Results of Osteotomy, Open Reduction, and Internal Fixation for Late-Presenting Malunited...

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Results of Osteotomy, OpenReduction, and Internal Fixation

for Late-Presenting MalunitedIntra-articular Fractures of the

Base of the Middle Phalanx

Francisco del Piñal, MD, Francisco J. García-Bernal, MD,Julio Delgado, MD, Marcos Sanmartín, MD, Javier Regalado, MD,

Santander, Spain

Purpose: To present our results in the treatment of late-presenting impaction fractures of the baseof the middle phalanx treated by osteotomy with full exposure of the articular surface to restore thenormal anatomy.Methods: Eleven patients with a malunited (impacted) fracture of the base of the middle phalanx weretreated by osteotomy more than 5 weeks after the injury. All fractures had varying degrees of impaction,comminution, and dorsal subluxation. The malunited joint surface was visualized by dislocating thejoint by hyperextension (shotgun approach). The restoration of the cup-shape contour of the middlephalangeal base was accomplished by osteotomy and mobilization of small osteochondral fragments.Rigid fixation was performed by cerclage wire, screws, or a combination of these. A distal radius bonegraft was placed beneath disimpacted fragments in 9 of the 11 procedures.Results: Ten of 11 patients were followed-up for more than than 1 year. One patient with a volar lateralimpaction fracture was lost to follow-up study 4 weeks after the surgery and was excluded from theresults. All patients except 1 achieved a functional range of motion of the proximal interphalangealjoint. Moderate limitations of the distal interphalangeal joint motion were common. Grip and thumb-affected finger tip pinch strengths were 95% and 90%, respectively, of the healthy side. The averagepain level (as rated on a visual analog scale of 0–10) improved from a preoperative score of 9.1 to apostoperative score of 0.8. One patient was somewhat dissatisfied; all other patients were satisfied orvery satisfied. All returned to their previous work at an average of 13 weeks after surgery.Conclusions: Favorable results have been achieved in this challenging scenario in the short- andmiddle-term in 9 of 10 patients. Previous surgery and moderate to severe wearing of the cartilageof the proximal phalanx head negatively affected the results. (J Hand Surg 2005;30A:1039.e1–1039.e14. Copyright © 2005 by the American Society for Surgery of the Hand.)Key words: Impaction fractures, malunion, PIP joint injuries, osteotomy.

rom the Instituto de Cirugía Plástica y de la Mano, Hospital Mutua Montañesa and Clínica Mompía, Santander, Spain.Received for publication November 16, 2004; accepted in revised form March 24, 2005.No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.Corresponding author: Dr. Francisco del Piñal, Dr Med, Calderón de la Barca 16-entlo, E- 39002-Santander, Spain; e-mail: [email protected] © 2005 by the American Society for Surgery of the Hand0363-5023/05/30A05-0001$30.00/0doi:10.1016/j.jhsa.2005.03.018

Note: To access the supplementary materials accompanying this article, visit the September 2005 online issue of Journal of Hand Surgery atwww.jhandsurg.org.

The Journal of Hand Surgery 1039.e1

http://www.jhandsurg.org

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1039.e2 The Journal of Hand Surgery / Vol. 30A No. 5 September 2005

ractures of phalanges often are neglected or areegarded as trivial injuries.1 When proper early treat-ent is not performed injuries to the proximal inter-

halangeal (PIP) joint may lead to prolonged disabil-ty, pain, and stiffness.2

Treatment for malunited fractures of the base ofhe middle phalanx varies from waiting until painrompts arthrodesis or joint replacement3 to someype of soft-tissue4 or osteochondral arthroplasty.5,6

iven the unpredictability of the results7–9 andts high technical complexity, case series aboutpen reduction and internal fixation (ORIF) areparse.2,7,8,10,11 In those articles the PIP joint usuallyas approached through the lateral side and the os-

eotomy was accomplished without exposure of therticular surface. In our experience this provides aimited and insufficient view of the deformity andreates difficulties in dealing with the depressed cen-ral fragments. To view the entire malunited base ofhe middle phalanx we propose the hyperextensionolar approach used by Eaton and Malerich4,12 toerform arthroplasties (the shotgun approach) com-ined with a thorough manipulation of the malunitedragments. This approach permits fixation withcrews and cerclage wire, allowing immediate mo-ion in most cases.

From July 1999 to July 2003 we treated 11 patientsith late-presenting impacted fractures of the base of

he middle phalanx by osteotomy to mobilize theealed displaced fragments and internal fixation. Weeport the subjective and objective outcomes of thisroup of patients after an average of 28 monthsminimum, 12 mo) of follow-up study. The descrip-ion of the surgical technique, indications of the typef internal fixation, and difficulties encountered areresented in detail.

aterials and Methodsatient Demographicsrom July 1999 to July 2003 we prospectively fol-

owed up 11 consecutive patients with malunitedmpacted fractures of the base of the middle phalanxreated by osteotomy, open reduction, and internalxation. All patients gave written consent to be in-luded in this study. The time from the traumaticvent to the surgery ranged from 5 to 22 weeksmean, 9 wk). Ten of the 11 patients had been on sickeave from their jobs since the injury. Patients’ agesnd affected fingers are presented in Table 1.

