[David C. Ring, Mark Cohen] Fractures of the Hand
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Transcript of [David C. Ring, Mark Cohen] Fractures of the Hand
of the Handand Wrist
DK3459_FM.indd 1 1/2/07 5:10:41 PM
DK3459_FM.indd 2 1/2/07 5:10:41 PM
New York London
Edited by
David C. RingMassachusetts General HospitalBoston, Massachusetts, U.S.A.
Mark S. CohenRush University Medical Center
Chicago, Illinois, U.S.A.
of the Handand Wrist
DK3459_FM.indd 3 1/2/07 5:10:41 PM
Informa Healthcare USA, Inc.270 Madison AvenueNew York, NY 10016
© 2007 by Informa Healthcare USA, Inc. Informa Healthcare is an Informa business
No claim to original U.S. Government worksPrinted in the United States of America on acid‑free paper10 9 8 7 6 5 4 3 2 1
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Preface
Fractures of the hand and wrist are among the most common musculoskeletal
injuries sustained by orthopedic patients. In fact, most people will suffer from
such an injury at some point in their lives. Although treatment is typically
straightforward, several pitfalls exist that often require the attention of a
trained specialist.
Our international panel of expert hand surgeons provides insights into new
developments and techniques for both basic and more challenging management
and treatment problems. Discussion of hand and wrist fractures is broken down
into chapters focusing on distal phalanx fractures, fingertip crush injuries,
phalangial shaft fractures, metacarpal fractures, carpal fracture dislocations,
and scaphoid fractures. Special attention is given to challenging proximal inter-
phalangeal fracture-dislocations, including evolving concepts in fixation and
arthroplasty, and the treatment of distal radius fractures.
We hope we have created a readable text for easy reference or complete
review of the practical and up-to-date aspects of fracture care.
David C. Ring
Mark S. Cohen
iii
Editors’ Note
We hope that this book on hand and wrist fractures and dislocations will be useful
in the care of injured patients. Our co-authors were generous with their time and
talents, and we are sure that you will benefit, as we did, from their wisdom and
intelligence. We made no attempt to be comprehensive, but instead aimed for a
concise and practical review of current concepts. Few texts focus on skeletal
injury in the hand and wrist, and we hope this book will be a useful reference
for both straightforward and challenging problems.
David C. Ring
Mark S. Cohen
v
Contents
Preface . . . . iii
Editors’ Note . . . . v
Contributors . . . . ix
1. Distal Fingertip and Thumb Injuries . . . . . . . . . . . . . . . . . . . . . . . 1Adrian L. Butler and Mark Baratz
2. Phalanx Shaft Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Mark S. Cohen
3. Dislocations and Fracture Dislocations of the
Metacarpophalangeal and Proximal Interphalangeal Joints . . . . . 41Randy R. Bindra
4. Operative Management of Metacarpal Fractures . . . . . . . . . . . . . 75William B. Geissler and William O. McCraney
5. Carpal Dislocations and Fracture Dislocations . . . . . . . . . . . . . . . 91Santiago A. Lozano-Calderon and David C. Ring
6. Fractures of the Scaphoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115Satoshi Toh
7. Distal Radius Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137Karl-Josef Prommersberger and Thomas Pillukat
Index . . . . 189
vii
Contributors
Mark Baratz Division of Hand and Upper Extremity Surgery, Allegheny
General Hospital, Pittsburgh, Pennsylvania, U.S.A.
Randy R. Bindra Hand Surgery, University of Arkansas for Medical
Sciences, Little Rock, Arkansas, U.S.A.
Adrian L. Butler Philadelphia Hand Center, King of Prussia, Pennsylvania,
U.S.A.
Mark S. Cohen Department of Orthopedic Surgery, Rush University
Medical Center, Chicago, Illinois, U.S.A.
William B. Geissler Department of Orthopedic Surgery, University
of Mississippi Medical Center, Jackson, Mississippi, U.S.A.
Santiago A. Lozano-Calderon Department of Orthopedic Surgery,
Massachusetts General Hospital, Boston, Massachusetts, U.S.A.
William O. McCraney Department of Orthopedic Surgery, University
of Mississippi Medical Center, Jackson, Mississippi, U.S.A.
Thomas Pillukat Klinik fur Handchirurgie, Bad Neustadt, Germany
Karl-Josef Prommersberger Klinik fur Handchirurgie, Bad Neustadt,
Germany
David C. Ring Department of Orthopedic Surgery, Massachusetts General
Hospital, Boston, Massachusetts, U.S.A.
Satoshi Toh Department of Orthopedic Surgery, Hirosaki University School
of Medicine, Hirosaki, Aomori, Japan
ix
1
Distal Fingertip and Thumb Injuries
Adrian L. Butler
Philadelphia Hand Center, King of Prussia,Pennsylvania, U.S.A.
Mark Baratz
Division of Hand and Upper Extremity Surgery, Allegheny General Hospital,Pittsburgh, Pennsylvania, U.S.A.
INTRODUCTION
Distal fingertip and thumb injuries are among the most common hand injuries.
We audited the Internet-based National Occupational Health and Safety
Commission Worker’s Compensation Database and found that 32% of the
claims in 1999 and 2000 (approximately 70,000 of 220,000 claims) involved
the upper extremity. When considering only patients aged 30 or younger, 50%
of the claims involved the upper extremity (1). Among upper-extremity injuries,
the fingertip is the most commonly involved site.
Many fingertip injuries create open wounds and fractures of the distal
phalanx. The vast majority of these can be cared for in the emergency depart-
ment. Injuries requiring internal fixation or soft-tissue coverage for skin
defects may be more easily managed in an operating room. Particular attention
must be given to preserving the integrity of the nail bed and matrix as well as sen-
sation to the finger pulp. A complete understanding of the anatomy of the distal
phalanx is essential to care for these injuries.
1
ANATOMY
A distinctive feature of the finger is the nail plate. It provides a hard protective
surface as well as dorsal support of the terminal one-half of the distal phalanx.
This provides the finger with myriad functions such as picking, scratching,
scraping, and prying. The nail plate is composed of compact epidermal cells
that undergo macrocystosis (swelling), nucleolysis (loss of nuclei), and gradual
cell collapse and flattening. Toughness of the nail plate is derived through the
deposition of keratin (2–5). The fingernail grows from the germinal matrix
and over the nail bed (sterile matrix) at a rate of approximately 1 mm per
week (2,3).
The proximal and lateral nail folds and the distal groove surround the nail
and help mold the nail into shape. The proximal nail fold is termed the epony-
chium and includes the cuticle or perionyx. The lateral fold is the perionychium,
and the terminal groove is the hyponychium (Fig. 1).
The lunula—the junction of the nail plate and matrix—decreases in size
from the thumb to the small finger. The light color of the lunula results from
Eponychium(A)
(B)
Nailwall
Insertion ExtensorTendon
Dorsal roofNail
foldVentral floor
Distal
interphalangeal
joint
Lunula
Nail bed
Hyponychium
Periosteum
LAT. NAIL FOLD
(PARONYCHIUM)CUTICLE
(PERIONYX)
PROX. NAIL FOLD
(EPONYCHIUM)
LUNULA
NAIL BED NAIL MATRIX
HYPONYCHIUM
granulosa cell layer
NAIL PLATE
Figure 1 Illustration of fingertip anatomy.
2 Butler and Baratz
incomplete cornification and the fact that, proximally, the nail bed does not
adhere to the nail plate (5). The perionyx or cuticle is fixed to the nail
plate, and the nail plate to the nail bed. The extraordinary adherence of the
nail plate to the nail bed stems from a corneous substance that is produced
by the epidermis beneath the nail. More proximally, the nail plate is softer
and more flexible with a loose attachment at the germinal matrix and
lunula (2). This becomes important when dealing with nail plate avulsions.
When the nail plate is injured proximally, it can avulse from the germinal
matrix but remain firmly attached to the cuticle and nail bed. The nail bed
has, in turn, a strong attachment to the periosteum of the distal phalanx.
As a result, distal nail plate injuries will usually result in lacerations to the
underlying nail bed with partial or complete detachment of the nail plate.
The variable adherence of the nail plate from distal to proximal can be rel-
evant in treating fingertip amputations. In order to have a stable adherent
nail plate, at least 5 mm of healthy nail bed distal to the lunula is required (5).
Sensation to the fingertip is provided by the radial and ulnar digital nerves.
The pulp of the finger is highly vascular with many arterioles (rete arteriosum)
branching and extending distally off a transverse arterial arch. Two additional
arterial arches are present dorsally: one at the level of the germinal matrix
(arcus unguicularis proximalis) and a second at the middle of the nail bed
(arcus unguicularis distalis). Along the base of the nail is the transverse
arcus venosus, which provides the majority of the venous outflow of the distal
fingertip (2,3).
Discriminatory sensation is evaluated by “two-point” testing. Normal
two-point discrimination is 5 mm or less. This degree of sensitivity comes by
virtue of a high concentration of Meissner’s corpuscles which sense light touch
and low-frequency vibration. Pacinian and Merkel mechanoreceptors help
sense pressure and constant touch, respectively. Ruffini end organs are also
present and sense both skin stretch and heat. Threshold sensitivity may be
tested using the Semmes–Weinstein monofilament test (6,7). Normal fingertip
monofilament values range from 1.65 to 2.83 (8). This is a useful tool for both
detecting and following the recovery of a dysfunctional nerve. These mechano-
receptors are present within the fat of the pulp, which is held by retinacular
septae to the palmar periosteum of the phalanx. The ungual tuberosity is the
site of attachment of these septae. This spade-like structure is unique to the
terminal aspect of the distal phalanx in homonids (9). The pulp of the fingertip
is a soft, highly sensitive and immobile fat pad which helps to disperse
contact pressures.
Both the extensor and flexor tendons insert on the distal phalanx proximal
to the germinal matrix. When evaluating injuries to the distal phalanx, it is
important to test for the function of these tendons. The average distance from
the terminal extensor tendon insertion to the proximal edge of the germinal
nail matrix was found to be 1.2 mm in a study of 16 cadavers (10). Internal
fixation of the terminal tendon places the germinal matrix at risk.
Distal Fingertip and Thumb Injuries 3
FRACTURES OF THE DISTAL PHALANX
Schneider classified fractures of the distal phalanx into tuft, shaft, and base frac-
tures (11). Additional consideration must be given to fractures that extend into the
distal interphalangeal (DIP) joint and those that involve extensor and flexor
tendon avulsion fractures.
Tuft and Shaft Fractures
Closed fractures of the tuft and shaft of the distal phalanx can be treated
nonoperatively. Surgical intervention should be considered for widely displaced
transverse fractures of the distal phalanx shaft, severely angulated fractures, and
injuries with complex wounds.
The vast majority of closed tuft and shaft fractures of the distal phalanx are
well-aligned and stable. Treatment is for comfort only as immediate active use of
the finger without immobilization will not affect the result. Immobilization of the
DIP joint for three to four weeks is reasonable for comfort. Fractures of the distal
phalanx shaft should be splinted until the phalanx is no longer significantly
tender. This typically takes three to four weeks. Radiographic evidence of
healing will lag behind clinical signs of healing.
Some physicians favor routine drainage of a substantial subungual
hematoma, whereas others only do this in an attempt to relieve severe pain.
There is very little room under the nail plate for hematoma expansion. A substan-
tial hematoma can cause severe pain, and there is a small risk of fingertip necrosis
(4). Perforating the nail plate to drain the hematoma provides substantial pain
relief. An 18-gage needle can be used to bore a small hole in the nail plate.
When the subungual hematoma occupies greater than 50% of the sterile matrix,
consideration should be given to complete nail removal and sterile matrix repair.
Widely displaced fractures of the distal phalanx are uncommon, but are
more likely to result in nonunion. Widely displaced and angulated fractures
may benefit from closed reduction and percutaneous fixation with a small
Kirschner wire (Fig. 2). In many cases, it is necessary to have the wire cross
the DIP joint to achieve adequate stabilization of the fracture. Stiffness of the
DIP is an expected consequence of a high-energy injury to the distal phalanx.
Temporary pinning of the DIP does not add substantially to DIP joint stiffness
and allows the surgeon to achieve the goal of a stable, aligned, and pain-free
fingertip.
Fractures at the Base of the Distal Phalanx
Flexor Digitorum Profundus Tendon Avulsion Injuries
Avulsions of the extensor and flexor tendons off the distal phalanx are frequently
associated with fractures at the base of the distal phalanx. Avulsions of the flexor
digitorum profundus tendons were classified by Leddy and Packer (12). Type I
injuries are ruptures of the tendon insertion from the bone with retraction of
4 Butler and Baratz
the tendon into the palm. Type II and III injuries involve bone attached to the
avulsed tendon. In Type II avulsions, the tendon retracts to the level of the prox-
imal interphalangeal (PIP) joint where it is held in place by intact long vinculum.
In Type III injuries, a relatively large bone fragment catches on the A4 pulley
Figure 2 Unstable distal phalanx fractures benefit from percutaneous Kirschner wire
fixation. (A) A young man crushed his fingertip. (B) The result was an unstable transverse
fracture of the distal phalanx. (C) A single longitudinal Kirschner wire provided adequate
stability after closed manipulative reduction. (D) The wire should cross the DIP joint in
order to gain adequate purchase and prevent an extensor lag. Abbreviation: DIP, distal
interphalangeal.
Distal Fingertip and Thumb Injuries 5
limiting tendon retraction to the level of the middle phalanx. Smith (13) described
an uncommon variant, that is, the base of the distal phalanx is avulsed from the
phalanx and the tendon is avulsed from the bone.
Type I injuries can be treated with primary repair within two to three weeks
of injury. Past this point a myostatic contracture of the musculotendinous unit
occurs, and it may be difficult to reattach without flexion of the finger, a maneuver
that may result in a permanent flexion contracture. A separate incision is
frequently required to retrieve the retracted tendon from the palm. The tendon
must be passed back through the flexor tendon sheath and pulley system. A
2–0 monofilament suture is woven through the end of the avulsed tendon
using a Bunnell stitch. The sutures and tendon are advanced through the
pulleys. The tendon is secured to the distal phalanx by passing the sutures on
heavy, straight needles on either side of the waist of the distal phalanx or
through the bone. The needles, with sutures, are passed through the nail bed
and nail plate and tied over the nail with a button. Alternatively, suture
anchors may be used, but with caution; care should be taken to avoid extending
the fracture from palmar to dorsal while creating the drill holes. In addition, when
this method is used, it is important to avoid penetration of the dorsal cortex with
the suture anchor.
Type II injuries are managed in a similar fashion. Because the vincula have
not been ruptured and the tendon has retracted only to the level of the PIP joint,
primary repair without excessive finger flexion is often possible up to four weeks
postinjury.
Repair of a type III injury is performed with the same method (Fig. 3). The
repair can be supplemented with one or two 0.035- or 0.045-inch Kirschner wires.
Occasionally, the fragment is large enough to accept a screw, but it may be wise
to protect this with a suture or Kirschner wire (Fig. 4).
Type IV injuries are very rare. The bone fragment can be repaired or
excised prior to tendon reattachment. Chronic injuries may be best treated
without surgery or with primary DIP fusion or tenodesis.
Terminal Extensor Tendon Avulsion (Mallet) Injuries
Mallet injuries with an avulsed bone fragment can, in most cases, be managed
with splinting of the DIP joint. The finger is examined with attention to the
degree of flexion at the DIP joint, passive extension of the DIP joint, and the
position of the PIP joint of the injured finger and the adjacent fingers (Fig. 5).
A finger with loss of active DIP extension, full passive extension, and no
swan-neck deformity is treated with a splint that holds the DIP joint in extension
(14–17). A wide variety of prefabricated and custom-made splints can be used,
and the patient’s needs and preferences should be taken into account. Hyper-
extension of the DIP joint diminishes the blood supply to the dorsal skin,
which may contribute to a pressure sore, particularly when a dorsal splint is
used. The joint is splinted in extension, full time for six to eight weeks and at
6 Butler and Baratz
Figure 3 (Continued on next page) Example of an acute Leddy and Packer Type III flexor
digitorum tendon avulsion of the fifth digit. (A) Full extension is achievable; (B) however,
finger flexion is absent. (C) Radiographs demonstrate an avulsion fracture at the insertion
of the FDP. (D) The fracture fragment has retracted to the level of the A4 pulley. (E)
Repair was achieved by exposing the insertion site of the FDP, (F) advancing the FDP
from the A4 pulley back to its insertion site, and (G) suturing the tendon through the
boney fragment and distal phalanx over a dorsal button. A temporary Kirschner wire was
used to immobilize the DIP joint in extension to prevent a flexion contracture. Abbreviations:
DIP, distal interphalangeal; FDP, flexor digitorum profundus.
Distal Fingertip and Thumb Injuries 7
night for an additional six to eight weeks. Two splints can be provided, one for
bathing and a second for general use. Patients are instructed to support the tip
of the finger on the edge of a counter top during splint changes to maintain the
DIP joint in extension.
If extension is restored after six weeks of splinting, the finger is splinted at
night for six weeks and during the day while performing heavy tasks. The dur-
ation of splinting may be shortened in patients with stiff joints, such as elderly
patients and laborers. In patients with supple joints, and in injuries in which
the initiation of treatment is delayed, the splinting duration may be extended.
Fingers with a mallet and compensatory swan-neck deformity are treated with
a custom splint that maintains the DIP in full extension and the PIP in a slightly
flexed position (Fig. 6). The adequacy of joint positioning in the splint can be
confirmed with a lateral radiograph of the digit. In health-care workers, we
have had good success with a small thermoplastic splint that can be covered
with a glove or a clear, sterile adhesive wrap.
Mallet fractures can, in most instances, be treated with splint immobiliz-
ation using the same principles outlined above. We consider surgical treatment
for the subset of mallet fractures where more than 25% of the articular surface is
involved or the DIP joint is subluxated; however, we counsel patients that an
acceptable outcome can still be achieved with nonoperative treatment as
long as there is no compensatory swan-neck deformity. Splint immobilization
for this subset of injuries may result in a prominent dorsal bump, a modest
extensor lag, a partial loss of DIP flexion, and radiographic evidence of post-
traumatic arthritis. However, function is typically unimpeded, and the need
Figure 3 (Continued from previous page)
8 Butler and Baratz
Figure 4 Leddy Type III FDP avulsion repaired with screws. (A) The FDP insertion site is
avulsed as a single large fragment in a 28-year-old man. (B) A Brunner incision was used.
(C) The fracture fragment is stuck at the A4 pulley. (D) The articular surface of the middle
phalanx is visible through the fracture. (E) A secure repair was achieved with two screws,
but an unrecognized fracture of the dorsal cortex subsequently displaced. The fractures ulti-
mately healed without loss of reduction. Abbreviation: FDP, flexor digitorum profundus.
Figure 5 A bony mallet injury. (A) Lack of full extension of the DIP joint of the long
finger with slight hyperextension at the PIP joint (slight swan-neck deformity). (B) A
lateral radiograph demonstrates an avulsion fracture of the terminal extensor tendon
off the dorsal surface of the distal phalanx. Abbreviations: DIP, distal interphalangeal;
PIP, proximal interphalangeal.
Distal Fingertip and Thumb Injuries 9
for subsequent surgery is rare. This joint has a remarkable ability to remodel
following fracture.
Several surgical techniques have been used to treat mallet fractures
(18–20). Open reduction and internal fixation with screws or tension wires has
been associated with wound problems, infection, loss of fixation, and nail
deformity, but is still used by some surgeons (21,22).
Percutaneous dorsal extension block pinning is increasingly popular, and
good results have been reported (23,24). The DIP joint is flexed 908, and a
Kirschner wire is advanced at a 458 angle over the avulsed bone fragment and
into the dorsal aspect of the middle phalanx. The DIP joint is then extended,
and a second Kirschner wire is advanced longitudinally from distal to proximal
across the DIP joint (Fig. 7). Pins are left in place approximately four weeks.
At that time, the pins are removed and active exercises are initiated. A splint
may be worn for an additional two or three weeks.
Articular Injuries
An axial load across the DIP joint frequently produces an impaction or pilon
injury to the base of the distal phalanx. With a bending moment to the DIP
joint, a collateral ligament condylar avulsion may be produced. Alternatively,
there may be volar or dorsal subluxation of the joint (Fig. 8). An adequate
reduction can often be obtained and maintained with one or two transverse
Kirschner wires (Fig. 8). Occasionally, internal fixation with screws is
appropriate.
Fractures Associated with Wounds
Many distal phalanx fractures are open fractures with injury to the sterile matrix,
germinal matrix, or both. Although these are open fractures, infection is uncom-
mon, probably because of the rich blood supply in this area. However, antibiotic
Figure 6 (A) The patient depicted in Figure 5 was treated in a custom splint which
maintains the DIP joint in extension and PIP joint in slight flexion to account for the
tendency towards a swan-neck deformity. (B) A lateral radiograph with the finger in the
custom splint confirms adequate reduction of the mallet injury. Abbreviations: DIP,
distal interphalangeal; PIP, proximal interphalangeal.
10 Butler and Baratz
Figure 7 Percutaneous fixation of a bony mallet. (A) Inability to extend the DIP joint.
(B) Flexion of the bony mallet injury brings the avulsion fracture fragment into improved
alignment. (C) With the DIP joint flexed, a Kirschner wire was advanced from distal to
proximal into the dorsal aspect of middle phalanx at the level of the DIP joint. (D)
After confirming an adequate dorsal block to DIP extension. (E) A second Kirschner
wire was advanced distal to proximal across the DIP joint. (F and G) Reduction is verified
under image intensification. (H) In this case, pin caps were used to cover the ends of the
pins. Abbreviation: DIP, distal interphalangeal. Source: Photos courtesy of Alex Shin, MD.
Distal Fingertip and Thumb Injuries 11
coverage for staphylococcus and streptococcus with a single dose of 1 or 2 g of
intravenous cefazolin and tetanus prophylaxis given in the emergency department
may be prudent. Digital block anesthesia facilitates wound evaluation, debride-
ment, and irrigation.
The more proximal the fracture, soft-tissue injuries associated with distal
phalanx fractures are more severe. Tuft and shaft fractures frequently involve
injury to the nail bed because of its firm attachment to the periosteum of the
dorsal terminal distal phalanx. These injuries may benefit from removal of
the nail plate and repair of the nail bed with an absorbable suture (25), although
this is debatable. In many cases, suturing of the skin and nail bed will reduce the
fracture. In addition, repair of the nail bed also facilitates the subsequent
formation of a new smooth and esthetically appealing nail plate. However, if
the nail bed is irreparable, it may be difficult to cover the dorsum of the fingertip
after removal of the nail plate. In these circumstances, leaving the nail plate in
place may act as a biologic dressing.
When removed, the nail plate should be cleansed and inserted under the
eponychium to prevent adhesion between the germinal matrix and eponychial
fold and to provide protection and support of the fracture. One or two sutures
can be placed through the nail plate to prevent it from dislodging. Sutures
should be placed in a manner that facilitates their removal. If the nail plate is
absent or unusable, the foil from a suture pack may be substituted.
Figure 8 A 25-year-old woman had an impacted articular fracture after an injury playing
basketball. (A) There is impaction and comminution of the volar half of the articular
surface and dorsal subluxation of the joint. (B) A percutaneous reduction and fixation
was achieved.
12 Butler and Baratz
Open fractures at the base of the distal phalanx usually involve injury to the
germinal matrix with the nail remaining firmly attached to the cuticle or perionyx
and distal to the nail bed. After irrigation and debridement, simple reduction of
the nail beneath the eponychium frequently results in fracture reduction
(26,27). However, this injury pattern is often rotationally unstable, and sup-
plementary fixation with a Kirschner wire is often required to obtain stability.
If injury to the nail bed is present, the nail plate should be removed, and the
nail bed repaired (25).
Open mallet fractures are treated using the method described by Doyle. The
joint is pinned in extension with a 0.045-inch Kirschner wire. The tendon and bone
are repaired to the distal phalanx with a pin, pull-out suture, or suture anchor.
SOFT-TISSUE COVERAGE
Fingertip amputations without exposed bone will heal by secondary intention
(Fig. 9); however, defects larger than 1 or 2 cm2 may benefit from soft-tissue
coverage as these may create a hook-nail deformity as the wound contracts
(3,4). Wounds larger than this or with exposed bone will heal, but may leave a
tender and easily reinjured fingertip. A major advantage of healing by secondary
intention is near-normal sensibility. Skin grafts and many local or regional flaps
will greatly reduce sensation.
Flaps used most frequently include the homodigital island flap and cross-
finger flap for the fingertips and a homodigital island or a modified Moberg for
the tip of the thumb. Thenar flaps are used occasionally in young patients
where the concern for a PIP joint flexion contracture is diminished. Local
advancement flaps, such as those described by Atasoy and Kutler, must be used
with caution as subcutaneous atrophy and fingertip sensitivity can result (28).
Thenar Flap
Thenar flaps are designed based on the flexible skin of the radial aspect of the
thenar eminence. This flap is ideal for fingertip injuries of the ring and small
fingers, but it is also useful for the long and index fingers. It is best suited for
younger patients with lax joints, such as young women. The flap should be
designed near the metacarpophalangeal (MP) joint crease. To minimize a
flexion contracture of the PIP joint, flexion should occur through the DIP joint
and MP joint of the finger. No more than 408 to 508 of flexion should occur at
the PIP joint. However, this can be difficult to control, and if more than 508 of
flexion is present at the proximal interphalangeal (IP) joint, an alternate
method of coverage should be considered as the joint is at increased risk for a
flexion contracture. The thumb should be palmarly abducted as this will minimize
the amount of flexion of the finger with the flap placed at the level of the MP joint.
The flap should be 1.5 to 2 times greater than the recipient area to ensure cov-
erage of the semicircular fingertip. The skin and subcutaneous tissue of the flap are
Distal Fingertip and Thumb Injuries 13
elevated off of the thenar musculature. Care should be taken to avoid injury to the
radial digital nerve and motor branch of median nerve. By designing an H-flap, it
may be possible to close the donor site. If primary closure is not possible, a full-
thickness graft is used to cover the donor site defect. This can be harvested from
the ulnar aspect of the hypothenar eminence or the medial aspect of the arm (29).
The flap is divided under a local anesthetic after 10 to 14 days.
In a review of 150 patients treated with the thenar flap, 96% good-to-
excellent results were obtained (30). Four percent of patients had a PIP joint
contracture and 3% reported transient donor site tenderness.
Cross-Finger Flap
Cross-finger flaps provide a predictable means to cover defects on the palmar
aspect of the digit. The choice of donor site for the cross-finger flap is commonly
Figure 9 Index fingertip amputation at two days (A and B), four weeks (C and D), and
eight weeks (E and F) after injury. Excellent cosmetic and functional results using healing
by secondary intention.
14 Butler and Baratz
the long finger for the thumb, index, and ring fingers. The ring finger is usually a
donor for the small finger. The dorsal skin and subcutaneous tissue of the middle
phalanx of the donor finger is transferred to the palmar skin defect of the injured
fingertip. The base of the flap is adjacent to the tissue defect of the recipient digit.
The flap is elevated off the peritendinous fascia deep to the dorsal veins. Fingertip
coverage is more challenging than coverage for more proximal defects, particu-
larly for the long and ring fingers (Fig. 10). Covering the fingertip with tissue
from the adjacent finger requires flexing the injured finger so that transferred
tissue will reach the fingertip. Flexion can be minimized by designing an
oblique flap that angles toward the fingertip. Full-thickness skin grafts can be
Figure 10 Circular saw injury involving significant skin and soft-tissue loss to the volar
aspect of the middle and distal phalanxes of the ring and long fingers (A). Cross-finger
flaps were created using the dorsal skin of the middle phalanx of the index and small
fingers leaving peritenon over the now exposed extensor tendons (B). Split-thickness
skin grafts were then used to cover the peritenon (C). Adequate soft-tissue coverage
was achieved by reflection of the skin grafts volarly on a pedicle adjacent to the finger
to be grafted (D). Slight flexion of the ring finger PIP joint was required to advance the
finger flap from the shorter small finger to the distal tip of the ring finger. Abbreviation:
PIP, proximal interphalangeal.
Distal Fingertip and Thumb Injuries 15
used to cover the donor site and can be taken from the medial aspect of the
brachium. Flaps are divided at 10 to 14 days (31).
Homodigital Island Flap
The homodigital island flap is an excellent means to provide durable, sensate
coverage to the fingertip, particularly the ulnar aspect of the thumb, and radial
aspects of the index and long fingers. A paddle of skin and fat matching the
dimensions of the defect is harvested just proximal to the defect. The paddle is
raised with its nerve and vessel. Through a Bruner incision, the neurovascular
bundle is mobilized with the flap to the base of the proximal phalanx. The
combination of a mobilized neurovascular bundle and slight PIP joint flexion
allows the flap to be transposed to the distal defect (Fig. 11). Finger flexion
can be initiated immediately by using a dorsal block splint to prevent undue
tension on the bundle. The splint is discontinued after two weeks, and unrestricted
motion is permitted (32).
Moberg Flap
In 1946, Moberg described a palmar advancement flap for covering the tip of the
thumb. This flap includes the skin and subcutaneous tissue proximal to the defect
on the tip of the thumb. Midaxial incisions are made on the radial and ulnar
aspects of the thumb just dorsal to neurovascular bundle. The flap is elevated
Figure 11 A homodigital island flap was used to cover a fingertip soft-tissue defect
involving the radial and volar aspects of the index finger (A). After the radial neurovascu-
lar bundle was identified proximally (B), a full-thickness flap of skin and soft tissue was
then raised and advanced distally to cover the defect (C). Primary closure of the donor
site was not achieved, and a split-thickness skin graft was required (D).
16 Butler and Baratz
off of the flexor sheath to the level of the MP joint. Flexion of the IP joint allows
the distal margin of the flap to reach the tip of the thumb MP joint (33). In a modi-
fication of the Moberg flap, the skin is incised at the MP joint converting the flap
to a neurovascular island flap. This allows the flap to reach the tip of the thumb
without the need for IP joint flexion (Fig. 12).
Free Toe Pulp Transfer
A free toe pulp flap from the great toe or the second toe can be used to cover
fingertip defects that cannot be covered by other means. The lateral border of
Figure 12 Partial thumb amputation (A and B) treated with a modified Moberg advance-
ment flap. After both neurovascular pedicles are identified and preserved, a pedicle of
tissue based on both these pedicles is advanced distally to cover the soft-tissue defect
(C and D). A skin graft is then used to cover the newly formed proximal skin defect
(E). Complete soft-tissue healing and nearly full ROM of the thumb MCP joint at six
months after injury (F and G). Abbreviations: MCP, metacarpophalangeal; ROM, range
of motion.
Distal Fingertip and Thumb Injuries 17
the great toe or the entire pulp of the second toe is harvested with its artery, vein,
and plantar collateral nerve. This is transferred to the defect accompanied by ana-
stamosis of the artery, vein, and nerve. The donor site is skin-grafted. Reported
results for this procedure have been variable. In one series of 12 patients,
partial or complete flap necrosis occurred in 38% of patients, cold intolerance
developed in 73%, occasional pain in 45%, and hypersensitivity in 36% (34).
In another series of eight patients, the only adverse outcome was cold intolerance
in 25% of patients (35). Few complications were observed at the toe donor site.
Average two-point discrimination improved to less than 9.8 mm.
CONCLUSION
Injuries to the distal phalanx are best managed when armed with an understand-
ing of the pertinent anatomy and options for treatment. Nonoperative treatment is
appropriate for most fractures, with the exception of articular fractures, widely
displaced shaft fractures, and fractures associated with avulsion of the flexor
digitorum profundus tendon. Open fractures require debridement and wound
care; care that can usually be provided in the emergency department. Advance-
ment flaps may be used to maintain digital length and provide a durable,
sensate fingertip.
REFERENCES
1. National Occupational Health and Safety Commission Worker’s Compensation Data
Base. http://nohs.info.au.com (accessed August 2004).
2. Zook EG. The perionychium: anatomy, physiology, and care of injuries. Clin Plast
Surg 1981; 8(1):21–31.
3. Verdan CE, Egloff DV. Fingertip injuries. Symp Pract Surg Hand 1981; 61(2):237–266.
4. Ditmars DM Jr. Fingertip and nailbed injuries. Occup Med 1989; 4(3):449–461.
5. Rosenthal EA. Treatment of fingertip and nail bed injuries. Symp Rehab After Hand
Surg 1983; 14(4):675–697.
6. Bell-Krotoski J. Advances in Sensibility Evaluation. Hand Clinics. Philadelphia:
Saunders, 1991.
7. Bell-Krotoski J. Sensibility Testing: State of the Art. Rehabilitation of the Hand.
3rd ed. St. Louis: Mosby, 1990.
8. Bell-Krotoski J. Light Touch–Deep Pressure Testing Using Semmes–Weinstein
Monofilaments. Rehabilitation of the Hand. 3rd ed. St. Louis: Mosby, 1990.
9. Shrewsbury MM, Johnson RK. Form, function, and evolution of the distal phalanx.
J Hand Surg 1983; 8:475–479.
10. Shum C, Bruno RJ, Ristic S, Rosenwasser MP, Strauch RJ. Examination of the
anatomic relationship of the proximal germinal nail matrix to the extensor tendon
insertion. J Hand Surg [Am] 2000; 25(6):1114–1117.
11. Schneider LH. Fractures of the distal phalanx. Hand Clinics 1988; 4:537–547.
12. Leddy LP, Packer JW. Avulsion of the profundus insertion in athletes. J Hand Surg
1979; 4:461–464.
18 Butler and Baratz
13. Smith JH. Avulsion of a profundus tendon with simultaneous intraarticular fracture of
the distal phalanx—a case report. J Hand Surg 1981; 6:600–601.
14. Lester B, Jeong GK, Perry D, Spero L. A simple effective splinting technique for the
mallet finger. Am J Orthod 2000; 29:202–206.
15. Abouna JM, Brown H. The treatment of mallet finger: the results in a series of 148 -
consecutive cases and a review of the literature. Br J Surg 1968; 55:653–667.
16. Crawford GP. The molded polythene splint for mallet finger deformities. J Hand Surg
1984; 9A:231–237.
17. Stack HG. A modified splint for mallet finger. J Hand Surg 1986; 11B:263.
18. Bischoff R, Buechler U, De Roche R, Jupiter J. Clinical results of tension band
fixation of avulsion fractures of the hand. J Hand Surg 1994; 19A:1019–1026.
19. Damron TA, Engber WD. Surgical treatment of mallet finger fractures by tension band
technique. Clin Orthod 1994; 300:133–140.
20. Yamanaka K, Sasaki T. Treatment of mallet fractures using compression fixation pins.
J Hand Surg 1999; 24B:358–360.
21. Jupiter JB, Sheppard JE. Tension wire fixation of avulsion fractures in the hand. Clin
Orthod 1987; 214:113–120.
