cme - semantic scholar · 2018-02-23 · bennett fracture is a two part fracture-disloca-tion in...

$: CME - Semantic Scholar · 2018-02-23 · Bennett fracture is a two part fracture-disloca-tion in which the entire thumb metacarpal is sub-luxateddorsally,radially,andproximallybythepull$
CME

Common Fractures and Dislocations ofthe Hand

Neil F. Jones, M.D.Jesse B. Jupiter, M.D.

Donald H. Lalonde, M.D.

Orange, Calif.; Boston, Mass.; andSaint John, New Brunswick, Canada

Learning Objectives: After reading this article, the participant should be ableto: 1. Describe the concept of early protected movement with Kirschner-wiredfinger fractures to the hand therapist. 2. Choose the most appropriate methodof fracture fixation to achieve the goal of a full range of motion. 3. Describe themethods of treatment available for the most common fractures and dislocationsof the hand.Background: The main goal of treatment of hand and finger fractures anddislocations is to attain a full range of wrist and nonscissoring finger motion afterthe treatment is accomplished. This CME article consists of literature review,illustrations, movies, and an online CME examination to bring the participantrecent available information on the topic.Methods: The authors reviewed literature regarding the most current treat-ment strategies for common hand and finger fractures and dislocations. Filmswere created to illustrate operative and rehabilitation methods used to treatthese problems. A series of multiple-choice questions, answers, discussions, andreferences were written and are provided online so that the participant canreceive the full benefit of this review.Results: Many treatment options are available, from buddy and Coban tapingto closed reduction with immobilization; percutaneous pins or screws; and openreduction with pins, screws, or plates. Knowledge of all available options isimportant because all can be used to achieve the goal of treatment in the shortesttime possible. The commonly used methods of treatment are reviewed andillustrated.Conclusions: Management of common hand and finger fractures and disloca-tions includes the need to focus on achieving a full range of motion aftertreatment. A balance of fracture reduction with minimal dissection and earlyprotected movement will achieve the goal. (Plast. Reconstr. Surg. 130: 722e, 2012.)

The majority of metacarpal and phalangealfractures can be treated nonoperatively.1,2

Optimal treatment will depend on whetherthe fracture can be reduced (reducible or irre-ducible) and whether the reduction can be main-tained (stable or unstable). Closed reduction andpercutaneous fixation or open reduction and in-ternal fixation of metacarpal and phalangeal frac-tures is indicated for irreducible fractures, openfractures, associated soft-tissue injury, segmental

bone loss, and multiple fractures, and relativelyindicated for intra-articular fractures and malro-tated fractures that cannot be corrected by closedreduction.3

From the Department of Orthopedic Surgery, University ofCalifornia, Irvine Medical Center; Harvard Medical School,Department of Orthopedic Surgery, Massachusetts GeneralHospital; and Dalhousie University.Received for publication January 5, 2012; accepted April 17,2012.Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e318267d67a

Disclosure: The authors have no financial interestin any of the products or devices mentioned in thisarticle.

Related Video content is available for this ar-ticle. The videos can be found under the “Re-lated Videos” section of the full-text article, or,for Ovid users, using the URL citations pub-lished in the article.

www.PRSJournal.com722e

INTRA-ARTICULAR FRACTURES OFTHE BASE OF THE THUMB

METACARPALBennett fracture is a two part fracture-disloca-

tion in which the entire thumb metacarpal is sub-luxated dorsally, radially, and proximally by the pullof the abductor pollicis longus4–7 (Fig. 1, left). If themetacarpal base can be reduced and Kirschnerwired closed, or if the fragment is less than 20 per-cent of the articular surface, closed reduction andpercutaneous fixation are preferred (Fig. 1, center).Longitudinal traction, adduction, and pronationare applied to the base of the thumb metacarpalunder fluoroscopy, and the base of the metacarpalis Kirschner wired to the index metacarpal or tra-pezium. The pins are removed after 4 weeks. Ifthere is an articular stepoff greater than 2 mmafter attempted closed reduction and percutane-ous fixation, open reduction and internal fixationis performed through a Wagner incision with 2.4-or 2.0-mm lag screws8 or Kirschner wires (Fig. 1,right). Long-term follow-up has confirmed supe-rior results in terms of pain, mobility, strength,and radiographic signs of arthritis in patients whounderwent closed reduction and percutaneousKirschner wiring or open reduction and internalfixation if there was less than 1 mm of articularstepoff after reduction.9 Conversely, patients witharticular incongruity after reduction had a higherincidence of symptomatic arthritis in long-termfollow-up.10,11 One study contradicts the principle

of anatomical reduction of intra-articular frac-tures, finding little evidence of symptomatic post-traumatic arthritis 10 years after nonoperativetreatment of Bennett fractures.12

