Dorsal Proximal Interphalangeal Joint Fracture- Dislocations: Evaluation and Treatment

Julie E. Adams, MD Ryan P. Calfee, MD, MSc Mark A. Vitale, MD, MPH Robert J. Strauch, MD O. Alton Barron, MD

Abstract on joint stability is helpful to outline Proximal interphalangeal joint injuries are common and often can be treated nonsur- treatment.1 gically. Some dorsal fracture-dislocations, however, require special attention or surgical Volar fracture-dislocations can oc- management to optimize outcomes. Treatment options for dorsal proximal interphalangeal cur, with a fragment avulsing off the fracture-dislocations include splinting, percutaneous pinning, fracture fi xation, external dorsal edge of the middle phalanx and fi xation devices, volar plate arthroplasty, and hemihamate arthroplasty. usually including the central slip inser- Instr Course Lect 2015;64:261–272. tion. Pure axial loading injuries result in a pilon-type fracture, in which the Injuries to the proximal interphalange- involves axial loading to the digit, often dorsal and volar cortices are disrupted al (PIP) joint are common. Although with a fl exion or an extension moment with impaction of the central articular many PIP injuries are treated nonsur- imparted to the digit. PIP joint frac- portion of the bone. Dorsal fracture- gically, some require special attention ture-dislocations can be divided into dislocations are the most common in- or surgical management for good out- three types based on the character of juries. When the joint is hyperextended, comes. The mechanism of injury in the middle phalanx articular fracture the volar plate ruptures, typically with PIP fracture-dislocations commonly fragment; further subdivision based a fragment avulsing from the middle phalanx insertion of the volar plate.2 Dr. Adams or an immediate family member has received royalties from Biomet; is a member of a speakers’ bureau or has This chapter focuses on the treatment made paid presentations on behalf of Arthrex; serves as a paid consultant to or is an employee of Articulinx; and serves as a board member, owner, offi cer, or committee member of the American Association for Hand Surgery, the American Shoulder of dorsal and pilon injuries. and Elbow Surgeons, the American Society for Surgery of the Hand, the Arthroscopy Association of North America, the Ruth Jackson Orthopaedic Society, and the Minnesota Orthopaedic Society. Dr. Calfee or an immediate family member Patient Evaluation serves as a paid consultant to or is an employee of Synthes; has received research or institutional support from Medartis; and serves as a board member, owner, offi cer, or committee member of the American Society for Surgery of the Hand. Dr. The patient evaluation includes ob- Strauch or an immediate family member serves as a board member, owner, offi cer, or committee member of the American taining an appropriate history and Society for Surgery of the Hand. Dr. Barron or an immediate family member has received royalties from Extremity Medical performing a physical examination. Ra- and serves as a paid consultant to or is an employee of Extremity Medical. Neither Dr. Vitale nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related diographs, including three views (PA, directly or indirectly to the subject of this chapter. lateral, and oblique) of the fi nger (not

Figure 2 Illustration showing fracture stability. Fractures of less than 30% of the joint are stable, those including 30% to 50% of the joint are tenuous, and those representing more than 50% of the joint are unstable. (Reproduced with permission from Kiefhaber TR, Stern PJ: Fracture-dislocations of the proximal interphalangeal joint. J Hand Surg Am 1998;23[3]:368-380.)