22. Kronlage SC, Faust D. Open reduction and screw fixation of mallet fractures. J Hand
Surg 2004; 29(2):135–138.
23. Mazurek MT, Hofmeister EP, Shin AY, Bishop AT. Extension-block pinning for
treatment of displaced mallet fractures. Am J Orthod 2002; 31(11):652–654.
24. Hofmeister EP, Mazurek MT, Shin AY, Bishop AT. Extension block pinning for large
mallet fractures. J Hand Surg 2003; 28A(3):453–459.
25. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and
prognosis. J Hand Surg 1984; 9A(2):247–252.
26. Robins RHC. Fingertip injuries. Hand 1970; 2(2):119–125.
27. Allen MJ. Conservative management of fingertip injuries in adults. Hand 1980;
12(3):257–265.
28. Ma GF, Cheng JC, Chan KT, Chan KM, Leung PC. Fingertip injuries—a prospective
study on seven methods of treatment on 200 cases. Ann Acad Med Singapore 1982;
11(2):207–213.
29. Schenck RR, Cheema TA. Hypothenar skin grafts for fingertip reconstruction. J Hand
Surg 1984; 9A(5):750–753.
30. Melone CP, Beasley RW, Carstens JH. The thenar flap—an analysis of its use in 150
cases. J Hand Surg [Am] 1982; 7(3):291–297.
31. Tempest MN. Cross-finger flaps in the treatment of injuries to the fingertip. Plast
Reconstr Surg 1952; 9(3):205–222.
32. Bidulph SL. The neurovascular flap in fingertip injuries. Hand 1979; 11(1):59–63.
33. Moberg E. Aspects of sensation in reconstruction surgery of the upper extremity.
J Bone Joint Surg 1964; 46A:817–825.
34. Ratcliffe RJ, McGrouther DA. Free toe pulp transfer in thumb reconstruction. J Hand
Surg 1991; 16B:165–168.
35. Deglise B, Botta Y. Microsurgical free toe pulp transfer for digital reconstruction. Ann
Plast Surg 1991; 26(4):341–346.
Distal Fingertip and Thumb Injuries 19
2
Phalanx Shaft Fractures
Mark S. Cohen
Department of Orthopedic Surgery, Rush University Medical Center,Chicago, Illinois, U.S.A.
INTRODUCTION
Fractures involving the hand are the most common of all skeletal injuries,
estimated at 1.5 million per year in the U.S.A. Phalanx fractures are particularly
problematic due to the propensity for stiffness and functional loss. The goals of
phalanx fracture treatment are restoration of anatomy and most importantly the
adjacent articular surfaces if involved. For displaced injuries, a stable reduction
is optimal with the least amount of surgical trauma. Early mobilization of the
hand allows for a more rapid return of function. However, immediate rehabilita-
tion is not essential for a favorable clinical result. This chapter covers the
principles of phalanx fracture treatment, from simple to complex injuries, with
a special emphasis on the indications and techniques of operative intervention.
FRACTURE EVALUATION
When evaluating an individual with a phalanx fracture, it is important to obtain a
proper history. The mechanism of injury can provide important clues as to the
energy level and potential instability of the fracture. Patient factors such as age,
hand dominance, occupation, and activity level help to individualize a treatment
plan. Examination should include a clinical evaluation of the injured digit includ-
ing sensory testing. Proper radiographs typically require three views: frontal,
lateral, and oblique projections, centered and perpendicular to the injured bone.
Occasionally, the latter provides the best visualization of fracture displacement.
21
Next, one has to determine the “personality” of the fracture. This is defined as
the inherent instability of the injury. Although the history and radiographs provide
information, occasionally the personality of the fracture can only be defined follow-
ing an attempted reduction. Some fractures, although displaced, are of low energy
with minimal periosteal stripping. Once reduced, these can be stable through an
Figure 1 (A) Frontal radiograph of displaced middle and ring fingers proximal phalanx
shaft fractures. Fractures appear to be unstable. (B) One manipulation led to an anatomic
reduction in the frontal and (C) lateral planes. This reduction appeared stable through a
limited arc of motion. The fracture was immobilized for three weeks. (D) Final extension
and (E) flexion several weeks after immobilization discontinued. Often the “personality”
of the fracture can only be defined following reduction. This fracture was clearly of low
energy with minimal periosteal stripping. It was a reducible and stable injury.
22 Cohen
arc of active motion and do not necessarily require surgical intervention (Fig. 1). If
initially displaced fractures are treated with immobilization alone, it is imperative to
document that the digit is not rotated. This requires active or gently passive flexion of
the finger as rotation is difficult to assess in extension.
The principles of phalangeal fracture care differ substantially from those of
metacarpal injuries. Unstable phalanx fractures tend to angulate dorsally (oppo-
site of the metacarpal) as the tension side of the bone is located anteriorly (Fig. 2).
In addition, unlike metacarpal injuries, phalanx fractures are particularly prone to
Figure 2 Illustration depicting the typical pattern of displacement of proximal phalanx
shaft fractures. The tension side of the bone is anterior resulting in dorsal angulation.
This and shortening lead to relative laxity of the extensor mechanism resulting in an exten-
sor lag at the proximal interphalangeal joint. Unlike metacarpal fractures, shortening is
poorly tolerated in the phalanges.
Figure 3 Cross-section through the proximal phalanx of a digit. Note the close approxi-
mation of the gliding surface of the extensor tendon which blankets the dorsal cortex and
the flexor tendons anteriorly. These anatomic features make phalangeal fractures particu-
larly prone to adhesions and stiffness.
Phalanx Shaft Fractures 23
adhesions and stiffness. This is due to the anatomy whereby the bony skeleton is
enveloped by the gliding surfaces of the flexor and extensor tendons (Fig. 3). Fur-
thermore, fracture displacement is much less tolerated at the phalanx level than in
the metacarpals. Although shortening of up to 1 cm (without rotation) can be
accepted in metacarpal fractures without functional loss, this is not the case in
the digit. Shortening of only 1 mm following a proximal phalanx fracture leads
to a 128 extensor lag at the proximal interphalangeal joint (Fig. 2).
REDUCIBLE AND STABLE INJURIES
As a general rule, phalanx fractures will heal adequately by approximately three
weeks to allow for protected rehabilitation. Non- or very minimally displaced
fractures can be immobilized in a cast or splint during this time, followed by a
gentle mobilization program with interval protective splinting. Fractures which
are displaced but which are deemed stable once reduced can be treated similarly.
However, these fractures have to be followed carefully, with consideration given
to weekly evaluation during healing. Redisplacement can occur in a cast and
during follow-up visits, the cast or splint should be removed, and the alignment
and rotation of the digit documented in partial flexion.
In stable proximal phalanx fractures (in reliable patients), consideration can
be given to the use of a functional brace (Fig. 4). The orthosis maintains the meta-
carpophalangeal joint in maximum flexion while leaving the interphalangeal
joints free for early mobilization. In this way, the extensor tendon functions as
a tension band helping maintain reduction of the fracture. Again, fractures that
Figure 4 Hand-based functional splint which can be used for proximal phalanx fractures
which are deemed stable. With the metacarpophalangeal joint at 908, the extensor tendon
functions as a tension band helping maintain reduction while allowing unrestricted inter-
phalangeal joint motion.
24 Cohen
are initially displaced and treated by closed methods must be followed very
closely due to the potential for loss of reduction.
REDUCIBLE AND UNSTABLE INJURIES
The majority of displaced phalangeal fractures are reducible by closed manipu-
lation. However, initial displacement and periosteal stripping make the fracture
unstable, and displacement recurs once external pressure is released. The
simplest method of treating reducible but unstable phalanx fractures is percuta-
neous Kirschner wire fixation. For oblique and spiral fractures, the pins can be
inserted from medial and lateral taking care to obtain purchase in both fracture
fragments. For more transverse fracture patterns, intramedullary pins, placed
antegrade from proximal to distal through the metacarpal head or metacarpopha-
langeal joint, can be used as well. More comminuted injuries can be amenable to
a combination of pinning methods (Fig. 5). The advantage of closed pinning is
that it obviates the need for an open approach to the fracture. If not opened,
these fractures rarely lead to digital stiffness and morbidity despite several
weeks of immobilization.
Belsky and Eaton described a very useful method of pin fixation for
phalangeal fractures that allows for early mobilization of the interphalangeal
joints. Percutaneous pins (typically 0.045 in.) are placed intramedullary from
an antegrade approach to maintain fracture reduction (Fig. 6). Functional
bracing can then be used to protect the construct while allowing for interphalan-
geal joint rehabilitation. Even if the pins are through the metacarpophalangeal
joint (our preferred method) and thus the extensor digitorum tendon, active
interphalangeal joint extension is possible through the intrinsic extensor
system. This greatly facilitates recovery of motion and function. The technique
is particularly useful for unstable proximal phalangeal base fractures that
typically occur at the proximal metaphyseal–diaphyseal junction with dorsal
comminution (Fig. 6).
An alternative method for treating oblique and spiral reducible and unstable
phalanx fractures involves limited internal fixation with screws placed through
very small incisions. This is termed “closed reduction and internal fixation.”
Limited midaxial incisions are used, and the lateral band of the extensor mecha-
nism retracted dorsally (Fig. 7). Typically, fracture reduction is maintained with
provisional Kirschner wires which are exchanged for 1.3 or 1.5 mm screws. Two
screws are required for adequate stability. Self-tapping implants make this
method much easier, obviating the need for tapping of the screw track.
However, the technique requires careful attention to detail. Special care must
also be taken with titanium screws. Owing to their ductility (the degree of
plastic deformation prior to failure), there is a small margin for error, and exces-
sive force or improper placement can lead to screw breakage (Fig. 7). With
internal screw fixation, early mobilization and return of function are possible.
Phalanx Shaft Fractures 25
This minimally invasive technique limits the morbidity of formal open reduction
and internal fixation (adhesions, extensor tendon lag, etc.).
Occasionally, reducible but unstable fractures can be effectively treated
with external fixation. This method is typically reserved for open fractures and
those with severe comminution where pin and/or screw fixation is not possible.
Figure 5 (A) Frontal radiograph depicting unstable middle finger proximal phalanx frac-
ture with comminution. This fracture turned out to be reducible and unstable. (B) Antero-
posterior and (C) lateral radiographs following percutaneous pin fixation. Note the
combination of pin methods utilized for this fracture with oblique and intramedullary
implants. This percutaneous technique obviated the need for open reduction with its
associated morbidity.
26 Cohen
Figure 6 (A) Anteroposterior and (B) lateral radiographs of middle finger proximal
phalanx base fracture. These are typically associated with dorsal comminution. The frac-
ture was reducible with manipulation. (C) Frontal and (D) lateral radiographs following
antegrade intramedullary pin fixation through the metacarpophalangeal joint. (E) Clinical
photograph of hand-based functional orthosis. The volar splint attachment maintains the
interphalangeal joints in extension between exercises. This is removable allowing inter-
phalangeal joint motion with the pins in place. (F) Note full interphalangeal joint
flexion obtained two weeks following surgery. This technique allows fracture stabilization
with early digital motion. Active digital extension is maintained through the intrinsic
muscles.
Phalanx Shaft Fractures 27
However, external fixation can be effective in certain closed injuries. An example
would be a severely comminuted periarticular fracture (Fig. 8). In this way, the
fixator can provide ligamentotaxis to maintain the articular surface and help
neutralize (protect) any pins that are used. External fixation provides adequate
Figure 7 (A) Frontal radiograph depicting long oblique fracture of the proximal phalanx
of the small finger. This fracture was reducible and unstable. (B) Intraoperative photograph
showing limited midaxial incision. Note the lateral band of the extensor mechanism cour-
sing obliquely in the wound. (C) Lateral band has been retracted dorsally allowing screw
placement. (D) Anteroposterior and (E) lateral radiographs following internal fixation.
Two 1.3 mm screws and one central 1.5 mm screw were used. Note that the distal
screw head was sheared off during placement. Titanium implants have low ductility,
and screw breakage can occur with excessive force.
28 Cohen
Figure 8 (A) Anteroposterior radiograph of a diaphyseal middle phalanx fracture of the
ring finger with an associated comminuted and displaced fracture of the distal interphalan-
geal joint. This fracture was reducible and unstable. (B) Postoperative frontal and (C)
lateral radiographs following percutaneous placement of an external fixator and a pin.
The fixator crosses the distal joint providing ligamentotaxis and neutralization to maintain
the reduction of both fractures. (D) Clinical photograph of the digit with the fixator in
place. (E) With this method, the patient has unrestricted motion of the metacarpophalan-
geal and proximal interphalangeal joints during fracture healing.
Phalanx Shaft Fractures 29
stability to allow for unrestricted mobilization of adjacent joints. Owing to the
close opposition of the fingers, the technique is probably most applicable to
the index and small fingers, where the fixator can be applied along the borders
of the hand.
IRREDUCIBLE PHALANX INJURIES
Irreducible fractures of the phalanges are those that cannot adequately be reduced
by closed methods. These require open reduction which is typically followed by
internal fixation. For the proximal phalanx, a dorsal skin incision is most com-
monly employed. For the best exposure, a longitudinal split is made through
the center of the extensor mechanism (Fig. 9). Lateral extensor sparing exposures
are possible, but make reduction and stabilization much more difficult and have
not been shown to significantly alter ultimate motion and function.
Care is taken to next open the periosteum of the phalanx, which is surpris-
ingly thick and often intact or only partially torn. For long oblique and spiral frac-
tures, interfragmentary screw fixation is best, using 1.3 and/or 1.5 mm implants.
The technique requires precision and attention to detail to a much greater extent
than that in larger bones. It is often helpful to open the fracture to appreciate its
anatomy in planning screw fixation. Care is taken to place the provisional pins
perpendicular to the fracture for optimal stability. These are then exchanged
for self-tapping screws. As a general rule, one should not place a screw closer
than three screw widths from a fracture spike to prevent fragmentation
(Fig. 10). The tip of the depth gage should be directed to the far cortex opposite
the fracture to decrease the potential for choosing too short of a screw (Fig. 11). A
countersink is important not only to limit hardware prominence, but also more
importantly to decrease stress risers as the screw is tightened. This also provides
greater contact between the screw head and the bone improving compression and
stability. Following fixation, the periosteum and extensor mechanism are meticu-
lously repaired in separate layers (Fig. 9).
Occasionally, irreducible oblique or spiral fractures that seem relatively
simple actually have significant nondisplaced fracture lines visible upon inspec-
tion. This makes screw fixation inadequate. A very useful technique to use in
these circumstances involves a composite tension band wiring technique
termed the “sidewinder” method. This involves parallel or crossed Kirschner
wires supplemented with fine monofilament wire which is wrapped around the
pins providing compression and stability (Fig. 12). The wire is placed in such
a way as to provide four strands across the fracture. This technique can be
useful as well in cases where screw fixation has failed, such as when a screw
has stripped or a spike fractured. It allows for stable fixation with a very low-
profile construct. We have found threaded pins to be helpful when using this
method, decreasing the chance for pin migration and helping anchor the wire
around the tips of the pins.
30 Cohen
Figure 9 (A) Anteroposterior radiograph of a comminuted and displaced proximal
phalanx fracture of the middle finger. The fracture was irreducible by manipulation. (B)
Intraoperative photograph during open reduction and internal fixation with interfragmen-
tary compression screws. Exposure is provided by splitting the extensor tendon dorsally in
the midline. (C) Complete closure of the periosteum over the hardware. (D) Anatomic
repair of the extensor tendon. (E) Postoperative anteroposterior and (F) lateral radiographs
following reduction and screw fixation.
Phalanx Shaft Fractures 31
An alternative to the sidewinder tension wiring technique involves trans-
osseous wiring. In this technique, mostly used for transverse fractures and par-
ticularly useful in amputations, an oblique pin is supplemented with
monofilament wire placed proximal and distal to the fracture through the bone.
Figure 10 Diagram depicting the closest safe position for a screw relative to a fracture
edge (shaded hole). Screws placed less than three screw diameters from a cortical margin
risk fragmentation of the fracture spike.
Figure 11 Placement of the depth gauge away from the fracture in obliquely placed
screws. Placing the depth gage tip on the near cortex may underestimate optimal screw
length. By placing the tip of the gage away from the fracture, the correct screw measure-
ment is obtained. This is especially important with self-tapping screws which require the
screw tip through the opposite cortex for purchase.
32 Cohen
Figure 12 (Continued on next page) (A) Anteroposterior radiograph of an oblique dis-
placed proximal phalanx fracture in the small finger of an adolescent male. The fracture
was irreducible due to soft-tissue interposition. (B) Intraoperative photograph depicting
sidewinder composite wiring technique used to stabilize the fracture. Note the nondis-
placed longitudinal fracture lines running proximal and distal to the fracture. These
made the fracture irreparable with screw fixation alone. The tension band wire supports
the fracture comminution that was appreciated only during open reduction. (C) Repair
of the periosteum and (D) extensor tendon following internal fixation. Note complete
coverage of the hardware with periosteum.
Phalanx Shaft Fractures 33
The fracture is reduced, the pin advanced, and the wire tightened providing ade-
quate stability (Fig. 13).
Plate fixation of the phalanges is reserved for irreducible transverse or short
oblique fractures. In addition, one can consider plate fixation in more complex
injuries involving a crush component with comminution of the bone where
early tendon gliding and soft-tissue mobilization is preferred (Fig. 14). It must
be understood; however, that plate fixation of the phalanges is fraught with
Figure 12 (Continued from previous page) (E) Anteroposterior and (F) lateral radio-
graphs depicting sidewinder fixation. Note that the wire was applied to obtain four
strands across the fracture. (G) Finger flexion and (H) extension in dynamic brace designed
to improve the mechanical advantage of the extensor mechanism and decrease the
occurrence of an extensor lag at the proximal interphalangeal joint. (I) Final flexion and
(J) extension of the digit. Note the proximal interphalangeal joint extensor lag despite peri-
osteal and tendon repair and early motion in a dynamic splint. Full terminal extension is
difficult to obtain following open reduction and violation of the extensor tendon.
34 Cohen
complications. The plate is typically positioned dorsally in a potential space
between the extensor tendon and the bone. Extensor adhesions and motion loss
are not uncommon, and a subset of plated phalanges require a second-stage
procedure involving hardware removal and tenolysis once bony union has
occurred to recover mobility. Screws that are too long can lead to flexor
tendon embarrassment (Fig. 15).
Although lateral plate placement is less problematic theoretically, this has
not been proven to be significantly better than dorsal plating and is much more
difficult. Newer smaller 1.3 mm implants are less bulky and may decrease
extensor tendon complications (Fig. 16). Whatever implant is chosen, attempts
are made to close some periosteum over the plate if possible. When applied in
compression for transverse fractures, the plates should be prebent to allow for
uniform compression of the cortex opposite the plate. The exception would be
Figure 13 (A) Anteroposterior and (B) lateral radiographs of displaced and unstable dia-
physeal fracture of the middle phalanx. The fracture was not reducible by manipulation
requiring limited open reduction. (C) Postoperative anteroposterior and (D) lateral radio-
graphs depicting transosseous wiring used for fracture fixation.
Phalanx Shaft Fractures 35
Figure 14 (Continued on next page) (A) Clinical photograph and (B) frontal radiograph
following roller/crush injury resulting in multiple proximal phalanx fractures. The frac-
tures were irreducible by closed manipulation. (C) Intraoperative photograph revealing
open reduction and internal plate fixation of the fractures. A dorsal plate was used
for the middle finger with bone graft and lateral plates for the index and ring fingers.
(D) Frontal and (E) lateral radiographs following internal plate fixation. (F) Clinical
photograph of final extension and (G) flexion. Crush injury associated with irreducible
and comminuted fractures can be an indication for plate fixation of the phalanges where
early mobilization is imperative.
36 Cohen
a short oblique fracture which is first reduced and stabilized by a single lag screw.
In this situation, the plate functions mainly in neutralization and is not prebent but
applied in neutral fashion without eccentric drilling of the screw holes.
It must be emphasized that any open reduction of phalanx injuries comes at
a cost, mainly an increased risk for extensor tendon adhesions and stiffness. This
is especially true when larger implants such as plates are required. To improve the
mechanical advantage of the extensor mechanism, dynamic splints have been
Figure 15 (A) Lateral radiograph of a proximal phalanx fracture treated with a dorsal
plate. Note that one of the proximal screws is too long protruding well past the anterior
cortex. (B) Clinical photograph of attempted digital extension. Note the significant exten-
sor lag. This is not uncommon following dorsal plating of the proximal phalanx. (C)
Photograph of attempted flexion. Limitation of motion is due to rupture of the profundus
tendon due to the sharp tip of the protruding screw. Plate fixation of the phalanges is
technically demanding and fraught with potential complications.
Figure 14 (Continued from previous page)
Phalanx Shaft Fractures 37
suggested following open reduction (Fig. 12). However, even with lower-profile
constructs, such as sidewinder wiring, and the use of aggressive rehabilitation,
loss of terminal extension is common when the extensor mechanism is
surgically violated. Fortunately, recovery of flexion is more predictable and is
more important for function. In addition, a minor degree of extensor lag typically
leads to minimal functional difficulties.
BIBLIOGRAPHY
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phalanx fractures. J Hand Surg 1984; 9A:725–729.
Birndorf MS, Daley R, Greenwald DP. Metacarpal fracture angulation decreases
flexor mechanical efficiency in human hands. Plast Reconstr Surg 1997;
99(4):1079–1083.
Figure 16 (A) Anteroposterior and (B) lateral radiographs of a displaced transverse
fracture of the middle finger proximal phalanx with comminution. The fracture was
irreducible by closed methods. (C) Frontal and (D) lateral radiographs following dorsal
plate fixation with low-profile 1.3-mm implant. These smaller implants are less bulky
and may limit extensor tendon complications following dorsal plating of the phalanges.
38 Cohen
Breddam M, Hansen TB. Subcapital fractures of the fourth and fifth metacarpal treated
without splinting and reposition. Scand J Plast Reconstr Surg 1995; 29(3):269–270.
Buchler U, Gupta A, Ruf S. Corrective osteotomy for post-traumatic malunion of the pha-
langes in the hand. J Hand Surg [Br] 1996; 21(1):33–42.
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treated with closed reduction and percutaneous pinning: a biomechanical analysis of
residual incongruity of the joint. J Bone Joint Surg [Am] 1997; 79(3):413–420.
DeJonge JJ, Kingma J, Van Der Lei B, Klasen HJ. Phalangeal fractures of the hand: an
analysis of gender and age-related incidence and aetiology. J Hand Surg 1994;
19B:168–170.
Emmett JE, Breck LW. A review of analysis of 11,000 fractures seen in a private practice
of orthopaedic surgery, 1937–1957. J Bone Joint Surg 1958; 40A:1169–1175.
Firoozbakhsh KK, Moneim MS, Doherty W, Naraghi FF. Internal fixation of oblique meta-
carpal fractures: a biomechanical evaluation by impact loading. Clin Orthop 1996;
325:296–301.
Fitoussi F, Ip WY, Chow SP. External fixation for comminuted phalangeal fractures: a
biomechanical cadaver study. J Hand Surg [Br] 1996; 21(6):760–764.
Gonzales MH, Hall RF. Intramedullary fixation of metacarpal and proximal phalangeal
fractures of the hand. Clin Orthop 1996; 327:47–54.
Hornbach EE, Cohen MS. Closed reduction and percutaneous pinning of fractures of the
proximal phalanx. J Hand Surg 2001; 26B:45–49.
Kahler DM. Fractures and dislocations of the base of the thumb. J South Orthop Assoc
1995; 4(1):69–76.
Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal
shaft fractures. J Am Acad Orthop Surg 2000; 8:111–121.
Lester B, Mallik A. Impending malunions of the hand: treatment of subacute, malaligned
fractures. Clin Orthop 1996; 327:55–62.
Liaw Y, Kalnins G, Kirsch G. Combined fourth and fifth metacarpal fracture and fifth car-
pometacarpal joint dislocation. J Hand Surg [Br] 1995; 20(2):249–252.
Lins RE, Myers BS, Spinner RJ, Levin LS. A comparative mechanical analysis of plate
fixation in a proximal phalangeal fracture model. J Hand Surg [Am] 1996;
21A(6):1059–1064.
Manueddu CA, Della Santa D. Fasciculated intramedullary pinning of metacarpal frac-
tures. J Hand Surg [Br] 1996; 21(2):230–236.
Ouellette EA, Freeland AE. Use of the minicondylar plate in metacarpal and phalangeal
fractures. Clin Orthop 1996; 327:38–46.
Pelto-Vasenius K, Hirvensalo E, Rokkane P. Absorbable pins in the treatment of hand
fractures. Ann Chir Gynaecol 1996; 85(4):353–358.
Sochart DH, Paul AS. A simple external fixator for use in metacarpal and phalangeal
fractures: a technique paper. J Orthop Trauma 1995; 9(4):333–335.
Swanson TV, Szabo RM, Anderson DD. Open hand fractures: prognosis and classification.
J Hand Surg 1991; 16A:101–107.
Toronto R, Donovan PJ, Macintyre J. An alternative method of treatment for metacarpal
fractures in athletes. Clin J Sport Med 1996; 7(1):4–8.
Vandenberk P, DeSmet L, Fabry G. Finger fractures in children treated with absorbable
pins. J Pediatr Orthop, Part B 1996; 5(1):27–30.
Weiss AP. Cerclage fixation for fracture dislocation of the proximal interphalangeal joint.
Clin Orthop 1996; 327:21–28.
Phalanx Shaft Fractures 39
3
Dislocations and Fracture Dislocationsof the Metacarpophalangeal andProximal Interphalangeal Joints
Randy R. Bindra
Hand Surgery, University of Arkansas for Medical Sciences, Little Rock,Arkansas, U.S.A.
INTRODUCTION
Fractures and dislocations of the metacarpophalangeal (MP) and proximal
interphalangeal (PIP) joints are most commonly seen in younger patients and
often related to sporting activities. Appropriate evaluation and timely interven-
tion are essential in order to ensure good outcomes and to avoid long-term
morbidity from pain and loss of motion. Although most dislocations can be
managed nonoperatively, operative intervention is usually indicated for larger
fractures associated with dislocations. Surgical intervention requires a good
knowledge of the anatomy and surgical approaches as well as familiarity with
instrumentation for the fixation of small fragments. An aggressive postoperative
rehabilitation program is essential for return to sport or preinjury level of activity.
METACARPOPHALANGEAL JOINT
Surgical Anatomy
The MP joint is a synovial joint with congruent articular surfaces that allow
multiplanar motion of flexion/extension, adduction/abduction/flexion, and
circumduction. Side–side stability is provided mainly by the collateral and
41
accessory collateral ligaments and to some extent by the lumbricals and the inter-
ossei. The metacarpal head is not a perfect sphere but rather a condyloid surface
wider volarly giving it a trapezoidal shape in its axial section. The collateral liga-
ments run from the fovea on the metacarpal head dorsally to the tubercle on the
volar-lateral base of the proximal phalanx and hence tighten during flexion. Con-
versely, the accessory collateral ligaments that originate just volar to the proper
collaterals and insert onto the volar plate are taut in extension. Dorsal displace-
ment of the phalanx is resisted by the volar plate that attaches loosely to the meta-
carpal neck proximally and has a thick firm attachment to the volar surface of the
proximal phalanx. The dorsal capsule is thin and loose to allow flexion of the MP
joint and provides relatively little stability to the joint. The thumb MP joint is
similar to those of the fingers, but has less side–side mobility and a large vari-
ation among individuals in its range of flexion-extension. Because of the lack
of adjacent support, the MP joints of the thumb and the border digits, index
and small, are most commonly injured.
Dislocation of the Metacarpophalangeal Joint
MP joints can be dislocated in a volar or dorsal direction as defined by the
relationship of the proximal phalanx to the metacarpal. The latter is the most
common resulting from hyperextension of the joint from falling on the
outstretched hand. Dorsal dislocations may be “simple,” in that they are reducible
by closed means. “Complex” dislocations require open reduction. Volar dislo-
cations are extremely rare with only a handful of case reports in literature and
are almost always complex.
Pathoanatomy
Hyperextension of the MP joint disrupts the volar plate, which commonly tears
from its weaker metacarpal attachment. Unless there is associated twisting of
the finger, the collateral ligaments remain intact. In a simple dislocation, the
phalanx remains in contact with the dorsal surface of the metacarpal. The deform-
ity is clinically obvious with the finger stuck in a claw position of extreme dorsi-
flexion at the MP joint. With continuation of the displacing forces, the metacarpal
head is pushed through the volar structures whereby it can get “buttonholed” in
the process as the volar plate displaces dorsal to the metacarpal head. The
proximal phalanx loses all contact with the metacarpal head and assumes a
position dorsal and parallel to the metacarpal with a less severe clinical
deformity. This type of dislocation, referred to as a complex MP dislocation, is
irreducible by closed means and was first described by Kaplan (1). The metacar-
pal head becomes wedged between the natatory ligament that supports the web
space dorsally and the superficial intermetacarpal ligament of the palmar fascia
anteriorly. In the small finger, the tendons of the flexor and abductor digiti
minimi are displaced ulnarly, and the long flexor tendons with the lumbricals
become positioned on the radial side of the metacarpal head. In index finger
42 Bindra
dislocations, the metacarpal head is caught between the flexor tendons ulnarly
and the lumbrical radially. The neurovascular bundles come to lie close to the
palmar skin tightly stretched across the front of the metacarpal head placing
them at risk of injury during a volar surgical approach. Less commonly, an osteo-
chondral fracture may be sheared off from the metacarpal head or phalanx base in
the process.
Volar dislocations are invariably irreducible with one of various anatomical
structures blocking reduction. These include interposition of the volar plate torn
from the base of the phalanx, the dorsal capsule detached from the metacarpal (2)
or the junctura tendinum between the ring and small finger extensors (3), and com-
binations of entrapment of the volar plate with the collateral or dorsal capsule (4).
Imaging
Radiographs in three planes, frontal, lateral, and oblique, are essential for the
evaluation and diagnosis of MP joint injuries. Lateral views may be difficult to
interpret because of overlapping adjacent digits. A widened joint space or an
interposed sesamoid bone implies volar plate interposition and a complex dislo-
cation (Fig. 1).
Closed Reduction
An attempt at closed reduction is usually justified. Local anesthetic infiltration
with or without sedation to promote muscle relaxation is all that is required in
most cases. Unlike the reduction maneuver common to all dislocations, the
Figure 1 Complex dorsal dislocation of the thumb metacarpophalangeal (MP) joint. The
appearance of sesamoid bones in the joint space suggests that the dislocation is complex.
Note the relative benign clinical appearance.
Metacarpophalangeal and Proximal Interphalangeal Joints 43
application of traction is contraindicated in this injury as it may create a negative
pressure and draw the volar plate into the joint causing a complex dislocation.
The wrist and interphalangeal joints are flexed to relax the flexor tendons and
with application of gentle compressive force the MP joint deformity is accentu-
ated by hyperextension followed by gentle flexion. If successful, the joint will
flex easily and a full arc of active motion is restored. If there is a “springy”
resistance to flexion and full MP joint flexion cannot be achieved, the dislocation
is a complex one and requires surgery.
Surgical Management
Kaplan’s original description of the injury included open reduction by a volar
approach (1). Although this exposure allows excellent visualization of the
anatomy, the risk of injury to the digital neurovascular bundle is extreme. A
dorsal approach is safer in this regard and has been reported to be effective in
surgical management of these injuries (5).
Volar approach: An oblique incision is centered across the volar promi-
nence of the metacarpal head. The incision is planned to allow distal and proxi-
mal extension in a zigzag fashion if required. The moment the skin incision is
made, the volar-displaced neurovascular bundle should be identified and
retracted. Palmar fascia fibers overlying the metacarpal head are released. The
A1 pulley must then be divided to relax the flexor tendons. Soft tissues are
retracted to either side of the head, and the volar plate is flipped out of the
joint with a hemostat. The joint is reduced with direct dorsal pressure on the
head. The joint is usually immediately stable. In cases of extreme instability,
the volar plate can be reattached with bone anchors to the metacarpal neck.
Dorsal approach: A longitudinal incision is made over the joint, and the
extensor mechanism is split longitudinally. If intact, the dorsal capsule is incised
as well. The volar plate is visualized overlying the metacarpal (Fig. 2). With
distraction applied to the joint, the volar plate is divided longitudinally and
with the help of a hemostat pushed back volarly. The proximal phalanx is then
flexed to reduce the joint. The extensor mechanism is repaired with a continuous
nonabsorbable suture.
Postoperative Management
Once the joint is reduced, stability is assessed through its range of motion. Unless
there is a significant collateral ligament injury, the joint is typically stable through
its normal arc. Following reduction, the patient can be fitted with a dorsal splint
blocking the last 308 of MP joint extension. Active motion is encouraged
within the splint. The splint is discontinued by the end of three weeks, and
active mobilization is encouraged. With collateral ligament instability, the MP
joint is immobilized for three weeks allowing interphalangeal joint motion alone.
44 Bindra
Fractures of the Metacarpophalangeal Joint
Fractures that are intraarticular to the MP joint involve either the head of the
metacarpal or the base of the proximal phalanx.
Fractures of the Metacarpal Head
There are several patterns of intraarticular fractures of the metacarpal head. The
index finger metacarpal head is the most prone to fracture and the thumb is the
least (6). The following are common fracture patterns.
Type 1: Oblique fractures of the metacarpal head exit into the joint making them
intraarticular injuries. These occur most commonly at the border metacarpals
(Fig. 3). The free joint fragments are usually shortened and rotated due to the
fracture geometry. The protruding metaphyseal spike of the proximal fragment
will cause obstruction of motion and stiffness is likely if not reduced.
Closed reduction by traction and derotation can be achieved in some cases,
but the reduction cannot be maintained without the application of some form of
traction or internal fixation. The most optimal method of stabilization of this
articular shear fracture is surgical fixation with interfragmentary lag screws
(Fig. 4). Fixation provides adequate stability to allow early motion out of a
protective splint. Surgical approach is dorsal by splitting or retracting the
extensor apparatus over the MP joint.
Figure 2 Dorsal surgical approach for open reduction of the case shown in Figure 1.
(A) Intraoperative photograph demonstrates the interposed soft tissue on the dorsum of
the metacarpal. (B) The soft tissue is mobilized and partly excised to allow the metacarpal
head to be delivered dorsally reducing the joint.
Metacarpophalangeal and Proximal Interphalangeal Joints 45
Type 2: Osteochondral fractures of the metacarpal head are the result of
direct trauma to the knuckle of the finger. The most common etiology is from
“fight-bite” injuries. These open fractures require urgent debridement and joint
lavage along with antibiotic coverage aimed at oral flora. The fracture fragments
Figure 3 (A) Oblique fracture of the metacarpal head of the index finger. The fracture is
unstable and the head is depressed along line of obliquity. (B) The fracture has been stabil-
ized with lag screws.