The mean age at surgery was 32 years (range,8 – 49 y). Seven patients were men, 10 were right-
anded, and 6 injuries occurred on the dominant T P e

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ide. Seven injuries were work related and wereovered under workers’ compensation. Two pa-ients (patients 2, 10) had a concomitant boneallet finger in the same digit. All were closed

racture-dislocations.In 9 cases the injury was overlooked by the initial

reating physician and treated as a sprain or a minorvulsion fracture. Two patients (patients 5, 7) hadrior surgery on the PIP joint elsewhere (Table 1).atient 5 had a failed attempt of ORIF with 2 screwsnd had developed severe pain. Patient 7 had beenreated by an extension block pinning13,14 2 monthsarlier but the joint redislocated immediately afteremoval of the K-wire (6 wk after the procedure).

Range of motion (ROM) of the PIP and DIP jointsas measured before surgery. Nine digits were kept

mmobilized for 1 to 2 weeks because they had beenisdiagnosed as sprains, and no specific exercises to

mprove ROM were recommended once the digitsere weaned from the splint. Degree of preoperativeain with motion of the PIP joint was determinedith a visual analog scale (VAS) (range: 0, no pain to0, unbearable pain) (Table 1). All patients had pre-perative posteroanterior (PA) and lateral radio-raphs taken.All fractures had varying degrees of impaction,

omminution, and dorsal subluxation. They werelassified according to Hastings and Carroll.15 Thereere 6 predominantly volar compression fracture-islocations and 5 volar-lateral compression frac-ure–dislocations. The degree of subluxation, per-entage of articular compromise (according to theethod of Hamer and Quinton16 [Appendix A; this

upplementary material can be viewed at the Jour-al’s Web site, www.jhandsurg.org]), and size of thetep-off were measured on PA and lateral views aseported in Table 1. (Measurements were taken withVernier caliper and rounded to the nearest 0.5 mm).omputed tomography was performed in all but 2atients to help delineate the fracture configurationnd plan the surgical approach (Fig. 1).

All surgeries were performed by the senior au-hor (F.P.) under the same protocol. Intraoperativehotographic records were taken from all jointurfaces before and after reduction. They weresed to assess the degree of comminution of theolar lip and of the joint surface and the degree ofear of the cartilage of the head of the proximalhalanx. The proportion of middle phalanx baseurface impacted also was calculated from thesehotographic records through a computer program
Volmed 2D; Informedia Designs, Leeds, UK). l
urgical Techniquehe surgery was performed with loupe magnification�3.5). A slightly modified Eaton and Malerich4,12

hotgun approach was used. Initially a V-shaped skinncision was made with the apex at the PIP jointexion crease and extending from the proximal to theistal digital crease. A flap with skin and subcutane-us tissue was raised to one side. Next a rectangularexor sheath flap spanning from the distal edge of the2 pulley to the proximal edge of the A4 pulley was

levated with its base opposite to that of the skin flap.he flexor tendons were retracted and the volar plateas released with a scalpel from the insertion of the

ccessory and proper collateral ligaments laterallynd from the proximal edge of the middle phalanxistally. A blade was introduced gently in the spaceetween the proximal phalanx condyles and the col-

igure 1. Sagittal computed axial tomography scan of the PIPoint of the small finger of a 31-year-old patient 2 months afterustaining a volar-lateral compression fracture (patient 6).

ateral ligament at both sides of the joint, and then by


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lightly twisting the blade the origin of the ligamentas released from the proximal phalanx. With trac-

ion on the middle phalanx and the tendons retractedo one side the joint was hyperextended gently untilhe base of the middle phalanx was exposed com-letely. Excessive force could damage the intact dor-al articular surface and should be avoided. At timesFreer elevator was introduced dorsally to the prox-

mal phalanx to release the dorsal capsule and anyendon adhesions that could block the reduction. Ino case did we need to resort to an independent

igure 2. (A) The joint has been dislocated by hyperextensionase before excision of granulating tissue and callus (arrows).efined. Note that the cartilage cover of the dorsal half of theen achieved by means of a screw (for a larger volar-ulnapplied to support the fragments.

orsal incision to release the capsule or the extensor

endon as recommended by Bilos et al.17 A full viewf the base of the middle phalanx always shouldrecede the next step.With fine rongeurs (1-mm bite) and small curettes

he fibrous tissue and new bone were removed untilll cartilage-containing fragments were delineatedFig. 2). The aim before beginning to mobilize theragments was to have all pieces delimited and readyo match. Some allowances should be made becauseeformation of the cartilage may have occurred as aonsequence of the original compressive forces.

un approach). (B) Corresponding view of the middle phalanxer debridement the cartilage-containing fragments have beenimal phalanx is partially worn out (arrows). (D) Fixation hasent) and a cerclage wire. Cancellous bone graft has been

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olarly. The articular fragments were separated withental picks, gently disimpacted, and elevated. Ide-lly in fragment mobilization we tried to preserveonnections to the neighbors but this was impossiblet times because of the severity of displacement; thusome of these small fragments, once repositioned,ehave as osteochondral grafts.Once the depressed fragments were reduced and

eveled the void underneath them was filled withancellous bone graft from the distal radius andacked tightly with a fine dental tamp. The decisiono use bone graft was made during surgery based onhe presence of subchondral voids and/or foreseeableenuous fixation. The volar fragment(s) was thenepositioned and this always involved elevation, de-otation, and dorsal displacement of the volar lip sohe concave base of the middle phalanx could beeshaped (see Discussion section).

