Common Fractures and Dislocations of the Hand

CME

Neil F. Jones, M.D. Learning Objectives: After reading this article, the participant should be able Jesse B. Jupiter, M.D. to: 1. Describe the concept of early protected movement with Kirschner-wired Donald H. Lalonde, M.D. finger fractures to the hand therapist. 2. Choose the most appropriate method Orange, Calif.; Boston, Mass.; and of fracture fixation to achieve the goal of a full range of motion. 3. Describe the Saint John, New Brunswick, Canada methods of treatment available for the most common fractures and dislocations of the hand. Background: The main goal of treatment of hand and finger fractures and dislocations is to attain a full range of wrist and nonscissoring finger motion after the treatment is accomplished. This CME article consists of literature review, illustrations, movies, and an online CME examination to bring the participant recent available information on the topic. Methods: The authors reviewed literature regarding the most current treatment strategies for common hand and finger fractures and dislocations. Films were created to illustrate operative and rehabilitation methods used to treat these problems. A series of multiple-choice questions, answers, discussions, and references were written and are provided online so that the participant can receive the full benefit of this review. Results: Many treatment options are available, from buddy and Coban taping to closed reduction with immobilization; percutaneous pins or screws; and open reduction with pins, screws, or plates. Knowledge of all available options is important because all can be used to achieve the goal of treatment in the shortest time possible. The commonly used methods of treatment are reviewed and illustrated. Conclusions: Management of common hand and finger fractures and dislocations includes the need to focus on achieving a full range of motion after treatment. A balance of fracture reduction with minimal dissection and early protected movement will achieve the goal. (Plast. Reconstr. Surg. 130: 722e, 2012.)

he majority of metacarpal and phalangeal bone loss, and multiple fractures, and relatively fractures can be treated nonoperatively.1,2 indicated for intra-articular fractures and malro- Optimal treatment will depend on whether tated fractures that cannot be corrected by closed T 3 the fracture can be reduced (reducible or irre- reduction. ducible) and whether the reduction can be maintained (stable or unstable). Closed reduction and percutaneous fixation or open reduction and internal fixation of metacarpal and phalangeal fractures is indicated for irreducible fractures, open Disclosure: The authors have no financial interest fractures, associated soft-tissue injury, segmental in any of the products or devices mentioned in this article.

From the Department of Orthopedic Surgery, University of California, Irvine Medical Center; Harvard Medical School, Department of Orthopedic Surgery, Massachusetts General Related Video content is available for this ar- Hospital; and Dalhousie University. ticle. The videos can be found under the “Re- Received for publication January 5, 2012; accepted April 17, lated Videos” section of the full-text article, or, 2012. for Ovid users, using the URL citations pub- Copyright ©2012 by the American Society of Plastic Surgeons lished in the article. DOI: 10.1097/PRS.0b013e318267d67a

722e www.PRSJournal.com Volume 130, Number 5 • Common Hand Fractures and Dislocations

INTRA-ARTICULAR FRACTURES OF of anatomical reduction of intra-articular frac- THE BASE OF THE THUMB tures, finding little evidence of symptomatic post- METACARPAL traumatic arthritis 10 years after nonoperative Bennett fracture is a two part fracture-disloca- treatment of Bennett fractures.12 tion in which the entire thumb metacarpal is subluxated dorsally, radially, and proximally by the pull ULNAR METACARPAL BASE FRACTURE of the abductor pollicis longus4–7 (Fig. 1, left). If the DISLOCATIONS metacarpal base can be reduced and Kirschner In reverse (baby) Bennett13 fractures, approx- wired closed, or if the fragment is less than 20 per- imately 25 to 30 percent of the radial base of the cent of the articular surface, closed reduction and small finger metacarpal remains articulating with percutaneous fixation are preferred (Fig. 1, center). the hamate, but the entire small finger metacarpal Longitudinal traction, adduction, and pronation is subluxated proximally and dorsally because of are applied to the base of the thumb metacarpal the pull of the extensor carpi ulnaris tendon. One under fluoroscopy, and the base of the metacarpal study showed that the majority of patients treated is Kirschner wired to the index metacarpal or tra- by immediate range of motion were asymptomatic pezium. The pins are removed after 4 weeks. If 4½ years later.14 Another study showed that 38 there is an articular stepoff greater than 2 mm percent of patients are symptomatic 4 years later after attempted closed reduction and percutane- regardless of the treatment.15 Most agree that resto- ous fixation, open reduction and internal fixation ration of articular congruity should be attempted is performed through a Wagner incision with 2.4- either by closed reduction and percutaneous fixa- or 2.0-mm lag screws8 or Kirschner wires (Fig. 1, tion or open reduction and internal fixation.16 right). Long-term follow-up has confirmed supe- Longitudinal traction is applied to the small rior results in terms of pain, mobility, strength, finger and pressure is applied to the dorsal aspect and radiographic signs of arthritis in patients who of the base of the small finger metacarpal followed underwent closed reduction and percutaneous by passive wrist extension and closed Kirschner Kirschner wiring or open reduction and internal wire fixation under fluoroscopy. If treatment has fixation if there was less than 1 mm of articular been delayed, closed reduction and percutaneous stepoff after reduction.9 Conversely, patients with fixation is not successful, multiple carpometacarpal articular incongruity after reduction had a higher joint fracture dislocations are present, or there is an incidence of symptomatic arthritis in long-term associated dorsal shear fracture of the hamate,17 follow-up.10,11 One study contradicts the principle open reduction and internal fixation is indicated

