Table of contents
Part I Surgical approach
Front matter
1 Foreword
V
Preface
VI
Acknowledgments
X
VII
Contributors
VIII
Abbreviations
IX
Approaches
3
1.1 Dorsal approach to the MCP joint of the finger
5
1.2 Midaxial approach to the proximal phalanx
9
1.3 Dorsal approach to the proximal phalanx
13
1.4 Palmar approach to the PIP joint
19
1.5
Midaxial approach to the PIP joint
27
1.6
Dorsal approach to the PIP joint
33
1.7
Midaxial approach to the middle phalanx
41
1.8
Dorsal approach to the middle phalanx
47
1.9
Palmar approach to the DIP joint
53
1.10 Dorsal approach to the DIP joint
57
1.11 Dorsal approach to the MCP joint of the thumb
63
1.12 Dorsoulnar approach to the MCP joint of the thumb
67
1.13 Dorsal approach to the IP joint of the thumb
73
1.14 Radiopalmar approach to the thumb base
77
1.15 Dorsal approach to the metacarpals
83
1.16 Dorsal approach to the thumb metacarpal
87
1.17 Dorsoradial approach to the 2nd metacarpal
91
1.18 Dorsal approach to the 5th metacarpal
95
1.19 Dorsoulnar approach to the 5th metacarpal base
99
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
Table of contents
Part II Cases 2 2.1
Proximal phalanx Proximal phalanx, base—articular fracture treated with an LCP T-plate and bone graft
2.2
105
palmar lag screw
265
277
3.3 PIP fracture dislocation—central impaction treated 129
with screws 3.4
137
2.5 Proximal phalanx, base—avulsion fractures treated with tension band wiring
263
3.2 PIP fracture dislocation—treated with a
2.4 Proximal phalanx, base—open intraarticular fracture treated with lag screws
external fixation
119
2.3 Proximal phalanx, base—vertical shearing fracture treated with lag screws
Proximal interphalangeal (PIP) joint
3.1 PIP fracture dislocation—treated with lag screws or 107
Proximal phalanx, base—articular fracture treated with a minicondylar plate and bone graft
3
291
PIP fracture dislocation—reconstruction with hemihamate arthroplasty
299
3.5 PIP fracture dislocation—malunion treated with osteotomy 143
and lag screw
313
4
Middle and distal phalanx
323
4.1
Middle phalanx—open fracture with bone loss treated
2.6 Proximal phalanx, base—avulsion fracture treated with a lag screw
151
2.7 Proximal phalanx, metaphysis—oblique fracture treated with a minicondylar plate
159
2.8 Proximal phalanx, metaphysis—transverse fracture treated with a locking T-plate
171
with bridging plate and bone graft
2.9 Proximal phalanx, metaphysis—unstable fracture treated with percutaneous K-wire
179
with minicondylar plates
185
193
329
4.3 Distal phalanx—mallet fracture treated with Ishiguro percutaneous K-wire
2.11 Proximal phalanx, diaphysis—transverse fracture treated with a minicondylar plate
4.2 Middle phalanx—unicondylar fracture treated with a lag screw
2.10 Proximal phalanx, metaphysis—multiple fractures treated
325
4.4 Distal phalanx—mallet fracture treated with a lag screw
337 347
2.12 Proximal phalanx, diaphysis—spiral fracture treated with lag screws
203
2.13 Proximal phalanx, diaphysis—open multifragmentary fracture treated with a bridging plate
215
2.14 Proximal phalanx, distal metaphysis—transverse neck fracture treated with a minicondylar plate
229
2.15 Proximal phalanx—unicondylar fracture treated with lag screws
239
2.16 Proximal phalanx—bicondylar fracture treated with lag screws
251
2.17 Proximal phalanx—bicondylar fracture with malunion treated with osteotomy and lag screws
257
XI
Table of contents
5
Thumb
359
5.1 Thumb proximal phalanx—long oblique fracture treated with lag screws
5.4
XII
461
473
6.5 Metacarpal—subcapital fracture treated with intramedullary K-wires
481
6.6 Metacarpal, head—intraarticular fracture treated with 409
screws 6.7
417
489
Metacarpal, base—intraarticular fracture treated with a T-plate
497
