fractures can be treated non-operatively. Some hand fractures, such as open injuries or markedly displaced intra-articular fractures, are almost always treated operatively. The treatment of many fractures, such as proximal interphalangeal joint fracture subluxations or spiral phalangeal fractures, is unclear. The aim of this review is to establish those injuries where the outcome of non-operative treatment is unlikely to be improved with surgery. This may help to prevent unnecessary surgery, concentrate work on finding the sub-groups that may benefit from surgery and to establish which injuries do so well with non-operative treatment that the only valuable clinical research in future will be large cohort studies of non-operative treatment or randomized controlled trials comparing operative and non-operative treatments. The relevant fractures are spiral metacarpal fractures, transverse metacarpal shaft and neck (boxer's) fractures, base of proximal phalanx avulsion fractures, thumb metacarpophalangeal joint ulnar and radial collateral ligament injuries and bony mallet injuries. For the majority of these injuries, current knowledge suggests that the outcome of non-operative treatment cannot reliably be improved upon with surgery.

Mallet fingers with bone avulsion and DIP joint subluxation

One-third of all mallet fingers are associated with a fracture. Mallet fractures associated with large fracture fragments may result in volar subluxation of the distal phalanx. The management of mallet fractures varies based on injury pattern and surgeon preference. These treatment options include splinting regimens, closed reduction and percutaneous pinning and open reduction and internal fixation. Although numerous surgical techniques have been described, there is little clear consensus on operative treatment. Moreover, there is insufficient evidence to support operative over nonoperative treatment for mallet fractures.

The Meniscus Arrow® as a fixation device for the treatment of mallet fractures: results of 50 cases

BACKGROUND

The treatment of mallet fractures is a controversial and challenging problem. Generally, mallet fractures are treated conservatively except those involving more than one third of the base of the distal phalanx. Many different surgical fixation techniques have been published. This paper describes a new fixation procedure using ultimate bioresorbable meniscal fixation nails (Meniscus Arrows®).

METHODS

Mallet fractures in 50 digits of 49 patients were fixed with this nail in an outpatient surgical procedure, mostly under local (Oberst-block) anaesthesia. The average operation time was 21 min.

RESULTS

According to the Crawford criteria, patient outcome was graded as excellent in 48 %, good in 22 %, and fair in 28 %. In one patient, the outcome was graded as poor, but the fracture was in a pre-existent arthritic joint. All fractures were consolidated without recurrent dislocation. Complications included one wound infection, which was successfully treated with antibiotics and without further consequences. No nail deformities occurred. Two times, the nail spontaneously and gradually dislocated during intensive use of the hand after, respectively, 3 and 6 months and could easily be removed under local anaesthesia without any functional sequelae.

CONCLUSION

The bioresorbable meniscal nail fixation technique provides a fast and successful surgical treatment for mallet fractures with a minimum of adverse events.

Current concepts: mallet finger

Loss of the extensor mechanism at the distal interphalangeal (DIP) joint leads to mallet finger also known as baseball finger or drop finger. This can be secondary to tendon substance disruption or to a bony avulsion. Soft tissue mallet finger is the result of a rupture of the extensor tendon in Zone 1, and a bony mallet finger is the result of an avulsion of the extensor tendon from the distal phalanx with a small fragment of bone attached to the avulsed tendon. Mallet finger leads to an imbalance in the distribution of the extensor force between the proximal interphalangeal (PIP) and DIP joints. If left untreated, mallet finger leads to a swan neck deformity from PIP joint hyper extension and DIP joint flexion. Most mallet finger injuries can be managed non-surgically, but occasionally surgery is recommended for either an acute or a chronic mallet finger or for salvage of failed prior treatment.

[Injuries of the distal interphalangeal joints]

Injuries of the distal interphalangeal joints mostly involve the extensor tendon. Its superficial position on the dorsal aspect of the finger often exposes the extensor tendon to closed and open injuries. Lesions of the extensor tendons are more common than those of the flexor tendons. Furthermore, injuries of the joint often occur as fractures of the dorsal base of the distal phalanx, and, less frequently, as fractures of the head of the middle phalanx. In all cases, correct diagnosis and therapy is essential. Incorrect diagnosis and neglecting of the injury by both surgeon and patient often lead to considerable complications, e.g., delayed healing and lack of function.

Peak load resistance of the JuggerKnot™ soft anchor technique compared with other common fixation techniques for large mallet finger fractures

INTRODUCTION

To identify the strongest peak load resistance among four mallet finger fracture fixation methods (Kirschner wire, pull-out wire, tension-band wiring and the JuggerKnot™ (Biomet) soft anchor fixation).

METHODS

Fixation techniques were assigned among 24 specimens from six cadaveric human hands in a randomized block fashion. Peak load resistance was tested at 30°, 45° and 60° of flexion of the distal interphalangeal joint.

RESULTS

The mean peak load of tension-band wiring was 67.8 N at 60° of flexion which was most superior. The JuggerKnot™ fixation had mean peak loads of 13.35 N (30°), 22.51 N (45°) and 32.96 N (60°). No complications of implant failure or fragmentation of the dorsal fragment was noted.

CONCLUSIONS

Tension-band wiring was the strongest fixation method but was most prominent on the skin surface as seen in three specimens. The JuggerKnot™ soft anchor fixation had similar peak load resistance as k-wire fixation and pull-out wiring.