Fig. 1. (Left) Intra-articular Bennett fracture of the base of the thumb metacarpal showing proximal and radial displacement of the entire thumb. (Center) Closed reduction and percutaneous Kirschner wire fixation of a Bennett fracture. (Right) Open reduction and internal fixation of a Bennett fracture with two 2.0-mm lag screws.

723e Plastic and Reconstructive Surgery • November 2012 through a dorsal longitudinal incision. Fixation is An alternate method of percutaneous pinning of achieved with oblique and transverse Kirschner a metacarpal shaft fracture is to use the “bouquet wires or by longitudinal intramedullary Kirschner arrangement” of multiple intramedullary Kirsch- wires first passed antegradely down the metacarpal ner wires inserted antegradely from the base of the shaft and then passed retrogradely back into the metacarpal.22–24 hamate. Open reduction and internal fixation of metacarpal shaft fractures is indicated for unsuccessful METACARPAL SHAFT FRACTURES closed reduction and percutaneous fixation, or for (1) significantly displaced transverse fractures or The geometry of metacarpal shaft fractures fractures that have residual angulation of greater may be transverse, oblique, spiral, or comminuted. than 10 degrees in the index and middle fingers, Transverse metacarpal shaft fractures exhibit apex 20 degrees in the ring finger, and 30 degrees in the dorsal angulation caused by the deforming force small finger; (2) spiral or oblique fractures with of the interosseous muscles (Fig. 2). Closed re- residual malrotation and scissoring; (3) multiple duction is indicated for 10 degrees of apex dorsal metacarpal shaft fractures when multiple Kirsch- angulation in the index and middle fingers, ner wires may not allow early movement after sur- greater than 20 degrees in the ring finger, and gery; (4) open metacarpal shaft fractures; or (5) greater than 30 degrees in the small finger. Most segmental metacarpal bone loss. metacarpal shaft fractures are inherently stable Metacarpal shaft fractures are exposed through and do not require fixation after closed reduction. a longitudinal incision to one side of the extensor Immobilization should not be continued longer tendon. The most simple fixation technique is to than 3 weeks; otherwise, stiffness may result.18,19 insert a Kirschner wire longitudinally down the med- Closed reduction and percutaneous fixation is in- ullary cavity of the metacarpal. The Kirschner wire is dicated if the fracture is unstable. Under fluoro- introduced antegradely at the fracture site into the scopic control, a single 0.062-inch Kirschner wire distal fragment and drilled out through the radial or can be inserted retrogradely into the metacarpal ulnar aspect of the metacarpal head and then drilled head to the radial or ulnar side of the extensor back retrogradely after the fracture has been re- tendon and then across the fracture site into the duced into the proximal fragment and even into the proximal metacarpal or even into the carpus.20,21 carpus. Longitudinal intramedullary Kirschner wire Metacarpal shaft fractures of the border digits, the fixation is an excellent solution for multiple open index and small finger metacarpals, can be Kirsch- transverse metacarpal shaft fractures. The crossed ner wired transversely to noninjured metacarpals. Kirschner wire configuration is more stable, but it is more difficult to achieve except for metacarpal shaft fractures of the border index and small finger metacarpals.25,26 Dorsal plate-and-screw fixation may be consid- ered for fixation of a single unstable metacarpal shaft fracture (Fig. 3) but is more usually indicated for multiple metacarpal fractures, open metacarpal fractures, and fractures where there is segmental bone loss or an associated dorsal soft-tissue injury. Low-profile 2.7- or 2.4-mm plates are usually applied dorsally, with fixation of at least four cortices both proximal and distal to the fracture site.27–29 The newer low-profile plates do not usually need to be removed unless a secondary tenol- ysis of the extensor tendons or capsulotomy of the metacarpophalangeal joint is necessary or if the patient feels that the plate is annoyingly palpable or causes cold intolerance. Spiral and long oblique metacarpal shaft fractures that are unstable or have persistent malrotation and scissoring after closed reduction are best treated with open reduc- Fig. 2. Middiaphyseal fractures of the ring and small finger tion and interfragmentary screw fixation.30 Fractures metacarpals showing apex dorsal angulation. that are amenable to screw fixation should be two to