Figure 4 (A) An oblique fracture of the metacarpal head has been approached dorsally
between the proprius and communis extensor tendons of the index finger. (B) The
displaced fragment is elevated and fixed internally with two lag screws.
46 Bindra
are generally small and treated by excision. A large osteochondral fragment that
is devoid of soft-tissue attachments will not heal without fixation. These should
be fixed rigidly using a headless screw to avoid hardware prominence in the
joint (Fig. 5).
Type 3: Collateral ligament avulsion fractures off the metacarpal head are
rare. The collateral ligament more commonly fails at its phalangeal insertion.
Smaller, nondisplaced fragments will heal if treated with immobilization.
Displaced fragments may fail to unite or heal in a displaced position leading to
ligamentous laxity and joint instability. Open reduction and fixation with a lag
screw is recommended for all displaced avulsion fractures. Small fragments
that cannot be fixed can be excised followed by repair of the ligament to bone
using bone anchors or transosseous sutures.
Type 4: Vertical fractures of the metacarpal head are rare. In this pattern,
the metacarpal head is split in the longitudinal plane as a result of direct
trauma. The fracture may occur in the sagittal or coronal planes. Longitudinal
fractures in the sagittal plane may be depressed due to the compression force
of the injury. Careful examination of the radiographs will demonstrate an appar-
ent widening of the joint space in comparison to the neighboring joints (Fig. 6).
Displacement or depression of the joint surface is an indication for operative
treatment. Open reduction by a dorsal approach allows access to the articular
fragments. The depressed articular surface can be elevated easily leaving a
defect that must be filled with bone graft to prevent subsequent collapse. If
possible, lag screws should be placed transversely to buttress the elevated
articular surface (Fig. 7).
Figure 5 (A) Osteochondral transverse fracture of the metacarpal head of the long finger.
(B) The fracture is exposed by a dorsal extensor splitting incision and internally fixed with
a longitudinally placed headless screw.
Metacarpophalangeal and Proximal Interphalangeal Joints 47
Coronal shear factures of the metacarpal head occur as a result of a shearing
force from the base of the proximal phalanx and are associated with a subluxation
of the MP joint which follows the displacement of the fragment. Such fractures
are difficult to treat nonoperatively due to the associated joint subluxation.
Figure 6 (A) Posteroanterior (PA) and (B) lateral views demonstrating a vertical fracture
in the sagittal plane of the metacarpal head with depression of the articular surface recog-
nized by the widened joint space.
Figure 7 (A) The fracture is approached dorsally and (B) the depressed articular frag-
ment is elevated. (C) The defect is grafted and stable fixation is achieved with two lag
screws as demonstrated radiographically.
48 Bindra
Smaller dorsal coronal fractures with stable joints can be treated by simple exci-
sion of the fragment as the dorsal articular surface of the metacarpal head does
not articulate with the phalanx in the arc of functional motion. However, larger
fragments have to be internally fixed to support the base of the proximal phalanx.
Volar coronal fractures pose the biggest treatment challenge. The pull of
the flexor tendons and the lack of support of the base of the proximal phalanx
results in volar subluxation of the MP joint. Although the joint can be reduced
by traction, the volar fragment remains displaced as it has no soft-tissue attach-
ments (Fig. 8). Open reduction is mandatory and has to be performed through an
anterior approach as the fragment cannot be visualized through the usual dorsal
approach to the MP joint. An anterior approach to the joint involves a zigzag
incision in the palm centered over the distal palmar crease (Fig. 9). The interval
between the neurovascular bundle and the flexor tendon sheath is developed.
The flexor tendons along with the intact flexor tendon sheath are reflected later-
ally off the volar plate by sharp dissection. The volar plate is then incised and
reflected distally. By maintaining traction on the digit to counteract displacing
forces, the fragment can be elevated to its normal position and fixed with tempor-
ary wires while the reduction is confirmed by radiography. At least two headless
screws or lag screws with the heads countersunk below the articular surface are
used. Joint stability is determined prior to closure. As visualization of the joint
surface is limited from the volar approach, intraoperative imaging is mandatory
to ensure that the joint is reduced and the articular congruity is restored (Fig. 10).
Figure 8 (A) Volar coronal fracture of the metacarpal head. Loss of joint space on the
posteroanterior (PA) view suggests joint subluxation that is confirmed with the (B)
oblique and (C) lateral views. The proximal phalanx follows the displaced volar articular
surface of the metacarpal head.
Metacarpophalangeal and Proximal Interphalangeal Joints 49
If secure fixation is achieved, protected motion can be early after the initial pain
and swelling are controlled. These fragments may develop late collapse due to
avascular necrosis.
Type 5: Transverse and comminuted metacarpal head fractures are usually
associated with significant comminution and are the result of violent injury to the
border metacarpals (Fig. 11). The injury is not uncommonly associated with sig-
nificant soft-tissue crushing and injury to the adjacent skeleton. Treatment in
these cases is dictated by the associated soft-tissue injury and often requires
open reduction and fixation (Fig. 12). Fixation of these fractures usually requires
some ingenuity using a combination of wires and screws and sometimes place-
ment of a neutralizing external fixator. Early mobilization may not be possible
in extremely comminuted and unstable fractures. Primary arthroplasty or arthrod-
esis may be considered in severe cases such as gun shot injuries where there is
significant loss of the articular surface of the joint.
Basal Fractures of the Proximal Phalanx
Fractures of the base of the proximal phalanx comprise 10% of all hand fractures
(7). These fractures can be classified into the following types.
Avulsion fractures: This is the commonest type and is usually sports-
related and results from avulsion of a variable-sized fragment off the volar-
lateral corner of the proximal phalanx (Fig. 13). Collateral avulsion from the
Figure 9 (A) The fracture is approached through a volar zigzag approach. (B) The volar
fragment is elevated with care to avoid stripping any tenuous soft-tissue attachments and
(C) fixed using screws directed dorsally. The screw heads are countersunk below the
articular surface.
50 Bindra
border digits can lead to significant symptoms of instability, whereas collateral
instability of the MP joint of inner digits may be asymptomatic in more sedentary
individuals. Anatomic reduction of the fragments should be the goal for all
collateral avulsion fractures in athletes or those with an active lifestyle and
Figure 10 (A) Frontal and (B) lateral radiographs postoperatively. The volar coronal
fracture has healed with minimal collapse of the volar fragment.
Figure 11 (A) Frontal and (B) oblique radiographs of a comminuted fracture of the
index metacarpal head caused by direct injury to the metacarpal head. The fracture was
irreducible by closed means and required open reduction.
Metacarpophalangeal and Proximal Interphalangeal Joints 51
injuries affecting border digits. Undisplaced or minimally displaced fragments
can be treated nonoperatively with immobilization in a hand-based splint.
Early motion with buddy taping to the adjacent digit may be considered by strap-
ping the digit to the one adjacent to the fracture. Thus, it is acceptable to strap the
long to the ring finger for a nondisplaced avulsion fracture from the ulnar corner
of the long finger proximal phalanx and to strap to the index finger for an avulsion
from the radial corner. If the fragment is displaced by more than 3 to 5 mm or
there is any joint subluxation, internal fixation must be considered regardless
of the size of the fragment as it is essential to restore integrity and correct
length of the ligament.
The border digits can be approached through a midaxial incision by dor-
sally reflecting the lateral band of the extensor apparatus to expose the fracture.
Avulsion fractures from the inner digits can be approached from a dorsal or volar
approach. Although the dorsal approach is easier to perform because of famili-
arity, the volar approach to the MP joint as described above is preferable as it
affords direct access to the fragment and allows better placement of a lag
screw compressing the fragment back to the phalanx (Fig. 14) (8). Depending
on the size of the fragment, one or two screws may be used for fixation. When
dealing with small fragments, careful drilling by hand using an oscillating
motion is preferable to powered drilling.
Compression fractures: The most common method of failure of the
proximal phalanx is a bending extraarticular fracture through the weaker
Figure 12 (A) Open reduction was performed using a dorsal approach. (B) After tempor-
ary fixation with Kirschner wires, (C) definitive fixation was performed using resorbable
radiolucent pins.
52 Bindra
Figure 13 (A) Frontal and (B) lateral radiographs of a radial collateral avulsion fracture
from the base of the proximal phalanx of the small finger. With a large fragment, displace-
ment can result in articular incongruity.
Figure 14 (A) Volar approach to the base of the proximal phalanx. (B) The flexor sheath
is left intact and reflected subperiosteally to expose the fracture (C and D). Care must be
taken to maintain the soft tissues attached to the fragment. (E) Fixation is achieved with
two lag screws.
Metacarpophalangeal and Proximal Interphalangeal Joints 53
metaphyseal bone. Less commonly, direct impact on the flexed MP joint drives
the metacarpal head into the phalangeal base resulting in an impaction fracture
with comminution and depression of the articular fragments (Fig. 15). Traction
alone is not effective in restoring congruity as articular fragments are displaced
into the metaphysis. Minor articular step-offs without angular deformity of the
phalanx may be treated nonoperatively, with early protected mobilization in a
removable splint. Surgical treatment is indicated when the articular surface frag-
ments are depressed more than 2 mm to prevent mechanical problems with MP
joint motion. Significant depression of the articular surface leads to rotational
deformity in flexion as the phalanx drops into a rotated position when the
depressed surface articulates with the radial head.
Preoperative workup with a computed tomography scan is helpful in
planning operative strategy. Open reduction of these injuries is challenging as
the fracture is comminuted and reduction requires careful elevation of tiny articu-
lar fragments. The base of the proximal phalanx can be exposed through a dorsal
tendon splitting incision and capsulotomy of the MP joint (Fig. 16). If the
metaphysis is largely intact, a dorsal metaphyseal window can be created
through which the articular surface is gently elevated back under vision. If
there is metaphyseal comminution, the cortical fragments are reflected to allow
access to the metaphysis from where articular fragments are gently elevated
back. The resulting metaphyseal defect is then packed with bone graft obtained
from the ipsilateral distal radius. An alternative such as allograft can be utilized
Figure 15 (A) Comminuted depressed fracture of the phalangeal base of the ring finger.
(B) Note the angular deformity of the phalanx at the metaphysis in addition to central
depression of the articular surface.
54 Bindra
at the discretion of the surgeon. The key to joint stability is packing the metaphy-
seal defect with bone graft. Additional stability is obtained by a buttress plate
applied to the lateral or dorsal surface of the phalanx although some authors
feel that internal fixation is not necessary (9). Early intermittent motion out of
a protective splint is started once the initial pain and swelling have subsided.
PROXIMAL INTERPHALANGEAL JOINT
Surgical Anatomy
The PIP joint functions as a hinge. The majority of motion is in the flexion-
extension plane with some allowance for minimal rotation and lateral movement
to allow some give when grasping objects of different shapes. The convex
surface of the proximal phalanx is only partially covered by the concave articular
surface of the middle phalanx. The proximal phalanx articular surface has two
condyles separated by a shallow sulcus into which fits a corresponding ridge
on the base of the middle phalanx providing some inherent bony stability.
Side-to-side stability of the joint is provided by collateral ligaments that run
from a notch just distal to the epicondyle of the proximal phalanx to insert onto
the anterior half of the lateral margin of the middle phalanx. The collateral liga-
ment has two distinct parts: a dorsal one that tightens during extension and a volar
one that tightens with flexion of the joint. Division of both these components can
Figure 16 (A) The metacarpophalangeal (MP) joint is exposed through a dorsal
approach to demonstrate articular incongruity. (B) The articular fragments have been elev-
ated with bone grafting of the metaphysis. (C) A lateral T-plate has been applied to correct
the metaphyseal angulation.
Metacarpophalangeal and Proximal Interphalangeal Joints 55
cause significant instability of the joint (10). An accessory collateral ligament
runs from the proximal phalanx to the lateral edge of the volar plate. The main
function of this ligament is to tension the volar plate and pull it proximally to
provide clearance for finger flexion. The volar plate is the third important stabi-
lizing structure and primarily prevents hyperextension of the joint. It is attached
distally to the base of the middle phalanx just volar to the articular surface. Proxi-
mally the volar plate gains attachment to bone by lateral extensions that attach to
the proximal phalanx just distal to and within the mouth of the second annular
pulley. The actual proximal edge of the plate remains free to move proximally
with digital flexion.
Dynamic stability of the PIP joint is provided by the central slip of the
extensor mechanism which is attached to the middle phalanx dorsally and the
flexor tendons that are held close to the joint by the third annular pulley attached
to the volar plate. In addition, the superficialis tendon also directly inserts by two
lateral slips on either side of the volar lateral edge of the middle phalanx over its
proximal third.
Proximal Interphalangeal Joint Fractures and Dislocations
Fractures may affect either the condyles of the proximal phalanx or the base of
the middle phalanx. The various fracture patterns are described below. Although
there are different patterns of injury, management principles are the same and are
discussed subsequently.
Condylar Fractures
Condylar fractures affect the younger population and are usually sports-related
(11). Sagittal fractures are caused by forced separation of the digits, whereas
coronal fractures can occur from impact on the joint in hyperflexion or in an
extended state. The small finger is most commonly involved and the long, the
least with equal incidence among the remaining digits (12).
Classification: Type 1: Unicondylar fracture with transverse metaphyseal
fracture occurs due to a combination of axial load with angular force and is stable
due to the transverse metaphyseal component. Unless initially displaced, these
fractures can be treated nonoperatively with early mobilization by buddy
taping to the digit adjacent to the fractured fragment.
Type 2: Unicondylar fracture with an oblique metaphyseal fracture of
varying length is by far the commonest accounting for one-half to two-thirds
of these fractures (Fig. 17). Owing to the obliquity of the metaphyseal fracture,
these fractures are highly unstable—even initially undisplaced fractures may
settle during the healing period and lead to an angular deformity of the digit.
Type 3: Bicondylar fractures with varying obliquity of the metaphyseal
component result in angular deformity that is less pronounced if there is equal
subsidence of both the fractured condyles. Stability of the fracture is determined
by the initial displacement and obliquity of the metaphyseal fracture component.
56 Bindra
Type 4: Coronal plane condyle fractures of the dorsal or volar part of the
phalanx head involve osteochondral fragments that are usually extremely
unstable injuries. If the fragment is displaced, there is associated joint subluxation
with proximal displacement of the middle phalanx.
Basal Fractures of the Middle Phalanx
Fractures of the base of the middle phalanx may or may not be associated with
dislocation of the PIP joint.
Type 1. Small avulsion fractures—volar or dorsal: These fractures
represent small fragments less than a third of the articular surface of the middle
phalanx base. The volar fracture is a relatively common injury occurring due to
a hyperextension force and represents an avulsion of the volar plate. Dorsal frac-
tures are less common and occur when the extended digit is suddenly bent by an
axial force causing an avulsion of the central slip of the extensor mechanism.
Type 2. Large avulsion fractures—volar or dorsal: When the size of
the detached fragment of the middle phalanx is more than 40% of the articular
surface, there is commonly associated joint instability and the PIP joint is
usually subluxated or dislocated dorsally. The joint instability is due to a combi-
nation of the loss of concavity of the middle phalanx base from displacement of
the volar lip and impaction of the articular surface along with disruption of
the collateral ligaments that remain attached to the volar fragment. Fracture
Figure 17 (A) A unicondylar fracture of the thumb proximal phalanx with an oblique
fracture line. (B) The fragment has collapsed resulting in a clinical angular deformity.
(C) Longitudinal alignment and articular congruity have been restored by open reduction
and screw fixation.
Metacarpophalangeal and Proximal Interphalangeal Joints 57
dislocations can be classified based on the degree of subluxation: A: ,25%, B:
25% to 50%, C: .50%. D: dislocated or on the amount of articular surface
involvement: Grade I: 0, II: 0% to 20% III: 20% to 40%, IV: .40% (13).
Type 3. Pilon fractures: Comminuted fractures that result in splaying of
the dorsal and volar cortices with compression of the central articular surface of
the middle phalanx are referred to as pilon fractures (14). Injury occurs due to
axial loading in neutral or hyperextension. Pilon fractures are highly comminuted
fractures with multiple small fragments that are often too small for internal
fixation (Fig. 18). The articular surface of the middle phalanx is disrupted and
if treated with immobilization without restoration of joint congruity and
alignment, results are poor with pain and stiffness of the joint.
Dislocations
Dislocations of the PIP joint can be classified by direction of the displaced middle
phalanx into dorsal, lateral, or volar.
Dorsal Dislocations
Dorsal dislocations of the PIP joint are by far the commonest type and occur as a
result of hyperextension injury to the digit. They may be associated with fractures
of the middle phalanx base anteriorly. The volar plate is avulsed from the base of
the middle phalanx usually with a small chip of bone. Larger avulsion fragments
Figure 18 (A) Posteroanterior (PA) and (B) lateral pilon fracture of the middle phalanx
base. There is comminution of the metaphysis with articular surface depression. (C and D)
Stability and joint congruity have been restored with open reduction and lag screw fixation
of the larger cortical fragments using a midlateral approach.
58 Bindra
are discussed below. The distal avulsion of volar plate in dorsal PIP dislocations
prevents entrapment of the plate within the joint in contrast to the MP joint in
which complex dislocations can occur due to volar plate entrapment within the
joint. In most dorsal dislocations, the volar plate maintains its attachments to
the proximal phalanx and its lateral attachments to the accessory collateral
ligament. These injuries are stable after closed reduction, and early motion is
encouraged providing hyperextension can be prevented by buddy taping or
dorsal block splinting. Postreduction films are essential to confirm concentric
reduction and exclude displaced bony fragments that may necessitate open
reduction (Fig. 19).
In more severe injuries, the collateral ligaments may also be ruptured at the
time of injury. Careful assessment of stability is essential after closed reduction of
the dorsal PIP joint. If the joint tends to dislocate when a position near full
extension is reached, extension block splinting should be used.
Lateral Dislocations
A more laterally directed force on the digit will cause the collateral ligament to
primarily fail. With continuing force, the volar plate is detached and the finger
dislocates laterally at the PIP joint (Fig. 20). The deformity is clinically very
Figure 19 (A) Dorsal dislocation of the ring finger PIP joint with small bone fragments
volar and dorsal to the PIP joint. (B) Closed reduction restored the volar plate avulsion
fracture, but there was an unexplained displaced dorsal fragment. The radial collateral
ligament was also clinically ruptured. (C) The joint was explored using a midlateral
approach and dislocated through the torn collateral ligament. (D) The dorsal fragment
was an osteochondral fragment consisting of almost the entire articular surface of the
middle phalanx. (E) This was restored and held with K-wires.
Metacarpophalangeal and Proximal Interphalangeal Joints 59
obvious. Closed reduction is usually successful and providing the joint can be
ranged without subluxation, early motion with buddy taping is permissible.
Primary ligament repair is advocated by some in athletes to ensure joint
stability, This can be achieved using a midlateral approach and repair with
bone anchors or transosseous sutures.
Volar Dislocation
Volar dislocations of the PIP joint are extremely uncommon. In an uncomplicated
volar dislocation, the central slip ruptures from the base of the middle phalanx
with or without a bony fragment (Fig. 21). In the more complex rotary
dislocation, there is an associated tear of the collateral ligament. The head of
the proximal phalanx can buttonhole between the lateral band and the central
slip which remains intact (15).
Simple volar dislocations can be reduced easily under digital block.
However, immobilization of the PIP joint in full extension for three to four
weeks is essential to allow healing of the central slip and prevention of a late
boutonniere deformity. Leaving the DIP joint free for active and passive
motions helps prevent volar subluxation of the lateral bands and extensor
mechanism imbalance. Complex rotary dislocations are irreducible and require
open reduction. A dorsal approach allows visualization of the interposed lateral
band. Once freed, the rent in the extensor apparatus is repaired and the joint is
reduced. Collateral ligament repair may be performed but is not absolutely
necessary. Early motion is commenced after surgery.
Figure 20 (A) Posteroanterior (PA) and (B) lateral views of proximal interphalangeal
(PIP) joint lateral dislocation in the ring finger. Note that the middle phalanx is aligned
with the proximal phalanx on the lateral view.
60 Bindra
Management of fracture dislocations require open reduction and fixation of
the displaced dorsal lip fragment and are discussed below.
Clinical Assessment
It is important to carefully examine a patient with a PIP joint injury. Malalign-
ment in the coronal plane usually suggests a depressed condyle fracture. The
PIP joint is swollen, and motion is invariably restricted. A significant dislocation
can be easily noted clinically, but minor subluxation is suspected when there is
severe restriction of joint motion. In a cooperative patient, it is often helpful to
try to pinpoint the area of maximal tenderness in order to localize the site of path-
ology. Continuity of the flexor and extensor tendons must be established by
asking the patient to gently move the digit in the desired direction.
Many patients with sporting injuries will have had the finger reduced or
splinted on the field prior to presentation to hospital. In such cases, it is very
helpful if information on the severity and original direction of displacement
can be gleaned from the patient. Thus, a joint that is normal on radiographs at
presentation may have been dislocated and management must be based on
history and physical findings.
Imaging
Evaluation of fractures around the PIP joint requires careful interpretation of
accurate PA, lateral, and oblique radiographs that are centered on the injured
Figure 21 (A) Simple volar dislocation with rupture of the central extensor slip.
(B) Volar fracture dislocation of the PIP joint with avulsion fracture of the central
extensor slip.
Metacarpophalangeal and Proximal Interphalangeal Joints 61
digit. Joint subluxation can only be adequately assessed on the true lateral view.
A coronal fracture of the proximal phalanx condyle can easily be missed if the
joint is stable. The only sign of the injury may be the presence of a double
projection in place of the normal single volar convexity of the proximal
phalangeal condyles.
Management of Condylar Fractures of the ProximalInterphalangeal Joint
Condylar fractures tend to cause joint incongruity and angular deformity of the
digit. Joint subluxation is less common and usually implies more severe injury
with associated ligamentous damage. Basal fractures of the proximal phalanx
and fracture dislocations follow the same management principles and are
discussed later.
Conservative Treatment
Nondisplaced fractures and joints stable after closed reduction can be treated
conservatively with immobilization in an intrinsic plus position. It is advisable
to repeat radiographs out of the splint after one week to ensure that there are
no signs of early collapse that can occur with almost two-thirds of oblique
unicondylar fractures. Buddy taping is an effective way of allowing protected
mobilization and can be started between two and three weeks. Most motion is
regained by six months, but swelling can persist for several months thereafter,
and some degree of residual swelling of the PIP joint is common. Patients
must be made aware of this at the time of presentation.
Some displaced bicondylar fractures are amenable to closed reduction by
traction. If a good reduction is achieved with less than a millimeter articular
displacement and normal rotational and angular alignment, immobilization
may be used. Usually, the displacement recurs when traction is released and
consideration may be given to application of continuous traction using
customized splinting or external fixation.
Operative treatment is indicated if closed reduction is not possible;
reduction cannot be maintained or is lost subsequently in the splint. Additional
surgery is also required if there is a middle phalanx volar fracture fragment
more than 40% of the articular surface or if the finger is unstable when extended
beyond 308.
Percutaneous Techniques
Fractures that are treated within a few days of presentation can be managed with
percutaneous techniques using either K-wires or miniature screws. The latter can
be inserted through specialized reduction clamps. The size of implant depends on
the fragment size, and good imaging is critical. Repeated blind attempts at
pinning may comminute small pieces or cause late collapse from thermal necro-
sis. In unicondylar fractures, a 0.6 or 0.9 mm K-wire is inserted into the fragment
62 Bindra
parallel to the articular surface through a stab incision. Using the wire as a joy-
stick, the fragment is realigned and the wire is driven through the opposite cortex.
Application of a clamp or forceps across the condyles externally will help to get
some compression across the fracture that cannot be achieved by the K-wiring
alone. A second wire may be passed in order to achieve rotational control. The
wires can be left outside the skin for removal at three weeks. Alternatively, a
small screw may be passed across the fracture using a targeting clap that
serves as a temporary fixation as well as a drill and screw guide. Newer cannu-
lated screws make the process even easier by allowing insertion of a screw
over a wire placed across the fracture.
Open Reduction
If treatment is delayed for more than 10 days, the organized hematoma and repair
tissue within the fracture may interfere with reduction. Anatomical reduction and
compression between the fractured fragments then requires open reduction. A
unicondylar fracture is approached through a midlateral incision defined by the
line joining the points formed by the flexion creases of the IP joints when the
digit is fully flexed (Fig. 22). Dissection is continued by elevation of the dorsal
skin flap to expose the lateral band of the extensor apparatus which is then
retracted dorsally with a skin hook after dividing the transverse retinacular
Figure 22 Steps in the operative management of unicondylar fractures. (A) The fracture
is exposed through a midlateral approach and a capsulotomy dorsal to the collateral liga-
ment. (B) A single K-wire is passed into the fragment after elevation. The K-wire is passed
through the opposite cortex for temporary fixation. (C) A small fragment screw is passed
across the fracture parallel to the K-wire. (D) The wire is then removed and replaced with a
second screw. (E) Final radiograph following internal fixation.
Metacarpophalangeal and Proximal Interphalangeal Joints 63
ligament. The collateral ligament is identified and a longitudinal capsulotomy is
made just dorsal to it. After washing out the joint hematoma, the articular surface
is visualized. The fractured condyle is mobilized with caution in order to avoid
stripping the collateral ligament and resultant loss of vascularity. A fine K-wire
inserted into the condyle will help with manipulation and reduction of the frac-
ture. Interposed granulation tissue is excised, and fracture surfaces can be com-
pressed by application of a reduction clamp whenever possible. The fracture is
temporarily fixed with a K-wire and a 1.5-mm screw is inserted parallel to it
after drilling. The K-wire is then removed and the wire track left is used for inser-
tion of a second screw. Screw length is critical and care must be taken to ensure
that the screw heads are well buried and that they do not protrude through the
opposite cortex to avoid impingement on either collateral ligament. Formal
repair of the transverse ligament of the extensor apparatus is not required. Post-
operatively, the finger is immobilized for comfort, and active motion with a pro-
tective splint is commenced after several days when the pain and swelling of
surgery are diminished.
Coronal condylar fractures pose the biggest management challenge.
Although clinical deformity is not immediately obvious due to limited motion,
a rotational deformity of the digit becomes obvious when mobility is regained
subsequently as the middle phalanx rotates when flexed onto a depressed
condyle. Displaced fractures lead to joint instability in flexion and left untreated
can lead to nonunion or malunion with significant joint stiffness. Nonoperative
treatment is ineffective as the condylar fragment has no soft-tissue attachment
and cannot be manipulated into position. The fracture is best exposed through
a lateral approach. The fragment is gently manipulated back into position and
can be fixed with a K-wire passed from dorsal to volar. The wire can be cut
close to bone and left buried with minimal risk of late migration. Alternatively,
the wire is passed through a stab incision from intact dorsal skin and can be left
outside for removal for three weeks. Screw fixation of these small fragments is
difficult but obviates problems associated with wires and provides better stability.
The screw is inserted from dorsal to volar using the lag screw technique (Fig. 23).
Again screw length is critical as a long screw will protrude through the articular
surface of the condyle on the volar surface and cause discomfort and impinge-
ment on flexion of the PIP joint.
Open reduction of bicondylar fractures requires good visualization and
access to the entire distal articular surface of the proximal phalanx. A curved
dorsal skin incision is made over the PIP joint and the extensor mechanism is
elevated in one of two ways. Either by making an incision between the lateral
band and extensor slip on either side or by creating a distally based V-shaped
flap with the apex of the V situated at the proximal third of the proximal
phalanx. A transverse capsulotomy will allow visualization of the joint. The
articular surface is first restored and provisionally held with a K-wire. The articu-
lar fragments are then stabilized to the shaft with an oblique K-wire. Although
this fixation will maintain reduction, it will not permit early motion, and
64 Bindra
consideration must be given to stable internal fixation with either a dorsal T-plate
or a laterally applied minicondylar plate. Although insertion of a lateral condylar
plate is technically more challenging, it causes less interference with the extensor
mechanism. The extensor tendon is repaired with nonabsorbable sutures.
Controlled active mobilization is started within a week.
Management of Dislocations and Fracture Dislocationsof the Proximal Interphalangeal Joint
In order to preserve motion that is imperative to normal hand function, the
goal of management of all PIP joint dislocations and fracture dislocations is to
restore joint alignment and to maintain adequate joint stability to allow early
functional range of motion exercises. Secondary goals are maintenance of
articular congruity and prevention of posttraumatic arthritis. The majority of
dislocations can be reduced by closed methods under digital block anesthesia
in the emergency room after which stability must be assessed through a range
of motion. All stable injuries and nondisplaced fractures can be managed
nonoperatively. When conservative measures fail, percutaneous techniques can
be employed to restore stability. Operative intervention for open reduction and
internal fixation are less frequently required and usually indicated for manage-
ment of late presentation.
Fractures that are associated with dislocation or subluxation of the PIP joint
usually involve the base of the middle phalanx. Volar lip fractures of the middle
Figure 23 (A) Unicondylar coronal fracture of the proximal phalanx. (B) The fracture
was stabilized with a single lag screw passed from dorsal to volar using a midlateral
approach.
Metacarpophalangeal and Proximal Interphalangeal Joints 65
phalanx which involve 40% or more of the articular surface are associated with
PIP joint instability and are a big management challenge.
Conservative Treatment
Closed reduction by traction and flexion of the PIP joint is successful in most cases
of PIP dislocations if seen within a few days after injury. Minor avulsion fractures
of the volar lip of the middle phalanx indicate volar plate avulsion and are a
common result of hyperextension injuries. Providing the joint is stable, these frac-
tures need no special management and the digit can be mobilized with buddy
taping to prevent hyperextension stress for three weeks. Splinting these injuries
in flexion is not necessary and will risk a flexion contracture of the joint.
In unstable injuries, the joint dislocates as the digit is brought into extension.
It is important to document the position at which this occurs. Immobilization of
the PIP joint in extreme flexion will stabilize the joint but lead to severe flexion
contracture and morbidity. If a position of more than 308 of flexion is necessary
to maintain reduction, consideration must be given to other methods of treatment.
A simple technique for treating dorsally unstable PIP joint fracture dislocation is
that of extension block splinting (16). This technique is applicable to cases where
closed reduction is achieved easily and where the fracture does not exceed 40% of
the articular surface of the middle phalanx. A splint is fashioned whose angle is
determined by the degree of flexion at which the PIP joint is stable. The flexion
angle is 108 more than the angle of stability determined by clinical examination
after closed reduction. The amount of flexion is reduced on a weekly basis by
about 25% and full extension is delayed for approximately six weeks.
Displaced chip fractures on the dorsum of the middle phalanx, however
small, are significant because they represent an avulsion of the central slip of
the extensor mechanism. Insufficiency of the central slip is not immediately
obvious because digital extension is maintained by the lateral bands. The triangu-
lar ligament holding the lateral bands eventually stretches causing the lateral
bands to subluxate volarly leading to hyperextension of the distal interphalangeal
joint and loss of ability to straighten the PIP joint—the boutonniere deformity.
The injured digit must be splinted with the PIP joint immobilized in full extension
for at least three weeks with the DIP joint free followed by gentle active
mobilization.
Percutaneous Techniques
The reduced but unstable PIP joint can easily be stabilized with a transarticular
pin. Although this technique may seem to be prone to stiffness, some authors
have reported results comparable to open reduction (17). An alternative technique
involves placement of a Kirschner wire as a block to PIP extension (18). The PIP
joint is reduced by applying manual traction and placing the joint into maximal
possible flexion. A smooth K-wire is then introduced percutaneously through the
center of the PIP joint to engage the distal articular surface of the proximal
phalanx. The wire is then driven obliquely into the shaft to engage the volar
66 Bindra
cortex of the proximal phalanx. The wire is left long outside the skin and effec-
tively forms a block to the last 308 of PIP extension. An extension-block K-wire
is more reliable than an extension blocking splint. The patient is put in a protec-
tive splint and instructed in pin care. Gentle active range of motion exercise is
started the next day and the wire is pulled after four weeks. It is essential to
monitor this pin closely, as a pin track infection may lead to a frank pyarthrosis.
Alternatively, continuous traction can be applied to the digit by applying
tension on a K-wire passed transversely across the middle phalanx. A 7.5 cm
radius circular frame is fashioned around the hand and incorporated into a
forearm splint (19). The amount of traction is adjusted by serial lateral radio-
graphs of the digit in the splint. The patient is instructed in passive motion of
the digit for 10 minutes every waking hour. The splint is discontinued after
three to five weeks. If adequate reduction of the articular surface of the middle
phalanx is not achieved by traction alone, the articular surface can be manipu-
lated percutaneously or by a small open incision. The fragments are then
stabilized by multiple small K-wires and traction is then applied (20).
Various forms of external fixators or K-wires have been described to treat
these injuries and consist of K-wires bent in tension (21), wires coiled into
springs (22), hinged device (23), force-couple devices (24), parallel spring-
framed systems (25), and pins and rubber (26). They are based on the concept
of providing stability by distraction of the soft tissues around the base of the
middle phalanx that stabilize and improve the alignment. It must be noted that
external fixation will not elevate all depressed and impacted fragments. Which-
ever form of external fixation is used, attempts should be made to elevate the
impacted fragments using a percutaneous blunt K-wire or freer dissector. External
fixators do have the advantage of avoiding soft-tissue stripping, soft-tissue dissec-
tion, and are not associated with the postoperative swelling seen after open
approaches. However, patients need to take care of the pin sites, and stiffness is
common. The simplest and most economic method is to create a low-profile
frame using K-wires as suggested by Haynes and Giddins (21). A wire is
placed across the proximal phalanx condyles, close to the axis of motion of the
PIP joint (Fig. 24). A second wire is passed transversely in the shaft of the
middle phalanx distal to the level of the fracture. The distal wire is then bent,
first 908 proximally, and then a second S-shaped bend is placed into the wire
and it is looped around the proximal transverse wire in such a way as to generate
tension and provide distraction to the joint. Early active motion is allowed with
this configuration and the wires are removed at three weeks. Postoperative radio-
graphs generally do show some widening of the middle phalanx base, but the
articular surfaces generally conform very well due to molding of the fragments
with motion (Fig. 25).
Open Reduction and Fixation
Operative fixation of fracture dislocations of the PIP joint involves reduction and
stabilization of the volar lip fracture of the middle phalanx thereby restoring joint
Metacarpophalangeal and Proximal Interphalangeal Joints 67
Figure 24 (A–F) proximal interphalangeal PIP joint fracture-dislocation treated with
distractor-external fixator. Creation of the distraction frame essentially involves bending
the distal wire to generate tension against the wire passed along the axis of the PIP
joint. Source: Courtesy of Dr. Grey Giddins.
Figure 25 (A) Lateral radiograph of a proximal interphalangeal (PIP) joint fracture-
dislocation. (B) This was treated by distraction external fixation frame created from
K-wires. (C) Note the remodeled articular surface of the middle phalanx following
active motion in distraction. Source: Courtesy of Dr. Grey Giddins.
