Choosing the proper implant for extra-articular fractures of proximal phalanges: A study on 75 cases

INTRODUCTION

Phalangeal fractures are the most common fractures of the hand and in particular the proximal phalanx of the long fingers is the most involved. These fractures can ben conservatively managed but, when the fracture pattern is considered unstable, surgical treatment is recommended. However, there is no consensus in literature about the proper surgical option for extra-articular proximal phalanx fractures.

MATERIAL AND METHODS

We compared clinical and radiographical results after treatment of 75 cases of extra-articular proximal phalanx fractures using three different surgical techniques: closed reduction and internal fixation (CRIF) with Kirschner wires (G1 group), open reduction internal fixation (ORIF) with plates and screws or lag screws (G2 group), and closed reduction and intramedullary screw fixation (CRIMEF)(G3 group).

RESULTS

We found no significant differences in term of union rate and time to fracture healing between the three groups. However, we found a significant reduction in time to return at work and in TAM at the final follow-up examination in G3 group (treated with CRIMEF) when compared with both G1 and G2. No differences in complications rate were found between three groups.

DISCUSSION

The surgical variability in the management of extra-articular phalanx fractures create lacks on standard guide for treatment.

CONCLUSIONS

In conclusion, our results showed good clinical and radiographical results with all the three surgical options. However, the closed reduction and internal fixation with intramedullary screws (CRIMEF) seems to be better in terms of time to return to work and TAM at the final follow-up, probably due to good primary stability and little risk of soft tissue adherence development.

Bilateral Dorsal Nail Curvature of the Thumb Distal Phalanx - A Case Report

Congenital dorsal curvature of the distal phalanx has been previously described as 'reverse Kirner' or 'ski-jump' deformity. This report describes bilateral occurrence in the thumbs. A 13-year-old male presented with difficulty caring for his thumbnails and in picking up small objects. Examination showed dorsal curvature of the distal phalanges of both thumbs, with greater curvature of the right side. Radiographs showed wedge-shaped epiphyses and dorsal curvature without coronal plane deviation of the distal phalanges. There was objective and subjective decrease in function associated with lateral pinch and tripod grasp. The reported aetiopathogenesis for Kirner deformity cannot explain the observed dorsal curvature. The bilateral nature makes a secondary physeal cause unlikely and suggests an embryologic basis. Due to the noticeable deficits in function, operative intervention may be warranted. Level of Evidence: Level V (Therapeutic).

Intramedullary Fixation of Hand Fractures and Arthrodeses

Intramedullary fixation has long been popular for fracture fixation in the upper extremity from the shoulder through the carpus. Recently, intramedullary fixation in the hand has gained increasing interest, specifically in the metacarpals and phalanges, corresponding with the development of improved cannulated headless screw technology. Along with the advantages of increased operative speed and less surgical dissection, which can promote rapid healing, many benefits exist, supporting their use despite some drawbacks. This article reviews the background and biomechanics of intramedullary fixation with a specific focus on cannulated headless screws, describes the application and techniques of intramedullary screw fixation in the hand, and details the associated outcomes and costs for metacarpal fractures, phalangeal fractures, and interphalangeal joint arthrodesis.

Pediatric Phalanx Fractures

Phalangeal fractures are extremely common in the pediatric and adolescent populations. The incidence of phalangeal fractures peaks in children ages 10 to 14 years, corresponding to the age in which children begin contact sports. Younger children are more likely to experience crush injuries, whereas older children often sustain phalangeal fractures during sports. The physis is particularly susceptible to fracture because of the biomechanically weak nature of the physis compared with the surrounding ligaments and bone. Phalangeal fractures are identified through a thorough physical examination and are subsequently confirmed with radiographic evaluation. Management of pediatric phalangeal fractures is dependent on the age of the child, the severity of the injury, and the degree of fracture displacement. Nondisplaced fractures are often managed nonsurgically with immobilization, whereas unstable, displaced fractures may require surgery, which is often a closed rather than open reduction and percutaneous pinning.

Dorso-ulnar reverse flow pedicled osseous flap for reconstruction of the distal phalanx of the thumb: A case report

Reconstruction of osseous defects of the distal phalanx of the thumb is usually addressed with free bone grafts or free vascularized bone flaps. Some reports demonstrated the possibility to harvest an osteo-cutaneous flap in the dorso-ulnar side of the first metacarpal bone with success. In the same manner, no reports are present in the literature in which bone deficits were reconstructed with this flap elevated as an exclusively osseous flap. We report our successful experience with one case of distal phalanx reconstruction of the thumb by mean of the dorso-ulnar reverse flow pedicled osseous flap. The patient was a 45-year-old woman with symptoms related to a cystic bone tumor that involved the entirety of the distal phalanx of the thumb. Flap dimensions were calculated based on x-ray gap measures, which resulted in need of 1.5 × 0.8 × 0.5 cm flap dimensions. An osseous flap was harvested and transposed from the ulnar side of the first metacarpal bone. K-wire fixation was utilized for bone flap stabilization. No complications occurred and excellent functional result was evaluated at 6 months follow-up. In our opinion, the flap may be considered as an alternative to free bone grafts in situations in which perilesional tissues may jeopardize the process of free graft taking and in cases in which free vascularized bone flaps are not feasible for patient or surgeon decision.

Distraction Osteogenesis for the Brachytelephalangic Thumb - A Case Report

Brachytelephalangy is a congenital condition characterised by the shortening of the distal phalanges, which affects appearance but does not cause severe functional disability. Therefore, most hand surgeons do not consider it to require surgical treatment, and there are limited options to improve the appearance of the affected digits. We present the case of a 55-year-old male patient with congenital brachytelephalangy of the thumb, who underwent a bone lengthening procedure using distraction osteogenesis with the Ilizarov minifixator. The distal phalanx was carefully osteotomised and gradually lengthened up to 5 mm with no adverse events observed. The patient was satisfied with the natural appearance of his thumb after the surgery. This gradual callus distraction method is a radical solution for people with brachytelephalangy, particularly after epiphyseal closure and can manage the external fixator on their own. Level of Evidence: Level V (Therapeutic).