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Fig. 3. (Left) Transverse fracture of the shaft of the index finger metacarpal. (Right) Open reduction and internal fixation with a 2.0-mm dorsal plate. three times longer than the diameter of the meta- between a plane at 90 degrees to the long axis of carpal. The proximal and distal apices of the fracture the metacarpal and the plane of the fracture itself are manipulated into anatomical position and tem- (Fig. 4). It is important to avoid fragmentation of porarily held with a reduction clamp or temporary the apex of each fracture by placing the screw a Kirschner wire. Two 2.7-mm screws or three 2.4- or minimum of two screw diameters away from the 2.0-mm screws should ideally be inserted midway apex of the fracture.

Fig. 4. (Left) Spiral fracture of the index and middle finger metacarpals. (Right) Open reduction and internal fixation of each spiral fracture with three 2.4- and 2.0-mm lag screws.

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Comminuted open fracture of the metacarpal A simple test to determine whether apex dor- shaft with segmental bone loss or associated with sal angulation of the ring and small finger meta- loss of the overlying dorsal soft tissues is best carpals is significant is to see whether the finger treated by de´bridement and provisional bony sta- adopts a posture of pseudoclawing. When the pa- bilization to maintain metacarpal length,31 using tient attempts to extend the ring or small finger, either transverse Kirschner wires into an adjacent the metacarpophalangeal joint will hyperextend noninjured metacarpal, spacer wires, locked in- and the proximal interphalangeal joint will flex.41 tramedullary nailing,32 or the newer generation of A prospective series comparing two groups of pa- miniature external fixators.33–35 Serial de´bride- tients with small finger metacarpal neck fractures ments are performed until the wound is clean treated nonoperatively and operatively showed no enough to allow delayed primary wound coverage difference in functional outcome despite residual and bone reconstruction.36,37 apex dorsal angulation in the nonoperated group.39,42 However, patients will occasionally complain of de- creased flexion of the finger, tenderness over a pal- METACARPAL NECK FRACTURES pable metacarpal head in the palm, or loss of prom- These fractures usually involve the ring and/or inence of the ring or small finger metacarpal head. small finger metacarpals and assume an apex dorsal Although it used to be felt that all metacarpal frac- angulation because of bony comminution along the tures needed to be immobilized with metacarpo- palmar cortex of the metacarpal neck and because phalangeal joint flexion, there is now a level I evi- the interosseous muscles flex the metacarpal head. dence study that Boxer (fifth metacarpal neck) Controversy remains as to how much apex dorsal fractures can now be immobilized with the metacar- angulation can be accepted (Fig. 5). Some surgeons pophalangeal joints in extension.43 believe that 40, 60, or even 70 degrees of apex dorsal angulation of the small finger metacarpal neck frac- PHALANGEAL FRACTURES AND EARLY ture is acceptable,38 but other surgeons believe that PROTECTED MOVEMENT persistent angulation of greater than 30 degrees is Several factors adversely affect the eventual unacceptable.39,40 range of motion after a phalanx fracture. Strick- Apex dorsal angulation of a metacarpal neck land et al.44 reported that 88 percent of motion was fracture can be better compensated for in the ring restored in patients younger than 20 years but less and small fingers because the ring and small finger than 60 percent of motion was restored in patients metacarpals have 20 to 30 degrees of motion at the older than 60. Intra-articular phalangeal fractures carpometacarpal joints, whereas there is almost no usually have a poorer prognosis than extra-artic- motion at the carpometacarpal joints of the index ular fractures.45 Prolonged immobilization is also and middle finger metacarpals. This is why most detrimental. Immobilization of a phalangeal frac- surgeons agree that any apex dorsal angulation of ture for less than 4 weeks is associated with motion greater than 10 to 15 degrees in the index and recovery of 80 percent, whereas, motion recovery middle finger metacarpals is an indication for frac- is only 66 percent of normal if immobilization is ture reduction. continued for longer than 4 weeks.44 As it is with flexor tendon repairs, early protected movement with Kirschner wire–fixated fractures can be beneficial in producing good results. (See Video, Supplemental Digital Content 1, which illustrates how to begin early protected movement 3 days after closed or open Kirschner wiring of finger fractures to achieve the same goals as in early protected movement after flexor tendon repair, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A577.) PHALANX SHAFT FRACTURES Nondisplaced stable fractures do not require reduction and can be treated by buddy-taping the Fig. 5. Metacarpal neck fracture of the small finger showing se- fractured finger to an adjacent finger.46 If there is vere apex dorsal angulation, requiring closed reduction. minimal pain associated with a nondisplaced sta-