REVIEW ON MALLET FINGER TREATMENT

Mallet finger is a common injury involving either an extensor tendon rupture at its insertion or an avulsion fracture involving the insertion of the terminal extensor tendon. It is usually caused by a forceful blow to the tip of the finger causing sudden flexion or a hyperextension injury. Fracture at the dorsal aspect of the base of the distal phalanx is commonly associated with palmar subluxation of the distal phalanx. Most mallet finger injuries are recommended to be treated with immobilisation of the distal interphalangeal joint in extension by splints. There is no consensus on the type of splint and the duration of use. Most studies have shown comparable results with different splints. Surgical fixation is still indicated in certain conditions such as open injuries, avulsion fracture involving at least one third of the articular surface with or without palmar subluxation of the distal phalanx and also failed splinting treatment.

[Operative treatment of osseous pull out of the extensor tendon using a hook plate]

OBJECTIVE

Anatomical reposition and stabilization of dorsal distal phalanx fractures with a hook plate.

INDICATIONS

Dislocated mallet fractures type Doyle IVb with dislocation of the fragment by more than 2 mm and/or tilting of the fragment as well as dislocation of the dorsal distal phalanx fractures type Doyle IVc.

CONTRAINDICATIONS

Florid inflammation of and injuries to the soft tissues in the operation area.

SURGICAL TECHNIQUE

Dorsal approach to the distal interphalangeal joint (Y-, S-, H-shaped). Preparation of the fragment, cleaning the fracture gap, repositioning of the fragment, mounting of the plate, placing the screw. Controlling by image converter. Suture of the skin; tape.

POSTOPERATIVE MANAGEMENT

Stack splint for 4 weeks. After week 3, start with exercising of the distal interphalangeal joint within the splint. Physiotherapy is usually not required. Full exertion after 6-8 weeks is possible. The period of inability to work is dependent on the patient's occupation. Due to the danger of perforation and infection, it is recommended that the plate be removed after 3-6 months.

RESULTS

From February 2002 to September 2009, 77 mallet fractures type Doyle IVb and IVc were operatively stabilized with a hook plate. In a retrospective study, 59 patients were followed up at a mean interval of 38.3 (3-69) months after the operation. Wound healing problems or inflammation were not observed. Visible disturbances of nail growth were macroscopically seen in 11.9%. Results were very good in 35 patients (59.3%), good in 16 patients (27.1%), sufficient in 5 patients (8.5%), satisfying in 1 patient (1.7%), and insufficient in 2 patients (3.4%).

Treatment options for mallet finger: a review

BACKGROUND

Mallet finger is a common injury. The aim of this review is to give an overview of the different treatment options of mallet injuries and their indications, outcomes, and potential complications.

METHODS

A literature-based study was conducted using the PubMed database comprising world literature from January of 1980 until January of 2010. The following search terms were used: "mallet" and "finger."

RESULTS

There are many variations in the design of splints; there are, however, only a few studies that compare the type of splints with one another. Splinting appears to be effective in uncomplicated and complicated cases. Equal results have been reported for early and delayed splinting therapy. To internally fixate a mallet finger, many different techniques have been reported; however, none of these studies examined their comparisons in a controlled setting. In chronic mallet injuries, a tenodermodesis followed by splinting or a tenotomy of the central slip is usually performed. If pain and impairment persist despite previous surgical corrective attempts, an arthrodesis of the distal interphalangeal joint should be performed.

CONCLUSIONS

Uncomplicated cases of mallet injuries are best treated by splinting therapy; cases that do not react to splinting therapy are best treated by surgical interventions. Controversy remains about whether mallet injuries with a larger dislocated bone fragment are best treated by surgery or by external splinting.

Open reduction internal fixation of the unstable mallet fracture

Unstable mallet fractures of the digit pose a challenge when treated surgically. We present the results of a technique, not earlier described, for the fixation of these uncommon injuries. The technique involves anatomical reduction and stable fixation of the distal articular fragment combined with stabilization of the distal interphalangeal joint with buried Kirschner wires allowing early mobilization of the digit. Twenty patients with an average follow-up of 12.7 months (10 mo to 21 mo) are presented. Results were good/excellent (Crawford's criteria) in 16 patients, fair in 3, and poor in 1 with those operated upon within 2 weeks postinjury achieving the best results. There were no incidences of fixation failure, loss of reduction, or posttraumatic osteoarthritis. One patient had a minor infection, but there were no cases of nail deformity or wound breakdown. There was high patient satisfaction and all patients returned to work after treatment. We conclude that this is a reliable technique with minimal complications and is comparable with other published operative and nonoperative treatment modalities.

A novel hook plate fixation technique for the treatment of mallet fractures

Bony mallet injuries are generally treated nonoperatively, but when the fragment involves a significant percentage of the articular surface, articular incongruity and instability can occur. A number of techniques have been described for the fixation of such fractures and each has its own problems. Anatomic reduction and secure fixation of small fragments can be challenging. Our objective is to describe a new surgical technique using a 1.3-mm hook plate that provides good reduction and stable fixation of a mallet fracture, with early mobilization of the distal interphalangeal joint.

Mallet fractures: a novel approach to internal fixation using a hook plate

A new treatment of mallet fractures of the distal phalanx is presented. Open reduction and internal fixation was performed using a "hook" plate fabricated from a 1.3 mm AO hand modular system straight plate. This technique avoids the need to place implants or wires through the small avulsion fragment while still being able to achieve a stable "tension-plate" type of fixation construct strong enough to allow protected early active motion of the distal interphalangeal joint. In minimising the need for prolonged splinting, patient comfort is also improved. In a consecutive series of nine fractures, union was achieved in all cases. At an average follow-up period of 17 months, four had excellent and five had good results using the Crawford rating scale. Using the Warren and Norris scale, all patients had a successful result. The final average active range of flexion of the distal interphalangeal joint was 64 degrees and there was no extensor lag.