The fixation technique varied according to theumber of fragments and the quality of the volar lipf the base of the proximal phalanx (Fig. 3). Ineneral terms our policy was as follows.

If there was a structurally intact volar marginalfragment, 1 or two 1.3- or 1.5-mm titanium lagscrews (Synthes, Paoli, PA) were applied. Thisvolar lip fragment then was used to hold the centralcomminuted fragments (Figs. 3A, B). Washerswere used when the volar fragment was thought tobe at risk for fragmentation.If there was not a structurally intact volar lipfragment then a modification of Weiss’s18 cerclagewire technique was used. The principle of thistechnique is to hold the fragments by encirclingwire around the base of the middle phalanx. Distalor proximal migration of the wire at the final turnof twisting is extremely frustrating. To overcomethis difficulty we recommend passing the encir-cling wire through a canal made with a 1-mmK-wire through the subchondral bone of the healthyplateau; this actually would be a hemicerclage. Ad-ditionally we have noticed with Weiss’s18 tech-nique that the small central fragments may extrudeduring the final tightening of the wire. To avoidthis the assistant pressed the fragments down withthe pulp of the finger or with the flat surface of aFreer elevator while the surgeon tightened the wire(Fig. 3C).If a volar fragment was large enough for screwfixation but not large enough to support all frag-
ments of the volar rim it was fixed with a screw w
and the rest of the volar rim was stabilized by acerclage or hemicerclage wire (Fig. 3D).

The joint then was reduced by combining tractionnd flexion. Fluoroscopy was used to check the re-uction. The collateral ligaments were not repaired.he flexor sheath was repaired and the skin waslosed.

When a strong volar buttress could not be restoredecause the fixation was not sturdy an extensionlock 1-mm K-wire was inserted in the head of theroximal phalanx.13,14

The postoperative regimen varied depending onhe stability achieved. When a good volar buttress

igure 3. The fixation techniques used are summarized inhis sketch where the base of the middle phalanx is viewedrom the proximal side. (A) Lag screws are used if the volarragment is intact structurally. (B) Even when there is severeomminution of the central area, if the volar fragment isturdy the use of lag screws is the preferred technique. (C)

eiss’s cerclage or hemicerclage wire technique is indicatedhen there is not a structurally intact volar lip fragment. (D)

f a volar fragment is large enough for screw fixation but notarge enough to retain all fragments of the volar rim it is fixedith a screw and the rest of the volar rim is stabilized by a

erclage or hemicerclage wire.

as obtained immediate protected ROM was started

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ith splints between exercises and buddy tapping forhe first 3 weeks. Extension was blocked at 30° byluminofoam splints or kissing splints.19,20 When a-wire was used to block dorsal subluxation the PIP

oint was immobilized for 3 weeks in approximately0° of flexion. The patient was advised to remove therotective splint several times a day and flexion andxtension of the PIP joint were encouraged; however,atients rarely moved much until after the K-wireas removed.After 4 or 5 weeks any flexion contracture was

reated with dynamic splinting (Capener splint;eRoyal, Powell, TN), foam-padded aluminum

plints at night, and in some resistant cases progres-ive casting. When flexion deficits were detectedhey were treated with static splinting 3 times a dayor 30 minutes.

ollow-Up Evaluationll patients were called to a final follow-up evalua-

ion at a minimum of 1 year (maximum, 5.2 y; mean,8 mo) after surgery. Additionally the time to returno work was recorded. This was decided based on aull objective evaluation and according to the indi-idual needs of each patient. Subjective final out-ome was evaluated with the Spanish validated ver-ion of the Disabilities of the Arm, Shoulder, andand (DASH) questionnaire.21 Patients also were

sked about the degree of pain through a VASrange: 0, no pain to 10, unbearable pain), theiregree of satisfaction (very satisfied, satisfied, nei-her satisfied nor unsatisfied, somewhat dissatisfied,issatisfied), and if they would repeat the surgerynd/or recommend it to others.

Active ROMs without joint isolation of the PIPnd DIP joints were measured using a goniometer.rip strength and thumb-affected finger tip pinch

trength were assessed and compared with the non-njured side with a dynamometer (Jamar, Padgettnstruments, Inc., Kansas City, KS) and a pinchauge (Padgett Instruments, Inc., Kansas City, KS),espectively. The presence of both coronal and sag-ttal instability and crepitus were assessed.