the arc of motion, without hinging or radiographs to ensure that a congruent joint subluxation. Second, early motion reduction is maintained. The digit is is desirable. Last, anatomic reduction fl exed to achieve congruent reduction of the articular surface is of secondary and gradually extended weekly by 10°, concern. ensuring that the joint remains reduced. A classifi cation system for PIP joint Unstable fracture-dislocations in- Figure 1 Lateral plain radiograph shows the V sign in which joint sub- injuries is based on clinical stability (sta- clude those involving more than 50% luxation or dislocation is present. ble, tenuous, or unstable) after reduction of the articular surface or 30% to 50% (Copyright Julie E. Adams, MD, and prior work that establishes stability of the surface but requiring more than Minneapolis, MN.) based on fracture size1,3,4 (Figure 2). 30° of fl exion to maintain reduction. Stable fracture-dislocations are those The treatment options for tenuous the hand) are needed. Occasionally, a that generally involve less than 30% and unstable fracture-dislocations in- subtle joint subluxation or dislocation of the articular surface of the middle clude splinting, pinning the joint, dorsal may be missed when the radiographs phalanx and remain congruently re- block pinning, fracture fi xation, exter- include overlapping digits or do not fo- duced throughout the arc of motion. nal fi xation, volar plate arthroplasty, or cus on the injured digit. The so-called V By obtaining a lateral plain radiograph hemihamate arthroplasty. sign is seen with subtle instability as the in full extension, it can be confi rmed middle phalanx slips relatively dorsal that subluxation is not present in these Extension Block Splinting to joint alignment (Figure 1). Unfor- patients. These injuries are treated by Extension block splinting is an option tunately, PIP fracture-dislocations are encouraging early motion. Patients may for tenuous fracture-dislocations but often deemed by the patient or the phy- present with a tendency to hyperextend requires vigilant monitoring to ensure sician to be a jammed fi nger or a sprain the PIP joint. These patients may bene- that recurrent subluxation does not oc- and may not be properly evaluated. fi t from buddy taping, dorsal blocking, cur. McElfresh et al3 described using or fi gure-of-8 splinting if hyperexten- extension block splinting in 17 patients Treatment Principles sion is a problem. with unstable PIP joints. A gauntlet cast and Classification Tenuous fracture-dislocations in- was applied with an outrigger that lim- Kiefhaber and Stern1 outlined import- volve 30% to 50% of the articular sur- ited terminal extension to 10° to 15° ant treatment principles with respect face and reduce when the joint is fl exed short of the position of instability but to PIP fracture-dislocations. Most im- less than 30°. Patients with this type of allowed full fl exion of the digit. The portantly, it is necessary to restore a injury may be treated with dorsal block digit was allowed progressive extension congruent and stable joint throughout splinting with close serial follow-up with a decrease in the extension block

of 25% per week. Although the results to midline), and a rubber band. The fi x- described in this series were satisfac- ator was maintained for 5 to 8 weeks, tory, this technique requires close fol- allowing full digital fl exion. Impor- low-up to ensure that the splint remains tantly, if this technique is considered, well fi tting and subluxation of the joint the dorsal cortex must remain intact. does not occur. Extension block splint- In his series, Agee noted complications ing is used with caution in swollen or that included loss of terminal dorsal thick fi ngers.3,5 An alternative to the interphalangeal fl exion secondary to outrigger is a fi nger-based splint, such adhesions, recurrent subluxation, in- as a fi gure-of-8 splint, a silver ring fection, and stiffness. Loss of terminal splint, or two portions of alumifoam extension is common, as is radiographic splinting each aligned over the dorsum evidence of arthrosis, which is typically of the middle and proximal phalanges asymptomatic.7,8 The average arc of mo- with an angled portion so that terminal tion after treatment was 95° in acute extension is limited.6 injuries, whereas chronic injuries had a disappointing arc of motion of 68°. Dynamic Traction, External Agee7,8 suggested caution when consid- Fixation Techniques, and ering this treatment option for patients Force-Couple Devices with chronic injuries. Figure 3 Photograph of a dy- Dynamic traction or external fi xation Others have described pur- namic external fi xation device that techniques (Figure 3) and force-couple pose-made or fabricated constructs allows active motion while maintaining a congruent reduction of the devices rely on the principle of ligamen- that include two or three K-wires with proximal interphalangeal joint. K1, totaxis and allow early range of motion or without rubber bands (Figure 3). K2, and K3 represent three trans- (ROM) while maintaining a congru- Usually, most constructs involve three versely oriented Kirschner wires across the head of the proximal ent reduction at the PIP joint. These 0.045-inch K-wires (or two 0.045-inch phalanx (K1), the midportion of the techniques are very useful for pilon and one 0.035-inch K-wires) and den- middle phalanx (K2), and the head fractures (except for force-couple de- tal rubber bands. These constructs of the middle phalanx (K3). Rubber bands (R) maintain traction across vices), tenuous fractures, and unstable are typically applied with one smooth the construct. (Reproduced with fractures. K-wire through the head of the prox- permission from Ellis SJ, Cheng Various constructs have been de- imal phalanx, a second through the R, Prokopis P, et al: Treatment of proximal interphalangeal dorsal scribed with two or three Kirschner head of the middle phalanx, and often fracture-dislocation injuries with dy- wires (K-wires) and rubber bands, a third lever K-wire through the middle namic external fi xation: A pins and purpose-made devices, or force-couple phalanx. The most proximal and distal rubber band system. J Hand Surg Am 2007;32[8]:1242-1250.) constructs. For these techniques to K-wires are bent at either side of the work, a closed reduction should be pos- digit to a 90°-angle distally and then sible. If closed reduction is not possible, into hooks. The middle K-wire acts as the offi ce visit 3 to 6 weeks after injury. an open reduction is necessary, at which a lever over which the proximal K-wire For such constructs, it is advisable to time the construct may be applied. passes. Distally, tension is obtained and remove the rubber bands fi rst and then Agee7,8 described using a force- maintained by applying dental rubber perform fl uoroscopic imaging to ensure couple device that consists of a thread- bands so that traction is applied and that the joint remains congruently re- ed 0.062-inch K-wire directed from the joint is congruently reduced. Early duced before the wires are removed. dorsally to volarly through the prox- motion is encouraged, and the patient is The complication rate in the literature imal half of the middle phalanx, two followed weekly with serial examination has been reported as 29%; however, smooth K-wires (one through the head and radiographs to ensure that congru- pin tract infections are among the most of the proximal phalanx and a second ent reduction is maintained. In most common complications but usually re- through the middle phalanx just dorsal cases, the fi xator can be removed during spond to oral antibiotics.9-30 As is the