ULNAR METACARPAL BASE FRACTUREDISLOCATIONS

In reverse (baby) Bennett13 fractures, approx-imately 25 to 30 percent of the radial base of thesmall finger metacarpal remains articulating withthe hamate, but the entire small finger metacarpalis subluxated proximally and dorsally because ofthe pull of the extensor carpi ulnaris tendon. Onestudy showed that the majority of patients treatedby immediate range of motion were asymptomatic4½ years later.14 Another study showed that 38percent of patients are symptomatic 4 years laterregardless of the treatment.15 Most agree that resto-ration of articular congruity should be attemptedeither by closed reduction and percutaneous fixa-tion or open reduction and internal fixation.16

Longitudinal traction is applied to the smallfinger and pressure is applied to the dorsal aspectof the base of the small finger metacarpal followedby passive wrist extension and closed Kirschnerwire fixation under fluoroscopy. If treatment hasbeen delayed, closed reduction and percutaneousfixation is not successful, multiple carpometacarpaljoint fracture dislocations are present, or there is anassociated dorsal shear fracture of the hamate,17

open reduction and internal fixation is indicated

Fig. 1. (Left) Intra-articular Bennett fracture of the base of the thumb metacarpal showing proximal and radialdisplacement of the entire thumb. (Center) Closed reduction and percutaneous Kirschner wire fixation of a Bennettfracture. (Right) Open reduction and internal fixation of a Bennett fracture with two 2.0-mm lag screws.

Volume 130, Number 5 • Common Hand Fractures and Dislocations

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through a dorsal longitudinal incision. Fixation isachieved with oblique and transverse Kirschnerwires or by longitudinal intramedullary Kirschnerwires first passed antegradely down the metacarpalshaft and then passed retrogradely back into thehamate.

METACARPAL SHAFT FRACTURESThe geometry of metacarpal shaft fractures

may be transverse, oblique, spiral, or comminuted.Transverse metacarpal shaft fractures exhibit apexdorsal angulation caused by the deforming forceof the interosseous muscles (Fig. 2). Closed re-duction is indicated for 10 degrees of apex dorsalangulation in the index and middle fingers,greater than 20 degrees in the ring finger, andgreater than 30 degrees in the small finger. Mostmetacarpal shaft fractures are inherently stableand do not require fixation after closed reduction.Immobilization should not be continued longerthan 3 weeks; otherwise, stiffness may result.18,19

Closed reduction and percutaneous fixation is in-dicated if the fracture is unstable. Under fluoro-scopic control, a single 0.062-inch Kirschner wirecan be inserted retrogradely into the metacarpalhead to the radial or ulnar side of the extensortendon and then across the fracture site into theproximal metacarpal or even into the carpus.20,21

Metacarpal shaft fractures of the border digits, theindex and small finger metacarpals, can be Kirsch-ner wired transversely to noninjured metacarpals.

An alternate method of percutaneous pinning ofa metacarpal shaft fracture is to use the “bouquetarrangement” of multiple intramedullary Kirsch-ner wires inserted antegradely from the base of themetacarpal.22–24

Open reduction and internal fixation of meta-carpal shaft fractures is indicated for unsuccessfulclosed reduction and percutaneous fixation, or for(1) significantly displaced transverse fractures orfractures that have residual angulation of greaterthan 10 degrees in the index and middle fingers,20 degrees in the ring finger, and 30 degrees in thesmall finger; (2) spiral or oblique fractures withresidual malrotation and scissoring; (3) multiplemetacarpal shaft fractures when multiple Kirsch-ner wires may not allow early movement after sur-gery; (4) open metacarpal shaft fractures; or (5)segmental metacarpal bone loss.

