Chapter 30: Hand Fractures and Dislocations

Mark H. Henry

Chapter Outline

Introduction to Hand Fractures and Dislocations

Fractures and dislocations of the hand are some of the most frequently encountered musculoskeletal injuries. In Canada, the annual incidence was found to be 29 per 10,000 in people older than 20 years of age, and 61 per 10,000 in people younger than 20 years of age.55 Males had 2.08 times greater risk until after age 65 when females become at greater risk.55,153 Another study reported 3.7 hand fractures per year per 1,000 men compared with 1.3 hand fractures per year per 1,000 women.8 The 1998 United States National Hospital Ambulatory Medical Care Survey found phalangeal (23%) and metacarpal (18%) fractures to be the second and third most common fractures below the elbow, peaking in the third decade for men and the second decade for women.29 Another series of 1,358 fractures reported the distribution as 57.4% for proximal phalanx, 30.4% for middle phalanx, and 12.2% for metacarpal.90 Of 502 phalangeal fractures, 192 were at the proximal phalanx (P1), 195 at the middle phalanx (P2), and 115 at the distal phalanx (P3).175 The small finger axis is the most commonly injured, constituting as high as 37% of total hand fractures.153 

Assessment of Hand Fractures and Dislocations

Hand Fractures and Dislocations Injury Mechanisms

The mechanism of injury description should include the magnitude, direction, point of contact, and type of force that caused the trauma. The high degree of variation with respect to mechanism of injury accounts for the broad spectrum of patterns seen in hand trauma. Axial load or “jamming” injuries are frequently sustained during ball sports or sudden reaches made during everyday activities such as in catching a falling object. Patterns frequently resulting from this mechanism are shearing articular fractures or metaphyseal compression fractures. Axial loading along the upper extremity must also raise suspicion of associated injuries to the carpus, forearm, elbow, and shoulder girdle. Diaphyseal fractures and joint dislocations usually require a bending component in the mechanism of injury, which can occur during ball-handling sports or when the hand is trapped by an object and unable to move with the rest of the arm. Individual digits can easily be caught in clothing, furniture, or workplace equipment to sustain torsional mechanisms of injury, resulting in spiral fractures or more complex dislocation patterns. Industrial settings or other environments with heavy objects and high forces lead to crushing mechanisms that combine bending, shearing, and torsion to produce unique patterns of skeletal injury and significant associated soft tissue damage. 

Injuries Associated with Hand Fractures and Dislocations

Open Injuries

The integument is easily damaged, and open fractures are common. Open wounds should not be probed in the emergency department; doing so may only drive surface contaminants deeper and rarely yields useful information. The need for prophylactic antibiotics in open hand fractures is controversial. The previous standard administration of Ancef no longer appears applicable with methicillin-resistant Staphylococcus aureus (MRSA) dominating most community-acquired infection profiles. Clindamycin, vancomycin, Bactrim, and the quinolones are useful agents against MRSA. Aminoglycosides are added for contaminated wounds and penicillin for soil or farm environments. No hard evidence exists to support continuation of antibiotics beyond the initial 24 hours. The exception to this may be bite wounds whose potential for osteomyelitis is significant if the tooth directly penetrates the cortex, allowing the saliva into the cancellous structure. Aggressive and early surgical debridement is needed for all bite wounds. 
The distal phalanx directly supports the nail matrix. With substantial displacement of the dorsal cortex, nail matrix disruption should be expected and direct repair planned. Reconstruction of residual open wounds overlying skeletal injury sites requires the use of flaps. Frequently, transposition flaps will suffice. Less frequently, pedicle or free flaps will prove necessary.80,76 The greatest challenge in the hand, and particularly the digit, is to achieve both thin and supple tissue coverage. A fascial flap covered with a split thickness skin graft provides this combination of features except at the volar pulp where a directly innervated glabrous cutaneous flap is needed (Fig. 30-1). 
Figure 30-1
 
Thin supple coverage of open hand trauma wounds can be accomplished with (A) thinner fascial flaps covered with a split-thickness skin graft or (B) bulkier cutaneous or fasciocutaneous flaps. C: Fasciocutaneous flaps at the digital level may demonstrate an even more substantial difference when compared with the thinness and flexibility of a grafted fascial flap (D, E).
Thin supple coverage of open hand trauma wounds can be accomplished with (A) thinner fascial flaps covered with a split-thickness skin graft or (B) bulkier cutaneous or fasciocutaneous flaps. C: Fasciocutaneous flaps at the digital level may demonstrate an even more substantial difference when compared with the thinness and flexibility of a grafted fascial flap (D, E).
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Figure 30-1
Thin supple coverage of open hand trauma wounds can be accomplished with (A) thinner fascial flaps covered with a split-thickness skin graft or (B) bulkier cutaneous or fasciocutaneous flaps. C: Fasciocutaneous flaps at the digital level may demonstrate an even more substantial difference when compared with the thinness and flexibility of a grafted fascial flap (D, E).
Thin supple coverage of open hand trauma wounds can be accomplished with (A) thinner fascial flaps covered with a split-thickness skin graft or (B) bulkier cutaneous or fasciocutaneous flaps. C: Fasciocutaneous flaps at the digital level may demonstrate an even more substantial difference when compared with the thinness and flexibility of a grafted fascial flap (D, E).
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Tendons

Closed extensor tendon ruptures near insertion points may accompany dislocations. Prime examples are terminal tendon ruptures sustained in association with distal interphalangeal (DIP) joint injuries and central slip ruptures sustained in association with proximal interphalangeal (PIP) joint injuries. Initial examination of the traumatized hand must include a survey that documents each potential tendon injury. Apart from these, tendon damage usually only occurs with an associated laceration or in open combined injuries. 

Nerves and Vessels

Apart from open combined injuries, these tissues are rarely injured as part of simple fractures and dislocations of the hand. In major open hand trauma, there is usually a significant zone of injury. Appropriate treatment includes excision of the devitalized tissues in the zone of injury including nerve and vessel tissues followed by reconstruction with autogenous grafts or adjacent transfers. 

Combined Injuries

The term combined refers to the association of a hand fracture with injury to at least one of the soft tissues listed above. These are most often open injuries with the soft tissue component of greatest significance being the injury to flexor tendons, extensor tendons, or both. The occurrence of this combined pattern of injury directly impacts the treatment strategy for the fracture itself. Many fracture patterns presenting as an isolated injury would be best cared for nonoperatively or with closed reduction and internal fixation (CRIF) using smooth stainless steel Kirschner wires (K-wires). The open wound leading to the fracture site automatically changes the surgical approach to open reduction, usually with open reduction and internal fixation (ORIF). The presence of an adjacent tendon repair site necessitates achieving skeletal stability sufficient to withstand the forces of an immediate tendon glide rehabilitation program. This often means the use of rigid internal fixation (Fig. 30-2). In a study limited to ORIF of intra-articular fractures, comminution and an initial open injury were identified as independent variables leading to a worse prognosis.164 Only 6 of 16 patients in another study of comminuted phalangeal fractures and associated soft tissue injuries achieved greater than 180 degrees of total active motion (TAM).34 The remainder of this chapter describes the most appropriate techniques for managing fractures and dislocations of the hand as isolated injuries. 
Figure 30-2
Major open hand trauma frequently requires the most stable forms of fixation to facilitate an aggressive early motion rehabilitation program focusing on tendon gliding.
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Massive Hand Trauma

The comprehensive planning required for treatment of massive hand trauma merits a textbook in its own right and is beyond the scope of this chapter. The majority of the complex decision-making in these injuries occurs with respect to the strategy chosen for the soft tissues (Fig. 30-3). With true degloving injuries and exposed bone and tendon, either pedicle or free flaps are required for coverage. Pedicle flaps are simpler and faster, but are limited in size and reach and are associated with a higher complication rate than thin fascial free flaps that can cover a defect of any size and shape.80,76 Clinical evaluation of these injuries is quite difficult because the patient is often unable or unwilling to do very much with respect to an interactive examination. Much of the determination regarding the extent of injury is made intraoperatively. Good quality radiographs are rarely obtained initially and usually consist of semi-oblique views of the hand with a high degree of bone overlap. Every effort should be made within the scope of total patient management to obtain additional radiographic views that can be set up properly so that associated injuries are not missed. More often than not the opportunity for these views first presents itself in the operating room. A very easy pitfall is to draw attention to the most obvious radiographic findings without taking the time to search for more subtle injuries. Radiographic evidence of foreign matter embedded in the hand should be sought as well as its absence at the conclusion of the debridement. 
Figure 30-3
 
Massive crushing trauma to the hand usually causes its most devastating effects, not to (A) the skeletal elements themselves, but rather diffusely through devitalization of (B) the soft tissues covering the bone.
Massive crushing trauma to the hand usually causes its most devastating effects, not to (A) the skeletal elements themselves, but rather diffusely through devitalization of (B) the soft tissues covering the bone.
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Figure 30-3
Massive crushing trauma to the hand usually causes its most devastating effects, not to (A) the skeletal elements themselves, but rather diffusely through devitalization of (B) the soft tissues covering the bone.
Massive crushing trauma to the hand usually causes its most devastating effects, not to (A) the skeletal elements themselves, but rather diffusely through devitalization of (B) the soft tissues covering the bone.
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The Gustilo classification of open fractures has been modified for the hand by reducing the 10-cm wound length threshold to 2 cm. The validity of the classification is supported by 62.5% normal hand function found after type I injuries compared with 21% following type III fractures.116 Another series found 92% poor results associated with grade IIIB and III C injuries.46 From a series of 200 open hand fractures, Swanson et al.159 differentiated type II wounds from type I wounds by three criteria: contamination at initial presentation, open for more than 24 hours before treatment, or in patients with systemic illness. Primary closure is not recommended for type II wounds. 
Both internal and external fixation may be appropriate in massive hand injuries. Standard indications for external fixation include gross contamination of the original wound, segmental bone loss or comminution, or the lack of availability of good soft tissue coverage.159 The biomechanics of external fixation in the hand are the same as elsewhere in the body with pin diameter constituting the chief determinant of fixator stiffness. Four pins, two proximally and two distally, are sufficient for most hand applications. A given hand injury may best be fixed by all internal, all external, or a combination of the two methods of fixation. An improved understanding and a wider array of elegant soft tissue coverage techniques have overcome previous concerns regarding exposure of hardware with internal fixation.80,76 
Whenever the injury involves the first web space (especially with crush injuries) the thumb and index metacarpals should be pinned into abduction to prevent a first web space contracture. No matter how the injury is managed, the strategy should plan for rehabilitation to begin, unobstructed by bulky external dressings, by 72 hours after surgery. In one series, 72 metacarpal and phalangeal fractures with severe associated soft tissue injury were treated with plates and screws yielding 46% good, 32% fair, and 22% poor results by the American Society for Surgery of the Hand (ASSH) criteria of TAM.24 The overall results for treatment of these severe injuries are most closely related to the soft tissue component rather than the status of the skeletal injury.67 In 245 open injuries studied prospectively, extensor tendon injury alone had 50% poor results, but flexor tendon or multiple soft tissue injuries produced 80% poor results.28 A series of 140 open fractures demonstrated better results at the metacarpal compared with the phalangeal level with the worst outcomes occurring for injuries at the proximal phalanx (P1) and PIP level, especially when associated with an overlying tendon injury.46 

Bone Loss

Segmental bone loss is a frequent finding in massive hand injuries. Once the wound has been rendered clean through either a single or multiple debridements, bone grafting is appropriate using corticocancellous bone or just cancellous bone, shaped and sized to match the curvature and volume of the missing segment. Stable fixation is achieved with either internal plate or external fixator application (Fig. 30-4). With proper debridement, immediate primary bone grafting is safe. A series of 12 patients with type III open fractures and another 20 patients with low-velocity gunshot phalangeal fractures both demonstrated 0% infection rates with the use of immediate autograft.66,139 If delayed bone grafting is planned, a temporary spacer may be used to preserve the volume that will later be occupied by the graft (Fig. 30-5). Bone loss that includes the articular surface represents an entirely different and much more complex problem. Strategies that have been advocated include autografts of metatarsal head, second, and third carpometacarpal (CMC) joints; immediate Silastic prosthetic replacement; osteoarticular allografts; primary arthrodesis; and free vascularized composite whole toe joint transfer.91 
Figure 30-4
When segmental bone loss occurs (A), shortening may be prevented by temporary stabilization (B).
 
Subsequent internal fixation (C, D) and bone grafting can restore the original anatomic parameters of the skeletal unit.
Subsequent internal fixation (C, D) and bone grafting can restore the original anatomic parameters of the skeletal unit.
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Subsequent internal fixation (C, D) and bone grafting can restore the original anatomic parameters of the skeletal unit.
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Figure 30-4
When segmental bone loss occurs (A), shortening may be prevented by temporary stabilization (B).
Subsequent internal fixation (C, D) and bone grafting can restore the original anatomic parameters of the skeletal unit.
Subsequent internal fixation (C, D) and bone grafting can restore the original anatomic parameters of the skeletal unit.
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Subsequent internal fixation (C, D) and bone grafting can restore the original anatomic parameters of the skeletal unit.
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Figure 30-5
 
When extensive contamination precludes the use of internal fixation or when bone reconstruction is to be done at a later date, the use of spacer wires or the application of an external fixator with distraction and compression capabilities can be useful.
When extensive contamination precludes the use of internal fixation or when bone reconstruction is to be done at a later date, the use of spacer wires or the application of an external fixator with distraction and compression capabilities can be useful.
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Figure 30-5
When extensive contamination precludes the use of internal fixation or when bone reconstruction is to be done at a later date, the use of spacer wires or the application of an external fixator with distraction and compression capabilities can be useful.
When extensive contamination precludes the use of internal fixation or when bone reconstruction is to be done at a later date, the use of spacer wires or the application of an external fixator with distraction and compression capabilities can be useful.
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Signs and Symptoms of Hand Fractures and Dislocations

Symptoms associated with a fracture or dislocation of the hand include pain, swelling, stiffness, weakness, deformity, and loss of coordination. Numbness and tingling signify associated nerve involvement (either direct injury to the nerve or as a secondary effect of swelling). Signs include tenderness, swelling, ecchymosis, deformity, crepitus, and instability. A better skeletal examination can often be obtained with the aid of anesthesia applied directly at the injury site or regionally. Isolated metacarpophalangeal (MP) joint dislocations and metacarpal fractures can be treated with direct injection of anesthetic into the injury site. More distal injuries are easily anesthetized with a digital block. More global pain relief can be obtained through nerve blocks performed at the wrist to include the median nerve, ulnar nerve, and dorsal cutaneous branches of the radial and ulnar nerves. The time following administration of the anesthetic can be used to cleanse any superficial wounds and to prepare splinting supplies. Pain-free demonstration of tendon excursion and fracture and ligament stability can then be performed. At the conclusion of the anesthetized skeletal examination, the injury can be promptly reduced and splinted. 
An important factor in many treatment algorithms is the presence of rotational deformity. The examiner must understand the appropriate method of assessment. The bones of the hand are short tubular structures. Malrotation at one bone segment is best represented by the alignment of the next more distal segment. This alignment is best demonstrated when the intervening joint is flexed to 90 degrees (Fig. 30-6). Comparing nail plate alignment is an inadequate method of evaluating rotation. Other unique physical examination findings will be discussed in association with specific injuries. 
Figure 30-6
 
Pronation of the ring finger proximal phalanx is easily demonstrated by the angular discrepancy of the middle phalanges viewed with the PIP joints flexed 90 degrees.
Pronation of the ring finger proximal phalanx is easily demonstrated by the angular discrepancy of the middle phalanges viewed with the PIP joints flexed 90 degrees.
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Figure 30-6
Pronation of the ring finger proximal phalanx is easily demonstrated by the angular discrepancy of the middle phalanges viewed with the PIP joints flexed 90 degrees.
Pronation of the ring finger proximal phalanx is easily demonstrated by the angular discrepancy of the middle phalanges viewed with the PIP joints flexed 90 degrees.
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Hand Fracture and Dislocation Imaging and Other Diagnostic Studies

Plain radiographic evaluation includes at least two projections with the beam centered at the level of interest. A third oblique view is often quite instructive, revealing displacement not evident on the standard posterior–anterior (PA) or lateral. Rarely are other imaging studies necessary in evaluating fractures and dislocations of the hand. In complex periarticular fractures, such as “pilon” fractures at the base of P2, computed tomography (CT) scans assist some surgeons with operative planning. Foreign bodies may not always be detected by standard radiographic projections. Glass or gravel is best seen with soft tissue technique. CT scans may detect plastic, glass, and wood. Ultrasound can detect objects that lack radiopacity. Magnetic resonance imaging (MRI) remains a more expensive backup for all types of foreign materials. 

Hand Fracture and Dislocation Classification

Unfortunately, the literature regarding these injuries has not been written in accordance with any defined classification scheme, and true comparisons are difficult to make. The AO comprehensive classification system proved to have poor interobserver (κ-coefficient of 0.44) and intraobserver (κ-coefficient of 0.62) agreement.161 Descriptions of fractures have been based largely on the location within the bone (head, neck, shaft, base) and further modified by the direction of the fracture plane (transverse, spiral, oblique, comminuted) and the measurable degree of displacement. Dislocations have been described by the direction the distal segment travels (dorsal, volar, rotatory) and further modified by the capacity (simple) or incapacity (complex) for closed reduction. In the sections that follow regarding each injury, it will be assumed that the above stated designations are in effect unless specific exceptions are noted. 

Hand Fracture and Dislocation Outcomes

In the modern era of hand surgery, outcomes research has become ever more refined with concepts such as the minimal clinically important difference, cost–utility analysis, Cochrane reviews, and a better understanding of how patient psychological status plays into reported symptoms.30,95,122,142,143,168,177 Functional loss is often underappreciated and difficult to measure. No statistically significant correlation could be drawn in a study comparing the American Medical Association impairment rating with the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire.176 In a series of 924 hand fractures, overall results were excellent or good in 90% of thumbs but only 59% to 76% of fingers, citing comminution and open or multiple fractures as poor prognostic indicators.90 Intra-articular extension appears to confer a worse prognosis with TAM of 169 degrees compared to TAM of 213 degrees in fractures without intra-articular extension.66 Only a few patterns of dislocation lead to residual instability. Fractures, however, can easily result in malunion. Some practitioners perceive a direct trade-off between stiffness and either residual instability or malunion. This is not necessarily the case. As the understanding of these difficult injuries improves along with new surgical techniques, it is becoming increasingly possible to achieve good hand function while avoiding complications for most isolated fractures and dislocations. Major hand trauma is another matter. 

Hand Fracture and Dislocation Treatment Options

One of the most fundamental principles of management is that the negative effects of surgery on the tissues should not exceed the negative effects of the original injury. Accordingly, nonoperative treatment plays a significant role in the management of fractures and dislocations of the hand. A corollary to this principle is that even though fractures and dislocations are fundamentally skeletal injuries, most of the difficult decision-making centers on management of the soft tissues. The injured part must not be considered in isolation. The multiple joints of the hand are maintained in a delicate balance by the intrinsic and extrinsic tendon systems such that a disturbance in one set of tissues will often significantly affect others. 
The fundamental rationale for treatment in fractures and dislocations of the hand is to achieve sufficient stability of the bone or joint injury to permit early motion rehabilitation without resulting in malunion for fractures or residual instability for dislocations. The preferred treatment option is the least invasive technique that can accomplish these goals.77 There are essentially five major treatment alternatives: immediate motion, temporary splinting, CRIF, ORIF, and immediate reconstruction.164,99,105,154,166 External fixation is a variation that has been, surprisingly enough, applied to even initially closed fractures.115 The general advantages of entirely nonoperative treatment are assumed to be lower cost and avoidance of the risks and complications associated with surgery and anesthesia. The generally presumed disadvantage is that stability is less assured than with some form of operative fixation. CRIF is expected to prevent overt deformity but not to achieve an anatomically perfect reduction. Pin tract infection is the prime complication that should be discussed with patients preparing for CRIF. Open fixation is considered to add the morbidity of surgical tissue trauma, titrated against the presumed advantage of achieving the most anatomic and stable reduction. 

Nonoperative Treatment of Hand Fractures and Dislocations

Critical elements in selecting between nonoperative and operative treatment are the assessments of rotational malalignment and stability.147 To define stability, some authors have used what seems to be the very reasonable criterion of maintenance of fracture reduction when the adjacent joints are taken through at least 30% of their normal motion.28 Contraction of soft tissues begins approximately 72 hours following injury. Motion should be instituted by this time for all joints stable enough to tolerate rehabilitation. Elevation and elastic compression promote edema control. The more aggressive the surgeon’s management of the injury has been, the more aggressive must be the rehabilitation. Low-energy isolated injuries have far less risk of stiffness than those created by high-energy trauma with large zones of injury. 
Reduction maneuvers should not cause added tissue trauma. If the injury is reducible at all, gentle manipulation will accomplish the reduction far more successfully than forceful longitudinal traction. The principle is relaxation of deforming forces through proximal joint positioning such as MP joint flexion to relax the intrinsics or wrist flexion to relax the digital flexor tendons. Often, a gentle back-and-forth rotatory maneuver is necessary to free a bony prominence from soft tissue entrapment. The mobile distal part is then reduced to the stable proximal part. 
Splints should immobilize the minimum number of joints possible and allow unrestricted motion of all other joints. One controversial point concerns the need to immobilize the wrist. Setting appropriate length–tension relationships in the extrinsic motors (in cases where they are deforming forces) is most easily accomplished through immobilization of the wrist in 25 to 35 degrees of extension. Wrist splinting in extension is extremely helpful in patients with low pain tolerance who tend to place the hand in a characteristic dysfunctional posture of wrist flexion–MP joint extension–interphalangeal (IP) joint flexion (the “wounded paw” position). Other patients who are capable of avoiding this position on their own often do not need wrist immobilization. A simple splint that is useful for injuries ranging from the CMC joints proximally to P1 fractures distally consists of a single slab of plaster or fiberglass applied dorsally. With a foundation at the forearm, the splint runs out to the level of the PIP joints distally with the wrist extended and the MP joints fully flexed. Full motion of the IP joints should be encouraged throughout the healing process. The total duration of immobilization should rarely exceed 3 to 4 weeks. Hand fractures are stable enough by this time to tolerate active range of motion (AROM) with further remodeling by 8 to 10 weeks. 
From this point forward, nonoperative treatment is considered alongside potential operative treatments for each segment of the ray, working from distal to proximal (Table 30-1). 
 
Table 30-1
Nonoperative Treatment
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Table 30-1
Nonoperative Treatment
Indications Contraindications
Nondisplaced fracture Open fracture or dislocation
Reduced fracture stable to motion stress Irreducible fracture or dislocation
Reduced dislocation stable to motion stress Associated soft tissue injuries requiring repair
Excessive patient comorbidity Multiple musculoskeletal injuries in same limb
Medically unstable Polytrauma patient, medically stable
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Introduction to Distal Phalanx (P3) Fractures

As the terminal point of contact with the environment, the distal phalanx experiences stress loading with nearly every use of the hand. The soft tissue coverage is limited, and local signs of fracture can usually be detected at the surface. When fractures accompany a nail bed injury, hematoma can be seen beneath the nail plate. When the seal between the nail plate and the hyponychium is also broken, the fracture is open and should be treated as such. The mechanism of injury often involves crushing, and the soft tissue injury is frequently of greater significance for long-term prognosis than the fracture. When one is suspicious of a distal phalanx fracture, radiographs should be taken as isolated views of the injured digit. 

Pathoanatomy and Applied Anatomy Relating to Distal Phalanx Fractures

Unique features of the distal phalanx include the ligaments that pass from the distal margin of the widened lateral base to the expanded proximal margins of the tuft. Small branches of the proper digital artery that supply the dorsal arcade just proximal to the nail fold pass under these ligaments very close to the base of the shaft of the distal phalanx. The tuft is an anchoring point for the specialized architecture of the digital pulp, a honeycomb structure of fibrous septae that contains pockets of fat in each compartment. The proximal part of the pulp is thicker and more mobile than the distal pulp. The proximal portion of a tuft fracture may become entrapped in the septae of the pulp and prove irreducible.5 The dorsal surface of the distal phalanx is the direct support for the germinal matrix and sterile matrix of the nail. The bone volarly and the nail plate dorsally create a three-layered sandwich with the matrix in the middle (Fig. 30-7). 
Figure 30-7
An intimate relationship exists between the three layers of the dorsal cortex of the distal phalanx, the nail matrix (both germinal and sterile), and the nail plate.
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Fractures in the distal phalanx can be conceived of as occurring in three primary regions: the tuft, the shaft, and the base (Fig. 30-8). The two mechanisms of injury experienced most frequently are a sudden axial load (as in ball sports) or crush injuries. Crush fractures of the tuft are often stable injuries held in place by the fibrous network of the pulp volarly and the splinting effect of the nail plate dorsally. Proximally, the digital flexor and terminal extensor tendons insert on the volar and dorsal bases of the distal phalanx. Since these are the last tendon attachments in the digit, all fracture planes occurring distal to these tendon insertions have been separated from any internal deforming forces. In contrast, volar and dorsal base fractures are unstable, with the entire force of a tendon pulling the small base fragment away from the remainder of the bone. Controlling rotation in these small pieces may be particularly difficult. Dorsal base intra-articular fractures due to the shearing component of an axial load injury should be distinguished from avulsion fractures occurring under tension from the terminal tendon. The latter are smaller fragments with the fracture line perpendicular to the line of tensile force in the tendon, whereas the former are larger fragments comprising a significant (>20%) portion of the articular surface with the fracture line perpendicular to the articular surface. These are very different injuries with different treatment requirements. In a similar fashion, the majority of bone flakes at the volar base of P3 are really flexor digitorum profundus (FDP) tendon ruptures occurring through bone. A small percentage of volar base fractures, especially when large in size, are not FDP avulsions but rather shearing fractures that are amenable to extension block splinting or fixation. 
Figure 30-8
 
Fracture patterns seen in the distal phalanx include (A) longitudinal shaft, (B) transverse shaft, (C) tuft, (D) dorsal base avulsion, (E) dorsal base shear, (F) volar base, and (G) complete articular.
Fracture patterns seen in the distal phalanx include (A) longitudinal shaft, (B) transverse shaft, (C) tuft, (D) dorsal base avulsion, (E) dorsal base shear, (F) volar base, and (G) complete articular.
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Figure 30-8
Fracture patterns seen in the distal phalanx include (A) longitudinal shaft, (B) transverse shaft, (C) tuft, (D) dorsal base avulsion, (E) dorsal base shear, (F) volar base, and (G) complete articular.
Fracture patterns seen in the distal phalanx include (A) longitudinal shaft, (B) transverse shaft, (C) tuft, (D) dorsal base avulsion, (E) dorsal base shear, (F) volar base, and (G) complete articular.
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Distal Phalanx Fracture Treatment Options

Many distal phalanx fractures can be treated with digital splints (Fig. 30-9). The splint should leave the PIP joint free but usually needs to cross the DIP joint simply to gain enough foundation to provide adequate stability. The splint may be removed daily to perform active DIP joint-blocking exercises. Aluminum and foam splints or plaster of Paris are common materials chosen. When surgery is contemplated the surgeon should consult a preoperative planning checklist (Table 30-2). 
Figure 30-9
Dorsal splinting of the distal phalanx and the DIP joint is easily accomplished with an aluminum and foam splint.
 