case with force-couple devices, radio- later to initiate active fl exion and exten- dorsal blocking wire is removed, and graphic evidence of arthritis is common sion. A mean PIP joint ROM of 94° was therapy is started with free passive and but usually asymptomatic. The average achieved at fi nal follow-up. active joint mobilization. At 5-year fol- arc of motion described in the literature low-up, reduction of the joint was main- ranges from 74° to near normal.9-30 Closed Reduction and tained, articular step-off was reduced, Percutaneous Pinning and PIP joint ROM averaged 83°. Transarticular and Different methods using percutaneously Vitale et al41 described a technique Dorsal Block Pinning placed K-wires for reduction and/or using volar to dorsal directed closed re- Transarticular and dorsal block pinning fi xation of the displaced volar fracture duction and percutaneous pinning of techniques have successfully been used fragments have been described with the volar fracture fragments and dorsal in unstable dorsal fracture-dislocations success. Lahav et al39 described a tech- block pinning (Figure 4). Closed re- of the PIP joint to reduce and stabilize nique using a 0.035-inch K-wire placed duction of the volar base of the middle the dislocated PIP joint. When used through the dorsal cortex of the middle phalanx is achieved with a pointed towel as the sole fi xation method, the volar phalanx to percutaneously reduce im- clamp followed by the insertion of two middle phalangeal fracture fragments pacted articular fragments, followed by or three 0.028-inch K-wires in a volar may not be completely reduced. Trans- the insertion of two volar-dorsal and to dorsal direction across the fracture articular pinning was fi rst described by two radial-ulnar 0.028-inch K-wires for site immediately lateral to either side of Bunnell31 and later by other authors. 32-35 fragment fi xation. They reported ex- the volar limb of the towel clamp. The Newington et al25 performed manual cellent interphalangeal ROM; however, K-wires are withdrawn from the digit closed reduction followed by a transar- it should be noted that this technique dorsally until they are nearly level with ticular smooth K-wire inserted through was used to treat middle phalanx volar the volar aspect of the volar fracture the PIP joint dorsally in 20° to 40° of lip fractures and PIP joint impaction fragment. A dorsal blocking 0.035- fl exion; the K-wire was removed at fractures without dislocation, not true inch K-wire is then used to maintain 3 weeks. At 16-year follow-up, they re- PIP fracture-dislocations. PIP joint reduction. All K-wires are ported a mean PIP joint ROM of 85°. Waris and Alanen40 described a removed at 3 to 4 weeks, after which A variation of this technique is to method of percutaneous fracture re- active PIP fl exion is performed in the place a K-wire into the head of the duction and dorsal block pinning in offi ce setting under a digital block to proximal phalanx while skiving dor- 15 dorsal PIP fracture-dislocations. help lyse any early tendon adhesions. sal to the middle phalangeal base to This technique involves fi rst perform- Temporary dorsal block splinting fol- direct the subluxated middle phalanx ing a closed reduction and dorsal block lowing pin removal is tapered off by volarly, a technique termed dorsal block pinning. A prebent 1.0-mm K-wire is 6 to 8 weeks. At fi nal follow-up, there pinning. First described by Sugawa then inserted percutaneously through a were no subluxations or dislocations, et al,36 full PIP joint fl exion is obtained 2.0-mm cortical hole in the distal por- mean PIP joint ROM was 89°, and pa- before K-wire insertion to transfi x the tion of the middle phalanx and passed tient-based outcome measures indicated extensor tendon in a position that the- through the intramedullary canal to high levels of function and little or no oretically allows active PIP fl exion disimpact and reduce the volar articular pain. postoperatively with the wire in place, fragments under fl uoroscopic guidance. The benefi t of closed reduction and in contrast to transarticular pinning in This wire is removed intraoperatively, percutaneous pinning is the avoidance which the joint is statically fi xed until leaving only the dorsal blocking wire of an open approach to the joint that K-wire removal. Small series have re- in place. The authors recommended may promote scarring of the joint cap- ported good short- to medium-term re- passive ROM exercises at the PIP joint sule and tendons, but truly anatomic sults.37,38 Inoue and Tamura38 described within the limits of the dorsal block- reduction of fracture fragments may not dorsal block pinning in 14 patients with ing K-wire, with active ROM of the be possible. It has been reported that injuries involving up to 50% of the metacarpophalangeal and dorsal inter- reduction of joint subluxation, not ana- joint surface. K-wires were removed at phalangeal joints started immediately tomic reduction of articular fragments, 3 weeks, with therapy starting 1 week postoperatively. After 2 to 4 weeks, the is the most important determinant of