Fractures of the phalanges

Fractures of the phalanges encompass a wide range of injury patterns with variable articular and soft tissue involvement. The goals of treatment whether conservative or surgical are the restoration of function while limiting the risk of complications. An armamentarium of fixation options allows the surgeon to appropriately treat these fractures with the intention of initiating early postoperative mobilization. Previous publications report variable rates of complications following internal fixation of phalangeal fractures which represents an unsolved problem. It is incumbent on the surgeon to utilize meticulous surgical technique, achieve anatomic reduction with stable fixation and initiate early postoperative mobilization where indicated. In the following text, we review the management of most types of phalangeal fractures, except fracture-dislocations of the proximal interphalangeal joint. These injuries comprise a wide spectrum of presentation; thus, an understanding of anatomical and mechanical principles is integral to achieving a successful outcome.

Current Outcomes and Treatments of Complex Phalangeal and Metacarpal Fractures

Phalangeal and metacarpal fractures that require operative treatment have documented complications in around 50% of patients. The most common of these complications are stiffness and malunion. These can be highly challenging problems for the hand surgeon. In this article, we discuss complications after phalangeal and metacarpal fractures and treatment strategies for these complications.

The Effect of Epiphysiodesis on the Longitudinal Bone Growth of Hands or Feet in Children With Macrodactyly Based on Long-term Quantitative Analysis

BACKGROUND

Treatment protocols for macrodactyly have not been elucidated due to its rarity and variety of clinical manifestations. This study aims to share our long-term clinical results of epiphysiodesis in children with macrodactyly.

METHODS

A retrospective chart review was performed for 17 patients with isolated macrodactyly treated with epiphysiodesis over 20 years. Length and width of each phalanx in both the affected finger and the corresponding unaffected finger in the contralateral hand were measured. Results were presented in ratios of the affected to unaffected side for each phalanx. Measuring of length and width of phalanx was performed preoperatively and postoperatively at 6, 12, and 24 months, and the last follow-up session. Postoperative satisfaction scoring was done with visual analogue scale.

RESULTS

The mean follow-up period was 7 years and 2 months. In the proximal phalanx, length ratio significantly decreased compared with preoperative state at after more than 24 months, in the middle phalanx after 6 months, in the distal phalanx after 12 months. When classified by the growth patterns, the progressive type showed significant decrease in length ratio at after 6 months, and the static type after 12 months. Patients were overall satisfied with the results.

CONCLUSION

Epiphysiodesis effectively regulated longitudinal growth with different degree of control for different phalanges in the long-term follow-up.

Surgical Technique: Lateral Plate Osteosynthesis of Proximal Phalanx Fractures

Dorsal plate fixation of proximal phalanx (PP) fractures is a conventional approach but interferes with the extensor mechanism and results in stiffness. Biomechanical studies have shown that laterally placed plates on the proximal phalanges are equally stable and rigid. This technique obviates the issue of tendon adhesion and may result in better postoperative range of motion and lower secondary procedures such as removal of implant and tenolysis. The low adoption of this technique may be related to lack of familiarity with the surgical approach. We describe our surgical technique with lateral plating of PP fractures and present our case that lateral plate osteosynthesis is an acceptable surgical fixation option for PP fractures, which extends the hand surgeon's armamentarium for more challenging and comminuted fractures.

Salter-Harris Type III Fracture of the Distal Phalanx: A Rare Juxtaphyseal Variant

Juxtaphyseal fractures of the distal phalanges of upper extremity digits are most commonly of the Salter-Harris II variety and occur most commonly in the thumb. The diagnosis of this injury is essential as it may present as an open fracture with a nailbed injury ("Seymour fracture"). However, an intra-articular, epiphyseal fracture may also occur and mimic a mallet deformity or Seymour fracture. Prompt diagnosis is essential to rule out an open fracture and obtain anatomical alignment and stability to attempt to reduce complications such as physeal arrest. Here, we present a patient with a displaced Salter-Harris type III fracture of his thumb distal phalanx and review his management and early-term outcome. We present this case to bring attention to this rare and unique injury, review the available literature, and discuss management and outcomes.

Massive bone allograft engineered with autologous vessels: A new perspective for the future

Reconstruction is very important to ensure good function and quality of life after bone tumor resection. For metacarpals and phalanges, amputation and toe transfer are the gold-standard indications; nevertheless, allograft reconstruction must also be taken into account. Unfortunately, because of its inert biological behavior, it undergoes progressive resorption, with frequent fracture. Several attempts have been made to induce new vascularization in massive bone allograft, with poor results. However, neo-angiogenesis was reported with vascular loops, and we therefore hypothesized that heterologous graft integration could be enhanced by creating a vascular loop through the graft. A 50-year-old male with chondrosarcoma of the ring finger of the left hand underwent wide resection. An allogenic middle phalanx of comparable size was then prepared to fill the defect. Two small windows were performed proximally and distally on the radial surface of the allogenic phalanx, and a 4 cm-long vein graft was inserted inside the medullary canal. Metacarpophalangeal joint stability was achieved by collateral ligament reconstruction with micro-anchors. The distal part of the allograft was then stabilized to the middle phalanx with a 1.5 mm-thick micro-plate and screws. The radial proper palmar digital artery was proximally and distally sutured end-to-end to the vein graft, under microscopy. At 12-month follow-up, the allograft was fused, and histology performed at plate removal at 18 months revealed viable spindle cells with osteoblastic differentiation, without evidence of atypia, in a dense fibrous stroma. At 22 months' follow-up, the patient was apparently disease-free, and satisfied with his manual function.

Unique Considerations for Paediatric Proximal Phalanx Fractures

Paediatric hand fracture care presents unique considerations and challenges. The proximal phalanx is the most injured location. This review details pearls for the examination of the injured paediatric hand, immobilisation considerations and treatment strategies. Over-treatment can lead to unnecessary stiffness, missed activities, increased healthcare costs or unnecessary surgical morbidity. Undertreatment can promote malunion and dysfunction. Fracture patterns discussed include those of the phalangeal head, neck, shaft and base. The concepts covered will help optimise the evaluation and treatment of children with injured proximal phalanges. Level of Evidence: Level V (Therapeutic).

Plating after lengthening in treating phalangeal and metacarpal deficiency: An alternative method

Objectives

This study aims to investigate whether plating after lengthening in patients with phalanges and metacarpals deficiency could significantly shorten the duration of external fixation and decrease bone healing index.