Standard PA and lateral x-ray views of all patientsere obtained. Any degree of dorsal subluxation,

esidual angular deformity, intra-articular step-off,resence of osteophytes, subchondral sclerosis, andigns of collapse were noted.

The scoring system devised by Ishida and Ikutalso was used to assess the final subjective and ob-
ective outcomes (Appendix B; this supplementary m
aterial can be viewed at the Journal’s Web site,ww.jhandsurg.org).

tatisticsonparametric statistical tests were performed tond an association between various factors and thenal outcome. The factors analyzed were age, timeetween trauma and surgery, previous treatment,umber of fragments impacted, damage to the artic-lar cartilage of the proximal phalanx, and PIP pre-perative total arc of motion. Final outcome mea-ures were PIP postoperative total arc of motion,ercentage of grip and pinch strength, DASH score,nd Ishida and Ikuta8 score. Spearman rank correla-ion, Mann-Whitney, and Kruskal-Wallis tests weresed as appropriate. Significant associations wereefined when the p value was less than .05. We alsoonsidered marginal associations when the p valueanged from .05 to .10.

esultshe intraoperative findings and treatments used areresented in Table 2. The average impacted surfaces calculated with a computerized program measured1% � 11% of the total surface. Seven patients hador more impacted fragments that needed reduction.Patient 4 was lost to follow-up study 4 weeks after

he surgery and is excluded from the results section.he clinical and radiologic results of 2 patients arehown in Figure 4. (Videos can be viewed at theournal’s Web site, www.jhandsurg.org). Detailedesults for each patient are reported in Table 3.

The average total arc of active ROM for the in-ured PIP joint was 77° (range, 20°–113°) with anverage flexion contracture of 14° (range, 3°–70°).he average total arc of motion of the DIP joint was5° (range, 0°–85°) with an average flexion contrac-ure of 2° (range, 0°–20°). When the failed surgerypatient 5) was excluded the arcs of motion improvedo 84° and 63° at the PIP and DIP joints, respectively.

Grip and thumb-affected finger tip pinch strengthveraged, respectively, 95% (range, 85%–104%) and0% (range, 80%–110%) of the healthy side. Whenhe dominant side was affected (6 patients) the aver-ge grip and pinch strengths were, respectively, 97%range, 89%–104%) and 95% (range, 80%–110%) ofhe nondominant side. When the nondominant sideas affected the average grip and pinch strengthsere, respectively, 92% (range, 85%–98%) and 84%

range, 80%–94%) compared with the dominant side.Pain level as measured by VAS decreased from a
ean score of 9.1 (range, 7–10) before surgery to 0.8


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range, 0–4) after surgery. All patients returned toheir previous levels of activity and would recom-end the surgery to others (including patient 5, the

ailed surgery, because it had provided pain allevia-ion). All workers (n � 9) returned to work at anverage of 13 weeks (range, 6–24 wk) after surgery.bjective analysis proved all joints to be stable tootion with no crepitus. The average DASH scoreas 7.6 (range, 0.7–47.1; median, 3.7). The average

shida and Ikuta score was 73.1 (range, 1–100; me-ian, 80). Both systems correlated well with eachther (r � –0.67, p � .034).Final follow-up radiographs showed no signs of

orsal subluxation, intra-articular step-off, osteo-hytes, subchondral sclerosis, or collapse in all but 1atient (patient 5). Slight joint narrowing and mildnlargement of the joint on the lateral view wereresent in most patients.Complications such as loss of fixation or infection

ave not been found. Patient 7 had a 10° ulnarngulation. This was caused by an inaccurate reduc-ion of the ulnar plateau that was underestimateduring the procedure. The deformity was suspectedight after the first dressing change and did notrogress afterward. Patient 11 presented with a 6°ngular deformity but the deformity was bilateral. Nother case of malalignment was noted. Althoughnatomic reduction has been achieved patient 5 hadhe worst functional result. This patient failed toollow postoperative instructions and missed some ofhe follow-up visits but he also had the worst damageo the articular surface of the head of the proximalhalanx. Gradually he lost motion and at the finalostoperative visit there was little appreciable motionTable 3). Radiographs showed signs of collapse andrthritis. No patient required removal of the internalardware. No additional surgery has been performedr is planned at this stage.A marginal negative correlation was observed be-

ween age and final PIP arc of motion (p � .057).atients with previous surgical treatment fared worse

n PIP arc of motion (p � .07), DASH score (p �06), and Ishida and Ikuta8 score (p � .03). Patientsith minor wear of the proximal phalanx head car-

ilage (Table 2) (PIP arc, 88°; DASH score, 3; Ishidand Ikuta8 score, 74) showed similar results com-ared with those without any proximal phalanx car-ilage involvement (Table 2) (mean PIP arc, 87°;ean DASH score, 3; Ishida and Ikuta8 score, 87).reater degrees of wear of the proximal phalanxead cartilage (Table 2) negatively affected the re-