Cutting out the foam over the dorsal nail fold skin relieves direct pressure where the skin is at greatest risk for ischemic necrosis.
Cutting out the foam over the dorsal nail fold skin relieves direct pressure where the skin is at greatest risk for ischemic necrosis.
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Figure 30-9
Dorsal splinting of the distal phalanx and the DIP joint is easily accomplished with an aluminum and foam splint.
Cutting out the foam over the dorsal nail fold skin relieves direct pressure where the skin is at greatest risk for ischemic necrosis.
Cutting out the foam over the dorsal nail fold skin relieves direct pressure where the skin is at greatest risk for ischemic necrosis.
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Table 30-2
Preoperative Planning Checklist
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Table 30-2
Preoperative Planning Checklist
Hand table mounted to OR table rail with additional support by extendable leg
Nonsterile brachial level tourniquet
Single hole extremity drape specific to hand table coverage
Mini-fluoroscopy unit with C-arm horizontal, located at the end of hand table on surgeon’s side
Technician’s instrument table located at the end of hand table to assistant’s side
Hand surgery instruments needed for fracture care: gauze packer, small elevators, microcurette
Power driver with both pistol grip (K-wires) and pencil grip (small drill bits) attachments
Kirschner wires of appropriate size to injured region (0.028- to 0.062-inch)
Modular plate and screw set ranging from 1- to 2.5-mm size
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Tuft Fractures

If the dorsal surface of the distal portion of the phalanx that supports the nail matrix has a significant step-off, especially with a concomitant nail plate avulsion, the fracture should be restored to a level surface and pinned to render support to the surgical repair of the nail matrix. Conversely, if the nail plate has maintained its seal at the hyponychium, and the dorsal surface of the distal phalanx is level, formal removal of the plate to perform a nail matrix repair is not necessary despite any measured percentage of hematoma occupying the area under the nail. Matrix defects should be split-thickness grafted from the adjacent nail bed. Following repair, the dorsal nail fold should be stented to prevent adherence to the matrix but still allow fluid drainage. The patient should be warned of the potential for nail deformity and the time required (4 to 5 months) for regrowth. 

Shaft Fractures

Most shaft fractures have sufficiently limited displacement that nonoperative management is appropriate. Active motion of the DIP joint can be pursued from the outset since the forces of the FDP and the terminal extensor tendon are not acting across the fracture. Only externally applied forces such as pinch will deform the fracture. Shaft fractures with wide displacement may not unite without closer approximation of the fragments. CRIF is usually sufficient for these fractures unless there is interposed tissue blocking the reduction (Fig. 30-10). K-wire fixation may also be preferable (0/5 malunions) compared with splinting (3/18 flexion malunions) when the fracture is transverse, extra-articular, and located at the base of the distal phalanx.6 In extreme cases where the fragments continue to separate longitudinally along the smooth-sided wires, axial compression can be achieved with a micro-sized headless screw (Fig. 30-11). 
Figure 30-10
 
Shaft fractures should first be axially compressed, then stabilized with a longitudinal K-wire that is drilled just short of the subchondral bone plate, and then axially tapped into the subchondral bone without spinning the wire.
Shaft fractures should first be axially compressed, then stabilized with a longitudinal K-wire that is drilled just short of the subchondral bone plate, and then axially tapped into the subchondral bone without spinning the wire.
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Figure 30-10
Shaft fractures should first be axially compressed, then stabilized with a longitudinal K-wire that is drilled just short of the subchondral bone plate, and then axially tapped into the subchondral bone without spinning the wire.
Shaft fractures should first be axially compressed, then stabilized with a longitudinal K-wire that is drilled just short of the subchondral bone plate, and then axially tapped into the subchondral bone without spinning the wire.
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Figure 30-11
 
Shaft fractures can be axially compressed to avoid nonunion resulting from distraction by using a variable pitch headless compression microsized screw placed over a guidewire.
Shaft fractures can be axially compressed to avoid nonunion resulting from distraction by using a variable pitch headless compression microsized screw placed over a guidewire.
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Figure 30-11
Shaft fractures can be axially compressed to avoid nonunion resulting from distraction by using a variable pitch headless compression microsized screw placed over a guidewire.
Shaft fractures can be axially compressed to avoid nonunion resulting from distraction by using a variable pitch headless compression microsized screw placed over a guidewire.
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Dorsal Base Fractures—CRIF

Closed reduction and pin fixation is the treatment of choice for shearing dorsal base fractures comprising over 25% of the articular surface (Fig. 30-12). A variety of fixation techniques have been described, but the mainstay is extension block pinning (Figs 30-13 and 30-14).84,93,112,133,186 Twenty-three patients treated with extension block pinning for fragments comprising an average of 40% of the joint surface had a mean flexion of 77 degrees with a 4-degree extensor lag with two losses of reduction.84 The difficulty in comparing the published outcomes for these injuries is that the literature has usually failed to distinguish between dorsal fractures that are merely bony variants of terminal tendon injuries and those that are the more significant intra-articular fractures discussed in this section. 
Figure 30-12
 
Dorsal base fractures from axial impaction with shearing rather than a traction avulsion injury may demonstrate subluxation of the volar fragment with rotation into extension of the smaller dorsal fragment. These features indicate the need for operative management of the injury.
Dorsal base fractures from axial impaction with shearing rather than a traction avulsion injury may demonstrate subluxation of the volar fragment with rotation into extension of the smaller dorsal fragment. These features indicate the need for operative management of the injury.
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Figure 30-12
Dorsal base fractures from axial impaction with shearing rather than a traction avulsion injury may demonstrate subluxation of the volar fragment with rotation into extension of the smaller dorsal fragment. These features indicate the need for operative management of the injury.
Dorsal base fractures from axial impaction with shearing rather than a traction avulsion injury may demonstrate subluxation of the volar fragment with rotation into extension of the smaller dorsal fragment. These features indicate the need for operative management of the injury.
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Figure 30-13
Dorsal base shearing articular fractures (A) can be stabilized by the extension block pinning technique (B) using two 0.045-inch K-wires.
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Figure 30-14
 
The steps of the extension block pinning method begin with (A) hyperflexion of the DIP joint to draw the smaller dorsal fragment volarly where it is (B) blocked from returning into further extension by the first 0.045-inch K-wire. The larger volar fragment is then reduced (C) first at the articular surface to meet the dorsal fragment followed by (D) extension of the shaft to approximate the metaphysis, and maintained by the second K-wire (E).
The steps of the extension block pinning method begin with (A) hyperflexion of the DIP joint to draw the smaller dorsal fragment volarly where it is (B) blocked from returning into further extension by the first 0.045-inch K-wire. The larger volar fragment is then reduced (C) first at the articular surface to meet the dorsal fragment followed by (D) extension of the shaft to approximate the metaphysis, and maintained by the second K-wire (E).
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Figure 30-14
The steps of the extension block pinning method begin with (A) hyperflexion of the DIP joint to draw the smaller dorsal fragment volarly where it is (B) blocked from returning into further extension by the first 0.045-inch K-wire. The larger volar fragment is then reduced (C) first at the articular surface to meet the dorsal fragment followed by (D) extension of the shaft to approximate the metaphysis, and maintained by the second K-wire (E).
The steps of the extension block pinning method begin with (A) hyperflexion of the DIP joint to draw the smaller dorsal fragment volarly where it is (B) blocked from returning into further extension by the first 0.045-inch K-wire. The larger volar fragment is then reduced (C) first at the articular surface to meet the dorsal fragment followed by (D) extension of the shaft to approximate the metaphysis, and maintained by the second K-wire (E).
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Dorsal Base Fractures—ORIF

Dorsal base fractures may rarely require ORIF. Although subluxation has been cited as a reason to perform ORIF, a biomechanical study showed that subluxation was not seen whenever the smaller fragment carried less than 43% of the articular surface.88 Thirty-three patients treated with ORIF using K-wires had a mean arc of 4 to 67 degrees of final motion.162 As an alternative method of ORIF, nine patients were treated with a custom “hook plate” formed by cutting a 1.3-mm modular straight plate and achieved an average of 64 degrees range of motion (ROM) of the DIP joint with no extensor lag.165 One method of avoiding the complications potentially associated with open DIP joint surgery (0/19) might be the 5 weeks of external fixation employed in 19 patients resulting in 70 degrees of flexion with a 2-degree average extensor lag.94 

Volar Base Fractures

ORIF is the treatment of choice for highly displaced volar base fractures that have a large intra-articular fragment and loss of FDP functional integrity. If the volar FDP fragment is large enough, it may be fixed with a compression screw. Extension block pinning is another rarely employed alternative. The remainder of small bone flakes located at the volar base of the distal phalanx are tendon avulsions and should be treated in accordance with modern principles of flexor tendon reinsertion. 

Postoperative Care

Healing at this level of the digit is often prolonged. Transverse shaft fractures may take 3 to 4 months before being able to resist maximum pinch force. For stable tuft and longitudinal fractures, splints may be removed and functional use of the hand instituted as soon as tolerated. Dorsal base fractures usually have the K-wires removed by 4 weeks with continued external protection for 2 to 3 more weeks when using traditional pinning techniques. The dorsal base extension block method works through the institution of passive extension exercises beginning at 4 weeks and coinciding with wire removal. The more distal the injury is in the digit, the more hypersensitivity to surface contact the patient is likely to have. Desensitization through progressively more stimulating contact is the earliest component of the rehabilitation program, with the goal of reincorporating the fingertip into as many activities of daily living as possible. 

Potential Pitfalls and Preventative Measures

The volar pulp space adjacent to distal phalanx fractures represents a tense three-dimensional hydrodynamic unit that will tend to expand when injured and forcibly distract fracture fragments from each other, resulting in the nonunions frequently seen at this level. The most common direction of displacement is in distraction. Smooth-sided K-wires are the most common devices used for P3 fracture fixation, but they can allow the fracture fragments to slide along the surface of the wires. The best way to defeat this is to place the wires as obliquely as possible and to use converging and diverging patterns (Fig. 30-15). To prevent K-wires from migrating into the DIP joint, tap, rather than drill them, into the subchondral bone at the base of the phalanx. To prevent pin tract infection, cut wires below skin level, but not too short resulting in an irretrievable pin. When performing the extension block pinning technique for dorsal base fractures, achieving a truly congruent joint is difficult. There are two typical problems: rotation of the smaller fragment into extension under the influence of the terminal extensor tendon and cantilevering of the volar articular-shaft fragment. A method to overcome the first problem is to use another K-wire percutaneously to hold pressure on the dorsal cortex of the small fragment while placing the extension block wire. The flat side of the wire rather than the sharp tip should be used for this reduction maneuver. The second problem is created by the surgeon holding the distal phalanx shaft fragment manually and applying the extension force for reduction. Instead of achieving a congruent joint reduction, the larger fragment cantilevers and reduces at the metaphyseal level but leaves an incongruent articular gap. Placing an instrument handle, such as a Freer elevator, transversely across the volar base just distal to the flexion crease and using the instrument to apply the extension force directly at the level of the joint can overcome this second problem. The reduction will first occur congruently at the joint and then secondarily at the metaphysis. 
Figure 30-15
 
Fracture fragment sliding along the smooth shaft of the K-wire is prevented by (A) maximum oblique placement from one lateral edge of the tuft to the opposite far lateral corner of the base, (B) two wires targeting the lateral corners of the base, (C) converging wire patterns, and (D) diverging wire patterns.
Fracture fragment sliding along the smooth shaft of the K-wire is prevented by (A) maximum oblique placement from one lateral edge of the tuft to the opposite far lateral corner of the base, (B) two wires targeting the lateral corners of the base, (C) converging wire patterns, and (D) diverging wire patterns.
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Figure 30-15
Fracture fragment sliding along the smooth shaft of the K-wire is prevented by (A) maximum oblique placement from one lateral edge of the tuft to the opposite far lateral corner of the base, (B) two wires targeting the lateral corners of the base, (C) converging wire patterns, and (D) diverging wire patterns.
Fracture fragment sliding along the smooth shaft of the K-wire is prevented by (A) maximum oblique placement from one lateral edge of the tuft to the opposite far lateral corner of the base, (B) two wires targeting the lateral corners of the base, (C) converging wire patterns, and (D) diverging wire patterns.
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Matrix tissue may fold into any dorsal opening of a fracture site, particularly at the base of the germinal matrix. If reduction of a distal phalanx fracture proves incomplete with a visible dorsal cortical gap on the lateral radiograph, this possibility must be considered and extrication performed to prevent both nonunion and nail deformity. Suturing the nail matrix can be difficult. Friable nail matrix tissue is easily torn as the needle is pushed rather than rolled along its axis during repair, a problem that is compounded by the needle tip’s tendency to catch on the dorsal cortex during the bottom of the stroke. These problems are overcome by using a special 6–0 chromic suture with a spatula-tipped needle that can be passed with a rolling motion of the fingers when loaded on a Castroviejo needle driver (Table 30-3). 
Table 30-3
Potential Pitfalls and Preventative Measures—P3 Fractures
Pitfall Prevention
Hydrostatic distraction of fragments Multiple wires converging/diverging
Pin migration into DIP joint Tap pin into subchondral bone rather than drilling
Pin infection Cut pins below skin level
Irretrievable pin Do not cut pins too short
Extended dorsal base fragment Direct nonpenetrating wire pressure held on fragment during reduction and fixation
Incongruent volar base fragment Reduce at articular surface first with instrument pressure, then extend and close metaphysis
Nail matrix incarceration Check lateral radiograph for contiguous dorsal cortex reduction
Tearing nail matrix during repair Special small spatula needle with rolling technique, no pushing
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Author’s Preferred Treatment (Fig. 30-16)

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Figure 30-16
Distal phalanx (P3) fractures.
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Tuft Fractures
 

Many tuft fractures can be splinted in a simple aluminum and foam splint for a duration determined by the patient’s symptoms alone. The time course for healing of the associated soft tissue injury may well determine the total duration of disability far more than that of the fracture itself. When the seal of the nail plate with the hyponychium has been broken and the tuft fracture is displaced, this represents an open fracture that should be treated on the day of injury with debridement followed by direct nail matrix repair. If the distal fragment is of substantial size, the dorsal cortex of the distal phalanx that supports the nail matrix will provide a more level surface if pinned with one or more 0.028-inch K-wires for 4 to 6 weeks.

 
Shaft Fractures
 

Longitudinal sagittal plane shaft fractures of the distal phalanx can be treated entirely nonoperatively if minimally displaced or with CRIF using oblique 0.028- to 0.035-inch K-wires for the rare displaced fracture. Two or more wires should be used to prevent sliding of the fracture along the smooth surface of a single wire. Care should be taken to avoid penetration of the nail matrix with the wire. If the fracture is at midshaft level or more distal, the wire will provide enough stability if driven to the subchondral base of the distal phalanx only. Fractures occurring at the metadiaphyseal junction may need to have the wire passed across the DIP joint to achieve sufficient stability.

 
Dorsal Base Fractures
 

Dorsal base intra-articular shear fractures produce a triangular dorsal fragment that is extended and translated by the pull of the terminal tendon. With proper collateral ligament damage, the larger articular fragment that is in continuity with the remainder of the phalanx may sublux volarly. ORIF adds excessive surgical trauma to this delicate set of tissues and the dorsal fragment is usually too small to accommodate fixation devices passing directly through it without experiencing comminution. The injury is best addressed by extension block pinning. The DIP joint is hyperflexed, drawing the dorsal fragment volarly to reach its natural position in relation to the head of P2. A 0.045-inch K-wire is then inserted at the dorsal margin of the fragment (but not through the fragment) to block it from returning to the retracted position under the influence of the terminal extensor tendon (Fig. 30-14). The remainder of the distal phalanx (consisting of the volar articular fragment and shaft) is then extended to meet the blocked smaller fragment and restore articular congruity. A second 0.045-inch K-wire is passed from the larger P3 fragment across the DIP joint into P2. The wires are retained for 4 weeks. Upon removal, passive extension exercises further compress the two fragments and assist in the final stages of cancellous bone healing. The treatment can still be executed up to 4 to 5 weeks after the initial injury, but the early callus that has formed between the two fragments must be dispersed or satisfactory approximation will not be achieved (Table 30-4).

Table 30-4
Surgical Steps—Extension Block Pinning of Dorsal Base P3 Fractures
Flex DIP joint to draw all fragments volarly relative to the head of P2
Place nonpenetrating wire pressure against the small dorsal base fragment to prevent it from rotating into extension under the influence of the terminal tendon
Place the extension blocking wire dorsal to the small fragment into the intercondylar notch of the head of P2
Pre-position the axial transarticular wire in the shaft of P3 but not entering the fracture site yet
Check the placement of both wires and fragment relationships on lateral fluoroscopy
Reduce the articular surface using instrument pressure at the volar base of the shaft fragment
Extend the shaft fragment resulting in closure of the metaphysis while maintaining the instrument pressure
Advance the axial wire across the DIP joint
Check the final fixation on fluoroscopy, adjust if needed, cut off pins, dress, and splint
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Introduction to Distal Interphalangeal (DIP) and Thumb Interphalangeal (IP) Joint Dislocations

Dislocations at the DIP/IP joint suffer from underappreciation and late presentation. Injuries are considered chronic after 3 weeks. Pure dislocations without tendon rupture are rare, usually result from ball-catching sports, are primarily dorsal in direction, and may occur in association with PIP joint dislocations (Fig. 30-17). Transverse open wounds in the volar skin crease are frequent (Fig. 30-18). Injury to a single collateral ligament or to the volar plate alone at the DIP joint is rare. 
Figure 30-17
Dislocations of the DIP joint are nearly always dorsal.
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Figure 30-18
Dorsal DIP dislocations are often open injuries, with a transverse rent in the flexion crease resulting from tearing rather than from direct laceration.
The wound should be debrided prior to reduction if possible.
The wound should be debrided prior to reduction if possible.
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Pathoanatomy and Applied Anatomy of Distal Interphalangeal and Thumb Joint Dislocations

The DIP/IP joint is a bicondylar ginglymus joint stabilized on each side by proper and accessory collateral ligaments and the volar plate. The proper collateral ligaments insert on the lateral tubercles at the base of P3, which also serve as the origin for the lateral ligaments to the tuft. The accessory collateral ligaments attach distally to the lateral margins of the volar plate. The volar plate of the DIP joint has a proximal attachment weakly confluent with the distal extent of the flexor digitorum superficialis (FDS) tendon but has no strong check-rein ligaments like those at the PIP joint. This is in keeping with the clinical observation that the volar plate detaches proximally when the DIP/IP joint dislocates dorsally. The joint is inherently stable owing to articular congruity and the dynamic balance of flexor and extensor tendons. However, the DIP/IP joint is not as intrinsically stable as the PIP joint and depends to a greater degree on its ligaments. 
The DIP/IP joints have complex motion patterns involving axial rotation that are different for each digit and designed to ensure conformity when the hand surrounds an object. The capacity for passive DIP/IP hyperextension is unique to modern humans, but the role this plays in the etiology of dislocation is unclear. Irreducible dorsal dislocations are thought to occur through a variety of different anatomic circumstances. Reasons include a trapped volar plate, the FDP trapped behind a single condyle of P2 (marked lateral displacement), P2 buttonholed through the volar plate or through a rent in the FDP, and thumb sesamoids. Volar dislocations may also be irreducible with the extensor tendon displaced around the head of P2. 

Distal Interphalangeal and Thumb Joint Dislocations Treatment Options

Nonoperative Management of Distal Interphalangeal and Thumb Joint Dislocations

Reduced dislocations that are stable may begin immediate AROM. The rare unstable dorsal dislocation should be immobilized in 20 degrees of flexion for up to 3 weeks before instituting AROM. The duration of the immobilization should be in direct proportion to the surgeon’s assessment of joint stability following reduction. Complete collateral ligament injuries should be protected from lateral stress for at least 4 weeks. When splinting at the level of the DIP/IP joint, extreme caution must be exercised with regard to the vascularity of the dorsal skin between the extension skin crease and the dorsal nail fold. It is not only direct pressure but merely the angle of hyperextension that can “wash out” the blood supply to this skin, potentially resulting in full-thickness necrosis. This complication is thought to occur at an angle representing 50% of the available passive hyperextension of the DIP joint and can be identified by blanching of the skin. 

Closed Reduction and Internal Fixation

It is possible that the degree of postreduction instability is great enough to require a brief period (3 to 4 weeks) of 0.045-inch K-wire stabilization across the joint (Fig. 30-19). The need for added stabilization occurs primarily when aggressive rehabilitation is required for adjacent hand injuries. 
Figure 30-19
Closed reduction and internal fixation of the DIP joint should assure (A) a congruent articulation in neutral on the lateral view, and (B) neutral pin placement on the AP view.
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Open Reduction

Delayed presentation (over 3 weeks) of a subluxed joint may require open reduction to resect scar tissue and permit a congruent reduction, but can result in additional postoperative stiffness. In one study, 10 patients with chronic dorsal fracture dislocations of the DIP and IP joints (average 8 weeks) underwent a volar plate arthroplasty with 4 weeks of K-wire fixation yielding a 42-degree average arc of motion for finger DIP joints and 51 degrees for thumb IP joints with an average flexion contracture of 12 degrees.134 Open dislocations require thorough debridement to prevent infection. The need for fixation with a K-wire should be based on the assessment of stability and is not necessarily required for all open dislocations. The wire may be placed either longitudinally or on an oblique path. The duration of pinning should not be longer than 4 weeks. The advantage of longitudinal pinning is the absence of any lateral wire protrusion to contact adjacent digits. The advantage of oblique pinning is the ability to remove both sections of the wire should breakage across the joint occur. When open reduction of the joint is required, a transverse dorsal incision at the distal joint crease from midaxial line to midaxial line provides ample exposure. Should additional exposure be required midaxial proximal extensions can be made. 
Potential Pitfalls and Preventative Measures.
Two primary complications of open surgery in this region are impaired wound healing and hypersensitivity. Dissecting and preserving longitudinal venous channels during the surgery facilitates venous drainage of the narrow skin flap between the wound and the dorsal nail fold. There is usually one major group of veins directly in the midline overlying the extensor tendon and one major group at each dorsolateral corner. The lateral venous groups are accompanied by the distal branches of the dorsal digital nerves. Transection of these small nerve branches with the subsequent formation of small neuromas adherent to the wound may be one reason for the high incidence of hypersensitivity in this region. The initial surgical incision should be just through dermis only, followed by careful longitudinal dissection of these neurovascular structures under magnification before proceeding with the remainder of the surgery (Table 30-5). 
Table 30-5
Potential Pitfalls and Preventative Measures—DIP Dislocations
Pitfall Prevention
Poor wound healing Gentle technique, preserve dorsal veins
Hypersensitivity Gentle technique, preserve small nerve branches
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Author’s Preferred Treatment (Fig. 30-20)

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Figure 30-20
DIP joint dislocations.
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Closed reduction and splinting is the preferred treatment for most injuries (Fig. 30-20). Should added pin stabilization prove necessary because of recurrent instability, a single longitudinal 0.045-inch K-wire is sufficient. Closed reduction may seem to be impossible. Interposed tissue is usually the cause and may include volar plate, collateral ligament, or tendon. Longitudinal traction rarely is successful in overcoming the blockade. Instead, proximal joint positioning to relax the involved tendons and gentle rotation may allow the interposed tissue to slip out of the joint.

 

Should open reduction prove necessary, my preferred incision for the DIP/IP joint is dorsal and transverse. The most distal of the major extensor creases corresponds to the joint level. Proximal extensions of 5 mm made in the midaxial lines create a small trapdoor effect that gives ample exposure for any procedure. The terminal extensor tendon or extensor pollicis longus (EPL) should be protected. Using a single prong skin hook is a gentle method to control the tendon without grasping and crushing its fibers with forceps while working to achieve reduction. One must search for small chondral or osteochondral injuries primarily for the purpose of removing the fragments from the joint to prevent subsequent third body wear.

Introduction to Middle Phalanx (P2) Fractures

This section is intentionally biased to concentrate on the intra-articular fractures that occur at the base of the middle phalanx. These are perhaps the most functionally devastating of all fractures and dislocations of the hand and the most technically difficult to treat. Many other fracture patterns that occur in the middle phalanx are the same as those patterns seen in the proximal phalanx. The literature rarely distinguishes between P1 and P2 when reporting on phalangeal fractures, and the majority of the published data on this subject is covered in the section on proximal phalanx fractures later in the chapter. 

Pathoanatomy and Applied Anatomy Relating to Middle Phalanx Fractures

Fractures of the middle phalanx can be grouped by the anatomic regions of head, neck, shaft, and base (Fig. 30-21). Tendon insertions that play a role in fracture deformation include the central slip at the dorsal base and the terminal tendon acting through the DIP joint. The FDS has a long insertion along the volar lateral margins of the shaft of P2 from the proximal one-fourth to the distal one-fourth. Fractures at the neck of P2 will usually angulate apex volar as the proximal fragment is flexed by the FDS and the distal fragment is extended by the terminal tendon (Fig. 30-22). Those at the base will usually angulate apex dorsal as the distal fragment is flexed by the FDS and the proximal fragment is extended by the central slip. Despite the theoretical resolution of these force vectors, actual P2 fractures are less predictable and subject to any variety of displacement patterns. Axial loading patterns of injury may produce unicondylar or bicondylar fractures of the head or intra-articular fractures of the base. Base fractures can be divided into partial articular fractures of the dorsal base, volar base, and lateral base or complete articular fractures that are usually comminuted and often referred to as “pilon” fractures. “Pilon” fractures are unstable in every direction including axially. 
Figure 30-21
Fracture patterns of P2 other than the specific base patterns discussed later include (A) intra-articular fractures of the head, (B) oblique shaft fractures, (C) longitudinal shaft fractures, and (D) transverse shaft fractures.
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Figure 30-22
 
The insertions of the flexor digitorum superficialis, the flexor digitorum profundus, and the components of the extensor apparatus typically cause fractures in the distal one-fourth of P2 to angulate apex volarly and these in the proximal one-fourth of P2 to angulate apex dorsally.
The insertions of the flexor digitorum superficialis, the flexor digitorum profundus, and the components of the extensor apparatus typically cause fractures in the distal one-fourth of P2 to angulate apex volarly and these in the proximal one-fourth of P2 to angulate apex dorsally.
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Figure 30-22
The insertions of the flexor digitorum superficialis, the flexor digitorum profundus, and the components of the extensor apparatus typically cause fractures in the distal one-fourth of P2 to angulate apex volarly and these in the proximal one-fourth of P2 to angulate apex dorsally.
The insertions of the flexor digitorum superficialis, the flexor digitorum profundus, and the components of the extensor apparatus typically cause fractures in the distal one-fourth of P2 to angulate apex volarly and these in the proximal one-fourth of P2 to angulate apex dorsally.
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Although the complete articular fractures are the most challenging ones in which to restore function, the force vectors of volar base fractures are perhaps more interesting. Fractures at the volar base of P2 can be particularly unstable in relation to the percentage of articular surface involved. When the volar fragment constitutes greater than around 40% of the articular surface, this fragment carries the majority of the proper collateral ligament insertion in addition to the accessory ligament and volar plate insertions (Fig. 30-23). The dorsal fragment and remainder of P2 will thus sublux proximally and dorsally with displacement being driven by the pull of the FDS and the central slip. The joint then hinges rather than glides, pivoting on the fracture margin of the dorsal fragment and abrading the articular cartilage on the head of P1. 
Figure 30-23
 
When the volar fragment of the base of P2 comprises more than 40% of the joint surface, the collateral ligaments attach to the volar, rather than the dorsal, fragment rendering the dorsal fragment with the shaft unstable in extension.
When the volar fragment of the base of P2 comprises more than 40% of the joint surface, the collateral ligaments attach to the volar, rather than the dorsal, fragment rendering the dorsal fragment with the shaft unstable in extension.
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Figure 30-23
When the volar fragment of the base of P2 comprises more than 40% of the joint surface, the collateral ligaments attach to the volar, rather than the dorsal, fragment rendering the dorsal fragment with the shaft unstable in extension.
When the volar fragment of the base of P2 comprises more than 40% of the joint surface, the collateral ligaments attach to the volar, rather than the dorsal, fragment rendering the dorsal fragment with the shaft unstable in extension.
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Middle Phalanx Fracture Treatment Options

Static Splinting

Many P2 fractures can be effectively managed entirely nonoperatively. The presence of comminution alone does not necessitate surgery. When crushing is the mechanism of injury, the periosteal envelope may remain relatively intact as long as fracture displacement is not significant. The inherent stability of the fracture is more related to the degree of displacement than the direction or number of fracture planes. Nevertheless, certain patterns are more stable than others. Transverse fractures are more stable than long oblique or spiral fractures, both of which tend to shorten and either laterally deviate or rotate to cause interference patterns with neighboring digits. Splinting is confined to the digit alone with dorsally applied aluminum and foam or custom orthoplast splints. Motion rehabilitation should be initiated by 3 weeks post injury with interim splinting until clinical signs of healing are present (but not longer than 6 weeks).22 Side strapping to an adjacent digit usually provides sufficient protection from external forces after the first 3 weeks. 