outcome, making closed reduction and percutaneous pinning an attractive option.42,43

Open Reduction and Internal Fixation Open reduction and internal fi xation (ORIF) of unstable dorsal PIP fracture-dislocations has been performed with K-wire, screw, cerclage wire, or volar miniplate fi xation. Wilson and Rowland44 and later McCue et al45 reported results using a midlateral approach over the PIP joint, with distal Figure 4 Lateral intraoperative fl uoroscopic view of a dorsal refl ection of the collateral ligament and proximal interphalangeal joint the volar plate and ORIF of the volar fracture-dislocation after reduc- fragment with one or more volar to dor- tion, percutaneous volar to dorsal Kirschner wire (K-wire) fi xation, and sal K-wires, followed by a transarticular a dorsal blocking K-wire. (Repro- K-wire transfi xing the PIP in fl exion duced with permission from Vitale for 3 weeks or more. Weiss46 described MA, White NJ, Strauch RJ: A percutaneous technique to treat unstable successful open cerclage wire fi xation dorsal fracture-dislocation of the Figure 5 Lateral postoperative for this injury. proximal interphalangeal joint. J radiograph of open reduction and ORIF with interfragmentary screws Hand Surg Am 2011;36:1453-1459.) internal fi xation of a dorsal proximal via a volar or a dorsal approach is a vi- interphalangeal joint fracture-dislocation with two volarly placed mini able option when there are suffi ciently K-wire, and a single 1.2-mm interfrag- interfragmentary screws. (Repro- large fracture fragments amenable to mentary screw was used for fi xation. duced with permission from Deitch screw fi xation47-50 (Figure 5). Hamil- The dorsal blocking or transarticular MA, Kiefhaber TR, Comisar BR, Stern PJ: Dorsal fracture-disloca- 50 ton et al described a technique using K-wire was removed at 12 days, on tions of the proximal interphalange- a volar Bruner incision, division of the average, when passive and active- al joint: Surgical complications and A3 pulley, proximal refl ection of the assisted fl exion was initiated in a dor- long-term results. J Hand Surg Am 1999;24[5]:914-923.) volar plate, collateral ligament release sal blocking splint, with extension of for a “shotgun” exposure of the joint as the PIP joint started at 4 weeks. At needed, and fi xation with one to three 3-year postoperative follow-up, aver- refl ected to expose the joint and the vo- mini-screws. Postoperative therapy was age active PIP joint ROM was 100°. lar fracture fragments. The volar frag- started within 2 to 9 days after surgery. Three patients sustained dislocation ments were disimpacted, and fi xation Terminal extension was blocked by us- or substantial subluxation postopera- was performed with 1.5- or 1.3-mm ing a fi gure-of-8 splint and full active tively, and radiographs demonstrated interfragmentary screws inserted dor- fl exion. At a follow-up of 42 months, minor residual dorsal subluxation and sally. Immediate postoperative active PIP joint ROM averaged 70°, with joint incongruity in 12 of 14 patients, fl exion was allowed, with passive ex- seven of nine patients reporting no pain although good clinical results were tension and fl exion initiated at week 2. at latest follow-up. achieved overall. At fi nal follow-up, mean ROM at the Grant et al48 described the results Lee and Toeh51 described a dorsal PIP joint was 85°. of ORIF using a volar approach to the approach with ORIF using interfrag- ORIF with a low-profile vo- PIP joint in 14 patients. Joint reduc- mentary screws in 12 unstable dorsal lar miniplate has recently been de- tion was achieved with either a dorsal PIP fracture-dislocations. Dorsally, scribed.52,53 Ikeda et al52 reported blocking K-wire or a transarticular the central slip and lateral bands were on a series of 19 unstable PIP