Patients and methods

Between February 2010 and December 2018, 11 phalanges in nine patients (6 males, 3 females; mean age: 28.4±4.4 years; range, 22 to 35 years) and nine metacarpals in six patients (2 males, 4 females; mean age: 21.0±2.9 years; range, 16 to 25 years) were lengthened at a rate of 0.25 mm in two increments. A unilateral external fixator was applied in all cases. A locking compression plate was applied at the end of the distraction period before the external fixator was removed. Removal of the plate was considered two years after the internal fixation.

Results

The desired length and bone consolidation were achieved in all cases. The additional lengths achieved in the phalanges and metacarpals group were 18.3 mm and 27.7 mm on average, respectively. The bone healing indexes in the phalanges and metacarpals were 1.33 and 1.44 mo/cm, respectively. No significant difference was observed in the pre- and postoperative range of motion of involved metacarpophalangeal joint of both phalangeal (95% CI: -0.469~1.014, t=0.820, p=0.432) and metacarpal (95% CI: -0.689~0.975, t=0.420, p=0.689) lengthening cases. Only one case of minor complication (track infection) occurred.

Conclusion

Plating after lengthening is an ideal method for phalanges and metacarpals deficiency. Its advantages include shorter duration of external fixation, lower complication rate, and early functional recovery.

Distal Phalangeal Replacement Using a Patient-Specific 3D-Printed Prosthesis: A Case Report

CASE

A 38-year-old man developed a nonunion of a comminuted distal phalanx fracture, which resulted in gross instability of the fingertip. To restore stability, a patient-specific 3D-printed distal phalangeal prosthesis was implanted, and the patient was able to return to his occupation with excellent 2-year outcomes.

CONCLUSION

This case highlights the application of 3D printing technology in the development of a patient-specific solution and discusses 6 important considerations for the design and planning process: Patient, Priorities, Point of fixation, Procedure, Problems, and People.

Modified Bilhaut-Cloquet Procedure for the Reconstruction of Wassel Type III Radial Polydactyly

BACKGROUND

The purpose of this research is to study the modified surgical effect of Wassel type III radial polydactyly thumbs of equal or nearly equal size treated.

METHODS

The study sample consisted of 12 reconstructed cases of Wassel type III radial polydactyly. The proximal phalanx was unequally combined by the curvature osteotomy and aligned the articular surface, and the distal phalanx was symmetrically combined. A fragment bone was filled in the depression of the distal phalanx to correct nail curvature and prevent seagull deformities. Twelve cases were available for assessment using an evaluation form on the Japanese Society for Surgery of the Hand.

RESULTS

An average functional point was 13.75 points (maximum 14 points). The interphalangeal joint motion was reduced, but this joint was stable in all cases. The cosmetic score was averaged 3.6 (maximum 4 points), and most parents were satisfied with the postoperative appearance and functional results.

CONCLUSION

Our modification of Bihaut-Cloquet procedure is an effective way to provide a well-functioning thumb for Wassel type III radial polydactyly thumbs.

LEVEL OF EVIDENCE

Level IV.

Combined great toe dorsal nail-skin flap and medial plantar flap for one-stage reconstruction of degloved finger

BACKGROUND

Historically, the degloved finger with the total loss of nail and skin had been resurfaced with an expanded great toe wrap-around flap transfer for better outcomes. The purpose of this study aims to present our experience with a related modified design, with total preservation of a weight-bearing plantar skin.

METHOD

From April 2016 to September 2019, nine fingers (5 index and 4 middle fingers) in nine cases, with skin loss to the base of the proximal phalangeal or metacarpophalangeal (MCP) joint level, were reconstructed with combined great toe dorsal nail-skin flap and medial plantar artery perforator (MPAP) flap. The dorsal great toe donor was covered with a thin groin flap, and the medial plantar site was covered with a full-thickness skin graft. The cutaneous nerves were preserved within both flaps. Standardized assessment of outcome in terms of sensory, functional, and esthetic performance of the reconstructed fingers was completed.

RESULTS

Flap survival was achieved in all cases. The contour of the reconstructed digits was comparable with the contralateral one. The fingers were available for a mean follow-up of 28 months (ranged, 22-39 months). The mean dimension of the great toe dorsal nail-skin flap was 8.5 × 4.0 cm (ranged, 6.5 × 3.5-11.0 × 4.5 cm). The average size of the MPAP flap was 6.5 × 4.5 cm (ranged, 5.0 × 3.5-8.0 × 5.5 cm). At the last follow-up, the functional and aesthetic consequences were satisfactory, as well as the restored sensory.

CONCLUSION

Reconstruction of degloved fingers with the great toe dorsal nail-skin flap combined MPAP flap, preserving a plantar weight-bearing area, results in excellent contour and functional outcome. Donor-site morbidity in the foot was minimal.

Alternative Noninvasive Treatment of Unstable Extra-articular Proximal and Middle Phalangeal Fractures: A Static Linear Traction Orthosis Design

Extra-articular unstable proximal and middle phalanx fractures are typically managed with surgical means with common complications of tendon tethering, stiffness, and secondary hand dysfunction. As a result, alternative conservative measures are being explored. The use of static linear traction through the application of an orthosis allows for fracture reduction and anatomic healing, with successful range of motion outcomes.

Glomus Tumors of the Distal Phalanx: A Retrospective Review of Clinical Diagnosis and Treatment

Glomus tumors (GTs) are rare and typically occur in distal digital bones, with a majority of cases comprising benign vascular tumors. The current study retrospectively reviewed 10 cases of GTs treated by the authors between January 2009 and December 2016. In 9 cases, the GTs were subungual; 1 case was periungual. The affected fingers included 2 thumbs, 3 index fingers, 3 middle fingers, and 2 little fingers. The GTs showed characteristic signs and symptoms. All patients underwent tumor excision. Pathological examination found a thin layer of fibrous membrane surrounding the excised tumor body, which contained small vessels surrounded by multilayered tumor cells. No recurrence was seen during follow-up. The results of this study suggested the following: (1) whole tumor excision is key to preventing GT recurrence; and (2) in case of considerable phalangeal cortex erosion, K-wire fixation followed by autogenous bone grafting can produce satisfactory outcomes, although accurate evidence-based indications for this management need to be established. [Orthopedics. 2022;45(2):e101-e106.].