Dynamic Extension Block Splinting

A nonoperative technique used specifically for volar base fractures is extension block splinting. Fractures at the volar base of P2 that involve less than 40% of the articular surface can usually be managed effectively with extension block splinting. The key to success with this treatment is absolute maintenance of a congruent reduction, avoiding the hinge motion that occurs with dorsal and proximal subluxation of the major fragment. Correct application of a dorsal extension block splint requires maintenance of contact between the dorsum of the proximal phalangeal segment and the splint. If the digit is allowed to “pull away” from the splint volarly, the PIP joint can extend beyond the safe range, sublux, and negate the desired effect of the splint. Once the splint is in place, weekly follow-up with a true lateral radiograph of the PIP joint is mandatory to monitor the advancement of extension at a rate of around 10 degrees per week (see below for details of extension block splinting). 

Condylar Fractures of the Head

Displaced unicondylar or bicondylar fractures of the head of P2 require a transverse wire to be placed across the condyles to maintain a level distal articular surface at the DIP joint. A second wire passed obliquely to the diaphysis of the opposite cortex will prevent lateral migration of the condylar fragment along the smooth shaft of the first wire which would create an articular gap (Fig. 30-24). This second wire also controls the rotation of the fragment in the sagittal plane that can occur with single wire fixation alone. If the patient presents late or soft tissue lies interposed in the fracture plane between condyles, achieving an accurate closed reduction is unlikely and open reduction may be required. Once opened, the opportunity for threaded lag screw fixation exists as opposed to smooth K-wire fixation. If the condylar fragment does not have a diaphyseal extension, then the location for lag screw placement is directly through the collateral ligament, which may negate the screw’s theoretical advantage over two diverging K-wires in terms of early motion. More complex bicondylar fractures that extend into the shaft require individualized strategies for stabilization, including fixation as definitive as laterally placed plates (Fig. 30-25). 
Figure 30-24
Condylar fractures at the head of P2 tend to slide along the pin interface producing an articular gap and/or step-off.
 
A: Unicondylar fractures require diverging wires to prevent fragment separation. B: In bicondylar fractures, converging wires are used to prevent fragment separation.
A: Unicondylar fractures require diverging wires to prevent fragment separation. B: In bicondylar fractures, converging wires are used to prevent fragment separation.
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Figure 30-24
Condylar fractures at the head of P2 tend to slide along the pin interface producing an articular gap and/or step-off.
A: Unicondylar fractures require diverging wires to prevent fragment separation. B: In bicondylar fractures, converging wires are used to prevent fragment separation.
A: Unicondylar fractures require diverging wires to prevent fragment separation. B: In bicondylar fractures, converging wires are used to prevent fragment separation.
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Figure 30-25
More complex bicondylar fractures can be stabilized by either (A) multiple wires in different planes or (B) a lateral plate and screws.
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Unstable Shaft Fractures

CRIF is usually accomplished with 0.035-inch K-wires depending on patient size (Fig. 30-26). K-wires that cross in the middle of the shaft produce a less stable pattern of fixation, particularly if the fracture is located at the level where the wires cross. For transverse or short oblique patterns, K-wire placement other than the crossing pattern may be difficult to achieve without violating either the DIP or PIP joint or directly penetrating a tendon (Fig. 30-27). Long oblique or spiral shaft fractures are amenable to relatively transverse placement of K-wires without joint or tendon penetration. When rotational alignment cannot be effectively restored by closed means, interfragmentary lag screw fixation is usually quite effective for spiral fractures. When comminution or axial instability is present, a limited number of P2 fractures may actually be most appropriately treated with plate and screw fixation (Fig. 30-28). 
Figure 30-26
Fractures of the neck of P2 can be pinned with (A) a single oblique pin only when local soft tissues and the geometry of the fracture itself add some inherent stability.
 
Correct placement is from the collateral recess distally to the opposite corner of the metaphyseal base. B: If there is a concomitant zone II extensor tendon repair needing protection, pinning can include the DIP joint with an oblique wire in P2 to prevent axial rotation.
Correct placement is from the collateral recess distally to the opposite corner of the metaphyseal base. B: If there is a concomitant zone II extensor tendon repair needing protection, pinning can include the DIP joint with an oblique wire in P2 to prevent axial rotation.
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Figure 30-26
Fractures of the neck of P2 can be pinned with (A) a single oblique pin only when local soft tissues and the geometry of the fracture itself add some inherent stability.
Correct placement is from the collateral recess distally to the opposite corner of the metaphyseal base. B: If there is a concomitant zone II extensor tendon repair needing protection, pinning can include the DIP joint with an oblique wire in P2 to prevent axial rotation.
Correct placement is from the collateral recess distally to the opposite corner of the metaphyseal base. B: If there is a concomitant zone II extensor tendon repair needing protection, pinning can include the DIP joint with an oblique wire in P2 to prevent axial rotation.
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Figure 30-27
 
Shaft fractures of P2 can be stabilized with (A) a single oblique pin from the collateral recess to the opposite base if relatively stable upon reduction, (B) converging wires in different planes when added stability is needed, or (C, D) diverging wires.
Shaft fractures of P2 can be stabilized with (A) a single oblique pin from the collateral recess to the opposite base if relatively stable upon reduction, (B) converging wires in different planes when added stability is needed, or (C, D) diverging wires.
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Figure 30-27
Shaft fractures of P2 can be stabilized with (A) a single oblique pin from the collateral recess to the opposite base if relatively stable upon reduction, (B) converging wires in different planes when added stability is needed, or (C, D) diverging wires.
Shaft fractures of P2 can be stabilized with (A) a single oblique pin from the collateral recess to the opposite base if relatively stable upon reduction, (B) converging wires in different planes when added stability is needed, or (C, D) diverging wires.
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Figure 30-28
More complex shaft fractures (A) can be stabilized by (B, C) multiple lag screws or (D) a lateral plate and screws.
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Temporary Transarticular Pinning for Partial Articular Base Fractures

Extension block pinning is an effective strategy for dorsal and volar base fractures (Fig. 30-29). An average PIP joint ROM of 91 degrees was achieved following CRIF of dorsal base fractures despite an extensor lag of over 10 degrees in five of nine patients.135 Ten patients with transarticular pinning of volar base fractures for 3 weeks with 2 additional weeks of extension block splinting achieved an average 85-degree arc of motion with an 8-degree flexion contracture and no severe degenerative changes at 16 year follow-up.120 Another study compared transarticular fixation (eight patients) to ORIF with lag screws (six patients) or ORIF with cerclage wires (five patients). At 7-year mean follow-up, cerclage wires produced the smallest arc of motion (median 48 degrees) compared to pinning (median 75 degrees). Eleven of the nineteen total patients healed with some degree of incongruence or frank subluxation.3 
A second interfragmentary wire may be added in the base of P2 itself.
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Figure 30-29
Extension block pinning includes at least one K-wire placed into the intercondylar notch of P1 to prevent dorsal displacement of the base of P2.
A second interfragmentary wire may be added in the base of P2 itself.
A second interfragmentary wire may be added in the base of P2 itself.
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Volar Base Fractures

A closed fixation strategy uniquely designed for volar base fractures is a force couple device that works to dynamically reduce the tendency for dorsal subluxation of P2.18 Acute volar base fractures involving more than 40% of the joint surface and those with sub-acute or chronic residual subluxation can be treated with volar plate arthroplasty. Seventeen patients followed at 11.5 years demonstrated a TAM of 85 degrees when operated on within 4 weeks of injury and 61 degrees when operated on later than 4 weeks from injury.43 A series of 56 patients with volar base fracture-dislocations treated by either volar plate arthroplasty (23/56) or ORIF (33/56) had minimal pain in 83%, but radiographic evidence of degenerative changes in 96% at 46-month follow-up.41 
Lag screw fixation is an excellent option for large volar fragments without comminution (Fig. 30-30). Seven patients undergoing lag screw fixation within 2 weeks of injury achieved an average PIP joint ROM of 100 degrees with a similar group of seven patients operated after 2 weeks achieving an average of 86 degrees.68 Another 12 digits followed for an average of 8.7 months after lag screw ORIF demonstrated combined PIP and DIP motion arcs that averaged 132 degrees.104 When followed up at an average of 42 months from surgery, nine similar patients demonstrated an average PIP range of 70 degrees with a 14-degree flexion contracture.70 Even displaced fractures more than 5 weeks from injury can be carefully corrected at the articular surface and supported by bone graft using the volar “shotgun” exposure.38 When comminution is excessive, restoration of the volar buttress with true hyaline cartilage is possible using a hemi-hamate osteochondral autograft. Thirteen patients treated with this strategy at an average of 45 days post injury for comminution of the volar 60% of the P2 base had an average PIP arc of motion of 85 degrees at 16-month follow-up.182 Another group of 33 patients achieved an average of a 70-degree arc of motion with a 20-degree flexion contracture and DASH score of 5.21 Minimum 4-year follow-up of eight hemi-hamate osteochondral graft patients yielded an average arc of PIP motion of 67 degrees, mild arthritis in two patients, and severe arthritis in two patients (Table 30-6).2 
Figure 30-30
Volar base fractures of P2 allow the shaft and dorsal base fragment to (A) sublux dorsally and proximally resulting in hinge, rather than gliding, motion.
 
Fixation of the volar base fragment must (B) restore the volar lip buttress against subluxation and re-create a congruent articulation.
Fixation of the volar base fragment must (B) restore the volar lip buttress against subluxation and re-create a congruent articulation.
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Figure 30-30
Volar base fractures of P2 allow the shaft and dorsal base fragment to (A) sublux dorsally and proximally resulting in hinge, rather than gliding, motion.
Fixation of the volar base fragment must (B) restore the volar lip buttress against subluxation and re-create a congruent articulation.
Fixation of the volar base fragment must (B) restore the volar lip buttress against subluxation and re-create a congruent articulation.
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Table 30-6
Surgical Steps—Osteochondral Reconstruction of Volar Base of P2 Fractures
Bruner incision from DIP to palmodigital flexion crease, reflect, and tack back skin flap
Mobilize neurovascular bundles to avoid traction during “shotgun” inversion of wound
Open rectangular flap in flexor sheath from A2 to A4 pulleys
Incise collateral ligaments tangentially from head of P1
Excise volar plate
Invert wound using “shotgun” maneuver, sweeping flexor tendons to side
Evaluate fracture and prepare recipient defect using flat straight saw cuts to form right angle
Harvest osteochondral graft from hamate larger than measurements at recipient defect
Trim graft to orient sagittal ridge to match defect and to restore volar lip flexion posture
Fix graft into defect with 2–3 lag screws (1.2–1.3 mm) and check orientation and fit
Reduce joint and test stability, must not sublux or dislocate even in full extension
Close flexor sheath and skin flaps, dress, and splint
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“Pilon” Fractures

The most functionally devastating injuries to the PIP joint are “pilon” fractures that involve the complete articular surface combined with metaphyseal compaction. These are highly unstable injuries refractory to standard surgical techniques. Although other adverse events such as pin tract infection may intercede, the primary complication is stiffness. Unique forms of treatment have been devised for these injury patterns involving “dynamic traction.”11,37,49,98,114,137,140,160,167 An alternative design uses a dorsal spring mechanism.53 The general principle is to establish a foundation at the center of rotation in the head of P1. From this foundation, traction (adjustable or elastic) is applied along the axis of P2 to hold the metaphyseal component of the fracture out to length while allowing early motion to remodel the articular surface. Dynamic traction with pins and rubber bands in 14 patients followed for 2.5 years produced average PIP motion of 74 degrees and a TAM of 196 degrees.114 Dynamic fixation with wires but not elasticity in eight patients yielded a final average motion of 12 to 88 degrees following wire removal at 6 weeks.89 Ideally, the patient should begin treatment acutely compared to delayed application of the device.27 Many types of device constructs are possible (Fig. 30-31). The simplest constructs involve only K-wires and rubber bands. Thirty-four patients from the armed services achieved a final average arc of motion at the PIP joint of 88 degrees and the DIP joint of 60 degrees using such a device with eight pin tract infections.137 Another group of nonmilitary personnel achieved average PIP arcs of 64 degrees and DIP arcs of 52 degrees.167 With the traction left in place for only 3.5 weeks on average, an average PIP arc of 94 degrees and thumb IP arc of 62.5 degrees were achieved in a total of six patients.140 Another six patients having the device removed between 3 and 4 weeks achieved average PIP range from 5 degrees to 89 degrees with two pin tract infections.11 Early removal of the device may be important as one group noted that their patients achieved minimal motion prior to removal of the device at a mean of 38 days with discomfort while in the device rated at 5.5/10.57 By an average of 26 months postoperatively, five out of eight patients already demonstrated step-off deformities or arthritis.49 
Figure 30-31
 
Strategies for managing “pilon” fractures at the base of P2 include (A) an adjustable unilateral hinged external fixator with distraction capabilities, (B) a wire spring construct, (C) the original configuration of pins and rubber bands, and (D) the same foundation augmented with an additional transverse wire across the metaphyseal base of P2 to resist dorsal subluxation.
Strategies for managing “pilon” fractures at the base of P2 include (A) an adjustable unilateral hinged external fixator with distraction capabilities, (B) a wire spring construct, (C) the original configuration of pins and rubber bands, and (D) the same foundation augmented with an additional transverse wire across the metaphyseal base of P2 to resist dorsal subluxation.
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Figure 30-31
Strategies for managing “pilon” fractures at the base of P2 include (A) an adjustable unilateral hinged external fixator with distraction capabilities, (B) a wire spring construct, (C) the original configuration of pins and rubber bands, and (D) the same foundation augmented with an additional transverse wire across the metaphyseal base of P2 to resist dorsal subluxation.
Strategies for managing “pilon” fractures at the base of P2 include (A) an adjustable unilateral hinged external fixator with distraction capabilities, (B) a wire spring construct, (C) the original configuration of pins and rubber bands, and (D) the same foundation augmented with an additional transverse wire across the metaphyseal base of P2 to resist dorsal subluxation.
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Potential Pitfalls and Preventative Measures.
Successful management of P2 base fractures is predicated on a congruent joint. Thus, true lateral radiographs of the PIP joint are of paramount importance. A dorsal joint space shaped like the letter “V” is a subtle clue to an incongruent joint. With a volar base fracture dislocation of P2, the shaft fragment subluxes relative to the head of P1. To prevent subluxation, the shaft of P2 must be forcibly constrained by the appropriately matched technique to the degree and nature of the subluxation. By the same token, the axial collapse and splaying of fragments that occurs in a pilon fracture must be resisted by an adequate method of fixation, internal or external. When dealing with open procedures involving small articular fragments, dissection must be very precise and gentle, limiting the degree of soft tissue stripping to avoid avascular necrosis of the small fragments. 
There are two critical steps in performing volar base osteochondral graft reconstructions. The first is to establish sharp and flat borders in the metaphyseal defect to receive and inset the graft in a stable fashion with broad cancellous surfaces for rapid bone healing. The second critical step is trimming the graft to fit this bed. The common pitfall is to set the graft’s articular surface perpendicular to the neutral axis of the bone. This fails to re-establish the volar buttress and a truly congruent joint surface. If the graft is cut correctly, once inset, it should replicate the buttressing function of the native volar base and prevent dorsal dislocation. Another pitfall is simply overstuffing the space with too large a graft which will limit PIP joint flexion, partially remediable by volar plate excision (Table 30-7). 
Table 30-7
Potential Pitfalls and Preventative Measures—P2 Fractures
Pitfall Prevention
Initially missing an incongruent PIP joint Precise true lateral imaging to detect subtleties such as the dorsal V-sign
Subsequent dorsal subluxation of P2 base Using appropriately matched technique to resist subluxation: dorsal blocking splint, dorsal blocking wire, restored volar articular lip supported by internal fixation
Axial collapse of pilon fracture Sufficient external or internal fixation devices to resist the forces of tendon contraction
Avascular necrosis of small articular fragments Limit open dissection and preserve collateral ligament attachments to small fragments
Inadequate restoration of volar articular lip in osteochondral reconstruction Rotate graft correctly by cutting the cancellous surfaces to fit the recipient bed so that articular surface of graft is not perpendicular to neutral axis of P2
Inadequate flexion after osteochondral reconstruction Size graft correctly without overstuffing and excise volar plate
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Author’s Preferred Treatment (Fig. 30-32)

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Figure 30-32
Middle phalanx (P2) fractures.
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Stable fractures are preferably treated by limited digital splints for 3 weeks or less and protected early motion thereafter with side strapping to an adjacent digit until clinically healed. Unstable but not comminuted fractures of the shaft can be treated well by temporary (3 weeks) closed pinning (Fig. 30-33). There are a few spiral fractures for which closed reduction will not achieve satisfactory control of rotation such that lag screw fixation with 1.2-mm screws is preferable to closed pinning techniques. These treatment strategies are also used in proximal phalanx fractures and more details may be found in that subsequent section of this chapter.

 
Figure 30-33
 
The relative biomechanical inferiority of K-wires crossing at the midshaft of the phalanx is offset by the lesser demands placed on P2 during rehabilitation than on P1 and the advantage of avoiding articular penetration to achieve a closed pinning.
The relative biomechanical inferiority of K-wires crossing at the midshaft of the phalanx is offset by the lesser demands placed on P2 during rehabilitation than on P1 and the advantage of avoiding articular penetration to achieve a closed pinning.
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Figure 30-33
The relative biomechanical inferiority of K-wires crossing at the midshaft of the phalanx is offset by the lesser demands placed on P2 during rehabilitation than on P1 and the advantage of avoiding articular penetration to achieve a closed pinning.
The relative biomechanical inferiority of K-wires crossing at the midshaft of the phalanx is offset by the lesser demands placed on P2 during rehabilitation than on P1 and the advantage of avoiding articular penetration to achieve a closed pinning.
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Dorsal Base Fractures
 

When a dorsal base fracture presents early, extension block pinning is an excellent treatment. The principles are all the same as described above for extension block pinning of dorsal base fractures in the distal phalanx. At the base of P2, the larger dorsal fragment (compared with the base of P3) is easier to work with and manipulate, but the PIP joint (compared with the DIP joint) imposes greater demands for a perfectly congruent joint reduction because of its more important role in overall digital function. The volar articular and shaft fragment is almost always subluxed proximally and volarly. When more than 10 to 14 days have passed since injury, it can be quite difficult (because of early soft tissue contracture) to achieve a closed reduction of this fragment relative to the head of P1. It is for these reasons that late-presenting dorsal base fractures are often better managed with ORIF to ensure the clearance of consolidating hematoma from between the fragments and exact approximation of the articular reduction (Fig. 30-34). In this setting, fixation with two 1.2-mm lag screws usually affords enough stability to pursue early motion. Use of the countersink tap is important to minimize dorsal prominence of the screw heads and to avoid pressure concentration that might comminute the still relatively small dorsal fragment. Even though the surgical procedure occurs distal to extensor zone IV, a priority still must be placed on active extensor tendon excursion during rehabilitation to avoid a long-term extensor lag. In select cases, additional support may be needed in the form of a buttress plate (Fig. 30-34). Intraoperative assessment of the stability of the fixation will guide the progression of rehabilitation to ensure against fixation failure, recognizing the small size of the thread purchase in cancellous rather than cortical bone at the metaphyseal base of P2.

 
Figure 30-34
Dorsal base fractures allow (A) the volar articular fragment and the attached shaft of P2 to sublux volarly and proximally.
 
B: A congruent joint is restored with sufficient stability to initiate early rehabilitation by lag screw fixation. An alternative fixation strategy is (C, D) a small custom-cut hook plate.
B: A congruent joint is restored with sufficient stability to initiate early rehabilitation by lag screw fixation. An alternative fixation strategy is (C, D) a small custom-cut hook plate.
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Figure 30-34
Dorsal base fractures allow (A) the volar articular fragment and the attached shaft of P2 to sublux volarly and proximally.
B: A congruent joint is restored with sufficient stability to initiate early rehabilitation by lag screw fixation. An alternative fixation strategy is (C, D) a small custom-cut hook plate.
B: A congruent joint is restored with sufficient stability to initiate early rehabilitation by lag screw fixation. An alternative fixation strategy is (C, D) a small custom-cut hook plate.
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Volar Base Fractures—Closed Treatment
 

Volar base fractures constituting less than 25% to 30% of the joint surface rarely require surgery unless presenting late with an incongruent joint. When seen acutely, these fractures are well managed with extension block splinting that begins at around 40 degrees and advances 10 to 15 degrees per week for the first 3 weeks. If the extension block splint cannot be eliminated in 3 weeks’ time, this treatment strategy may not be appropriate. Fractures constituting more than 25% but less than 40% of the joint surface pose a difficulty in treatment planning as they are an intermediate group where the disadvantages of the two primary options are relatively well matched. It is difficult to predict in advance how the disadvantages will play out over the course of treatment for an individual patient. The disadvantage of extension block splinting or pinning is that with a greater amount of joint surface involved, the blocking must begin at a higher angle and it will take longer to achieve full extension. A permanent fixed flexion contracture is the consequence to be avoided. This must be compared with the overall tendency for loss of joint motion associated with ORIF or open reconstruction.

 
Volar Base Fractures—ORIF
 

When the volar fragment(s) constitute greater than 40% of the joint surface, an open procedure offers the greatest assurance of achieving a congruent joint as a final result. The distinction between the need for ORIF for one or two relatively large fragments or open reconstruction for highly comminuted multiple fragments often cannot be made until the time of surgery. One should always be prepared for both possibilities in the preoperative planning discussions with the patient. Dorsal base fractures usually provide a single fragment of reasonable size for direct lag screw fixation. Volar base fractures are not so easy. One or two large fragments that facilitate lag screw fixation are the exception rather than the rule. In this case, two 1.2-mm lag screws are appropriate. Placement is side by side with one screw in the radial half of the base fragment and the other in the ulnar half. If two separate radial and ulnar volar base fragments are found, this strategy is still acceptable provided that the fragment diameter is at least three times the screw diameter and compression can be achieved without causing fragment comminution. The countersink tap is useful in this regard. With increasing comminution and loss of metaphyseal support for the articular fragments, the original bone may still be salvaged by a volar buttress plate to avoid progressing to the next rung of the reconstructive ladder, osteochondral reconstruction.23

 
Volar Base Fractures—Osteochondral Reconstruction
 

A Bruner incision is made using one limb over P1 and a second over P2. The flexor tendon sheath is reflected as a single rectangular flap hinging on its lateral margin between the distal margin of the A2 pulley and the proximal margin of the A4 pulley. The FDS and FDP are retracted laterally, one to either side, and the collateral ligament origins are dissected as a sleeve from the lateral surfaces of the head of P1. Release of the volar plate allows complete hyperextension of the PIP joint and presentation of both joint surfaces toward the surgeon. This is the so-called “shotgun” approach, and its variations center on the management of the volar plate. This approach is also used for volar plate arthroplasty and ORIF. In the former procedure, the volar plate is released distally so that it may be advanced to replace the defect in the volar articular surface. In the latter, it should remain attached to the fragments as an important source of blood supply. When performing a reconstruction of irreparable comminution, the volar plate no longer has an anatomic connection to the volar base of P2, and complete excision will facilitate restoration of PIP flexion after graft reconstruction. The defect in the volar articular surface may range anywhere from 40% up to almost 90%, often with irregular margins. A small saw or burr should be used to straighten the irregular margins into sharp orthogonal cuts that define a clear bed of cancellous bone in the metaphysis that can be accurately measured for reconstruction. The articular surface at the base of P2 has a sagittally oriented ridge that interdigitates with the groove between the two condyles at the head of P1. This relationship is important not only for preserving joint congruence but also for maintaining stability in the setting of collateral ligament releases. An excellent geometric match has been found in the distal articular surface of the hamate at the ridge that separates the ring from the small finger CMC joints. The measurements taken from the defect at the base of P2 are transposed to the hamate and a small saw and osteotomes are used to remove the osteochondral graft from its donor site. The graft is then exactly trimmed to match the defect and secured with two 1.2-mm lag screws (Fig. 30-35). The joint is checked clinically and radiographically for maintenance of congruence through a full ROM. The flexor sheath is reapproximated with 6–0 monofilament sutures and the PIP joint splinted for protection. Immediate active motion rehabilitation is begun within days of surgery. These same techniques can be extrapolated for use in alternative sites such as the thumb IP joint with the use of a partial FDP-reflecting approach (Fig. 30-36).

 
Figure 30-35
 
Volar base fractures with comminution of a substantial portion of the articular surface and subluxation can be reconstructed with an osteochondral graft from the hamate with particular emphasis placed on re-creating the volar lip buttress and a truly congruent reproduction of the radius of curvature.
Volar base fractures with comminution of a substantial portion of the articular surface and subluxation can be reconstructed with an osteochondral graft from the hamate with particular emphasis placed on re-creating the volar lip buttress and a truly congruent reproduction of the radius of curvature.
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Figure 30-35
Volar base fractures with comminution of a substantial portion of the articular surface and subluxation can be reconstructed with an osteochondral graft from the hamate with particular emphasis placed on re-creating the volar lip buttress and a truly congruent reproduction of the radius of curvature.
Volar base fractures with comminution of a substantial portion of the articular surface and subluxation can be reconstructed with an osteochondral graft from the hamate with particular emphasis placed on re-creating the volar lip buttress and a truly congruent reproduction of the radius of curvature.
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Figure 30-36
A congruent osteochondral reconstruction of a chronic volar base fracture dislocation can also be performed in the thumb with a partial FPL-reflecting approach.
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“Pilon” Fractures—ORIF
 

Complete articular fractures of the base of P2 may be treated by entirely closed reduction and stabilization. If significant metaphyseal bone loss is present or if the articular fragments at the base of P2 do not reduce sufficiently with traction alone, a small incision can be made through which cancellous bone graft can be added to fill the metaphyseal void and to assist in supporting a reduction of the articular fragments. Transverse 0.035-inch K-wires may be placed at the subchondral level to maintain the articular relationships. The fracture must then be reduced at the metaphyseal level and undergo stabilization sufficient to withstand the rigors of early motion that must accompany the rehabilitation of articular fractures. It is at this point that the significant variations in technique arise along with different devices available for stabilization. My previous preference was for an off-the-shelf unilateral hinged external fixator. The device, which is no longer available, allowed free AROM with a gear disengaged or passive range of motion (PROM) with the gear engaged and the ability to hold and stretch the end points of motion (Fig. 30-37). External fixators for “pilon” fractures are not well received by patients who tend to refuse to move the PIP joint much while the device is in place. For these reasons, my current preference is to treat “pilon” fractures with ORIF, a transition that has been aided by the increasing availability of small locking plates. This is a well-received option by patients, provided that stable fixation is achieved and the result maintained during the stress of therapy (Fig. 30-38).

