The internal fixation in closed dislocation of the proximal interphalangeal joint with volar basal fracture of middle phalanx
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Abstract:
Objective To investigate therapeutic efficacy of the internal fixation in the closed dislocation of the proximal interphalangeal joint(PIP joint) with the volar basal fracture of the middle phalanx.Methods 20 patients with closed dislocation of the PIP joint with the volar basal fracture of the middle phalanx accepted Kischner wire fixation treatment,splint protection for 3 to 4 weeks and rehabilitation after operation.Results 20 patients all have been followed up after operation over a period of 3 to 6 months,the image evaluation showed the reduced and united of the bone fracture.The active range of motion at the PIP joint was 0~20(18±1)°in extension and 30~90(68±5)°in flexion;the passive range of motion was 5~20(15±2)°in extension and 50~100(78±8)°in flexion.Conclusions The therapeutic efficacy is satisfactory with internal fixation in the treatment to the closed dislocation of the PIP joint with the volar basal fracture of the middle phalanx.Keywords:
Interphalangeal Joint
Phalanx
Distal interphalangeal joint
Middle finger
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Avulsion fracture
Subluxation
Phalanx
Interphalangeal Joint
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A preliminary report is presented of 12 patients with dorsal fracture-dislocations of the proximal interphalangeal joint with a central depressed fragment treated by volar buttress plating, with good results. A preliminary report is presented of 12 patients with dorsal fracture-dislocations of the proximal interphalangeal joint with a central depressed fragment treated by volar buttress plating, with good results. It is well-known that a central depressed fragment commonly exists at the proximal interphalangeal (PIP) joint with dorsal fracture-dislocations (Fig. 1).1Wilson J.N. Rowland S.A. Fracture-dislocation of the proximal interphalangeal joint of the finger: treatment by open reduction and internal fixation.J Bone Joint Surg Am. 1966; 48: 493-502Crossref PubMed Scopus (66) Google Scholar The aims of treatment are to reduce the dislocation and regain normal gliding of the joint after restoration of the articular surface. For this purpose, open reduction internal fixation (ORIF) is recommended as rigid fixation because it allows early motion after surgery.2Watanabe K. Kino Y. Yajima H. Factors affecting the functional results of open reduction and internal fixation for fracture-dislocations of the proximal interphalangeal joint.Hand Surg. 2015; 20: 107-114Crossref PubMed Scopus (19) Google Scholar This article presents a preliminary report of 12 patients treated by volar buttress plating for this injury. This study was approved by the ethics committee at our hospital. Between September, 2011 and October, 2017, we performed volar buttress plating for 12 patients who had experienced a dorsal fracture-dislocation of the PIP joint with a central depressed fragment, including 1 female and 11 male patients (mean age, 33 years; range, 18‒49 years). The index finger was injured in 3 patients, the middle finger in 1, the ring finger in 6, and the little finger in 2. The causes of injury included ball sports in 6 patients, falls in 4, and traffic accidents in 2. Surgeries were performed under the supervision of the author. The mean follow-up was 6 months (range, 3‒12 months). The mean occupied ratio of the bone fragment at the articular surface according to the lateral view was 21.7% (range, 10% to 50%) for the volar triangular fragment, 29.6% (range, 10% to 60%) for the central depressed fragment, and 48.8% (range, 25% to 65%) for the dorsal fragment. After dislocation of the PIP joint is reduced by pushing the dorsal base of the middle phalanx in a volar direction, a 1.5-mm-diameter K-wire is inserted as a block pin into the head of proximal phalanx under fluoroscopic guidance to prevent redislocation. Subsequently, ORIF is performed with the hand in the supine position. A modified Bruner incision is used for the skin, avoiding the PIP crease (Fig. 2). The A3, C1, and C2 pulleys are resected to prevent postoperative flexor tendon adhesion and irritation caused by the hardware. The volar triangular fragment with the volar plate and insertion of the bifurcated flexor digitorum superficialis (FDS) tendon are exposed by retracting the flexor digitorum profundus tendon laterally. To facilitate subsequent exposure, the proximal portion of the A4 pulley is slit as necessary, but not more than half the length. To secure the site for placing a mini T-plate, an incision is made at the central part of middle phalanx to which the bifurcated FDS tendon is attached (Fig. 3A ), taking care to preserve the FDS insertion. After retracting the volar triangular fragment proximally with the volar plate as a hinge, the central depressed