68 Bindra
stability. A direct approach to the fragment can be undertaken using a volar
Bruner approach extending from the proximal digital crease to the distal
interphalangeal joint crease. The flexor tendon sheath is opened between the
A2 and A4 pulleys and reflected laterally. Often the sheath is torn in this
region and can be excised without any functional loss. The flexor tendons are
retracted to one side to expose the traumatized volar plate (Fig. 26). The plate
is mobilized by releasing its lateral attachments to the collateral ligaments and
reflected proximally. The attachments of the collateral ligaments to the base
of the middle phalanx are partially released in a volar to dorsal direction and
the digit is gently hyperextended until it is fully doubled over or “shotgunned.”
The volar fragment and the entire articular surfaces are then fully visualized.
Small comminuted fragments are removed and the major volar fragment
is elevated, reduced, and held either with a circumferential wire loop or with
two small screws passed from volar to dorsal (Fig. 27) (27). When the fragments
are small or too comminuted for fixation, an osteochondral graft obtained from
the dorsal lip of the hamate can be used to replace the volar lip of the middle
phalanx (28).
Pilon fractures can also be treated surgically but require considerable care
to avoid stripping soft-tissue attachments of small fragments. These fractures
may be better approached using a midlateral approach. By dividing the transverse
Figure 26 Volar approach for fixation of a large volar fracture of the middle phalanx
associated with dorsal proximal interphalangeal (PIP) joint subluxation. (A) The
flexor tendon sheath between the second and forth annular pulleys has been opened.
(B) The collateral ligaments have been released allowing the joint to be hyperexten-
ded and “shotgunned” open. (C) Reduction of the base of the middle phalanx articular
surface.
Metacarpophalangeal and Proximal Interphalangeal Joints 69
retinaculum, the lateral band of the extensor apparatus can be elevated giving
exposure to the fragments. Fixation is achieved using lag screws passed from
the dorsal cortex in the bare area between the two lateral bands.
A displaced larger dorsal fragment of the middle phalanx will result in joint
incongruity and instability from loss of the dorsal concavity of the middle
phalanx in addition to causing insufficiency of the extensor apparatus. Conserva-
tive treatment can be undertaken if the fragment is anatomically reduced with the
PIP joint in full extension. Separation more than 2 mm must not be accepted and
internal fixation with a pin or screw inserted from dorsal to volar percutaneously
or by open reduction.
SALVAGE
For those patients that present late where the articular surface of the middle
phalanx cannot be salvaged either due to displacement with healing or extensive
comminution, it is possible to restore some motion and stability by doing a volar
plate arthroplasty (29). This technique uses the volar plate to reconstitute the
volar aspect of the middle phalanx base. In order to create a volar plate arthro-
plasty, the joint is exposed with the usual volar approach retracting the flexor
tendons. When elevating the volar plate, it is essential to preserve length by divid-
ing it as far distally as possible right up to and including some volar periosteum of
the middle phalanx. The volar plate is then divided laterally along its attachment
to the collateral ligaments and reflected proximally. The PIP dislocation is then
Figure 27 (A) Anteroposterior and (B) lateral preoperative radiographs of a dorsal frac-
ture dislocation of the proximal interphalangeal (PIP) joint. (B) This was treated by open
reduction and fixation of the middle phalangeal fracture through a volar approach with
miniature screw fixation.
70 Bindra
reduced by inserting a dissector into the joint and using it as a lever. In delayed
cases, it may be necessary to excise scar tissue within the joint, partially release
the contracted collateral ligaments or do a careful dorsal capsular release. It is
essential to fully reduce the PIP joint and ensure that it can be fully flexed
prior to creating the arthroplasty. A 2 mm wide trough is then created along
the entire length of the volar margin of the middle phalanx for attachment of
the volar plate. A pullout wire placed through the distal volar plate is passed
through two drill holes at either edge of the trough and brought out on the
dorsum of the finger where it can be tied over a button. The joint is temporarily
pinned for two to three weeks, and active motion with dorsal block splinting is
started thereafter.
It must be emphasized that recurrent dorsal dislocation may occur even
after a properly performed volar plate arthroplasty. This is most commonly due
to inadequate bone remaining on the volar aspect of the middle phalanx to func-
tion as a hinge. With loss of the stabilizing effect of the concave base of the
middle phalanx, the dorsal pull of the central slip and superficialis tendon
create a rotational force that tends to subluxate the middle phalanx base. In
this case, joint stability requires restoration of a functional palmar buttress on
the base of the middle phalanx. This can be accomplished with an osteochondral
hamate graft as noted above.
SUMMARY
There are several different types of injuries affecting the MP and PIP joints. Some
are simple and easily treatable. The management of more severe injuries requires
knowledge of injury pathomechanics for recognition, surgical anatomy for open
reduction, and skill with internal fixation of small fragments. The basic prin-
ciples, however, do not change. The joint must be reduced, stabilized, and the
articular surface realigned with the least invasive methods possible. When
closed reduction is not successful, percutaneous or open techniques must be
attempted.
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proximal phalanges by cancellous bone grafting only. J Hand Surg 1999; 26B:
455–458.
10. Minamikawa Y, Horii E, Amadio PC, et al. Stability and constraint of the proximal
interphalangeal joint. J Hand Surg 1993; 18A:198–204.
11. Weiss APC, Hastings H. Distal unicondylar fractures of the proximal phalanx. J Hand
Surg 1993; 18A:594–599.
12. London PS. Sprains and fractures involving the interphalangeal joints. Hand 1971;
3:155–158.
13. Schenck R. Classification of fractures and dislocations of the proximal interphalangeal
joint. Hand Clin 1994; 10:179–185.
14. Stern PJ, Roman RJ, Kiefhaber TR, McDonough JJ. Pilon fractures of the proximal
interphalangeal joint. J Hand Surg [Am] 1991; 16(5):844–850.
15. Grant IR. Irreducible rotational anterior dislocation of the proximal interphalangeal
joint A spin drier injury. J Hand Surg 1993; 18B:648–651.
16. McElfresh EC, Dobyns JH. Intra-articular metacarpal head fractures. J Hand Surg
1983; 8A:383–393.
17. Aladin A, Davis TR. Dorsal fracture-dislocation of the proximal interphalangeal joint:
a comparative study of percutaneous Kirschner wire fixation versus open reduction
and internal fixation. J Hand Surg 2005; 30B:120–128.
18. Viegas SF. Extension block pinning for proximal interphalangeal joint fracture
dislocations: preliminary report of a new technique. J Hand Surg 1992; 17A:896–901.
19. Schenck RR. Dynamic traction and early passive movement for fractures of the
proximal interphalangeal joint. J Hand Surg 1986; 11A:850–858.
20. Sarris I, Goitz RJ, Sotereanos DG. Dynamic traction and minimal internal fixation for
thumb and digital pilon fractures. J Hand Surg 2004; 29A:39–43.
21. Haynes MC, Giddins GEB. Dynamic external fixation for pilon fractures of the
interphalangeal joints. J Hand Surg 2001; 26B:122–124.
22. Johnson D, Tiernan E, Richards AM, Cole RP. Dynamic external fixation for complex
intra-articular phalangeal fractures. J Hand Surg 2004; 29B:76–81.
23. Krakauer JD, Stern PJ. Hinged device for fractures involving the proximal interpha-
langeal joint. Clin Orthop Relat Res 1996; 327:29–37.
24. Agee JM. Unstable fracture dislocation of the proximal interphalangeal joint:
treatment with a force couple splint. Clin Orthop Relat Res 1987; 214:101–112.
25. Fahmy NRM. The Stockport Serpentine Spring System for the treatment of displaced
comminuted intraarticular phalangeal fractures. J Hand Surg 1990; 15B:303–311.
26. Suzuki Y, Matsunaga T, Sato S, Yokoi T. The pins and rubbers traction system for
treatment of comminuted intraarticular fractures and fracture-dislocations in the
hand. J Hand Surg 1994; 19B:98–107.
72 Bindra
27. Weiss APC. Cerclage fixation for fracture dislocation of the proximal interphalangeal
joint. Clin Orthop Relat Res 1996; 327:21–28.
28. Williams RMM, Kiefhaber TM, Sommerkamp TG, Stern PJ. Treatment of unstable
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J Hand Surg 2003; 28A:856–865.
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Metacarpophalangeal and Proximal Interphalangeal Joints 73
4
Operative Management ofMetacarpal Fractures
William B. Geissler and William O. McCraney
Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson,Mississippi, U.S.A.
INTRODUCTION
The hand is an instrument of both performance and protection. Accidents invari-
ably occur, resulting in fractures of the metacarpals and phalanges. The economic
cost of hand injuries is staggering. It is estimated that one-third of all injuries
involve the upper extremity. This involves 16 million patients per year in the
U.S. alone. It is estimated that 1.5 million hand fractures occur annually in the
U.S., which results in 16 million lost work days, 2 billion dollars in lost
wages, and 4 billion in costs to industry annually in the U.S. (1).
There are potential and specific problems and complications that may occur
with fractures of the hand. Hand fractures generally involve small fragments,
which may be difficult to anatomically reduce and securely repair. There is a
high risk for tendon and joint adhesions, due to the close association of both
the flexor and extensor tendons to the bone. This may result in joint stiffness
and permanent loss of motion. Surgical incision carries the risk of function-
limiting scar formation. The physician must always balance the potential
benefit of increased biomechanical stability that may be gained through surgical
management against the risk of potential scarring and stiffness.
Fracture fixation need not be absolutely rigid, but must be reliable and allow
for early rehabilitation. If surgical intervention is recommended, the implant
75
selected must provide sufficient structure stability to allow immediate active range
of motion in order to offset the increased risk of scarring and stiffness associated
with fracture exposure and fixation. Early fracture stabilization and rehabilitation
are utilized in an effort to reduce the elements of fracture disease—meaning the
stiffness and atrophy associated with prolonged immobilization.
It is important to remember that the majority of hand fractures are closed,
simple, and stable. The vast majority of hand fractures do not require operative
management. The intact, intrametacarpal ligaments prevent shortening of a frac-
tured metacarpal more than 3 to 4 mm (2). Most hand fractures demonstrate
minimal displacement, defined as less than 1 to 2 mm of translation and less
than 108 of angulation, and absence of rotational malalignment or substantial
visual deformity. These fractures can be treated with a brief period of immobil-
ization (or with protective splints that allow some motion—extension block
splints, for example) followed by active exercises (3–8).
Fractures with greater displacement, rotational malalignment, or substan-
tial deformity, multiple fractures, and fracture associated with greater soft-
tissue injury should be considered for operative stabilization. Second and fifth
metacarpal fractures are more likely to shorten as they only have the suspensory
effect of only one intrametacarpal ligament. It has been shown that approximately
78 of extensor lag develops in the finger for each 2 mm of residual metacarpal
shortening after fracture healing (9). The unbalanced pull of the extrinsic
flexor tendons and intrinsic muscles may cause dorsal angulation of the distal
fragment of metacarpal fractures (10,11). Angulation greater than 308, shortening
of more than 4 mm, or a combination of these two, interferes with the normal
intrinsic muscle dynamics of the hand and may cause weakness, clawing, and
potential cramping (10–12). Specifically, the metacarpals do not tolerate malro-
tation. It has been shown that 58 of malrotation may translate up to 1.5 cm of
digital finger overlap during flexion (8,13).
EXTRAARTICULAR BASE FRACTURES
The majority of extraarticular metacarpal base fractures are stable. Most fractures
are impacted, which results in a stable fracture configuration. However, when
associated soft-tissue trauma occurs, this can disrupt the intrinsic capsular liga-
ments and the fracture may become unstable, particularly when multiple metacar-
pal base fractures are involved. When multiple extraarticular base fractures are
present, open reduction and internal fixation are recommended (7,14) (Fig. 1).
A dorsal incision may be made, centered between the involved metacarpals,
and dissection is carried down to the base of the metacarpal. When fractures
involve the base or distal portion of the metacarpal, generally plate fixation is rec-
ommended. Plates are named for their anatomic shape and due to the proximal
location of the fractures, a T-shaped plate or mini-condylar plate may be utilized.
It is important to remember that when a T-plate is used it is important to place the
screws in the T-portion of the plate first. If the screws are placed first in the
76 Geissler and McCraney
longitudinal portion of the plate, the T-section of the plate may be kicked up and
not sit fully congruent on the base of the metacarpal. When the screw is then
placed in the T-portion after the longitudinal screws are already placed, this
screw may displace the fracture as it is being seated if the plate is not congruent
on the bone. For this reason, when a T-plate is utilized, always place the screws
on the T-portion first before the longitudinal section. This also aids in com-
pression of the fracture site.
INTRAARTICULAR METACARPAL BASE FRACTURES
Intraarticular metacarpal base fractures are most common in the small finger
metacarpal. The vast majority of these are stable and adequately aligned. The
extent of articular injury and, in particular, articular surface impaction may not
be apparent on plain radiographs, and computed tomography may more accu-
rately define the fracture. The articular fragments are small and difficult to
handle. If operative treatment is elected, it is wise to provide some means of
distracting the small finger metacarpal with respect to the carpus (a small external
fixator between the metacarpal and hamate may be useful in this regard), the frag-
ments are elevated and the resulting metaphyseal defect grafted with cancellous
bone from the distal radius, and the fragments are stabilized with small Kirschner
Figure 1 Open reduction internal fixation is recommended when multiple extraarticular
metacarpal base fractures are present. (A) A PA radiograph demonstrates extraarticular
base fractures of the index through small metacarpals. (B) A PA radiograph demonstrates
fixation of the multiple base metacarpal fractures. Each metacarpal fracture was stabilized
with a mini-condylar plate due to the position of the fracture near the base of the metacar-
pal. Abbreviation: PA, posteroanterior.
Operative Management of Metacarpal Fractures 77
wires, and—on rare occasions—with screws. It has not been clearly demonstrated
that operative fixation is superior to nonoperative treatment.
CARPAL–METACARPAL FRACTURE DISLOCATIONS
Carpal–metacarpal fracture dislocations are the result of high-energy trauma
(Fig. 2). The fifth metacarpal is most frequently involved (15). The fifth metacar-
pal carpal joint is a concave, convex saddle-type joint. This joint allows 208 to
308 of flexion extension at the base and allows the small finger to oppose the
thumb. Carpal–metacarpal fracture dislocations are classified as epiphyseal,
two-part, three-part, and comminuted.
Radiographically, a 308 oblique pronated view outlines the fifth metacarpal
base. This is very useful to gain further detail about the amount of displacement
of a fracture dislocation of the fifth carpal–metacarpal joint. The 308 oblique
supinated view particularly outlines the index and long metacarpal base and
the potential amount of articular displacement.
Two-part carpal–metacarpal fracture dislocations of the small metacarpal
are frequently unstable due to the pull of the extensor carpi ulnaris tendon. The
fracture tends to translate proximally due to the pull of the tendon on the
oblique slope of the fracture line. The fracture is easily reduced by longitudinal
traction and if the fracture fragment is small, two Kirschner wires may be placed
transversely from the fifth metacarpal through the fragment into the base of the
fourth metacarpal (Fig. 3). This adds further stability to the fracture configuration
by placing the pins into the base of the fourth metacarpal as well. It is particularly
important to note when placing Kirschner wires on the ulnar side of the hand, to
make an incision and insert the Kirschner wires through a soft-tissue protector, or
utilize an oscillating drill to prevent branches of the dorsal sensory branch of the
ulnar nerve becoming wrapped around the Kirschner wires as they are being
inserted. This avoids the potential for neuritis of the dorsal sensory branch of
the ulnar nerve.
Figure 2 Multiple carpal–metacarpal dislocations are uncommon. (A) A PA radiograph
showing dislocation of the carpal–metacarpal joints. (B) The dislocations were reduced by
open reduction and stabilized by Kirschner wire fixation.
78 Geissler and McCraney
Three-part intraarticular fractures may be stabilized either by K-wire,
T-plate, mini-condylar plate, or external fixation if there is extensive comminu-
tion present (Fig. 4). When Kirschner wires are utilized, they are placed through
the intraarticular fragments and advanced into the base of the fourth metacarpal
Figure 3 Two-part carpal–metacarpal fracture dislocations are relatively unstable. (A)
A PA radiograph showing the small radial-based fragment. The small metacarpal is at
risk to displace proximally secondary to pull of the extensor carpi ulnaris. (B) With
gentle longitudinal traction, the metacarpal was reduced and two Kirschner wires were
placed across the fracture site into the base of the fourth metacarpal for added stability.
Figure 4 (A) A PA radiograph demonstrating a two-part carpal–metacarpal fracture
dislocation. The fracture fragment is relatively large enough to accept screw fixation.
(B) A PA radiograph showing the fracture reduced by plate stabilization. Lag screw fix-
ation is utilized to capture the relatively large fragment at the base of the fifth metacarpal.
Operative Management of Metacarpal Fractures 79
Figure 5 (A) A PA radiograph showing a comminuted fracture of the base of the fifth
metacarpal. (B) Due to the amount of comminution, the fracture was stabilized by
K-wire jail. Notice how the transverse Kirschner wire stabilizes the articular surface,
but also is advanced into the fourth metacarpal for added stability.
Figure 6 (A) Frequently, fractures of the base of the metacarpal may be associated with a
head fracture of the adjacent digit as demonstrated in this PA radiograph. (B) A PA radio-
graph demonstrating fixation of the metacarpal head fracture to the ring finger and Kirsch-
ner wire fixation to the base of the fifth metacarpal fracture.
80 Geissler and McCraney
for added stability (Fig. 5). It is important to remember that when a fracture of the
metacarpal base is identified on X ray, the head of the adjoining metacarpal must
be closely evaluated. Fractures of the head and base adjoining metacarpal frac-
tures frequently coexist (8) (Fig. 6).
METACARPAL SHAFT FRACTURES
The vast majority of isolated metacarpal shaft fractures are stable. Border meta-
carpal fractures are less stable due to lack of soft-tissue support. Transverse frac-
tures may angulate with the apex dorsally. This is due to the pull of intrinsic
musculature, causing the metacarpal head to flex. Owing to the mobility of the
saddle joint of the hamate, it is possible to accept up to 208 of angulation to trans-
verse fractures of the shaft of the ring and small metacarpals. The carpal–meta-
carpal joints of the index and long fingers are relatively immobile. Owing to the
lack of mobility to the index and long metacarpals, patients may not tolerate the
presence of a flexed metacarpal head in the palm, particularly with gripping. For
this reason, only 58 to 108 of angulation may be accepted for the index and long
metacarpals (16).
Most transverse isolated metacarpal fractures are stable. Because the cam
effect of the metacarpal head (the metacarpal head is wider anteriorly and the
collateral ligaments tighten in flexion) can lead to stiffness of the metacarpopha-
langeal (MP) joint if it is immobilized in extension, metacarpal fractures are
usually immobilized in a splint with the MP joints immobilized at approximately
708 of flexion. The interphalangeal joints are splinted in extension (17–19).
Multiple modes of fixation are available for unstable transverse metacarpal
fractures. Kirschner wire stabilization is particularly useful in patients who would
like to avoid the scar associated with internal fixation (Fig. 7). In an unstable fifth
metacarpal fracture, two Kirschner wires are placed transversely proximal and
two Kirschner wires are placed distal to the fracture line due to the motion at
the base of the fourth and fifth metacarpals. The pins are left outside the skin
and removed in the office approximately three to four weeks later. Digital
range of motion can be initiated while the pins are in place, but the disadvantage
of this is a potential increase in the risk of pin track infection.
Plate fixation can be useful in contact athletes or in patients that want to
return to work as quickly as possible (Fig. 8). For the metacarpals, 2-mm
plates are recommended. Four cortices both proximal and distal to the fracture
line are required for adequate fracture stability (7,8). Immediate digital range
of motion may be started after plate fixation, and strengthening is usually initiated
at four weeks postoperatively. Particularly, in the contact sport athlete, the patient
may be cleared to return to play in the first several weeks wearing a fracture brace
if it is felt adequate fracture stability has been achieved with plate fixation.
A number of surgical approaches have been recommended when multiple
metacarpal fractures are present (20). The easiest is a vertical incision centered
between the two metacarpal bones that are fractured. If fractures exist for the
Operative Management of Metacarpal Fractures 81
index through small metacarpals, two longitudinal incisions may be made. One is
between the index and long fingers, and the second is between the ring and small
fingers. Alternatively, an oblique dorsal incision can be made or a straight trans-
verse incision may be made on the dorsum of the hand to approach multiple meta-
carpal fractures. The interval between the extensor digitorum communis tendons
is utilized. The periosteum is elevated and if plate fixation is utilized, it is import-
ant to close the periosteum over the plate to decrease extensor tendon irritation
from the plate itself. Unlike fractures of the phalanges, plate fixation of the meta-
carpals is very well tolerated, as the extensor tendons are not as closely adhered to
the bone as compared to the phalanges.
Lag screws are the implant of choice for spiral fractures of the metacarpals
(Fig. 9). To utilize a lag screw, the fracture line needs at least twice the diameter
of the bone (7,8,21–24). A minimum of two screws is required. One screw may
be placed perpendicular to the shaft, which helps prevent translation of the frac-
ture, and a second screw is placed perpendicular to the fracture to provide com-
pression of the fracture. Alternatively, the two screws may be placed bisecting the
angle of the fracture and the shaft (7,8,21–24). It is recommended that 2.0 or
1.5 mm screws be used if lag screw fixation is utilized for a spiral metacarpal
fracture (7,8,21–24).
Figure 7 (A) A PA radiograph showing a displaced fracture of the fifth metacarpal at the
junction of the middle and distal thirds. (B) Under fluoroscopy, the fracture was percuta-
neously reduced and stabilized. Two Kirschner wires were placed both proximal and distal
to the fracture site for stability. The advantage of percutaneous fixation is it is very
cosmetic which may be desirable in the female patient.
82 Geissler and McCraney
Oblique metacarpal fractures have a tendency to shorten along the oblique
slope of the fracture line, particularly the index and small metacarpals, due to the
lack of support of the transverse metacarpal ligament. With an oblique metacar-
pal fracture, the fracture line is usually too short for lag screw fixation alone and a
single lag screw needs to be neutralized by a plate. It is recommended that 2.0 or
1.5 mm screws and plates be used. Usually, the fracture is compressed by the lag
screw and once fracture stability is achieved, a T-plate or L-plate is then placed
on the dorsum of the metacarpal. Four cortices, both proximal and distal to the
fracture line, are required for adequate stability (7,8,21–24).
Figure 8 (A) Lateral radiograph showing a displaced transverse fracture of the long
metacarpal. (B) The fracture was stabilized by plate fixation. The patient was allowed
to return to sports in two weeks following suture removal in a playing cast.
Operative Management of Metacarpal Fractures 83
When considering when to use a lag screw to stabilize a bone fragment, the
fracture fragment should be at least three times the diameter of the screw (7,8).
During open reduction, stabilization by a screw is preferable to a Kirschner
wire. The advantage of a screw over a wire is that it can compress the fracture
to provide added stability. If the fragment is large enough to place a Kirschner
wire, then it is usually large enough to compress with a screw. A 0.45 Kirschner
wire is equal in diameter to a 1.1 mm drill bit. Therefore, if the surgeon can get a
0.45 Kirschner wire into a bone fragment, this is the same size as the drill bit for
the 1.5 mm screw. The Kirschner wire can be removed and fixation can be
Figure 9 (A) PA radiographs showing spiral fractures involving the long and ring meta-
carpals. (B) Clinical radiograph showing the amount of rotation of the involved long and
ring digits secondary to rotation of the fracture fragments. (C) A PA radiograph demon-
strating lag screw fixation of the spiral fractures involving the long and ring metacarpals.
Lag screw fixation is the implant of choice in spiral metacarpal fractures.
84 Geissler and McCraney
improved by utilizing the screw. Similarly, a 0.065 Kirschner wire is equal in
diameter to a 1.5 mm drill bit. The 1.5 mm drill bit is utilized for placement of
a 2.0 mm screw. If the fracture fragment is large enough to support a 0.065
Kirschner wire, it is usually large enough for the fixation for improved stabiliz-
ation with a 2.0 mm screw.
METACARPAL NECK FRACTURES
Fractures of the metacarpal neck are very common (Boxer’s fracture). This is
usually the result of a direct impact from a clenched fist. It is important to be
wary of open injuries either to the fracture site or the joint itself. Excessive
palmar tilt to the distal head fragment can occur secondary to the pull of the
extrinsic flexor tendon. It is controversial how much angulation to accept to
the ring and small metacarpals. Most authors recommend accepting up to 308
to 408 of greater angulation. There should be no rotation or clawing deformity
to the finger. Owing to the more rigid carpal–metacarpal joint to the index and
long fingers, up to only 108 of angulation may be acceptable for metacarpal
head fractures that involve the index and long metacarpals (16,25,26).
Several methods of fixation have been recommended for metacarpal neck
fractures. These include transverse pinning of the metacarpal head into the adja-
cent metacarpal and intramedullary pinning. The latter is particularly appealing
because it keeps the wires away from the relatively mobile skin near the MP
joints thereby limiting the risk of pin track infection and also limits interference
with the extensor tendons.
For fractures that involve comminution, plate fixation with either a mini-
condylar plate or a T-plate may be an option as well (Fig. 10).
Figure 10 (A) A PA radiograph demonstrating a comminuted fracture to the metacarpal
neck of the fifth metacarpal. (B) The fracture was stabilized by a mini-condylar plate due
to the amount of comminution.
Operative Management of Metacarpal Fractures 85
METACARPAL HEAD FRACTURES
Intraarticular fractures involving the metacarpal head are uncommon. These
fractures have been classified as vertical, horizontal, oblique sagittal, and
comminuted. A Brewerton (27) radiographic view is recommended to view
the articular detail of the metacarpal head (Fig. 11). This view is obtained
by flexing the metacarpal phalangeal joint and placing the dorsum of the
Figure 11 (A) Brewerton radiographic view showing the articular detail of the metacar-
pal heads. (B) A PA radiograph revealing the displaced intraarticular fracture to the long
metacarpal head. (C) The displaced intraarticular fracture was stabilized by lag screw fix-
ation. The fracture was approached by splitting the extensor digitorum communis tendon
and exposing the articular surface. Close attention was made to preserve the collateral liga-
ments, so it would not affect the blood supply to the metacarpal head.
86 Geissler and McCraney
hand flat on a cassette. This view outlines the articular surface to the
metacarpals.
The metacarpal head is approached by a dorsal incision. The central
slip of the extensor digitorum communis tendon may be split or may be
accessed between the sagittal band and the extensor tendon, particularly
between the long and ring metacarpals. In fractures involving the index
and small metacarpal head, the interval between the extensor digitorum com-
munis and extensor indicis proprius is utilized for the index finger and the
interval between the extensor digitorum communis and extensor digiti
minimi is utilized for the small finger. It is important to keep the soft-
tissue fragments attached to the bone fragments to prevent avascular necrosis.
Kirschner wires, lag screw fixation, or potentially headless cannulated screws
or plate fixation have all been recommended for comminuted intraarticular
fractures of the metacarpal head (Fig. 11). In very rare instances, metacarpal
phalangeal joint arthroplasty may be utilized in elderly patients with exten-
sive comminution (28).
CONCLUSIONS
Symptoms resulting from tendon adhesions and joint contracture are the most
common complications associated with hand fractures. Stiffness has been
directly correlated with the severity of the initial fracture and the presence
and severity of initial soft-tissue injuries and excessive immobilization greater
than four weeks. If internal fixation is considered, it must be adequately
strong enough to support early rehabilitation in order to prevent tendon adhe-
sions and joint contractures from forming. The worst scenario is to consider
open reduction internal fixation with poor stability that requires excessive
immobilization rather than early range of motion. Following the principles out-
lined in this chapter may potentially decrease the complication rate from these
very difficult fractures.
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Operative Management of Metacarpal Fractures 89
5
Carpal Dislocations and FractureDislocations
Santiago A. Lozano-Calderon and David C. Ring
Department of Orthopedic Surgery, Massachusetts General Hospital, Boston,Massachusetts, U.S.A.
INTRODUCTION
Dislocations and fracture dislocations of the carpus are uncommon injuries.
Fracture dislocations of the radiocarpal joint are considered as a type of distal
radius fracture (1). The most common carpal dislocation is the dorsal perilunate
dislocation (2–6), named because the carpus dislocates dorsally around the
lunate, with the lunate remaining in its normal relationship with the distal
radius in most cases, and occasionally dislocating volarward. Perilunate injuries
follow a predictable circular progression of injury from the radial to the ulnar side
of the wrist with variations in the injury pattern arising from the fact that at each
point failure can occur through either ligament or bone (2,7). Other types of
carpal dislocations, including midcarpal, axial, and isolated carpal dislocations
and fracture dislocations, are rare (2).
Current concepts of carpal dislocations are derived from relatively few ret-
rospective case series, some anatomical observations, and collective experience
or wisdom. There is substantial variation in the reported radiological and clinical
outcomes (8), and there are many debatable issues in the management of these
uncommon injuries. It is clear, however, that even with early, accurate diagnosis
and appropriate treatment, substantial permanent wrist dysfunction should be
expected in most cases.
91
EPIDEMIOLOGY AND MECHANISM OF INJURY
Carpal dislocations and fracture dislocations occur in young patients with strong
bone that are involved in relatively high-energy injuries such as motor vehicle
collisions and high-energy falls (from a height, during sports, downstairs, etc.)
(2,9,10). Most patients are relatively young adult males: average 32 years of
age, range 16 to 78 years; 94% males (3,10–15).
Perilunate injuries are thought to occur with forceful wrist hyperextension,
ulnar deviation, and intercarpal supination. The spectrum of injury observed
reflects the injury forces and failure through ligament or bone at each anatomical
area. The proposal by Mayfield and colleagues that perilunate instability pro-
gresses from radial to ulnar around the lunate in four stages is consistent with
observed injury patterns: Stage 1 is injury to the scapholunate interosseous liga-
ment; Stage II adds dorsal dislocation of the capitate with respect to the lunate;
Stage III adds injury to the lunotriquetral ligament; and in Stage IV, the hand
and wrist return to normal alignment with the radius and the lunate dislocates
volarly (Fig. 1) (7,16,17).
At each stage, there are alternative bony or ligamentous injuries.
Progressing from radial to ulnar around the lunate these include: (i) radial
Figure 1 Mayfield described four stages of perilunate dislocation. The first stage is
rupture of the scapholunate interosseous ligament. Next the capitolunate joint dislocates
through the space of Poirier. The third stage is rupture of the lunotriquetral ligament.
Finally the lunate completely dislocates and the remainder of the wrist returns to
normal alignment with the radius. Source: From Ref. 7.
92 Lozano-Calderon and Ring
styloid fracture as an alternative to radiocarpal ligament injury; (ii) scaphoid
fracture instead of scapholunate interosseous ligament injury; (iii) capitate frac-
ture instead of capitolunate dislocation; and (iv) triquetral fracture instead of
lunotriquetral interosseous ligament injury (Fig. 2).
The injury mechanisms for rare carpal dislocations and fracture dislo-
cations are incompletely understood (18). The Mayo group has proposed the
reverse perilunar dislocation concept, suggesting that some perilunate injuries
may progress from ulnar to radial, resulting in relatively more severe ulnar
than radial injury. Following the example of Mayfield and colleagues, they
demonstrated a progression of reverse perilunar dislocations in cadavers. Three
stages were described: Stage 1 adds a tear of the lunotriquetral ligament; Stage 2
adds disruption of the palmar ulnar leash complex as well as the dorsal radiocar-
pal ligament and the dorsal intercarpal ligament; and Stage 3 adds a tear of
the scapholunate ligament with consequent perilunate dislocation (Fig. 3).
These injuries are thought to occur in extension of the wrist but with associated
hyperpronation at the moment of impact (19).
CLASSIFICATION
The first classification system for carpal dislocations and fracture dislocations
was proposed by Green and O’Brien in 1978 (18,20) in an attempt to help
resolve some of the inconsistencies and controversies in the literature. Their
most important contribution was a system that recognized perilunate dislocations,
lunate dislocations, and fracture dislocations as part of a continuum of injuries
with similar mechanisms. They proposed six groups based on the radiographic
Figure 2 Each of the areas of injury in a perilunate dislocation can occur either through
bone (the so-called greater arc) or through ligaments (the lesser arc). Source: From Ref. 2.
Carpal Dislocations and Fracture Dislocations 93
appearance of the injury: (i) dorsal perilunate and volar lunate dislocations;
(ii) dorsal transscaphoid perilunate dislocation; (iii) volar perilunate/dorsal
lunate dislocations; (iv) variants including four subgroups [transradial styloid
perilunate dislocation (subgroup A), naviculo-capitate syndrome (subgroup B),
transtriquetral fracture dislocation (subgroup C), and miscellaneous injuries
(subgroup D)]; (v) isolated rotatory scaphoid subluxation, which is divided in
subgroups A and B, acute scaphoid subluxation, and recurrent scaphoid subluxa-
tion, respectively; and (vi) total dislocation of the scaphoid (Table 1).
Figure 3 A reverse Mayfield progression has been described progressing from the luno-
triquetral ligament through the space of Poirier and then through the scapholunate liga-
ment. Source: Courtesy of Mayo Foundation 2002.
Table 1 Green’s and O’Brien’s Classification for Carpal Dislocations
Classification of Carpal Dislocations: (Green and O’Brien, 1978)
Dorsal perilunate/volar lunate dislocationa
Dorsal transscaphoid perilunate dislocationa
Volar perilunate/dorsal lunate dislocation
Variants
Transradial styloid perilunate dislocationa
Naviculocapitate syndrome
Transqtriquetral fracture-dislocation
Miscellaneous
Isolated rotatory scaphoid subluxation
Acute subluxation
Recurrent subluxation
Total dislocation of the scaphoid
aMost common patterns of injury.
94 Lozano-Calderon and Ring
Mayfield and colleagues modified this classification system after several
cadaveric studies contributed to an improved understanding of the mechanism
of injury. Their system has become the most widely accepted and utilized
system for classifying carpal dislocations and fracture dislocations. They classi-
fied carpal dislocations and fracture dislocations into four groups: (i) dislocations
and fracture dislocations of the lesser arc; (ii) dislocations and fracture dislo-
cations of the greater arc; (iii) variants; and (iv) radiocarpal dislocations and
fracture dislocations (16,17).