Figure 30-37
 
A hinged external fixator can be used to control “pilon” fractures beginning with (A) the placement of a transverse K-wire through the center of PIP rotation in the head of P1 followed by assembly of the device around that foundation wire. If performed correctly the result will be (B) a congruent joint when healed.
A hinged external fixator can be used to control “pilon” fractures beginning with (A) the placement of a transverse K-wire through the center of PIP rotation in the head of P1 followed by assembly of the device around that foundation wire. If performed correctly the result will be (B) a congruent joint when healed.
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Figure 30-37
A hinged external fixator can be used to control “pilon” fractures beginning with (A) the placement of a transverse K-wire through the center of PIP rotation in the head of P1 followed by assembly of the device around that foundation wire. If performed correctly the result will be (B) a congruent joint when healed.
A hinged external fixator can be used to control “pilon” fractures beginning with (A) the placement of a transverse K-wire through the center of PIP rotation in the head of P1 followed by assembly of the device around that foundation wire. If performed correctly the result will be (B) a congruent joint when healed.
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Figure 30-38
Some “pilon” fractures are amenable to ORIF which then avoids the complications of pin tract infection associated with the dynamic traction strategies.
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Introduction to Proximal Interphalangeal (PIP) Joint Dislocations

Dislocations of the PIP joint have a high rate of missed diagnoses that are passed off as “sprains.” Although a large number of incomplete injuries occur (especially in ball-handling sports), complete disruptions of the collateral ligaments and the volar plate are also frequent. Since dramatic swelling is often present even with minor injuries to the PIP joint, this sign may often be dismissed by initial examiners of the patient. Careful palpation for localized tenderness may direct attention to one of the collateral ligaments, the volar plate, or the insertion of the central slip. The capacity for active PIP extension against resistance from a starting position of PIP flexion confirms the integrity of the central slip. Limitation of passive DIP flexion while the PIP joint is held in extension may appear several weeks following the initial injury and signifies a developing boutonnière deformity. Congruence on the lateral radiograph is the key to detecting residual subluxation. Correct axial rotational alignment is demonstrated when both P1 and P2 are seen in a true lateral projection on the same film. 
Residual instability is quite rare in pure dislocations as opposed to fracture-dislocations where it is the chief issue at stake. It manifests as hyperextension laxity following volar plate injuries managed with an inadequate initial degree of extension blocking. Correction of hyperextension instability can be performed with either delayed reattachment of the volar plate or a capsulotenodesis reconstruction. In pure dislocations, stiffness is the primary concern. Stiffness can occur following any injury pattern and responds best at the late stage to complete collateral ligament excision.108 Chronic missed dislocations require open reduction with a predictable amount of subsequent stiffness. Patients should be counseled to expect permanent residual enlargement of the joint and for the final resolution of stiffness and aching to take as long as 12 to 18 months. 

Pathoanatomy and Applied Anatomy Relating to Proximal Interphalangeal (PIP) Joint Dislocations

The head of P1 is quite different from that of the metacarpal. There is no cam effect. The head is bicondylar, and the collateral ligaments originate from the center axis of joint rotation. Nevertheless, the accessory collateral ligaments and volar plate are lax in flexion and will become contracted if immobilized in that position. At the volar base of P2, there are tubercles for the confluence of the proper and accessory collateral ligaments with the volar plate. This junction is referred to as the “critical corner.” This three-sided box design provides excellent inherent joint stability. The volar plate anatomy is unique at the PIP joint with the presence of strong check-rein ligaments that originate inside the margins of the A2 pulley, confluent with the C1 pulley fibers and the oblique retinacular ligament. The distal insertion of the volar plate is strong only at its lateral margins. The undersurface of the central slip has an articulating fibrocartilage that may aid in stabilization, prevent central slip attenuation, and increase the extensor moment arm. Although primarily a hinge, the PIP joint accommodates 7 to 10 degrees of lateral deviation and slight axial rotation. The normal ROM may be up to 120 degrees of flexion. In contrast to the other small joints of the hand, PIP joint volar plate disruptions usually occur distally. The proper collateral ligaments are the primary stabilizers to lateral stress, and a greater than 20-degree opening signifies complete disruption. Collateral ligament disruption is usually proximal, but the fibers traditionally stay positioned over their anatomic origin for subsequent healing. 
Recognized patterns of dislocation are dorsal dislocation, pure volar dislocation, and rotatory volar dislocation (Fig. 30-39). Dorsal dislocations involve volar plate injury (usually distally, with or without a small flake of bone). To sustain a pure volar dislocation, the patient must rupture the volar plate, at least one collateral ligament, and the central slip. Rotatory volar dislocation occurs as the head of P1 passes between the central slip and the lateral bands, which can form a noose effect and prevent reduction (Fig. 30-40). Irreducible dislocations obstructed by the volar plate or flexor tendons are uncommon injuries. 
Figure 30-39
Three variants of PIP dislocation are seen.
 
A: The most common, dorsal, (B) pure volar with central slip disruption, and (C) volar rotatory (note that P2 is seen as a true lateral whereas P1 is seen in oblique profile).
A: The most common, dorsal, (B) pure volar with central slip disruption, and (C) volar rotatory (note that P2 is seen as a true lateral whereas P1 is seen in oblique profile).
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Figure 30-39
Three variants of PIP dislocation are seen.
A: The most common, dorsal, (B) pure volar with central slip disruption, and (C) volar rotatory (note that P2 is seen as a true lateral whereas P1 is seen in oblique profile).
A: The most common, dorsal, (B) pure volar with central slip disruption, and (C) volar rotatory (note that P2 is seen as a true lateral whereas P1 is seen in oblique profile).
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Figure 30-40
In volar rotatory dislocations, the head of P1 protrudes between the intact central slip and one lateral band, which create a noose effect preventing reduction especially if longitudinal traction is applied.
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Proximal Interphalangeal (PIP) Joint Dislocations Treatment Options

Dorsal Dislocations—Nonoperative Management

Isolated volar plate injuries can be managed with immediate AROM while strapped to an adjacent digit. Fortunately, the majority of hyperextension injuries remain congruent even at full extension and do not require extension block splinting. However, one must consider that the distal volar plate is poorly vascularized, and a lack of early healing may lead to chronic hyperextension laxity. Swelling and pain serve to limit patients from full extension, and side strapping to an adjacent digit further inhibits maximum extension enough that extension block splinting is rarely necessary. When formal extension block splinting is chosen (usually only in the situation of fracture subluxation), the rate of progression each week is determined by the severity of the initial injury but should reach full extension no later than 3 weeks from injury. 

Pure Volar Dislocations—Nonoperative Management

With pure volar dislocations, central slip disruption occurs and will result in a boutonnière deformity if not treated properly. Careful examination consisting of PIP extension against resistance from a starting position of full flexion will prevent missing the diagnosis of a central slip disruption. Limitation of passive DIP flexion is an early sign of a developing boutonnière deformity. Even when identified late, the treatment of choice is extension splinting at the PIP joint with immediate active DIP blocking exercises. Active DIP flexion pulls the whole extensor mechanism (including the ruptured central slip) distally through the intact lateral bands. The duration of PIP extension splinting is 6 weeks. Short arc of motion exercises can begin at 4 weeks, returning to the extension splint between sessions. 

Rotatory Volar Dislocations—Nonoperative Management

Rotatory volar dislocations where the head of P1 is trapped between the central slip and lateral band may be difficult to reduce owing to the noose effect exerted by these two soft tissue structures. The key to closed reduction (if it is possible at all) is to relax both structures. Wrist extension relaxes the extrinsic component, and full MP joint flexion relaxes the intrinsic component. A gentle rotating maneuver that avoids excessive longitudinal traction stands the highest chance of success. A few of these dislocations remain irreducible even in the most skilled hands. When a reduction can be achieved, early mobilization is then instituted with adjacent digit strapping (usually the more radial) in an attempt to prevent stiffness. 

Open Reduction

There are two indications for open treatment of PIP joint injuries: an open injury or an irreducible dislocation.126 Lateral dislocations may also be irreducible because of interposition of a torn collateral ligament (Fig. 30-41). A midaxial (or dual midaxial) incision allows for management of both dorsal and volar dislocations. Controversy remains as to the need for direct repair of complete collateral ligament ruptures and volar plate injuries. Direct repair is probably only functionally necessary in the long term for the radial collateral ligament (RCL) of the index finger. Chronic reconstruction of collateral ligament deficiency is rarely necessary and is an even more technically demanding procedure with a high propensity for generating stiffness but may be accomplished by a variety of techniques. 
Figure 30-41
Entrapment of a collateral ligament can prevent reduction of the PIP joint; lateral stress examination demonstrates the high degree of instability in this situation.
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Potential Pitfalls and Preventative Measures

Straight longitudinal traction is almost never the answer to accomplishing a reduction and certainly is the surest way to fail at the PIP joint. Relaxation of the most powerful tendon forces acting across the joint is the key to facilitating a smooth reduction that does not cause additional hyaline cartilage damage. Postreduction clinical and radiographic assessment is crucial with an emphasis on the lateral radiograph in full extension to assess congruence. The patient should be able to move the finger through a near full ROM under the influence of the digital block used to accomplish the reduction. Open dislocations should be taken seriously for their potentially high rate of complications and debrided prior to reduction (Table 30-8). 
Table 30-8
Potential Pitfalls and Preventative Measures—PIP Joint Dislocations
Pitfall Prevention
Attempting to use longitudinal traction to reduce the dislocation Gentle rotatory maneuvers and strategic proximal joint positioning to relax tendons
Failing to achieve a congruent reduction True lateral radiograph in flexion and extension or lateral fluoroscopy with motion
Infection following open dislocations Definitive surgical debridement in operating room prior to reduction
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Author’s Preferred Treatment (Fig. 30-42)

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Figure 30-42
PIP joint dislocations.
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Once reduced, rotatory volar dislocations, isolated collateral ligament ruptures, and dorsal dislocations congruent in full extension on the lateral radiograph can all begin immediate AROM with adjacent digit strapping. Dorsal dislocations that are subluxed on the extension lateral radiograph require a few weeks of extension block splinting before progressing (however, this is an almost unheard of situation with pure dislocation and no fracture component). Volar dislocations with central slip disruptions require 6 weeks of PIP extension splinting followed by nighttime static extension splinting for 2 additional weeks. The DIP joint should be unsplinted and actively flexed throughout the entire recovery period. Short arc motion of the PIP joint can begin at 4 weeks.

 

Open dorsal dislocations usually have a transverse rent in the skin at the flexion crease. Debridement of this wound should precede reduction of the dislocation. Any joint debris should be cleared out to prevent third body wear. The “critical corner” warrants particular attention. For closed irreducible joints, unilateral or bilateral midaxial incisions allow excellent access to both volar and dorsal structures without violating the extensor mechanism. Postoperative management follows the same time courses stated above for nonoperative management based on the injury pattern and severity.

Introduction to Proximal Phalanx (P1) Fractures

Recognized proximal phalanx fracture patterns include intra-articular fractures of the head, extra-articular fractures of the neck and shaft, and both extra-articular and intra-articular fractures of the base (Fig. 30-43). Further describing the pattern of the fracture as transverse, short oblique, long oblique, or spiral for shaft fractures and partial or complete articular for intra-articular fractures (along with the degree and direction of displacement) provides the necessary information to support treatment decisions. A specific fracture pattern that risks extreme PIP limitation is that of the neck of the proximal phalanx, where a volar spike of bone from the proximal fracture fragment impinges into the subcapital recess volar to the neck of P1 (Fig. 30-43B). If the fracture heals in this position, full PIP flexion is prevented by obstruction of the space for volar plate in-folding. This pattern is best identified on an individual digital lateral radiograph and warrants operative treatment to prevent a functionally disabling malunion. 
Figure 30-43
 
Fracture patterns appearing in P1 include (A) complete articular fractures of the head, (B) subcapital fractures with impingement in the volar plate recess, (C) transverse fractures of the shaft or base, (D) oblique fractures of the shaft, and (E) articular fractures of the base.
Fracture patterns appearing in P1 include (A) complete articular fractures of the head, (B) subcapital fractures with impingement in the volar plate recess, (C) transverse fractures of the shaft or base, (D) oblique fractures of the shaft, and (E) articular fractures of the base.
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Fracture patterns appearing in P1 include (A) complete articular fractures of the head, (B) subcapital fractures with impingement in the volar plate recess, (C) transverse fractures of the shaft or base, (D) oblique fractures of the shaft, and (E) articular fractures of the base.
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Figure 30-43
Fracture patterns appearing in P1 include (A) complete articular fractures of the head, (B) subcapital fractures with impingement in the volar plate recess, (C) transverse fractures of the shaft or base, (D) oblique fractures of the shaft, and (E) articular fractures of the base.
Fracture patterns appearing in P1 include (A) complete articular fractures of the head, (B) subcapital fractures with impingement in the volar plate recess, (C) transverse fractures of the shaft or base, (D) oblique fractures of the shaft, and (E) articular fractures of the base.
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Fracture patterns appearing in P1 include (A) complete articular fractures of the head, (B) subcapital fractures with impingement in the volar plate recess, (C) transverse fractures of the shaft or base, (D) oblique fractures of the shaft, and (E) articular fractures of the base.
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Pathoanatomy and Applied Anatomy Relating to Proximal Phalanx (P1) Fractures

Local Soft Tissue Relationships

Fracture of the proximal phalanx may well be one of the more frustrating hand injuries to manage owing to the local soft tissue anatomy.99,105 Whereas the metacarpal has only a cord-like extensor tendon running well dorsal to it, the proximal phalanx is closely invested by a sheet-like extensor mechanism with a complex array of decussating collagen fibers (Fig. 30-44). Surgical disturbance of the fine balance between these fibers can permanently alter the long-term function of the digit. The operative approach to P1 can be either dorsal or lateral. The dorsal approach may be technically simpler but transgresses the extensor mechanism and should not be used unless an open trauma has already disrupted the tendon. The lateral midaxial approach allows the fracture to be fully exposed and hardware placed in its proper lateral position (if hardware is indicated) without directly violating the extensor mechanism.79 If prominent hardware is to be placed, the intrinsic tendon on that side (usually ulnar) may be resected. The proximal phalanx is not a cylinder, but rather highly elliptical (in fact, tunnel-shaped) in cross section, with a thicker dorsal cortex. 
Figure 30-44
 
The proximal phalanx is closely invested by the sheet of the zone IV extensor tendon dorsally, the blending of the intrinsic wing tendons laterally and volarly, and the flexor tendons and flexor sheath directly volarly.
The proximal phalanx is closely invested by the sheet of the zone IV extensor tendon dorsally, the blending of the intrinsic wing tendons laterally and volarly, and the flexor tendons and flexor sheath directly volarly.
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Figure 30-44
The proximal phalanx is closely invested by the sheet of the zone IV extensor tendon dorsally, the blending of the intrinsic wing tendons laterally and volarly, and the flexor tendons and flexor sheath directly volarly.
The proximal phalanx is closely invested by the sheet of the zone IV extensor tendon dorsally, the blending of the intrinsic wing tendons laterally and volarly, and the flexor tendons and flexor sheath directly volarly.
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Deforming Forces

At the proximal phalangeal level, both intrinsic and extrinsic tendon forces deform the fracture. They result in a predictable apex volar deformity for transverse and short oblique fractures. These forces can be used with benefit during rehabilitation. If the MP joints are maximally flexed (the intrinsic plus position), the intrinsic muscle forces acting through the extensor mechanism overlying P1 create a tension band effect that helps to maintain fracture reduction (Fig. 30-45). Active PIP joint motion will heighten this effect and forms the basis for nonoperative fracture management.56 Spiral and long oblique fractures tend to shorten and rotate rather than angulate. These fractures also have more complex patterns of deformity that are not so easily controlled through the joint positioning just described. One can expect 12 degrees of extensor lag at the PIP joint for each millimeter of shortening and 1.5 degrees of extensor lag for each degree of apex palmar fracture angulation.173 
Figure 30-45
 
Flexing the MP joints fully causes the extensor apparatus to function as a tension band to a transverse fracture in the P1 shaft, helping to reduce the deformity and stabilize the fracture when the PIP joint is actively flexed.
Flexing the MP joints fully causes the extensor apparatus to function as a tension band to a transverse fracture in the P1 shaft, helping to reduce the deformity and stabilize the fracture when the PIP joint is actively flexed.
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Figure 30-45
Flexing the MP joints fully causes the extensor apparatus to function as a tension band to a transverse fracture in the P1 shaft, helping to reduce the deformity and stabilize the fracture when the PIP joint is actively flexed.
Flexing the MP joints fully causes the extensor apparatus to function as a tension band to a transverse fracture in the P1 shaft, helping to reduce the deformity and stabilize the fracture when the PIP joint is actively flexed.
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Biomechanics of Fixation

Transverse and short oblique proximal phalanx shaft fractures deform through apex volar bending. Laboratory investigation has shown the biomechanical inefficiency of dorsally applied plates in an apex volar bending model that correlated with the clinical forces experienced at the P1 level.111 Even with plate fixation, the soft tissue envelope has been shown to add stability under load application.127 This is particularly true in the most proximal 6 to 9 millimeters at the base of P1.181 The most valuable foundation in a fixation paradigm is a well-placed lag screw across a noncomminuted fracture interface, although some surgeons have bypassed the step of lagging the screw in favor of less labor-intensive bicortical screws.136 Long oblique and spiral proximal phalanx fractures demonstrate less angular deformity than transverse fractures, instead shortening and rotating axially. 

Proximal Phalanx (P1) Fracture Treatment Options

Nonoperative Management

This is the preferred treatment for many phalangeal fractures that are either minimally displaced or easily rendered stable by reduction. Compared with oblique, spiral, or comminuted fractures, transverse fractures will generally prove to be stable after reduction. Stable proximal phalangeal fractures are ideal candidates for dorsal splinting with the MP joint in flexion. Only 4 of the 45 patients treated with intrinsic plus splinting failed to achieve full motion by 6 weeks.48 Another 65 patients treated with intrinsic plus splinting achieved 86% of normal motion.56 The splint should be discontinued at 3 weeks, followed by AROM exercises without resistance. Stable, nondisplaced fractures may even be treated by a program of immediate AROM, protected only with adjacent digit strapping. The key message for nonoperative management is that a carefully formed splint and/or adjacent digit strapping can effectively maintain an existing and reasonably stable reduction butt splints and strapping cannot accomplish a reduction in their own right. All patients undergoing nonoperative management should be reviewed at a week to verify maintenance of reduction both clinically and radiographically. 

Operative Management

Closed Reduction and Internal Fixation

This is the treatment of choice for the category of reducible but unstable isolated fractures, both extra-articular and some intra-articular.77 A higher degree of care must be exercised when pursuing CRIF in the phalanges compared with the metacarpals because of the close investment by the broad extensor mechanism. Pin entry sites should be chosen carefully to minimize tethering of the extensor mechanism. In the proximal two-thirds of P1, this is virtually impossible. As one approaches the distal one-third, a direct lateral approach can be made volar to the interosseous tendon. For long oblique and spiral fractures, three K-wires (0.045- or 0.035-inch) are placed perpendicular to the fracture plane (Fig. 30-46). For neck fractures, retrograde pinning may be necessary (Fig. 30-47). For short oblique and transverse fractures, longitudinal K-wires (0.045-inch) are placed through the MP joint (Fig. 30-48). Twelve patients achieved an average TAM of 265 degrees with two longitudinal pins placed across the MP joint and down the shaft of the proximal phalanx.85 Trocar-tipped K-wires rather than diamond-tipped or surgeon-cut wires should be used. The wire should be passed through the soft tissues and down to bone before activating the wire driver. Pins should be cut just below the skin surface to prevent pin tract infection or left protruding for ease of removal at the surgeon’s discretion. Absolute parallelism of the K-wires for oblique fractures risks the fracture displacing as it slides along the wires. Some degree of convergence or divergence of the wires will help to prevent this consequence of using smooth wires. The procedure of CRIF is made more difficult than it may initially appear by the challenge of obtaining a truly accurate reduction by closed means. Commercially available devices have been specially designed for closed intramedullary rodding of the phalanx (Fig. 30-49). Routinely, pins should be removed by 3 weeks. When this is done, any final limitations of motion are most likely due to the injury itself rather than the pins. In 35 fractures of the proximal phalanx treated by percutaneous pinning, 32% developed a PIP flexion contracture averaging 18 degrees.50 A slight variation on the theme is “intrafocal” pinning used in five patients to achieve an average PIP range of 90 degrees.32 
Figure 30-46
 
Closed reduction and internal fixation of P1 shaft fractures can be accomplished (A) longitudinally through the MP joint but not the metacarpal head, (B) or through the metacarpal head, (C) with the wires for either of these options running parallel in the phalanx, or (D) entering at the collateral recess and crossing, or (E) passing transversely.
Closed reduction and internal fixation of P1 shaft fractures can be accomplished (A) longitudinally through the MP joint but not the metacarpal head, (B) or through the metacarpal head, (C) with the wires for either of these options running parallel in the phalanx, or (D) entering at the collateral recess and crossing, or (E) passing transversely.
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Figure 30-46
Closed reduction and internal fixation of P1 shaft fractures can be accomplished (A) longitudinally through the MP joint but not the metacarpal head, (B) or through the metacarpal head, (C) with the wires for either of these options running parallel in the phalanx, or (D) entering at the collateral recess and crossing, or (E) passing transversely.
Closed reduction and internal fixation of P1 shaft fractures can be accomplished (A) longitudinally through the MP joint but not the metacarpal head, (B) or through the metacarpal head, (C) with the wires for either of these options running parallel in the phalanx, or (D) entering at the collateral recess and crossing, or (E) passing transversely.
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Figure 30-47
 
Fractures of the proximal phalangeal neck angulated apex volarly (A), can be stabilized by (B) antegrade pinning with a rotational control crosswire if the fracture is sufficiently proximal, but very distal fractures (C, D) usually require retrograde pinning.
Fractures of the proximal phalangeal neck angulated apex volarly (A), can be stabilized by (B) antegrade pinning with a rotational control crosswire if the fracture is sufficiently proximal, but very distal fractures (C, D) usually require retrograde pinning.
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Fractures of the proximal phalangeal neck angulated apex volarly (A), can be stabilized by (B) antegrade pinning with a rotational control crosswire if the fracture is sufficiently proximal, but very distal fractures (C, D) usually require retrograde pinning.
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Figure 30-47
Fractures of the proximal phalangeal neck angulated apex volarly (A), can be stabilized by (B) antegrade pinning with a rotational control crosswire if the fracture is sufficiently proximal, but very distal fractures (C, D) usually require retrograde pinning.
Fractures of the proximal phalangeal neck angulated apex volarly (A), can be stabilized by (B) antegrade pinning with a rotational control crosswire if the fracture is sufficiently proximal, but very distal fractures (C, D) usually require retrograde pinning.
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Fractures of the proximal phalangeal neck angulated apex volarly (A), can be stabilized by (B) antegrade pinning with a rotational control crosswire if the fracture is sufficiently proximal, but very distal fractures (C, D) usually require retrograde pinning.
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Figure 30-48
Transverse shaft fractures of P1 are best stabilized by 0.045-inch K-wires passed longitudinally through the metacarpal head and removed at 3 weeks.
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Figure 30-49
 
A: Proximal phalanx fractures can be stabilized by closed placement of a specially designed device that achieves (B) three-point fixation with a rotational locking sleeve proximally.
A: Proximal phalanx fractures can be stabilized by closed placement of a specially designed device that achieves (B) three-point fixation with a rotational locking sleeve proximally.
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Figure 30-49
A: Proximal phalanx fractures can be stabilized by closed placement of a specially designed device that achieves (B) three-point fixation with a rotational locking sleeve proximally.
A: Proximal phalanx fractures can be stabilized by closed placement of a specially designed device that achieves (B) three-point fixation with a rotational locking sleeve proximally.
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Open Reduction and Internal Fixation

ORIF is the technique of choice for severe open fractures with multiple associated soft tissue injuries and for patients with multiple fractures (within the same hand or polytrauma patients). It is also the technique of choice for intra-articular fractures with displacement in P1. In a series of 38 distal unicondylar fractures of P1, 5 of 7 initially nondisplaced and unfixed fractures and 4 of 10 fixed with a single K-wire went on to displace.180 Displaced fractures at the intra-articular base of P1 with more than 20% articular involvement should be internally fixed. Using a volar A1 pulley approach, 10 patients had fixation of lateral base fractures with full motion recovery, good stability, and over 90% contralateral grip strength.100 The role of ORIF for an isolated, noncomminuted, extra-articular fracture of the phalanx is clearly defined only for the rare irreducible fracture. Spiral fractures may benefit from ORIF with lag screws to achieve precise control over rotation, provided that surgeons experienced in this specific technique can minimize soft tissue disruption.77,79 Most surgeons will be more comfortable with CRIF for those fractures that can be reduced. The 40-month follow-up of 32 patients prospectively randomized to percutaneous pinning versus lag screw fixation for long oblique and spiral shaft fractures found no differences in function, pain scores, ROM, or grip strength, but with a mean loss of active extension of 8 degrees in the pinning group and 27 degrees in the screw fixation group.86 Surgical technique was such that there were 8 malunions out of the 15 lag screw patients using screws as large as 2 mm. Three of the seventeen K-wire patients required subsequent formal extensor tenolysis for tethering but none of the lag screw patients did.86 ORIF with screws and/or plates is considerably more technically demanding than in the metacarpal for a number of reasons including the proximity of the extensor mechanism, the origins of the fibro-osseous flexor tendon sheath, and the size and consistency of the bone. More than just the technical complexity of ORIF is the problem of the postoperative response of the surrounding soft tissues to the surgical dissection and the presence of hardware (Table 30-9). 
Table 30-9
Surgical Steps—Lag Screw Fixation of Spiral Proximal Phalanx Fractures
Midaxial incision, mobilizing dorsal branch of proper digital nerve dorsally
Single layer sleeve approach volar to zone IV extensor, through periosteum to bone
Elevate as one tissue flap from subperiosteal with no dissection between layers
Curette out clot and debris from fracture site to precisely define fracture edges
Reduce fracture with Adson-Brown forceps, precise interdigitation of fracture edges
Convert to bone-holding clamp to maintain reduction vs. continue holding with forceps
Carefully check rotation clinically using hands-free tenodesis testing
Core drill, overdrill, countersink, depth gauge, and place 2–3 lag screws, 1.2–1.7 mm
Return soft tissue sleeve into position, close wound with 5–0 monofilament, dress, and splint
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Options for ORIF include intra-osseous wiring, composite wiring, screw-only fixation, or screw and plate fixation.34,66,139,77,79,26,74,138,158 The familiarity of the surgeon with the specific technique is probably the most important factor in the selection of a method. Of 30 patients followed for 2.3 years after tension band wiring, 17 had a TAM of over 195 degrees and 13 had a TAM of between 130 and 195 degrees.138 More recently, attention has increasingly turned to the use of screw and plate technology (Figs 30-50 and 30-51). The relative bulkiness of plates at the phalangeal level compared with the metacarpals can result in the need for their removal even with initially excellent results. The results of internal fixation are intimately related to the associated injuries present. The gravest danger, however, occurs when the surgeon elects ORIF but is then unable to secure rigid fixation of the fracture. In this situation, the patient has been subjected to the “worst of both worlds,” and a poor outcome can be reliably predicted. 
Figure 30-50
In long oblique fractures of the shaft with shortening an exact reduction and stability sufficient to withstand early motion can be achieved through lag screw fixation only.
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Figure 30-51
More complex fractures of the shaft (A) can be well stabilized by (B) lateral plating.
 