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right angles either to the fracture line or to the longitudinal axis of the phalanx and should en- gage both cortices (Fig. 6). If local anesthesia is used, rotational alignment can be checked by ask- ing the patient to actively flex and extend their finger. If malalignment persists clinically or is ob- served radiographically, conversion to open reduction and internal fixation is indicated. Closed reduction of middle phalangeal fractures can be achieved by flexing the proximal and dorsal interphalangeal joints to 90 degrees. Two crossed 0.035- or 0.045-inch Kirschner wires are then inserted in the midcoronal plane, antegradely from the base of the phalanx to the subchondral bone at the head of the phalanx, or they are introduced retrogradely from the retrocondylar fossa at Video 1. Supplemental Digital Content 1, illustrating how to be- the head of the phalanx to the subchondral bone at ginearlyprotectedmovement3daysafterclosedoropenKirsch- the lateral bases of the phalanx. It is preferable to ner wiring of finger fractures to achieve the same goals as in early avoid Kirschner wiring across the proximal inter- protectedmovementafterflexortendonrepair,isavailableinthe phalangeal joint if possible. “Related Videos” section of the full-text article on PRSJournal.com If closed reduction and percutaneous fixation or, for Ovid users, at http://links.lww.com/PRS/A577. of a proximal or middle phalangeal shaft fracture is unsuccessful, open reduction and internal fixation is necessary. (See Video, Supplemental Dig- ble fracture, immediate gentle active range of mo- ital Content 2, which illustrates the operative re- tion exercises can be started with buddy-taping. If duction of a 4-week-old middle phalanx fracture there is pain or instability, the digit should be that was healing in a malunited position, available immobilized in a splint in the position of safety, in the “Related Videos” section of the full-text with the metacarpophalangeal joint flexed 70 de- article on PRSJournal.com or, for Ovid users, at grees and the proximal and dorsal interphalan- http://links.lww.com/PRS/A578. The fracture was geal joints in full extension to prevent contracture opened and Kirschner wired, and early protected of the collateral ligaments.47 Splint immobiliza- movement was initiated at 3 days postoperatively.) tion should not be continued for longer than 3 Fractures of the proximal phalanx are approached weeks; otherwise, 60 percent of patients will de- through a Pratt extensor tendon-splitting incision velop stiffness.19,48,49 or by excising one of the lateral bands51 (Fig. 7). Closed reduction of displaced proximal pha- Fractures of the middle phalanx can be approached lanx fractures causing dysfunction begins with lon- by elevating the conjoined lateral bands. Open re- gitudinal traction to disimpact the fracture. Flex- duction of long oblique and spiral phalangeal frac- ion of the metacarpophalangeal joint stabilizes tures allows anatomical reduction by keying the apex the proximal fracture fragment. Flexion of the of the fracture into the corresponding fragments, distal fragment to correct angulation and malro- and provisional fixation with a reduction clamp52or tation is performed. Reduction is maintained by two or three transverse Kirschner wires. For more immobilization in an extension block splint for 3 rigid fixation, two or three 2.0- or 1.5-mm lag screws weeks with the metacarpophalangeal joints flexed Fig. 8) are used for proximal phalangeal fractures 90 degrees and the interphalangeal joints straight. and 1.5- or 1.3-mm screws are used for middle pha- Active flexion of the fingers and extension back to langeal fractures. Ideally, screws should be inserted the limit of the splint can be initiated within a few in the plane that bisects the fracture line and the days for stable transverse fractures, but inherently long axis of the phalanx and should be positioned unstable spiral or oblique fractures should be im- at least two screw diameters away from the apex of mobilized for the entire time. any fracture line.53–58 If fluoroscopy or radiography reveals loss of Finally, some transverse phalangeal shaft frac- reduction, closed reduction and percutaneous fix- tures are amenable to rigid fixation with a low- ation or open reduction and internal fixation may profile miniplate or mini–condylar plate.27,58,59 Po- be required.50 Under fluoroscopy, two or three sitioning the plate laterally rather than dorsally 0.035- or 0.045-inch Kirschner wires are inserted at prevents interference with gliding of the overlying