Lesser arc injuries—pure dislocations—include perilunate dislocations
and lunate dislocations (2,7,10). Greater arc injuries—perilunate fracture
dislocations (21–23)—include transscaphoid perilunate fracture dislocations
(fracture of the scaphoid rather than rupture of the scapholunate interosseous
ligament); trans-scapho-capitate fracture dislocations (fractures of the scaphoid
and capitate, instead of scapholunate and lunate–capitate ligament ruptures);
trans-scapho-capitate-hamate-triquetral fracture dislocations (fractures of the
scaphoid, capitate, hamate, and triquetrum instead of ligament rupture between
the lunate and these bones); and lastly, the volar transscaphoid perilunate fracture
dislocation (Fig. 4). The most prevalent of these injuries is the trans-scapho-
perilunate fracture dislocation (6,7,10,11,24–27). It has been proposed that
greater arc injuries result when greater forces are experienced by the wrist
during extension than during ulnar deviation and intercarpal supination (2,16).
Among Mayfield and colleagues’ Group 3 or variant injuries are fracture
dislocations that involve the radial styloid, the scapho-capitate syndrome (simul-
taneous fracture of the scaphoid and the capitate without lunate dislocation—
most likely just a reduced transscaphoid, transcapitate perilunate dislocation),
and the isolated dislocation of any carpal bone. The first subgroup, radial
styloid fracture dislocations, is the most common entity in this subset.
Watson and Jeffrey (2) proposed a classification with five injury types:
(i) perilunate dislocation, (ii) radiocarpal dislocation, (iii) midcarpal dislocation,
(iv) axial-carpal dislocation; and (v) isolated carpal injuries (2). The strength
of this system is its ability to account for all described carpal dislocations and
fracture dislocations according to the anatomic pattern of trauma.
Figure 4 The patterns of greater arc injury. Source: From Ref. 7.
Carpal Dislocations and Fracture Dislocations 95
Cooney and colleagues suggested classifying carpal dislocations and
fracture dislocations into five groups: (i) dorsal perilunate dislocations or lesser
arc injuries; (ii) transcarpal fracture dislocation or greater arc injuries, which
includes transstyloid, transscapho, scapho-capitate, and transtriquetral fracture
dislocation types; (iii) radiocarpal dislocations and fracture dislocations; (iv)
longitudinal or axial dislocations and fracture dislocations; and (v) isolated
carpal bone dislocations and fracture dislocations (Table 2).
DIAGNOSIS
Published case series of perilunate injuries emphasize a substantial percentage of
delayed diagnosis, between 25% and 43% (6,10,26,28,29). Factors that may
contribute to the potential for delayed diagnosis include: (i) association with
severe or life-threatening injuries that require emergent treatment; (ii) alcohol
intoxication and alcohol abuse; and (iii) misinterpretation of radiographs.
Clinical Diagnosis
A thorough secondary survey after primary resuscitation of a critically injured
patient with serial repeat examinations as the patient recovers will help to limit
the potential for a carpal dislocation or fracture dislocation to be overlooked.
During the inspection, the involved limb should be evaluated for open wounds
or penetrating trauma. These are uncommon, but in addition to the need for more
expedient operative treatment, they are also associated with diminished results
(10). Most injuries are associated with obvious deformity, pain, swelling, and
ecchymosis. Some patients may have instability or crepitation during palpation.
There is a substantial risk of acute carpal tunnel syndrome in association
with carpal dislocations and fracture dislocations. Careful evaluation of light
touch sensation and intrinsic hand muscle strength are important. Patients
should also be warned about the risk of developing acute carpal tunnel syndrome
after leaving the emergency room following reduction as this problem can
develop hours to days after the injury.
Table 2 Cooney et al.’s Classification for Carpal Dislocations
Dorsal perilunate dislocations or Lesser arc injuries
Transcarpal fracture dislocations or Greater arc injuries
Transstyloid injuries
Transscaphoid injuries
Scaphocapitate injuries
Transtriquetral
Radiocarpal dislocations
Longitudinal or axial dislocations
Isolated carpal bone dislocations
Source: From Ref. 11.
96 Lozano-Calderon and Ring
Radiographic Diagnosis
Perilunate injuries and even complete lunate dislocations can be overlooked
initially. Wrist anatomy is complex, and careful interpretation of good quality
radiographs is helpful in making a timely and accurate diagnosis. At a
minimum, good quality posteroanterior (PA) and lateral radiographs should
be obtained. Additional oblique views and radiographs made with the wrist in
traction may be beneficial.
It can be difficult to get good quality radiographs in an injured and uncom-
fortable patient. The PA view is made with the volar surface of the hand, wrist,
and forearm flat on the film, usually with the shoulder abducted 908, the elbow at
908, the wrist in neutral radioulnar deviation, and the forearm supported in neutral
rotation. The beam is focused on the midcarpus and is triggered at a distance of
40 inches, perpendicular to the hand. Proper alignment is confirmed as longitudi-
nal alignment of the axes of the middle finger, third metacarpal, and the radius
(30–32) (Fig. 5). The lateral projection is made with the hand, wrist, and
forearm placed perpendicular to the cassette. Alignment in neutral wrist flexion
is necessary and it is monitored by ensuring that the longitudinal axes of the
third metacarpal, capitate, and radius are aligned (Fig. 6). Appropriate rotation
can be confirmed in the film by the fact that the distal pole of the scaphoid
is located between the palmar surface of the capitate and the palmar surface of
the trapezium; the volar margin of the pisiform is between the volar surface
of the capitate and the volar tip of the distal pole of the scaphoid (30–32); and
the inferior pole of the lunate is between the capitate and the inferior pole
of the scaphoid.
Figure 5 In a posteroanterior radiograph of a normal wrist, the axes of the long finger
metacarpal, capitate, and radius shaft should align.
Carpal Dislocations and Fracture Dislocations 97
Interpretation of the radiographs should include careful evaluation of the
carpal arcs emphasized by Gilula and Weeks (33). He described two arcs that
correspond to the articular surfaces of the radiocarpal joint (proximal arc) and
the midcarpal joint (distal arc) in the PA radiograph. The continuous
and smooth shape of both arcs is an indirect sign of adequate positioning of
the carpal bones. Any alteration in this continuous pattern is an indication
of malalignment of one or more carpal bones. The proximal arc is formed by
the proximal articular surfaces of the scaphoid, the lunate, and the triquetrum.
The distal arc is formed by the articular surface of the head of the capitate,
the trapezium’s proximal articular surface, and the proximal articular surface
of the hamate (33) (Fig. 7).
In perilunate dislocations, the carpal height will be reduced, and an
overlap between the proximal and distal rows (lunate and capitate) will
obscure the midcarpal space. The carpal ratio (measurement of carpal height)
is calculated as the longitudinal length of the carpus (measured from the
distal articular radial surface to the capitate-third metacarpal junction),
divided by the longitudinal length of the metacarpal longitudinal length (2,7)
(Fig. 8). The average value is: 0.54 (range: 0.51–0.57) (34). An alternative
method for quantifying carpal height was developed to account for the fact
that many wrist radiographs do not include the entire third metacarpal. The
modified carpal height ratio is calculated as the ratio of the height of the
carpus to the height of the long axis of the capitate (Fig. 9). The normal
value of this modified ratio is 1.57, ranging from 1.52 to 1.62. A reduction in
the intercarpal space and an overlap of the carpal bones were described as
the “crowded carpal sign” by Klein and Webb (35).
Other things to look for on the PA radiograph include: (i) the lunate having
a triangular rather than a trapezoidal shape and overlaps with the capitate in both
Figure 6 The axes of the long finger metacarpal, capitate, and radial shaft should also
align on a lateral radiograph with the wrist in neutral flexion.
98 Lozano-Calderon and Ring
perilunate and lunate dislocations; (ii) the so-called “Terry Thomas” sign or
widening of the scapholunate space; and (iii) the “Scaphoid Ring” sign caused
by volar flexion and rotation of the scaphoid so that the distal pole is viewed
along its central axis, and the cortex forms a ring (PA view) (Fig. 10). Finally,
associated fractures of the radial styloid, scaphoid, capitate, triquetrum, and/or
hamate may be seen.
Figure 8 The carpal height ratio is measured as the quotient of the height of the carpus
from the lunate facet of the distal radius to the distal end of the capitate and the length of
the long finger metacarpal. It averages 0.54.
Figure 7 Gilula is credited with describing arcs defined by the proximal and distal articu-
lar surfaces of the proximal carpal row and the proximal articular surfaces of the distal
carpal row. Abnormal disjunction or overlap of the arcs is suspicious for ligament injury.
Carpal Dislocations and Fracture Dislocations 99
In the lateral view, the relationships of the radius, lunate, and capitate should be
carefully evaluated. In perilunate dislocations and fracture dislocations, the articular
relation between the radius and the lunate is maintained, but the capitate is dislocated
dorsally from its articulation with the lunate. When the lunate is completely dislo-
cated, the relationship between the capitate and radius is relatively normal, and the
Figure 9 A modified carpal height ratio is useful when the entire third metacarpal is not
included on the radiograph. The modified carpal height ratio is the quotient of the height of
the carpus over the height of the capitate. Its average value is 1.57.
Figure 10 Findings in X rays (antero-posterior projection) characteristic of perilunate
dislocations and fracture dislocations. (1) Broken Gilula’s arcs, (2) Terry Thomas sign
(scapholunate disruption), (3) crowded carpus sign, (4) triangular shape of the lunate,
(5) scaphoid signet ring sign (where the distal pole of the scaphoid looks like a
ring because it is seen on end), (6) reduced carpal height, (7) associated fractures.
Source: Template courtesy of Taleisnik.
100 Lozano-Calderon and Ring
lunate is dislocated volarly or dorsally according to the type of injury. Complete
volar dislocation is sometimes overlooked when the lunate is assumed to be the pisi-
form. The “empty” or “spilled teacup sign” has been used to emphasize the charac-
teristic appearance of the lunate when it is completely dislocated and rotated on a
hinge of intact volar radiocarpal capsule and ligament (Fig. 11B).
The normal capitolunate angle is 08 and any value above 158 is considered
abnormal. This angle is measured by drawing a line through the longitudinal axis
of the capitate and another one perpendicular to the axis of the lunate. The normal
scapholunate angle is less than 608 and any value above 808 is considered abnor-
mal. Values between 608 and 808 are considered borderline. This angle is
Figure 11 Complete lunate dislocation can occur in a volar (A, B) or a dorsal direction
(C, D), but dorsal is rare. Source: From Ref. 2.
Carpal Dislocations and Fracture Dislocations 101
obtained by drawing longitudinal lines through the longitudinal axes of the
scaphoid and the lunate on a proper lateral radiograph. The radiolunate angle
normally is 08 and any value greater than 158 is abnormal. This is measured as
the angulation between a line drawn through the longitudinal axis of the radius
and a perpendicular line to the longitudinal axis of the lunate (Fig. 12).
Radiographs taken while traction is applied to the wrist are useful for the
assessment of osseous and articular compromise. In complex injuries, computed
tomography may be useful to further characterize the injury, particularly any
associated fractures.
TREATMENT
Proposed treatments have included closed reduction and cast immobilization;
closed reduction, percutaneous pin fixation, and cast immobilization; and open
reduction and internal fixation. Factors associated with worse results include
delayed treatment, injuries associated with an open wound, and nonanatomic
reduction (2,10,26).
These are uncommon injuries and the best available evidence is from
large retrospective case series. There are no prospective clinical trials to
guide management of these injuries.
Treatment Techniques
Closed Manipulative Reduction
For acute injuries, a closed, manipulative reduction should be performed soon
after the dislocation is identified to limit the risk of acute carpal tunnel syndrome,
Figure 12 A patient with a transscaphoid perilunate fracture dislocation was treated with
open reduction. (A) The scaphoid was repaired with a screw. (B) The intercarpal and
midcarpal articulations were pinned temporarily with percutaneously inserted wires.
102 Lozano-Calderon and Ring
and to allow planning of operative repair at a more convenient time. Delayed
diagnosis usually necessitates open reduction.
Muscle relaxation facilitates manipulative reduction. In the emergency
room, this can be accomplished with a combination of conscious sedation (the
administration of short-acting benzodiazepine sedatives and narcotics to an
awake patient) with or without local or regional anesthesia (intraarticular
anesthesia, Bier block, or peripheral nerve block). The ideal setting for closed
manipulative reduction is the operating room where either a brachial plexus
block or pharmacological paralysis can be administered.
In either setting, muscle relaxation can be facilitated by finger-trap traction.
After anesthesia administration, the fingers are placed in the traps and the arm is
suspended with the elbow at a 908 angle. Weight of 5 to 15 kg of is suspended
from the brachium on a well-padded strap for about 10 minutes.
When muscle relaxation is established, the finger traps are removed to
allow manipulation. For a perilunate or volar lunate dislocation, with axial trac-
tion, the wrist is fully extended and then flexed with the thumb placed over the
lunate volarly (36). In this manner, the lunate is held in position with respect
to the radius, whereas the capitolunate joint and other carpal articulations are
reduced. An image intensifier is useful in order to confirm reduction while the
patient is still under optimal anesthesia. It is also much easier to get a good
quality lateral radiograph because it can be adjusted under direct radiographic
monitoring. If an image intensifier is not available, plain radiographs are obtained
as described above.
Closed Reduction and Cast Immobilization
The traditional recommendation for immobilization after closed manipulative
reduction was an above-elbow, thumb spica cast (4,6,11,20,25,28,37,38). It has
been recommended that the wrist be placed in as much flexion as it was when
reduction was achieved, and the forearm in some pronation to help realign the
scaphoid; however, this would increase the potential for acute carpal tunnel syn-
drome. After four weeks, the long-arm cast is replaced by a cast that immobilizes
the wrist and thumb, but not the elbow (a below-elbow, or short arm, thumb
spica cast) for an additional four weeks. After eight weeks of cast immobilization,
exercises to improve wrist motion and strength are initiated.
This protocol can result in reasonable short-term results (11,20). The series
of Cooney et al. included nine patients treated with closed reduction within a
week of injury and cast immobilization. Using the modified Mayo wrist score
(11), the results for patients treated with manipulative reduction and casting
had results comparable to patients treated percutaneously or with open operative
treatment.
This was the most popular method of treatment until approximately the late
1970s when concern regarding residual carpal malalignment led most authors to
prefer more invasive treatments (20,22,24,39–41). Adkison and Chapman (24)
reported that 68% of their patients had inadequate carpal alignment after
Carpal Dislocations and Fracture Dislocations 103
closed treatment. The results of closed treatment of fracture dislocations (greater
arc injuries) are particularly poor (2,7).
Closed Reduction and Percutaneous Pinning
Several case reports and case series advocate percutaneous fixation of the carpal
bones in order to improve the alignment of the carpal bones after closed reduction
(10,26,42). Raab et al. (42) compared small series of athletes with perilunate dis-
locations treated with either closed reduction and percutaneous pinning (five
patients) or open reduction and internal fixation (five patients). They noted a
more rapid return to sport in patients treated percutaneously (five weeks after
pinning compared to 10 weeks with open treatment), but it makes no sense
why this would be so other than the fact that the surgeon allowed the former
group to play sooner. Very little detail was presented regarding the function or
radiographic result, and the follow-up was very short.
Percutaneous pinning is technically demanding, particularly when fractures
are present. This technique should be done only if complete anatomic reduction
of the lunate, the capitate, and the scaphoid, including associated fractures, can be
achieved by closed reduction. It can be difficult to realign the carpal bones with
manipulative reduction alone (7,43). It may prove useful to insert temporarily
smooth Kirschner wires (0.062 inch diameter) into the lunate and the scaphoid
in order to directly correct rotational and angular malalignment. Next the sca-
phoid is pinned to the lunate and the capitate with several smooth Kirschner
wires (usually 0.045 inch diameter). Kirschner wires between the triquetrum
and lunate are also inserted. The pins can be trimmed so that they remain
under the skin to be removed at a second operative procedure or they can be
bent and trimmed outside the skin for later removal in the office. Traditionally,
the wrist is immobilized with a thumb spica, above-elbow cast for six weeks fol-
lowed by a below-elbow thumb spica cast for four weeks. It may not be necessary
to include the elbow, and the thumb in the cast and practice varies. The pins are
removed between 8 and 12 weeks after surgery.
The authors strongly feel that percutaneous fixation of displaced, unstable
scaphoid and capitate fractures cannot be adequately monitored with image inten-
sification alone. Wrist arthroscopy can provide adequate visualization to confirm
reduction; however, arthroscopic-assisted, percutaneous treatment of perilunate
fracture dislocations should be considered experimentally at this time.
Open Reduction and Internal Fixation
Open reduction and internal fixation is the only option for patients with delayed
diagnosis, inadequate reduction, acute carpal tunnel syndrome, and open wounds.
It is currently the treatment of choice for all types of carpal dislocations and fracture
dislocations (3,10,13,22,24,44). Open reduction facilitates alignment of the carpus
and provides direct assessment and repair of each injury component. It also allows
for removal of small osteochondral fragments which are not uncommon in
these injuries.
104 Lozano-Calderon and Ring
Various operative approaches have been suggested including volar, dorsal,
or combined exposures. Sotereanos et al. (13) reviewed the existing literature, but
did not find a clear advantage to one of these approaches.
Whatever approach is selected, intraoperative traction can facilitate
treatment, particularly with delayed treatment or whenever the wrist remains
dislocated. Intraoperative traction can be provided by sterile finger-trap traction,
which can be applied horizontally to facilitate the operative exposure. Alterna-
tively, an external fixator can be applied across the wrist and used to apply trac-
tion. This external fixator can then be kept in place after the surgery as an
alternative to a cast (1). This is particularly useful when treating acute injuries
where avoiding constrictive circumferential casts and dressings may help limit
swelling and finger stiffness.
The volar approach to perilunate injuries has several advantages including:
(i) an extended release of the carpal tunnel; (ii) potential access to the stouter,
more important volar aspect of the triquetrolunate interosseous ligament; and
(iii) repair of volar radiocarpal ligament injury. Disadvantages include: (i) the
preference of most surgeons to limit incision of the important volar radiocarpal
capsule leading to a more limited view of the carpus through the traumatic rent
in the capsule with consequently greater difficulty judging alignment and fre-
quent inability to see or repair the volar triquetrolunate ligament; (ii) no access
to the stouter, more important dorsal aspect of the scapholunate interosseous liga-
ment; and (iii) inadequate assessment of carpal fractures and technical difficulties
in their reduction and fixation.
The dorsal capsule is felt to be less important and is therefore more
readily incised in whatever manner the surgeon feels is most useful (transverse,
longitudinal, and oblique orientations have been described). The decision on cap-
sular incision is often facilitated by the nature of the traumatic capsular injury. A
very broad exposure (sufficient to see a scaphoid fracture and the lunotriquetral
joint) is obtained by mobilizing the extensor pollicis longus from the third
dorsal compartment transposing it radially into the subcutaneous tissues,
followed by elevation of the second and fourth dorsal compartments off of the
distal radius.
A 0.062-inch Kirschner wire is inserted into the lunate as a “joystick” to
realign the bone. The realigned lunate is then stabilized to the distal radius
with a 0.045 or 0.062-inch Kirschner wire. The scaphoid is realigned in a
similar fashion and then pinned to the capitate.
Most surgeons provide definitive stabilization with temporary smooth
Kirschner wires between the scaphoid and lunate, the triquetrum and lunate,
and the scaphoid and capitate (Fig. 12). Additional wires are often used. Tempor-
ary screws can also be used (Figs. 13 and 14). When screws are placed between
the scaphoid and lunate, and the lunate and triquetrum, the midcarpal joint can be
allowed to move sooner. One disadvantage of Kirschner wires is the risk of infec-
tion if they are left out of the skin (or if swelling results in them protruding
through the skin). The use of buried Kirschner wires or screws requires a
Carpal Dislocations and Fracture Dislocations 105
second surgery for implant removal. The wires or screws are left in place for at
least two to three months. Wires are protected with a cast, and the wrist is not
allowed to move for the entire time. With screws, wrist motion and exercises
are usually initiated within a month of surgery.
Figure 13 (A) A posteroanterior radiograph of a transscaphoid perilunate fracture dislo-
cation. The lunate is triangular in shape. (B) On the lateral capitolunate, dislocation is
apparent. (C) Upon dorsal exposure, dislocation of the carpus is apparent. (D) External fix-
ation and open reduction were accomplished. (E) A fracture of the scaphoid was reduced
dorsally and secured with a volar percutaneous screw. (F) The triquetrolunate interval was
temporarily secured with a screw.
106 Lozano-Calderon and Ring
Figure 14 A 40-year-old man injured his wrist in a motor cycle accident. (A) A PA
radiograph showed a transstyloid perilunate dislocation. (B) Complete dislocation of the
lunate was seen on the lateral radiograph. (C) The radial styloid fracture and the triquetro-
lunate and scapholunate intervals were secured with screws and the corresponding
ligaments secured with suture anchors. (D) The short radiolunate ligaments were also
repaired with a suture anchor. (E) A PA radiograph after screw removal shows good
carpal alignment. (F) The lateral radiograph also shows good alignment. (G) Good
function was obtained, (H) although the wrist was quite stiff. Abbreviation: PA,
posteroanterior.
Carpal Dislocations and Fracture Dislocations 107
The accessible portions of the interosseous ligaments can be repaired either
with small suture anchors or drill holes in the bones. The ligaments usually
remain attached to the lunate and need to be reattached to the scaphoid and
lunate (2). Some authors recommend repair of the volar portion of the triquetro-
lunate ligament because it is the stoutest portion of that ligament, but we believe
there is insufficient access to do this in most patients.
When the carpal bones are realigned and stabilized, the ligaments usually
line up into their correct positions, and may heal without direct repair. Although
the current preferred treatment is direct open repair, the advantages of this over
realignment and stabilization are unproven.
Associated Fractures
A fracture of the scaphoid can be reduced through a dorsal incision and repaired
with a countersunk dorsally inserted screw or a volar, percutaneously inserted
screw (Fig. 13). Fracture of the capitate is repaired from dorsal with a counter-
sunk screw. Fractures of the radial styloid and triquetrum can be stabilized
with Kirschner wires or screws (Fig. 14). Ulnar styloid fractures are approached
through a direct ulnar incision and repaired with a tension band wiring technique
(45). In some patients with extreme instability, temporary immobilization of the
wrist with a plate can be useful (Fig. 15). Some fractures are so complex that an
acute proximal row carpectomy is merited (Fig. 16).
PROGNOSIS/RESULTS
The data available to guide treatment and prognosis are of limited quality, a fact
that is not surprising given the relatively infrequency of these injuries. Most
studies are case reports or case series that combined different types of injuries
and different treatment options. Other problems are the short follow-up of
most of these patients and the various evaluation techniques and instruments
used in these studies.
Garcia-Elias et al. (26), in their retrospective review of 91 cases, reported a
statistically significant impact on clinical outcomes while using a modified
Witvoet and Allieu score (46), when treatment was delayed longer than one
week, reduction was not maintained appropriately, and the lunate had a signifi-
cant rotational component (26). Herzberg et al. (10) found a difference in
terms of clinical and radiological outcomes if treatment was delayed greater
than 45 days or if injury was open. The anatomical pattern of injury had a
more limited affect on the outcome.
Data that demonstrate an association between open injures and worse
prognosis (2,8,10,26) likely reflect greater displacement and more significant
soft-tissue damage. Series from Herzberg et al. in 1993 addressed this issue
after evaluating clinical outcomes of 166 patients with a modified Green and
O’Brien score instrument. They found a statistically significant correlation
between poor outcomes and open lesions.
108 Lozano-Calderon and Ring
Figure 15 A 25-year-old man sustained complex injuries to the hand and wrist. (A) This
injury oblique radiograph demonstrates a transscaphoid perilunate injury. (B) A lateral
radiograph suggests fracture dislocation of the index through small carpometacarpal
joints as well. (C) Anteroposterior and lateral radiographs demonstrate screw fixation of
the scaphoid and temporary plate fixation of the carpus. (D) Anteroposterior and lateral
radiographs after plate removal demonstrate healing and good alignment. (E) Half of
his wrist flexion and extension were regained. (F) His function is very good.
Carpal Dislocations and Fracture Dislocations 109
Figure 16 A 38-year-old man had a complex, widely displaced transscaphoid, transtri-
quetral perilunate fracture dislocation. (A) Fracture fragments extend well proximal in
the forearm. (B) The lunate is widely dislocated and fractured. (C) An acute proximal
row carpectomy was elected. The distal radioulnar joint was unstable. (D) The radial
styloid was secured with Kirschner wires and the wrist immobilized with an external
fixator. (E) The final radiographic result was good. (F) Reasonable function was restored
given the complexity of the injury.
110 Lozano-Calderon and Ring
Russell (6) reviewed 59 patients with wrist dislocations and fracture dislo-
cations and found an association between nonanatomical reduction and dimin-
ished wrist function. In Pai’s series of 20 patients, diminished results were
observed in patients that did not have initial anatomic reduction or presented
with malunion or secondary degenerative arthritis. Herzberg et al. (10) reported
better outcomes in patients that achieved anatomic reduction and adequately
maintained it independent of the fixation method. Altissimi et al. (25), in their
analysis of 19 cases, found worse results in patients that did not have initial ade-
quate and stable reduction. In general, they progressed to chronic stability and
secondary degenerative arthritis. Lastly, one of the largest series confirming
this association of good outcomes and initial adequate reduction is the series of
Garcia-Elias (91 patients) where good outcomes were statistically significantly
related to the carpal alignment (26). This concern of anatomic reduction is par-
ticularly true in fracture dislocations, where nonunion and avascular necrosis
are also associated with nonanatomic reduction, as reported in series and case
reports (5,6,10,25,26).
The influence of surgical technique is less well established. As a general
rule, it seems that techniques that achieve and maintain anatomical reduction
are correlated with better results (3,10,22,24,44,47).
Older series suggested worse outcomes in patients with fracture dislo-
cations (6,13,25,38,48); however, more recent and larger series have not born
this out (10,13,49). Herzberg et al.’s review of 166 patients and Garcia-Elias’
review of 91 patients found no correlation between clinical outcomes and type
of lesion.
COMPLICATIONS
Median Neuropathy
Rates of incidence for median neuropathy in association with carpal dislocations
and fracture dislocations range from 11% to 45% in various series
(20,24,26,28,44,48). Median nerve symptoms resolved in most patients even
when the carpal tunnel was not released; however, we believe that carpal
tunnel release is merited in the presence of any median nerve symptoms or
dysfunction and should be strongly considered for all high-energy injuries with
substantial swelling even when median nerve dysfunction is not present.
Avascular Necrosis
It is quite impressive that avascular necrosis is extremely uncommon after these
injuries in spite of the dislocation, soft-tissue injury, and inherently limited
blood supply to the carpal bones. When this rare complication presents, it
seems to depend on the initial degree of displacement and the injury to the
capsular flap where the lunate usually attaches (10,11,13,26,27,48). Avascular
necrosis seems most frequent in perilunate fracture dislocations treated closed
Carpal Dislocations and Fracture Dislocations 111
leading to scaphoid nonunion and avascular necrosis of the proximal
pole (11,26,50).
Late Complications/Salvage Procedures
The most common late complication is arthrosis. Salvage options include total or
partial wrist arthrodesis and proximal row carpectomy. Patients must be willing
to sacrifice motion and be exposed to the risks of surgery for the goal of
pain relief (51–54).
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114 Lozano-Calderon and Ring
6
Fractures of the Scaphoid
Satoshi Toh
Department of Orthopedic Surgery, Hirosaki UniversitySchool of Medicine, Hirosaki, Aomori, Japan
INTRODUCTION
Scaphoid fractures are prevalent in young, active people. There is often a strong
desire to return to sports or work. Delayed diagnosis and nonunion of the
scaphoid are fairly common as well, probably as a result of several factors,
including the difficulty of radiographic diagnosis of nondisplaced fractures and
underestimation of the injury by the patient.
The goal of treatment is solid union in good alignment. Malalignment
[either malunion (1) or nonunion with malalignment] contributes to a dorsal inter-
calated segmental instability (DISI) deformity (2–4) that may be followed by
carpal collapse and eventual osteoarthrosis (5–7)—the so-called scapholunate
advanced collapse (SLAC) (8) or scaphoid nonunion advanced collapse
(SNAC) wrist (9).
The development of countersunk, variable pitched screws (such as the
Herbert screw) improved fixation of scaphoid fractures (10). Percutaneous
screw insertion—which we and others developed with the standard Herbert
screw—has been greatly facilitated by the development of cannulated screws. Per-
cutaneous screw fixation has become an accepted alternative to cast immobiliz-
ation for the treatment of nondisplaced fractures of the scaphoid and allows
patients to avoid prolonged cast immobilization (11–18). Arthroscopic-assisted
percutaneous fixation of displaced scaphoid fractures is also increasingly common.
115
MECHANISM AND EPIDEMIOLOGY
Fracture of the scaphoid is usually the result of a fall onto the outstretched hand
resulting in hyperextension and ulnar deviation of the wrist (19). Injuries that
cause forceful wrist extension (e.g., sports activities and car accidents) may
also cause scaphoid fractures. In Japan, from the late 1980s, we have seen an
increase in wrist flexion scaphoid fractures due to the increasing popularity of
punching game machines (20,21). In these punching games, as in Karate or fight-
ing, the wrist is in slight palmar flexion and slight radial deviation. With radial
deviation and flexion, the waist of the scaphoid is impacted between the
distal and volar edge of the radius and the trapezium and trapezoid over the
radioscaphocapitate ligament (21).
Fracture of the scaphoid is the most frequent carpal fracture and occurs
most commonly in young active individuals. The average age of occurrence in
athletes has been reported as being approximately 17 years of age (22). This is
similar to our observations in Japan of a peak during high school age, between
15 and 18 years, with an increasing overall prevalence that may be related to
the growing popularity of sports and punching game machines (20,21).
DIAGNOSIS
There is some tendency for the diagnosis of fracture of the scaphoid to be delayed
because of misdiagnosis or because patients do not see a doctor immediately after
injury. The latter seems particularly common in children, some of whom may be
reluctant to tell their parents about their use of a punching machine or fighting. A
delayed presentation is also common among athletes because members of sports
clubs or teams do not want to lose their position. In addition, the clinical
symptoms are not usually severe, and may resemble a wrist sprain—something
an athlete may have experienced numerous times and may not be particularly
concerned about. Many patients with delayed presentations are found to have
nonunion (23).
When examining a patient with wrist pain, detecting the tender spot is the
most important finding on examination. Tenderness with palpation of the
scaphoid radially in the so-called anatomical snuffbox (between the extensor
pollicis longus dorsally and the abductor pollicis longus and extensor pollicis
longus volarly), volarly at the distal pole of the scaphoid, and with axial
compression of the thumb are all useful palpatory examination maneuvers for
scaphoid fracture. Provocative maneuvers of the wrist, such as the scaphoid
shift test reported by Watson et al. (24), which originally was initially described
to check for scapholunate dissociation or rotatory instability of the scaphoid, are
also helpful to diagnose this fracture.
The radiographic examination should consist of posteroanterior (PA),
lateral, and semipronated and semisupinated oblique views. A view of the
116 Toh
scaphoid with the wrist in ulnar deviation is useful because it extends the
scaphoid, making its longitudinal axis more perpendicular to the X-ray
beam. Nondisplaced fractures can be very subtle and difficult to see on plain
radiographs.
When a fracture is suspected based upon the injury mechanism and
examination, but the radiographs are interpreted as normal, a suspected or
occult scaphoid fracture is diagnosed. The management of suspected scaphoid
fractures has traditionally consisted of two weeks of cast or splint immobilization
followed by repeat radiographical and clinical examination. In the vast majority
of patients, the repeat examination will resolve the issue. When suspicion for
fracture persists after repeat evaluation, the use of a bone scan has largely been
replaced by the use of magnetic resonance imaging (MRI), depending on its
availability and relative cost.
It is not yet clear whether attempts to triage suspected scaphoid fractures
in the acute setting with more sophisticated diagnostic tests are worthwhile. It
takes a few days after a fracture before a bone scan will be useful. MRI is not
usually immediately available, but it can be obtained within a few days in
many centers. Worldwide, an MRI is generally difficult to obtain in any
circumstance, let alone in a timely fashion. Computed tomography (CT) is
more readily available in some centers, but may not be best for suspected
fractures because nondisplaced fractures can be very subtle on CT, can have
a similar appearance to vascular channels, and may be distorted by volume
averaging. Given that most suspected scaphoids are not true scaphoid
fractures, any costs of advanced radiological interventions will have to be
balanced by the potential costs due to lost work, although even a wrist
sprain usually requires a few weeks of rest.
Diagnosis of displacement is very important. Fracture displacement (or
instability) is strongly associated with nonunion. The lines of Gilula should be
checked for irregularity (25) and in the lateral view, the rotation of the lunate
with respect to the radius are evaluated. The diagnosis of fracture displacement
or instability is usually made as follows (Fig. 1):
1. One millimeter or greater gap or translation at the fracture site.
2. Radiolunate angle greater than 108 to 158 on a true lateral radiograph
(third metacarpal in line with the radial shaft; lower margin of the
pisiform between the lower margins of the capitate and the distal
pole of the scaphoid).
3. Carpal height ratio (CHR) of the affected side is less than the opposite
side and the discrepancy is 0.03 or greater (26).
4. Scaphoid length is shorter on the affected side and the discrepancy is
1 mm or greater (27).
CT and MRI provide very detailed depictions of the scaphoid and
may be more useful for diagnosing displacement. CT is cheaper, more
Fractures of the Scaphoid 117
readily available, and perhaps superior for bone imaging, at least as far as dis-
placement and other fracture detail are concerned (28,29). The best scan plane
for evaluating the scaphoid fracture is along the long axis of the scaphoid.
Scans in line with the longitudinal axis plane can be obtained by placing
the patient in the prone position with the arm overhead, fully pronated, and
flat on the table, and the forearm passing through the gantry at a 458
angle (30). A “coronal plane” scan in this axis is obtained by supinating the
forearm 908 (Fig. 2). Alternatively, a high-resolution scan can be obtained
and reformatted in selected planes using image manipulation software.
Any gapping or angular or translational displacement suggests instability of
the fracture.
CLASSIFICATION
Herbert’s classification is widely recognized and useful (10). The modification of
this system, described by Filan and Herbert in 1996, omitted Type B5 (commin-
uted fractures) and Type C (delayed union) because they did not form natural
groups. All fractures diagnosed more than six weeks after the initial injury
were classified as Type D (nonunion) in the newer system, reflecting concerns
about delayed diagnosis (Fig. 3).
Figure 1 Diagnosis of scaphoid fracture displacement. The following radiographic
factors indicate fracture instability. (A) One millimeter or greater translation or gap at
the fracture site on any view. (B) Greater than 158 dorsal angulation of the lunate with
respect to the radius. (C) When the carpal height ratio (CHR) of the affected side is
less than the opposite side by at least 0.03. The CHR is defined as L2 divided by L1.
(D) If the scaphoid length is greater than 1 mm and shorter than the affected side. Abbrevi-
ation: CHR, carpal height ratio.