Specific care should be taken to (C) contour the plate meticulously to fit the cortex and to place the hardware in (D) the true midlateral position.
Specific care should be taken to (C) contour the plate meticulously to fit the cortex and to place the hardware in (D) the true midlateral position.
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Figure 30-51
More complex fractures of the shaft (A) can be well stabilized by (B) lateral plating.
Specific care should be taken to (C) contour the plate meticulously to fit the cortex and to place the hardware in (D) the true midlateral position.
Specific care should be taken to (C) contour the plate meticulously to fit the cortex and to place the hardware in (D) the true midlateral position.
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Intra-Articular Fractures

Two intra-articular patterns are seen distally at the phalangeal head, unicondylar (partial articular fracture), or bicondylar (complete articular fracture). The condylar fragments are usually extremely small, can be fragile, and receive their blood supply from the attached collateral ligaments. Fixation of a single condyle is most rigid when accomplished with a compression screw placed transversely, entering near the collateral ligament origin (Fig. 30-52). This can be quite challenging technically, and the bone stock may only tolerate K-wire or composite wiring techniques (Fig. 30-53). Tri-plane fractures of the head of the proximal phalanx are well managed with 1.2-mm lag screws (Fig. 30-54).26 Complete articular fractures can be fixed with screws alone if one of the two condyles has an extended spike. If not, mini-condylar or locking plate fixation may be necessary to achieve excellent rigidity. Again, the bone stock may not tolerate the application of this device, and wiring techniques remain an alternative strategy. 
Figure 30-52
 
A: Unicondylar fractures of the head of P1 benefit from compression between the articular fragments through (B, C) lag screw fixation.
A: Unicondylar fractures of the head of P1 benefit from compression between the articular fragments through (B, C) lag screw fixation.
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Figure 30-52
A: Unicondylar fractures of the head of P1 benefit from compression between the articular fragments through (B, C) lag screw fixation.
A: Unicondylar fractures of the head of P1 benefit from compression between the articular fragments through (B, C) lag screw fixation.
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Figure 30-53
 
When a unicondylar fracture of the head of P1 has a proximal shaft extension on the smaller fragment, K-wire fixation in a diverging pattern can prevent migration of the fragment that would otherwise occur with a single smooth K-wire as the only fixation.
When a unicondylar fracture of the head of P1 has a proximal shaft extension on the smaller fragment, K-wire fixation in a diverging pattern can prevent migration of the fragment that would otherwise occur with a single smooth K-wire as the only fixation.
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Figure 30-53
When a unicondylar fracture of the head of P1 has a proximal shaft extension on the smaller fragment, K-wire fixation in a diverging pattern can prevent migration of the fragment that would otherwise occur with a single smooth K-wire as the only fixation.
When a unicondylar fracture of the head of P1 has a proximal shaft extension on the smaller fragment, K-wire fixation in a diverging pattern can prevent migration of the fragment that would otherwise occur with a single smooth K-wire as the only fixation.
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Figure 30-54
Tri-plane fractures of the proximal phalangeal head can be well stabilized by two small lag screws (1.2 to 1.5 mm).
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The final group of articular fractures is that seen at the lateral corner of the phalangeal base. The most direct fixation uses a volar approach and a single lag screw for fixation to achieve full motion by 3 weeks.144 Comminuted intra-articular fractures of the proximal phalangeal base can be stabilized by a small volar plate placed through the A1 pulley approach (Fig. 30-55).74 A specific subset of proximal phalangeal base fractures that are purely impactions by nature may be treated by supporting the impacted fragments with packed cancellous bone only; in one series of 10 patients followed for 32 months there was no secondary displacement and an average MP joint flexion of 88 degrees, and a PIP joint flexion of 95 degrees was achieved.158 
Figure 30-55
Comminuted volar shearing fractures of the base of P1 may require volar buttress plating for adequate stability to permit early rehabilitation.
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Postoperative Care.
Nonoperative management should restrict splinting to 3 weeks followed by AROM that can include adjacent digit strapping if necessary. Similarly, CRIF should allow for pin removal at 3 weeks, with AROM beginning no later than this time. If ORIF is chosen, AROM should begin within 72 hours of surgery and edema control should be foremost in the treatment plan using cohesive elastic bandages.58 AROM alone may be insufficient to counteract extensor lag at the joint distal to the site of fixation. Rapidly accelerating the extensor tendon concentrically without resistance best limits local adhesion formation (Fig. 30-56).75 These exercises can be supplemented with the use of electrical muscle stimulation during outpatient therapy sessions. Night splinting with the PIP joint in extension can be helpful but will not by itself overcome an extensor lag. 
Figure 30-56
 
Following (A) lag screw fixation of a shaft fracture in P1, (B) complete PIP joint flexion and (C) PIP joint hyperextension are achievable with an aggressive special therapy program of resisted zone IV extensor tendon preload followed by sudden release with follow-through.
Following (A) lag screw fixation of a shaft fracture in P1, (B) complete PIP joint flexion and (C) PIP joint hyperextension are achievable with an aggressive special therapy program of resisted zone IV extensor tendon preload followed by sudden release with follow-through.
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Figure 30-56
Following (A) lag screw fixation of a shaft fracture in P1, (B) complete PIP joint flexion and (C) PIP joint hyperextension are achievable with an aggressive special therapy program of resisted zone IV extensor tendon preload followed by sudden release with follow-through.
Following (A) lag screw fixation of a shaft fracture in P1, (B) complete PIP joint flexion and (C) PIP joint hyperextension are achievable with an aggressive special therapy program of resisted zone IV extensor tendon preload followed by sudden release with follow-through.
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Potential Pitfalls and Preventative Measures.
Longitudinal wires drilled past the head of P1 into the PIP joint and then later withdrawn may migrate back into the PIP joint during rehabilitation and cause hyaline cartilage damage to the base of P2. During initial placement, the wire should be drilled up to but not into the subchondral bone and then impacted. Pins should not be placed through tendons. All cases, closed or open, should be carefully checked clinically for angulation and rotation using a no-touch technique that does not distort the judgment of alignment. Open surgery should be performed strictly laterally with no dorsal incisions, no zone IV extensor splitting, and especially no dorsal plates. When approaching laterally, be careful not to transect the dorsal nerve branch that passes obliquely from the proper digital nerve. Drilling at too high a speed will create a larger hole than the diameter of the bit because of “whip” and the screw will lose purchase. Over-tightening small titanium screws can shear off the heads, but rarely if a fingertip hold is used on the screwdriver. If the plate is not contoured correctly, as it is tightened down, the plate will induce a malunion (Table 30-10). 
 
Table 30-10
Potential Pitfalls and Preventative Measures—P1 Fractures
Pitfall Prevention
Distal pin migration into PIP joint Tap rather than drill up to subchondral plate in head of P1 without penetrating
Tendon tethering by pins Only place pins from entry points adjacent to but not through tendons; remove by 3 weeks, 4 weeks at the absolute latest
Malrotation leading to malunion Careful clinical check of rotation; two axial pins for transverse fractures distal to metaphysis
Zone IV extensor adhesions Midaxial surgery only, no dorsal incisions, no incisions through the zone IV extensor, no dorsally placed plates
Neuroma of dorsal digital nerve branch Mobilize dorsal oblique branch out of operative field
Overdrilling the far hole on lag screws leading to poor fixation Use low speed to avoid distal “whipping” of the small drill bit; larger size “rescue” screws
Shearing the head off small titanium screws Use only fingertip tightening, no key pinch hold on the screwdriver
Inducing malunion with the plate Take off and recontour the plate as many times as needed so that, when tightened down fully, it does not force the bone into malalignment or malrotation
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Author’s Preferred Treatment (Fig. 30-57)

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Figure 30-57
Proximal phalanx (P1) fractures.
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Closed Reduction and Internal Fixation
 

CRIF is my preferred treatment for all isolated, closed transverse, and short oblique fractures of the proximal phalanx (Fig. 30-58). Longitudinal pinning with two K-wires passing through the metacarpal head with the MP joint flexed 80 to 90 degrees has yielded reliable results.77 In larger patients, two 0.045-inch K-wires can be fitted into the medullary canal. In smaller patients, one 0.045-inch and one 0.035-inch wire may be more compatible. When rotational interlock is felt between the fragments, one wire can be used. The wires are placed one each on either side of the thick central extensor tendon dorsal to the MP joint, and may be placed just proximal to the sagittal band fibers. The wires are then passed through the base fragment, across the fracture site, and down the distal shaft of the phalanx to the head. Closed pinning is also a valuable technique for nondisplaced fractures at the head of P1. Both a transverse pin connecting the two condyles as well as an oblique pin from the condyle to the opposite diaphyseal cortex should be used for a unicondylar fracture. For bicondylar fractures, two oblique pins are needed. The oblique pins are best cut for retrieval proximally rather than distally as their passage through the periarticular soft tissues will interfere with PIP joint motion. Closed pinning also represents a reasonable treatment option for nondisplaced long oblique or spiral fractures that are suspected of subsequent displacement when subjected to the stress of motion rehabilitation. However, practically I have not found this fracture pattern to exist. I see either truly nondisplaced fractures that I expect to remain stable and treat nonoperatively or displaced long oblique and spiral fractures that I prefer to treat with open reduction.

 
Figure 30-58
 
Transverse P1 fractures without comminution should achieve sufficient interfragmentary stability to have axial rotational control with a single wire alone that targets the (A) intercondylar notch and going (B) all the way to the subchondral bone.
Transverse P1 fractures without comminution should achieve sufficient interfragmentary stability to have axial rotational control with a single wire alone that targets the (A) intercondylar notch and going (B) all the way to the subchondral bone.
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Figure 30-58
Transverse P1 fractures without comminution should achieve sufficient interfragmentary stability to have axial rotational control with a single wire alone that targets the (A) intercondylar notch and going (B) all the way to the subchondral bone.
Transverse P1 fractures without comminution should achieve sufficient interfragmentary stability to have axial rotational control with a single wire alone that targets the (A) intercondylar notch and going (B) all the way to the subchondral bone.
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Open Reduction and Internal Fixation with Lag Screws
 

This is my preferred treatment for long oblique and spiral fractures of the shaft and displaced partial articular fractures (Fig. 30-59). I have found it difficult to correct all the shortening and rotation of long oblique and spiral fractures by closed means alone. There is a natural trade-off between the undeniable added surgical trauma of an open approach and the benefits of an anatomically precise reduction. When lag screws alone are used for fixation, full motion rehabilitation can begin immediately.79,75 This is not the case with K-wires that tether soft tissues, limiting motion, and risking pin tract infection. Performing the open fixation gently and precisely to minimize soft tissue trauma is more easily described than executed. I prefer to operate on closed fractures around postinjury day 3 to 5 when even adult periosteum will thicken dramatically in response to injury and can be surgically manipulated as a tissue flap. A true midaxial incision is in the neutral tension lines of the skin and brings the approach down to the volar leading edge of the intrinsic wing tendon. One of the most important principles in open fixation of a P1 fracture is not to create planes of surgical dissection either superficial or deep to the zone IV extensor tendon. The only dissection that should occur at the subcutaneous level is to identify dorsal cutaneous nerve branches passing obliquely from the proper digital nerves and to mobilize them effectively to avoid neuromas. Other than this, the approach should create a single tissue flap from skin through periosteum to bone.79 A sharp blade is needed to carefully preserve the periosteum for later repair using fine monofilament resorbable sutures. This creates an additional gliding layer of protection for the extensor mechanism. A fine-tipped curette must be used to clear the fracture interface of all clot and soft tissue or a truly anatomic interdigitated reduction will not be possible. In a simple two-fragment diaphyseal fracture, there will be inherent stability between the bone edges once the fracture has been reduced. The role of internal fixation is then to exploit this inherent stability by further compressing the fracture line, which is optimized by interfragmentary lag screws. Although provisional fixation of the fracture with K-wires has been recommended by others, I have found that an absolutely perfect reduction is not well maintained by smooth wires, which invariably allow the reduction to slip a little. This ensures that the drill path will not be exactly in the desired location and that final placement of the screw or plate will thus be imperfect. I prefer to hold the reduction manually with either a bone clamp specialized for the short tubular bones of the hand or with Brown‑Adson forceps. After reduction and provisional stabilization, the steps are core drilling followed by countersinking the near bone surface. Countersinking not only recesses the screw head but also distributes the force of compression, lessening the chance of propagating a new fracture line. Measuring for screw length is done next, and the time for the scrub technician to procure the correct screw can be used to drill the gliding hole. Self-tapping screws are a little difficult to start into bone as some axial load is necessary to get them to bite, but application of this load off the true axis will toggle the screw. A fine touch must be learned over the course of many cases using these implants. Screws are tightened with a “chuck” pinch on the screwdriver using three fingers, not with the more forceful key pinch that may shear the head off the shaft of the screw. The rules for selecting screw-only fixation include fracture length that is at least two times the bone diameter, and fragment width that is at least three times the screw diameter. Adherence to strict principles is mandatory; multiple drill bit passes are not well tolerated by the phalanx. Screws of 1.2- to 1.5-mm diameters are appropriate for P1. Biomechanically, it is desirable to have at least one screw placed perpendicular to the neutral axis of the bone. The remaining screws should be perpendicular to the fracture plane. In a spiral fracture, one screw can satisfy both of these requirements simultaneously and is termed the “ideal” screw. In an oblique fracture this will not be the case.

 
Figure 30-59
Partial articular fractures that can be rendered stable by interfragmentary compression are excellent candidates for lag screw fixation.
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Plates at the Phalangeal Level
 

Plates at the phalangeal level are not desirable because of their bulk and propensity for tendon adherence, and I avoid using them whenever possible. This is my treatment of choice for fractures with comminution and bone loss and complete articular fractures of the phalangeal head that are unstable. Since the biomechanics of P1 fractures create an apex palmar sagittal plane deformity, the plate would (impossibly so) have to be applied to the volar surface of the bone to have its optimum tension band effect. Lateral placement is then the next most desirable option, and this corresponds well to the surgical access that is least harmful to the soft tissues.79 A midaxial incision is carried volar to the margin of the extensor mechanism, straight through periosteum, and the entire soft tissue sleeve is elevated as a single unit, avoiding any dissection of planes surrounding the extensor tendon. When plates are used, one should attempt to place screws as perpendicular to the surface of the plate as possible (Fig. 30-60). The heads of obliquely placed screws have a prominent edge. Plates should also be painstakingly contoured to ensure both the lowest profile as well as proper biomechanical function (preload, dynamic compression, buttress effect). One must not hesitate to remove a plate and recontour it after the first two screws have been placed if it is clear that the shape is not correct. Application of an incorrectly contoured plate guarantees an imperfect fracture reduction. A common error is with plates ending near the metaphyseal flare that must have a small bend at the last hole to accommodate the curvature of the bone at this level. Small-size locking plates represent a tremendous advantage over the only previously available implant that offered fixed angle stability, the minicondylar plate (Fig. 30-61). The minicondylar plate could not be fully contoured to the bone surface before placing the blade; a locking plate can. If more than 50% cross-sectional area of the bone is comminuted or lost, bone graft may be required.

 
Figure 30-60
Plate fixation in P1 must be contoured meticulously to restore the normal anatomic shape of the bone.
 
The condylar blade plate can also be used at the metaphyseal base of a proximal phalanx. An oblique screw is often advantageous to achieve an extra point of compression in the metaphyseal fragment.
The condylar blade plate can also be used at the metaphyseal base of a proximal phalanx. An oblique screw is often advantageous to achieve an extra point of compression in the metaphyseal fragment.
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Figure 30-60
Plate fixation in P1 must be contoured meticulously to restore the normal anatomic shape of the bone.
The condylar blade plate can also be used at the metaphyseal base of a proximal phalanx. An oblique screw is often advantageous to achieve an extra point of compression in the metaphyseal fragment.
The condylar blade plate can also be used at the metaphyseal base of a proximal phalanx. An oblique screw is often advantageous to achieve an extra point of compression in the metaphyseal fragment.
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Figure 30-61
Small locking plates can span zones of comminution and obviate the need to use the fixed angle blade plate.
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Introduction to Metacarpophalangeal (MP) Joint Dislocations

Dorsal MP joint dislocations are the most common. Simple dislocations are reducible and present with a hyperextension posture. They are really subluxations, as some contact remains between the base of P1 and the metacarpal head. The volar plate stays volar or distal to the metacarpal head. Reduction should be achieved with simple flexion of the joint; excessive longitudinal traction on the finger should be avoided. Longitudinal traction can convert a simple into a complex dislocation. A complex MP dislocation is, by definition, irreducible, most often because of volar plate interposition (Fig. 30-62). Complex dislocations occur most frequently in the index finger. A pathognomonic radiographic sign of complex dislocation is the appearance of a sesamoid in the joint space (Fig. 30-63). Concomitant injuries include small chip fractures on the dorsum of the metacarpal head that have been sheared off in complex dislocations by the volar base of P1.69,83 Other difficult fractures to detect are bony collateral ligament avulsions. 
Figure 30-62
The typical complex dorsal dislocation of the MP joint presents with complete overriding of the phalanx on the metacarpal.
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Note the sesamoid interposed in the joint space.
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Figure 30-63
Metacarpophalangeal joint dislocation in the thumb, like the fingers, is typically dorsal.
Note the sesamoid interposed in the joint space.
Note the sesamoid interposed in the joint space.
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Most dorsal dislocations will be stable following reduction and do not need surgical repair of the ligaments or volar plate. Volar dislocations are rare but particularly unstable. Volar dislocations risk late instability and should have the ligaments repaired.118 Obstructions to reducing volar dislocations include the volar plate, collateral ligament, and dorsal capsule. Irreducible thumb volar dislocations have been reported to involve the EPL, extensor pollicis brevis (EPB), flexor pollicis longus, and trapping of the radial condyle of the metacarpal in a rent dorsal to the accessory collateral–volar plate complex.83 
Small fracture fragments at the collateral insertions (base of P1 or metacarpal head) need special consideration as such injuries share the features of ligament instability and the consequences of an intra-articular fracture.144,141,145 Isolated collateral ligament injuries are more common on the radial aspect of the small finger followed by the index finger. A differential diagnosis to consider with posttraumatic swelling at the MP joint level is rupture of the sagittal bands (confirmed by visible or palpable ulnar subluxation of the zone V extensor tendon), which requires protection in extension for 4 weeks. A rare variant injury to the MP joint is a dorsal capsular tear (Boxer’s knuckle) that can prove persistently symptomatic. In a series of 16 patients that included extensor tendon dislocation in 7, surgical closure of the rent found in the dorsal capsule or extensor hood was reported to be successful in all cases.9 
Complete rupture of the ulnar collateral ligament (UCL) of the thumb MP joint is a common injury that less frequently may accompany a full MP joint dislocation (Fig. 30-63). Circumferential palpation of the MP joint can often localize pain to the UCL, RCL, volar plate, or combinations of these. Following joint injection with local anesthetic, any instability can be revealed by stress testing in full extension and 30 degrees of flexion. Flexing the joint relaxes the volar plate so that only the collateral ligament resists examination force applied in the coronal plane. In full extension, an intact volar plate may mask a ruptured proper collateral ligament, yielding a false negative conclusion of stability. (Fig. 30-64A). If clinical uncertainty remains, stress radiographs may also be performed (Fig. 30-64B). A consistent role has not yet been found for MRI in the diagnosis of the Stener lesion (a distally ruptured UCL blocked from healing by the interposed adductor aponeurosis).82 In a series of 24 patients, a palpable tender mass on the ulnar side of the MP joint was used as the sole diagnostic criterion for the Stener lesion. Operative treatment was performed for those felt to have the lesion and nonoperative management for those who did not, resulting in only a single case of long-term instability.1 
Figure 30-64
 
A: Clinical stress testing of the ulnar collateral ligament in 30 degrees of flexion prevents reaching a false negative conclusion when an intact volar plate obscures the instability of a complete proper ulnar collateral ligament rupture. B: Radiographic stress testing is also useful when there is clinical uncertainty.
A: Clinical stress testing of the ulnar collateral ligament in 30 degrees of flexion prevents reaching a false negative conclusion when an intact volar plate obscures the instability of a complete proper ulnar collateral ligament rupture. B: Radiographic stress testing is also useful when there is clinical uncertainty.
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Figure 30-64
A: Clinical stress testing of the ulnar collateral ligament in 30 degrees of flexion prevents reaching a false negative conclusion when an intact volar plate obscures the instability of a complete proper ulnar collateral ligament rupture. B: Radiographic stress testing is also useful when there is clinical uncertainty.
A: Clinical stress testing of the ulnar collateral ligament in 30 degrees of flexion prevents reaching a false negative conclusion when an intact volar plate obscures the instability of a complete proper ulnar collateral ligament rupture. B: Radiographic stress testing is also useful when there is clinical uncertainty.
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Pathoanatomy and Applied Anatomy Relating to Metacarpophalangeal (MP) Joint Dislocations

The anatomy of the MP joint is like the same three-sided box previously presented for the PIP joint, composed of the proper collateral ligaments, the accessory collateral ligaments, and the volar plate. The radial and ulnar proper collateral ligaments are the primary stabilizers to motion in all planes including distraction, dorsopalmar translation, abduction‑adduction, and supination‑pronation. The accessory collateral ligaments supplement adduction‑abduction stability. The volar plates are connected to each other by the deep transverse intermetacarpal ligament. The MP collateral ligaments have an origin dorsal to the center axis of joint rotation. This feature combines with two others (a greater width of the metacarpal head volarly and a greater distance from the center of rotation to the volar articular surface than the distal articular surface) to maximize tension in the true collateral portion of the ligament when the joint is in full flexion. Consequently, stress testing to determine the presence of instability must be performed in full flexion. 
Access for open reduction of complex dislocations is a topic of great controversy. Central MP joints can be approached either dorsally or volarly. Although the volar plate is the most commonly noted structure in the prevention of reduction, the flexor tendons, lumbricals, deep transverse intermetacarpal ligaments, juncturae tendinae, and dorsal capsule have all been implicated.132 In a series of 10 operatively treated ligament ruptures, most were distal with the ligament occasionally trapped between the intrinsic tendon and the sagittal band, including 2 associated dorsal interosseous ruptures at the phalangeal insertion.39 
The thumb MP joint, in addition to its primary plane of flexion and extension, allows abduction‑adduction and a slight amount of rotation (pronation with flexion). The range of flexion and extension has a wide natural variation that may be related to the flatness of the metacarpal head and may also play a role in predisposition to injury for those with less motion. With a one-sided collateral ligament injury, the phalanx tends to subluxate volarly in a rotatory fashion, pivoting around the opposite intact collateral ligament. The UCL may have a two-level injury consisting of a fracture of the ulnar base of P1 with the ligament also rupturing off the fracture fragment.63 Of particular importance is the proximal edge of the adductor aponeurosis that forms the anatomic basis of the Stener lesion. The torn UCL stump comes to lie dorsal to the aponeurosis and is thus prevented from healing to its anatomic insertion on the volar, ulnar base of the proximal phalanx. The true incidence of the Stener lesion remains unknown because of widely disparate reports. The abductor pollicis brevis also sends fibers to the extensor mechanism and the RCL can be obstructed from reaching the base of P1 to heal correctly even though the precise pattern that constitutes a classic Stener lesion does not exist on the radial side. RCL injuries have been found to occur at the phalangeal insertion in 13 of 38 cases and at the metacarpal origin in 25 of 38.31 

Metacarpophalangeal (MP) Joint Dislocations Treatment Options

Nonoperative Management—Fingers

For reducible dorsal dislocations and collateral ligament injuries, nonoperative management is the treatment of choice. Collateral ligament injuries should be immobilized in incomplete flexion (50 degrees) for 3 weeks followed by AROM while the digit is strapped to an adjacent digit to resist lateral deviation stress. Even with fracture fragments constituting up to 25% of the width of the phalangeal base, early active mobilization using side strap protection led to normal motion and grip strength in six of seven patients with a mean DASH score of 3.1.141 Dorsal dislocations will normally prove stable during early AROM. Only in an exceptional case would the use of extension block splinting of 20 degrees or so for 2 to 3 weeks be required. In a high-demand patient, the RCL of the index MP joint should be considered for operative repair. 

Nonoperative Management—Thumb

Nonoperative management is the mainstay of treatment for thumb MP joint injuries. Only the complete UCL injury with a Stener lesion and volar dislocations require more aggressive treatment. The standard treatment consists of 4 weeks of static MP joint immobilization with the IP joint left free. Management in the presence of a fracture at the ulnar base of P1 is more controversial. Nine patients with less than 2-mm displacement of such a fragment treated nonoperatively all had chronic pain with pinch strength rated at 36% of normal. Following operative treatment, pinch improved to 89% of normal with symptom resolution.42 Conversely, 28 patients with ulnar base fractures but with a joint clinically assessed as stable to stress testing were managed nonoperatively resulting in equivalent grip and pinch strengths to the contralateral side, and 93% were pain-free despite a 60% rate of fibrous union.149 RCL disruptions and pure dorsal dislocations can be successfully managed by a 4-week period of MP joint immobilization. 

Open Reduction—Fingers

Volar dislocations, complex dorsal dislocations, and collateral ligament disruptions associated with large bone fragments should be treated with open reduction and repair (Fig. 30-65). RCL injuries repaired late risk a higher incidence of pinch weakness and should be attended to promptly. Open repair or reconstruction with a free tendon graft may also be required in chronic cases with persistent symptoms following initial nonoperative management. Of 33 patients with MP collateral ligament avulsion fractures from the base of the proximal phalanx, the 8 that were treated nonoperatively initially all went on to symptomatic nonunion requiring subsequent surgery.144 In a similar series of 19 patients with the avulsion occurring at the metacarpal head, successful results occurred in the 11 displaced fragments internally fixed through a dorsal approach, but three of seven initially nondisplaced fragments went on to symptomatic nonunion requiring surgery.145 Volar MP dislocations should have repair of the collateral ligaments and volar plate to prevent late instability. Either a dorsal or a volar approach is acceptable, and the one that provides access to the major pathology should be chosen based on the individual patient’s preoperative findings. Dorsally, a midline longitudinal incision provides good access to manage any associated osteochondral fractures. One may have to split the volar plate longitudinally and draw it around the sides of the metacarpal head to accomplish a reduction. The volar approach avoids splitting the volar plate but risks injury to digital nerves which are tented over the deformity and lying directly under the dermis. With a volar approach, the volar plate can be pulled back out of the joint and reduced without splitting it. 
Figure 30-65
Collateral ligament injuries that (A) avulse a large bone fragment at the metacarpal head can be stabilized by direct bone fixation (B).
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The duration of immobilization should be in direct proportion to the surgeon’s assessment of instability following reduction. Whereas most patients may begin AROM immediately, those injuries that demonstrate an extra degree of instability during the postreduction assessment should be immobilized in partial flexion for 3 weeks. Whether simple or complex, the dislocations should be immobilized in only partial (50-degree) flexion to allow ligament healing under appropriate tension. After 3 weeks, AROM is progressed until 6 weeks, when full passive motion including hyperextension is allowed. 

Open Reduction—Thumb

Surgical management of thumb MP joint injuries is largely limited to UCL disruptions with a Stener lesion and volar or irreducible MP dislocations. Determining the presence of a Stener lesion on the ulnar side of the joint remains an inexact science; therefore, open management can be argued to be the treatment of choice for all widely unstable ulnar-sided disruptions. Pure ligamentous midsubstance ruptures can be repaired by direct suture. The usual site of disruption is distally at the phalangeal insertion where bone anchors can be used for ligament reinsertion. Over-tensioning should be avoided as insertion sites malpositioned volarly or distally on the proximal phalanx will cause loss of motion.12 With bony avulsion fragments, screw fixation, tension band wiring, intraosseous wiring, or fragment excision with ligament anchorage may all be used at the surgeon’s discretion. 