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f proximal phalanx cartilage head the PIP arc ofotion (mean, 38°), DASH score (mean, 26), and

shida and Ikuta8 score (mean, 38) were worse com-ared with patients without articular cartilage in-olvement. The linear correlation coefficient (Spear-an test) was calculated for PIP arc of motion (r �

.43, p � .21), DASH score (r � –0.48, p � .16),nd Ishida and Ikuta8 score (r � –0.65, p � .04)mong these variables for proximal phalanx headartilage status. Grip and pinch strengths were de-reased in patients who started immediate nonpro-ected postoperative motion (p � .03 and p � .09,espectively). These differences persisted even whenroups were separated according to dominance. Nother significant or marginal associations were seenn the remaining factors that were analyzed.

iscussioneconstruction of malunited-impacted fractures of

he middle phalanx is challenging. To deal with thisifficult problem there are several options, from ar-hrodesis3 to joint transfer.22

The volar plate arthroplasty by Eaton and

igure 4. Patient 6. (A) Posteroanterior and (B) lateral x-ray fiame as the patient shown in Figs. 1 and 2.) (Video can be

alerich4,12 is a common technique for treating dor- t

al PIP joint fracture-dislocations. In a long-termeview Dionysian and Eaton23 reported a remarkable1° of active ROM in 9 patients treated 4 or moreeeks after the injury at an average follow-up periodf 11 years. Other researchers could not reproduceimilar results,8,24 particularly when the extent ofomminution was excessive. Hastings and Carroll15

eported 4 failures out of 5 patients treated after 3eeks because of recurrent dislocation, pain, or an-ylosis.Distraction arthroplasty has been recommended

ven in the chronic setting.25,26 Good functional re-ults even in the setting of persistent dorsal sublux-tion and major step-offs are reported, with an im-rovement in active ROM from 13° to 88°.25 Thisonanatomic reconstruction27–32 conflicts with theiews of other researchers,16,33–35 who argue that theccuracy of anatomic reduction is the most importantactor to achieve a good result and that late remod-ling does not occur.34,35 In late-presenting casesizuseki et al36 concluded that distraction arthro-

lasty was not beneficial if joint incongruity existed.Recently hemihamate osteochondral autograft ar-

nd (C, D) ROM 2 years after the surgery. (This patient is theat the Journal’s Web site, www.jhandsurg.org.)

lms a

hroplasty was introduced as an alternative to volar


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late arthroplasty. Williams et al5 reported the resultsf a series of 13 patients who suffered major impac-ion of the base of the middle phalanx who hadeconstruction with Hastings’s technique. At an av-rage follow-up time of 17 months they achieved anctive ROM of 85° at the PIP joint. Most patientsere treated in the acute period but 4 were in the

hronic stage (�3 wk). Unfortunately the results ofilliams et al5 are difficult to compare because itas not specified whether they were acute or chronic.Open reduction with osteotomy and K-wire inter-

al fixation with or without bone graft has beeneported scarcely in the literature.2,7,8,10,11 Wilsonnd Rowland2 reported 12 of 15 cases treated bypen reduction and osteotomy more than 3 weeksfter the injury. After the collateral ligament wasivided the joint was reduced and maintained in 30°f flexion with a transarticular K-wire. Then thesteotomy of the volar fragment was performed andhe volar fragment was reduced. They emphasizedhe importance of restoring the volar buttress bysteotomy and elevation of the volar lip but theyound that elevation of central depressed fragmentsechnically was not feasible in chronic cases. McCuet al10 reported 21 fracture-dislocations in the athleticopulation but it is not clear how many were oldnjuries. They released the volar plate after dividinghe pulleys to retract the flexor tendons but also used

lateral approach. They did not use bone graft toupport the volar lip as advocated by Wilson andowland.2 Radiographic results were not reported.Zemel et al11 reported reconstruction with reduc-

ion and osteotomy through a lateral approach in 14atients with malunited fractures of the base of theIP joint. They reported an increase in the PIP activeexion from 30° to 68°. Similar to Wilson and Row-

and2 they performed the osteotomy and elevation ofepressed fragments after reduction of the middlehalanx and transfixion of the joint in 30° with a-wire. In our view this creates technical difficulties

nd greatly impairs the accuracy of the reduction.Wolfe and Katz7 reported 2 late-presenting cases

ith fracture of the base of the middle phalanx. Theydvocated the shotgun approach for volar base frac-ures but it is not clear whether they used it in thehronic cases. One patient achieved a PIP motionrom 17° extension lag to 95° of flexion. The otheratient had surgery at 10 weeks after the injury buthey found that the joint was not reconstructable;ence, they proceeded to perform a volar plate ar-hroplasty. They concluded that late treatment uni-

formly is less successful at restoring motion. IshidaT P *

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nd Ikuta8 reported 9 excellent and good results outf 12 patients treated with ORIF but they did notention any details about surgical technique and

everity of the fractures. Despite these good resultshey favored an osteochondral graft to treat patientsith chronically damaged articular surfaces or com-inuted palmar fragments.As shown in Figure 5 open wedge osteotomy and

