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A 34-year-old male sustains the closed finger injury shown in Figure A one week ago. He undergoes closed reduction and pinning shown in Figure B to correct alignment. Which of the following is responsible for the apex palmar fracture deformity noted on the preoperative radiographs?
Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx
Intrinsic muscle fibrosis and intrinsic minus contracture
PIP joint volar plate attenuation and extensor tendon disruption
Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands
Flexor tendon disruption with associated overpull of the extensor mechanism
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The clinical presentation is consistent with a transverse proximal phalanx fracture. These fracture have an apex palmar angulated deformity under the indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx.
If proximal phalanx fractures are allowed to heal with the apex palmar deformity, an extensor lag will result. Therefore CRPP or ORIF is indicated in transverse fractures with > 10° angulation. To correct this deformity prior to surgical fixation, the MCP joint should be flexed, which allows the extensor mechanism as a whole to function as a tension band to help reduce the fracture. This is referred to as intrinsic plus splinting. Collateral ligament, capsule, and intrinsic muscle attachments render transverse fractures in the proximal 6 to 9 mm of the P1 base more stable than fractures located distally.
Henry provides a review of fractures of the proximal phalanx and metacarpals. He states that most transverse or short oblique P1 fractures without comminution are best stabilized by two 0.045-inch K-wires placed longitudinally through the fully flexed MCP joint. A single wire alone risks rotational malunion, but some fracture patterns may provide inherent rotational stability that would allow use of one wire for angular control.
Figure A shows a transverse fracture of the proximal phalanx with apex volar angulation. Figure B shows two K-wires placed transarticular through the MCP joint in a flexed (intrinsic plus) posture to correct the deformity and stabilize the fracture.
Answer 2: Intrinsic muscle fibrosis and contracture is usually associated with chronic crush injuries and significant soft tissue damage.
Answer 3: This is describing a swan neck deformity.
Answer 4: This is describing a Boutonnierre deformity.
Answer 5: Flexor tendon disruption is not likely in this closed injury pattern.
J Am Acad Orthop Surg. 2008 Oct;16(10):586-95. PMID: 18832602 (Link to Abstract)
HPI - A 32-year-old male, right hand dominant, is involved in a bar altercation when he punched the skull of another individual. The patient had immediate pain in his right hand and went to the emergency room. An initial reduction was performed and the patient was placed in a splint. Post reduction films are shown. He presents to your office 4 days after the injury.
How would you treat this fracture assuming there has been no change in the post reduction films?
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What is the optimal treatment for the proximal phalanx fracture shown in Figure A?
Open reduction and placement of two 0.045-inch K-wires placed longitudinally through the metacarpal head
Application of a 1.5-mm straight plate applied dorsally through and extensor tendon splitting approach
Open reduction and lag screw fixation with 1.3mm screws through a radial approach
Placement of a 1.5-mm condylar blade plate through a radial approach
Open reduction and retrograde passage of two 0.045-inch K-wires retrograde trough the PIP joint
Open reduction and lag screw fixation through a radial approach is the treatment of choice for long oblique proximal phalanx fractures.
Lag screws (1.3 mm is preferred to 1.5 mm) can achieve stability through interfragmentary compression in a two-part spiral or long oblique fracture of the proximal phalanx that rivals the stability of an intact bone. This capability, combined with the need to achieve precise correction of rotation in spiral fractures, makes open reduction and lag screw fixation the treatment of choice for the spiral P1 shaft fracture.
Kawamura et al. discuss the treatment options for closed phalangeal and metacarpal fractures. They state that percutanous fixation with K-wires can be successful in the setting of an adequate closed reduction. However, lag screw fixation may be the best choice for open fixation of long oblique phalangeal and metacarpal fractures.
Henry et al. outline the methods of stablization for phalangeal and metacarpal fractures. With regards to long oblique proximal phalanx fractures, they state that open reduction and lag screw fixation the treatment of choice for the spiral P1 shaft fracture. This is due to the lack of inherent stability of the long fracture segment, and the tendency for the fracture to shorten even in the presence of smooth k-wire fixation.
Freeland et al. provide a review which cites new developments in the treatment of extra-articular hand fractures in adults.
Figure A shows a long obligue fracture of the index finger proximal phalanx. Illustration A demonstrates fixation of this injury with interfragmentary lag screws.
Answers 1,5: Most transverse P1 fractures without comminution are best stabilized by two 0.045-inch
K-wires placed longitudinally through the metacarpal head or PIP joint, depending on the location of the fracture.
Answers 2,4: Application of plates is usually reserved for comminuted bicondylar phalanx fractures, and is performed through a radial approach if possible to avoid postoperative adhesions.
Kawamura K, Chung KC
Hand Clin. 2006 Aug;22(3):287-95. PMID: 16843795 (Link to Abstract)
Freeland AE, Orbay JL
Clin. Orthop. Relat. Res.. 2006 Apr;445:133-45. PMID: 16505726 (Link to Abstract)
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HPI - 20 year old male presents with finger pain after a fall on outstretched hand. Closed injury. XRays are shown.
Is the current position of the fracture acceptable?
HPI - 1st surgery 3 Months ago open fracture middle phalanx index finger treated with a mini plate. It resulted in skin necrosis and non union.
2nd surgery reverse cross finger flap and K wire fixation.
How would you have treated this OPEN middle phalanx fracture on INITIAL presentation (see preoperative images above)?
HPI - acute injury with cricet ball while playing cricket
How would you treat this injury?
HPI - fall in the washroom
operative or conservative