Acute open reduction and rigid internal fixation of proximal interphalangeal fracture dislocation

We report the application and results of a technique of open reduction and rigid internal fixation of dorsal fracture/dislocation screw in two cases. Articular was stabilized. approach, of the proximal interphalangeal congruity was restored, joint with an interfragmentary joint exercises. Excellent results the surgical and the proximal interphalangeal

joint

This technique permitted immediate range-of-motion

were obtained in both cases. Previous descriptions or the results of this technique.

have not detailed the indications,

(J HAND SURC 1992;17A:512-7.)

Andrew Edward

Green, Akelman,

MD,

Jennifer

Smith,

OTR/L,

CHT, Maureen

Redding,

RPT, CHT,

and

MD, Providence,

R.I.
orsal fracture/dislocation of the proximal interphalangeal (PIP) joint is a relatively common and potentially disabling injury of the finger. Secondary joint stiffness, persisting subluxation, degenerative arthritis. and pain are common sequelae. There are many descriptions of closed treatment,4-7 and some authors support open treatment in appropriate cases. , 3. 8 However. there are only a few reports of the results of open treatment.. 9-3In most, the final result represents a significant reduction in PIP joint range of motion.

From the Department of Orthopaedics and the Division of Hand, Upper Extremity and Microvascular Surgery, Rhode Island Hospital/Brown University, Providence, R.I. Received for publication Oct. 23, 1990; accepted in revised form
Aug. 23, 1991. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Andrew Green. MD, Department of Orthopaedics,

Rhode Island Hospital, 593 Eddy St., Providence. RI 02903. 3/l/34139

Fig. 1. Case 1. A, Position after closed reduction; palmar base fracture is rotated, phalanx is dorsally subluxated. B, Splinted position after closed manipulation.

and middle

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THE JOURNAL

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Pro.wimtrl interphalangeal joint fracture dislocation

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Fig ;. 2. Case 1. Palmar base fragment fixed with A0 minifragment B, Anteroposterior view.

screw. A, Lateral view.

sue :cessful treatn nent is predicated on achieving accurate red uction, preve nting chronic instability, and preserving pain-free rar ige of motion. Frevious repot .ts have described open reduction and

internal fixation (ORIF) with Kirschner (K-j wires and interosseous wiring or fragment excision and pal plate arthroplasty. Recent refinements of the AOiA SIF instrumentation have permitted the wide-range aI )pli-

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The Journal of HAND SURGERY

Fig. 3. Case 2. Position rotated.

after closed

manipulation

of PIP joint;

palmar

base fragment

is

Fig. 4. Case 2. Palmar base fragment fixed with A0 minifragment

screw.

Fig. 5. Palmar base fragment gitudinally.

fixed with A0 minifragment

screw. The palmar plate is split lon-

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Fig. 6. Case 1. X-ray follow-up at 12 months. A, Lateral view. B, Anteroposterior view cation of the principles of anatomic rigid internal fixation 1 fractures in the hand.14. I5 Although the use of to minift .agment screws for dorsal PIP joint fracture/dislocatic Ins is suggested,. l5 we were unable to find a report in the literature that described a surgical approach or restults. We have used ORIF in the treatment of two patients who rsustained dorsal fracture/dislocation of the PIP joint. In both cases an anterior apprcoath wa s used to perform articular reduction, and fixat ion was achieved with minifragment cortical screws. Case reports Case 1. A 16-year-old right-handed all-state basketball player jammed his right long finger durin g a game :. A dorsal PIP joint fracture dislocation was redu ted by Ilis coach.

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The palmar plate was not detached. Anatomic reduction of the fragment was held with a small K-wire. Next a 1.5 mm screw hole was drilled and tapped, and a 2 mm minifragment cortical screw was placed through the palmar fragment and into the middle phalanx (Fig. 5). A lag technique was not required to achieve fixation. The longitudinal palmar plate incision was closed with absorbable suture, and the flexor tendon sheath was closed with 6-O nylon suture. Hand therapy. In both cases progressive active and passive range of motion were begun on the first postoperative day. Intrinsic plus palmar splinting was used. The first patient was splinted in full extension for 5 weeks, and the second was splinted with a 15-degree

Fig. 7. Case 1. Clinical follow-up at 6 months

X-ray films demonstrated dorsal subluxation and a large rotated anterior articular fragment (Fig. 1, A). Splinting reduced the subluxation, but the joint surface remained incongruous (Fig. 1, B). ORIF was performed on day 5 to stabilize the joint and correct the articular incongruity (Fig. 2).
woman fell at work and jammed her right long finger (Fig. 3). Closed reduction of a dorsal PIP joint fracture/dislocation was considered inadequate because of dorsal subluxation and fragment rotation. ORIF was performed electively on day 8 to correct articular incongruity and stabilize the joint (Fig. 4).

joint.8.

Case 2. A 29-year-old right-handed

Materials and methods Surgical technique. A palmar zigzag skin incision was made with elevation of an ulna-based flap at the level of the flexor tendon sheath. The flexor tendon sheath was opened through a rectangular flap. The flexor tendons were retracted to expose the palmar plate and the fracture site. In both cases the fracture fragment was avulsed from the base of the middle phalanx by the palmar plate and its articular surface was rotated 90 degrees into the fracture site. Longitudinal division of the palmar plate permitted exposure of the PIP joint and created a bare bony surface on the palmar fragment.

only palmar plate injury or small avulsion fractures of the palmar base of the middle phalanx. Less commonly, there is a more extensive fracture of the middle phalanx. In many cases, extension block splinting can be used in treatment. The anatomy of the palmar plate complex and the extent of injury are crucial determinants of treatment selection for dorsal fracture/dislocations of the PIP 17 Fractures that involve more than about 35% to 40% of the articular surface are associated with complete disruption of the collateral accessory ligament complex. In these cases maintenance of reduction through closed techniques may not be possible. Fractures with single anterior fragments can be rotated and be irreducible. ORIF has been advocated for such acute injuries with minimal comminution. Previous reports have described K-wire or interosseous cerclage wire fixation through either a midlateral or a palmar approach, and most have recommended K-wire stabilization of the PIP joint., . 9-. Eaton and Malerich advocated palmar plate arthroplasty for comminuted fractures with articular incongruity. Most authors recommended early surgery when indicated. The majority of these injuries can be treated with closed reduction, splinting, and early motion. In some instances, however, this is not possible, and ORIF is required. Most reports have emphasized prevention of
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persistent subluxation rather than correction of articular incongruity. The joint incongruity in our cases is probably unique and, in our opinion, warranted open reduction and internal fixation in these young and active patients. Although it is technically demanding, our method of ORIF has the significant advantage of achieving rigid anatomic fixation of the fracture and repair of the palmar plate complex. This stabilizes the joint, obviates the need for transarticular fixation, and permits almost immediate range-of-motion exercises. In addition, avoiding the collateral ligaments with the palmar approach may contribute to improved range of motion. Use of a lag technique for minifragment screw fixation can be technically difficult and may not be required for fixation of metaphyseal bone fragments. REFERENCES
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