levation of the depressed central fragments are nec-ssary to restore the joint congruency and avoidesidual dorsal subluxation. To do so a full view ofhe articular surface is necessary; this is providednadequately by the lateral midline approach. Never-heless, the shotgun approach provides a unique viewf the joint surface, which in our opinion is key toerforming fragment delineation and disimpactionith accuracy.In 6 cases an extension block wire was used to

eep the reduction and unload the comminuted volarragments.13,14 The rationale behind this precautions that in the Hastings and Carroll15 and Deitch et al24

eries all patients who redislocated after loss of fix-tion had more than 50% joint involvement. By pre-enting any load transmission through the anterior

igure 5. Impacted fracture-dislocation and clues for approprelements have been depicted: dorsal subluxated main frag

allus is shown in gray) (above center). If only the central depalposition is not corrected then a widened and flattened o

ubluxation will result (notice V-sign) (left column). If, howerformed to restore the volar buttress, disregarding the centratendency to erode the head of the proximal phalanx (in red)

equires not only mobilizing the articular fragment but relea

art of the middle phalanx the K-wire not only blocks o

orsal subluxation but above all avoids flattening ofhe articular surface of the base of the middle pha-anx, a deformity that will increase the risk for lateorsal subluxation.2,11 Although patients with a-wire extension block were encouraged to move inprotected range of flexion little motion could be

bserved while the K-wire stood in place, presum-bly because of transient joint incongruence.

As a result of our experience in the treatment ofcute PIP joint fractures and in the very early cases ofhis series in which transient flexion contracture wascommon event we discontinued suturing the volar

late to the volar margin of the middle phalanx.illiams et al5 warned that not repairing the volar

late could be associated with recurrent dorsal sub-uxation. Neither our experience nor Hamlet andastings’s anatomic study (presented in 2001 at the6th Annual Meeting of the American Society forurgery of the Hand) support this statement. In anttempt to overcome flexion contracture we havetarted to use dynamic and static extension splintsggressively beginning at week 4.15,23,31,35

Small limitations at the DIP joint were com-on.15,23 Dionysian and Eaton23 blamed adhesions

rrection of deforming elements. In this simplified sketch onlycentral impacted fragment, and the volar lip fragment (thefragment is elevated (bone graft in yellow) but the volar lipreverse-sloped joint surface with a tendency toward dorsalnly an open wedge osteotomy of the volar lip fragment is

essed fragments, a widened incongruous joint will result withlso to slight dorsal subluxation (right column). Full correctionnd reducing the volar lip (center below).

iate coment,ressed

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ible, besides oblique retinacular tightness secondaryo mild volar migration of the lateral bands afterurgical stretching of the dorsal extensor mechanisma boutonniere-like imbalance). Adherences of theexor tendon in the digital canal secondary to theurgical procedure also may be involved. Althoughhis was not included in our study we noticed thatome of our patients had less active than passiveexion of the DIP joint.A combination of unfavorable factors—damage to

he head of the proximal phalanx, previous surgery,nd lack of motivation—in our opinion are the com-ined cause of our failed case (patient 5); this was aimple case from a technical standpoint. Accordingo Zemel et al11 and Ishida and Ikuta8 open reductionnd osteotomy are contraindicated when comminutedalmar fragments exist. Although we agree that un-vailability of cartilage at the base of the middlehalanx and erosions and osteochondral fracturesffecting the proximal phalanx head are contraindi-ations for this procedure, we disagree that commi-ution precludes a good result provided there is car-ilage available for reconstruction. Six patients in thiseries presented with 3 or more fragments impactedTable 2). Their average PIP arc (79°) was similar tohat of the 3 patients who had 1 or 2 fragments (77°)p � .98). On the other hand greater degrees of wearf the proximal phalanx head cartilage were associ-ted with a worse final PIP arc (38°) compared withhose without proximal phalanx cartilage involve-ent (87°), although we were unable to prove it

tatistically (p � .21). A larger number of patientsould be necessary to clarify this point.If surgical exploration shows that the cartilage on

he base of the middle phalanx is absent or damagedeverely we do not recommend proceeding with theeconstruction and other alternatives should be con-idered. Additionally although they are not absoluteontraindications to reconstruction, previous surgerynd lack of motivation may be other bad prognosisactors. Bilos et al17 found the worst results in theireries in patients who had had a prior ORIF. Laterhese patients required a volar plate arthroplasty as aalvage procedure. Similarly the 2 patients in oureries who had had prior ORIF procedures presentedhe worse subjective and objective outcomes (pa-ients 5 and 7). Unmotivated or uncooperative pa-ients probably do not benefit from open reductionnd osteotomy. According to Light37 patients muste able and willing to participate in the essentialostoperative phase of rehabilitation to achieve a
ood functional result.
We have failed to encounter major degenerativeigns in 9 of 10 cases but slight joint narrowingnd/or mild enlargement of the joint in the lateraliew were common. Reconstructive osteotomyannot be expected to create a normal joint.37 First,arious degrees of cartilage damage on the head ofhe proximal phalanx were seen, not only second-ry to the initial trauma but most probably wearings a result of motion against a rough surface (thencongruent base of the middle phalanx [Fig. 3C]).econd, during the time the joint was incongruentnd the time it was immobilized after surgery theartilage is not nourished normally and somehanges must be expected. Finally and most im-ortant is our concern about the blood supply ofhe mobilized fragments: although we took greatare to preserve peripheral soft tissues attached tohe volar marginal fragment or other peripheralragments, the central depressed fragments wereevoid of soft-tissue connections (although byommon sense they also could become avasculary the fracture mechanism itself). Thus as pointedut by Light37 the fate of the hyaline cartilage ofhose fragments after 10 or 20 years is unknown.onger-term follow-up study is necessary to know