Metacarpal shaft fractures are exposed througha longitudinal incision to one side of the extensortendon. The most simple fixation technique is toinsert a Kirschner wire longitudinally down the med-ullary cavity of the metacarpal. The Kirschner wire isintroduced antegradely at the fracture site into thedistal fragment and drilled out through the radial orulnar aspect of the metacarpal head and then drilledback retrogradely after the fracture has been re-duced into the proximal fragment and even into thecarpus. Longitudinal intramedullary Kirschner wirefixation is an excellent solution for multiple opentransverse metacarpal shaft fractures. The crossedKirschner wire configuration is more stable, but it ismore difficult to achieve except for metacarpal shaftfractures of the border index and small fingermetacarpals.25,26

Dorsal plate-and-screw fixation may be consid-ered for fixation of a single unstable metacarpalshaft fracture (Fig. 3) but is more usually indicatedfor multiple metacarpal fractures, open metacar-pal fractures, and fractures where there is segmen-tal bone loss or an associated dorsal soft-tissueinjury. Low-profile 2.7- or 2.4-mm plates are usu-ally applied dorsally, with fixation of at least fourcortices both proximal and distal to the fracturesite.27–29 The newer low-profile plates do not usu-ally need to be removed unless a secondary tenol-ysis of the extensor tendons or capsulotomy of themetacarpophalangeal joint is necessary or if thepatient feels that the plate is annoyingly palpableor causes cold intolerance. Spiral and long obliquemetacarpal shaft fractures that are unstable orhave persistent malrotation and scissoring afterclosed reduction are best treated with open reduc-tion and interfragmentary screw fixation.30 Fracturesthat are amenable to screw fixation should be two to

Fig. 2. Middiaphyseal fractures of the ring and small fingermetacarpals showing apex dorsal angulation.

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three times longer than the diameter of the meta-carpal. The proximal and distal apices of the fractureare manipulated into anatomical position and tem-porarily held with a reduction clamp or temporaryKirschner wire. Two 2.7-mm screws or three 2.4- or2.0-mm screws should ideally be inserted midway

between a plane at 90 degrees to the long axis ofthe metacarpal and the plane of the fracture itself(Fig. 4). It is important to avoid fragmentation ofthe apex of each fracture by placing the screw aminimum of two screw diameters away from theapex of the fracture.

Fig. 3. (Left) Transverse fracture of the shaft of the index finger metacarpal. (Right)Open reduction and internal fixation with a 2.0-mm dorsal plate.

Fig. 4. (Left) Spiral fracture of the index and middle finger metacarpals. (Right) Openreduction and internal fixation of each spiral fracture with three 2.4- and 2.0-mm lagscrews.


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Comminuted open fracture of the metacarpalshaft with segmental bone loss or associated withloss of the overlying dorsal soft tissues is besttreated by debridement and provisional bony sta-bilization to maintain metacarpal length,31 usingeither transverse Kirschner wires into an adjacentnoninjured metacarpal, spacer wires, locked in-tramedullary nailing,32 or the newer generation ofminiature external fixators.33–35 Serial debride-ments are performed until the wound is cleanenough to allow delayed primary wound coverageand bone reconstruction.36,37

METACARPAL NECK FRACTURESThese fractures usually involve the ring and/or

small finger metacarpals and assume an apex dorsalangulation because of bony comminution along thepalmar cortex of the metacarpal neck and becausethe interosseous muscles flex the metacarpal head.Controversy remains as to how much apex dorsalangulation can be accepted (Fig. 5). Some surgeonsbelieve that 40, 60, or even 70 degrees of apex dorsalangulation of the small finger metacarpal neck frac-ture is acceptable,38 but other surgeons believe thatpersistent angulation of greater than 30 degrees isunacceptable.39,40

Apex dorsal angulation of a metacarpal neckfracture can be better compensated for in the ringand small fingers because the ring and small fingermetacarpals have 20 to 30 degrees of motion at thecarpometacarpal joints, whereas there is almost nomotion at the carpometacarpal joints of the indexand middle finger metacarpals. This is why mostsurgeons agree that any apex dorsal angulation ofgreater than 10 to 15 degrees in the index andmiddle finger metacarpals is an indication for frac-ture reduction.