Intramedullary Suture Anchor Fixation of a Type Vb Flexor Digitorum Profundus Avulsion: A Case Report

CASE

Flexor digitorum profundus avulsions are common injuries that manifest as tendinous or bony avulsions from the distal phalanx. Rarely, additional fractures can occur in the distal phalanx. For such injuries, repair of the avulsion and fracture is recommended but difficult because of limited bone stock for fixation.

CONCLUSION

We present a case of a 28-year-old man with a combined flexor digitorum profundus bony avulsion and bony mallet finger, and describe a strategic fixation technique using an intramedullary suture anchor and dorsal button that provided stable fixation and resulted in excellent motion and function, with return to sport at 12 weeks.

Comparative analysis of the effects of AO mini-plate and Kirschner wire pinning in the metacarpal fractures: A retrospective study

The aim of this study was to investigate the clinical effect of AO miniplate screw internal fixation and Kirschner wire (KW) in the treatment of metacarpal fractures.We retrospectively analyzed the clinical data of 590 metacarpal fracture patients admitted to our hospital from March 2016 to March 2019. Among them, 290 patients were treated with KWs; 300 were treated with AO microplate internal fixation. The clinical, radiological results, time of surgery, and complications were observed and compared between the 2 groups.The imaging characteristics and preoperative fracture types of the 2 groups were similar and comparable (P > .05). The operation time, length of hospital stay, and fracture healing time of AO group were shorter than those of KW group, and the differences were statistically significant (41.22 ± 7.23 vs 25.64 ± 6.29; 7.13 ± 2.38 vs 5.26 ± 1.71; 67.43 ± 22.01 vs 52.57 ± 17.46, P < .05). In addition, the incidence of postoperative complications in AO group was lower than that in KW group (8.3% vs 15.2%, P < .05). In terms of surgical knuckle extension, flexion, and total mobility (compared with the uninjured hand), patients in the AO plate group were significantly improved compared with patients in the KW group, and the difference was statistically significant (4 vs 10 degree; 19 vs 10 degree; 14 vs 29 degree, P < .05); The average degree of finger rotation deformity in AO plate group was significantly lower than that in KW group (1 vs 6 degree, P < .05). In terms of grip strength (compared with the healthy hand), the average grip strength of AO plate group was significantly higher than that of KW group (93% vs 83%, P < .05). Patients in the OA plate group had a lower Disabilities of the Arm, Shoulder and Hand score (P < .05).Compared with KW fixation, AO mini-plate and screw fixation for the metacarpal fracture has a better effect, which can effectively shorten the operation time and reduce the trauma to patients. It can provide patients with better stability and realize the early movement of the palm, promote fracture healing and joint function recovery; it can reduce the incidence of postoperative complications, which has certain safety. In addition, it can effectively reduce the risk of poor finger rotation.

Needle-in-needle Pinning Technique Using Disposable Hypodermic Needles for Fractures of Distal Phalanx With Dorsal Disruption

Fingertip injuries are frequently encountered by the hand surgeon, and often present with a combination of the following: avulsed or broken nail plate, nail bed disruption, and/or distal phalangeal fracture. Recommended management of these injuries consists of reduction of the fracture followed by repair of soft tissues. To achieve an anatomic reduction and sufficient stability of the fracture, current management consists of temporary Kirschner-wire stabilization. Hypodermic needles can be substituted to secure temporary transosseous fixation. We describe a technique for stabilizing open distal phalangeal fracture using hypodermic needles which are readily available. Eight patients over 12 months have been treated with this technique which has proven to be successful. We would advocate that providers consider this technique when Kirschner-wires or other necessary instruments are unavailable.

Comparison of single and double dorsal wires in the extension block technique for mallet fractures: Retrospective observational study

Mallet fractures are avulsion fractures of the extensor tendon from the distal phalanx base and often occur due to sudden flexion or axial loading. In this study, we aimed to compare the clinical and radiological results of patients treated with single and double dorsal wires from the dorsal in the extension block method.Patients to whom a single wire from dorsal was applied were assigned to Group 1 (n: 22), and those to whom double wires were applied were assigned to Group 2 (n: 23). Surgical treatment was decided for patients with more than 1/3 of the fracture fragment containing the joint surface and volar subluxation. The range of motion of the distal interphalangeal (DIP) joint was measured with a goniometer. The displacement of the fragment was measured before and after surgery on lateral radiographs. The presence of bridging callus formation on anterior-posterior and lateral radiographs was evaluated for a union.There were 30 male (66.7%) and 15 (33.3%) female patients. The mean age of the patients was 32 years. Radiographic union was obtained in all patients. Pseudoarthrosis was not observed in any patient. The Crawford score was excellent in 13 (28.9%) cases, the score was good in 18 (40%) cases, the scores were moderate in 13 (28.9%) cases, and the score was poor in 1 case (2.2%). There were no complications in 35 (77.8%) cases, dorsal bump complications occurred in 9 cases (20%), and osteoarthritis and dorsal bump complications occurred in 1 (2.2%) case. We did not observe nail deformity, skin necrosis, infection, or fingertip sensitivity. We found similar functional and clinical results between the groups.We recommend using single dorsal wire, as using double dorsal wires requires extra operation time, effort, and fluoroscopy.

Complications Following Transosseous Repair of Zone I Flexor Tendon Injuries

PURPOSE

Multiple techniques are described for repair of zone I flexor tendon injuries, many of which are fraught with complications. This study evaluated the clinical complications after a transosseous repair technique.

METHODS

A retrospective review of a single institutional database identified all zone I flexor digitorum profundus (FDP) injuries repaired using a transosseous technique. In this technique, 2 nonabsorbable sutures were passed from volar to dorsal through transosseous tunnels and tied dorsally over the distal phalanx proximal to the germinal matrix. Demographics, injury characteristics, operative details, and complications were reviewed.

RESULTS

Eight patients met the inclusion criteria. Average age was 31 years (range, 15-66 years) and all patients were male. Eight fingers were included: ring (4), small (3), and middle (1). Seven injuries were closed and one was open. Average time between injury and surgery was 13 days (range, 4-34 days). Five patients experienced complications, including osteomyelitis, chronic draining granuloma, and abnormal nail growth. Three patients required an additional operative procedure for management of complications.