Ligament Reconstruction

Cases presenting late with residual instability (after degeneration of the ligament substance has occurred) may require reconstructive methods.54 Twenty-six patients with tendon reconstruction for the thumb UCL followed for 4.5 years had 85% normal ROM and key pinch strength equal to the opposite side at 9.07 kg (20 lbs).64 High-grade RCL tears that are widely unstable may benefit from direct soft tissue advancement and repair with 38 patients at 10-month follow-up achieving 92% of normal pinch; 87% were symptom free.31 

Associated Osteochondral Injuries to the Metacarpal Head or a Base of P1 Fracture

Careful inspection of the dorsal aspect of the metacarpal head should identify any chondral or osteochondral fractures. There are three strategies to manage these fractures. If the fragment is small and extremely unstable, it should be excised. If the fragment has a large subchondral bone base, it can be fixed with a countersunk screw. If fixation is not possible but the fragment can be stably trapped in its bed by the congruent opposing joint surface, it can be further restrained with fine resorbable sutures. For collateral ligament injuries associated with bone fragments, there are two options. If the bone fragment is both large and solid enough to receive definitive fixation, ORIF may be performed with a tension band wire or lag screw. Twenty-five patients with base of P1 ligament avulsion injuries were reported to have recovered full motion by 3 weeks following volar approach single lag screw fixation.144 If the bone fragment is too small or too comminuted, the bone can be excised and the end of the ligament reinserted to the cancellous bed of either the metacarpal head or the base of the proximal phalanx. This can be accomplished with a mini-bone anchor or by transosseous suture. Surgery may not always be necessary to achieve grip and key pinch strength in avulsion fractures of the lateral base of P1. For example, 27 of 30 nonoperatively treated patients achieved clinical stability despite a 25% incidence of radiographic nonunion, but with only 19 of 30 reporting no pain.103 
Potential Pitfalls and Preventative Measures.
Hypersensitivity and small cutaneous neuroma formation are often considered the banes of hand surgery. Although never totally avoidable, these unwanted complications can be minimized by a thorough knowledge of the branching patterns of the cutaneous nerves and meticulous attention to detail at the time of surgery. The dorsal digital nerve along the ulnar side of the thumb MP joint is at high risk of injury. It should be mobilized dorsally for the procedure and checked each time before drilling. Perhaps the greatest risk is during closure of the adductor aponeurosis along the margin of the EPL tendon. It is quite easy to simply capture the nerve branch with one of these sutures if it is not visualized to be clear with each suture pass. 
First web space contracture can easily occur following immobilization of any hand injury and especially when the injury is located in the first web space. Since the first web is located at the level of the MP joint, all positioning forces designed to prevent contracture act on the proximal phalanx and across the MP joint. The value of pinning the thumb MP joint with a 0.045-inch K-wire during the 4-week period of immobilization in a thumb spica splint is that the splint may be appropriately molded to abduct the thumb and avoid web space contracture (Table 30-11). 
Table 30-11
Potential Pitfalls and Preventative Measures—MP Joint Dislocations
Pitfall Prevention
Converting a simple MP dorsal finger dislocation to complex No longitudinal traction, reduce by accentuating angular deformity, and sliding the base of the proximal phalanx back into place over the contour of the metacarpal head
Injury to proper digital nerve during open reduction of finger complex dislocation, particularly radial digital nerve to index Once through dermis, must find and protect nerve, realizing pathoanatomy displaces the nerve from its normal position
Injury to dorsal digital nerve during closure of adductor aponeurosis after treating Stener lesion of thumb ulnar collateral Must visualize dorsal digital nerve branch during each pass of the needle to close the aponeurosis
First web space contracture after ulnar collateral repair or reconstruction of thumb Pin MP joint to support the radially directed force on proximal phalanx necessary to prevent first web contracture
Permanent loss of motion in thumb MP joint Ensure anatomic targeting of anchor for repair and insertion points for graft. Typical error is too dorsal a placement on the proximal phalanx
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Author’s Preferred Treatment (Fig. 30-66)

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Figure 30-66
MP joint dislocations.
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Careful review of the published literature regarding both finger and thumb MP joint ligament injuries indicates that the clinical assessment of instability is paramount in planning subsequent treatment. Local anesthetic injection into the MP joint allows vigorous stress testing of the ligament to be performed without fighting the patient or causing undue pain. Testing in both extension and flexion reveals the absolute value of deviation as well as the discrepancy compared with the uninjured side. The feel at the end point is also a significant piece of information. A greater than 15-degree difference side to side and a soft end point are stronger indicators of complete ligament disruption than the absolute value of the joint angle when stressed. The integrity of the volar plate should be assessed along with the appearance of rotatory subluxation. I use a combination of the clinical degree of instability and the presence of a palpable Stener lesion to choose direct repair of the thumb UCL, the index RCL, and large bony avulsion injuries. The management of complete RCL ruptures is currently in a state of transition in the field of hand surgery. Subluxation into pronation by the proximal phalanx pivoting on the intact UCL has led to increasing interest in early direct repairs. When I can appreciate rotatory subluxation on the examination, I now prefer RCL repair. Volar dislocations risk late instability if not surgically repaired. When the patient presents late following a complete ligament rupture, direct repair is rarely possible. The simplest reconstruction is then to create a proximally based flap of retracted ligament and advance it back to the anatomic insertion at the volar base of the proximal phalanx. This tissue is not always of sufficient quality. When that is the case, a free tendon graft (plantaris or palmaris longus) can be placed through drill holes to reconstruct the ligament. With appropriate rehabilitation, these patients can still achieve near-normal motion.

 
Open Reduction of Finger MP Dislocations
 

The border digits, the index and small fingers, can easily be approached with a midaxial incision that offers all the advantages that are proposed for both volar and dorsal approaches. Cartilage injuries on the metacarpal head can be well visualized, the digital nerves are easily protected, and the volar plate can be guided back into its correct position. For the long and ring fingers I prefer a dorsal transverse incision made at the level of the distal portion of the metacarpal head. This level can reliably be found at the dorsal apex of the sloping V shape of the web commissure. The sagittal bands do not need to be divided but rather they can be retracted distally to access the joint. The volar plate can be reduced without dividing it through a combination of wrist flexion to relax the extrinsic flexor tendons and MP hyperextension. A Freer elevator then guides the volar plate to the distal surface of the metacarpal head before attempting to reduce the joint itself. For the RCL of the index, an absorbable 1.3-mm bone anchor can be used for repair of insertional ruptures and a 4–0 absorbable monofilament suture for midsubstance ruptures. Pinning of the joint is not necessary in fingers as adjacent digit strapping provides enough restraint to excessive coronal plane deviation to protect the healing repair. The exception to this is the rare high-energy volar dislocation that is so unstable as to require 3 weeks of transarticular pin fixation.

 
Thumb MP Collateral Ligament Repair
 

The operative technique consists of a chevron incision over the ulnar aspect of the MP joint ensuring adequate volar exposure at the base of the proximal phalanx. Care must be taken with the superficial branches of the radial nerve to avoid neuroma formation. There is usually one large branch passing through the surgical field that is best mobilized dorsally. An incision in the adductor aponeurosis is made just ulnar to the EPL tendon with a cuff being left for repair. Reflection of this layer reveals the joint capsule and torn collateral ligament. Whereas all patterns of disruption have been reported, the most frequent is that of distal avulsion from the base of the proximal phalanx. Often there is a transverse rent in the dorsal capsule and evidence of volar plate injury as well. Direct repair is easiest with an absorbable 1.3-mm bone anchor placed at the true insertion site on the volar lateral tubercle to restore normal anatomy and reduce the rotatory subluxation of the joint. The repair may include a suture through the volar plate margin to re-create the “critical corner.” The joint is pinned with a 0.045-inch K-wire before tying the anchor sutures to prevent inadvertent radial deviation and early rupture of the repair during the first 4 weeks postoperatively. A large bone fragment carrying the point of ligament insertion can be stabilized with one or two lag screws (Fig. 30-67). The IP joint should be left free for motion at all times. Motion at the MP joint can begin in a protected fashion at 4 weeks following pin removal and then in an unprotected fashion by 6 weeks. Power pinch activities that stress the ligament in the coronal plane of the thumb should be avoided for up to 3 months after repair.

 
Figure 30-67
 
When a substantial bone fragment accompanies an ulnar collateral ligament injury to the MP joint, lag screw compression provides excellent stability through direct bone healing, provided that there is not a multilevel injury of the ligament separating it from the bone fragment as well.
When a substantial bone fragment accompanies an ulnar collateral ligament injury to the MP joint, lag screw compression provides excellent stability through direct bone healing, provided that there is not a multilevel injury of the ligament separating it from the bone fragment as well.
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Figure 30-67
When a substantial bone fragment accompanies an ulnar collateral ligament injury to the MP joint, lag screw compression provides excellent stability through direct bone healing, provided that there is not a multilevel injury of the ligament separating it from the bone fragment as well.
When a substantial bone fragment accompanies an ulnar collateral ligament injury to the MP joint, lag screw compression provides excellent stability through direct bone healing, provided that there is not a multilevel injury of the ligament separating it from the bone fragment as well.
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Free Tendon Graft Reconstruction of the Thumb UCL
 

The approach to the ulnar base of the thumb is the same as for simple repair. The correct anatomic sites of ligament origin at the metacarpal head and insertion at the phalangeal base should be easily discernable, having remnants of the original ligament fibers. Drill tunnels are made from each of these points obliquely directed away from the joint with a 3-mm bit. Free tendon graft may be harvested by conventional methods from either the palmaris longus (within the operative field) or the plantaris (a more appropriate size match). The tendon is passed through each of the drill holes, tensioned, and secured with 3-mm interference screws (Table 30-12).

 
Table 30-12
Surgical Steps—Free Tendon Graft Reconstruction of Thumb UCL
Midaxial ulnar approach, staying out of web space, and protecting dorsal digital nerve
Clear old scar and ruptured ligament fibers from anatomic points of UCL attachment
Drill oblique 3-mm tunnels from point of attachment out to radial cortex
Draw free tendon graft (palmaris or other) into tunnel by traction suture on straight Keith needle
Fix graft into place with 3-mm interference screw, pull back to test fixation
Repeat insertion of free graft into other tunnel, tension graft, and fix with interference screw
Check tension on graft and adjust fixation if needed, check range of motion
Check dorsal nerve branch, close wound with absorbable monofilament, dress, and splint
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Introduction to Metacarpal Fractures

Fracture patterns may be broken down into those of the metacarpal head, neck, and shaft. Intra-articular fractures of the metacarpal base are covered in the next section on CMC joint fracture dislocations. Metacarpal head fractures present in a variety of patterns requiring different treatment strategies aimed at restoring a smooth congruent joint surface. Transverse metacarpal neck and shaft fractures will typically demonstrate apex dorsal angulation. The normal anatomic neck to shaft angle of 15 degrees should be recalled when assessing the amount of angulation in subcapital fractures. Radiographic assessment of apex dorsal angulation has a high interobserver and intraobserver variability.107 Pseudoclawing is a term used to describe a dynamic imbalance manifested as a hyperextension deformity of the MP joint and a flexion deformity of the PIP joint (Fig. 30-68). This occurs as a compensatory response to the apex dorsal angulation of the metacarpal fracture (usually at the neck) and represents a clinical indication for correcting the fracture angulation. Oblique and spiral fractures tend to shorten and rotate more than angulate (Fig. 30-69). As with all hand fractures, evaluation of rotation remains one of the most critical assessments to avoid a functionally disabling malunion. Ten degrees of malrotation (which risks as much as 2 cm of overlap at the digital tip) should represent the upper tolerable limit. The problem of overlapping bone shadows has led to the development of a number of specialized radiographic views (Fig. 30-70). The Brewerton and Mehara views may show otherwise occult fractures at the metacarpal bases. The reverse oblique projection allows a more accurate estimation of angulation at the second metacarpal neck. The skyline view may show vertical impaction fractures of the metacarpal head not appreciable on any other projection. 
Figure 30-68
 
Pseudoclawing is an imbalance of compensatory MP joint hyperextension and PIP joint flexion that occurs on attempted digital extension in proportion to the degree of apex dorsal angulation at the metacarpal fracture site and represents one indication for surgery.
Pseudoclawing is an imbalance of compensatory MP joint hyperextension and PIP joint flexion that occurs on attempted digital extension in proportion to the degree of apex dorsal angulation at the metacarpal fracture site and represents one indication for surgery.
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Figure 30-68
Pseudoclawing is an imbalance of compensatory MP joint hyperextension and PIP joint flexion that occurs on attempted digital extension in proportion to the degree of apex dorsal angulation at the metacarpal fracture site and represents one indication for surgery.
Pseudoclawing is an imbalance of compensatory MP joint hyperextension and PIP joint flexion that occurs on attempted digital extension in proportion to the degree of apex dorsal angulation at the metacarpal fracture site and represents one indication for surgery.
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Figure 30-69
Long oblique and spiral fractures of the metacarpal shaft tend to shorten and rotate more than angulate.
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Figure 30-70
 
Specialized radiographic views may help to define injury patterns in the metacarpal including (A) the Brewerton view for the metacarpal bases, (B) the Mehara view for the index CMC relationships, (C) the reverse oblique view for angulation in the index metacarpal neck, and (D) the skyline view for vertical impaction fractures of the metacarpal head.
Specialized radiographic views may help to define injury patterns in the metacarpal including (A) the Brewerton view for the metacarpal bases, (B) the Mehara view for the index CMC relationships, (C) the reverse oblique view for angulation in the index metacarpal neck, and (D) the skyline view for vertical impaction fractures of the metacarpal head.
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Figure 30-70
Specialized radiographic views may help to define injury patterns in the metacarpal including (A) the Brewerton view for the metacarpal bases, (B) the Mehara view for the index CMC relationships, (C) the reverse oblique view for angulation in the index metacarpal neck, and (D) the skyline view for vertical impaction fractures of the metacarpal head.
Specialized radiographic views may help to define injury patterns in the metacarpal including (A) the Brewerton view for the metacarpal bases, (B) the Mehara view for the index CMC relationships, (C) the reverse oblique view for angulation in the index metacarpal neck, and (D) the skyline view for vertical impaction fractures of the metacarpal head.
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Pathoanatomy and Applied Anatomy Relating to Metacarpal Fractures

The metacarpals are the key skeletal elements participating in the formation of the three arches of the hand. There are two transverse arches that exist at the CMC and MP joint levels. The metacarpals themselves are longitudinally arched with a fairly broad convex dorsal surface. Intramedullary geometry is highly variable but with a consistently 20% thicker volar cortex. Surgical access to the metacarpals is easily achieved through incisions placed over the intermetacarpal valleys and curved distally to avoid entering the digital web commissures. 
The metacarpals are held tightly bound to each other by strong interosseous ligaments at their bases and by the deep transverse intermetacarpal ligaments distally. These connections help to maintain the transverse arches of the hand, but flattening can occur with multiple metacarpal fractures or crushing injuries. Shortening of individual metacarpal fractures is limited by these same ligaments (more effectively for the central metacarpals than for the border metacarpals). For each 2 mm of metacarpal shortening, 7 degrees of extensor lag can be expected.157 One of the weakest points in the metacarpal is the volar aspect of the neck, where comminution is often present. In the sagittal plane, the primary deforming forces are the intrinsic muscles, which can be counteracted through MP joint flexion, an important component of the reduction maneuver for metacarpal fractures. Correction of apex dorsal angulation and rotational control is achieved indirectly by grasping the finger to exert control over the distal metacarpal fragment. Flexion of the PIP joint for reduction, as has been long recommended, is an unnecessary maneuver that actually encumbers the reduction process by tensioning the intrinsics. 

Metacarpal Fracture Treatment Options

Nonoperative Management

Many metacarpal neck and shaft fractures can be treated nonoperatively. Twenty-seven small finger metacarpal fractures with initial angulation of 40 degrees were reduced and treated in a short hand cast for 4 weeks with only three patients losing reduction beyond 15 degrees.36 Intra-articular fractures of the head and base may also be treated nonoperatively, provided the fracture plane is both stable and minimally displaced. Metacarpal fractures with significant rotation or shortening cannot be effectively controlled through entirely nonoperative means. However, initial shortening and extensor lag has been shown to improve over time where 42 such patients eventually achieved 94% of contralateral grip strength by 1 year.7 An externally applied splint exerts indirect (but not direct) control over fracture position through positioning and reduction of myotendinous deforming forces. A splint is able to preserve a fracture position that is inherently stable but is not capable of reducing and maintaining an unstable position. The stability of a metacarpal fracture is determined primarily by the adjacent structures (periosteum, adjacent metacarpals, deep transverse intermetacarpal, and proximal interosseous ligaments) as well as the degrees of initial displacement and comminution. Splinting should be directed at pain control and neutralization of deforming forces. Surface contact should be as broad as possible with an appropriate amount of padding. The splint may be discontinued as soon as the patient can comfortably perform ROM with the hand and not later than 3 weeks. IP joint motion should begin immediately following injury. A dorsal splint in full MP joint flexion meets the patient’s needs well but may be more than is required. Some have advocated functional mobilization for metacarpal fractures without splinting at all.16 Compared with simple adjacent digit strapping in 73 patients, a molded metacarpal brace for less than 40-degree angulated fractures of the small finger metacarpal neck yielded similar clinical results with less pain.72 Defining the acceptable limits of deformity for each injury location is the subject of much controversy. Functionally, pseudoclawing is unacceptable. Also, the patient may be troubled by the appearance of a dorsal prominence at the fracture site or a shift in the metacarpal head from its dorsally visible position toward the palm. Only rarely will the shift toward the palm create a functional problem. Each patient may have different degrees of deformity that he or she is willing to tolerate. A correlation between deformity and symptoms has not been clearly established. Greater degrees of angulation are tolerable in neck fractures than in shaft fractures. Greater angulation is tolerable in the ring and small metacarpals than in the index and long metacarpals because of the increased mobility of the ulnar-sided CMC joints. Biomechanically significant decay in flexor tendon efficiency because of slack in the flexor digiti minimi and third volar interosseous occurs with angulations over 30 degrees in the fifth metacarpal neck, the site of greatest allowable angulation.4,14 

Operative Management

Closed Reduction and Internal Fixation

CRIF is the mainstay of treatment for isolated metacarpal fractures not meeting the criteria for nonoperative treatment (Fig. 30-71). Twenty-five patients with small finger metacarpal fractures achieved excellent functional results following stabilization with three transverse K-wires and demonstrated no shortening, appreciable angulation, or complications.61 A comparison between transverse and intramedullary K-wires in 59 patients failed to show any differences in outcome with no complications in either group.183 CRIF may be used for both extra-articular and intra-articular fractures provided that the fracture is anatomically reducible and stable to the stress of motion with only K-wire fixation. CRIF is the minimum treatment necessary for metacarpal base fractures that cannot be held reduced by nonoperative means (Fig. 30-72). Another closed reduction combined with stabilization option that has been reported is external fixation.115 
Figure 30-71
 
Closed reduction and internal fixation is effective for metacarpal neck fractures despite the smaller size of the head fragment and the need to achieve separation of the two wires that pass through it for control of fragment rotation in the sagittal plane.
Closed reduction and internal fixation is effective for metacarpal neck fractures despite the smaller size of the head fragment and the need to achieve separation of the two wires that pass through it for control of fragment rotation in the sagittal plane.
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Figure 30-71
Closed reduction and internal fixation is effective for metacarpal neck fractures despite the smaller size of the head fragment and the need to achieve separation of the two wires that pass through it for control of fragment rotation in the sagittal plane.
Closed reduction and internal fixation is effective for metacarpal neck fractures despite the smaller size of the head fragment and the need to achieve separation of the two wires that pass through it for control of fragment rotation in the sagittal plane.
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Figure 30-72
 
Extra-articular fractures of the thumb metacarpal (A) can be effective managed by (B) retrograde longitudinal pinning across the fracture into the base fragment.
Extra-articular fractures of the thumb metacarpal (A) can be effective managed by (B) retrograde longitudinal pinning across the fracture into the base fragment.
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Figure 30-72
Extra-articular fractures of the thumb metacarpal (A) can be effective managed by (B) retrograde longitudinal pinning across the fracture into the base fragment.
Extra-articular fractures of the thumb metacarpal (A) can be effective managed by (B) retrograde longitudinal pinning across the fracture into the base fragment.
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Intramedullary Fixation

Intramedullary fixation strategies are best matched with transverse and short oblique fracture patterns and include a single large diameter rod such as a Steinmann pin, an expandable intramedullary device, multiple prebent K-wires, or specially manufactured devices inserted at the metacarpal base designed to achieve three-point intramedullary fixation (Fig. 30-73).10,10,125 A single Steinmann pin may be inserted open through the fracture site with the two fragments then impacted over it. Rotational control is achieved by fracture fragment interlock, and motion can be started immediately. The strategy of multiple, stacked prebent wires has received broader acceptance than the other two strategies, perhaps owing to the closed technique used for introduction.110 The wires are prebent such that three point-contact is obtained dorsally at the proximal and distal ends of the metacarpal and volarly at the mid-diaphysis. This bow opposes the natural dorsal convexity of the metacarpal and is the basis for the apparently secure fixation achieved with this technique. The pins are stacked into the canal, filling it and imparting improved rotational control; as many as three to five 0.045-inch K-wires may be required. Locking intramedullary nails can also be used in special cases such as gunshot wounds.10 
Figure 30-73
 
Fractures of the metacarpal at the same level that cannot be treated by transverse pinning (A) can be stabilized by (B) a specially manufactured device shaped for three-point fixation and closed intramedullary application with a rotational locking sleeve used proximally. This device is also effective (C) in oblique fracture patterns and (D) fractures near the base.
Fractures of the metacarpal at the same level that cannot be treated by transverse pinning (A) can be stabilized by (B) a specially manufactured device shaped for three-point fixation and closed intramedullary application with a rotational locking sleeve used proximally. This device is also effective (C) in oblique fracture patterns and (D) fractures near the base.
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Fractures of the metacarpal at the same level that cannot be treated by transverse pinning (A) can be stabilized by (B) a specially manufactured device shaped for three-point fixation and closed intramedullary application with a rotational locking sleeve used proximally. This device is also effective (C) in oblique fracture patterns and (D) fractures near the base.
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Figure 30-73
Fractures of the metacarpal at the same level that cannot be treated by transverse pinning (A) can be stabilized by (B) a specially manufactured device shaped for three-point fixation and closed intramedullary application with a rotational locking sleeve used proximally. This device is also effective (C) in oblique fracture patterns and (D) fractures near the base.
Fractures of the metacarpal at the same level that cannot be treated by transverse pinning (A) can be stabilized by (B) a specially manufactured device shaped for three-point fixation and closed intramedullary application with a rotational locking sleeve used proximally. This device is also effective (C) in oblique fracture patterns and (D) fractures near the base.
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Fractures of the metacarpal at the same level that cannot be treated by transverse pinning (A) can be stabilized by (B) a specially manufactured device shaped for three-point fixation and closed intramedullary application with a rotational locking sleeve used proximally. This device is also effective (C) in oblique fracture patterns and (D) fractures near the base.
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Open Reduction and Internal Fixation

ORIF is the treatment of choice for intra-articular fractures that cannot be reduced and held by closed means. Internal fixation is also required for multiple fractures without inherent stability and for open fractures especially when associated with tendon disruptions.59,150 Internal fixation can be accomplished with intraosseous wiring, composite wiring, screws only, or screws and plates (Fig. 30-74). Wiring techniques have traditionally held the advantage over plate and screw application in terms of technical ease and availability of materials. However, with the modular plating systems now available specifically for use in hand surgery, lower profile fixation can be achieved with greater rigidity (Fig. 30-75).121 The most important consideration is that the surgeon should choose the method of internal fixation with which he or she is the most comfortable, keeping in mind that even plate fixation can fail.40 A nonrandomized study of 52 patients found no statistically significant differences in functional outcome between intramedullary nailing and plate–screw fixation of extra-articular metacarpal fractures.130 Unlike the plate–screw patients, 5/38 intramedullary patients lost reduction, had intramedullary penetration into the MP joint, and had more secondary surgeries for hardware removal. 
Figure 30-74
When rotational control is not sufficient with intramedullary fixation alone, composite wiring is useful and also adds a compressive force across the fracture site.
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Figure 30-75
Plates are indicated for use with comminuted fractures lacking inherent stability and open fractures with associated soft tissue injury requiring immediate aggressive rehabilitation.
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Metacarpal Head Fractures

For partial articular metacarpal head fractures, screw-only fixation is the treatment of choice with up to 79 degrees of ROM achieved.163 If sufficient interlock of bone spicules occurs, a single 1.2- to1.5-mm countersunk screw can control rotation of the fragment. If interlock is not effective, two screws are preferred even if this means downsizing the screw diameter to accommodate both of them in the fragment without causing comminution (Fig. 30-76). For complete articular head fractures, the condylar blade plate used to be required. The currently available small size hand modular locking plates allow fixed angle support of comminuted periarticular fractures with the ability to contour the plate first and avoid the complexity associated with inserting the blade plate (Fig. 30-77). 
Figure 30-76
Metacarpal head fractures consisting of only a few fragments are best stabilized by countersunk small lag screws.
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Figure 30-77
Metacarpal head fractures with (A) high degrees of comminution and inherent instability may require (B) plate stabilization to avoid collapse.
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Postoperative Care.
The importance of early motion must be considered in direct proportion to the magnitude of the injury or the surgical procedure performed.117 Modern plating systems tolerate applied loads in cadaver specimens sufficient for immediate full active motion rehabilitation.148 The more tissue damage that is present, the more aggressive must be the motion program. One frequently overlooked factor that greatly confounds progress in therapy is edema control. External compression wraps to the zone of injury with cohesive elastic bandages work to minimize the presence of edema from the outset. When internal fixation has been required, one must anticipate the development of an extensor lag at the MP joint. Specific attention should be given to extensor tendon gliding in zone VI to overcome a developing lag. Rapid tendon activation has been successful in breaking free developing adhesions between the peritendinous tissues and their surroundings. (Fig. 30-78).75 Patients should be allowed to use the hand for light activities throughout the healing period. Light resistance activities can begin at 6 weeks. Extremely forceful use patterns should be deferred until 3 months. 
Figure 30-78
Even following ORIF, when a properly designed rehabilitation program is administered, (A) complete flexion and (B) hyperextension is possible.
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Potential Pitfalls and Preventative Measures.
The metacarpal is the most proximal bone in the ray. Rotational malunions here will be the most obvious and functionally disabling. In large part, the management of metacarpal fractures is all about ensuring that rotation is correct. Length and angulation are, of course, not to be forgotten. The assessment of rotation both preoperatively and intraoperatively merits discussion. In both cases, the examiner should not touch the digit during the assessment. The awake, preoperative patient may require an anesthetic block to relieve enough pain so that he or she is capable of flexing sufficiently to demonstrate the rotational status of the digit. In the anesthetized patient, tenodesis driven by full range wrist motion produces sufficient flexion and extension of the digit that rotational alignment can be accurately judged. 
When performing transverse pinning of metacarpals, intraoperative imaging will effectively demonstrate depth of pin penetration and coronal plane fracture orientation. Metacarpal overlap obscures any individual metacarpal lateral view. Ensuring that the pins have penetrated both cortices of both metacarpals cannot be judged radiographically and must be determined by feel at the time of placement. If the reduction is difficult to obtain closed or tends to slip as the pins are driven, the case does not have to be converted to a full open reduction. A small instrument such as a dental pick or microelevator can be placed percutaneously at the fracture site to directly control reduction whereas the surgeon proceeds with the otherwise entirely closed pinning. Compared to plating of phalangeal fractures, there is even greater risk of inducing an iatrogenic rotational malunion when tightening down the screws. If a metacarpal plate has not been axially contoured correctly, when the screws are tightened, the plate will actually rotate the distal fragment out of an otherwise previously correct reduction. For this reason, no matter how many times the reduction has already been clinically evaluated, it must be evaluated at least one more time upon final placement of all fixations (Table 30-13). 
Table 30-13
Potential Pitfalls and Preventative Measures—Metacarpal Fractures
Pitfall Prevention
Tendon tethering by pins Only place pins in the coronal plane and remain proximal to the sagittal bands; remove by 3 weeks, 4 weeks at the absolute latest
Malrotation leading to malunion Careful clinical check of rotation
Failing to achieve purchase through all four cortices during transverse pinning Judgment that the pin has passed all four cortices is by feel, not by radiographic image
Pin placement creates translation malposition of fragment Resist translation with percutaneous placement of small bone elevator
Overdrilling the far hole on lag screws leading to poor fixation Use low speed to avoid distal “whipping” of the small drill bit; larger size “rescue” screws
Shearing the head off small titanium screws Use only fingertip tightening, no key pinch hold on the screwdriver
Inducing malunion with the plate Take off and recontour the plate as many times as needed so that, when tightened down fully, it does not force the bone into malalignment or malrotation
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Author’s Preferred Treatment (Fig. 30-79)

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Figure 30-79
Metacarpal fractures.
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Nonoperative Management
 

Many extra-articular and some intra-articular fractures, which are categorized as stable by virtue of having over 30% normal ROM without motion at the fracture site, can be managed with entirely nonoperative means using temporary splinting. Patients with entirely nondisplaced fractures that have excellent inherent stability do not require any external immobilization at all and can begin immediate AROM, usually with the added protection of adjacent digit strapping. Patients with stable metacarpal shaft fractures can be returned to nearly all light activities in a hand-based splint that is continued for a maximum of 3 weeks. Stable neck and intra-articular head fractures are more effectively protected by support that covers from the PIP level to the forearm with the MP joints in full flexion. At least one adjacent digit is included with the affected ray. IP joint motion should begin immediately with all strategies.