fragment is carefully mobilized using a small elevator and reduced to the anatomical position by pushing it against the head of the proximal phalanx. The fracture void caused by reducing a central depressed fragment is filled with the required amount of β-tricalcium phosphate granules or cancellous bone harvested from the distal radius. A mini 4-holed T-plate (Variax Hand, Stryker, Kalamazoo, MI) is applied beneath the insertion of the FDS tendon by sliding the plate distally over the surface of the volar triangular fragment and the middle phalanx. The plate is fixed by inserting 1.7-mm-diameter screws into the 2 distal holes at the shaft of the middle phalanx such that the proximal edge of the plate is located at the border between the volar triangular fragment and the volar plate (Fig. 3B). Screw insertion is usually unnecessary for the 2 proximal holes. After checking the congruity of the articular surface of the PIP joint using fluoroscopy, the block pin is removed and smoothness of joint gliding is confirmed by gentle passive motion. The wound is closed after the insertion of FDS tendon is resutured to cover the plate.Figure 3Illustrations of volar buttress plating procedure for typical dorsal fracture-dislocation of PIP joint with central depressed fragment. A Schemas showing reduction of dorsal fragment using a K-wire and volar exposure of fracture site. Red dashed line indicates incision for plate placement. B Schemas showing reduction of central depressed fragment using a small elevator and volar buttress plate placement using β-tricalcium phosphate granules. *, Central depressed fragment, †, volar triangular fragment with volar plate; FDP; flexor digitorum profundus; M, middle phalanx; P, proximal phalanx.View Large Image Figure ViewerDownload (PPT) Active flexion-extension motion is allowed from the first day after surgery as pain and swelling allow. To prevent PIP flexion contractures, the use of a night orthosis is recommended with the PIP joint in extension for 3 weeks after surgery. The mean final range of motion was 94.2° (range, 85° to 115°) of flexion and –7.1° (range, –15° to 5°) of extension at the PIP joint and 62.9° (range, 45° to 85°) of flexion and 0° (range, –15° to 10°) of extension at the distal interphalangeal joint. The mean total range of motion of the PIP joint and distal interphalangeal joint was 87° (range, 70° to 120°) and 65° (range, 45° to 85°), respectively. There were no cases of postoperative subluxation of the PIP joint (Fig. 4). Dorsal fracture-dislocations of the PIP joint are challenging to treat. In the absence of a central depressed fragment, the choice of treatment is based on the stability of the PIP joint and the size of the volar triangular fragment.3Caggiano N.M. Harper C.M. Rozental T.D. Management of proximal interphalangeal joint fracture dislocations.Hand Clin. 2018; 34: 149-165Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Repair of the articular surface is necessary because of the incongruity of the PIP joint, irrespective of the size of the volar triangular fragment when a central depressed fragment exists.1Wilson J.N. Rowland S.A. Fracture-dislocation of the proximal interphalangeal joint of the finger: treatment by open reduction and internal fixation.J Bone Joint Surg Am. 1966; 48: 493-502Crossref PubMed Scopus (66) Google Scholar, 2Watanabe K. Kino Y. Yajima H. Factors affecting the functional results of open reduction and internal fixation for fracture-dislocations of the proximal interphalangeal joint.Hand Surg. 2015; 20: 107-114Crossref PubMed Scopus (19) Google Scholar, 4Ikeda M. Kobayashi Y. Saito I. Ishii T. Shimizu A. Oka Y. Open reduction and internal fixation for dorsal fracture dislocations of the proximal interphalangeal joint using a miniplate.Tech Hand Up Extrem Surg. 2011; 15: 219-224Crossref PubMed Scopus (17) Google Scholar Although there are many methods of ORIF including K-wire fixation,1Wilson J.N. Rowland S.A. Fracture-dislocation of the proximal interphalangeal joint of the finger: treatment by open reduction and internal fixation.J Bone Joint Surg Am. 1966; 48: 493-502Crossref PubMed Scopus (66) Google Scholar cerclage wiring,5Weiss A.P. Cerclage fixation for fracture dislocation of the proximal interphalangeal joint.Clin Orthop Relat Res. 1996; 327: 21-28Crossref PubMed Scopus (56) Google Scholar screw fixation,6Green A. Smith J. Redding M. Akelman E. Acute open reduction and rigid internal fixation of proximal interphalangeal joint fracture dislocation.J Hand Surg Am. 1992; 17: 512-517Abstract Full Text PDF PubMed Scopus (55) Google Scholar and volar plating,4Ikeda M. Kobayashi Y. Saito I. Ishii T. Shimizu A. Oka Y. Open reduction and internal fixation for dorsal fracture dislocations of the proximal interphalangeal joint using a miniplate.Tech Hand Up Extrem Surg. 2011; 15: 219-224Crossref PubMed Scopus (17) Google Scholar, 7Cheah A.E. Tan D.M. Chong A.K. Chew W.Y. Volar plating for