CONCLUSIONS

Transosseous repair of zone I flexor digitorum profundus injuries with a buried dorsal suture is associated with a high rate of clinical complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Kirner's deformity of the fifth finger: A case report

RATIONALE

Kirner's deformity is an uncommon deformity of finger, characterized by palmo-radial curvature of distal phalanx of the fifth finger. The specific mechanism remains unknown yet. This study aims to present a case report to add the knowledge on this type of deformity.

PATIENT CONCERNS

A 9-year-old girl presenting with deformity of her fifth finger since she was born was admitted to our hand surgery clinic. MRI findings showed widened epiphyseal plate, L-shaped physis, but normal flexor digitorum profundus tendon insertion, without any significantly enhanced soft issues.

DIAGNOSIS

Kirner's deformity of the fifth finger.

INTERVENTIONS

We presented 2 surgical choices for the patient: one was wedge osteotomy of the distal phalanx to correct the mechanical line of the distal phalanx and fixation with Kirschner wire and the other one was cut-off of deep flexor tendon insertion with brace immobilization, but her guardians refused either of them.

OUTCOMES

Consecutive follow-up was performed for 19 months after the first visit, showing no any change in finger shape and function.

LESSONS

The L-shaped epiphyses may be the cause of Kirner's deformity and further attention should be paid on in the clinic. This case report provided a basis for the etiological diagnosis and future treatment of Kirner's deformity.

Delta Wiring Technique to Treat Bony Mallet Finger: No Need of Transfixation Pin

Extension-block pinning is a popular surgical treatment method for mallet fractures but is associated with several pitfalls. Transfixation Kirschner wires used in the extension-block pinning technique may cause iatrogenic nail bed injury, bone fragment rotation, chondral damage, or osteoarthritis. The objective of this study was to determine the result of the delta wiring technique in mallet fractures with fracture fragment involving more than one-third of the distal phalanx articular surface. The authors are reporting 5 cases of mallet fractures treated with delta wiring technique with good functional and radiologic outcomes. Radiologic outcomes were evaluated on the basis of postoperative and follow-up x-rays and functional outcomes were evaluated using Crawford's criteria. Five patients (4 males, 1 female) with a mean age of 26.8 years (range, 20 to 33 y) were included. The mean time between the injury and surgery was 5 days (range, 3 to 7 d), and the mean follow-up period was 8.6 months (range, 8 to 10 mo). Radiographic bone union was achieved in all patients within an average of 6.4 weeks (range, 6 to 7 wk). At the final follow-up, the distal interphalangeal joint had an average degree of flexion of 73 degrees (range, 70 to 75 degrees) and an average extension deficit of 5.40 (range, 0 to 8 degrees). According to Crawford's criteria, 1 patient had excellent results and 4 patients had good results. No patient reported pain at the final follow-up with a visual analog scale score mean of 0.6 (range, 0 to 2). Satisfactory clinical and radiologic outcomes were obtained with the delta wiring technique. Future prospective and randomized studies are justified to confirm the efficacy of this technique.

Management of Unstable Phalangeal Shaft Fractures Using External Minifixator

BACKGROUND

Fractures of the hand are the most common fractures in the skeletal system and phalangeal fractures constitute about 46% of all hand fractures. Operative treatment of unstable phalangeal fractures should aim at anatomic fracture reduction and stable fixation that allows early mobilization of the affected finger's joints . This study evaluates the results of fixation of unstable shaft fractures of finger proximal or middle phalanges using a non-spanning external minifixator.

MATERIAL AND METHODS

32 men and 8 women aged 17 to 60 (median, 31.25) years suffering from fractures of 44 phalanges in 40 hands were included in the study. Four of the fractured phalanges were middle phalanges and 40 were proximal phalanges .All fractures were fixed using a mini external fixator. All procedures were done under regional anaesthetic block. The fixator was applied after closed reduction of fractures. Additional procedures included wound debridement in open fractures, and tendon repair was needed in 4 cases. We excluded fractures where intraarticular fracture extension mandates open reduction and internal fixation.

RESULTS

At the end of the follow-up period (mean follow-up 11.5 months), patients were assessed clinically and radiologically. 26 fingers (59.1 %) had "excellent" results , 14 fingers (31.8 %) had "good" results and 4 fingers (9.1%) had "poor" results as their P.I.P. flexion ranges were &lt; 80˚.

CONCLUSION

External fixation of displaced phalangeal shaft fractures is an effective method of treatment in terms of a minimally invasive technique with rigid fracture fixation allowing early mobilization after surgery.

Elastic fixation of mallet finger fractures using two K-wires: A case report of a new fixation technique

RATIONALE

Mallet finger fracture is a common sports-related injury that may lead to the tearing of extensor tendon and protrusion of a bony fragment located at the base of the distal phalanx. We affirmed that the elastic fixation of with two K-wires technique is a good method to deal with Mallet Finger fractures that fractures could gain effective fixation than the conventional treatment method and avoid surgical incision complication PATIENT CONCERNS:: We reported a 33-year-old female patient came to our hospital complaining of mild pain, swelling and her right little finger was deformed because of sport's injury.

DIAGNOSIS

Acute mallet finger fracture type IV B according to Doyle classification of mallet injuries.

INTERVENTIONS

We performed an emergency operation for the elastic fixation of the mallet finger fractures with two K-wires.

OUTCOMES

After the surgery, the patient showed functional recovery. No evidence of recurrence was noted 6 months after the operation, and the patient showed no symptoms of sports-related injuries.

LESSONS

We discuss the clinical diagnosis, treatment, and follow-up of the patient and suggest that elastic fixation with two K-wires is a good method to treat mallet finger fractures.

[Reconstruction of the middle phalangeal base of the finger using an osteocartilaginous autograft from the hamate]

OBJECTIVE

Restoration of proximal interphalangeal joint stability with preservation of mobility by reconstruction of the middle phalanx base using an osteochondral graft from the carpometacarpal joint surface of the hamate.

INDICATIONS

Acute and older isolated destruction of the palmar middle phalanx base >25%.