f osteoarthritis develops over time. Eventually, ifespite our best efforts degeneration occurs, theact that we have preserved the joint architecturellows a better scenario for other reconstructiverocedures (joint replacement arthroplasty or fu-ion) to be performed.

The authors thank Robert Jenkins for correcting the English version ofhis article and Marco-Antonio Gandarillas, MD, Head of Department of

ork Related Injuries and Preventive Medicine, Hospital Sierrallana,antander, Spain, for his help with the statistical analysis.

eferences1. Watson-Jones R. Fractures and other joint injuries. 3rd ed.

Edinburgh: Livingstone, 1944:578–602.2. Wilson JN, Rowland SA. Fracture-dislocation of the proxi-

mal interphalangeal joint of the finger. Treatment by openreduction and internal fixation. J Bone Joint Surg 1966;48A:493–502.

3. Peimer CA, Putnam MD. Proximal interphalangeal jointfollowing traumatic arthritis. Hand Clin 1987;3:415–426.

4. Eaton RG, Malerich MM. Volar plate arthroplasty of theproximal interphalangeal joint: a review of ten years’ expe-rience. J Hand Surg 1980;5:85–98.

5. Williams RMM, Kiefhaber TR, Sommerkamp TG, Stern PJ.Treatment of unstable dorsal proximal interphalangeal frac-ture/dislocations using a hemi-hamate autograft. J HandSurg 2003;28A:856–865.

6. Ishida O, Ikuta Y, Kuroki H. Ipsilateral osteochondral graft-
ing for finger joint repair. J Hand Surg 1994;19A:372–377.

1

1

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7. Wolfe SW, Katz LD. Intra-articular impaction fractures ofthe phalanges. J Hand Surg 1995;20A:327–333.

8. Ishida O, Ikuta Y. Results of treatment of chronic dorsalfracture-dislocations of the proximal interphalangeal jointsof the fingers. J Hand Surg 1998;23B:798–801.

9. Glickel SZ, Barron OA. Proximal interphalangeal joint frac-ture dislocations. Hand Clin 2000;16:333–344.

0. McCue FC, Honner R, Johnson MC Jr, Gleck JH. Athleticinjuries of the proximal interphalangeal joint requiring sur-gical treatment. J Bone Joint Surg 1970;52A:937–955.

1. Zemel NP, Stark HH, Asworth CR, Boyes JH. Chronicfracture dislocation of the proximal interphalangeal joint—treatment by osteotomy and bone grafting. J Hand Surg1981;6:447–455.

2. Malerich MM, Eaton RG. The volar plate reconstruction forfracture-dislocation of the proximal interphalangeal joint.Hand Clin 1994;10:251–260.

3. Viegas SF. Extension block pinning for proximal interpha-langeal joint fracture dislocations: preliminary report of anew technique. J Hand Surg 1992;17A:896–901.

4. Twyman RS, David HG. The doorstop procedure. A tech-nique for treating unstable fracture dislocations of the prox-imal interphalangeal joint. J Hand Surg 1993;18B:714–715.

5. Hastings H 2nd, Carroll C 4th. Treatment of closed articularfractures of the metacarpophalangeal and proximal interpha-langeal joints. Hand Clin 1988;4:503–527.

6. Hamer DW, Quinton DN. Dorsal fracture subluxation of theproximal interphalangeal joints treated by extension blocksplintage. J Hand Surg 1992;17B:586–590.

7. Bilos ZJ, Vender MI, Bonavolonta M, Knutson K. Fracturesubluxation of proximal interphalangeal joint treated by pal-mar plate advancement. J Hand Surg 1994;19A:189–196.

8. Weiss A-PC. Cerclage fixation for fracture dislocation of theproximal interphalangeal joint. Clin Orthop 1996;327:21–28.

9. McElfresh EC, Dobyns JH, O’Brien ET. Management offracture dislocation of the proximal interphalangeal joint byextension-block splinting. J Bone Joint Surg 1972;54A:1705–1711.

0. Dobyns JH, McElfresh EC. Extension block splinting. HandClin 1994;10:229–237.

1. Rosales RS, Delgado EB, Diez de la Lastra-Bosch I. Eval-uation of the Spanish version of the DASH and carpal tunnelsyndrome health-related quality-of-life instruments: cross-cultural adaptation process and reliability. J Hand Surg2002;27A:334–343.