 
Closed Reduction and Internal Fixation
 

Transverse pinning to adjacent metacarpals is my treatment of choice for all unstable closed metacarpal fractures except multiple adjacent fractures at the same level that include a border digit. The biomechanics of the transverse pinning strategy is that of external fixation. Four points of control are needed. The two points closest to the fracture site on either side should be as close together as possible. The two farthest from the fracture site should be as far apart as possible. The proximal intermetacarpal and CMC ligaments are stout enough to qualify as the most proximal point of fixation such that only one 0.045-inch K-wire is required proximal to the fracture site. The distalmost pin should avoid transgression of the sagittal bands. This must be titrated clinically against the goal of placing the point of fixation as far from the fracture site as possible. The transverse pinning strategy works equally well for central (long and ring) and border (index and small) metacarpals (Fig. 30-80). If the four finger metacarpals are thought of as occurring in two columns (a radial column for index and long and an ulnar column for ring and small) then most combinations of multiple metacarpal fractures can still be fixed with this strategy, and it can always be used if there is only one fracture per column. If both metacarpals in the column are fractured, but at different levels, they can be used to stabilize each other reciprocally (Fig. 30-81). The specific requirement for reciprocal stabilization to be effective is that there is a zone in the diaphysis of both bones where two pins can be placed with adequate spacing from each other (distal to one fracture site and proximal to the other). At the conclusion of the procedure, one has the choice of leaving the pins protruding through the skin or cutting them off beneath the skin. In previous editions of this chapter I had advocated allowing pins of less than 4 weeks’ duration to be left outside the skin for ease of removal, but I now cut nearly all pins below the skin level given the prevalence of MRSA in the community. The hand is initially splinted in full MP flexion to resist the development of contractures. Early motion can proceed while the pins are still in place.

 
Figure 30-80
Transverse closed reduction and internal fixation functions under the same biomechanical principles as external fixation.
 
Note the distal wire is placed just proximal to the collateral recess of both bones and has also avoided tethering the sagittal bands.
Note the distal wire is placed just proximal to the collateral recess of both bones and has also avoided tethering the sagittal bands.
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Figure 30-80
Transverse closed reduction and internal fixation functions under the same biomechanical principles as external fixation.
Note the distal wire is placed just proximal to the collateral recess of both bones and has also avoided tethering the sagittal bands.
Note the distal wire is placed just proximal to the collateral recess of both bones and has also avoided tethering the sagittal bands.
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Figure 30-81
 
Reciprocal transverse stabilization of adjacent metacarpal fractures is possible when the levels of the two fractures are separated enough to be able to place two pins that fall distal to the first fracture and proximal to the second such that the first metacarpal is sufficiently stabilized in turn to provide stability to the other metacarpal.
Reciprocal transverse stabilization of adjacent metacarpal fractures is possible when the levels of the two fractures are separated enough to be able to place two pins that fall distal to the first fracture and proximal to the second such that the first metacarpal is sufficiently stabilized in turn to provide stability to the other metacarpal.
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Figure 30-81
Reciprocal transverse stabilization of adjacent metacarpal fractures is possible when the levels of the two fractures are separated enough to be able to place two pins that fall distal to the first fracture and proximal to the second such that the first metacarpal is sufficiently stabilized in turn to provide stability to the other metacarpal.
Reciprocal transverse stabilization of adjacent metacarpal fractures is possible when the levels of the two fractures are separated enough to be able to place two pins that fall distal to the first fracture and proximal to the second such that the first metacarpal is sufficiently stabilized in turn to provide stability to the other metacarpal.
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Open Reduction and Internal Fixation
 

ORIF is my treatment of choice for open fractures and multiple fractures not meeting the criteria for reciprocal transverse stabilization. When fracture plane interlock between bone spicules is present, intraosseous wiring, composite wiring, screw-only, or screw and plate fixation may all be considered. I prefer lag screw fixation for long-oblique or spiral fractures since CRIF cannot control the reduction of these patterns nearly as well as transverse fractures (Fig. 30-82). To select screw-only fixation, the ratio of the length of the oblique or spiral fracture plane to the bone diameter must be at least 2:1. Furthermore, to avoid comminution, the screws must pass through an area in the bone spike where the screw’s outer diameter is less than one-third the width of the spike. The screw sizes most appropriate for a metacarpal are 1.5 and 1.7 mm. Multiple open transverse or short oblique fractures of the mid-diaphysis from open crushing injuries are nicely managed with intramedullary pins. Rotational control can be supplemented with a composite wire loop. When interfragmentary compression cannot be achieved owing to the presence of comminution or bone loss, plates and screws are indicated.

 
Figure 30-82
 
Interfragmentary lag screws allow stable fixation of (A) adjacent metacarpals and (B) three fragment fractures with an intermediate butterfly fragment sufficient to permit full immediate motion rehabilitation.
Interfragmentary lag screws allow stable fixation of (A) adjacent metacarpals and (B) three fragment fractures with an intermediate butterfly fragment sufficient to permit full immediate motion rehabilitation.
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Figure 30-82
Interfragmentary lag screws allow stable fixation of (A) adjacent metacarpals and (B) three fragment fractures with an intermediate butterfly fragment sufficient to permit full immediate motion rehabilitation.
Interfragmentary lag screws allow stable fixation of (A) adjacent metacarpals and (B) three fragment fractures with an intermediate butterfly fragment sufficient to permit full immediate motion rehabilitation.
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As with all techniques of internal fixation, it is essential to cover the hardware with periosteal closure to provide a separate gliding layer. I prefer to operate 3 to 5 days following injury so that the periosteum will have thickened in response to injury and can be both dissected as a discrete tissue flap and closed with solid suture purchase. Unlike over the proximal phalanx, the extensor tendons at this level are discrete cords, and placement of the hardware away from them should be possible in most cases. Placement of the plate dorsally puts it on the tension cortex of the bone, but in this position it interferes most directly with the extensor tendons. Placement of the plate in a true lateral position allows sagittal plane forces to be resisted by the width of the plate rather than its thickness, and doing so is almost always possible, just technically more difficult. This is my choice for plate placement unless extenuating circumstances dictate dorsal placement. One such circumstance is fracture comminution extending all the way to the base of the metacarpal. All the technical comments made in the section on proximal phalangeal fractures apply equally here (Table 30-14).

 
 
Table 30-14
Surgical Steps—Plating of Comminuted Metacarpal Fractures
Longitudinal incision not overlying path of extensor digitorum communis tendon
Avoid tendon and create single layer of musculoperiosteal envelope down to fracture, minimizing periosteal stripping from fracture to only the location where plate will be placed
Prepare fracture site with curettage of clot and debris to permit accurate reduction
Provisional reduction using Adson-Brown forceps and small elevators
Select plate length and type, including decision for locking vs. nonlocking (at least four diaphyseal cortices beyond zone of comminution)
Provisionally contour plate, check, recontour, check, repeat…
Fix plate to bone with one proximal and one distal screw near ends of plate, nonlocking screws
Check clinically and radiographically length, alignment, and rotation; redo earlier steps if not correct
Add second proximal and distal screws (if locking screws to be used, now is the time)
Recheck all parameters, but especially rotation at this key stage; redo earlier steps if not correct
Complete fixation by placing remaining midzone screws
Final check of all parameters clinically and radiographically, close wound with absorbable monofilament, dress, and splint intrinsic plus position
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Introduction to Carpometacarpal (CMC) Joint Dislocations and Fracture Dislocations

Dislocations and fracture-dislocations at the finger CMC joints are usually high-energy injuries with involvement of associated structures, often neurovascular (Fig. 30-83). Particular care must be given to the examination of ulnar nerve function, especially motor, because of its close proximity to the fifth CMC joint. Frequently, the pattern is one of fracture-dislocation involving the metacarpal bases, the distal carpal bones, or both.101 Overlap on the lateral x-ray obscures accurate depiction of the injury pattern, and most authors recommend at least one variant of an oblique view.185 The Brewerton view may be helpful in this respect, profiling individual metacarpal bases. When fracture dislocations include the dorsal cortex of the hamate, CT may be necessary to fully evaluate the pathoanatomy. Another pattern to recognize is dislocation of one CMC joint with fracture of an adjacent metacarpal base. Shortening can be evaluated by noting a disruption in the normal cascade seen distally at the MP joints. Volar CMC dislocations are rare. 
Figure 30-83
Fractures of CMC joints (A) are typically high-energy injuries with (B) comminution of both the metacarpal base and the distal carpal row.
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Most thumb CMC dislocations are dorsal and are thought to occur through axial loading of a partially flexed thumb (Fig. 30-84). Motorcyclists may be uniquely prone to sustaining this rare injury and to having the injury missed on initial evaluation. The injury will often be reduced before being seen by the surgeon. Clinical diagnosis is then based on identifying the residual instability. Differentiating complete from incomplete ligament rupture is essential, as initial operative treatment is appropriate only for complete disruptions. Instillation of local anesthetic into the joint may be required to allow an unimpeded examination. Manual stress testing compared to the contralateral side should allow for diagnosis in most cases. 
Figure 30-84
Pure dislocations of the thumb CMC joint are rare injuries and typically occur dorsoradially.
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The majority of thumb metacarpal base fractures are intra-articular (Fig. 30-85). The majority of thumb CMC joint injuries are fracture-dislocations rather than pure dislocations. The smaller fracture fragment at the thumb metacarpal volar base is deeply placed and not palpable. Eponyms associated with these fracture-dislocations are Bennett’s (partial articular) and Rolando’s (complete articular). Specific x-rays must be obtained in the true AP and lateral planes of the thumb (not a series of hand x-rays) if injuries along this axis are to be correctly identified (Fig. 30-86). 
Figure 30-85
 
The most recognized patterns of thumb metacarpal base intra-articular fractures are (A) the partial articular Bennett fracture and (B) the complete articular Rolando fracture.
The most recognized patterns of thumb metacarpal base intra-articular fractures are (A) the partial articular Bennett fracture and (B) the complete articular Rolando fracture.
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Figure 30-85
The most recognized patterns of thumb metacarpal base intra-articular fractures are (A) the partial articular Bennett fracture and (B) the complete articular Rolando fracture.
The most recognized patterns of thumb metacarpal base intra-articular fractures are (A) the partial articular Bennett fracture and (B) the complete articular Rolando fracture.
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Figure 30-86
The thumb does not reside in the same plane as the rest of the hand.
 
A true AP of the thumb can be obtained with the Robert’s view.
A true AP of the thumb can be obtained with the Robert’s view.
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Figure 30-86
The thumb does not reside in the same plane as the rest of the hand.
A true AP of the thumb can be obtained with the Robert’s view.
A true AP of the thumb can be obtained with the Robert’s view.
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Pathoanatomy and Applied Anatomy Relating to Carpometacarpal (CMC) Joint Dislocations and Fracture Dislocations

Finger CMC Joints

Stability at the finger CMC joints is provided by a system of four ligaments. There is a high degree of variation with dorsal, multiple palmar, and two sets of interosseous ligaments (only one between the long and ring metacarpals).47,119 The interosseous ligaments are the strongest and have a V configuration with the base of the V oriented toward the fourth metacarpal. ROM of the index and long CMC joints is limited to less than 5 degrees, with 15 degrees at the ring, and up to 25 to 30 degrees at the small finger. Small finger CMC motion is reduced 28% to 40% when the ring finger is immobilized.52 The axis of motion is located near the base of the metacarpal. The index metacarpal has a particularly stable configuration through its wedge-shaped articulation with the trapezoid. The small finger CMC joint is the only joint not having a gliding configuration but instead is a modified saddle-shaped joint. The increased mobility on the ulnar side of the hand may predispose to its greater frequency of injury. Critical soft tissue relationships to appreciate during treatment of injuries to the CMC joints are the positions of the motor branch of the ulnar nerve directly in front of the fifth CMC joint and the deep palmar arch in front of the third CMC joint. Of all hand fractures and dislocations, injury at the CMC level requires the highest degree of vigilance regarding associated neurologic injury. The high-energy mechanism of these injuries and profound degrees of swelling may lead to worsened outcomes through residual long-term nerve compression. 

Thumb CMC Joint

Branches of both the lateral antebrachial cutaneous and superficial radial nerve ramify throughout the region of the thumb base on the radial side. Three tendons pass through this region: The abductor pollicis longus (APL), extensor pollicis brevis (EPB), and EPL. The radial artery passes beneath the APL and EPB on its course to the first web space and lies just proximal to the CMC joint. The joint anatomy includes reciprocal saddle-shaped surfaces of the distal trapezium and proximal metacarpal. The axis of this concavoconvex joint is then itself curved in a third plane with the convexity lateral. The normal ROM at the thumb CMC joint is around 50 degrees of flexion‑extension, 40 degrees of abduction‑adduction, and 15 degrees of pronation‑supination. There is consensus as to which ligaments are anatomically present at the trapeziometacarpal joint (Fig. 30-87). They are the superficial anterior oblique, deep anterior oblique (beak), ulnar collateral, intermetacarpal, posterior oblique, and dorsoradial ligaments.13 A point of confluence exists at the palmar ulnar tubercle of the first metacarpal base. There was a period of disagreement regarding the primary stabilizing ligament in preventing dislocation between the deep anterior oblique and the dorsoradial ligament. Although the deep anterior oblique was previously considered the primary stabilizer, more recent research has effectively demonstrated that the dorsoradial ligament is the prime restraint to dislocation. The dorsoradial ligament is the shortest ligament in the group and the first to become taut with dorsal or dorsoradial subluxation.13 Selective ligament sectioning showed that deficiency of the dorsoradial ligament led to the greatest degree of subluxation.174 Dorsal dislocation usually occurs through rupture of the dorsal ligaments with a sleeve-type avulsion of the anterior oblique ligament as it peels off the volar surface of the first metacarpal.156 Supination may also play a significant role in the mechanism of this injury. Deformation of fractures at the base of the thumb metacarpal occurs with a complex motion (Fig. 30-88). The distal metacarpal is adducted and supinated by the adductor pollicis. At the same time, the APL pulls the metacarpal radially and proximally. Reduction maneuvers must attempt to counteract each of these forces. Probably the most difficult aspect of the reduction to maintain through splinting is the radial displacement of the base. 
Figure 30-87
The superficial anterior oblique and ulnar collateral ligaments are not primary stabilizers.
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Figure 30-87
The primary stabilizing ligaments of the thumb CMC joint include the deep anterior oblique, dorsoradial, posterior oblique, and intermetacarpal ligaments.
The superficial anterior oblique and ulnar collateral ligaments are not primary stabilizers.
The superficial anterior oblique and ulnar collateral ligaments are not primary stabilizers.
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Figure 30-88
Displacement of Bennett fractures is driven primarily by the abductor pollicis longus (proximal migration) and the adductor pollicis (adduction and supination).
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Carpometacarpal (CMC) Joint Dislocations and Fracture Dislocations Treatment Options

Nonoperative Management

Closed reduction is usually possible early but may be difficult later following injury. Dorsal finger CMC fracture-dislocations usually cannot be held effectively by external means alone. Although usually acceptable as the least invasive method of treatment for most injuries, entirely nonoperative management of pure thumb CMC dislocations does not provide sufficient stability for accurate healing of the ligaments. It is not possible through external means to maintain complete control over the reduction of a widely displaced intra-articular fracture-dislocation at the base of the thumb throughout the entire period of healing. However, the need to achieve anatomic union in these fractures has been questioned. Although no one study is definitive, the risk of significant malunion when managing an initially widely displaced intra-articular fracture is too great to warrant entirely nonoperative management. 

Operative Management

Finger CMC Dislocations and Fracture Dislocations

For those injuries that can be accurately reduced, CRIF is the treatment of choice. The technique involves restoration of anatomic length to the shortened and dislocated metacarpals through the combined application of traction and direct pressure at the metacarpal bases. Manual reduction is then followed by placement of 0.045-inch K-wires from the metacarpal bases into either the carpal bones or into adjacent stable metacarpals (Fig. 30-89). Adequacy of reduction as well as stability should be evaluated both radiographically and clinically. Pins should remain for 6 weeks. Unlike most other hand fractures, residual instability, rather than stiffness, is the risk with this injury. Initially open fractures and those with tissue interposition preventing reduction will require ORIF. Open reduction is much more likely to be required in cases presenting late and may be accomplished as long as 3 months after the initial injury (Fig. 30-90). The stabilization strategy is the same as for CRIF with the open part of the procedure being used strictly for reduction purposes. Excellent long-term stability without pain is achieved in the majority of cases. In more severe cases, immediate arthrodesis of the CMC joints may be required.71 
Figure 30-89
Isolated CMC fracture dislocations can be reduced and pinned closed to a stable adjacent metacarpal and to the distal carpal row.
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Figure 30-90
 
Multiple highly unstable CMC dislocations are at high risk of incomplete reduction and require (A) multiple points of fixation and (B) a careful check on the lateral radiograph to identify any residual dorsal subluxation.
Multiple highly unstable CMC dislocations are at high risk of incomplete reduction and require (A) multiple points of fixation and (B) a careful check on the lateral radiograph to identify any residual dorsal subluxation.
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Figure 30-90
Multiple highly unstable CMC dislocations are at high risk of incomplete reduction and require (A) multiple points of fixation and (B) a careful check on the lateral radiograph to identify any residual dorsal subluxation.
Multiple highly unstable CMC dislocations are at high risk of incomplete reduction and require (A) multiple points of fixation and (B) a careful check on the lateral radiograph to identify any residual dorsal subluxation.
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Thumb CMC Pure Dislocations

Surprisingly, even the results of CRIF have not been sufficient to consistently prevent long-term symptoms of instability and arthritis in pure thumb CMC dislocations. In a series of eight dislocations pinned for 6 weeks and immobilized for a total of 7.4 weeks, four required ligament reconstruction (three for symptomatic instability and one for progression of early posttraumatic arthritis).146 Based on these poor results, the same authors subsequently treated the next nine patients with early ligament reconstruction, resulting in no late symptoms, full motion, and normal grip strength (Fig. 30-91). 
Figure 30-91
 
Reconstruction of the thumb CMC ligaments can be performed with (A) a split flexor carpi radialis graft woven through a bone tunnel in the thumb metacarpal base, exiting the dorsal cortex, passing deep to the abductor pollicis longus, around the intact remaining flexor carpi radialis, and back to the volar radial aspect of the metacarpal base. B: This procedure is accomplished through a traditional Wagner approach.
Reconstruction of the thumb CMC ligaments can be performed with (A) a split flexor carpi radialis graft woven through a bone tunnel in the thumb metacarpal base, exiting the dorsal cortex, passing deep to the abductor pollicis longus, around the intact remaining flexor carpi radialis, and back to the volar radial aspect of the metacarpal base. B: This procedure is accomplished through a traditional Wagner approach.
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Figure 30-91
Reconstruction of the thumb CMC ligaments can be performed with (A) a split flexor carpi radialis graft woven through a bone tunnel in the thumb metacarpal base, exiting the dorsal cortex, passing deep to the abductor pollicis longus, around the intact remaining flexor carpi radialis, and back to the volar radial aspect of the metacarpal base. B: This procedure is accomplished through a traditional Wagner approach.
Reconstruction of the thumb CMC ligaments can be performed with (A) a split flexor carpi radialis graft woven through a bone tunnel in the thumb metacarpal base, exiting the dorsal cortex, passing deep to the abductor pollicis longus, around the intact remaining flexor carpi radialis, and back to the volar radial aspect of the metacarpal base. B: This procedure is accomplished through a traditional Wagner approach.
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Thumb CMC Fracture Dislocations

Closed reduction and internal K-wire (0.045-inch) stabilization is the treatment of choice for nearly all Bennett fractures and most Rolando fractures (Fig. 30-92). Arthroscopy may be added to guide the reduction.33 In a series of 32 patients followed for 7 years with intra-articular step-offs of less than 1 mm, no difference was found between closed pinning and ORIF for Bennett fractures, with the exception of a higher incidence of adduction contracture in the pinning group.113 Advocates of internal fixation may choose to manage less comminuted Rolando fractures and some Bennett fractures with ORIF.109 When there are reasonably large fragments that will support purchase of at least one solid screw per fragment, one may consider plate and screw stabilization of a Rolando fracture (Fig. 30-93). However, ORIF of a Rolando fracture is not for the occasional hand surgeon. Comminution is the rule rather than the exception, and restoration of normal anatomy is quite difficult. The combination of limited internal fixation and external fixation to support the length and unload the articular reduction may be helpful in complex Rolando fractures.51 A series of 10 patients managed this way and followed at 35 months showed 88% key pinch strength compared to the contralateral side with 9 of 10 patients having good or fair overall satisfaction.20 Whereas some series have de-emphasized the role of anatomic reduction in improving long-term results, others have stressed its role. Eighteen patients followed to 10.7 years showed a clear correlation between the quality of reduction and posttraumatic arthritis.170 A similar series with over 7-year follow-up demonstrated a clear correlation between radiographic posttraumatic arthritis and greater than 1-mm articular step-off in the final reduction.169 Twenty-one patients achieved 80% of normal grip strength despite radiographic signs of degeneration in sixteen that did not correlate to clinical outcome.17 Thirty-one patients followed at 7.3 years demonstrated a correlation of both radiographic signs of osteoarthritis and (more importantly) symptoms of pain with the final residual displacement when healing occurred with more than a 2-mm articular step-off.97 
Figure 30-92
Bennett fractures can be stabilized by closed pinning of the articular reduction, with or without additional stabilization of the thumb metacarpal shaft to the trapezium.
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Figure 30-93
 
Rolando fractures are highly unstable and require techniques such as fixed angle plates adjacent to the subchondral bone to resist collapse and sometimes even a smaller second plate placed at 90 degrees to the primary plate.
Rolando fractures are highly unstable and require techniques such as fixed angle plates adjacent to the subchondral bone to resist collapse and sometimes even a smaller second plate placed at 90 degrees to the primary plate.
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Figure 30-93
Rolando fractures are highly unstable and require techniques such as fixed angle plates adjacent to the subchondral bone to resist collapse and sometimes even a smaller second plate placed at 90 degrees to the primary plate.
Rolando fractures are highly unstable and require techniques such as fixed angle plates adjacent to the subchondral bone to resist collapse and sometimes even a smaller second plate placed at 90 degrees to the primary plate.
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Postoperative Care.
Immobilization should last from 6 to 8 weeks in an orthoplast splint. The primary problem with finger CMC joint injuries is residual instability, not joint stiffness. The MP joints should be left free throughout the aftercare period with attention paid to excursion of the common digital extensor tendons. For thumb CMC joint injuries, immobilization is continued for 6 weeks in a thumb spica splint. The IP joint should be left free throughout the postoperative period. Following cast removal the patient undergoes a standard progression of ROM exercises that graduates as tolerated into functional use by 8 to 10 weeks. Forceful pinch loading is avoided for 3 months after surgery. 
Potential Pitfalls and Preventative Measures.
Treatment of both finger and thumb CMC joint injuries provides ample opportunity for the occurrence of two complications frequent in hand surgery: injury to cutaneous nerves and pin tract infections. The injury to cutaneous nerves is likely to occur by a pin rather than during dissection and particularly when approaching the radial side of the thumb base. Pins are retained longer here (6 weeks) than for stabilization of metacarpal (removed by 4 weeks) or phalangeal (removed by 3 weeks) fractures. There is thus more time for a pin tract infection to develop. The most important points for finger CMC joint fracture-dislocations are to be sure the joints are fully reduced, and not to miss associated carpal bone fractures. Although most isolated single ray CMC fracture-dislocations occur in the small finger axis, there is a reproducible pattern that will occasionally be seen for the index ray where the articular base is split into two good-quality fragments very amenable to a percutaneous headless compression screw fixation (Fig. 30-94). 
Figure 30-94
An isolated index metacarpal CMC fracture-dislocation can be percutaneously reduced and stably fixed with a headless variable pitch compression screw.
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Comminuted fractures of the thumb CMC joint are indeed difficult injuries to treat but are made much simpler by approaching their management as follows: visualize where the shaft of the thumb metacarpal lies in a correct functional position relative to the rest of the hand and pin it there (to the index metacarpal) with two 0.062-inch K-wires. Then make the articular surface of the metacarpal base congruent with supportive bone graft and/or small subchondral wires through a limited opening. What originally appeared as an impossible undertaking now becomes a relatively simple two-step process (Table 30-15). 
Table 30-15
Potential Pitfalls and Preventative Measures—CMC Dislocations and Fracture-dislocations
Pitfall Prevention
Cutaneous nerve injury by K-wire Know the anatomy, place the wire tip all the way to bone by hand, do not spin the wire unless the tip has bone contact, do not make advance incisions and spread the tract around the wire
Pin tract infection Cut the pins below the skin surface by enough distance that swelling reduction and external splint pressure cannot induce a protrusion
Incongruent joint Imaging with beam oriented to accurately pass through CMC joint; when in doubt—open
Residual dorsal subluxation Tangential profile views; when in doubt—open
Missed hamate/capitate fractures Careful palpation; tangential profile views; when in doubt—open
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Author’s Preferred Treatment (Fig. 30-95)

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Figure 30-95
CMC joint dislocations and fracture dislocations.
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Finger CMC Joint Pure Dislocations
 

Pure dislocations rarely occur without fracture of either the metacarpal bases or carpal bones of the distal row. However, the absence of such fractures creates an opportunity for successful management by CRIF. The metacarpal bases must be felt to engage their articulations fully and demonstrate complete congruence on radiographs. Only when the x-ray beam passes tangentially through the joint can an accurate assessment be made. K-wires are retained for 6 weeks with an additional 2 weeks of splint protection before initiating wrist and CMC rehabilitation. All other joints remain mobile throughout the postoperative period.

 
Finger CMC Joint Fracture-dislocations
 

If an accurate closed reduction can be achieved, CRIF is an excellent choice. Cases seen weeks after injury or those with tissue interposition will likely require ORIF to achieve accurate reduction. The approach may be dictated by the presence of an open traumatic wound. Branches of the superficial radial nerve and dorsal cutaneous branch of the ulnar nerve must be identified and protected not only from the surgical approach but also during pin placement. The common extensor tendons overlie the central metacarpal bases, and the wrist extensor tendons insert on the border metacarpals. Incision of the extensor retinaculum increases the lateral mobility of these tendons, allowing the surgeon to work around them. Bone and cartilage fragments too small for fixation but large enough to create third body wear in the joint should be removed. Fixation is founded upon 0.045-inch K-wire passage from the metacarpal bases across the CMC joints into the distal carpal row. If adjacent metacarpals are stable without CMC joint injury, transverse stabilization between metacarpal bases is an excellent addition. Evaluation of the dorsal cortices of the hamate and capitate should be performed on each case as these are also often fractured. Large bone fragments should be restored to their cancellous beds and fixed with countersunk compression screws. Small bone fragments should be excised.

 
Thumb CMC Joint Pure Dislocations
 

The literature simply does not support CRIF as a valid treatment for this injury despite basic principles that should allow this method to produce satisfactory results. Although some articles suggest that one needs to perform immediate free tendon graft reconstruction of complete thumb CMC dislocations, this has not been my experience. I have consistently found open ligament repair to produce stable and pain-free motion. The reproducible surgical findings are a sleeve-like avulsion of the deep anterior oblique ligament from the volar surface of the metacarpal and a rupture of the dorsoradial and posterior oblique ligaments. The rupture has usually been distal from the metacarpal insertion. The procedure is easily accomplished by inserting a series of 1.3-mm bone anchors around the margin of the metacarpal base and using the sutures for anatomic repair of the dorsal ligaments. The joint should be pinned in a reduced position before tying down the dorsal ligaments. The deep anterior oblique ligament comes to lie flush with the metacarpal surface when the joint is reduced and stabilized. Pins are retained for 6 weeks with the thumb CMC joint motion instituted at that time. Light pinch is also allowed with progression to power pinch by 3 months postoperatively.