unstable proximal interphalangeal joint dorsal fracture-dislocations.J Hand Surg Am. 2012; 37: 28-33Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar enabling motion early after surgery, all have been considered technically demanding. However, volar buttress plating is not technically difficult if the steps described are followed. Our technique of repair of the articular surface is similar to that described by Ikeda et al,4Ikeda M. Kobayashi Y. Saito I. Ishii T. Shimizu A. Oka Y. Open reduction and internal fixation for dorsal fracture dislocations of the proximal interphalangeal joint using a miniplate.Tech Hand Up Extrem Surg. 2011; 15: 219-224Crossref PubMed Scopus (17) Google Scholar except that the plate is simply used as a buttress plate. Sufficient support of the articular surface obtained by filling β-tricalcium phosphate granules or cancellous bone into the fracture void eliminates the need to insert screws into the subchondral bone. Because screws are not inserted through the volar triangular fragment, there is less risk of destroying the fragment even if its size is small. Although this procedure minimizes postoperative flexor tendon adhesion by resecting the A3 pulley, it is still apt to cause flexion contracture of the PIP joint. We found that using a nighttime extension orthosis was helpful in preventing this problem. The limitation of this study was the short follow-up. Patients were discharged from follow-up because the treatment goal had been achieved, not because they were lost to follow-up. Because injuries of the articular surface cannot be completely restored by any treatment, future posttraumatic osteoarthrosis may develop . In this respect, even a follow-up of 6 months may be inadequate. However, mild posttraumatic osteoarthrosis of the finger joint is unlikely to influence range of motion and pain. Hence, we do not believe that long-term follow-up would have changed our conclusions notably. Volar buttress plating for dorsal fracture-dislocations of the PIP joint with a central depressed fragment is a useful technique with simple postoperative rehabilitations. Nevertheless, indications and complications of the procedure require further investigation. Download .xml (.0 MB) Help with xml files Data Profile
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Finger joint
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Simultaneous volar dislocation of distal interphalangeal (DIP) joint and volar fracture-subluxation of proximal interphalangeal (PIP) joint of the same finger has not been reported yet. A 19-year-old man was referred due to pain on the deformed left little finger after a ball injury. Radiographs showed volar dislocation of the DIP joint and dorsal lip fracture of the middle phalanx with volar subluxation of PIP joint of the little finger. This case was unique in terms of the mechanism of injury which was hyperflexion type in two adjacent joints of the same finger. The patient was treated by closed reduction of DIP joint dislocation and open reduction and internal fixation of the PIP joint fracture-subluxation and application of dorsal external fixator due to instability. Finally, full flexion of the PIP joint and full extension of the DIP joint were obtained but with 10 degree extension lag at the PIP joint and DIP joint flexion ranging from 0 degree to 30 degrees. Some loss of motion in small joints of the fingers after hyperflexion injuries should be expected.
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Objective
To investigate the clinical efficacy of mini-bone anchor in the treatment of volar plate avulsion injury of proximal interphalangeal joint.
Methods
From June 2015 to May 2018, 5 patients with dorsal dislocation of proximal interphalangeal joint caused by finger hyperextension injury were treated. The volar plate avulsion accompanied by articular surface avulsion fracture at the base of middle phalanx occurred. The volar approach was used to remove fragments and reconstruct the insertion of volar plate avulsion with mini-anchor.
Results
All the wounds achieved primary healing. The follow-up period ranged from 4 to 26 months with an average of 12 months. The flexion and extension of the proximal interphalangeal joint ranged from 50° to 85°. The joint was stable and had no lateral abnormal movement. There was no obvious pain and discomfort during the joint movement. According to the upper extremity functional evaluation criteria issued by the Hand Surgery Society of the Chinese Medical Association, the results were excellent in 2 cases and good in 3 cases.
Conclusion
The reconstruction of volar plate insertion with mini-bone anchor can provide the initial stability of the proximal interphalangeal joint, help early functional exercise, and help to reconstruct the basal articular surface of the middle phalanx. It is one of the ideal choices for the treatment of volar plate avulsion injury of proximal interphalangeal joint.
