Finger Fractures

Incidence

 

1 / 1000 per year female

1.5 / 1000 per year male

 

Phalangeal fractures

- represent more than half of all hand fractures

 

Goals of Treatment

 

Restore normal function of the finger

 

1.  Restoration of bony anatomy

 

2.  Early motion

- inherent fracture stability

- splinting

- adequate internal fixation

- dynamic external fixation

 

Examination

 

Obvious swelling / bruising / deformity

 

Compound injuries

 

Rotational alignment

1.  With active flexion, all fingers point towards scaphoid tuberosity

2.  Evidence digital overlap (see below)

3.  Plane of nail beds all in same plane

- LF often slightly different rotation

 

Finger MalrotationFinger rotation normal

 

Tendon avulsion

 

X-rays

 

3 planes centred on MCPJ  middle finger

- AP

- lateral

- oblique

 

Care to look for subtle evidence joint subluxation

 

Principles Closed Treatment

 

POSI (Position of Safe Immobilisation)

- 20o wrist extension

- flexion of MCPJ to 60 - 70o

- IP joints in extension

- thumb in abduction

 

Acceptable alignment

 

Pun etal JBJS Am 1989

- 10o angulation in both planes

- no rotation

- 50% overlay

 

Surgical approaches

 

A.  Midaxial

- dorsal to NV bundle

- make dots on flexion creases with finger flexed

- this marks incision

- approach P1 by excision of one sagittal band

- less tendon disruption

- more difficult visualisation / access

 

B.  Midlateral

- volar to NV bundle

 

C.  Dorsal approach

- direct doral incision

- divide extensor hood over P1

- between lateral bands P2

- repair extensor mechanism at end

- risks scarring down of extensor tendon to implant

 

Types of injuries

 

1.  Extra-articular fractures

 

A.  Distal phalanx tuft fractures

B.  Shaft fractures of the distal, middle and proximal phalanges

 

2.  Joint injuries

 

DIPJ   

- dislocations

- mallet

- Pilon fractures

- Flexor tendon avulsion           

 

PIPJ    

- dorsal dislocations

- dorsal fracture dislocations

- volar dislocations

- Pilon fractures

- Condylar fractures

 

MCPJ dislocations

 

Tuft fractures

 

Most common hand injury

- usually crush mechanism

 

Management

- trephination of subungal haematoma (relieves pain)

- repair nail bed disruption

- irrigation and washout of open injuries

 

Distal phalangeal shaft fractures

 

Distal Phalanx Fracture 1Distal Phalanx Fracture 2

 

Non displaced fractures

– splint DIPJ for 2-3 weeks

 

Displaced

- higher energy fractures

- washout open wounds

- repair nail bed

- bony reduction with percutaneous K wire

- distal phalanx just under nail bed

 

Shaft fractures middle / proximal phalanges

 

Undisplaced

- usually stable

- buddy strap 3-4 weeks

 

Finger Fracture Undisplaced

 

Displaced

 

Finger Phalangeal Shaft FractureProximal Phalanx Shaft Fracture

 

Unstable fractures

- oblique, spiral, comminuted fractures

 

Transverse fractures P1 / characteristic deformity

- insertion of intrinsics at base PP flex fragment

- insertion of central slip to MP extend fragment

 

Finger Phalangeal Shaft Fracture Lateral

 

Fractures of P2 distal to insertion FDS / characteristic deformity

- FDS will flex fragment

- extensor tendon will extend fragment

 

Closed reduction

- relaxation of intrinsics

- axial traction

- reduction of deformity / POSI

 

ORIF

 

A.  Transverse fractures

- cross K wire

- Lister’s intra-osseous wire fixation

- plating

 

Hand Phalange Circular WireFinger Cross K Wires

 

B.  Long oblique / spiral fractures

 

Definition

- fracture must be at lease 2 x diameter bone

- can treat with 2 x lag screws

- one perpedicular to fracture to lag

- one perpendicular to shaft to resist shear

 

Options

- percutaneous K wires / screw fixation / plating

 

FInger Lag Screws

 

DIPJ Dislocations

 

Dorsal

- most common

- closed reduction with dorsal traction

- failed closed reduction – volar plate, FDP

- 60% injuries open

- splint joint in flexion 2- 3/52 weeks

- ROM at 1/52

 

Volar

- rare

- failed closed reduction – extensor tendon

- DIPJ extension splint 6-8/52

 

Mallet fractures

 

Mallet Finger

 

Mechanism

- axial load

- extensor tendon attached to bony fragment

 

Closed treatment

- mallet splint (Stack)

- expect 10o extensor lag with mild loss ROM

- good results with non – op management

 

ORIF

 

Bony Mallet Thumb

 

Indication

- volar subluxation of distal phalanx

- fragment > 50% joint surface

- chronic > 12 weeks old

 

Open treatment

- high incidence of complications

- percutaneous K wire recommended

 

Technique

1.  Reduce and axial K wire

2.  Dorsal blocking K wire / axial K wire

 

Wehbe and Schneider JBJS Am 1984

- 21 patients with intra-articular fractures

- 15 treated non operatively

- 6 treated operatively

- nil improvement in outcome

- worsened surgical morbidity

 

Pilon fractures base distal phalanx

 

Impaction injuries

 

Management

- ORIF very difficult

- all attempts at closed reduction +/- percutaneous pinning should be made

- fallback of arthrodesis / arthroplasty

 

FDP avulsions

 

Leddy and Packer classification

I   Vinculae are ruptured, tendon retracts to palm

II  Vinculae intact, tendon remains at PIPJ

III Large bony fragment, ensnared beyond A4 pulley

 