A simple test to determine whether apex dor-sal angulation of the ring and small finger meta-carpals is significant is to see whether the fingeradopts a posture of pseudoclawing. When the pa-tient attempts to extend the ring or small finger,the metacarpophalangeal joint will hyperextendand the proximal interphalangeal joint will flex.41

A prospective series comparing two groups of pa-tients with small finger metacarpal neck fracturestreated nonoperatively and operatively showed nodifference in functional outcome despite residualapex dorsal angulation in the nonoperated group.39,42

However, patients will occasionally complain of de-creased flexion of the finger, tenderness over a pal-pable metacarpal head in the palm, or loss of prom-inence of the ring or small finger metacarpal head.Although it used to be felt that all metacarpal frac-tures needed to be immobilized with metacarpo-phalangeal joint flexion, there is now a level I evi-dence study that Boxer (fifth metacarpal neck)fractures can now be immobilized with the metacar-pophalangeal joints in extension.43

PHALANGEAL FRACTURES AND EARLYPROTECTED MOVEMENT

Several factors adversely affect the eventualrange of motion after a phalanx fracture. Strick-land et al.44 reported that 88 percent of motion wasrestored in patients younger than 20 years but lessthan 60 percent of motion was restored in patientsolder than 60. Intra-articular phalangeal fracturesusually have a poorer prognosis than extra-artic-ular fractures.45 Prolonged immobilization is alsodetrimental. Immobilization of a phalangeal frac-ture for less than 4 weeks is associated with motionrecovery of 80 percent, whereas, motion recoveryis only 66 percent of normal if immobilization iscontinued for longer than 4 weeks.44

As it is with flexor tendon repairs, early pro-tected movement with Kirschner wire–fixated frac-tures can be beneficial in producing good results.(See Video, Supplemental Digital Content 1,which illustrates how to begin early protectedmovement 3 days after closed or open Kirschnerwiring of finger fractures to achieve the same goalsas in early protected movement after flexor ten-don repair, available in the “Related Videos” sec-tion of the full-text article on PRSJournal.com or,for Ovid users, at http://links.lww.com/PRS/A577.)

PHALANX SHAFT FRACTURESNondisplaced stable fractures do not require

reduction and can be treated by buddy-taping thefractured finger to an adjacent finger.46 If there isminimal pain associated with a nondisplaced sta-

Fig. 5. Metacarpal neck fracture of the small finger showing se-vere apex dorsal angulation, requiring closed reduction.


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http://links.lww.com/PRS/A577

ble fracture, immediate gentle active range of mo-tion exercises can be started with buddy-taping. Ifthere is pain or instability, the digit should beimmobilized in a splint in the position of safety,with the metacarpophalangeal joint flexed 70 de-grees and the proximal and dorsal interphalan-geal joints in full extension to prevent contractureof the collateral ligaments.47 Splint immobiliza-tion should not be continued for longer than 3weeks; otherwise, 60 percent of patients will de-velop stiffness.19,48,49

Closed reduction of displaced proximal pha-lanx fractures causing dysfunction begins with lon-gitudinal traction to disimpact the fracture. Flex-ion of the metacarpophalangeal joint stabilizesthe proximal fracture fragment. Flexion of thedistal fragment to correct angulation and malro-tation is performed. Reduction is maintained byimmobilization in an extension block splint for 3weeks with the metacarpophalangeal joints flexed90 degrees and the interphalangeal joints straight.Active flexion of the fingers and extension back tothe limit of the splint can be initiated within a fewdays for stable transverse fractures, but inherentlyunstable spiral or oblique fractures should be im-mobilized for the entire time.

If fluoroscopy or radiography reveals loss ofreduction, closed reduction and percutaneous fix-ation or open reduction and internal fixation maybe required.50 Under fluoroscopy, two or three0.035- or 0.045-inch Kirschner wires are inserted at

right angles either to the fracture line or to thelongitudinal axis of the phalanx and should en-gage both cortices (Fig. 6). If local anesthesia isused, rotational alignment can be checked by ask-ing the patient to actively flex and extend theirfinger. If malalignment persists clinically or is ob-served radiographically, conversion to open re-duction and internal fixation is indicated.