118 Toh
TREATMENT CONSIDERATIONS
Acute unstable fractures (Type B) and delayed and nonunion fractures (Type D)
are indications for operative intervention. Scaphoid fractures that are part of a
more complex injury pattern (perilunate fracture dislocation, or combined
distal radius and scaphoid fracture) are also best treated operatively. For acute
Figure 2 CT of the scaphoid. (A) The patient lies prone and the wrist crosses the
gantry at a 458 angle. (B) This sagittal image depicts a displaced fracture of the scaphoid
waist in a 36-year-old man who presented three months after the initial injury with non-
union. (C) This coronal image depicts a proximal pole nonunion in a 20-year-old man
who presented 11 months after the initial injury. (D) Percutaneous screw fixation using
dorsal approach at 11 months after the initial injury. (E) PA radiograph four months
after the operation revealed solid bony fusion. Abbreviations: CT, computed tomography;
PA, posteroanterior.
Fractures of the Scaphoid 119
stable fractures (Type A), conservative treatment achieves a high union rate and
excellent wrist function, but requires prolonged cast immobilization. According
to Leslie’s paper, six to eight weeks were required for fractures of the distal
pole, 8 to 12 weeks for fractures of the waist, and 12 to 20 weeks for fractures
proximal pole (31). However, in practice, there is substantial variation in these
times and even in the type of cast used. Dias et al. (32) have shown that radio-
graphs cannot reliably determine union, so the time of immobilization will be
determined mostly by the surgeon’s preference, radiographic appearance, and
clinical findings.
An alternative to immobilization is to insert a screw into the scaphoid
percutaneously, and forego cast immobilization. Percutaneous fixation can be
used with displaced fractures if wrist arthroscopy is used to monitor and
ensure adequate reduction. Percutaneous fixation may also be appropriate for
some patients with Type D1 fractures (fibrous union) when good alignment is
present, and a bone graft is felt to be unnecessary (Fig. 4). This may be more
reliable in relatively recent fractures. For long-standing nonunions, it remains
Figure 3 Classification of scaphoid fractures according to Herbert. (A) The original
Herbert classification. Type A fractures are stable acute fractures including: A1, fracture
of scaphoid tubercle; A2, incomplete or nondisplaced fracture through the scaphoid
waist. Type B fractures are acute and unstable including: B1, distal oblique fracture; B2,
complete fracture of the waist; B3, proximal pole fracture; B4, trans-scaphoid-perilunate
fracture dislocation; and Type B5 comminuted fractures. Type C comprised delayed
unions and Type D established nonunions either stable/fibrous (D1) or unstable pseudo-
arthrosis (D2). (B) The modified Herbert classification of Filan and Herbert omitted
Type B5 fractures and Type C fractures, which were now included as a type of D1 fracture.
Type A fractures are defined as presenting within six weeks of the initial injury. Additional
subtypes of nonunion were added.
120 Toh
somewhat unclear how to define a fracture as a stable or fibrous union. It has also
not been demonstrated that percutaneous treatment is effective for all stable
nonunions, regardless of age. Although the concept is worthy of further study,
caution is warranted.
For Type D1 nonunions which require curettage and type D2 nonunions
which require bone grafting to correct the length and deformity such as DISI,
open reduction from a volar approach and screw fixation is recommended
(Fig. 5). In the more advanced types of nonunions—in particular, multiply
operated patients or nonunions associated with avascular necrosis of the proximal
pole—vascularized bone grafting from the distal radius or other salvage
operations such as partial carpal fusion or proximal row carpectomy are indicated
depending on the case (Fig. 6) (33–36).
Figure 4 Percutaneous fixation of a delayed union of the scaphoid. (A) PA radiograph of
a waist fracture in a 53-year-old man. The fracture line was not clear. (B) PA view one
month after the initial injury. The fracture line was more clearly identifiable. (C) PA
view three months after the initial injury shows an established nonunion. (D and E)
Oblique and lateral radiographs eight months after operative treatment with percutaneous
screw fixation through a dorsal approach shows union. Abbreviation: PA, posteroanterior.
Fractures of the Scaphoid 121
OPERATIVE TECHNIQUES
Percutaneous Screw Fixation Using Image Intensifier
Anesthesia
Alternatives for anesthesia include general or regional anesthesia. The latter
can be administered as an intravenous regional anesthesia (Bier block) or as a
brachial plexus block.
Figure 5 Nonunion with pseudoarthrosis (Type D2). (A and B) Oblique and lateral
radiographs of a waist fracture in a 15-year-old boy immediately after the initial injury.
The fracture was treated in a cast. (C and D) Radiographs two months later revealed
bony absorption and widening of the fracture site, shortening of length of the scaphoid,
and dorsal rotation of the lunate.
Type A Type B Type D1 Type D2-4
Cast Percutaneous
screw fixation w/o
open reduction
ORIF ORIF w/ BG
Vascularized BG
Other salvage op.
Patients w/
special
background
Good
reduction
Poor
reduction
Type B4
**
****
Figure 6 Algorithm of treatment options depending on Filan and Herbert classification.�Patient who does not want long-term immobilization, or who wants to return to sports activi-
ties as soon as possible or whose fracture is combined with another fracture such as distal end
of the radius. ��Cases of delayed fibrous union when good alignment can be achieved and a
bone graft is unnecessary. ���Comminuted fracture open reduction and internal fixation with
screw. Abbreviations: BG, bone grafting; ORIF, open reduction and internal fixation.
122 Toh
Approaches
There are two approaches for percutaneous screw insertion: volar and dorsal. In
the volar approach, the trapezium hinders insertion of the screw in the proper
location of the scaphoid. Some authors recommend removal of the foot process
of the trapezium to gain access to the entry location to target the axis of the
scaphoid. It is easier to place the screw in the central axis of the scaphoid
using a dorsal approach (37–39). The dorsal approach is particularly useful for
small fractures of the proximal pole (10).
Volar approach: A 1-cm transverse or longitudinal skin incision is often
made over the scaphotrapezium joint (Fig. 7). The joint is identified, and its
capsule is incised transversely. The beak of the trapezium is resected if this
proves helpful for screw placement.
Wrist arthroscopy can be used to confirm displacement and to monitor
reduction. The fracture cannot be seen through the radiocarpal portals, but is well
visualized via midcarpal portals. If the fracture is displaced or unstable, a reduction
Figure 7 A 1-cm transverse skin incision over the scaphotrapezium joint is used for
volar percutaneous screw fixation.
Fractures of the Scaphoid 123
is performed either by manipulating the wrist into extension and radial deviation, or
using Kirschner wires inserted into each fragment as “joysticks” to manipulate the
fracture. Alternatively, a single wire can be placed in the distal pole of the scaphoid,
used to manipulate the fracture, then driven across the fracture site for provisional
stabilization. The reduction may be evaluated using wrist arthroscopy.
When using a noncannulated screw, the fracture is first stabilized tempor-
arily by a Kirschner wire inserted ulnarward and parallel to the intended line of
the screw. Then the wire is pulled volarward to rotate the scaphoid, and a second
wire is inserted along the intended line of the screw (Fig. 8). Using the second
Figure 8 Percutaneous screw fixation. Volar approach. (A) The fracture is stabilized
with a temporary Kirschner wire. The wire is pulled volarward to rotate the scaphoid.
(B) A guide pin for the cannulated screw is then inserted along the intended line of the
screw. (C) Image intensifier views from the operation. The arrow indicates a guide pin.
(D) Using the second wire as a guide pin, a cannulated screw is inserted. With the original
Herbert screw, after removal of the second wire, the screw is inserted free-hand. (E and F)
Radiographs after screw insertion.
124 Toh
wire as a guide pin, a cannulated screw is inserted (Fig. 8D). With the original
Herbert screw, after removal of the second wire, the screw is inserted free-
hand. If there is no problem with stability of the fracture site, the first Kirschner
wire is removed (Fig. 8E and F).
When using a cannulated screw, a second wire is only needed to secure a
displaced fracture. For nondisplaced fractures, an incision of more than a few
millimeters is not necessary, although it might be used to excise part of the
trapezium to facilitate screw passage. In most cases, the wire is placed across
the fracture and the screw is placed over it. It can be difficult to pass the screw
pass the trapezium and obtain good positioning. A more radial starting point
and partial excision of the trapezium may help. Alternatives include drilling
the wire for the screw through the trapezium and either passing a countersink
over the wire as a way of resecting part of the edge of the trapezium or even
passing the screw through the trapezium.
Dorsal approach: This is an elegant technique that results in the wire
being automatically inserted along the central axis of the scaphoid. It was
originally reported by Slade who performed this technique keeping the hand
vertically (16,40). The author performs it in a horizontal position (Fig. 9).
After flexion and ulnar deviation followed by forearm pronation, the image
intensifier is used to obtain a good perpendicular view of the long axis of the
scaphoid. The scaphoid is visualized as two rings: distal and proximal
(Fig. 10). The guide wire is then inserted perpendicularly through the centers
of the two rings. After inserting only the tip of the wire and confirming its
position proper (Fig. 11), the guide wire is advanced to the volar side
(Fig. 12). Then the screw is inserted (Fig. 13). If instability exists at the fracture
site, reduction is obtained as described above and a Kirschner wire is used for
stabilization of the fracture site before inserting the guide wire.
Figure 9 Percutaneous screw fixation. Dorsal approach. Position of the hand and wrist.
Slade performed this technique keeping the hand in a vertical position (A) and the author
used a horizontal position (B).
Fractures of the Scaphoid 125
Implants
Many cannulated screws are available and each has advantages and disadvan-
tages for osteosynthesis of scaphoid fractures. The screw which we prefer to
use now is a double-thread screw developed by Dr. Tanaka of Japan. The charac-
teristic of this screw system is that the diameter of the guide wire is 1.2 mm
thicker than that of the other cannulated screws, and the screw is self-drilling
and self-tapping (Fig. 14). This is essentially a cannulated self-tapping double-
headed, countersunk, variable pitched screw (like a Herbert screw), and other
screws of this type are available.
Figure 10 Percutaneous screw fixation. Dorsal approach. Views of the insertion point of
the guide wire. After ulnar deviation (A) and flexion followed by forearm pronation, the
image intensifier is used to obtain a good perpendicular view of the long axis of the
scaphoid. The scaphoid is visualized as two rings: distal and proximal (B).
Figure 11 Percutaneous screw fixation. Dorsal approach. The guide wire is then inserted
perpendicularly through the centers of the two rings (A). After inserting only the tip of the
wire (B), its proper positioning is confirmed (C).
126 Toh
Postoperative Management
Patients are immobilized for comfort for two to three weeks (Figs. 2 and 15).
After removal of the cast or splint, wrist range of motion exercises is initiated.
Once bony union is established and the patient had regained at least 80% of
wrist motion and grip power compared to the opposite, uninjured wrist, resump-
tion of sports activity is permitted, usually around three months after the
operation (Fig. 16).
Figure 13 Percutaneous screw fixation. Dorsal approach. Then the screw is inserted
free-hand. PA (A) and lateral (B) radiographs reveal good screw position. The hole of
the cannulated screw is seen in the position of the wrist which is the same as for insertion
of the guide wire (C). Abbreviation: PA, posteroanterior.
Figure 12 Percutaneous screw fixation. Dorsal approach. PA (A) and lateral (B) image
intensifier views reveal that the wire is inserted along the central axis of the scaphoid.
Abbreviation: PA, posteroanterior.
Fractures of the Scaphoid 127
Figure 14 Author’s preferred screw. The double-thread screw was developed by
Dr. Tanaka of Japan. Its characteristics are that the diameter of the guide wire (A) is
1.2 mm thicker than that of the other cannulated screws and it is, therefore, stronger,
and the screw is self-drilling and self-tapping (B).
Figure 15 Case with Type A2. This is an 18-year-old male with a scaphoid waist frac-
ture. Posteroanterior (A) and lateral (B) radiographs at 26 months after the surgery
revealed good bony fusion. Good functional results were also achieved (C and D).
128 Toh
Results
From 1988 to date, 103 patients (91 men and 12 women), all with follow-up times
over six months, had percutaneous fixation of a fractured scaphoid in our center.
The average age was 29 years (range 11 to 73 years). Thirty-two patients had
Figure 16 Patient with Type D1 nonunion. (A and B) A waist fracture in a 19-year-old
man was treated by percutaneous screw fixation using dorsal approach at 30 days after
the initial injury. PA radiograph (A) and CT scan (B). (C–E: ) Three months later,
good bony fusion was revealed in PA (C) and lateral radiographs and CT scan (E).
(F and G) Due to achievement of about 80% of ROM and grip power of the opposite
healthy side, resumption of sports activity was permitted. Abbreviations: CT, computed
tomography; PA, posteroanterior; ROM, range of motion.
Fractures of the Scaphoid 129
acute stable fractures, 47 had acute unstable fractures, and 24 had delayed fibrous
union according to the modified Herbert’s classification. The duration from injury
to operative treatment in the fibrous union group averaged 104 days (range 42 to
316 days) (Fig. 17). We used standard Herbert screws in 49 patients and
cannulated screws of various types in 54 patients.
One of the 103 cases achieved bony fusion but revealed symptomatic
malunion. One patient with delayed union used sonic accelerated fracture
healing system (SAFHS) (low-intensity pulsed ultrasound) and achieved union
without a second operation. In three patients, union was not achieved—one
nonunion healed after a subsequent open surgery with bone grafting (Fig. 18). In
the remaining 98 cases, union and good wrist function were documented.
Figure 17 Patient with Type D1 nonunion. In this 14-year-old boy, the duration between
injury and to operation was 107 days. Oblique (A) and lateral (B) radiographs revealed
Type D1 nonunion. (C and D) Percutaneous screw (Herbert–Whipple) fixation was per-
formed. PA (A) and lateral (B) radiographs revealed good bony fusion. Abbreviation:
PA, posteroanterior.
130 Toh
The four persistent nonunions, delayed unions, and malunions seemed to be
related to technical problems in the initial operations. For example, one patient
(Fig. 18) operated two months after the injury had inadequate reduction, resulting
in nonunion. Four months later, a second operation was performed using the
Russe method (41). The graft harvested from the iliac crest was remodeled to
match the shape of the inside of the scaphoid because of severe bone absorption
Figure 18 Nonunion after percutaneous screw fixation. In this 19-year-old male, the
initial operation was performed two months after the injury. Unfortunately, the fracture
was not reduced perfectly before fixation was performed (A), resulting in nonunion (B).
Four months later, a second operation was performed following the Russe method
(C). PA (D) and lateral (E) radiographs five months later revealed good bony fusion.
The range of motion of the wrist (89%) and grip power (90%) were almost acceptable.
Abbreviation: PA, posteroanterior.
Fractures of the Scaphoid 131
(Fig. 18). Six months after the second operation, the wrist motion and grip
strength were satisfactory.
Open Reduction and Internal Fixation with Bone Grafting
For cases that require curettage and bone grafting to correct length and angular
deformity, we use open reduction, structural bone grafting, and internal fixation
from a volar approach. As reported by Fernandez (27), for nonunion with
malalignment, we use a wedge-shaped graft to correct the scaphoid length and
malalignment including DISI deformity. Alternatively, one can fill the opening
wedge defect anteriorly with pure cancellous graft, using the screw for primary
structural support. This simplifies the technical aspects of the procedure.
Preoperative Planning
Using PA radiographs of both the injured and uninjured wrists in maximum ulnar
deviation, the length of the scaphoids are calculated (Fig. 19). From this, the size
and shape of the grafted bone is planned preoperatively.
Operative Procedure
A zigzag skin incision is performed on the volar side of the wrist. The flexor carpi
radialis (FCR) sheath is used to gain deeper exposure. The wrist capsule is
incised. The fracture site is opened, and the nonunion site with the fibrous
tissue is resected until the previously sclerotic fracture surfaces are fresh and
able to bleed. Using two Kirschner wires as joysticks, the gap of the nonunion
site is opened and resected. In a case with DISI deformity, the rotation of the
Figure 19 Preoperative planning for cases with established nonunion. Using the PA
radiographs of both the opposite uninjured wrist (A) and the injured wrist in maximum
ulnar deviation (B), the length of the scaphoids were calculated. PA radiograph
seven months after the open reduction and bone grafting revealed good bony fusion
(C). Abbreviation: PA, posteroanterior.
132 Toh
lunate is corrected using a spring made by inserting a Kirschner wire in the lunate
(42). Alternatively, the lunate can be temporarily pinned to the radius in proper
alignment. The position is maintained during the bone grafting. A silicone
block is used as a trial spacer, and a tricortical corticocancellous bone graft is
obtained in the same size and shape as this silicone block (Fig. 20).
After grafting the bone, a Kirschner wire is inserted to stabilize both the
proximal and distal fragments and grafted bone. Then a guide wire is inserted
in the same manner as the percutaneous methods from volar or dorsal side. We
prefer to use a volar graft and dorsal percutaneous screw insertion.
Postoperative Management
The wrist is usually immobilized in a cast for four weeks. After removal of the
cast, wrist range of motion exercises is initiated. If a Kirschner wire has been
inserted to stabilize the alignment of the lunate, it is removed six weeks after
the operation. Resumption of sports activity is managed as for percutaneous
treatment.
Results
From 1984 to 2003, we performed open reduction and screw fixation with bone
grafting for 109 patients with Type D nonunions. Ages ranged from 12 to 64
years (average 26 years). The duration from injury averaged 29 months (range
six weeks to 487 months). In five of the 109 cases, union was not achieved.
The reasons for failure were inadequate screw length, incorrect screw position,
and improper size of grafted bone. In two of these five failed cases, an additional
Figure 20 Open reduction and volar wedged bone graft technique. (A) Volar approach
for nonunion of the scaphoid. Using two Kirschner wires as joysticks, the gap of the
nonunion site is opened and resected. (B) In a case with DISI deformity, the rotation of
the lunate is corrected using a spring made by inserting a Kirschner wire in the lunate.
The position is maintained during the bone grafting. (C) A silicon block is used as a
trial spacer, and tricortical corticocancellous bone graft is obtained in the same size and
shape as this silicon block. Abbreviation: DISI, dorsal intercalated segmental instability.
Fractures of the Scaphoid 133
bone graft was performed, and good bony union was achieved. In the remaining
three cases, patients did not desire further operation. In the remaining 104 cases,
union and good wrist function were achieved.
Pitfalls and Pearls
Poor results seem to be related to inadequate reduction, screw position, or screw
length. Trumble et al. (43) reported that the time to union was significantly
shorter when the screw had been placed in the central third of the proximal
pole of the scaphoid. The insertion techniques for the original Herbert screw
were somewhat difficult for less-experienced surgeons. However, cannulated
screws have been developed to resolve this problem. In the volar approach, the
trapezium hinders insertion of the screw in the proper location of the scaphoid.
Direct visualization of the fracture site using arthroscopy may make open
exposures unnecessary for displaced fractures and stable nonunions (44–46).
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136 Toh
7
Distal Radius Fractures
Karl-Josef Prommersberger and Thomas Pillukat
Klinik fur Handchirurgie, Bad Neustadt, Germany
INTRODUCTION
Fractures of the distal radius are extremely common injuries, which are steadily
becoming a public health issue. Although it was once believed that all patients
with distal radius fractures did relatively well, regardless of the treatment, it is
now well-recognized that undertreated distal radius fractures may be often
associated with poor results. The primary goals of treatment should be restoration
of pain-free hand and wrist function and prevention of long-term disability.
EPIDEMIOLOGY
In the 1970s and 1980s, fractures of the distal radius were estimated to account
for upwards of one-sixth of all fractures seen in the emergency room (1,2).
Some have suggested that they may account for approximately 25% of all
long-bone fractures (3).
Fractures of the distal radius are associated with osteoporosis. They are
more common in women than in men with an incidence increasing rapidly
after menopause and reaching a maximum between 60 and 69 years (4–10).
The most common injury mechanism is a fall from a standing height (11,12).
Hegeman et al. (13) assessed the bone mineral density (BMD) of the
lumbar spine and hip in 94 women (mean age, 69 years) with a distal radius frac-
ture. A low BMD was found in 85% of the patients, and osteoporosis was diag-
nosed in 51%. Ring and Jupiter (14) suspected that fracture of the distal radius is
typically a fracture of relative fit osteoporotic individuals. Looking at the survival
137
among elderly patients after fractures of the distal radius, Rozental et al. (15)
found at seven years after the fracture that survival rates after distal radius frac-
tures were notably lower than those expected for individuals of the same age and
gender in standard populations. Men were twice as likely to die as women and did
so almost twice as quickly. In addition, in older males, a recent study found that a
fracture of the distal radius was associated with a risk of hip fractures statistically
significantly greater than in women (16). As the population ages, fractures of the
distal radius may become a significant challenge to the orthopedic surgeon and
the health care system.
CLASSIFICATION
Despite the fact that the observations of Colles, Barton, Smith, and Pouteau were
made solely from postmortem specimens, their descriptions of fracture mor-
phology have served as guidelines for treating surgeons over 150 years and may
still provide a comfortable base for communication among clinicians (17). Classi-
fication systems for fractures of the distal radius have focused on the direction of
fracture displacement, the radiographic appearance, the mechanism of injury, the
articular joint surface involvement, and the degree of comminution (5,18–26).
We have found the classification system of Fernandez (26) extremely helpful in
decision-making in our clinical practice and the arbeitsgemeinschaft fur osteo-
synthesefragen/association for the study of internal fixation (AO/ASIF) Compre-
hensive Classification of Fractures (23) useful in preparing scientific papers.
The Comprehensive Classification of Fractures (AO/ASIF Classification)
The Comprehensive Classification of Fractures (or AO classification) divided
fractures of the distal radius into three types: extraarticular fractures (type A),
partial articular fractures (type B), and complete articular fractures (type C).
Further divisions into groups and subgroups are based upon patterns and severity
of articular and metaphyseal comminution. Observer reliability and reproducibil-
ity is adequate for the three basic types of the classification but was less reliable
when analyzing the groups and subgroups (27–31).
Fernandez’ Classification
Fernandez divided distal radius fractures into five major types (Fig. 1). Type I
fractures are bending fractures of the metaphysis in which one cortex fails to
tension stress and the opposite cortex shows a certain degree of comminution.
Type II fractures are shearing fractures of the joint surface. Type III fractures
are compression fractures of the joint surface with impaction of the subchondral
and metaphyseal cancellous bone. Type IV fractures are avulsion fractures of
ligament attachments, including ulnar and radial styloid fractures associated
with radiocarpal fracture dislocations. Type V fractures result from high-energy
138 Prommersberger and Pillukat
injuries and involve combinations of bending, compression, shearing, and
avulsion mechanism and often bone loss.
Figure 1 Fernandez’ classification for fractures of the distal radius.
Distal Radius Fractures 139
Distal Radioulnar Joint
In 1996, Fernandez and Jupiter (32) established a prognosis- and treatment-
oriented classification of distal radioulnar joint injuries associated with fractures
of the lower end of the radius. Depending on the residual stability of the distal
radioulnar joint (DRUJ) after reduction and stabilization of the radius, three
basic types of DRUJ lesions were differentiated. Type I are stable DRUJ
lesions, which means that the joint is clinically stable and the radiographs show
articular congruity. Type II are unstable DRUJ lesions with clinical and radio-
graphic evidence of subluxation or dislocation of the ulnar head. Type III are
potentially unstable lesions due to extension of distal radius fracture in the
sigmoid notch or due to a fracture of the ulnar head.
FUNCTIONAL AND RADIOGRAPHIC ANATOMY
The distal radius articulates with both the proximal carpal row and the head of the
ulna. The radiocarpal articular surface is divided into the scaphoid and lunate
fossae. These two concave articular surfaces are separated from each other by
a bony dorsal-volar ridge, the crista radii (33). The articular surface of the
distal radius inclines volarward in the sagittal plane an average of 108 to 128
(34–41) and inclines ulnarward in the frontal plane an average of 228 (42–45).
The sigmoid notch is a concave structure that articulates with the ulnar head
(46). The shape and the orientation of the sigmoid notch of the radius vary in
relation to the ulnar variance (47). With rotation of the radius about the ulna,
the ulnar head translates volarly in supination and dorsally in pronation (48–50).
The ulnar side of the wrist is supported by the triangular fibrocartilage
complex (TFCC), which articulates with both the lunate and the triquetrum.
The TFCC and radioulnar ligaments were attached to the ulnar edge of the
distal radius and may be injured in lunate fossa fractures, and disruptions of
distal radioulnar joint (51–53). The radial border of the TFCC is attached
along the entire margin of the lunate fossa of the distal radius and onto
its border with the sigmoid notch. The TFCC originates from the base of the
ulnar styloid.
Although the volar metaphyseal surface of the distal radius is relatively flat,
the dorsal aspect of the distal end of the radius is convex with specific areas for
anchoring the extensor retinaculum. The first dorsal extensor compartment
tendons run through a groove on the radial styloid. The extensor pollicis
longus (EPL) is routed around Lister’s tubercle, which functions as a fulcrum.
Ligamentotaxis for reduction of fractures of the distal radius is possible
because of dorsal and volar radiocarpal ligaments (54). The volar ligaments trans-
mit more force to fracture fragments around the distal radius than do the dorsal
ligaments when traction is applied across the wrist joint.
Several investigators, such as Medoff and Kopylov (55), Pechlaner (56),
and Rikli and Regazzoni (57), have realized that the distal metaphyseal and
140 Prommersberger and Pillukat
articular regions of the radius and the ulna represent structural units or
“columns.” Rikli and Regazzoni described an ulnar column comprising the
distal ulna, TFCC, and distal radioulnar joint; an intermediate column made up
of the lunate fossa and sigmoid notch of the radius; and a lateral column including
the scaphoid fossa and radial styloid process. Medoff and Pechlaner divided frac-
tures of distal radius into five fracture components: the radial column, which is
comprised three orthogonally oriented cortical surfaces; the dorsal and the
volar rim, and the intra-articular and ulnar split. These concepts have added sub-
stantially to our understanding of methods for achieving operative stability of
complex fractures and have lead to the development of implants designed specifi-
cally for the anatomy of the various columns.
The radiographic anatomy of the distal radius and its relationship to the
distal end of the ulna can be evaluated using four measurements: the volar tilt,
the ulnar inclination, the radial length, and the ulnar variance (Fig. 2). To
provide reliable data, a standardized radiographic technique is essential.
Because the elbow and shoulder positions affect the relationship between the
distal radius and the ulna, the standard posterior–anterior view of the wrist
should be obtained with the elbow flexed 908 and the shoulder abducted 908
with the forearm and wrist in a neutral position. The hand is placed palm flat
on the cassette without any flexion, extension, or deviation. A correct position
of the examination shows the edge or the entire groove of the extensor carpi
ulnaris tendon is at or radial to the fovea at the base of the ulnar styloid. The
lateral view of the wrist is taken with the elbow flexed 908 and adducted
against the trunk with the forearm and wrist in neutral position whilst a vertical
X-ray beam enters radially and exits ulnarly at the level of the distal pole of the
scaphoid (58). A correct position of the examination shows the volar surface of
the pisiform located at the midpoint between the volar surface of the distal
pole of the scaphoid and volar surface of the capitate head. For both, the postero-
anterior (PA) view and the lateral of the wrist at least 5 cm of the distal radius
have to be included to allow for accurate assessment of the long axis of the radius.
Radial length, also called radial height or length of the radial styloid, is
defined as the distance between two lines perpendicular to the long axis of the
radius, one passing through the distal tip of the radial styloid and the other
passing through the most distal aspect of the ulnar articular surface of the
radius. The average is 11 to 12 mm (34,40). This distance is less useful in asses-
sing relative radial shortening, because it reflects loss of ulnar inclination of the
articular surface of the distal radius and not the position of the distal articular
surface of the radius relative to the articular surface of the distal ulna.
The ulnar variance describes the relative positions of the distal articular sur-
faces of the radius and the ulna. All methods used to measure ulnar variance have
shown to be highly reliable with respect to intra- and interobserver variations
(59,60). Therefore, clinicians may use whichever technique he or she prefers
when measuring ulnar variance. According to Gelberman et al. (61), the measure-
ment can be obtained as the difference along the line of the longitudinal axis of
Distal Radius Fractures 141
the forearm between a perpendicular line at the ulnar edge of the lunate facet of
the distal radius articular surface and another perpendicular at the distal articular
surface of the ulnar head. A difference of 2 mm in length between the radius and
the ulna is considered normal (62). A positive ulnar variance occurs when the
articular surface of the ulna is distal to the distal articular surface of the radius.
Post-traumatic positive ulnar variance due to radial shortening can cause ulnar
impaction with degenerative tears of the TFCC and the luno-triquetral ligament
(51–53,63).
Figure 2 Radiographic anatomy of the distal radius. (A) The volar tilt is determined by a
line (Z) perpendicular to the long axis (X) of the radius, as determined by a line through the
center of its medullary space at 2 cm (B) and 5 cm (A)proximal to the radiocarpal joint and
a line (Y) joining the most distal parts of the dorsal and the volar rims of the radial articular
surface. (B) Radial length is defined as the distance (D–E) between two lines perpendicu-
lar to the long axis of the radius, one passing through the distal tip of the radial styloid and
the other passing through the most distal aspect of the ulnar articular surface of the radius
(C). The degree of ulnar inclination is derived by an intersection of a line formed between
the radial styloid and the sigmoid notch (Y) and one perpendicular to the long axis of the
radius (Z). (C) According to Gelberman et al. (61), the ulnar variance is determined as the
difference along the line of the longitudinal axis of the forearm between a perpendicular
line at the ulnar edge of the lunate facet of the distal radius articular surface and
another perpendicular at the distal articular surface of the ulnar head.
142 Prommersberger and Pillukat
The volar tilt, also known as dorsal tilt, dorsal angle, volar tilt, and volar
slope, is determined by a line joining the most distal parts of the dorsal and the
volar rims of the radial articular surface. The degree of the volar tilt is derived
by an intersection of the line of volar tilt and one perpendicular to the long
axis of the radius, as determined by a line through the center of its medullary
space at 2 and 5 cm proximal to the radiocarpal joint (41).
The ulnar inclination, also called radial inclination or radial tilt, describes
the angulation of the distal radial articular surface in relationship with the long
axis of the radius in the frontal view. It is determined by a line perpendicular
to the long axis of the radius and a line formed between the radial styloid and
the distal sigmoid notch (64).
When evaluating the extent of deformity caused by an extraarticular frac-
ture of the distal radius, comparing the radiologic criteria outlined above to those
of the opposite uninjured side will clarify the extent of displacement (65). For
intra-articular fractures, several investigators have shown that computed tomo-
graphy (CT) scans improve the sensitivity of measurement of articular surface
gapping, improved the accuracy of detection of comminution, and altered
proposed treatment plans within observers (66–70). In addition, CT appears to
be a superior diagnostic modality for detecting and quantifying sigmoid notch
fracture step-off and articular gapping as well as subluxation and dislocation of
the distal radioulnar joint (71–73).
In most distal radius fractures, standard radiographs of the wrist in two
plains will be adequate to control the reduction and to measure the final radiologi-
cal result at the time of fracture union. In a study of Chern et al. (74), sonogra-
phically guided monitoring compared well with conventional radiographic
techniques during closed reduction of extraarticular distal radial fractures.
However, after open reduction and internal fixation of the distal radius screw
position relative to the articular surface may be difficult to determine on standard
PA and lateral radiographs taken perpendicular to the long axis of the forearm in
both the frontal and the sagittal planes, in part because of the failure of standard
radiographic views to compensate for the normal inclination and tilt of the distal
radius articular surface. In addition, the dorsal plate often obscures the articular
surface itself on both PA and lateral views. Boyer et al. (75) have shown the
so-called anatomic tilt PA and lateral radiographs of the distal radius to be an
accurate and clinically useful tool for the evaluation of both the presence and
location of screw penetration of the articular surface after dorsal plating. Distinc-
tive to volar fixed-angle plating of the distal radius, the optimal position of the
distal fixed-angle support is in the subchondral bone immediately proximal to
the articular surface. Standard radiographic imaging of the distal radius during
placement of a volar fixed-angle plate does not provide adequate visualization
of the subchondral bone–distal support interface. To address this specific issue
of whether volar hardware placed at the immediate subchondral bone level has
effectively avoided the radiocarpal joint, Smith and Henry (76) described a 458
pronated oblique view of the distal radius. If there are concerns in regard to
Distal Radius Fractures 143
screw penetration in the articular surface of the distal radius, CT scanning may be
helpful (77) (Fig. 3).
BIOMECHANICS
Normal wrist biomechanics depend upon maintenance of the anatomical position
of the distal end of the radius with respect to the carpus and the distal end of the
ulna. Normal wrist motion consists of greater than 1208 of wrist flexion and
extension, 508 of wrist radial and ulnar deviation, and 1508 of forearm rotation
at the DRUJ (78). The distal radius carries 80% of the axial load through the
wrist, and the distal ulna carries 20% (79).
In clinical and laboratory studies, multidirectional deformity of the distal
radius caused alterations of the radiocarpal joint, the midcarpal joint, and the
distal radioulnar joint (80). The osseous deformity affects the normal mechanics
of the radiocarpal joint producing a limitation of the extension-flexion arc of
motion. In addition, the malalignment affects the normal load transmission
through the radiocarpal joint, but also across the whole wrist joint. Dorsal
tilting of radial surface shifts axial loading through the wrist dorsally and
ulnarly and decreases the joint contact area. The pressure distribution on the
radial articular surfaces becomes more concentrated (81–84) and may represent
a prearthritic condition of the wrist joint (85).
Furthermore, shortening of the radius and dorsal tilting of the articular
surface increase the force borne by the ulna. The load through the ulna increases
from 21% to 67% of the total load as the angulation of the distal radius fragment
increases from 108 of volar tilt to 458 of dorsal tilt (86). Lengthening of the ulna
by 2.5 mm increases the force borne by the ulna from 18.4% to 41.9% of the total
axial load (79).
Malalignment of the surface of the distal radius in both the sagittal and
coronal planes may result in a decreased mechanical advantage of the flexor
tendons as they pass through the carpal tunnel (87), diminishing grip strength.
In addition, median nerve compression neuropathy can also be encountered as
a result of the deformity of the distal radius (88–94).
At the midcarpal level, dorsal tilt of the distal radius may lead to a compen-
satory flexion deformity as an adaptive response to the dorsally rotated proximal
carpal row (95), an extrinsic midcarpal dynamic instability (96), and a fixed
carpal malalignment in dorsiflexion (97).
Angular and shortening deformity of the distal radius may cause incongruity
of the distal radioulnar joint and reduction of radioulnar contact area (98).
Radial shortening in relation to the distal part of the ulna can increase the
strain in the TFCC (99) and result in a disruption of the deep portion of the
dorsal radioulnar ligament (100). These factors may limit the arc of forearm
rotation (101,102).