 
Thumb CMC Joint Fracture-dislocations
 

The majority of these can be treated with CRIF, most of the remainder augmented with small openings to control small articular fragments or pack bone graft into the metaphysis, and the final minority with full ORIF. The soft tissue anatomy of this region should be taken into account when placing pins. The drill should not be activated until the pin is solidly placed down to bone. Pins may be placed from the main thumb metacarpal fragment into the small volar fragment, the trapezium, and the index metacarpal in variable combinations based on the unique fracture characteristics of each patient.

 

The goals of treatment in a Rolando fracture are different. The primary aim is to provide distraction to allow healing through the often-comminuted metaphyseal zone. This is best accomplished by pinning the thumb metacarpal (two 0.062-inch K-wires) to the index metacarpal rather than to the trapezium. It is in these cases of complete articular comminution that making a small opening to place an elevator into the metaphysis may prove useful. The articular fragments can be molded against the distal surface of the trapezium and kept there by either packing bone graft in behind them or with additional smaller caliber (0.035-inch) pins placed transversely at the subchondral level to maintain articular congruity. The advantage of plate and screw stabilization of an intra-articular fracture in general is usually to allow early motion of the joint for the sake of cartilage nutrition and preservation of long-term ROM. The small fragments at the base of the thumb metacarpal are more at risk of devascularization with a widely open procedure that includes periosteal stripping to place a small titanium plate. I have not experienced that long-term loss of motion is a problem at the trapeziometacarpal joint following 6 weeks of pin immobilization for these fractures but I have observed that the presence of the plate results in adherence of the EPL and EPB tendons and can cause long-term loss of motion of both the MP and IP joint, which is a clinically relevant problem.

 

If ORIF is chosen for a select case, a Wagner incision along the glabrous/nonglabrous border of the thumb base may be curved in a volar and transverse direction to expose the thenar muscle group. Reflection of these muscles reveals the joint capsule volar to the insertion of the APL. Arthrotomy reveals the intra-articular fracture, and subperiosteal dissection along the shaft allows for placement of a plate. Stable internal fixation of Rolando fractures is only possible when the fragments are large enough to accept the purchase of individual screws. My current fixation of choice in this situation is a titanium locking condylar plate (either 1.7 mm or 2.3 mm depending on the size of the patient). Eccentric drilling of the condylar holes can add transverse compression between the articular base fragments. If ORIF is chosen for a Bennett fracture, a smaller version of the same approach is used to allow sufficient access to compress the reduction and place an interfragmentary lag screw from dorsal to volar. Micro-sized variable pitch headless screws are also well suited to the fragment sizes seen in a Bennett fracture (Table 30-16).

 
 
Table 30-16
Surgical Steps—Multiple CMC Fracture Dislocations
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Table 30-16
Surgical Steps—Multiple CMC Fracture Dislocations
Approach short longitudinal at ulnar border of common digital extensors
Small arthrotomy at the junction of long metacarpal to capitate and ring metacarpal to hamate so both CMC joints can be visualized for true congruence
Curette and reduce all fracture and dislocation components to the injury, focusing on residual dorsal subluxation and shortening as the two most common reduction errors
Hold dorsal fragments of capitate/hamate approximated to volar counterparts with small bone instruments, and permanently fix with small lag screws in sagittal plane
Identify the most stable metacarpal and begin there as foundation (usually radial) and then link other metacarpals to this anchor point and to distal row
Progressively rebuild the transverse arch of the hand by pinning in coronal/oblique plane successive metacarpals to each other and to distal carpal row
Cut pins below skin level and away from extensor tendons
Check congruence by direct visualization through original arthrotomy and radiographically with tangential views; check for residual dorsal subluxation
Check clinical rotational alignment of each metacarpal axis; close wound with absorbable monofilament, dress, and splint
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Management of Expected Adverse Outcomes and Unexpected Complications

Published complication rates associated with rigid internal fixation are high and often attributable to the complex nature of the injuries for which this treatment method is selected. In a series of 41 metacarpal and 27 phalangeal fractures, complications of hardware (45%), extensor lag (19%), and infection (12%) were seen.128 Another series of 37 phalangeal fractures reported a 92% complication rate including 60% extensor lag and 38% fixed flexion contracture.131 Increased complication rates were associated with intra-articular/periarticular locations, with extension to the shaft, open injuries, associated soft tissue injury, and the need for bone graft. As long as 18 months may be required for soreness and stiffness to abate following small joint dislocations. In 490 severe phalangeal fractures there were 31(6%) nonunions, 44(9%) malunions, and 8(2%) infections.176 
In 200 open hand fractures there were 9 deep infections, 18 malunions, 17 delayed unions or nonunions, 23 fixation-related complications, and 2 late amputations.159 These complications were usually associated with Swanson type II wounds (14% compared with 1.4% in type I wounds), but not with the use of internal fixation, high-energy injury, large wound size, or associated soft tissue injury. 

Infection

Despite the excellent vascularity of the hand, infection still occurs with open fractures. In current practice, MRSA is the most commonly isolated species. The role of antibiotics in reducing the infection rate in noncontaminated open wounds with intact vessels has not been supported. When 198 patients were randomized in a double-blind placebo-controlled study with flucloxacillin for open distal phalangeal fractures, there were seven superficial and no deep infections (three with antibiotic, four without).155 In 408 K-wire hand fracture fixation cases there was a 14% complication rate that was unaffected by the use of empiric antibiotics.87 

Stiffness

Perhaps the most feared complication and certainly one of the most common following a fracture or dislocation in the hand is stiffness. Twenty-two of 54 patients failed to achieve TAM over 180 degrees following plate fixation of phalangeal fractures.102 Stiffness is a product of the magnitude of the original trauma, the age and genetic composition of the patient, the duration of immobilization, the position of immobilization, and the invasiveness of any surgical intervention. The primary factors influencing stiffness are the associated soft tissue injury and the age of the patient.28,180 Too often, the position of immobilization violates the fundamental principles of splinting ligaments at full length and balancing tendon forces that act across the fracture site.58 First web space contractures are common and can be minimized by pinning or splinting the thumb metacarpal in maximum abduction. Active versus passive motion discrepancies most commonly appear in the form of an extensor lag. The overlying extensor tendon becomes adherent to the fracture site and its subsequent failure of excursion produces an extensor lag at the next most distal joint. This is most common at the PIP joint following fractures of P1 with adherence of the flat and broad extensor tendon in zone IV. Only 11% of phalangeal fractures fixed with plates had a TAM of >220 degrees.131 A focused rehabilitation technique that uses the differential viscoelastic properties of tendon and scar tissue can be used to maximize extensor excursion over both phalangeal and metacarpal fractures.75 Once a fixed contracture has been established by the time of tissue homeostasis following the initial trauma, tenocapsulolysis is required if the patient desires to improve motion.108 One of the chief concerns with operative management of thumb MP ligament disruptions has been the loss of motion. Loss of motion may be more significant in patients undergoing late reconstructions as occurred in 21 patients from a series of 70 free tendon grafts.103 

Hypersensitivity

The size and structure of the hand provides for very little padding between the surface and a complex array of small caliber nerve branches. There are very few locations for either surgical incisions or percutaneous pins where small nerve branches are more than a centimeter away. Hypersensitivity is a frequently seen consequence of the mechanism of injury itself. Crush injuries are almost invariably accompanied by some degree of hypersensitivity. When surgical management is performed soon after the injury, the procedure itself is often erroneously blamed for causing the hypersensitivity. Hypersensitivity may be further heightened by cold intolerance.123 Some areas are at higher risk than others. Neuroma formation through direct injury or nerve encasement in postoperative scar should be guarded against when one is operating along the ulnar side of the thumb MP joint with its high concentration of small dorsal digital nerve branches and at the radial side of the wrist near the superficial radial nerve. Treatment is based on a combination of specific medications designed to reduce nerve pain such as gabapentin, amitriptyline, or pregabalin and a progressive contact desensitization therapy program. Gentle surface contact essentially trains the sensitive nerve fibers to tolerate that level of stimulation before then progressing to more intense stimulation. Eventually, the patient works his or her way up to normal use of the hand over a period of weeks. In the meantime, overstimulation of the nerve pain by traction and motion must be avoided even if this means slower progress in the motion program. Failure to heed this principle will result in progression from straightforward hypersensitivity to complex regional pain syndromes and a downward spiral of worsening pain and function that far exceeds the simple early reduction in motion. 

Malunion and Deformity

Malunion is a frequently encountered complication in hand fractures owing to a lack of understanding regarding hand biomechanics, to an unfounded belief that all hand fractures do well with nonoperative treatment, or to a noncompliant patient. Malunions are managed with corrective osteotomy. Each aspect of the deformity must be well understood from angular to rotational to length considerations. The main decision is whether to place the osteotomy at the site of original deformity or to make a compensatory osteotomy that produces reciprocal deformities. Fundamentally, it is best to make the correction at the site of the original deformity. The problem is hardware interference with soft tissues. The plate and screws usually necessary to stabilize the correction may not fit well at the site of original deformity. Another consideration is the healing potential of metaphyseal as compared with diaphyseal regions, particularly if the diaphyseal bone has been stripped of its blood supply during prior procedures. A popular location for rotational corrections in particular is the metacarpal base for the above reasons. 
Sagittal plane malunion of the proximal phalanx with apex volar usually occurs because of failure to splint the hand in the position of full MP flexion that will correct the dynamic imbalance across the fracture site. Rotational malunion typically stems from the improper choice of nonoperative treatment when direct fixation was needed to control rotation. Spiral fractures are difficult to correctly reduce closed, and rotational malunions can easily result from CRIF especially at the level of the proximal phalanx. Nail plate alignment is an inadequate method of assessing rotation, which should be judged by parallelism of the short tubular bone segment distal to the injured one with the intervening joint flexed to 90 degrees. Corrective osteotomy is more successful at the metacarpal level than the phalangeal level.65 Correction of a sagittal plane or multidirectional malunion is best accomplished at the site of the original fracture (Fig. 30-96).106,172 Significant stiffness often accompanies the malunion. A concomitant tenocapsulolysis can be performed if rigid fixation of the osteotomy is achieved. The alternative is to break the solution down into two parts: Stage one achieves correction of the skeletal deformity through osteotomy and stage two improves motion through tenocapsulolysis. These patients achieve the greatest gains in motion even though the measured final range may be less than that of other patients with less severe injuries.170,19 For mild to moderate malunions, a realistic assessment regarding the expected improvement in function must be weighed carefully against the predicted degree of digital stiffness created by the osteotomy procedure itself and the hardware utilized.173,184 Intra-articular osteotomy is an extremely demanding undertaking and should be restricted to carefully selected patients (Fig. 30-97). Five patients undergoing extra-articular osteotomy for malunited unicondylar fractures of the proximal phalanx saw an increase in average PIP motion from 40 degrees preoperatively to 86 degrees postoperatively.73 Surgery may be performed as late as several months after the initial injury through the original fracture plane. 
Figure 30-96
Malunion of P1 fractures is typically apex volar but may include multiplanar deformity, best corrected at the level of original trauma.
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Figure 30-97
Intra-articular corrective osteotomy is a demanding undertaking but can produce excellent results when precise attention is given to restoring articular congruence.
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Malunion of a metacarpal fracture usually presents as an apex dorsal sagittal plane deformity. Patients may complain of the cosmetic deformity, pain at the dorsal prominence, or grip discomfort with a prominent metacarpal head in the palm. Patients should be counseled to evaluate their deformity and decide if their dissatisfaction is sufficient to warrant undergoing corrective osteotomy. The osteotomy should be delayed until tissue homeostasis has been achieved unless an opportunity for early intervention (less than 6 weeks) exists (Fig. 30-98). Correction is best achieved through the site of the original fracture with rigid internal fixation followed by immediate motion. In choosing between opening wedge, closing wedge, pivot osteotomy, or oblique osteotomy, the exact pattern of deformity needs to be assessed and the osteotomy designed to most closely restore normal anatomy. This will demand a different cut for each patient, but the simpler the intended osteotomy, the more likely the surgeon can achieve a good result. Shortening must be considered if a closing wedge is planned. An extensor lag at the MP joint of 7 degrees can be predicted for every 2 mm of shortening.156 Rotational malunion in a metacarpal may also occur, causing digital overlap. Osteotomy can be performed at the site of original injury or at the metacarpal base. Rotational osteotomy performed at the base of the metacarpal offers broader cancellous surfaces for healing and can correct up to 25 to 30 degrees of rotation.92 If the plane of deformity is more complex than pure rotation, it may be wiser to attempt multiplanar correction through the original fracture site. 
Figure 30-98
 
Nascent malunions that have healed by callus but where the original fracture plane can be cut with an osteotome by hand rather than a saw (A, C) are excellent opportunities to achieve a true anatomic restoration (B, D) as opposed to a close approximation.
Nascent malunions that have healed by callus but where the original fracture plane can be cut with an osteotome by hand rather than a saw (A, C) are excellent opportunities to achieve a true anatomic restoration (B, D) as opposed to a close approximation.
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Figure 30-98
Nascent malunions that have healed by callus but where the original fracture plane can be cut with an osteotome by hand rather than a saw (A, C) are excellent opportunities to achieve a true anatomic restoration (B, D) as opposed to a close approximation.
Nascent malunions that have healed by callus but where the original fracture plane can be cut with an osteotome by hand rather than a saw (A, C) are excellent opportunities to achieve a true anatomic restoration (B, D) as opposed to a close approximation.
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Intra-articular osteotomy at the metacarpal head has infrequent indications, as correction of an intra-articular malunion is extremely difficult. In long-term follow-up, intra-articular malunion at the metacarpal base leads to osteoarthritis (65%), decreased grip (49%), and pain (38%).96 Arthrodesis is the preferred solution for these problems, even for the fifth metacarpal. It reliably improves grip strength with the elimination of pain. Compensatory triquetrohamate motion may alleviate the effect of arthrodesis on the mobility of the ulnar side of the hand. An alternative is a resection arthroplasty at the small CMC with the small metacarpal fused laterally to the ring metacarpal to prevent subsidence.44 

Nonunion

Nonunion is a rare complication in hand fractures with the exception of distal phalanx fractures, when CRIF has caused distraction, or in fractures treated with ORIF where excessive periosteal stripping has occurred. Nonunions are treated no differently than anywhere else in the body. Hypertrophic nonunions may be addressed by compression alone using a dynamic compression plate. Nonunions with bone loss or inadequate vascular supply require supplementary bone grafting in addition to stable fixation. Tuft fractures of the distal phalanx frequently result in fibrous union but are rarely symptomatic long term. Transverse shaft fractures of the distal phalanx left without support too early may result in an apex volar malunion or nonunion after being repeatedly subjected to pinch forces. Micro-sized headless variable pitch screws can be used for percutaneous compression of P3 shaft nonunions, but caution is still required in assessing the relationship of the screw to the sagittal plane dimension of P3, risking both fracture extension and damage to the overlying nail apparatus (Fig. 30-99).81 Other distal phalanx nonunions may have sufficient bone loss as to require supplementary bone graft (Fig. 30-100).25,129 If no bone loss is present, simple compression across a tubular bone hypertrophic nonunion with a short plate should be sufficient to achieve healing. If bone loss is present, a longer plate and corticocancellous or cancellous bone graft may be required. 
Figure 30-99
 
Nonunions of the distal phalanx shaft can be managed by adding compression across the nonunion site with a headless, variable pitch, cannulated micro screw; healing is prolonged.
Nonunions of the distal phalanx shaft can be managed by adding compression across the nonunion site with a headless, variable pitch, cannulated micro screw; healing is prolonged.
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Figure 30-99
Nonunions of the distal phalanx shaft can be managed by adding compression across the nonunion site with a headless, variable pitch, cannulated micro screw; healing is prolonged.
Nonunions of the distal phalanx shaft can be managed by adding compression across the nonunion site with a headless, variable pitch, cannulated micro screw; healing is prolonged.
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Figure 30-100
Some nonunions are primarily characterized by the lack of adequate bone stock and mostly require the dense packing of high-quality cancellous graft.
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Residual Instability

Residual instability following dislocation is rare distally, but more common proximally. All five CMC joints are quite subject to recurrent instability particularly with pure dislocation patterns rather than fracture-dislocations. The reason is that in pure dislocation, all the ligaments are ruptured and require ligament-to-bone or ligament-to-ligament healing. Fracture-dislocations usually occur with one or more stabilizing ligaments remaining attached to key bone fragments so that bone-to-bone healing restores joint stability. In one series, re-dislocation occurred in 6 of 56 dorsal fracture-dislocations of the PIP joint.29 Chronic instability following closed treatment of a complete MP joint RCL injury may need to be treated surgically. A small population of patients exists with chronic hyperextension laxity at the thumb MP joint that may be either passive (volar plate only) or active (involving the intrinsics) and may require surgical advancement of the volar plate for reconstruction and restoration of stability. Late symptomatic instability after finger CMC fracture-dislocation can be evaluated with lidocaine injection into the joint. If relief is provided, arthrodesis is a reliable way to eliminate the pain. The fifth CMC joint may be fused in 20 to 30 degrees of flexion with little long-term loss of hand motion, apparently through increased compensatory triquetrohamate motion. Thumb CMC painful residual instability is treated by ligament reconstruction rather than arthrodesis. 

Posttraumatic Arthritis

As in other locations throughout the body, intra-articular fractures and residual joint instability may cause accelerated hyaline cartilage wear and lead to posttraumatic arthritis. A poor correlation exists between the radiographic appearance of posttraumatic arthritis and clinical loss of function and pain. Patients should be managed for the arthritis on the basis of clinical deficits and not based on radiographic abnormality. Posttraumatic arthritis of the thumb MP joint can be successfully managed by arthrodesis with excellent overall hand function. Few other joints in the hand can be fused with so little impact on function (index and long finger CMC joints) (Fig. 30-101). Finger MP and PIP joint fusions result in tremendous loss of function. 
Figure 30-101
Index and long CMC joints tolerate fusion well without functional loss, especially when accomplished with low-profile fixation that avoids interference with the digital extensor tendons.
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Hardware Complications

K-wires are appropriate tools for performing internal fixation of hand fractures and occasionally for stabilizing dislocations but they can demonstrate complication rates as high as 15%.152 Pin tract infections are the most common complication seen. Infections used to be rare when pins were left in for less than 4 weeks and usually responded well to removal of the pin and administration of oral antibiotics. With the increasing prevalence of MRSA in the community, exposed pins pose a greater risk than in the past and may be more safely cut below the skin level. Another hardware complication is simply irritation of adjacent tissues such as overlying tendons by the presence of prominent hardware. Given the delicate and thin tissues of the hand, even implants measuring a few millimeters thick are enough to produce persistent symptoms for many patients. In one series, 7 of 57 patients required plate removal.124 Another series reported a complication rate of 82% following plate fixation for phalangeal fractures compared with 31% for metacarpal plates.171 A unique concern with plates, however, is the potential for delayed or nonunion in transverse metacarpal fractures (30%) as opposed to fracture sites with a broader interface (7%).60 

Tendon Rupture

Tendon ruptures can occur in association with dislocations of the joint adjacent to the site of tendon insertion. Failure to recognize this associated injury may occur with an inadequate examination. The consequence is usually a deformity posture such as mallet finger at the DIP joint or a boutonnière deformity at the PIP joint. Open reconstructions of chronic terminal tendon ruptures with either local tissues or free tendon grafts have not proven particularly successful. For disabling terminal tendon deficiencies in a high angle of flexion, arthrodesis of the DIP joint is a permanent and durable solution to the problem. The loss of motion associated with arthrodesis is not as well tolerated at the PIP joint where every effort should be made to restore active extension. Mild deformities especially when identified reasonably early may respond to a program of PIP extension splinting and DIP joint flexion exercises. Success is dependent on the natural tendency of collagen-based scar to contract. For more substantial deficiencies, surgical reconstruction with local tissues or a free tendon graft may be required once passive motion has first been regained through either rehabilitation or a previously staged surgical capsulectomy. 

Nail Matrix

Nail deformities can occur when a crush mechanism of injury includes the zone of the nail or when fixation hardware damages the delicate matrix tissues. Temporary or permanent passage of fixation devices through the region of the germinal matrix should be avoided, and sterile matrix penetration should be either temporary or by suture material. A rare but troublesome complication is entrapment of the germinal matrix in a transverse fracture gap (which can occur with a reasonably normal external appearance of the digit) that both prevents fracture healing and results in permanent nail deformity (Table 30-17). 
 
Table 30-17
Common Adverse Outcomes and Complications
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Table 30-17
Common Adverse Outcomes and Complications
Infection
Stiffness
Hypersensitivity
Malunion and deformity
Nonunion
Residual instability
Posttraumatic arthritis
Hardware complications
Tendon rupture
Nail matrix abnormalities
X

Summary, Controversies, and Future Directions

Decision-Making

There is not a great deal of controversy surrounding the technical methods of reduction and fixation for fractures and dislocations of the hand. Controversy is much greater when it comes to deciding how specific fractures and dislocations should be managed. Most surgeons understand and accept the basic principle that the least invasive method should be employed that will result in stable, anatomically correct healing and still permit enough motion rehabilitation to achieve a useful and functional final result. The problem lies in the fact that the data simply do not exist anywhere in the published literature to definitively link specific treatment strategies to the many different fracture patterns that exist. Each of the various small bones in the hand (P3, P2, P1, metacarpal) responds to treatment differently. There are numerous varieties of the fracture pattern alone in each of these bones, not to mention the associated soft tissue injuries that impact final outcome substantially. No study has used sufficiently rigorous statistics to separate all the groups and stratify the results. The same holds true for dislocations. 
The area where decision-making becomes particularly difficult is that of coordinating more complex reconstructions involving multiple tissues. When the original management of skeletal trauma to the hand yields unsatisfactory results, secondary surgery may be required. The timing and order of events is very much a matter of individual surgeon experience and preference. The foundation for good hand function is a stable inner skeletal structure and a well-vascularized and supple outer envelope of integument. These are the first steps to be accomplished in any reconstruction. The next step is to ensure passively supple joints that are also stable. This infrastructure is then powered by three groups of tendons responsible for active motion in the hand: the extrinsic extensors, the extrinsic flexors, and the intrinsics. Good motion facilitates interaction with the environment, a function that also requires sensibility. Reconstructive surgery of nerves is well timed to coincide with tendon procedures. Three stages have been outlined here, but this does not necessarily mean that three distinct surgical procedures are required. Judging, which combinations of procedures will yield the best results, is the province of an experienced revision hand surgeon. In general, procedures that require the same type of rehabilitation may be combined whereas those that have disparate therapy goals should be separated as distinct surgical events. When a series of surgical procedures is staged, tissue homeostasis after the former procedure should be achieved before executing the subsequent procedure. 

Posttraumatic Arthritis

The only alternative to arthrodesis apart from microvascular whole joint transfer was previously the implantation of a Swanson-type one piece silicone prosthesis with the attendant high rates of prosthetic fracture and generation of silicone debris leading to osteolysis. Since earlier editions of this text, new prosthetic implants have become available for total joint replacement of the MP and PIP joints. There are models with metal on polyethylene-bearing surfaces as well as pyrolytic carbon-bearing surfaces. Rates of loosening, osteolysis from debris, and prosthetic breakage will determine if these models offer a new opportunity for improved hand motion and function to those with posttraumatic arthritis in the MP and PIP joints. Prosthetic hemiarthroplasty for unreconstructable intra-articular fractures with cartilage loss is being explored, but long-term wear tolerance has yet to be proven.78 

Managing Skeletal Loss

Skeletal loss can occur at either periarticular locations or in the diaphysis. Diaphyseal loss is by far the more straightforward issue. Current controversies relate to the choice of purely cancellous graft with bridge plating as opposed to corticocancellous grafts. Additional controversy exists regarding the timing of bone grafting for open fractures. The traditions have been corticocancellous grafts with delay. New trends are for immediate grafting after extensive debridement and using purely cancellous graft.151 Osteoarticular defects can be replaced with nonvascularized osteoarticular autografts as long as the defect only involves at most one-half of a joint.91 Partial toe joint osteochondral grafts to the PIP joint of the hand resulted in significant motion loss in three of five cases and resorption in one.62 The most common sites requiring partial osteoarticular grafts are single condyles at the head of P1 and the volar base of P2. Toe PIP joints provide well-matched condyle donor sites. The dorsal portion of the hamate provides an excellent donor site for the volar base of P2. Nonvascularized whole joint transfers have been unsuccessful. If an entire joint requires autogenous replacement, a vascularized whole joint transfer from the foot is required. Unique cases offer the opportunity to create a pedicled, vascularized whole joint transfer from one unsalvageable digit to an adjacent digit. 

Associated Wounds

Achieving stable wound coverage is a prerequisite to any other reconstruction. It is often performed at the same time as skeletal reconstruction and should be performed prior to most other reconstructions except first-stage tendon grafting. Methods of wound reconstruction include primary closure, secondary closure, split- or full-thickness skin grafts, transposition flaps, pedicle flaps, and free flaps. The simplest strategy that provides for optimum gliding of subjacent structures without contracture formation should be chosen. The challenge for more complex wounds that require flap reconstruction in the hand is finding tissue that is both supple and thin. Current trends are for earlier applications (within 72 hours) of increasingly thinner flaps. A useful strategy involves fascial flaps that are covered with split-thickness skin grafts. The lateral arm flap inverted to orient the muscular surface to receive the skin graft has performed particularly well in this respect.76 The fascia overlying the serratus anterior is thin with a reliable, large, and long pedicle. One criticism of skin-grafted fascial flaps is that they are slightly more difficult to operate through at the time of further revision compared with cutaneous flaps. The current trend in microsurgery for perforator flaps has spawned a number of cutaneous flaps thin enough for use around the hand, wrist, and forearm but not the digits. 

Bioabsorbable Implants

A polylactic acid plate and screw system tested in vitro showed maintenance of strength for 8 weeks comparable to titanium but then degraded with loss of strength over 12 weeks under four-point bending stress.15 Testing in 112 fresh-frozen cadavers of 2-mm poly-L/DL-lactide plates demonstrated an overall stability comparable to that of 1.7-mm titanium plates.178,179 Studies such as these appear in the literature, but the regular use of bioabsorbable implants in the hand simply has not caught on clinically. One concern may be reports of sterile abscess formation around implants of the same materials used in other orthopedic applications. In a small series of 12 cases, 2 lost reduction and 3 demonstrated a sustained excessive soft tissue reaction to the implant of copolymer L-lactide and glycolic acid with keloid formation.45 Since the last edition of this text there has been no apparent advance toward greater use of bioabsorbable implants for hand fractures. 

Summary

Fractures and dislocations of the hand represent a diverse group of injuries that share a common theme in management. The hand is a delicate organ that requires both stability and flexibility; function follows form. Although rough guidelines can be drawn from the published literature, it remains the responsibility of individual surgeons to judge which fractures and dislocations can be managed by each of the various methods discussed in this chapter. 
There are three basic treatment options for most fractures and dislocations of the hand: splinting, CRIF, and ORIF. Many fractures and the majority of dislocations in the hand have enough inherent stability to be managed nonoperatively. Testing for inherent stability in the office setting using active motion under the protection of injectable anesthetics should demonstrate those fractures and dislocations that can safely be managed without surgery. Malrotated, multiple, high-energy, and open fractures are usually treated operatively. CMC dislocations and fracture dislocations (unlike MP and PIP joint injuries) are usually treated operatively. The majority of operatively treated hand fractures and dislocations are closed and isolated injuries for which CRIF is usually an appropriate method. The exceptions to this are noted throughout the chapter. A few select injury patterns such as intra-articular P2 base fractures have specific and unique treatments that must be remembered and used according to the indications described. Once underway with treatment, one should stay focused on edema control and promoting early motion. The final steps to a successful outcome lie in avoiding complications such as nerve hypersensitivity and pin tract infections. When complications do occur, the key is in planning a well-thought-out correction in terms of risk benefit analysis and staging. Finally, patients should be counseled regarding expectations, which are that fractures and dislocations of the hand produce swelling, stiffness, and aching that frequently takes more than a year to overcome. 

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