Closed reduction of middle phalangeal frac-tures can be achieved by flexing the proximal anddorsal interphalangeal joints to 90 degrees. Twocrossed 0.035- or 0.045-inch Kirschner wires arethen inserted in the midcoronal plane, antegradelyfrom the base of the phalanx to the subchondralbone at the head of the phalanx, or they are intro-duced retrogradely from the retrocondylar fossa atthe head of the phalanx to the subchondral bone atthe lateral bases of the phalanx. It is preferable toavoid Kirschner wiring across the proximal inter-phalangeal joint if possible.

If closed reduction and percutaneous fixationof a proximal or middle phalangeal shaft fractureis unsuccessful, open reduction and internal fix-ation is necessary. (See Video, Supplemental Dig-ital Content 2, which illustrates the operative re-duction of a 4-week-old middle phalanx fracturethat was healing in a malunited position, availablein the “Related Videos” section of the full-textarticle on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A578. The fracture wasopened and Kirschner wired, and early protectedmovement was initiated at 3 days postoperatively.)Fractures of the proximal phalanx are approachedthrough a Pratt extensor tendon-splitting incisionor by excising one of the lateral bands51 (Fig. 7).Fractures of the middle phalanx can be approachedby elevating the conjoined lateral bands. Open re-duction of long oblique and spiral phalangeal frac-tures allows anatomical reduction by keying the apexof the fracture into the corresponding fragments,and provisional fixation with a reduction clamp52ortwo or three transverse Kirschner wires. For morerigid fixation, two or three 2.0- or 1.5-mm lag screwsFig. 8) are used for proximal phalangeal fracturesand 1.5- or 1.3-mm screws are used for middle pha-langeal fractures. Ideally, screws should be insertedin the plane that bisects the fracture line and thelong axis of the phalanx and should be positionedat least two screw diameters away from the apex ofany fracture line.53–58

Finally, some transverse phalangeal shaft frac-tures are amenable to rigid fixation with a low-profile miniplate or mini–condylar plate.27,58,59 Po-sitioning the plate laterally rather than dorsallyprevents interference with gliding of the overlying

Video 1. Supplemental Digital Content 1, illustrating how to be-gin early protected movement 3 days after closed or open Kirsch-ner wiring of finger fractures to achieve the same goals as in earlyprotected movement after flexor tendon repair, is available in the“Related Videos” section of the full-text article on PRSJournal.comor, for Ovid users, at http://links.lww.com/PRS/A577.


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extensor tendon. Closed reduction with Kirschnerwires is preferred by many over plate fixation be-cause closed Kirschner wired finger tissues do notneed to recover from extensive dissection, andbecause there is concern about tissues gliding overplates and the scar they induce in fingers. How-ever, several reports imply that there is no signif-icant difference in outcome when comparing pha-langeal fractures treated by plate fixation andKirschner wire fixation.60–62 There is no differencein the incidence of infection between buried andprotruding Kirschner wires.63

CONDYLAR FRACTURES OF THEPROXIMAL AND MIDDLE PHALANGES

Condylar fractures are inherently unstable. Ifnonoperative splint immobilization is chosen fortreatment of nondisplaced unicondylar fractures,weekly radiographic follow-up is mandatory to de-tect any proximal or palmar displacement. Fordisplaced unicondylar fractures, closed reductionand percutaneous fixation should be attempted. Ifarticular congruity can be confirmed under fluo-roscopy, the fracture is fixed percutaneously withtwo Kirschner wires or miniscrews 1.3 or 1.5 mmin diameter.64 An alternative technique is to drill

Fig. 6. (Left) Displaced long oblique fracture of the proximal phalanx of the index finger. (Center) Closed reductionand percutaneous Kirschner wire fixation of the long oblique fracture of the proximal phalanx with three transverseKirschner wires. (Right) Rotatory malalignment of the finger.

Video 2. Supplemental Digital Content 2 illustrates the opera-tive reduction of a 4-week-old middle phalanx fracture that washealing in a malunited position. The fracture was opened andKirschner wired, and early protected movement was initiated at3 days postoperatively. Video 2 is available in the “Related Vid-eos” section of the full-text article on PRSJournal.com or, for Ovidusers, at http://links.lww.com/PRS/A578.


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Fig. 7. Operative exposure of a long oblique fracture of the proximal phalanx by retractingone of the lateral bands.

Fig. 8. Open reduction and lag screw fixation of the long oblique fracture of theproximal phalanx.