6.8 Metacarpal, neck—malunion treated with osteotomy, 423
tension band suture, and intramedullay K-wire
509
6.9 Metacarpal, shaft—nonunion treated with LCP and 433
5.10 Thumb proximal phalanx—atrophic nonunion treated with a minicondylar plate
with a bridging plate
397
5.9 Thumb proximal phalanx—complex fracture with bone loss treated with combined fixation
449
6.4 Metacarpal, shaft—multifragmentary fracture treated
5.8 Thumb metacarpal, base—malunion treated with osteotomy and LCP
screw and neutralization plate
389
5.7 Thumb metacarpal, base—multifragmentary articular fracture treated with an external fixator
443
6.3 Metacarpal—short oblique fracture treated with a lag
5.6 Thumb metacarpal, base—Rolando three-part articular fracture treated with an LCP T-plate
interfragmentary lag screws
381
5.5 Thumb metacarpal, base—Bennett fracture treated with lag screws
441
6.2 Metacarpal—long oblique fracture treated with
Thumb metacarpal, base—Bennett fracture treated with closed reduction and percutaneous K-wire
an LCP
373
5.3 Thumb metacarpal, base—extraarticular fracture treated with an LCP condylar plate
Metacarpals
6.1 Metacarpal—transverse fracture treated with 361
5.2 Thumb proximal phalanx—pilon fracture treated with an LCP T-plate
6
bone graft
517
6.10 Metacarpal, base—fracture with delayed union treated 437
with a lag screw, neutralization plate, and bone graft
525
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
Table of contents
Appendix 7
Complex injuries
535
7.1 Proximal phalanx rotational deformity treated with osteotomy and T-plate
Further reading
553
537
7.2 Transmetacarpal amputation treated with replantation and internal fixation with T-plates and K-wires
545
XIII
1.1 Dorsal approach to the MCP joint of the finger 1 Surgical approach Fig 1.1-1 Injuries involving the metacarpophalangeal (MCP) joint of the finger can be treated using a dorsal approach.
2 Indications
The dorsal approach to the MCP joint is indicated for injuries of the MCP collateral ligaments (a) (either avulsion fractures or ligament ruptures), and intraarticular fractures of the metacarpal head or intraarticular or extraarticular fractures of the base of the proximal phalanx (b). Fig 1.1-2a–b
a
b
5
Part I Surgical approaches
3 Surgical anatomy Fig 1.1-3 The tendons of the extensor digitorum and the extensor hood cover the MCP joints dorsally. The extensor tendon receives the insertions of the tendons of the interosseous and lumbrical muscles via the extensor hood.
Tendon of the lumbrical muscle
Proximal to the index MCP joint, the extensor indicis tendon lies ulnar to the extensor digitorum tendon, and at the little finger, the extensor digiti minimi tendon is ulnar to the extensor digitorum tendon.
Tendons of the interosseus muscles
Oblique and Transverse fibres of the extensor hood (sagittal band) Tendon of the extensor digitorum
Dorsal interosseus muscle
4 Skin incision Fig 1.1-4 Make a gently curved longitudinal incision over the MCP joint. Depending on the fracture pattern, the incision is placed over the dorsoradial or dorsoulnar aspect of the MCP joint. In general, a radially curved incision is preferred over the second MCP joint, as is a dorsoulnar curved incision over the fifth MCP joint.
Extension of the incision Fig 1.1-5 If necessary, the incision can be extended distally or proximally in a curvilinear or longitudinal manner.
6
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
1 Approaches 1.1 Dorsal approach to the MCP joint of the finger
4 Skin incision (cont) Exposure of the extensor apparatus Fig 1.1-6 The skin flap is elevated from the extensor apparatus, without damaging the surrounding loose connective tissue, the sensory nerve branches, or the longitudinal veins.
