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Dorsal Proximal Interphalangeal Joint Fracture- Dislocations: Evaluation and Treatment

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Dorsal Proximal Interphalangeal Joint Fracture- Dislocations: Evaluation and Treatment 23 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 © 2015 AAOS Instructional Course Lectures, Volume 64 261 Hand and Wrist 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 262 © 2015 AAOS Instructional Course Lectures, Volume 64 Dorsal Proximal Interphalangeal Joint Fracture-Dislocations: Evaluation and Treatment Chapter 23 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 main- taining 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.
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