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Average 4.2 of 33 Ratings
A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. Which of the following is true regarding open reduction and screw fixation of this injury?
High risk of symptomatic implant
Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively
High rates of post-operative infection are common
Open reduction via an approach through the nail bed leads to significant post-operative nail deformity
Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively
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Open reduction and internal fixation of distal phalanx fracture non-unions frequently requires the post-operative removal of the fixation implant after complete fracture healing.
Chim et al followed 14 patients with non-union of fractures of the shaft of the distal phalanx who were treated with open reduction and screw fixation. The implants required removal in 13/14 patients, and the mean post-operative range of motion of the DIP joints was 56 degrees. No immobilization was required postoperatively, and bone grafting was only necessary in two patients with severely comminuted fractures. Finally, the authors recommended approaching the fracture through the nailbed for the best exposure, and found no postoperative nail growth complications. Postoperative infections were not common in their series.
Mejis et al describe two patients with non-unions of the thumb distal phalanx treated with a single compression screw using a minimally invasive approach. Both patients healed their fractures using this technique.
Meijs CM, Verhofstad MH
J Hand Surg Am. 34(6):1127-9. PMID: 19442455 (Link to Abstract)
Meijs, JHS 2009
Chim H, Teoh LC, Yong FC
J Hand Surg Eur Vol. 2008 Feb;33(1):71-6. PMID: 18332024 (Link to Abstract)
Chim, JHS 2008
Please rate question.
Average 1.0 of 60 Ratings
What is the most frequently encountered form of osseous injury associated with dorsal proximal interphalangeal joint(PIP) fracture-dislocations?
Middle phalanx palmar lip fractures
Proximal phalanx extraarticular fractures
Middle phalanx dorsal lip fractures
Middle phalanx dorsal and palmar lip fractures (pilon)
Proximal phalanx palmar lip fractures
Middle phalanx palmar lip fractures are the most frequently encountered form of osseous injury associated with dorsal PIP joint fracture-dislocations. Pure PIP joint hyperextension often disrupts the palmar plate either at its distal insertion or by creating a tension fracture at the palmar lip of the middle phalanx.
The review article by Kiefhaber and Stern detail that the restoration of the middle phalangeal base to glide around the proximal phalangeal head during the flexion arc is the primary goal. Hinging (instead of articular gliding) at the fracture site must be avoided by eliminating joint subluxation and then re-establish joint stability to prevent recurrent subluxation. Early motion of the PIP and anatomic restoration of the fractured joint surface is a desirable but is secondary compared to reduction of the middle phalanx on the condyles of the proximal phalanx.
Illustration A demonstrates a middle phalanx palmar lip fracture.
Kiefhaber TR, Stern PJ.
J Hand Surg Am. 1998 May;23(3):368-80. PMID: 9620177 (Link to Abstract)
Kiefhaber, JHS 1998
Average 3.0 of 11 Ratings
A 28-year-old professional baseball player injures his middle finger sliding into the catchers shin guard at home plate. He complains of pain and deformity of the middle finger. A radiograph is provided in figure A. All of the following are true EXCEPT:
Anatomic reconstruction of the articular surface is prognostic of clinical function
Proximal interphalangeal joint subluxation precludes a normal gliding flexion arc
Hinging at the fracture site must be avoided
Early motion should be initiated in postoperative therapy
Early degenerative arthritis can be expected if the joint is not adequately reduced.
The radiograph demonstrates a dorsal fracture dislocation of the proximal interphalangeal joint of the middle finger. Kiefhaber and Stern review the presentation, evaluation, and treatment of PIP fractures. Congruent reduction of the joint to allow the middle phalanx to glide around the proximal phalangeal head is paramount to prevent joint subluxation and instability. Anatomic reconstruction of the articular surface is desirable but not necessary for successful clinical outcome.
HPI - 1 week old injury over finger Rt ring finger, treated by bone setter.
How would you treat this fracture-dislocation?
Average 1.0 of 80 Ratings
A 20-year-old football player presents with a one week history of right index finger pain which started after his hand got caught in a face mask during a tackle. Physical exam shows swelling of the digit with no breaks in the skin, and no active flexion. AP, lateral, and oblique radiographs are provided in Figures A, B, and C respectively. Which of the following structures most often prevents closed reduction of this injury?