Key words:
Volar plate; Treatment outcome; Proximal interphalangeal joint; Mini-anchor
Interphalangeal Joint
Avulsion fracture
Finger joint
Phalanx
Distal interphalangeal joint
Joint stability
Proximal phalanx
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Various operative techniques have been described for unstable dorsal fracture dislocations of the proximal interphalangeal (PIP) joint with articular involvement. However, this injury still remains a therapeutic challenge for hand surgeons because no single technique guarantees successful outcomes. We performed a novel procedure using a low-profile miniplate, which allows for anatomic reduction, rigid internal fixation, and early finger joint motion. Between March 2003 and May 2009, 18 consecutive patients who suffered from 19 dorsal fracture dislocations of the PIP joint with volar articular fracture of the middle phalanx involving more than 40% of the articular surface were treated using this technique. The postoperative follow-up period averaged 16.6 months (range, 12-18 mo). Bony union was obtained in all cases. No patient showed residual dorsal subluxation. Active motion of the PIP joint averaged 85.0 degrees (range, 62-105 degrees), flexion contracture averaged 5.4 degrees (range, 0-17 degrees), and percent total active interphalangeal joint motion averaged 89.0% (range, 60%-100%). Two patients had restricted active distal interphalangeal joint flexion owing to tendon adhesion resulting from the use of a relatively long plate in the first few cases of this series. No major complications were reported for the other 16 patients. We describe the surgical technique, indications, complications, and postoperative management for this technique.
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Background: To evaluate the treatment of severe dorsal fracture dislocation (DFD) injuries of the proximal interphalangeal joint (PIPJ) by open reduction, bone grafting and fixation with mini-hook plates.Method: Thirteen patients with extensive dorsal fracture dislocation of PIP joints were reconstructed with fabricated hook plate with elevation and bone grafting of depressed articular fragment.Result: Hook plate treatment of PIP joint fracture dislocation restore articular anatomy and joint congruence at a single sitting and permits post operative mobilisation without the need for extension blocking splint.Conclusion: Hook plate fixation is very useful in such circumstances and hook enables their ability to grasp the small volar lip fragment and early mobilization is possible.
Interphalangeal Joint
Distal interphalangeal joint
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Subluxation
Interphalangeal Joint
Articular surface
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Objective
To investigate the treatment and surgical results of acute volar plate avulsion fracture of proximal interphalangeal joint.
Methods
From August 2013 to June 2016, data of 15 cases of acute volar plate avulsion fracture of proximal interphalangeal joint were retrospectively analyzed. There were 8 males and 7 females aged 18-43 years old with an average of 28.6 years old. There were 4 cases of index finger, 6 cases of middle finger, 2 cases of ring finger and 3 cases of little finger. Eight injuries resulted from falls, four from finger breaking and three from crushing. The time from injury to operation was 5-9 days, with an average of 6.7 days. The acute volar plate avulsion fracture of proximal interphalangeal joint were treated by double thread compression suture fixation, and Kirschner wires were used to obliquely fix the interphalangeal joint. After the operation, the fore arm was fixed by plaster for 3-4 weeks. After the removal of the plaster, the flexion and extension function of the distal interphalangeal joint and the metacarpophalangeal joint was performed under the guidance of the rehabilitation instructor in a state of no weight. The finger was evaluated by X-ray every 2 weeks until the fracture healing. After 5-8 weeks, the Kirschner wire was removed when the fracture line disappeared, and the active flexion and extension of the proximal interphalangeal joint was guided by the rehabilitation instructor.
Resuts
In this group of 15 patients, all the incisions healed at the first stage. There was no surgical complications such as skin necrosis, and needle path infection and no abnormal finger feeling or blood circulation disorder. All patients were followed up for 8-32 months (mean, 21.7 months). 8 months after operation, the DASH score was 1.5 to 7.0 points with an average of 4.6 points. At the latest follow-up, there was no pain, swelling and joint contracture in the proximal interphalangeal joints. The dorsal extension of joints were stable, and the degree of active joint activity was: 90°±7° of the metacarpophalangeal joint, 80°±6° of the proximal interphalangeal joint, 78°±7° of the distal interphalangeal joint, and 248°±22° of total active activity. According to TAM system assessment criteria: there was excellent in 12 cases, good in 2 cases, fair in 1 case, and excellent rate was 93.3%(14/15).
Conclusion
Double thread compression suture fixation for the treatment of acute volar plate avulsion fracture of proximal interphalangeal joints could reduce the damage to the accessory structure of the joint, and reach adequate exposure in the operationfor fixing the bone block firmly. After operation, good fracture healing and good finger function could be achieved, so the double thread compression suture fixation is an effective surgical method.
Key words:
Finger joint; Volar plate; Fractures, bone; Fracture fixation
Kirschner wire
Avulsion fracture
Interphalangeal Joint
Distal interphalangeal joint
Finger joint
Metacarpophalangeal joint
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Interphalangeal Joint
Distal interphalangeal joint
Finger joint
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