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Fig. 6. (Left) Displaced long oblique fracture of the proximal phalanx of the index finger. (Center) Closed reduction and percutaneous Kirschner wire fixation of the long oblique fracture of the proximal phalanx with three transverse Kirschner wires. (Right) Rotatory malalignment of the finger.

extensor tendon. Closed reduction with Kirschner wires is preferred by many over plate fixation because closed Kirschner wired finger tissues do not need to recover from extensive dissection, and because there is concern about tissues gliding over plates and the scar they induce in fingers. How- ever, several reports imply that there is no significant difference in outcome when comparing phalangeal fractures treated by plate fixation and Kirschner wire fixation.60–62 There is no difference in the incidence of infection between buried and protruding Kirschner wires.63

CONDYLAR FRACTURES OF THE PROXIMAL AND MIDDLE PHALANGES Condylar fractures are inherently unstable. If nonoperative splint immobilization is chosen for treatment of nondisplaced unicondylar fractures, weekly radiographic follow-up is mandatory to de- Video 2. Supplemental Digital Content 2 illustrates the opera- tect any proximal or palmar displacement. For tive reduction of a 4-week-old middle phalanx fracture that was displaced unicondylar fractures, closed reduction healing in a malunited position. The fracture was opened and and percutaneous fixation should be attempted. If Kirschner wired, and early protected movement was initiated at articular congruity can be confirmed under fluo- 3 days postoperatively. Video 2 is available in the “Related Vid- roscopy, the fracture is fixed percutaneously with eos” section of the full-text article on PRSJournal.com or, for Ovid two Kirschner wires or miniscrews 1.3 or 1.5 mm users, at http://links.lww.com/PRS/A578. in diameter.64 An alternative technique is to drill

728e Volume 130, Number 5 • Common Hand Fractures and Dislocations

Fig. 7. Operative exposure of a long oblique fracture of the proximal phalanx by retracting one of the lateral bands.

Fig. 8. Open reduction and lag screw fixation of the long oblique fracture of the proximal phalanx.