CONTRAINDICATIONS

Destruction of the head of the proximal phalanx, advanced chondropathia of the head of the proximal phalanx, extensive soft tissue injury with loss of skin coverage at the proximal interphalangeal joint.

SURGICAL TECHNIQUE

The fractured middle phalangeal base is debrided and the defect is replaced by a size-matched autograft from the dorsal carpometacarpal hamate osteoarticular surface that is secured in place with miniscrews.

POSTOPERATIVE MANAGEMENT

Immobilization for 2 weeks in a below-elbow cast in intrinsic plus position. Subsequent immobilization by a splint including the distal and proximal interphalangeal joint.

RESULTS

Healing was achieved in 100% with restoration of joint congruity in 12 of 13 cases and slight subluxation in 1 case. Follow up was possible in 9 cases after 22 ± 16 (5-51) months. The average range of motion in the reconstructed joint achieved 0/9/73°, grip strength 82% of the unaffected side. Of the 9 patients, 5 developed a mild flexion contracture of the proximal interphalangeal joint. The DASH score achieved 4 ± 3 (0-8) points, pain at rest was 1 ± 2 (0-5), pain at exercise 2 ± 2 (0-5) on a visual analogue scale (0-10). All patients were satisfied and willing to undergo the procedure again. According to the literature, reconstruction of the base of the middle phalanx by using an osteochondral graft from the hamate is a reliable procedure to restore stability and mobility of the joint.

A Rare Manifestation of Primary Bone Lymphoma: Solitary Diffuse Large B-Cell Lymphoma of the Little Finger

Solitary primary non-Hodgkin bone lymphoma of the hand is a rare entity with only 3 cases reported in the literature. We report the case of a 77-year-old patient with isolated large B-cell bone lymphoma of the proximal phalanx of the little finger without rheumatoid arthritis or methotrexate treatment. The patient was treated with digital amputation and at 6 months' follow-up showed no relapse or dissemination of the disease.

[Glomus tumour of the distal phalanx]

A glomus tumour is a benign, small, rare tumour, primarily localised to the fingers. Literature describes a delayed diagnosis, and patients will describe a classic triad of symptoms: paroxysmal pain, hypersensitivity, and pinpoint pain at the location of the tumour. MRI can confirm the presence and the localisation of a glomus tumour, and an osseous defect can often be found by X-ray. If the patient show classic symptoms, exploratory surgery should be performed, despite negative radiology. Excision of the tumour will provide immediate pain relief and has a very low rate of recurrence.

[Long delay until correct diagnosis of glomus tumours in the distal phalanx]

Glomus tumours tend to be diagnosed with long delay due to lack of knowledge about the condition. This is a case report of two patients with longstanding symptoms, which remained undiagnosed for several years despite X-ray and MRI. One was operated on without finding the tumour at the initial surgical procedure, and the other had the diagnosis confirmed by ultrasound. Both were cured of the pain, when the subungual tumour was excised.

Complications of Proximal Interphalangeal Joint Injuries: Prevention and Treatment

Proximal interphalangeal joint injuries are one of the most common injuries of the hand. The severity of injury can vary from a minor sprain to a complex intra-articular fracture. Because of the complex anatomy of the joint, complications may occur even after an appropriate treatment. This article provides a comprehensive review on existing techniques to manage complications and imparts practical points to help prevent further complications after proximal interphalangeal joint injury.

Multiple unexpected lesions of metachondromatosis detected by technetium-99m methylene diphosphonate SPECT/CT: A case report

RATIONALE

Metachondromatosis (MC) is a very rare genetic disease, which is infrequently reported worldwide, which leads to osteochondroma and enchondromatosis. The disease has been shown to be associated with loss of function of the tumor suppressor gene "protein tyrosine phosphatase, non-receptor type 11" (PTPN11).

PATIENT CONCERNS

A 12-year-old female was admitted to the hospital with pain due to an enlarged mass in her left fifth finger.

DIAGNOSIS

Examination of the left hand by computed tomography (CT) revealed an expanding type of round and low-density lesion in the fifth proximal phalanx. The patient then underwent technetium-99m methylene diphosphonate single-photon emission CT/CT (Tc-MDP SPECT/CT) to assess the nature of the lesion. The SPECT/CT image revealed dilated osteopathy and increased activity of the fifth proximal phalanx on the left hand. Unexpectedly, the examination of the right hand revealed slight expanded lesions and increased activities of the third metacarpal and proximal phalange, as well as the fourth proximal phalange and the middle phalanx. On the basis of the patient's symptoms and the results of the above-mentioned examinations, we diagnosed the patient as having MC in her hands.

INTERVENTION

Considering the pain of the fifth finger of the left hand, the patient underwent debridement of the fifth proximal phalanx of the left hand and internal fixation with bone graft taken from the body.

OUTCOMES

The patient was discharged after a week of observation. One year later, she was admitted to the hospital again for removal of the bone healing internal fixation after osteoma surgery. Preoperative Tc-MDP SPECT/CT revealed that the left-handed lesions displayed postoperative changes, while the multiple lesions in the right hand increased in volume but remained unchanged in number.

LESSONS

This case revealed the CT and Tc-MDP SPECT/CT imaging features of MC. Specifically, SPECT/CT imaging contributed to the diagnosis of clinically asymptomatic bone lesions, and the 3D SPECT/CT fusion allowed a more comprehensive and intuitive view of the lesion by combining anatomy and function.

Tips Under the Skin: A Simple Modification of Extension Block Pinning for Mallet Fractures

Pins exposed out of the skin after surgery for mallet fractures keep patients from washing their hands. The authors buried the tips of all pins under the skin while performing extension block pinning for 14 patients with mallet fractures. The patients were allowed to wash their hands 4 to 5 days postoperatively, without any dressing or splinting. The pins were removed at a mean of 8 weeks postoperatively. Solid union was achieved in all 14 fractures. No pull-out or subsidence of the pin was observed. No patient developed infection or other pin-related complications. Mean extension lag at final follow-up was 4°. [Orthopedics. 2018; 41(2):e299-e302.].