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a Kirschner wire into the condylar fragment and usethis as a joystick to manipulate the fragment intoanatomical position. Care must be taken in closedreduction of these small delicate bone fragments, aslarge forces can cause irreparable damage.

If closed reduction and percutaneous fixationfails, open reduction and internal fixation is re-quired through a dorsal longitudinal incision onthe side of the condylar fragment. The fracture isexposed by incising the extensor tendon betweenthe lateral band and central slip (Fig. 9, left). Thecentral slip should not be detached from its in-sertion on the base of the middle phalanx and,similarly, the collateral ligaments should not bedetached from the condylar fragment. The frac-ture is anatomically reduced under direct vision atthe articular surface and so that the condylar apexkeys into the defect on the phalangeal shaft. Re-duction is maintained provisionally with a smalltowel clip, cannulated clamp,65or Kirschner wire.The fracture is then fixed with two parallel trans-verse 0.028- or 0.035-inch Kirschner wires or two1.3- or 1.5-mm lag screws if the facture fragmentis three times the diameter of the screw (Fig. 9,right, and Fig. 10). Early range of motion can bestarted carefully, but the proximal interphalan-geal joint is splinted in extension to prevent thecommon complication of extensor lag.

Anatomical reduction of bicondylar or com-minuted fractures is not usually possible by closedreduction. Articular congruency is initially achievedby fixing the two condylar fragments together witha miniscrew or Kirschner wire, and then the largercondylar fragment is fixed to the shaft with a screwor Kirschner wire.59,66 Dynamic traction devices maybe indicated for comminuted fractures.

INTRA-ARTICULAR FRACTURES OFTHE BASE OF THE MIDDLE PHALANX

Volar dislocation of the proximal interphalan-geal joint may occasionally produce an avulsionfracture of the insertion of the central slip fromthe dorsal base of the middle phalanx. Nondis-placed fractures can be treated by immobilizationof the proximal interphalangeal joint in full ex-tension in a splint. Fractures that are displacedmore than 2 mm require either closed or openreduction through an incision between the lateralband and central slip and fixation with a Kirschnerwire or a small screw and temporary Kirschnerwire fixation of the proximal interphalangeal jointin extension for 3 weeks.

DORSAL PROXIMALINTERPHALANGEAL JOINT

DISLOCATIONSMost dorsal dislocations and stable fracture-

dislocations of the proximal interphalangeal jointcan be treated nonoperatively, but it is vitally im-portant to avoid prolonged immobilization, whichresults in either permanent stiffness or a flexioncontracture of the proximal interphalangeal joint.It can be very helpful to view active proximal in-terphalangeal joint motion under live fluoroscopyin a lateral view to fully evaluate the stability of thejoint after reduction of a dislocation. The fingercan be elevated and wrapped with self-adherenttape to reduce swelling and then the finger can bebuddy-taped to an adjacent finger and activerange of motion exercises started. It should beemphasized to patients that stiffness and swellingof the finger can persist even up to 1 year afterinjury but that prevention of swelling and rapidrestoration of full range of motion are importantfor achieving a good result. Chronic hyperexten-sion deformities of the proximal interphalangealjoint can be successfully treated by tenodesis of theproximal interphalangeal joint using one slip ofthe flexor digitorum sublimis tendon.67

Stable fracture-dislocations in which the avul-sion fracture is less than 40 percent of the articularsurface and the much rarer unstable pure dorsaldislocations without an avulsion fracture can betreated with 3 weeks of dorsal block splinting.68

After a true lateral radiograph has confirmed con-centric reduction of the proximal interphalangealjoint, a dorsal splint is applied to the finger withthe proximal interphalangeal joint in 30 degreesof flexion. Patients are able to actively flex theproximal interphalangeal joint, but the splintblocks extension before the point of potential re-displacement. The splint is extended progressively10 to 15 degrees per week to allow increasingextension, but it is important to obtain true lateralradiographs every week to document that thejoint remains reduced and has not redislocatedor subluxated.