729e Plastic and Reconstructive Surgery • November 2012 a Kirschner wire into the condylar fragment and use DORSAL PROXIMAL this as a joystick to manipulate the fragment into INTERPHALANGEAL JOINT anatomical position. Care must be taken in closed DISLOCATIONS reduction of these small delicate bone fragments, as Most dorsal dislocations and stable fracture- large forces can cause irreparable damage. dislocations of the proximal interphalangeal joint If closed reduction and percutaneous fixation can be treated nonoperatively, but it is vitally im- fails, open reduction and internal fixation is re- portant to avoid prolonged immobilization, which quired through a dorsal longitudinal incision on results in either permanent stiffness or a flexion the side of the condylar fragment. The fracture is contracture of the proximal interphalangeal joint. exposed by incising the extensor tendon between It can be very helpful to view active proximal in- the lateral band and central slip (Fig. 9, left). The terphalangeal joint motion under live fluoroscopy central slip should not be detached from its in- in a lateral view to fully evaluate the stability of the sertion on the base of the middle phalanx and, joint after reduction of a dislocation. The finger similarly, the collateral ligaments should not be can be elevated and wrapped with self-adherent detached from the condylar fragment. The frac- tape to reduce swelling and then the finger can be ture is anatomically reduced under direct vision at buddy-taped to an adjacent finger and active the articular surface and so that the condylar apex range of motion exercises started. It should be keys into the defect on the phalangeal shaft. Re- emphasized to patients that stiffness and swelling duction is maintained provisionally with a small of the finger can persist even up to 1 year after towel clip, cannulated clamp,65or Kirschner wire. injury but that prevention of swelling and rapid The fracture is then fixed with two parallel trans- restoration of full range of motion are important verse 0.028- or 0.035-inch Kirschner wires or two for achieving a good result. Chronic hyperexten- 1.3- or 1.5-mm lag screws if the facture fragment sion deformities of the proximal interphalangeal is three times the diameter of the screw (Fig. 9, joint can be successfully treated by tenodesis of the proximal interphalangeal joint using one slip of right, and Fig. 10). Early range of motion can be 67 started carefully, but the proximal interphalan- the flexor digitorum sublimis tendon. geal joint is splinted in extension to prevent the Stable fracture-dislocations in which the avulsion fracture is less than 40 percent of the articular common complication of extensor lag. surface and the much rarer unstable pure dorsal Anatomical reduction of bicondylar or com- dislocations without an avulsion fracture can be minuted fractures is not usually possible by closed treated with 3 weeks of dorsal block splinting.68 reduction. Articular congruency is initially achieved After a true lateral radiograph has confirmed con- by fixing the two condylar fragments together with centric reduction of the proximal interphalangeal a miniscrew or Kirschner wire, and then the larger joint, a dorsal splint is applied to the finger with condylar fragment is fixed to the shaft with a screw 59,66 the proximal interphalangeal joint in 30 degrees or Kirschner wire. Dynamic traction devices may of flexion. Patients are able to actively flex the be indicated for comminuted fractures. proximal interphalangeal joint, but the splint blocks extension before the point of potential re- displacement. The splint is extended progressively INTRA-ARTICULAR FRACTURES OF 10 to 15 degrees per week to allow increasing THE BASE OF THE MIDDLE PHALANX extension, but it is important to obtain true lateral Volar dislocation of the proximal interphalan- radiographs every week to document that the geal joint may occasionally produce an avulsion joint remains reduced and has not redislocated fracture of the insertion of the central slip from or subluxated. the dorsal base of the middle phalanx. Nondis- For unstable fracture-dislocations of the prox- placed fractures can be treated by immobilization imal interphalangeal joint where the volar frag- of the proximal interphalangeal joint in full ex- ment is greater than 40 percent of the articular tension in a splint. Fractures that are displaced surface, there is no consensus as to the optimal more than 2 mm require either closed or open treatment.69–72 Occasionally, an extension block reduction through an incision between the lateral pin may be used,73,74 in which a 0.035-inch Kirsch- band and central slip and fixation with a Kirschner ner wire is drilled into the head of the proximal wire or a small screw and temporary Kirschner phalanx between the central slip and lateral bands wire fixation of the proximal interphalangeal joint at an angle of approximately 30 degrees, to block in extension for 3 weeks. dorsal subluxation of the middle phalanx but al-

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Fig. 9. (Left) Bicondylar fracture of the head of the proximal phalanx. (Right) Fixation with two 2.0- and 1.5-mm lag screws.

Fig. 10. Extensive bicondylar fracture of the proximal phalanx fixed with three compression screws. low gentle flexion of the proximal interphalangeal congruency and allow early protective movement joint and extension up to the point where the without generating the scarring induced by open middle phalanx is prevented from further exten- reduction, available in the “Related Videos” sec- sion by the extension block pin (Fig. 11). (See tion of the full-text article on PRSJournal.com or, Video, Supplemental Digital Content 3, which il- for Ovid users, at http://links.lww.com/PRS/A579.) lustrates the closed operative reduction of a dorsal Various dynamic skeletal traction devices have subluxation of the base of the middle phalanx with been described to apply both longitudinal traction a dorsal blocking Kirschner wire to restore joint to the finger and a palmar directed force to pre-