Finger reconstruction using induced membrane technique and ulnar pedicled forearm flap: a case report

INTRODUCTION

Injuries referred to as "rollover hands" are associated with multiple and complex lesions of the dorsal aspect of the hand. We present a case of a multitissular reconstruction following a severe injury of the dorsum of the fingers in a 45-year-old woman.

MATERIALS AND METHODS

The bone loss reconstruction was performed in two stages using the Masquelet induced membrane technique. In the first stage, a cement spacer was inserted into the phalanx bone defects. For the second stage, the membrane induced by the foreign-body reaction was opened, the spacer was removed, and an autologous cancellous bone graft was inserted into the defects. The skin coverage was obtained using a reverse ulnar artery forearm pedicled flap. The digits were covered jointly. Three surgical procedures over the course of a 2-month period were required to desyndactylize the fingers and to defat the flap.

RESULTS

At the 2-year follow-up examination, the patient exhibited good integration of their hand use in daily living. The esthetic result was deemed to be satisfactory. Definitive bone consolidation occurred 4 months after the second stage.

CONCLUSIONS

Rollover hands are typically a challenge for both the patient and the hand surgeon. The risk of septic complications, as well as the need for several stages of surgical reconstruction, makes the Masquelet technique particularly attractive for the treatment of phalanx bone defects consecutive to rollover injuries.

Mallet Fractures of the Thumb Compared With Mallet Fractures of the Fingers

BACKGROUND

The purpose of this study was to look for differences in mechanism, radiographic findings, and treatment between mallet fractures of the thumb and mallet fractures of the index through small fingers.

METHODS

This retrospective study included 24 mallet fractures of the thumb and 392 mallet fractures of other digits. We compared demographics, injury factors (side, dominant hand, time between injury and first visit, and injury mechanism), subluxation, fragment size, treatment, and time from injury to final evaluation between the 2 groups.

RESULTS

Mallet fractures of the thumb presented for treatment sooner after injury (2.9 vs 13 days on average), had less fragment displacement (27% vs 33%), and less articular involvement (39% vs 46% on average). None of the mallet fractures of the thumb had radiographic evidence of subluxation, whereas 25% of mallet fractures of other fingers had initial or later subluxation.

CONCLUSIONS

Mallet fractures of the thumb are not likely to subluxate.

Reconstruction of large area defect of the nail bed by cross finger fascial flap combined with split-thickness toe nail bed graft: A new surgical method

Fingertip injury commonly results in avulsion of the nail bed. For large area defects of the nail bed with distal phalanx exposure, methods for reconstruction of soft tissue defects are scarcely mentioned in the literature.From May 2014 to January 2016, 6 patients with large area defects of the nail bed with distal phalanx exposure were enrolled. A new surgical method, cross finger fascial flap combined with thin split-thickness toe nail bed graft, was applied in all patients.All the 6 patients were followed-up at least 3 months. Good blood supply and no infections were observed. The lengths of the thumb or fingers were preserved. Acceptable appearance and nail bed growth were noted. The donor sites showed no dysfunction or deformity.Cross finger fascial flap combined with thin split-thickness toe nail bed graft is a new and rewarding surgical method to reconstruct large area defect of the nail bed with distal phalanx exposure.

Pilon Fractures of the Base of the Proximal Phalanx: Direct Intraosseous Joint Reduction with Bone-Grafting and Mini-Screws: A Case Report

CASE

A 31-year-old woman sustained a closed pilon fracture of the base of the second proximal phalanx. Computed tomography showed comminution, central depression, and splaying of the articular surface. We used a method of direct intraosseous joint reduction in combination with bone-grafting and mini-screws to treat the fracture. For reduction, a golf-club-shaped instrument was inserted into the medullary cavity through a drill-hole in the phalanx.

CONCLUSION

The advantage of this technique is that it leaves the joint capsular complex and the extensor hood intact. A stable joint was achieved, and early rehabilitation was possible. The clinical outcome and radiographic results were very good.

Florid reactive periostitis in the fifth phalange of a professional boxer: A case report

RATIONALE

Florid reactive periostitis is a rare, benign bone and chondrogenic lesion that develops most frequently in the phalanges of the hands. Although the definitive cause of florid reactive periostitis is unknown, the major inciting factor is generally considered to be trauma, including repetitive minor trauma.

PATIENT CONCERNS

We present a case of florid reactive periostitis affecting two contiguous phalangeal bones of the left fifth phalange of a 23-year-old male professional boxer. The patient had experienced chronic pain around the metacarpophalangeal joint of the left fifth phalange when punching with the left hand; this pain was improved but not resolved after conservative treatment.

INTERVENTIONS

Plain radiography of the fifth phalange revealed a bulging bone lesion on the volar side of the proximal phalanx and metacarpal of the left fifth phalange. Computed tomography also showed raised bony lesions on the volar side of these bones without bony destruction or intraregional calcification. Surgery was performed and histopathology revealed that the bone specimens comprised a mixture of fibrous connective tissue and relatively immature bone covered by bland osteoblasts.

DIAGNOSES

These findings were suggestive of a benign bone formation process, and the lesion was diagnosed as florid reactive periostitis.

OUTCOMES

The pain and tenderness in the left fifth phalange experienced during boxing had completely resolved by 6 months postoperatively, and 12 years postoperatively the patient had full range of motion and no recurrence of pain.

LESSONS

Traction force, such as those associated with "leading jabs," may induce repetitive minor trauma and subsequent periosteal damage, resulting in the gradual development of bulging bone ridges on the volar surface of the proximal fifth phalange and metacarpus of the hand.

The "Fish Hook" Technique for Bony Mallet Finger

This study describes a new technique called the "fish hook" technique for the treatment of bony mallet finger. This technique catches the dorsal fragment with a bent K-wire shaped like a fish hook. Transarticular fixation is performed with another K-wire. This technique does not directly penetrate the bone fragment to prevent fragment comminution. This study included 26 patients with mallet finger fractures who underwent surgery using the fish hook technique between 2010 and 2014. The fractures were classified according to the method of Wehbe and Schneider. The fracture fragment was fixed with a fish hook technique in all patients. The K-wire was removed after 6 weeks, when bone union was achieved. Clinical parameters, including range of motion and extensor lag, were assessed at the distal interphalangeal joint according to Crawford's criteria. The mean follow-up period was 12.8 months. Mean extensor lag was 3°, and mean range of flexion of the distal interphalangeal joint was 76°. All patients achieved bone union after 6 weeks. According to Crawford's criteria, there were 20 excellent results, 5 good results, and 1 fair result. No complications, including skin necrosis, pin loosening, and nail deformity, occurred. The fish hook technique is an effective treatment option for bony mallet finger and provides good clinical and radiologic results. [Orthopedics.2016; 39(5):295-298.].