fracture- dislocations treated with volar Volar Plate Arthroplasty blade. The joint is then shotgunned application of a miniplate and early ac- First published by Eaton and Littler54 (fully hyperextended), and the fractured tive motion, with a mean of 85° of PIP in 1976 and validated by a long-term base of the middle phalanx is inspected joint ROM at fi nal follow-up. Cheah follow-up study in 2000,55 volar plate (Figure 6). The volar fracture trough et al53 described a similar technique, in arthroplasty is a useful treatment option must be level, even if a small amount which the proximal end of the plate was for dorsal fracture-dislocations of the of articular cartilage and subchondral modifi ed with hooks to capture com- PIP joint. bone must be removed to achieve this. minuted fragments of the volar lip of As contemporary fi xation tech- (This minimizes the risk of malrotation the middle phalanx. At fi nal follow-up, niques have improved and alternatives with PIP joint fl exion.) If any articu- active ROM of the PIP joint was 75°. such as hemihamate reconstruction lar impaction is identifi ed, and if volar The authors reported a 39% complica- have been developed, the indications plate arthroplasty will be performed, tion rate, with four patients requiring for volar plate arthroplasty have nar- then this should be disimpacted, teased eventual implant removal. rowed. The ideal indication is a dorsal open, and held reduced with a single ORIF may allow for restoration of fracture-dislocation, in which 30% to small crouton of allograft or autograft. articular congruity and rigid fi xation 50% of the articular surface is fractured This technique helps to reconstitute the and permit immediate mobilization, and comminuted, and, therefore, is not remaining arc of the middle phalan geal with the disadvantage of potentially amenable to internal fi xation. Preoper- base and diminish the likelihood of greater soft-tissue trauma that may ative evaluation must include PA and resubluxation. promote adhesions and postoperative lateral views of the fi nger. It must be A 2-0 or 3-0 monofi lament suture stiffness. To date, no benefi t in ROM determined if there is any angulation or is then placed through the radial and has been demonstrated clinically with impaction of the remaining dorsal artic- ulnar borders of the volar plate. Next, early ROM permitted by ORIF tech- ular surface, which must be addressed two Keith needles are passed through niques because the results obtained at the time of surgery. The outcomes of the lateral edges of the cancellous bed with simple transarticular pinning volar plate arthroplasty are technique of the fractured base of the middle have been shown to be equivalent to driven. phalanx immediately adjacent to the or better than those with ORIF with Although the fundamental features remaining articular surface. As the either screws or cerclage wiring.43 of volar plate arthroplasty remain the PIP joint is reduced, the suture limbs ORIF may be most helpful when there same, the classic technique has been are drawn through the middle phalanx are one or two large volar fragments, modifi ed in several useful ways during base, keeping the volar plate spread as but substantial comminution or small the past three decades.56,57 A volar zig- broadly as possible over the proximal volar fragments are relative contraindi- zag approach centered over the PIP phalangeal condyles. cations to ORIF. In addition, it is often joint is used to preserve the A2 and A4 The PIP joint is fl exed suffi ciently diffi cult to discern from preoperative pulleys. The fl exor sheath is opened di- to allow full contact of the volar plate radiographs the true number of frag- rectly over the PIP joint, and the fl exor into the trough at the level of the joint ments and the extent of comminution. tendons are retracted to one side to ex- cartilage. After making a small dorsal What may appear to be a single large pose the volar plate and the fracture. incision to prevent the lateral bands fragment may, in fact, represent sev- Some fracture fragments are usually at- from being bound down by the suture eral comminuted fragments; thus, it tached to the volar plate and, if they are limbs, the suture is tied over the peri- is prudent to have a backup plan in small, are excised. If large, they can be osteum. (Alternatively, suture anchors case ORIF is not possible. In addition, left in place to enhance bone-to-bone can be used to attach the volar plate to one series demonstrated more frequent healing. the base of middle phalanx.) complications and poorer motion in Full visualization of the fractured Fluoroscopic evaluation is used to patients treated with ORIF who had base of the middle phalanx is a critical verify that joint congruency has been more than one fracture fragment step in volar plate arthroplasty, which reestablished with no residual sublux- compared with patients with only one is achieved by fully releasing both PIP ation (Figure 7). The arc of passive mo- fragment.50 joint collateral ligaments with a No. 15 tion is then assessed. If full extension is

Figure 7 Whether sutures are passed through bone or suture anchors are used, the intraoperative arc of motion must be congruent to prevent a subpar outcome.