Figures A, B, and C demonstrate a dorsal dislocation of the DIP joint without associated fracture.
Abouzahr et al conducted a case report and literature review on irreducible dorsal DIP dislocations. The authors found that the most common block to reduction with a closed injury is an interposed volar plate, which is avulsed from its origin on the middle phalanx. They recommened open reduction and extraction of the volar plate if one is unable to achieve concentric stable reduction after two attempts. Furthermore, the authors determined that in open injuries, the FDP tendon is primarily responsible for irreducibility. The collateral ligaments are less likely to be involved in this case because there is little coronal deformity present. The dorsal capsule is typically not a block to reduction, and the central slip is disrupted (but does not block reduction) in volar PIP joint dislocations.
Abouzahr MK, Poblete JV.
J Trauma. 1997 Apr;42(4):743-5. PMID: 9137270 (Link to Abstract)
Abouzahr, JTACS 1997
Average 3.0 of 14 Ratings
A 27-year-old man falls on his hand at work. He notices an immediate deformity of his ring finger. Radiographs are provided in Figure A. Which of the following is the most appropriate initial treatment?
Closed reduction, buddy taping, and early motion to prevent stiffness
Closed reduction and full time extension splinting
Open reduction and repair of the central slip of the extensor tendon
Open reduction and repair of the volar plate
Amputation and immediate return to work
The radiograph demonstrates a volar PIP dislocation. The central slip of the extensor tendon is frequently ruptured and will lead to a boutonneire deformity if left untreated. The PIP must be immobilized in extension to allow the extensor mechanism to heal. Immobilization in extension should be maintained for 6 weeks to allow soft tissue healing. Open reduction and repair of the central slip would be the appropriate treatment for a developing boutonneire deformity that presents in a subacute or chronic time basis.
Illustrations A and B demonstrate a schematic and clinical photo of central slip disruption and secondary deformity with PIP flexion and DIP hyperextension (Boutonniere Deformity).
Posner et al reviewed 7 patients with chronic palmar dislocations of the PIP joint who were treated with open reduction and reconstruction of the extensor mechanism. All patients acheived satisfactory range of motion and the authors concluded that this technique is preferable to arthrodesis.
Peimer et al reviewed 15 patients with palmar dislocations of the PIP joint. Twelve of the fifteen were evaluated on a delayed basis (average 11 weeks following injury) and underwent open reduction and surgical repair of the extensor tendon. Three of the fifteen were seen earlier following injury and were treated with closed reduction and pinning. All fifteen patients acheived satisfactory clinical outcomes although finger range of motion was not fully recovered in any case.
Posner MA, Kapila D.
J Hand Surg Am. 1986 Mar;11(2):253-8. PMID: 3958459 (Link to Abstract)
Posner, JHS 1986
Peimer CA, Sullivan DJ, Wild DR.
J Hand Surg Am. 1984 Jan;9A(1):39-48. PMID: 6693741 (Link to Abstract)
Peimer, JHS 1984
Average 3.0 of 21 Ratings
A collegiate baseball player injures his left small finger sliding into third base. He complains of pain and swelling. The finger is ecchymotic, swollen throughout, and painful with attempted range of motion of the PIP joint. No sensory or vascular deficits are present. A radiograph is provided in Figure A. Which of the following interventions will provide the best outcome?
Buddy taping the small finger to the ring finger
Immobilization of the MCP in flexion and the PIP and DIP in extension with a custom splint
Open reduction internal fixation
PIP joint arthrodesis
The radiograph shows an oblique fracture of the distal proximal phalanx that extends into the joint with an articular step off. Open reduction internal fixation will correct the deformity, expedite finger rehabilitation, and prevent early degenerative arthritis. Closed treatment without fixation will not reliably hold the fracture reduced while the bone heals. Arthrodesis is unnecessary in this young, active patient.
Average 4.0 of 21 Ratings
HPI - 10 days old injury left middle finger, treated with finger splint
Would you get a CT scan to determine proper treatment?