Enchondroma in the distal phalanx of the finger: An observational study of 34 cases in a single institution

The goal of our study was to report the clinical presentation, treatment, and complications of enchondroma in the distal phalanx of the finger. This was a retrospective study of 34 patients (19 women and 15 men) who underwent surgery between May 2004 and September 2012 for enchondroma in the distal phalanx of the finger. The average age of the patients was 39.38 ± 10.97 years old (range 14-59). The presenting symptoms and imaging features were recorded. The surgical procedure was performed under regional or general anesthesia. The surgical technique involved removal of tumors by opening a cortical window and curetting the cavity. The defects were filled with an injectable calcium phosphate cement. All patients received follow-up in our outpatient clinic every 6 months. Expansion of bone or thinning of the cortex present in the radiological imaging, including anteroposterior and lateral plain radiographs of the fingers, was used to assess for tumor recurrence. The observational end-point was reoperation.All tumors were confirmed as enchondromas by the pathological results. None of the patients had a tumor recurrence. Three patients (9% of cases) developed an infection. After antibiotic treatment, 2 patients were cured, and 1 patient required an amputation. Enchondroma in the distal phalanx of the finger presents with a variety of clinical symptoms. Injectable calcium phosphate cement is adequate for bone grafting. Postoperative infection is more common than tumor recurrence. If patients have an infection or bilateral bone cortex defects, bone grafting is challenging.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Phalangeal Neck Fractures in Adults

The author investigated the pattern of injury and outcome of management in 11 adults with phalangeal neck fractures. The mean age was 40 years. The fracture occurred at the neck of the proximal phalanx of the thumb in seven cases and at the neck of the middle phalanx of the fingers in the remaining four cases. One patient had an undisplaced (Type I) fracture and was treated with splinting; the final result was graded as excellent. Nine patients had Type II fractures (the displaced distal fragment maintaining bone-to-bone contact with the proximal fragment) and all patients were treated with closed reduction and single K-wire fixation. The final outcome of Type II fractures was considered good in eight patients and fair in one patient. One patient had a Type III fracture (the displaced distal fragment was rotated 180° with no bone-to-bone contact with the proximal fragment). The fracture required open reduction and K-wire fixation and the final result was poor.

Stability of the distal phalanx fracture - A biomechanical study on the importance of the nail and the influence of fixation by crossing Kirschner wires

BACKGROUND

With respect to the stability of displaced distal-phalanx fracture, the relevance of nail loss and the biomechanical effects of fixation using crossed Kirschner wires have not been investigated. The present study aimed to determine whether the nail or the type of fixation contributes to stabilizing distal-phalanx fracture.

METHODS

In 48 specimens (fingers), a model of the comminuted fracture of the distal phalanx (AO type A3) was created by resecting a 1-mm osseous segment from the distal phalanx. Specimens were assigned to one of four groups, depending on whether the fracture was accompanied with nail loss, and whether the fracture fixation employed a single Kirschner wire or a crossing of two Kirschner wires. Each specimen was subjected to either a bending or a torsion test.

FINDINGS

Regardless of the fixation form, the mean peak bending and torsion forces were higher for the specimens with the nail intact. Furthermore, these forces were also higher in specimens which had received fixations based on the Kirschner wires, compared to those specimens which had received fixations based on a single Kirschner wire. The highest mean peak torque 1.39 (0.12) N·m was found for the specimens with no nail loss and fixation using two crossed Kirschner wires, while the lowest mean peak torsion 0.46 (0.02) N·m was found for specimens with nail loss and fixation using a single Kirschner wire.

INTERPRETATION

Our results suggest that the nail can provide additional stability for comminuted fractures of the distal phalanx after fixation. Furthermore, when nail loss occurs, fixation using two crossed Kirschner wires can provide significantly more stability than fixation using single Kirschner wire.

Glomus tumor – A case report

INTRODUCTION

Glomus tumor is a neuromyoarterial tumor. It is a rare tumor which accounts for about 2% of all hand tumors. The diagnosis is based on the triad of symptoms, clinical examination which includes three tests, magnetic resonance imaging, and ultrasound imaging. The most common treatment is surgical excision, using transungual or lateral subperiosteal approach. Sclerotherapy and radiotherapy may be the treatments of choice, but they are less effective. The recurrence rate is high – from 5% to 50%.

CASE OUTLINE

We diagnosed a glomus tumor of 1 cm in diameter in the distal phalanx of the fourth finger of the right hand in a 30-year-old woman. She had been visiting different physicians for more than two years and had been variously diagnosed. We performed a biopsy of the tumor, which was bleeding profusely during the procedure. Upon biopsy results, the tumor was excised with transungual approach. Two and a half months after the procedure the patient was feeling well.

CONCLUSION

There should be higher awareness of this tumor in order to diagnose it more easily and treat it accordingly, and thus alleviate the severe pain which the tumor causes. When it is considered as the possible cause of the lesion, the diagnosing is easier and treatment is immediate.

Implantation of a denaturated cellulose adhesion barrier after plate osteosynthesis of finger proximal phalangeal fractures: results of a randomized controlled trial

Adhesions after osteosynthesis of finger proximal phalangeal fractures often cause stiffness. To minimize adhesions, the use of an adhesion barrier has been proposed. The results until now have not been convincing. The aim of this prospective randomized trial was to evaluate the use of an adhesion barrier. The trial included any isolated, closed proximal phalangeal fracture needing plate osteosynthesis. The patients were randomized into two groups: with or without application of the adhesion barrier. The outcomes we measured were finger ranges of motion and DASH score at 6 weeks and 6 months post-operatively. A total of 42 patients (42 fingers) entered the study; 37 completed the study. The key baseline characteristics were comparable. At 6 weeks there was a trend favouring the adhesion barrier that disappeared at 6 months. Overall the results do not support the use of this device.