Figure 6 Intraoperative photograph of shotgunning and hyperextending the autograft to restore the volar buttress proximal interphalangeal joint after the release of the collateral ligaments; the of the PIP joint, which resists persistent fractured base of the middle phalanx also is inspected. Sutures are placed in dorsal subluxation and is suffi cient for the lateral margins of the volar plate and passed dorsally via Keith needles. early joint mobilization. lacking, the checkrein ligaments of the Stability of the PIP joint is uniformly Indications and volar plate are feathered and stretched good if the reduction is maintained Contraindications to allow full extension. If fl exion is without any resubluxation. Patient sat- Hemihamate arthroplasty is indicat- lacking, the dorsal capsule is released, isfaction is high but not uniform. ed to treat the unstable dorsal PIP and an extensor tenolysis performed as fracture-dislocations that are not needed. Hemihamate Arthroplasty amenable to ORIF or volar plate ar- Postoperatively, the PIP joint is In 1999, Hastings et al59 fi rst described throplasty. It also is indicated for chron- transfi xed with a 0.045-inch K-wire in hemihamate arthroplasty as a treat- ic injuries in which bony fragments can 30° to 35° of fl exion for 3 weeks and ment of otherwise unreconstructable no longer be reduced and maintained then removed. Active fl exion with an dorsal fracture-dislocations of the PIP either internally or with external fi xa- extension block splint is then started, joint. This procedure takes advantage tion. Ideally, this procedure is applied followed by active extension at 4 weeks of the similar coronal plane morphol- to fractures involving more than 50% and dynamic passive extension at ogy of the distal articular surface of of the articular surface of the middle 5 weeks. the hamate and the proximal articular phalanx that have compromised the Careful technique and intraopera- surface of the middle phalanx. When entire volar buttress for the PIP joint.12 tive assessment minimize the risk for treating acute or chronic injuries to Hemihamate arthroplasty is contra- resubluxation and malrotation, two the volar PIP articular surface of the indicated in PIP fracture-dislocations important complications of volar plate middle phalanx that are not amenable that involve both the volar and dorsal arthroplasty. A fl exion contracture is to internal fi xation and do not reduce articular surfaces. In these instances, quite common; if mild, it does not affect acceptably with ligamentotaxis, hemi- there is no solid dorsal cortex to which functional outcomes.42,55 hamate arthroplasty provides a treat- the hamate autograft can be fi xed. The limited reports in the literature ment option. In essence, this procedure Relative contraindications include reveal mean motion arcs between 62° replaces comminuted bone and bony near-complete fractures of the middle and 90°.42,55,57,58 Less motion can be an- fragments that have been deformed phalanx that leave only a small dorsal ticipated for revision or delayed cases. over time with a single osteochondral rim of intact surface and those injuries

with additional sagittal fracture lines vi- sualized on AP imaging.60 In such cases, there is little remaining bone dorsally and, provided that the articular surface radius of curvature of the native middle phalanx is only 45% to 61% of the hamate, the replacement of the entire articular surface cannot be expected with the relatively fl atter hamate.61 Fractures with substantial extension into the volar diaphysis of the middle phalanx should be approached with caution because of the large bony void likely to be encoun- tered and the potential involvement of the insertion of the fl exor digitorum superfi cialis.