Type 1

- must be operated within 10 days to avoid contractures

- otherwise 2 stage reconstruction

 

Type 2 / 3

- can operate within 6 weeks

- ORIF large fragments

 

Condylar fractures of head of P1 / P2

 

Mechanism

- torsional and valgus impaction

 

London classification

Type 1  Unicondylar, undisplaced

Type 2  Unicondylar, displaced

Type 3  Bicondylar

 

Displaced unicondylar

- percutaneous K wire

- ORIF with screw

 

Finger Unicondylar Displaced FractureFinger Unicondylar Fracture ORIF APFinger Unicondylar Fracture ORIF Lateral

 

Open reduction

- P1 – between central slip and lateral band

- P2 – lateral to terminal extensor tendon

- must preserve collateral ligament which supplies blood

 

Type III bicondylar fractures

- difficult fractures

- 90 degree condylar plate

- lag screw and plate

- high risk of joint stiffness

 

PIPJ Dislocations

 

Types

- Dorsal

- Lateral

- Volar

 

Stabilisers

 

Proper collateral ligaments

- primary stabilisers

- insert volar third of the base of PP

 

Accessory collateral ligaments

- inserts on and stabilises lateral margin of volar plate

 

Volar plate

- thick distally

- thin proximally, allowing collapse during flexion

 

Dorsal dislocations PIPJ

 

Most common joint injury of the hand

- hinge joint permitting 110o ROM

- volar plate fails distally

- collateral ligaments may be intact

- may be a fracture

 

Mechanism

- hyperextension

- axial loading of the flexed fingertip

 

Stability

- dependant on integrity of the collateral ligaments

- if fragment is > 40 – 50%, the attachment of the true collateral ligament is lost

- unstable

 

Eaton Classification

 

I Simple hyperextension

- buddy strap, early ROM

 

II Dorsal dislocation

- reduced and assess stability

- buddy strap if stable

- extension splint 10o further than instability

- each week extend further by 10o

- early aggressive ROM program

 

Dorsal Dislocation Simple

 

IIIA  fracture < 40% volar articular surface

- closed treatment with extension block

 

Finger Dorsal Dislocation Extension Blocking Splint

 

IIIB fracture > 40% + Pilon fractures

- inherently unstable

- extension blocking requires extreme flexion for stability, so risk of flexion contracture is high

- aim for congruent articular surface and early ROM

 

PIPJ Dislocation and Large Bony Fragment

 

IIIB Treatment Options

 

1.  Dorsal Blocking K wire

2.  Slade Dynamic Distraction External Fixator

3.  Compass Hinge

4.  Volar Plate Arthroplasty

 

Dorsal Blocking K wire

 

Technique

- flexion P2

- dorsal entry into P1

- 40o flexion

- early removal at 3/52

- Improvement compared to extension blocking

 

Suzuki / Slade Dynamic Distraction external fixator

 

Concept

- closed reduction through ligamentotaxis

- early motion of PIPJ

 

Technique

- transverse K wire in rotational centre / head P1

- transverse K wire distal P2

- attached by rubber bands

- third K wire mid-diaphysis P2,  prevents dorsal translation of MP

 

Deshmuhk S etal JBJS Br July 2004

- 12 patients complex fracture dislocations PIPJ

- treated with modified pin / rubber band system

- average 84o ROM

- nil radiological osteolysis or clinical osteomyelitis

- all returned to occupation

 

Hotchkiss designed PIP compass hinge

 

Technique

- K wire to centre head of P1 to set centre rotation

- 2 x  K wires each in P1 / P2

- barrel over centre of rotation

- options of active motion, passive ROM, locked

 

Bain I JBJS Br 1998

- 12 patients

- mean range of motion 12 – 86o

- only half presented within 2 week of injury

- combined operation with ORIF and volar plate arthroplasty

- nil osteomyelitis

- hinge on for 6 weeks

 

Volar plate arthroplasty / Volar plate advancement

 

Technique

- incise accessory collaterals to release volar plate

- excise bony fragment

- suture proximal volar plate into defect

- pass sutures through drill holes in base P2

- tie over button dorsally

- dorsal blocking splint 4 - 6 / 52

 

Finger Volar Plate Arthroplasty

 

Volar PIPJ dislocations

 

Finger Volar DislocationFinger Post Volar Dislocation

 

A.  Straight volar dislocation

 

Assessment of central slip post reduction critical

- if can active extend to within 30o, splint extended

- if nil active, surgical repair to prevent boutonniere

 

B.  Volar rotary subluxation

- condyle button holes between central slip and lateral band

- irreducible dislocation

 

Lateral PIPJ dislocations

 

Rupture of one collateral ligament and volar plate

- may be bony avulsion

 

Management

- reduce and hold in extension 2/52, then protected ROM

- can perform primary repair or reconstruct

 

MCPJ Dislocation

 

Simple

- volar plate not interposed

- MCPJ 90o hyper-extended

- reduce via wrist flexion and volar translation of PP

- avoid hyperextension and axial distraction which may convert this injury to a complex dislocation

- extension blocking splint 3-4 weeks

 

Complex

- volar plate / lumbrical tendon / flexor tendons interposed

- joint space widened

- requires open reduction, dorsal or volar

- volar more direct but risk NV bundles

- protected motion post operatively

 

MCPJ Destruction

 

Cause

- infection

- trauma

 

Options

- joint replacement

- fusion

 

MCPJ DestructionMCPJ Fusion APMCPJ Fusion Lateral

 

MCPJ Replacement