For unstable fracture-dislocations of the prox-imal interphalangeal joint where the volar frag-ment is greater than 40 percent of the articularsurface, there is no consensus as to the optimaltreatment.69–72 Occasionally, an extension blockpin may be used,73,74 in which a 0.035-inch Kirsch-ner wire is drilled into the head of the proximalphalanx between the central slip and lateral bandsat an angle of approximately 30 degrees, to blockdorsal subluxation of the middle phalanx but al-


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low gentle flexion of the proximal interphalangealjoint and extension up to the point where themiddle phalanx is prevented from further exten-sion by the extension block pin (Fig. 11). (SeeVideo, Supplemental Digital Content 3, which il-lustrates the closed operative reduction of a dorsalsubluxation of the base of the middle phalanx witha dorsal blocking Kirschner wire to restore joint

congruency and allow early protective movementwithout generating the scarring induced by openreduction, available in the “Related Videos” sec-tion of the full-text article on PRSJournal.com or,for Ovid users, at http://links.lww.com/PRS/A579.)

Various dynamic skeletal traction devices havebeen described to apply both longitudinal tractionto the finger and a palmar directed force to pre-

Fig. 9. (Left) Bicondylar fracture of the head of the proximal phalanx. (Right) Fixation with two 2.0- and1.5-mm lag screws.

Fig. 10. Extensive bicondylar fracture of the proximal phalanx fixed with three compression screws.


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vent recurrent dorsal subluxation of the middlephalanx, yet still allow early active range of mo-tion. These devices rely on the principle of liga-mentotaxis and are especially suited to the treat-ment of comminuted fractures and pilon fracturesof the base of the middle phalanx. The Schenckdynamic skeletal traction splint75 is effective butcumbersome.

The Agee force couple76–79 is difficult to fab-ricate, but the newer devices such as the StockportSerpentine Spring System80–82 and the Agee JointJack are much simpler to apply.83 Unstable frac-ture-dislocations where there is a single large volarfragment greater than 40 percent of the articularsurface are potentially amenable to open reduc-tion and internal fixation with one or two smallKirschner wires or a small lag screw followed byearly range-of-motion exercises.84–86

Many unstable proximal interphalangeal jointfracture-dislocations are not amenable to openreduction and internal fixation because the volarfragment is comminuted. In these circumstances,the base of the middle phalanx can be resurfacedby advancement of the volar plate, which also pre-vents dorsal resubluxation. This technique of vo-lar plate arthroplasty87,88 is performed through avolar Bruner incision, with retraction of the flexortendons between the A2 and A4 pulleys and ex-cision of the true collateral ligaments89 to allowshotgun exposure of the proximal interphalan-geal joint. A transverse groove is made in the volar

base of the middle phalanx, and the volar plate isadvanced into this trough and fixed either with apullout wire or miniature bone anchors. After con-firming congruous reduction of the middle pha-lanx with respect to the head of the proximalphalanx, a 0.035-inch Kirschner wire is used totransfix the proximal interphalangeal joint in 30degrees of flexion to maintain reduction for 3weeks. The Kirschner wire is removed at 3 weeksand active flexion exercises are begun using adorsal extension block splint for a further 1 to 2weeks. Eaton and Malerich88 reported a 10-yearfollow-up of patients with both acute and chronicproximal interphalangeal joint fracture-disloca-tions treated by volar plate arthroplasty, with anaverage range of motion of 6/95 degrees for pa-tients treated within 6 weeks of injury and 12/78degrees for patients treated beyond 6 weeks afterinjury. More recently, Hastings has advocatedtreating unstable fracture-dislocations of the prox-imal interphalangeal joint by restoring the volarbuttress of the base of the middle phalanx with ahemihamate autograft.90

ULNAR COLLATERAL LIGAMENTINJURIES OF THE

METACARPOPHALANGEAL JOINT OFTHE THUMB

Ulnar collateral ligament injuries occur morefrequently than radial collateral ligament injuries,

Video 3. Supplemental Digital Content 3, which illustrates theclosed operative reduction of a dorsal subluxation of the base ofthe middle phalanx with a dorsal blocking Kirschner wire to restorejoint congruency and allow early protective movement withoutgenerating the scarring induced by open reduction, is available inthe “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A579.

Fig. 11. (Left and center) Two dorsal Kirschner wires betweenthe central slip and the lateral band reduce the dorsally sub-luxated middle phalanx, yet allow movement while the boneheals (lateral view). (Right) Dorsal view.