Surgical Technique The surgical technique for hemihamate arthroplasty has been described previ- ously.62-64 Surgical exposure for hemi- Figure 8 Illustrations showing the donor site and the recipient site at the hamate arthroplasty can be identical volar middle phalanx. Dimensions of the graft to be harvested are shown in the appropriate orientation with respect to the defect size dimensions to that used for ORIF and volar plate (A, B, and C). CMC = carpometacarpal, MC = metacarpal, PIP = proximal arthroplasty. A large volar V-shaped in- interphalangeal. (Reproduced with permission from Calfee RP, Kiefhaber cision is centered at the PIP joint, ex- TR, Sommerkamp TG, Stern PJ: Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture- tending distally and proximally to the dislocations. J Hand Surg Am 2009;34[7]:1232-1241.) dorsal interphalangeal fl exion crease and the metacarpal-phalangeal fl exion crease, respectively. Both neurovascular phalanx medially and laterally to obtain preparation is somewhat triangular and bundles should be exposed and isolated. a complete release. The PIP joint can becomes less deep moving distally away In chronic injuries, these bundles are then be hyperextended (or shotgunned) from the joint; this facilitates canting encased in fi brotic tissues, and release to visualize both articular surfaces as the graft appropriately during insetting. is necessary to prevent traction injury the fl exor tendons fall to one side. In The remaining defect is measured for during joint exposure. With the fl exor chronic cases, tenolysis of the extensor its width, depth, and length (Figure 8). pulley system exposed, a surgical win- tendon is accomplished at this point The PIP joint is taken out of hyperex- dow is opened between the A2 and by passing a Freer elevator along the tension during hamate harvest. A4 pulleys. The fl exor tendons are re- proximal phalanx just deep to the ex- The hamate harvest can be accom- tracted to either side while the lateral tensor mechanism. Comminuted bony plished through a transverse or a lon- border of the volar plate and its distal fragments are excised to leave a smooth gitudinal skin incision over the fourth insertion are released. The collateral lig- surface to receive the hamate autograft, and fi fth carpometacarpal (CMC) aments are released off the proximal leaving small bony lips on the medial joint. Care should be taken in the sub- phalanx. The most effi cient release of and lateral surfaces of the middle pha- cutaneous tissues to preserve the sen- these collateral ligaments is done with lanx if possible. The remaining articular sory branches of the dorsal cutaneous a scalpel, starting within the joint and surface is débrided as needed to provide branch of the ulnar nerve. The CMC then passing proximally deep to the a transverse base on which to place the capsule should be sharply incised lon- collateral ligament along the proximal autograft. The ideal bony defect after gitudinally and elevated subperiosteally

surrounding periosteum and the pulley remnant. The skin is closed in routine fashion, and a dorsal blocking splint applied.

Postoperative Care and Outcomes Patients are started on early active ROM within 1 week, with a dorsal blocking splint preventing the fi nal 15° of extension at the PIP joint. Elastic garments are helpful for edema control. The patient pursues active motion within the confi nes of the splint, with more ag- Figure 9 The hemihamate graft is contoured and secured to the remain- gressive passive ROM done at 6 weeks ing portion of the middle phalanx via small screws. It is important to cant the allograft to restore the stabilizing buttress effect of the volar cortex of the or coinciding with radiographic union. middle phalanx. PIP = proximal interphalangeal. (Reproduced with permission Outcomes of hemihamate arthro- from Calfee RP, Kiefhaber TR, Sommerkamp TG, Stern PJ: Hemi-hamate plasty are documented in only small se- arthroplasty provides functional reconstruction of acute and chronic proximal 59 interphalangeal fracture-dislocations. J Hand Surg Am 2009;34[7]:1232-1241.) ries. Hastings et al originally described fi ve cases with a resultant 77° of PIP joint ROM. In a series of 22 patients fol- off the dorsal hamate and the base of graft such that the volar buttress is re- lowed at a mean of 4.5 years, these joints the fourth and fi fth metacarpal. This stored compared with creating a fl at had an average 19° fl exion contracture exposure should allow centering of the volar surface for the PIP joint. The and mean PIP fl exion of 89° (PIP arc harvested hamate on its central ridge graft may be held provisionally with a 70°).60 The PIP joint is expected to be between the fourth and fi fth meta- K-wire before defi nitive fi xation with somewhat larger than the contralateral carpal. The desired graft size is then two to three screws, typically 1.3 mm side with well-preserved dorsal inter- marked, and initial bony cuts can be or 1.5 mm in size (Figure 9). The joint phalangeal joint motion. Patient-rated planned with K-wire puncture followed is then reduced, and stability is checked outcomes are generally positive, with by an osteotome or simply cutting with through a range of motions. Fluoros- Disabilities of the Arm, Shoulder and an oscillating saw (Figure 8). Before copy should be used to demonstrate Hand scores less than 10, which indicate harvesting the actual graft, it is helpful that the volar buttress was restored and minimal upper extremity disability, and to remove a rectangular portion of the the screw lengths are appropriate. The visual analog pain ratings less than 2 of dorsal hamate just proximal to the in- articular cartilage on the distal hamate a possible 10. Potential complications— tended graft to allow entry of a small is often thicker than that on the prox- including lack of motion, iatrogenic curved osteotome to divide the deep imal middle phalanx, which results in fracture of the dorsal middle phalanx, portion of the graft.60 This deeper en- a radiograph that demonstrates a graft and fl exor pulley insuffi ciency—are try point will allow harvest of a more that is slightly depressed, although di- possible and may necessitate salvage rectangular graft compared with a tri- rect vision will confi rm appropriate procedures. These outcomes are con- angular graft. The CMC capsule may alignment of the articular cartilage sistent with another small series from be closed after harvest. between the hamate and the native Switzerland, although revision proce- The graft is then placed in the middle phalanx. The palmar-distal dures were performed in 4 of their 10 defect of the middle phalanx (dorsal prominence of the graft in the meta- patients (PIP arthrolysis, screw short- hamate cortex now forming volar mid- physeal region can be contoured gently ening, and neurolysis of the dorsal cu- dle phalanx cortex), with the PIP joint with a rongeur. The distal corners of taneous ulnar nerve).65 When PIP joints hyperextended, taking care to cant the the volar plate are then repaired to the are treated on a chronic basis, outcomes