Fellmann et al. (103) found that an anatomical reduction of acute distal
radial fracture correlated with a significantly better range of motion, whereas
144 Prommersberger and Pillukat
Figure 3 (Continued on next page) Open reduction and internal fixation of a dorsally
angulated, comminuted distal radius fracture with 908 to 908 plates position. (A) An
intraarticular fracture of the distal radius was stabilized with an external fixator. (B and
C) Preoperative CT demonstrated substantial intraarticular and metaphyseal comminution.
(D and E) The postoperative radiographs demonstrate the situation after open reduction
and internal fixation with a 908 to 908 plating with one plate applied lateral to the radial
styloid and use of a volar fixed-angle plate without bone grafting. On the anteroposterior
view, the articular surface of the radius seems to be well restored. However, there may be
some concerns whether the distal pegs have effectively avoided the radiocarpal joint. In
addition, the distal pegs and screws obscure the articular surface on the lateral view. (F
and G) Postoperative CT demonstrates that screw penetration in the articular surface of
the distal radius was avoided. To diminish side effects from the hardware, the software
program for CT has to be modified. Abbreviation: CT, computed tomography.
Distal Radius Fractures 145
McQueen and Caspers (104) found that motion was significantly worse in wrists
with dorsal angulation of more than 128. Jenkins and Mintowt-Czyz (105) and
Cooney et al. (106) reported that decreased grip strength had a close relationship
with the severity of residual fracture deformity. Aro and Koivunen (107) found
that the functional end result was unsatisfactory in only 4% of the patients
with an acceptable anatomic result, compared with 25% of the patients with
minor shortening and 31% of the patients with gross shortening of the radius.
TREATMENT
General Considerations
In spite of the anatomic and biomechanic rationale supporting attempts to restore
the alignment of the fractured distal radius, the need for anatomic reduction
Figure 3 (Continued from previous page)
146 Prommersberger and Pillukat
remains controversial, and several studies have championed one side or the other.
Furthermore, in spite of the explosion of new implants designed specifically for
internal fixation of distal radius fractures, the role of traditional treatment
methods such as closed reduction and casting, percutaneous K-wire pinning,
and/or external fixation must also be considered (108).
In a prospective study, Anzarut et al. (109) looked at the radiological and
patient-reported functional outcomes in 74 patients who were at least 50 years
of age with conservatively treated distal radius fractures. The average dorsal/volar tilt measured by a radiologist was 3.48 dorsal; overall 47 patients (64%)
were considered to have an acceptable radiographic reduction (dorsal tilt ,108
or volar tilt ,208). Acceptable radiographic reduction was not associated with
better generic physical or mental health status, lesser degrees of upper-extremity
disability, or greater satisfaction with outcomes than was unacceptable reduction.
The average score on the DASH (disabilities of the arm, shoulder, and hand)
was 24 (SD 17). Forty-four (60%) of the 74 patients were satisfied with their
functional status six months after injury. The DASH score averaged 27
(SD 19) in patients judged to have unacceptable dorsal/volar tilt and 22
(SD 16) in patients with an acceptable radiographic result.
In a prospective, randomized study of 57 patients older than 60 years of age
with unstable, extraarticular fractures of the distal radius, Azzopardi et al. (110)
looked at the outcome of immobilization in a cast alone compared with that using
supplementary, percutaneous pinning. At one year, the mean volar/dorsal tilt,
radial length, and ulnar inclination were significantly better in patients treated
using percutaneous wire fixation than in patients by immobilization in a cast
alone, but ulnar variance was not. Nonetheless, there was no significant differ-
ence in functional outcome in terms of pain, range of movement, grip strength,
activities of daily living, and the SF-36 score except for an improvement of the
range of motion in ulnar deviation in the percutaneous wire group. The authors
concluded that percutaneous pinning of unstable, extraarticular fractures of the
distal radius provides an improvement in the radiological parameters compared
with immobilization in cast alone, but this does not correlate with an improved
functional outcome in the investigated population of elderly people.
Harley et al. (111) evaluated augmented external fixation versus percuta-
neous pinning and casting for unstable fractures of the distal radius in a prospec-
tive fashion with a one-year radiographic and clinical follow-up period. Their
hypothesis was that external fixation with augmentation would provide superior
results compared with percutaneous pinning and casting. Fifty patients younger
than 65 years of age were randomized into these treatment groups. Over 80%
of the fractures were classified as AO/ASIF C2 or C3 and there was a similar dis-
tribution of fracture types in each group. The use of augmented external fixation
did not improve the mean radiographic outcome with respect to radial length,
ulnar inclination, and volar tilt. Improved articular surface reduction was noted
with the use of an external fixator but overall only three patients were recognized
to have steps or gaps greater than 2 mm. No significant differences in mean
Distal Radius Fractures 147
DASH scores, total range of motion, and grip strength were found between
the groups. However, all three patients diagnosed with a chronic regional pain
syndrome had external fixation.
Kreder et al. (112) conducted a prospective, randomized study comparing
open reduction and internal fixation with indirect reduction and percutaneous
fixation for treatment of displaced intra-articular fractures of the distal radius.
Internal fixation, usually involving an arthrotomy, was performed either
through an extended carpal tunnel approach on the volar side or between the
third and fourth compartments on the dorsum of the wrist. If necessary, fixation
by small- or mini-fragment plates and screws was supplemented with K-wires or
an external fixator. Percutaneous fixation was limited to percutaneous K-wires,
cannulated or regular small- or mini-fragment screws, and/or external skeletal
fixation. An arthrotomy was not performed. A total of 179 adult patients were fol-
lowed for two years with careful patient-related and physician-related outcome
assessments. There were no statistically significant differences in the radiological
restoration of anatomical features or the range of movement between the two
groups. However, during the study period, patients treated with indirect reduction
and external fixation had a more rapid return of function and a better functional
outcome as those who underwent open reduction and internal fixation, provided
that the intraarticular step and gap deformity were minimized.
The Cochrane Musculoskeletal Injuries Trial Registry reviewed 44
“eligible” trials, such as those mentioned above, over a 13-year period compris-
ing a total of 3193 patients with 3197 fractures. They concluded that there is
neither enough evidence to tell whether surgery gives a better result nor which
type of surgery is best for most types of fractures. In other words, there is
neither “one way” nor “one implant” to treat fractures of the distal radius and
often different ways of treatment lead to similar results.
The relationship between anatomy and function of the distal radius may be
more notable in active, healthy patients and after high-energy injury. Substantial
malalignment will lead to carpal malalignment and distal radioulnar joint dys-
function. Associated problems such as carpal fractures or ligament injuries,
acute carpal tunnel syndrome, and hand swelling and stiffness are important
sources of dysfunction after distal radius fractures. Furthermore, many of our
treatments can lead to problems.
To achieve the goal of restoring the distal radius as a base for optimal hand
and wrist function, we consider three questions: (i) Who is the patient? Infirm or
healthy? High-demand or low-demand? Good bone/high-energy versus poor
bone/low energy? (ii) What is the extent and pattern of articular involvement?
(iii) What is the integrity of metaphyseal support?
The first question highlights the role of the patient interview and examin-
ation. The history and physical examination should include age, occupation,
daily activity level, and general medical condition. The population of healthy
older people is expanding rapidly. Many of these patients remain active well
into their eighth decade, some of them pursuing activities such as skiing, golf,
148 Prommersberger and Pillukat
or tennis. On the other hand, most of the older persons have at least one chronic
medical condition and many have multiple medical conditions. Keeping in mind
that in the elderly the bone of the distal radius is weaker and thus not only more
likely to fracture but also more likely to collapse with plaster immobilization, the
aggressiveness with which we treat the fracture must be tempered by the patient’s
functional limits and general medical condition rather than by the patient’s age.
Therefore, we have found it helpful for treatment purposes to divide adult patients
with fracture of the distal radius into two groups: the physiological young and/or
active and the physiological old and/or inactive. In addition to age and activity,
the physical examination should define the urgency of treatment by inspecting
the wrist for wounds, tendon, and nerve function, with special attention to the
function of the median nerve.
The second question addresses the extent of fractures involving the articu-
lations between the radius and the proximal carpal row, and the radius with the
ulnar head. As shown by Kreder et al. (112), the final outcome on distal radius
fractures following fracture union depends primarily on residual joint stability
and the presence or absence of post-traumatic arthritis of the DRUJ. For the
radiocarpal joint surface of the distal radius, it is generally accepted that a
greater than 2 mm step-offs or gaps seen on plain radiographs is likely to lead
to an unacceptable outcome. In a retrospective study, Knirk and Jupiter (113)
investigated the effect of residual radiocarpal incongruity after intra-articular
fractures of the distal end of the radius in young adults. At a mean follow-up
of 6.7 years, there was radiographic evidence of post-traumatic arthritis in 28
(65%) of the fractures. Accurate articular restoration was the most critical
factor in achieving a successful result. Of the 24 fractures that healed with
residual incongruity of the radiocarpal joint, arthritis was noted in 91%,
whereas of the 19 fractures that healed with a congruous joint, arthritis developed
in only 11%. In addition, radial styloid fractures with the fracture line ending at
the scapholunate gap should be suspected of the concurrence of the distal radial
fracture with a scapholunate dissociation (114).
The third question directs the surgeon to determine the metaphyseal
support. If the volar metaphysis is involved, the fracture may be reducible but
will never maintain reduction. Those dorsal fractures with involvement of
greater then one-third of the sagittal diameter of the radius metaphysis may redis-
place despite excellent close reduction, because those fractures are inherently
unstable. Extensive metaphyseal comminution with involvement of both the
dorsal and volar metaphysis makes it more difficult to restore the alignment of
the distal fragments and leaves them with little or no bone-to-bone contact to
help prevent loss of alignment despite external fixation with or without ancillary
K-wires or internal fixation with a single dorsal or volar plate.
Treatment options for fractures of the distal radius can be divided into non-
operative or operative treatment. The surgical options of treatment of distal radial
fractures can be categorized into three main tools that may be used individually
or in combination to obtain optimal stability: percutaneous pinning, external
Distal Radius Fractures 149
fixation, and internal fixation. Whether patients have a nondisplaced fracture
requiring a minimal degree of immobilization or a markedly displaced fracture
requiring open reduction and internal fixation, all patients need to be instructed
and encouraged to perform hand and finger exercises, such as the “six pack” of
exercises described by Dobyns and Linscheid (115). Most patients can perform
these on their own, but some may benefit from supervised hand therapy. Shoulder
and elbow motion should also be encouraged and maintained during healing,
especially in the elderly.
Nondisplaced Distal Radius Fractures
Nondisplaced and minimally displaced distal radius fractures can be treated with
a removable prefabricated splint of the wrist, leaving the elbow, fingers, and
thumb free to avoid stiffness. O’Connor et al. (116) conducted a study in
which 66 adult patients with minimally displaced distal radial fractures were ran-
domly assigned to treatment with either a plaster cast or a lightweight removable
splint. Outcome assessment by clinical and radiological evaluation, and an inde-
pendent physiotherapy assessment showed greater satisfaction, few treatment-
related problems, and a superior functional assessment score at six weeks for
the removable splint compared to the cast.
A prefabricated, functional brace can also recommended for those patients
with displaced fractures which need closed manipulation as reported in a prospec-
tive, randomized study by Tumia et al. (117). A total of 339 patients were placed
into two groups, those with minimally displaced fractures not requiring manipu-
lation and those with displaced fractures which needed manipulation. Treatment
was by either a conventional Colles’ plaster cast or with a prefabricated func-
tional brace. Similar results were obtained in both groups with regard to the
reduction and to pain scores but the brace provided better grip strength in the
early stage of treatment. This was statistically significant after five weeks for
both manipulated and nonmanipulated fractures. There was no significant differ-
ence in the functional outcome between the two treatment groups. However,
younger patients and those with less initial displacement had better functional
results.
Displaced Distal Radius Fractures
On the basis of the large body of clinical and experimental evidence, we believe
that an attempt at anatomic reduction of most distal radius fractures is warranted.
However, if substantial displacement is present—defined as intra-articular dis-
placement greater than 2 mm, metaphyseal angulation greater than 208, or meta-
physeal shortening from a collapse greater than 3 mm—there is a high risk for
secondary displacement during the immobilization period (118). In a prospective
study, Nesbitt et al. (119) evaluated the radiographic outcome of unstable distal
radius fractures in 50 patients with three or more instability factors as described
by Lafontaine et al. (120) treated by closed reduction and sugar tong splinting.
150 Prommersberger and Pillukat
At four weeks after reduction, only 46% of these unstable distal radius fractures
maintained an adequate reduction. Of the 54% of fractures that failed to maintain
an adequate reduction, age was the only statistically significant predictor of sec-
ondary displacement. In our experience, secondary displacement is associated
with a suboptimal outcome and sequelae in active or “physiologically young”
patients. Again, when developing a treatment program the treating physician
must always bear in mind the patient’s functional demands and general
(medical) condition.
Closed Reduction
A good long-term prognosis after closed reduction and casting can be expected
when there is limited displacement. There are essentially two different techniques
for obtaining closed reduction, direct manipulation of the distal radius fragment,
and longitudinal traction through the hand, wrist, and fracture site. It has been
suggested that longitudinal traction results in a better reduction, is less painful,
and has a lower rate of redisplacement than direct manipulation. Earnshaw et al.
(121) compared these two methods in a prospective, randomized controlled
trial. Two hundred and twenty-five patients that displaced Colles’ fractures
were randomized to treatment with closed reduction with either finger-trap trac-
tion or manual manipulation. All underwent cast immobilization. The fractures
were assessed radiographically by measurement of the ulnar inclination, volar
tilt, and radial shortening before reduction, immediately after reduction, and at
one and five weeks after reduction. No significant differences were found
between the alignment of the fractures in the two treatment groups at any time.
However, the percentages of fractures in an acceptable alignment (,108 dorsal
tilt and radial shortening ,5 mm) were only 27% and 32% at five weeks after
finger-trap traction and manual manipulation, respectively.
The greatest challenge of closed treatment of dorsally displaced fractures of
the distal radius is maintaining the position obtained by reduction of the fracture.
The Cotton-Loder position with extreme volar flexion and ulnar deviation of the
wrist might be mechanically effective in restoring volar tilt; however, this pos-
ition can be dangerous, causing excessive median nerve compression and may
also contribute to hand stiffness because it is difficult to close the fist with the
wrist in this position. Our recommended position of immobilization for a dorsally
tilted metaphyseal fracture is that of a neutral position with respect to extension/flexion, and a slight ulnar deviation of the wrist. Although an argument can be
made for immobilization of Colles’ fractures in a sugar tong splint or a long-
arm cast, we favor immobilization in a below-elbow cast or a prefabricated, func-
tional brace because we feel that stability of the fracture determines maintenance
of reduction far more than the method of immobilization. If displacement of the
fracture would influence the patient and surgeon to consider operative care, radio-
graphs should be used to monitor the fracture prior to the establishment of early
healing that would make manipulative reduction more difficult (i.e., within
two weeks). The patient should be warned that loss of reduction may occur.
Distal Radius Fractures 151
If redisplacement during the immobilization period occurs, remanipulation has
been shown to have little value (122)—again most likely a reflection of the
inherent instability of the fracture—and operative treatment should be con-
sidered. Jupiter et al. (123) achieved excellent and good results with open
reduction and internal fixation in 18 of 20 patients aged 60 years and older
who presented to their institution with a radius fracture made complex by
virtue of displacement after closed reduction and cast or external fixation
immobilization.
Closed Reduction and Percutaneous K-Wire Fixation
Percutaneous pinning alone is contraindicated in extraarticular fractures with
marked metaphyseal comminution, in soft osteoporotic bone, and in fractures
with severe shortening. It can be recommended for reducible extraarticular or
simple intraarticular fractures without metaphyseal comminution and with
good bone stock (Fig. 4). A variety of different techniques have been described
in the literature. These include pins placed through the radial styloid, crossing
pins from the radial and ulnar sides of the distal fragment into the distal shaft,
intrafocal pinning as advocated by Kapandji (124), and transulnar pinning with
or without transfixation of the DRUJ. In a prospective study on 96 patients
with extraarticular or intra-articular dorsally displaced fractures of the distal
radius, Lenoble et al. (125) compared the radiological and clinical outcome
after transstyloid fixation and immobilization with Kapandji fixation and early
mobilization. Pain and reflex dystrophy were more frequent after Kapandji fix-
ation and early mobilization, but the range of movement was better although
this became statistically significant after six weeks. The radiological reduction
was better soon after Kapandji fixation, but there was some loss of reduction
and increased radial shortening during the first three postoperative months. The
clinical result at two years follow-up was similar in both groups. Percutaneous
fixation techniques may be more reliable when supplemented with additional
stabilization from bone grafts, bone graft substitutes, calcium phosphate bone
cement, or external fixation (126).
To avoid injury to the sensory branch of the radial nerve, it has been
suggested that the K-wires be inserted through a small skin incision after blunt
dissection with a small hemostat down to the bone. Alternatively, an oscillating
wire driver can be used. The wires can be either cut beneath the skin or cut to lie
outside the skin. To minimize the risk of pin infection, we prefer to cut off the
wires just below the skin and then bent it back to the bone. However, this requires
an operative procedure to remove the wires six to eight weeks later. In the rare
situation of a deep infection after percutaneous pinning, operative treatment
including removal of the pins is necessary. However, pin track infections are
usually superficial and can be treated with wound care and antibiotics. Ruschel
and Albertoni (127) observed six complications in 29 unstable extraarticular
distal radius fractures treated by intrafocal Kapandji pinning. Four patients
152 Prommersberger and Pillukat
developed reflex sympathetic dystrophy (RSD), one patient had a superficial
K-wire infection, and another patient had radial nerve superficial branch
paresthesia.
External Fixation
External fixation remains a valuable option in the management of fractures of the
distal radius (Fig. 5). Depending on the specific mechanical features inherent in
Figure 4 (A–C) K-wire fixation of a distal radius fracture.
Distal Radius Fractures 153
the fracture pattern, external fixation may act as a joint distractor, neutralization
frame, buttress, or even for compression. In acute fractures, an external fixator is
mainly used with joint distraction to obtain an indirect reduction of comminuted
fractures by applying tension on the capsuloligamentous structures attached to
the distal radius and after the device is statically locked to maintain fracture frag-
ment alignment. Attention is important not only in the recognition of indications,
functions, and limitations of the external fixation, but also on the application of a
specific external fixator. It has been recognized that excessive distraction is
harmful to the hand and median nerve and can created stiffness and develop
Figure 5 (A–D) External fixation for an unstable fracture of the distal end of the radius.
154 Prommersberger and Pillukat
sympathetic reflex dystrophy. In addition, distraction alone does not provide ana-
tomical reduction in every case, especially in those fractures with intra-articular
fragments and severe comminution. Finally, distraction alone often cannot
prevent a secondary collapse. Therefore, several authors have advocated
limited open reduction, supplementary pin fixation, or bone grafting in addition
to external fixation (128–132). Others have tried to create dynamic fixators that
maintain length and alignment but allow for wrist flexion and extension (133–
135). By avoiding wrist traction, investigators hoped to avoid wrist stiffness,
finger stiffness, or nonunion, all secondary to overdistraction. Overdistraction
of the wrist can be avoided by applying a “nonbridging” fixator which does
not span the wrist joint. The distal pins of a nonbridging external fixator are
placed in the distal fracture fragments directly, permitting at least a limited arc
of wrist motion (136). In a prospective comparison of spanning and nonspanning
external fixators, McQueen (137) has found improved radiological results, grip,
and wrist flexion in the nonspanning group at all stages of review. However,
the results by Krishnan et al. (138), also comparing static bridging and
dynamic nonbridging external fixation in a prospective randomized study, did
not demonstrate a statistically significant difference in the radiological and clini-
cal outcomes achieved with these two treatments.
External fixation can also be used for temporary fixation in severe open
fractures until the soft-tissue situation allow an open reduction and internal fix-
ation and as a neutralization frame to unload and protect a fracture that has
more tenuous internal fixation due to fracture complexity or osteoporosis.
Limited Open Reduction and Internal Fixation
The choice of surgical approach is dependent on the type of fracture, direction of
displacement, associated injuries (if any) and now, where volar locking plates for
the fixation of dorsally displaced distal radius fractures are available, in many
fractures on the preference of the treating surgeon. Pneumatic tourniquet
control is strictly recommended for all open procedures.
Dorsal approach: A lazy-S or a straight longitudinal dorsal midline
incision is made from the midcarpus proximally centered over the radius, extend-
ing between 8 and 10 cm (139). The third extensor compartment is opened, with
the EPL tendon mobilized proximally and distally so that it can be transposed.
The fourth and the second dorsal compartments are elevated with sharp sub-
periosteal dissection. Some surgeons prefer to resect the terminal branch of
the posterior interosseous nerve. The fourth compartment extensor tendons are
then retracted ulnarward, and the second and third compartments radialward.
Using a T-plate for fixation of the radius fracture, Lister’s tubercle is ronguered
flush with the shaft, while it is preserved when using a Pi-plate or two small
plates. With extraarticular fractures or shearing dorsal fracture dislocation, the
dorsal wrist capsule can be preserved because the accuracy of the reduction
can easily be confirmed by the interdigitation of the fracture lines and by
Distal Radius Fractures 155
fluoroscopic control. To reduce the fragments under direct vision for complex
intra-articular fractures with impacted articular fragments as well as for fractures
associated with carpal bone or ligament injuries, the dorsal wrist capsule is
opened by an incision along the dorsal rim of the distal radius, exploring the
underlying proximal carpal row and the articular surface of the distal radius.
After reduction and fixation of the fracture, the capsulotomy—if performed—is
closed with side-to-side sutures and the extensor retinaculum is reapproximated,
leaving the EPL tendon subcutaneous.
Volar approaches: The most commonly used volar exposure of the distal
radius is the distal part of the Henry (140) approach between the flexor carpi
radialis and the radial artery. A longitudinal incision from the wrist flexion
crease proximally, extending 5 to 8 cm is used. The flexor carpi radialis tendon
and the flexor tendons are retracted ulnarly, thus protecting the median nerve,
while the radial artery is retracted radially. The pronator quadratus is identified
and with an L-shaped incision at its most radial and distal attachment elevated
off of the radius with sharp dissection and retracted ulnarly. The volar carpal liga-
ments should not be incised. If a carpal tunnel release is necessary, a separate
incision on the ulnar side of the palm should be made so that the volar cutaneous
branch of the median nerve is not transected by connecting the incisions. After
reduction and fixation of the fracture, the implant is covered by suturing the
pronator quadratus to the edge of the brachioradialis.
An extension of this approach can provide access to the articular surface
and to the dorsal aspect of the radius (141). The first extensor compartment is
opened and the brachioradialis tendon is released from its attachment at the
distal radius to enable reduction of the radial styloid. To visualize the intra-
articular fragments and the dorsal die-punch, the proximal shaft fragment must
be pronated “out of the way” with a bone clamp. This gives free—intrafocal—
access to the articular fragments through the fracture plane. After indirect
reduction of these fragments against the proximal carpal row, the shaft fragment
is supinated back in place.
With more complex volarly displaced fractures, particularly with involve-
ment of the volar die-punch fragment, and to avoid two incisions—if a carpal
tunnel release is planned—in volar shearing fractures, a different approach is
chosen. An incision is outlined to extend from the midpalm obliquely crossing
the wrist flexor crease and extending proximally for 6 to 10 cm. The flexor reti-
naculum is opened at its ulnar border. The space between the ulnar vascular struc-
tures and the flexor tendons is dissected. The ulnar neurovascular bundle together
with the flexor carpi ulnaris tendon are retracted ulnarly, whereas the flexor
tendons, median nerve, and radial artery are retracted radially, exposing the pro-
nator quadratus. After elevating the muscle from the radius, an excellent exposure
of the medial side of the radius is given.
Approach to the radial styloid: In some circumstances, a specific
approach to the radial styloid may be useful. This can be done with a longitudinal
156 Prommersberger and Pillukat
incision between the first and second extensor compartments. Throughout the
whole procedure, care must be taken to protect the branches of the superficial
radial nerve and lateral antebrachial cutaneous nerves. The exposure includes
subperiosteal elevation of the extensor compartments, which are then retracted
away from the fracture site. If the exposure is extended distally to the tip of
the radial styloid, then the dorsal branch of the radial artery is at risk.
Limited open reduction and internal fixation: The concept of limited
open reduction is defined as a selective surgical exposure of fracture fragments
in association with closed reduction and in conjunction with arthroscopic treat-
ment of distal radius fractures. Articular and metaphyseal fragments which
remain displaced after closed reduction are approached through limited incisions
in an effort to achieve anatomic reduction with minimal soft-tissue disruption
devascularization of the fragments. The choice of surgical approach depends
on the location of the displaced fragment. The limited incision allows only the
use of small implants such as wires, tension bands, and small buttress plates.
The following fractures cannot be managed by limited open reduction: irre-
ducible metaphyseal fractures, shearing marginal fractures of the joint surfaces,
irreducible intra-articular fractures, radiocarpal fracture dislocations, redisplaced
fractures after closed reduction, fractures associated with carpal or DRUJ injuries
which need to be addressed operatively, and fractures associated with soft-tissue
lesions. The choice of surgical approach depends on the location and direction of
displacement of the fracture fragments, but also on the implant that the surgeon
prefers to use for stabilization of the fracture. In addition, soft-tissue problems as
well as associated carpal and DRUJ injuries may influence the choice of the sur-
gical approach. Volarly displaced fractures have to be approached through volar
exposures. But dorsally angulated fractures can be approached dorsally or volarly
using a volar fixed-angle plate fixation (Fig. 6). Volar incisions are also appropri-
ate for primary repair of a torn wrist capsule in radiocarpal fracture dislocations
and whenever median nerve decompression is indicated.
Combined dorsal and volar exposure and fixation: Complex articular
and metaphyseal fractures of the distal radius may merit a combined dorsal and
volar exposure and plate fixation (142,143). A single dorsal or volar plate may not
provide adequate stability, and the distal fragments may displace in the direction
opposite to the plate. The combined dorsal and volar plate can cradle the articular
fragments, compressing them together and providing improved support at the
metaphyseal level (Fig. 7).
Distraction plating: As an alternative for double plating, internal dis-
traction plating can also be used for the treatment of highly comminuted distal
radius fractures especially in the elderly patient (144). The technique involves
the use of 3.5 or 2.7 dynamic compression plates. The instrumentation is
applied in distraction dorsally from the radial diaphysis, bypassing the
Distal Radius Fractures 157
comminuted segment, and fixed to the long metacarpal (Fig. 8). A disadvantage
of this technique is the need for a second operation to remove the plate.
Implants for Internal Fixation
An innumerable and ever-increasing variety of implants for internal fixation of
fractures of the distal radius continue to appear, largely as a result of the attempts
by many different companies to corner a part of this market. This together with a
Figure 6 Fixation of a dorsally displaced distal radius fracture with a volar fixed-angle
device. (A and B) Radiographs of a 40-year-old man showing an extraarticular dorsally
displaced distal radius fracture. (C and D) Postoperative radiographs demonstrating
anatomic reconstruction of the distal radius using a volar fixed-angle plate and screws.
158 Prommersberger and Pillukat
Figure 7 (Continued on next page) Combined dorsal and volar plate fixation of a
complex fracture of the distal radius. (A) Radiograph of a type V complex distal radius
fracture according to Fernandez in an elderly woman. (B and C) Preoperative CT scans
reveal the severity of both intraarticular and metaphyseal comminution with involvement
of the radial column, the central articular surface, the dorsal and the volar rim, and a split of
the ulnar facet. In addition, CT scans demonstrate degenerative changes at the tip of the
radial styloid. (D and E) Postoperative radiographs showing an acceptable reduction
and restoration of radial length after open reduction, bone grafting, and volar and dorsal
plate fixation. However, the dorsal plate obscures the articular surface on the frontal
view. (F–H) Postoperative computed tomography scans confirm an acceptable realign-
ment of the severely comminuted articular surface. Abbreviation: CT, computed
tomography.
Distal Radius Fractures 159
steady stream of case series (level 4 evidence) claiming excellent results in the
treatment of distal radial fractures using one special plate or another may be tire-
some (145–156). Nonetheless, we believe that there have been some important
developments. One was the inauguration of fixed-angle plate fixation and the
other the development of the fragment specific fixation. Walz et al. (157) com-
pared the loss of reduction after internal fixation of distal radius fractures in
elderly patients following plate fixation with a conventional T-plate with that fol-
lowing fixed-angle plate fixation. The two groups were comparable with respect
to age and fracture type, but there were more women in the group with the fixed-
angle plate fixation. A loss of reduction was found in 12 of the 30 patients treated
with a conventional T-plate (40%), whereas a loss of reduction was observed only
in two out of 44 patients (4.5%), which were treated with a fixed-angle device. In
a biomechanical study, Dodds et al. (158) compared the fragment-specific fix-
ation with low-profile modular implants and the augmented external fixation
for intraarticular distal radius fractures. In the four-part fracture pattern,
Figure 7 (Continued from previous page)
160 Prommersberger and Pillukat
Figure 8 (Continued on next page) Internal distraction plating of distal radius fracture.
(A) Radiograph of a 25-year-old, right-handed patient, who was injured in a motorcycle
accident, with a fracture of the distal third of the ulna, and an open highly comminuted
intraarticular distal radius fracture type V according to Fernandez. (B) Notice the fracture
fragments in the wound. (C) These radiographs demonstrate the open reduction and
internal fixation of the distal ulna fracture combined with repair of the laceration of the
FDP V tendon, and the external fixation of the distal radius fracture. After the external fix-
ation of the distal radius fracture, the distal radioulnar joint was still grossly unstable and
was temporarily stabilized with an outlier of the external fixator. Notice the persisting
gross deformity of the distal radius. (D) A postoperative PA radiograph demonstrates
bridge plate fixation with ancillary Kirschner wires. (E) Five months postoperatively,
the patient presented with a broken plate which was then removed. (F and G) Final clinical
and radiographical examination 13 months after the injury showed an arc of motion of
wrist extension/flexion of 45/508, wrist ulnar/radial deviation of 20/108, and a
forearm supination/pronation of 70/808.
Distal Radius Fractures 161
fragment-specific fixation was shown to be significantly more stable when com-
pared with static augmented external fixation. Meanwhile, it has been shown in
several clinical and laboratory studies that these ultrathin modular implants
that can be shaped to customize fixation for different fragment configurations
Figure 8 (Continued from previous page)
162 Prommersberger and Pillukat
provide an extremely high degree of stability allowing active, unresisted motion
exercises within a week of surgery even in unstable intraarticular fractures of the
distal radius.
Again, we believe that there is not one best method or one superior implant
to treat fractures of the distal radius and that often different ways of treatment
result in a similar outcome. The treating physician must always bear in mind
that the primary goal in the treatment of distal radius fractures is to restore
hand and wrist function and to prevent long-term disability. On the other hand,
recognizing that distal radius fractures are associated with a high rate of compli-
cations and frequently poor results should lead us to be more aggressive in the
original case of these fractures.
ASSOCIATED INJURIES
As a result of the original trauma, distal radius fractures can be associated with
several soft-tissue and bony injuries. Injuries associated with fractures of the
distal radius are open fractures, nerve injuries, lesions of the distal radioulnar
joint with or without fractures of the distal ulnar, and injuries to the carpal liga-
ments and bones. Associated injuries often lead to more problems than the distal
radius fracture itself and might have a negative effect on the final outcome, par-
ticularly if they are missed initially. Associated injuries can influence decision-
making on whether to operate on a distal radius fracture or not as well as how
to fix the fracture.
Open Fractures
Open fractures of the distal radius are unusual. However, all open fractures—
whether there is a massive skin injury or a pinpoint—are indications for emer-
gency operative treatment of the injury. Preoperative cultures are advised as
the first step of the treatment plan followed by broad-spectrum antibiotic
therapy, debridement, and irrigation of the wound with saline solution.
Decision-making how to deal with the fracture itself depends on the wound situ-
ation on the one hand—result of a low- or high-energy trauma, suitable cleaned or
not, open for less or more than eight hours—and the fracture stability. If there is
any doubt about the wound situation, the wound is left open and closed seconda-
rily, and the fracture is fixed with use of an external fixator. If the wound could be
suitably cleaned and the fracture is unstable, we are not afraid to stabilize the
fracture with an internal fixation or a combined internal and external fixations.
Nerve Injuries
Although ulnar nerve dysfunction is less frequent, symptoms of median nerve
dysfunction is the most common problem associated with acute distal radius frac-
tures (90,159–164). However, in general, they were resolved, if a satisfactory
reduction of the fracture is obtained. Therefore, we recommend immediate
Distal Radius Fractures 163
reduction for all distal radius fractures with neurologic symptoms, but do not rou-
tinely release the carpal tunnel, even in patients with fractures, which require
operative treatment unless there is previous history of carpal tunnel syndrome
or a massive swelling, so that compartment syndrome must be considered.
Carpal Injuries
Resulting from a similar injury mechanism, intraarticular and extraarticular frac-
tures of the distal radius are often accompanied by soft-tissue and bony injuries
within the carpus. Initially, these injuries are often missed because the attention is
drawn to the obvious deformity of the distal radius, but may in part be responsible
for continued discomfort even after a seemingly well-healed fracture (165).
Therefore, our treatment plan for the setting of distal radius fracture suspected
to be associated with a carpal ligament disruption calls for diagnostics of the
carpal ligaments (166). Special attention is mandatory in the evaluation of the
carpal architecture after reduction of the distal radius fracture, particularly in
intra-articular fracture with the fracture line entering the ridge between the
scaphoid and lunate fossa (114). Traction radiograms may be helpful to detect
complete scapholunate ligament tears because the scaphoid translates distally
under traction, if the ligament is completely disrupted (167). If there are
further concerns, a CT with intraarticular injection of gadolinium or an MRI
with intravenous gadolinium should be recommended in distal radius fractures
which do not require operative treatment and arthroscopy or direct visualization
of the carpal ligaments in distal radius fractures requiring surgical treatment.
Treatment plans for distal radius fractures associated with carpal bone or
ligament injuries must take into account the stability of the distal radius fracture
and the severity of the carpal injury. Nondisplaced carpal fractures usually
require no additional treatment because the methods used for immobilization
of the radius are sufficient. Because it takes a long time to heal the scaphoid
even in a nondisplaced fracture, internal fixation of the scaphoid may be rec-
ommended in the setting of distal radius fracture combined with a nondisplaced
scaphoid fracture to allow mobilization of the wrist joint after healing of the distal
radius fracture (168) (Fig. 9). Although partial nondissociative carpal ligament
lesions may heal uneventfully during the immobilization time required for
healing of the distal radius fracture, dissociative lesions require aggressive treat-
ment. This includes reduction of the carpal malalignment, ligament repair, and
temporary K-wire stabilization (Fig. 10).