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Video 3. Supplemental Digital Content 3, which illustrates the closed operative reduction of a dorsal subluxation of the base of Fig. 11. (Left and center) Two dorsal Kirschner wires between the middle phalanx with a dorsal blocking Kirschner wire to restore the central slip and the lateral band reduce the dorsally sub- joint congruency and allow early protective movement without luxated middle phalanx, yet allow movement while the bone generating the scarring induced by open reduction, is available in heals (lateral view). (Right) Dorsal view. the “Related Videos” section of the full-text article on PRSJournal. com or, for Ovid users, at http://links.lww.com/PRS/A579. vent recurrent dorsal subluxation of the middle phalanx, yet still allow early active range of mo- base of the middle phalanx, and the volar plate is tion. These devices rely on the principle of liga- advanced into this trough and fixed either with a mentotaxis and are especially suited to the treat- pullout wire or miniature bone anchors. After con- ment of comminuted fractures and pilon fractures firming congruous reduction of the middle pha- of the base of the middle phalanx. The Schenck lanx with respect to the head of the proximal dynamic skeletal traction splint75 is effective but phalanx, a 0.035-inch Kirschner wire is used to cumbersome. transfix the proximal interphalangeal joint in 30 The Agee force couple76–79 is difficult to fab- degrees of flexion to maintain reduction for 3 ricate, but the newer devices such as the Stockport weeks. The Kirschner wire is removed at 3 weeks Serpentine Spring System80–82 and the Agee Joint and active flexion exercises are begun using a 83 dorsal extension block splint for a further 1 to 2 Jack are much simpler to apply. Unstable frac- 88 ture-dislocations where there is a single large volar weeks. Eaton and Malerich reported a 10-year fragment greater than 40 percent of the articular follow-up of patients with both acute and chronic surface are potentially amenable to open reduc- proximal interphalangeal joint fracture-dislocation and internal fixation with one or two small tions treated by volar plate arthroplasty, with an Kirschner wires or a small lag screw followed by average range of motion of 6/95 degrees for pa- early range-of-motion exercises.84–86 tients treated within 6 weeks of injury and 12/78 Many unstable proximal interphalangeal joint degrees for patients treated beyond 6 weeks after fracture-dislocations are not amenable to open injury. More recently, Hastings has advocated reduction and internal fixation because the volar treating unstable fracture-dislocations of the prox- fragment is comminuted. In these circumstances, imal interphalangeal joint by restoring the volar buttress of the base of the middle phalanx with a the base of the middle phalanx can be resurfaced 90 by advancement of the volar plate, which also pre- hemihamate autograft. vents dorsal resubluxation. This technique of volar plate arthroplasty87,88 is performed through a ULNAR COLLATERAL LIGAMENT volar Bruner incision, with retraction of the flexor INJURIES OF THE tendons between the A2 and A4 pulleys and ex- METACARPOPHALANGEAL JOINT OF cision of the true collateral ligaments89 to allow THE THUMB shotgun exposure of the proximal interphalan- Ulnar collateral ligament injuries occur more geal joint. A transverse groove is made in the volar frequently than radial collateral ligament injuries,

732e Volume 130, Number 5 • Common Hand Fractures and Dislocations with an incidence of 65 to 90 percent of metacarpophalangeal joint injuries.91 The ulnar collateral ligament is injured by an abduction force at the metacarpophalangeal joint and has been termed skier’s thumb.92 The ligament is torn five times more frequently at its distal insertion from the base of the proximal phalanx than it is torn or avulsed from its proximal origin from the metacarpal head, although midsubstance tears are frequently seen.93 The collateral ligament may re- main intact but avulse a small fracture from the ulnar base of the proximal phalanx or less commonly from the metacarpal head. Stener94,95 described the proximal portion of the ulnar collateral ligament being flipped proximally and superficial to the adductor aponeurosis in two-thirds of complete ulnar collateral ligament injuries. Therefore, the adductor aponeurosis is interposed between the proximal and distal ends of the ulnar collateral ligament and the ligament cannot heal regardless of cast immobilization. If there is a Stener lesion, surgery is indicated. If a Stener lesion can be ruled out by physical examination, magnetic resonance imaging, or ultrasound, the ligament can be ex- pected to heal with nonoperative immobilization for 4 to 6 weeks. Because a Stener lesion cannot occur in a partial rupture of the ulnar collateral ligament, it is Fig. 12. (Above) Ulnar collateral ligament tear of the metacar- important to distinguish between partial and com- pophalangeal joint of the left thumb. (Below) Stress test show- plete ruptures of the ligament, because partial rup- ing greater than 40 degrees of radial deviation on radial stress tures can be treated by cast immobilization but com- of the thumb at the metacarpophalangeal joint, with no def- plete ruptures with a high likelihood of a Stener inite endpoint. lesion provide an indication for open reduction and repair. Distinction between partial and complete If the posteroanterior radiograph shows an tears is usually made clinically based on the following avulsion fracture with more than 2 mm of dis- criteria: (1) a complete tear has greater than 35 to placement or a large avulsion fracture, open re- 45 degrees of laxity on radial stress; (2) a complete duction and internal fixation is indicated. The tear has greater than 15 degrees of laxity compared ulnar collateral ligament is approached through with the opposite thumb; (3) a partial tear usually an S-shaped incision centered over the ulnar has a discrete endpoint to radial stress, whereas a aspect of the metacarpophalangeal joint. The complete tear has no endpoint to radial stress Stener lesion, if present, presents as an edematous under local anesthetic block (Fig. 12); and (4) mass proximal and superficial to the adductor ultrasound or magnetic resonance imaging can aponeurosis. The aponeurosis is incised parallel to be helpful. its insertion on the extensor pollicis longus ten- If the posteroanterior radiograph shows a don and reflected volarly. If a tear is found within small undisplaced or minimally displaced avulsion the substance of the ulnar collateral ligament, this fracture from the ulnar base of the proximal pha- is repaired with figure-of-eight or mattress sutures. lanx, this implies that the ulnar collateral ligament Usually, the ligament is avulsed from its distal in- is at least partially intact. These patients can be sertion and can be reattached either with a pullout treated by immobilization in a thumb spica cast suture or with a miniature bone anchor.97 A suture with the interphalangeal joint left free for 4 weeks should also be placed from the volar and distal as- followed by 2 weeks of controlled mobilization in pect of the repaired ulnar collateral ligament to the a short opponens splint.96 volar plate, and any significant tear in the dorsal

