Review Question - QID 219806

This 32-year-old male sustained an unstable dorsal PIP fracture-dislocation of the long finger middle phalanx, which was treated with open reduction, internal fixation (ORIF) to ensure a congruent proximal interphalangeal joint (PIPJ). The most likely complication following this surgery would be loss of motion (Answer 3).

Phalanx fractures are ubiquitous injuries, with a high predilection for those engaging in contact sports. While the majority of these fractures can be treated nonoperatively, length-unstable extra-articular fractures, rotational deformities, and unstable intra-articular fractures often necessitate surgical intervention. The latter entity is deemed unstable when fracture displacement occurs; the fracture comprises greater than 30% of the joint, or the finger requires greater than 30 degrees of PIP flexion to maintain reduction regardless of fracture size. Many treatment options exist, including external fixation, closed reduction percutaneous pinning/extension block pinning, ORIF, hemi-hamate arthroplasty, and volar plate arthroplasty. Regardless of treatment, the most common complication to arise following the surgery includes loss of motion secondary to prolonged.

Elfar and Mann examine the pathoanatomy, evaluation, and treatment of fracture-dislocations associated with the PIP joint. The authors report a fracture fragment comprising less than 30% of the joint is likely stable, while anything between 30-50% is tenuous, and anything above 50% is considered unstable. The authors also postulate outcomes as largely dependent on a well-aligned, well-reduced joint, which restores normal joint kinematics and, thus, motion. They conclude the outcomes for a specific injury is predicated on expedient diagnosis and recognition of injury severity, which enables the initiation of appropriate management.

Hamilton et al. performed a retrospective review of 9 patients receiving mini-screw fixation (1.1-2 mm in size) to manage unstable PIPJ fracture-dislocations (comprising a mean articular surface percentage of 56%), with a mean follow-up of 3.5 years. The authors noted a 21-degree difference in ROM in the PIPJ (70 vs. 91 degrees), with an average flexion contracture of 14 degrees in the affected finger. Moreover, the authors noted incremental decreases in ROM as more fracture fragments were present. While the authors acknowledge mini-screw fixation can be performed for fractures with multiple fragments, the most appropriate candidates are those with one large fracture fragment.

Figures A & B represent orthogonal views of the left middle phalanx demonstrating a PIP fracture dislocation comprising 40% of the joint with dorsal subluxation.

Incorrect Answers:
Answers 1,2, 4, and 5: while these complications can and do occur, they do not occur at the frequency as loss of motion.