Associated DRUJ Lesions
The stability of the DRUJ depends on the congruity of the sigmoid notch and the
ulnar head, the integrity of the TFCC and the capsular, as well as on the stability
of the ulnar styloid. Therefore, assessment of the DRUJ requires that the radius is
adequately restored with respect to length and shape and that the anatomic
164 Prommersberger and Pillukat
relationship of the sigmoid notch and the ulnar head is re-established. According
to Fernandez and Jupiter (32), associated lesions of the DRUJ are categorized as
stable, unstable, and potentially unstable. Type I lesions with the DRUJ clinically
stable and radiographically congruent allow early forearm rotation and do not
require special external support. Type II lesions with the joint clinical and radio-
graphic evidence of subluxation or even dislocation require operative treatment.
Tension band or interosseous wire is recommended to fix the ulnar styloid frag-
ment when its avulsion at the base is causing DRUJ instability. If the instability of
the DRUJ is caused by a massive tear of TFCC, the TFCC lesions may be treated
with arthroscopic or open repair. Immobilization with the forearm in neutral pos-
ition for six weeks is indispensable. For those type III DRUJ lesions, in which the
fracture of the ulnar head could be rigidly fixed with plate and screws (169)
(Fig. 11), functional aftercare with early active forearm rotation is possible.
Type III lesions with instability of the DRUJ due to dorsally displaced dorsoulnar
fragment of the distal radius require exact anatomic reduction of the sigmoid
notch to gain DRUJ stability (170).
Figure 9 Radius fracture associated with fracture of the scaphoid. (A) An oblique radio-
graph of a diaphyseal radius fracture with extension in the radiocarpal joint associated with
a transverse fracture of the scaphoid. (B) Postoperative radiograph showing reconstruction
of the metaphyseal radius fracture with three transverse lag screws, additional lag screw
fixation of the radial styloid fragment, and neutralization plating of the diaphyseal
radius fracture as well as Herbert screw fixation of the scaphoid fracture through an
extended volar approach.
Distal Radius Fractures 165
Figure 10 Fracture of the distal radius associated with a complete scapholunate ligament
rupture. (A and B) Radiographs, after closed reduction and immobilization in a cast,
showing partial insufficient reduction and a step-off between the scaphoid and the
lunate fossae suspicious for scapholunate ligament tear. (C and D) Radiographs, after
open reduction and internal fixation with a 908 to 908 plating using fixed-angle devices
and stabilization of the scapholunate injury with two additional K-wires.
166 Prommersberger and Pillukat
Figure 11 Distal radius fracture associated with fracture of the ulna head. (A and B)
Dorsally displaced intraarticular fracture of the distal radius associated with a fracture
of the ulna head and a fracture at the base of the ulnar styloid in an elderly woman.
(C and D) After open reduction and volar fixed-angle plate fixation, the distal radioulnar
joint (DRUJ) was grossly unstable. The ulna head fracture was treated with blade plate
fixation. Because of persisting instability of the DRUJ, stabilization of the ulnar styloid
fracture was provided with K-wire and tension band wiring.
Distal Radius Fractures 167
COMPLICATIONS
Although it was once widely believed that patients with fracture of the distal
radius generally do very well regardless of the radiological result, it is now
appreciated that fractures of the distal radius fractures are susceptible to
several complications, many of which will lead to poor clinical results. In a
study of 565 Colles’ fractures, Cooney et al. (106) found a complication rate
of 31%. The main complications were median neuropathy, finger stiffness,
RSD, degenerative changes at the radiocarpal and distal radioulnar joints,
malunion, nonunuion, and tendon ruptures.
Reflex Sympathetic Dystrophy
RSD (complex regional pain syndrome type I) is a complex of symptoms charac-
terized by diffuse pain, usually with associated swelling, vasomotor instability,
and severe functional impairment of the extremity. RSD presents with very
varied symptoms and signs occurring in different combinations and intensity.
The incidence of RSD after fractures of the distal radius has been variably
reported at between 0.02% and 32% (171–175). The higher estimates of the
prevalence of RSD most likely reflect a broader definition of the problem, includ-
ing patients with stiffness and swelling that are more related to anxiety, fear, and
other psychological difficulties associated with treatment and recovery from
injury. With a more strict definition—one that requires objective evidence of a
role of sympathetic nerves in the pain via measurement of the response to a
stellate ganglion block—the prevalence of true RSD is very low.
If RSD is suspected, prompt intervention is recommended to prevent many
of the problems of this serious complication. RSD may be present in the patient
who has increasing finger stiffness associated with an inordinate amount of pain,
or paresthesias, and swelling during fracture healing. These might be caused by
tight dressings, casts, or splints. Removal of a dressing or cast to relieve pressure,
elevation of the swollen hand, and intensive physiotherapy are mostly adequate to
prevent the development of full RSD. However, in the severe condition, more
aggressive intervention with sympathetic blocks, appropriate medication, and
physiotherapy is necessary. Recognition and treatment of acute carpal tunnel
syndrome may also abort the development of RSD.
Nonunion
Although nonunions of fractures of the ulnar styloid process associated with
distal radius fractures are quite common and mostly do not cause symptoms, non-
unions of distal radius fractures are an extremely rare occurrence and are usually
symptomatic (176–181). In a study of more than 2000 fractures of the distal end
of the radius, Bacorn and Kurtzke (182) reported a nonunion rate of 0.2%.
Watson-Jones (183) reported one case of distal radius nonunion of 3199 fractures.
In 1998, Segalman and Clark (184) presented a series of 12 distal radius
168 Prommersberger and Pillukat
nonunions in 11 patients treated during a 24-year period. Recently, we reported
on our experience with 23 nonunions of the distal radius (185).
Some investigators have speculated that delay and arrest in healing of a
fracture of the distal radius may have become more common since surgical treat-
ment of distal radius fractures has become more popular (186). Indeed, factors
associated with fracture treatment may contribute to the failure of fractures of
the distal radius to unite, including inadequate immobilization, inadequate
fixation during open reduction, and excessive distraction during application of
an external fixator. In addition, some medical conditions and some drugs may
disturb the bone metabolism and, therefore, may delay or even prevent fracture
healing. Segalman and Clark (184) reported 15 comorbid medical condition in
their 11 patients with 12 distal radius nonunions including diabetes mellitus,
peripheral vascular disease, peripheral neuropathy, and psychiatric disorders,
alcoholism, hypothyroidism, morbid obesity, and scleroderma. The most striking
association of the five patients treated for radial fracture nonunion by Smith and
Wright (187) was that all patients were heavy smokers. Tobacco previously has
been implicated in an increase in the nonunion rate in patients having spinal
fusion and limited intercarpal arthrodesis. In addition, three of the five patients
reported by Smith and Wright were heavy alcohol abusers. Alcoholism may
negatively affect compliance of the patients during fracture treatment.
A distal radial fracture nonunion should be suspected clinically if there is
continuing pain after remobilization of the wrist associated with an advancing
deformity. The pain is related to the use of the hand and shows no sign of improv-
ing. The diagnosis may be confirmed by showing movement at the fracture site on
lateral radiographs with the wrist in flexion and extension. If there is any doubt
regarding the radiographic signs of fracture union, a CT scan should be
recommended (188).
Because of the rarity of nonunion after fracture of the distal end of the
radius, it is not surprising that there is no consensus on the optimum mode of
operative treatment. A small, osteoporotic distal fragment, associated soft-tissue
contracture with radial deviation of the carpus and hand, and atrophic status at
the site of the nonunion are features that can make surgical correction of a
distal radial nonunion difficult and has led some authors to recommend total
wrist fusion (180,184,189). Several series describe surgical attempts to gain
union (179,186,190,191).
Segalman and Clark (184) used the extent of the metaphyseal subchondral
bone supporting the articular surface distal to the site of the nonunion as a criterion
to determine the appropriate treatment. They suggested that surgical attempts to
gain bony union are worthwhile when at least 5 mm of subchondral bone
beneath the lunate facet of the distal radius is available for application of implants.
For nonunions with less than 5 mm of subchondral bone supporting the articular
surface distal to the nonunion site, they recommend total wrist arthrodeses.
We compared the results of reconstruction of distal radial fracture nonunions
in 10 patients in whom the distal fragment had less than 5 mm of subchondral bone
Distal Radius Fractures 169
supporting the articular surface distal to the site of the nonunion with those of
reconstruction of nonunions of the distal radius in 13 patients with a larger
distal fragment (185). The overall functional and radiographic outcomes were
similar, but more postoperative complications were observed in the patients
with small fragments than in the patients with large fragments. On the basis of
this experience, and because the radiocarpal and midcarpal articulations are
often uninvolved, we think that an attempt to maintain functional mobility of
the wrist by obtaining anatomic realignment of the distal fragment and union of
the fracture seems warranted. Total wrist arthrodeses should be reserved as a
final resort.
Malunion
In spite of advances in the treatment of fractures of the distal radius, malunion is
still a common complication. Malunion of the distal radius usually occurs follow-
ing conservative treatment; however, now that internal fixation of fractures of the
distal radius has become more commonplace, we are seeing an increasing number
of radial malunions after operative treatment.
Malunion of the distal end of the radius may be extraarticular with a meta-
physeal angulation, loss of length relative to the ulna, and rotational deformity of
the distal fragment (192). In addition, the distal fragment may be translated in
either the sagittal or the frontal plane (193). Distal radial malunion may be
intra-articular with a step-off or a gap at the radiocarpal and/or the distal radio-
ulnar joint or both, intra-articular and extraarticular.
It may be true that not all nonanatomically aligned fractures of the distal
radius result in a poor functioning outcome. However, in our experience many
patients with malunited fractures of the distal end of the radius complain of
decreased range of wrist motion and forearm rotation, weakness and pain,
especially on the ulnar side of the wrist, where an ulnocarpal impaction as a
result of radial shortening often exists. Many patients, both men and women,
complain of the cosmetic deformity. In a small number of patients, there may
be a carpal tunnel syndrome caused by the deformity of the wrist. All these com-
plaints are related to the disorder of the wrist joint caused by the deformity at the
radiocarpal level, the distal radioulnar joint, and the midcarpal level.
Treatment options for symptomatic malunion of the distal radius must take
into account the patient’s motivation, the functional demands of the patient, and
the anatomy of the deformity. Newer fixation devices allowing more stable fixation
of osteoporotic bone have made consideration of the bone quality less important.
Intervention to correct symptomatic malunions may be categorized into four broad
areas: procedures aimed at restoring anatomic relationships, procedures aimed
solely at gaining a functional improvement, procedures aimed at eliminating
pain, and procedures that combined two or more of the above approaches.
Procedures aimed at eliminating pain are wrist denervation and arthrodesis.
Arthrodesis may involve the total wrist joint or only radius, scaphoid, and lunate
170 Prommersberger and Pillukat
(194–196). From the different procedures aimed solely at gaining a functional
improvement on forearm rotation, we have had very satisfactory results with
Bowers hemiresection interpositional arthroplasty (197,198). Procedures aimed
at restoring anatomic relationships between the distal end of the radius and the
carpus as well as the distal end of the ulna are primarily osteotomies of the
distal radius and the ulna.
The aim of a radial corrective osteotomy is to improve wrist function and
diminish pain by restoring the anatomic position of the distal end of the radius in
relation to the carpus and to the distal end of the ulna. Therefore, corrective
osteotomy is considered whenever there is a radiological malunion, but under-
taken only when there is a substantial likelihood that improved radiological align-
ment will lead to improvement in symptoms and function. It is important to
distinguish symptomatic and asymptomatic malunions. There are no fixed radio-
logical parameters to determine the indication for corrective osteotomy.
Poor general health and marked degenerative changes of the radiocarpal
joint are contraindications for radial osteotomy. Additional contraindications
include fixed carpal malalignment, evidence of a sympathetic reflex dystrophy,
limited function of the fingers, as well as severe osteoporosis. A slight instability
of the distal radioulnar joint is not a contraindication for radial osteotomy,
because the corrective osteotomy reestablishes, in general, its stability. Also a
marked instability of the distal radioulnar joint is no contraindication for radial
osteotomy, but requires a simultaneous procedure on the ulnar side of the wrist
(198–201). There is no upper age limit for osteotomy of the distal radius pro-
vided that there is adequate bone quality and impaired wrist function. Regarding
distal radial malunion in children, due to the remodeling capacity of the distal
radial metaphysis, osteotomy is rarely necessary.
Ideally, radial corrective osteotomy should be performed as soon after the
fracture as it is decided that the patient meets the criteria and the swelling is sub-
sided. Jupiter and Ring (202) evaluated the time of intervention comparing two
groups of patients who had had a corrective osteotomy of the distal radius.
One group had had the surgery an average of eight weeks after the initial
injury, and a comparable group had had the osteotomy an average of 40 weeks
after the fracture. The overall functional and radiographic outcomes were
similar, but earlier intervention reduced the total duration of disability and the
time until the patient returned back to work was significantly shorter in patients
out of the early-intervention group.
Preoperative work-up includes an exact evaluation of the clinical situation
and the radiological findings. The indication for corrective osteotomy is usually
based on plain radiographs of the injured wrist. Comparison of the opposite side
is helpful to determine ulnar variance and the inclination in the frontal and sagit-
tal planes. A CT may be helpful to detect degenerative changes and malalignment
of the distal radioulnar joint as well as rotational deformity of the distal radius
(192). An arthroscopy of the wrist may be indicated to assess the articular carti-
lage and the ligaments. Preoperative drawing of the planned surgical intervention
Distal Radius Fractures 171
showing the level of osteotomy, the angle of correction, and the change in ulnar
variance is important. Nowadays, the preoperative planning of the surgical inter-
vention is often done on a computer (193,203–205).
Most surgeons feel that the approach to expose the distal part of the radius
depends on the direction of the deformity using a classic volar Henry approach
for volarly tilted malunions and a dorsal incision between the third and fourth
dorsal compartments for dorsally angulated malunions as outlined by Fernandez
(206–208). Because of formation of callus and remodeling at the site of the frac-
ture localized upon the dorsal aspect of the radius in dorsal malunions, visual
alignment of cortical surfaces may be difficult and inaccurate by using a dorsal
approach. In addition, the morbidity of dorsal plates such as extensor tendon com-
plications has been well documented (209–212). In 1937, Campbell (213–215)
published a technique in which the radius is osteotomized through a radial
approach. Now that newer plates designed specifically for the volar fixation of
dorsally unstable distal radius fractures by incorporating buttress pins and
screws that lock to the plate are available, the idea to correct dorsally tilted mal-
union through a volar or a radial approach has become more popular (216–220).
However, there are many facts which may influence the approach to the distal
radius for corrective osteotomy.
For corrective osteotomy of a dorsal malunion of the distal radius following
volar plate fixation, the radius can easily be approached using the prior incision. If
the distal fragment of the radius following dorsal plating is displaced in the direction
opposite to the plate or if the fracture is overcorrected a second approach on the
volar aspect of the radius may be needed. In the rare situation where an additional
procedure on the carpal ligaments or on the ulnar side of the wrist is required sim-
ultaneously with the radial corrective osteotomy, the radius should be approached
dorsally. Corrective osteotomy should include correction of malrotation of the
radius along with correction of angular deformities and radial shortening. Correct
rotational alignment of the distal radius with respect to the radial diaphysis can
easily be achieved by application of a buttress plate on the volar aspect of the
radius. In patients with a soft-tissue problem associated with distal radius malunion,
such as extensor pollicis longus or flexor pollicis longus rupture, the soft-tissue
problem may influence the choice of the approach to the radius (Fig. 12).
The osteotomy can be performed either at the prior fracture site or at a
different site. In many cases, it is technically easier to perform the osteotomy
proximal to the original fracture site. However, this can result in a severe hump-
back deformity of the distal radius and/or a dislocation of the DRUJ. The hump-
back deformity with the long axis of the carpus volar to the long axis of the radius
may disturb force transmission and can lead to a refracture after hardware
removal. Such problems can be avoided by locating the osteotomy as close to
the original fracture site as possible and by exact preoperative planning of the
center of rotation. The center of rotation can lie in, on, or outside the margins
of the radial cortex (221). When a limited lengthening is needed, the center of
rotation lies on the bone margins, and an incomplete opening-wedge osteotomy
172 Prommersberger and Pillukat
Figure 12 (Continued on next page) Dorsally tilted malunion of the distal radius follow-
ing volar plating associated with rupture of the flexor pollicis longus tendon. (A and B)
Dorsal malunion of the distal radius following volar plating of a dorsally displaced fracture
with a nonlocking device. (C and D) Intraoperative views showing the rupture of the flexor
pollicis longus tendon and the loose distal screws. (E) Intraoperative view showing the
reconstruction of the flexor pollicis longus tendon and the reconstruction of the distal
radius with osteotomy, bone grafting, and volar fixed-angle plate fixation. (F and G)
Radiographs, after corrective osteotomy. Notice the large cortical iliac bone graft. (H
and I) Radiological appearance of the wrist four months after corrective surgery
showing the radius healed with an acceptable reduction and restoration of the length.
Distal Radius Fractures 173
is enough. This situation is encountered in many volar malunions. When the
radius needs to be largely lengthened, the center of rotation is away from the
bone and a complete osteotomy is required. This situation is rarely given in
volarly angulated malunion but in most dorsal malunion.
It is important to restore the anatomic relationship between the distal radius
and the distal ulna. Radial shortening up to 12 mm can be corrected with a radial
osteotomy alone. If radial lengthening is complicated by soft-tissue contracture,
complete tenotomy or z-lengthening of the brachioradialis tendon may be helpful
(222). Although callotaxis is an useful technique to achieve satisfactory radial
length for young patients with growth arrest, combined radius–ulna osteotomy
can be recommended for elderly people (223,224).
Figure 12 (Continued from previous page)
174 Prommersberger and Pillukat
Mostly, the defect created by the open-wedge osteotomy is filled with
corticocancellous or with cancellous bone graft harvested from the iliac crest.
Some investigators have reported about the use of bone substitute (225,226).
Hemicallotaxis is also described for correction of the radial deformity (227). In
most volarly angulated malunions in the sagittal plane, the graft will form a
triangular shape with its apex placed dorsally. For dorsally tilted malunions, a
double trapezoidal-shaped graft is needed to fill the gap. In 1988, Watson and
Castle (228) picked by a technique described by Durman in 1935 (229) cutting
the graft longitudinally from the distal end of the proximal fragment of the
radius. Campbell (213) harvested the graft from the distal ulna. Whatever is
used to fill the osteotomy gap, the large cancellous bone surface of the osteotomy
of the distal radius guarantees a fast integration of the bone graft, respectively, the
bone substitution and a fast consolidation (230).
Every technique used for fixation of the distal radius in acute radius
fractures, such as pinning and plating, can also be used to stabilize the distal
radius in corrective osteotomy. However, decision-making how to fix the
radius should take into account the quality of the bone graft and the interval
between the injury and the corrective osteotomy. To avoid implant failure, the
used plate should be strong, especially in a longstanding malunion and if the
bone graft is very tiny. Another option for stabilization of the site of the correc-
tive osteotomy is an external fixator with pins placed in the distal fragment (227).
This allows postoperative adjustment should the restoration of length or
alignment prove to be inadequate.
More than 100 papers on radial corrective osteotomy were published over
the last three decades. All of them show that corrective osteotomy improves wrist
and forearm motion as well as grip strength and diminishes pain. In a study pub-
lished in 2002, we were able to show that patients with no or only a minor residual
deformity after corrective osteotomy had significantly better results than those
with a gross residual deformity (231).
Recently, we published a study on corrective osteotomy for intra-articular
malunion of the distal part of the radius (232). We found that intra-articular
osteotomy can be performed with acceptable safety and efficacy. The results of
intra-articular corrective osteotomy are comparable with those of osteotomy
for the treatment of extraarticular malunion. However, the indication is limited
by both chronology and the type of injury. It is preferable to reserve such a pro-
cedure for those malunited fractures that have a relative simple intraarticular
component. CT scans are absolutely necessary to plan the surgical procedure.
Tendon Injury
Tendon injury associated with fractures of the distal radius is uncommon.
However, an unique complication that can occur in extraarticular distal radius
fractures is spontaneous rupture of the EPL tendon. This more commonly
occurs within four to eight weeks of the fracture (233–235).
Distal Radius Fractures 175
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Distal Radius Fractures 187
Index
Amputation
index fingertip, 14
thumb, 17
AO Classification. See Comprehensive
Classification of Fractures
(AO/ASIF Classification)
Arcs, 99
Articular injuries, 10, 12
ASIF Classification. See Comprehensive
Classification of Fractures
(AO/ASIF Classification)
Avascular necrosis
carpal dislocations, 111–112
Avulsion fractures, 49–51
open reduction, 52
radial collateral
small finger, 53
Avulsion injuries
digitorum tendon, 5–6
flexor digitorum profundus
tendon, 4–5
terminal extensor tendon
distal and fingertip
injuries, 5–6
Bone grafting
internal fixation
scaphoid fractures, 132–135
Bony mallet
percutaneous fixation, 11
Carpal
crowded sign, 98
height ratio, 99, 100
Carpal dislocations, 91–114
avascular necrosis, 111–112
classification, 93–96
clinical diagnosis, 96
closed reduction
and cast immobilization,
103–104
manipulation, 102–103
and percutaneous pinning, 104
complications, 111–112
Cooney’s classification, 96
diagnosis, 96–102
epidemiology, 92–93
Green and O’Brien’s
classification, 94
open reduction and internal fixation,
104–107
prognosis, 108–110
radiographic diagnosis, 97–98
treatment, 102–105
Carpal injuries
distal radius fractures, 164
Carpal-metacarpal fracture dislocations,
78–80
Cast immobilization
carpal dislocations, 103–104
Circular saw injury, 15
189
Classification
AO/ASIF, 138
Cooney’s, 96
Fernandez, 138–139
Green and O’Brien’s, 94
Herbert’s
scaphoid fractures, 118, 120
Closed reduction
carpal dislocations, 102–103,
103–104, 104
distal radius fractures, 151–152
internal fixation, 26
metacarpophalangeal joint, 43–44
and percutaneous K-wire fixation
distal radius fractures, 152–153
Comminuted and displaced proximal
phalanx fractures
middle finger, 31
Comminuted depressed fractures
phalangeal base of ring finger, 54
Comminuted fractures
fifth metacarpal, 80
index metacarpal head, 51
Comprehensive Classification of
Fractures (AO/ASIF
Classification), 138
Compression fractures, 52–54
Condylar fractures
PIP joint, 56–57
Cooney’s classification
carpal dislocations, 96
Cross-finger flaps, 14–16
Crowded carpal sign, 98
Crush injury
multiple proximal phalanx
fractures, 35–36
Cuticle, 3
Diaphyseal middle phalanx fractures
ring finger, 29
Digitorum tendon avulsion, 5–6
DIP. See Distal interphalangeal (DIP) joint
Discriminatory sensation, 3
Dislocations. See also Carpal dislocations
carpal-metacarpal fracture, 78–80
lunate
complete, 101
[Dislocations]
metacarpophalangeal joint, 42
MP joints, 41–74
multiple carpal-metacarpal, 78
PIP joint, 41–74, 58–59
Displaced and unstable diaphyseal
fractures
middle finger, 35
Displaced fractures
distal radius, 150–163
fifth metacarpal, 82
long metacarpal, 83
middle finger, 31, 38
proximal phalanx shaft, 22
Distal and fingertip injuries, 1–20
anatomy, 2–3
distal phalanx fractures
base, 4–5
incidence, 1
terminal extensor tendon avulsion
(mallet) injuries, 5–6
Distal interphalangeal (DIP)
joint, 4, 5, 6, 9, 10, 11, 13
Distal phalanx fractures, 4–5
distal and fingertip injuries
base, 4–5
tuft and shaft fractures, 4–5
unstable, 5
Distal radioulnar joint fractures, 140
Distal radius fractures, 137
associated injuries, 163–167
biomechanics, 144–146
classification, 138–140
closed reduction, 151–152
and percutaneous K-wire fixation,
152–153
combined dorsal and volar exposure
and fixation, 157
complications, 168–175
displaced, 150–163
distraction plating, 157–158
DRUJ injuries, 164–167
epidemiology, 137–138
external fixation, 153–158
dorsal approach, 155–156
radial styloid approach, 156–157
volar approach, 156
190 Index
[Distal radius fractures]
functional and radiographic anatomy,
140–144
implants for internal fixation,
158–163
malunion, 170–175
nondisplaced
treatment, 150
nonunion, 168–170
open reduction and internal fixation,
145–146, 157
tendon injuries, 175
treatment, 146–150
Distraction plating
distal radius fractures, 157–158
Extensor pollicis longus (EPL), 140
Extensor tendons, 3
External fixation
distal radius fractures, 153–158
dorsal approach, 155–156
radial styloid approach, 156–157
volar approach, 156
FDP. See Flexor digitorum profundus
(FDP) tendon
Fernandez classification, 138–139
Fifth metacarpal
comminuted fractures, 80
displaced fractures, 82
Fight-bite injuries, 46
Finger
index
metacarpal fractures, 46
long
metacarpal, 98
metacarpal head fractures, 47
middle
comminuted and displaced proximal
phalanx fracture, 31
displaced and unstable diaphyseal
fractures, 35
displaced proximal phalanx shaft
fractures, 22
displaced transverse fractures, 38
proximal phalanx base
fracture, 26–28
[Finger]
ring
displaced proximal phalanx shaft
fractures, 22
phalangeal base
comminuted depressed fracture, 54
small
oblique displaced proximal phalanx
fractures, 33–34
radial collateral avulsion
fractures, 53
Fingertip. See also Distal and fingertip
injuries
sensation, 3
Fixation. See also External fixation
internal
closed reduction, 26
distal radius fractures, 158–163
open reduction, 104–107,
145–146, 157
percutaneous
bony mallet, 11
percutaneous K-wire
closed reduction, 152–153
Flaps
cross-finger, 14–16
homodigital island, 13, 16
moberg, 16–17
thenar, 13–14
Flexor digitorum profundus (FDP)
tendon, 7, 9
avulsion injuries, 4–5
Flexor tendons, 3
Fracture dislocations, 91–114
transscaphoid perilunate, 102, 106,
107, 109, 110
two-part carpal-metacarpal, 79
Fractures. See also Fractures under
distal radius; metacarpal;
phalanx; scaphoid
avulsion, 49–51
comminuted
fifth metacarpal, 80
index metacarpal head, 51
comminuted and displaced proximal
phalanx
middle finger, 31
Index 191
[Fractures]
comminuted depressed
phalangeal base of ring finger, 54
compression, 52–54
condylar
PIP joint, 56–57
diaphyseal middle finger, 35
diaphyseal middle phalanx
ring finger, 29
displaced middle and ring fingers
proximal phalanx shaft, 22
displaced transverse
long metacarpal, 83
middle finger, 38
distal phalanx, 4–5
distal and fingertip injuries, 4–5
distal radioulnar joint, 140
mallet, 9–10
metacarpal, 45–50
index finger, 46
operative management, 75–90,
76–77, 77–78
extraarticular base, 76–77
intra-articular base, 77–78
metacarpal head, 86–87
metacarpal neck, 85
metacarpal shaft, 81–85
MP joints, 41–74
nondisplaced distal radius
treatment, 150
oblique displaced proximal phalanx
small finger, 33–34
osteochondral transverse
metacarpal head of long
finger, 47
PIP joint, 41–74
proximal phalanx, 37
displacement pattern, 23
radial collateral avulsion
small finger, 53
screws, 32
spiral
metacarpals, 84
tuft and shaft
distal phalanx fractures, 4–5
vertical
metacarpal head, 48
[Fractures]
volar coronal, 51
metacarpal head, 49
wounds, 10–11
Free toe pulp transfer, 17–18
Greater arc injury
patterns, 95
Green and O’Brien’s classification
carpal dislocations, 94
Hand-based functional splints
proximal phalanx fractures, 24
Hematoma
subungual, 4
Herbert’s classification
scaphoid fractures, 118, 120
Homodigital island flaps, 13, 16
Implants
internal fixation
distal radius fractures, 158–163
Index finger
metacarpal fractures, 46
Index fingertip amputation, 14
Index metacarpal head
comminuted fracture, 51
Internal fixation
bone grafting
scaphoid fractures, 132–135
closed reduction, 26
implants
distal radius fractures, 158–163
open reduction
carpal dislocations, 104–107
distal radius fractures,
145–146, 157
Lag screws
metacarpal head
oblique fracture, 46
vertical fracture, 48
Lister’s tubercle, 142
Long finger
metacarpal, 47, 98
Long metacarpal
displaced transverse fractures, 83
192 Index
Lunate dislocations
complete, 101
Lunula, 2–3
Mallet fractures, 9–10
Mallet injuries
distal and fingertip injuries, 5–6
Malunion
distal radius fractures, 170–175
Median neuropathy
carpal dislocations, 111
Meissner’s corpuscles, 3
Metacarpal
fractures, 45–50, 85, 86–87
comminuted, 80
index, 51
displaced, 82
displaced transverse, 83
index finger, 46
long finger, 47
operative management, 75–90
extra-articular base, 76–77
intra-articular base, 77–78
shaft, 81–85
vertical, 48
long finger, 98
Metacarpophalangeal (MP) joints, 13
articular incongruity, 55
closed reduction, 43–44
dislocations, 41–74, 42
dorsal approach, 44
fractures, 41–74
hyperextension, 42
imaging, 43
pathoanatomy, 42–43
postoperative management, 44
surgical anatomy, 41–42
surgical management, 44
volar approach, 44
Middle finger
comminuted and displaced proximal
phalanx fracture, 31
displaced and unstable diaphyseal
fractures, 35
displaced proximal phalanx shaft
fractures, 22
displaced transverse fractures, 38
[Middle finger]
proximal phalanx base fracture, 27
proximal phalanx fracture with
comminution, 26
Middle phalanx
basal fractures, 57–58
volar fractures, 69
Moberg flap, 16–17
MP. See Metacarpophalangeal
(MP) joints
Multiple carpal-metacarpal
dislocations, 78
Nail
distal groove, 2
folds, 2
plate, 2
Nerve injuries
distal radius fractures, 163–164
Nondisplaced distal radius fractures
treatment, 150
Oblique displaced proximal phalanx
fractures
small finger, 33–34
Oblique fractures
metacarpal head of index finger, 46
Open fractures
distal radius fractures, 163
Open reduction
avulsion fractures, 52
and internal fixation
carpal dislocations, 104–107
distal radius fractures,
145–146, 157
internal fixation with bone grafting
scaphoid fractures, 132–133,
132–135
Osteochondral transverse fractures
metacarpal head of long finger, 47
Percutaneous fixation
bony mallet, 11
Percutaneous K-wire fixation
closed reduction
distal radius fractures, 152–153
Percutaneous pinning
carpal dislocations, 104
Index 193
Percutaneous screw fixation using
image intensifier
scaphoid fractures, 122–124
dorsal approach, 125–126
implants, 126–127
postoperative, 127–132
Phalanx. See also Proximal phalanx
middle
basal fractures, 57–58
fractures, 29
volar fractures, 69
ring finger
comminuted depressed
fracture, 54
shaft fractures, 21–40
evaluation, 21–22
irreducible, 30–31
vs. metacarpal injuries, 23
proximal, 22
reducible and stable injuries, 24
reducible and unstable injuries,
25–26
Pinning
percutaneous
carpal dislocations, 104
Proximal interphalangeal (PIP)
joint, 5
clinical assessment, 61
condylar fractures, 56–57
classification, 56–57
conservative treatment, 62
open reduction, 63–65
percutaneous techniques, 62–63
dislocations, 58–59
conservative treatment, 66
and fractures, 41–74
management, 65–66
open reduction and fixation,
67–70
percutaneous techniques, 66–67
dorsal dislocations, 58–59
dorsal fracture dislocation, 70
fracture dislocation
distractor-external fixator, 68
imaging, 61–62
lateral dislocations, 59–60
salvage, 70–71
[Proximal interphalangeal (PIP) joint]
surgical anatomy, 55–56
volar dislocation, 60–61
Proximal phalanx
basal fractures, 49–50
cross-section, 23
displaced shaft fractures
middle and ring fingers, 22
fractures, 37
oblique fracture, 28
shaft fractures
displacement pattern, 23
volar approach, 53
Pseudoarthrosis
nonunion, 122
Radial collateral avulsion
fractures
small finger, 53
Radius. See Distal radius fractures
Reduction. See also Closed reduction;
open reduction
closed manipulation
carpal dislocations, 102–103
Reflex sympathetic dystrophy (RSD)
distal radius fractures, 168
Rete arteriosum, 3
Reverse Mayfield progression, 94
Ring finger
displaced proximal phalanx shaft
fractures, 22
phalangeal base
comminuted depressed
fracture, 54
Ring sign
scaphoid, 99
signet, 101
Roller/crush injury
multiple proximal phalanx fractures,
35–36
RSD. See Reflex sympathetic dystrophy
(RSD)
Scaphoid fractures, 115–136
diagnosis, 116–118
Herbert’s classification, 118, 120
mechanism and epidemiology, 116
194 Index
[Scaphoid fractures]
open reduction and internal fixation
with bone grafting, 132–135
operative, 132–133
pitfalls, 134
postoperative, 133
preoperative, 132
percutaneous screw fixation
using image intensifier,
122–124
dorsal approach, 125–126
implants, 126–127
postoperative, 127–132
screws, 128
volar approach, 122–125
treatment, 119–122
Scaphoid ring sign, 99
Screws, 128
fractures, 32
lag, 46, 48
Sensation
discriminatory, 3
Sidewinder method, 30
Sigmoid notch, 142
Sign
crowded carpal, 98
scaphoid ring, 99
signet ring, 101
spilled teacup, 101
Terry Thomas, 99
Signet ring sign, 101
Small finger
oblique displaced proximal phalanx
fractures, 33–34
radial collateral avulsion
fractures, 53
Soft-tissue coverage, 13–15
Spilled teacup sign, 101
Spiral fractures
metacarpals, 84
Splints
hand-based functional
proximal phalanx
fractures, 24
Tendons
digitorum, 5–6
extensor, 3
flexor, 3
flexor digitorum profundus, 4–5
injuries, 175
terminal extensor, 5–6
Terminal extensor tendon avulsion
(mallet) injuries
distal and fingertip injuries, 5–6
Terry Thomas sign, 99
TFCC. See Triangular fibrocartilage
complex (TFCC)
Thenar flaps, 13–14
Thumb
partial amputation, 17
Transosseous wiring, 30
Transscaphoid perilunate fracture
dislocations, 102, 106, 107,
109, 110
Transverse arcus venosus, 3
Triangular fibrocartilage complex
(TFCC), 142
Tuft and shaft fractures
distal phalanx fractures, 4–5
Two-part carpal-metacarpal fracture
dislocations, 79
Two-point testing, 3
Unstable middle finger proximal phalanx
fracture with comminution, 26
Vertical fractures
metacarpal head
lag screws, 48
Volar coronal fractures, 51
metacarpal head, 49
Volar zigzag approach
volar coronal fractures, 49
Wounds
fractures, 10–11
Wrist
long finger metacarpal, 98
Index 195