2. Tsubokawa N, Yoshizu T, Maki Y. Long-term results of freevascularized second toe joint transfers to finger proximalinterphalangeal joints. J Hand Surg 2003;28A:443–447.

3. Dionysian E, Eaton RG. The long-term outcome of volar

plate arthroplasty of the proximal interphalangeal joint.J Hand Surg 2000;25A:429–437.

4. Deitch MA, Kiefhaber TR, Comisar BR, Stern PJ. Dorsalfracture dislocations of the proximal interphalangeal joint:surgical complications and long-term results. J Hand Surg1999;23A:914–923.

5. Fahmy NRM, Kenny N, Kehoe N. Chronic fracture disloca-tions of the proximal interphalangeal joint. Treatment by the“S” Quattro. J Hand Surg 1994;19B:783–787.

6. Patel MR, Joshi BB. Distraction method for chronic dorsalfracture dislocation of the proximal interphalangeal joint.Hand Clin 1994;10:327–337.

7. Agee JM. Unstable fracture dislocations of the proximalinterphalangeal joint. Treatment with the force couple splint.Clin Orthop 1987;214:101–112.

8. Stern PJ, Roman RJ, Kiefhaber TR, McDonough JJ. Pilonfractures of the proximal interphalangeal joint. J Hand Surg1991;16A:844–850.

9. Schenck RR. The dynamic traction method. Combiningmovement and traction for intra-articular fractures of thephalanges. Hand Clin 1994;10:187–198.

0. Slade JF III, Baxamusa TH, Wolfe SW. External fixation ofthe proximal interphalangeal joint fracture-dislocations. At-las Hand Clin 2000;5:1–29.

1. Duteille F, Pasquier P, Lim A, Dautel G. Treatment ofcomplex interphalangeal joint with dynamic externaltraction: a series of 20 cases. Plast Reconstr Surg 2003;111:1623–1629.

2. Majumder S, Peck F, Watson JS, Lees VC. Lessons learnedfrom the management of complex intra-articular fractures atthe base of the middle phalanges of fingers. J Hand Surg2003;28B:559–565.

3. Krakauer JD, Stern PJ. Hinged device for fractures involvingthe proximal interphalangeal joint. Clin Orthop 1996;327:29–37.

4. Seno N, Hashizume H, Inoue H, Imatani J, Morito Y. Frac-tures of the base of the middle phalanx of the finger. Clas-sification, management and long-term results. J Bone JointSurg 1997;79B:758–763.

5. Nagy L, Büchler U, Birkbeck D. Comminuted, impactedfractures at the base of the middle phalanx of the finger,treated by open reduction and internal fixation: short-termresults in 38 cases. Hand Surg 1997;2:5–16.

6. Mizuseki T, Tsuge K, Ikuta Y. Distraction arthrolysis forPIP joint contracture using an external fixator. Tech HandUpper Extrem Surg 1999;3:58–65.

7. Light TR. Salvage of intraarticular malunions of the handand wrist. The role of realignment osteotomy. Clin Orthop
1987;214:126–135.

AHiotpfssplsasdmpHi


ppendix A. Hamer and Quinton’s Methodamer and Quinton’s16 method to calculate the area

nvolved at the base of the middle phalanx is basedn the constant relationship between the diameter ofhe articular surface to the head of the proximalhalanx and that of the middle phalanx, which isound to be 1:0.82. (A) By measuring the articularurface on the head of the proximal phalanx and theize of the undamaged area on the base of the middlehalanx, a more realistic fracture size can be calcu-ated. (B) Dorsal displacement is calculated by mea-uring the distance in millimeters between the longxis of the proximal and middle phalanges. To mea-ure the percentage of subluxation this distance isivided by the estimated size of the diameter of theiddle phalanx base: (diameter of the head of the

roximal phalanx � 0.82) � 100. (Reprinted fromamer and Quinton16 with permission from the Brit-

sh Society for Surgery of the Hand.)

Appendix B. Scoring System for Evaluation of theResults of PIP Joint Fracture–DislocationAccording to Ishida and Ikuta.8

ROM �90° 60 points�75° 40�45° 20�45° 0

Pain No pain with activity 20Occasional pain 10Frequently painful 0

Deformity None 5Moderate 2Angulation �20° 0

Instability None 5Moderate 2Angulation �20° 0

ADL disorder None 5Moderate 2Severe 0

Radiographicevaluation

Normal 5

Moderateosteoarthriticchange

2

Severe osteoarthriticchange orsubluxation

0

Excellent, �80 points; good, �60 points; fair �40 points; poor�40 points.

ADL, activities of daily living.

A


ppendix C.

Results of Osteotomy, Open Reduction, and Internal Fixation for Late-Presenting Malunited...

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Transcript of Results of Osteotomy, Open Reduction, and Internal Fixation for Late-Presenting Malunited...