can be quite acceptable, although they proximal interphalangeal joint. J Hand traction system. J Hand Surg Br Surg Am 1991;16(5):844-850. 1997;22(6):730-735. are expected to be slightly more mod- est than in acute cases. Notably, in the 3. McElfresh EC, Dobyns JH, O’Brien 14. De Smet L, Boone P: Treatment of ET: Management of fracture-dis- fracture-dislocation of the proximal three chronic cases that lost PIP mo- location of the proximal interpha- interphalangeal joint using the Su- tion after hemihamate arthroplasty, langeal joints by extension-block zuki external fi xator. J Orthop Trauma all had preoperative PIP motion arcs splinting. J Bone Joint Surg Am 2002;16(9):668-671. 1972;54(8):1705-1711. greater than 45°. Series by Calfee et al60 15. Deshmukh SC, Kumar D, Mathur K, and Afendras et al66 have documented 4. Hastings H II, Carroll C IV: Treat- Thomas B: Complex fracture-disloca- ment of closed articular fractures of tion of the proximal interphalangeal radiographic outcomes with joint space the metacarpophalangeal and proxi- joint of the hand: Results of a modi- narrowing frequently observed at 4 to mal interphalangeal joints. Hand Clin fi ed pins and rubbers traction system. 5 years, with advanced arthritis in two 1988;4(3):503-527. J Bone Joint Surg Br 2004;86(3):406-412. of eight patients, although this fi nding 5. Hamer DW, Quinton DN: Dorsal 16. Duteille F, Pasquier P, Lim A, Dautel G: Treatment of complex failed to correlate with patient-rated fracture subluxation of the proximal interphalangeal joints treated by interphalangeal joint fractures outcomes. extension block splintage. J Hand Surg with dynamic external traction: A To date, donor-site morbidity in the Br 1992;17(5):586-590. series of 20 cases. Plast Reconstr Surg 2003;111(5):1623-1629. form of CMC joint instability or ar- 6. Strong ML: A new method of throsis requiring salvage has not been extension-block splinting for the 17. Ellis SJ, Cheng R, Prokopis P, et al: proximal interphalangeal joint: Treatment of proximal interphalange- reported after harvest of the dorsal Preliminary report. J Hand Surg Am al dorsal fracture-dislocation injuries hamate. This is likely secondary to the 1980;5(6):606-607. with dynamic external fi xation: A pins large articular surface of the hamate and rubber band system. J Hand Surg 7. Agee JM: Unstable fracture disloca- Am 2007;32(8):1242-1250. relative to that needed for hemihamate tions of the proximal interphalan- arthroplasty (such that only 26% of the geal joint: Treatment with the force 18. Fahmy NR: The Stockport Serpentine couple splint. Clin Orthop Relat Res Spring System for the treatment of hamate articular surface is routinely re- 1987;214:101-112. displaced comminuted intra-articular quired) and the CMC joints have re- phalangeal fractures. J Hand Surg Br 8. Agee JM: Unstable fracture disloca- 1990;15(3):303-311. tained mechanical stability after harvest tions of the proximal interphalangeal in cadaver investigations.61,67 joint of the fi ngers: A preliminary 19. Fahmy NR, Kenny N, Kehoe N: report of a new treatment technique. J Chronic fracture dislocations of the Hand Surg Am 1978;3(4):386-389. proximal interphalangeal joint: Treat- Summary ment by the “S” Quattro. J Hand Surg Dorsal PIP fracture-dislocations can 9. Allison DM: Fractures of the base of Br 1994;19(6):783-787. the middle phalanx treated by a dy- be challenging to treat. There are many namic external fi xation device. J Hand 20. 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