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with an incidence of 65 to 90 percent of metacar-pophalangeal joint injuries.91 The ulnar collateralligament is injured by an abduction force at themetacarpophalangeal joint and has been termedskier’s thumb.92 The ligament is torn five timesmore frequently at its distal insertion from thebase of the proximal phalanx than it is torn oravulsed from its proximal origin from the meta-carpal head, although midsubstance tears are fre-quently seen.93 The collateral ligament may re-main intact but avulse a small fracture from theulnar base of the proximal phalanx or less com-monly from the metacarpal head.

Stener94,95 described the proximal portion ofthe ulnar collateral ligament being flipped prox-imally and superficial to the adductor aponeurosisin two-thirds of complete ulnar collateral ligamentinjuries. Therefore, the adductor aponeurosis isinterposed between the proximal and distal endsof the ulnar collateral ligament and the liga-ment cannot heal regardless of cast immobili-zation. If there is a Stener lesion, surgery isindicated. If a Stener lesion can be ruled out byphysical examination, magnetic resonance im-aging, or ultrasound, the ligament can be ex-pected to heal with nonoperative immobiliza-tion for 4 to 6 weeks.

Because a Stener lesion cannot occur in a par-tial rupture of the ulnar collateral ligament, it isimportant to distinguish between partial and com-plete ruptures of the ligament, because partial rup-tures can be treated by cast immobilization but com-plete ruptures with a high likelihood of a Stenerlesion provide an indication for open reduction andrepair. Distinction between partial and completetears is usually made clinically based on the followingcriteria: (1) a complete tear has greater than 35 to45 degrees of laxity on radial stress; (2) a completetear has greater than 15 degrees of laxity comparedwith the opposite thumb; (3) a partial tear usuallyhas a discrete endpoint to radial stress, whereas acomplete tear has no endpoint to radial stressunder local anesthetic block (Fig. 12); and (4)ultrasound or magnetic resonance imaging canbe helpful.

If the posteroanterior radiograph shows asmall undisplaced or minimally displaced avulsionfracture from the ulnar base of the proximal pha-lanx, this implies that the ulnar collateral ligamentis at least partially intact. These patients can betreated by immobilization in a thumb spica castwith the interphalangeal joint left free for 4 weeksfollowed by 2 weeks of controlled mobilization ina short opponens splint.96

If the posteroanterior radiograph shows anavulsion fracture with more than 2 mm of dis-placement or a large avulsion fracture, open re-duction and internal fixation is indicated. Theulnar collateral ligament is approached throughan S-shaped incision centered over the ulnaraspect of the metacarpophalangeal joint. TheStener lesion, if present, presents as an edematousmass proximal and superficial to the adductoraponeurosis. The aponeurosis is incised parallel toits insertion on the extensor pollicis longus ten-don and reflected volarly. If a tear is found withinthe substance of the ulnar collateral ligament, thisis repaired with figure-of-eight or mattress sutures.Usually, the ligament is avulsed from its distal in-sertion and can be reattached either with a pulloutsuture or with a miniature bone anchor.97 A sutureshould also be placed from the volar and distal as-pect of the repaired ulnar collateral ligament to thevolar plate, and any significant tear in the dorsal

Fig. 12. (Above) Ulnar collateral ligament tear of the metacar-pophalangeal joint of the left thumb. (Below) Stress test show-ing greater than 40 degrees of radial deviation on radial stressof the thumb at the metacarpophalangeal joint, with no def-inite endpoint.


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ulnar capsule should be repaired to prevent volarsubluxation of the proximal phalanx. The strengthof the repair is then tested by gently stressing thethumb into radial deviation, and only if there is asuggestion of some remaining laxity should themetacarpophalangeal joint be pinned with a 0.045-inch Kirschner wire in slight flexion and ulnar de-viation. After repair of the adductor aponeurosis, thethumb is immobilized in a thumb spica splint withthe interphalangeal joint free for 4 weeks.

Neil F. Jones, M.D.University of California Irvine

101 The City Drive South, Pavilion IIIOrange, Calif. 92868

[email protected]

ACKNOWLEDGMENTThe authors thank Dr. Alison Martin, Dalhousie

University, for the excellent artwork of the dorsal blockingKirschner wires for proximal interphalangeal joint frac-ture dorsal dislocation.

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