733e Plastic and Reconstructive Surgery • November 2012 ulnar capsule should be repaired to prevent volar 15. Kjaer-Petersen K, Jurik AG, Petersen LK. Intra-articular frac- subluxation of the proximal phalanx. The strength tures at the base of the fifth metacarpal: A clinical and ra- of the repair is then tested by gently stressing the diographical study of 64 cases. J Hand Surg Br. 1992;17:144– 147. thumb into radial deviation, and only if there is a 16. Foster RJ. Stabilization of ulnar carpometacarpal disloca- suggestion of some remaining laxity should the tions or fracture dislocations. Clin Orthop Relat Res. 1996;327: metacarpophalangeal joint be pinned with a 0.045- 94–97. inch Kirschner wire in slight flexion and ulnar de- 17. Loth TS, McMillan MD. Coronal dorsal hamate fractures. viation. After repair of the adductor aponeurosis, the J Hand Surg Am. 1988;13:616–618. 18. James JI. Common, simple errors in the management of thumb is immobilized in a thumb spica splint with hand injuries. Proc R Soc Med. 1970;63:69–71. the interphalangeal joint free for 4 weeks. 19. Wright TA. Early mobilization in fractures of the metacarpals and phalanges. Can J Surg. 1968;11:491–498. Neil F. Jones, M.D. 20. Grundberg AB. Intramedullary fixation for fractures of the University of California Irvine hand. J Hand Surg Am. 1981;6:568–573. 101 The City Drive South, Pavilion III 21. Vom Saal FH. Intramedullary fixation in fractures of the Orange, Calif. 92868 hand and fingers. J Bone Joint Surg Am. 1953;35:5–16. [email protected] 22. Foucher G. “Bouquet” osteosynthesis in metacarpal neck fractures: A series of 66 patients. J Hand Surg Am. 1995;20: S86–S90. ACKNOWLEDGMENT 23. Gonzalez MH, Igram CM, Hall RF Jr. Flexible intramedullary The authors thank Dr. Alison Martin, Dalhousie nailing for metacarpal fractures. J Hand Surg Am. 1995;20: University, for the excellent artwork of the dorsal blocking 382–387. Kirschner wires for proximal interphalangeal joint frac- 24. Liew KH, Chan BK, Low CO. Metacarpal and proximal phalangeal fractures: Fixation with multiple intramedullary ture dorsal dislocation. Kirschner wires. Hand Surg. 2000;5:125–130. 25. Botte MJ, Davis JL, Rose BA, et al. Complications of smooth REFERENCES pin fixation of fractures and dislocations in the hand and wrist. Clin Orthop Relat Res. 1992;276:194–201. 1. Stern PJ. Management of fractures of the hand over the last 26. Caffee HH. Atraumatic placement of Kirschner wires. Plast 25 years. J Hand Surg Am. 2000;25:817–823. Reconstr Surg. 1979;63:433. 2. Jupiter JB, Ring DC. AO Manual of Fracture Management: Hand 27. Dabezies EJ, Schutte JP. Fixation of metacarpal and phalan- and Wrist. Davos, Switzerland: AO Publishing; 2005. geal fractures with miniature plates and screws. J Hand Surg 3. Freeland AE, Geissler WB, Weiss AP. 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