Green Et Al - Acute ORIF of PIP Fracture Dislocation_JHS 1992

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Acute open reduction and rigid internal fixationof p roximal in terphalangeal jointfracture dislocationWe report the application and results of a technique of open reduction and rigid internal fixationof dorsal fracture/dislocation of the proximal interphalangeal joint with an interfragmentaryscrew in two cases. Articular congruity was restored, and the proximal interphalangeal jointwas stabilized. This technique permitted immediate range-of-motion exercises. Excellent resultswere obtained in both cases. Previous descriptions have not detailed the indications, the surgicalapproach, or the results of this technique. (J HAND SURC 1992;17A:512-7.)

Andrew Green, MD, Jennifer Smith, OTR/L, CHT, Maureen Redding, RPT, CHT, andEdward Akelman, MD, Providence, R.I.

From the Department of Orthopaedics and the Division of Hand,Upper Extremity and Microvascular Surgery, Rhode Island Hos-pital/Brown University, Providence, R.I.

Received for publication Oct. 23, 1990; accepted in revised formAug. 23, 1991.

No benefits in any form have been received or will be received froma commercial party related directly or indirectly to the subject ofthis article.

Reprint requests: Andrew Green. MD, Department of Orthopaedics,Rhode Island Hospital, 593 Eddy St., Providence. RI 02903.

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D rsal fracture/dislocation of the prox-imal interphalangeal (PIP) joint is a relatively commonand potentially disabling injury of the finger. Secondaryjoint stiffness, persisting subluxation, degenerative ar-thritis. and pain are common sequelae. There aremany descriptions of closed treatment,4-7 and some au-thors support open treatment in appropriate cases. , 3. 8However. there are only a few reports of the results ofopen treatment.. 9-3In most, the final result representsa significant reduction in PIP joint range of motion.

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

512 THE JOURNAL OF HAND SURGERY


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Vol. 17A. No. 3May 1992 Pro.wimtrl interphalangeal joint fracture dislocation 513

suecessful treatn nent is predicated on achieving accuratered uction, preve nting chronic instability, and preserv-ing pain-free rar ige of motion.F revious repot .ts have described open reduction and

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

internal fixation (ORIF) with Kirschner (K-j wiresinterosseous wiring or fragment excision and palplate arthroplasty. Recent refinements of the AOiAinstrumentation have permitted the wide-range aI

andSIF)pli-


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514 Green et al.The Journal of

HAND SURGERY

Fig. 3. Case 2. Position after closed manipulation of PIP joint; palmar base fragment isrotated.

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

Fig. 5. Palmar base fragment fixed with A0 minifragment screw. The palmar plate is split lon-gitudinally.


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cation of the principles of anatomic rigid internal fix-ation 1o fractures in the hand.14. I5 Although the use ofminift .agment screws for dorsal PIP joint fracture/dis-locaticIns is suggested,. l5 we were unable to find areport in the literature that described a surgical approachor restults.

We have used ORIF in the treatment of two patientswho r ustained dorsal fracture/dislocation of the PIP

Fig. 6. Case 1. X-ray follow-up at 12 months. A, Lateral view. B, Anteroposterior view

joint. In both cases an anterior apprcperform articular reduction, and fixatwith minifragment cortical screws.Case reports

Case 1. A 16-year-old right-handedplayer jammed his right long finger durinPIP joint fracture dislocation was redu

oath wa s used toion was achieved

all-state basketballg a game :. A dorsalted by I is coach.


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516 Green et al.The Journal of

HAND SURGERY

The palmar plate was not detached. Anatomic reductionof the fragment was held with a small K-wire. Next a1.5 mm screw hole was drilled and tapped, and a 2mm minifragment cortical screw was placed throughthe palmar fragment and into the middle phalanx (Fig.5). A lag technique was not required to achieve fixation.The longitudinal palmar plate incision was closed withabsorbable suture, and the flexor tendon sheath wasclosed with 6-O nylon suture.

Hand therapy. In both cases progressive active andpassive range of motion were begun on the first post-operative day. Intrinsic plus palmar splinting was used.The first patient was splinted in full extension for 5weeks, and the second was splinted with a 15-degree

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

X-ray films demonstrated dorsal subluxation and a large ro-tated anterior articular fragment (Fig. 1, A). Splinting reducedthe subluxation, but the joint surface remained incongruous(Fig. 1, B). ORIF was performed on day 5 to stabilize thejoint and correct the articular incongruity (Fig. 2).

Case 2. A 29-year-old right-handed woman fell at workand jammed her right long finger (Fig. 3). Closed reductionof a dorsal PIP joint fracture/dislocation was considered in-adequate because of dorsal subluxation and fragment rotation.ORIF was performed electively on day 8 to correct articularincongruity and stabilize the joint (Fig. 4).

Materials and methodsSurgical technique. A palmar zigzag skin incisionwas made with elevation of an ulna-based flap at thelevel of the flexor tendon sheath. The flexor tendonsheath was opened through a rectangular flap. Theflexor tendons were retracted to expose the palmar plateand the fracture site. In both cases the fracture fragmentwas avulsed from the base of the middle phalanx bythe palmar plate and its articular surface was rotated90 degrees into the fracture site. Longitudinal divisionof the palmar plate permitted exposure of the PIP jointand created a bare bony surface on the palmar fragment.

only palmar plate injury or small avulsion fractures ofthe palmar base of the middle phalanx. Less commonly,there is a more extensive fracture of the middle phalanx.In many cases, extension block splinting can be usedin treatment.

The anatomy of the palmar plate complex and theextent of injury are crucial determinants of treatmentselection for dorsal fracture/dislocations of the PIP

joint.8. II. Ih. 17 Fractures that involve more than about35% to 40% of the articular surface are associated withcomplete disruption of the collateral accessory ligamentcomplex. In these cases maintenance of reductionthrough closed techniques may not be possible.

Fractures with single anterior fragments can be ro-tated and be irreducible. ORIF has been advocated forsuch acute injuries with minimal comminution. Pre-vious reports have described K-wire or interosseouscerclage wire fixation through either a midlateral or apalmar approach, and most have recommended K-wirestabilization of the PIP joint., . 9-. Eaton andMalerich advocated palmar plate arthroplasty forcomminuted fractures with articular incongruity. Mostauthors recommended early surgery when indicated.

The majority of these injuries can be treated withclosed reduction, splinting, and early motion. In someinstances, however, this is not possible, and ORIF isrequired. Most reports have emphasized prevention of


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Vol. llA, No. 3May 1992 Proximal int erphalangeal joint fracture dislocation 517

persistent subluxation rather than correction of articularincongruity. The joint incongruity in our cases is prob-ably unique and, in our opinion, warranted open re-duction and internal fixation in these young and activepatients.

Although it is technically demanding, our method ofORIF has the significant advantage of achieving rigidanatomic fixation of the fracture and repair of the palmarplate complex. This stabilizes the joint, obviates theneed for transarticular fixation, and permits almost im-mediate range-of-motion exercises. In addition, avoid-ing the collateral ligaments with the palmar approachmay contribute to improved range of motion. Use of alag technique for minifragment screw fixation can betechnically difficult and may not be required for fixationof metaphyseal bone fragments.

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Green Et Al - Acute ORIF of PIP Fracture Dislocation_JHS 1992

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