Exposure of the joint capsule Fig 1.1-7 The extensor digitorum tendon can be split longitudinally. In the index and little fingers, the incision can be made between the two extensor tendons. Alternatively, the extensor hood can be incised parallel to the extensor digitorum tendon, leaving a small fringe for subsequent repair. Depending on the fracture pattern, the incision is dorsoulnar or dorsoradial. In general, a dorsoulnar incision is preferable to prevent subluxation of the extensor tendon to the ulnar side, should the repair fail.
7
Part I Surgical approaches
4 Skin incision (cont) Capsulotomy Fig 1.1-8 A longitudinal capsulotomy is made to open the MCP joint.
5 Wound closure
The joint capsule is repaired with fine sutures. The extensor tendon can be repaired with a running suture, using either slowly resorbable or nonresorbable material.
Fig 1.1-9a–b
a
b
Video
Video 1.1-1 This video provides a demonstration of a dorsal approach to the MCP joint of the finger.
8
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
1.2 Midaxial approach to the proximal phalanx
1 Surgical approach Fig 1.2-1 Injuries involving the proximal phalanx can be treated using a midaxial approach.
2 Indications Fig 1.2-2a–f The midaxial approach is indicated for oblique (a–b), spiral (c), multifragmentary (d), or transverse fractures of the diaphysis (e) and metaphysis (f). It may also be indicated for proximal metaphyseal fractures.
A midaxial approach to the proximal phalanx of the thumb is also possible.
a
b
c
d
e
f
9
Part I Surgical approaches
3 Surgical anatomy Nerve identification Fig 1.2-3 Identify and protect the dorsal branches of the radial, ulnar, and median nerves.
4 Planning the incision Fig 1.2-4 To plan the line of the incision, fully flex the finger as shown and mark the dorsal ends of the flexor creases with dots.
Fig 1.2-5 Extend the finger and connect the dots in a line. The resulting line is safe for a skin incision. The digital artery and digital nerve will lie palmar to this line.
10
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
1 Approaches 1.2 Midaxial approach to the proximal phalanx
5 Skin incision Fig 1.2-6 For proximal fractures, make a skin incision from B to C. For further exposure, the incision can be extended to A.
Retraction of the oblique fibers of the lateral band Fig 1.2-7 Retract the oblique fibers of the lateral band using two retractors.
Fig 1.2-8 Try to preserve the periosteum, which should be elevated only immediately adjacent to the fracture line in order to avoid scar formation, tendon adhesion, and fragment devascularization.
Alternative: resection of the oblique fibers of the lateral band Fig 1.2-9 It is occasionally necessary, in order to view very proximal fractures, to resect unilaterally oblique fibers of the lateral band. This resection also avoids impingement with the planned implant and intrinsic tendon adhesions.
11
Part I Surgical approaches
5 Skin incision (cont) Palmar access Fig 1.2-10a–b Avoid penetration of the flexor tendon sheaths. In cases of tendon laceration, however, the midaxial approach can be used in order to perform tendon repair.
a
b
Video
Video 1.2-1 This video provides a demonstration of the midaxial approach to the proximal phalanx.
12
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
1.3 Dorsal approach to the proximal phalanx
1 Surgical approach Fig 1.3-1 Injuries involving the proximal phalanx can be treated using a dorsal approach.
2 Indications
The dorsal approach is indicated to access intraarticular (a–b), metaphyseal (c), or diaphyseal (d) fractures of the proximal phalanx, or any basal intraarticular fracture extending into the metaphysis or diaphysis (e). Fig 1.3-2a–e
A dorsal approach to the proximal phalanx of the thumb is also possible.
a
b
c
d
e
13
Part I Surgical approaches
3 Surgical anatomy Nerve identification
Blunt dissection extends the approach through the thin subcutaneous tissue, taking care to identify and protect the dorsal sensory branches of the radial, ulnar, and median nerves.
Fig 1.3-3a–b
a
b
Vein identification Fig 1.3-4 The dorsal venous system of the fingers has longitudinal and transverse branches. Be careful to preserve the longitudinal branches. The transverse branches may be ligated, or cauterized with a bipolar cautery, for better exposure, but preserve as many dorsal veins as possible to avoid venous congestion and swelling.
14
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
1 Approaches 1.3 Dorsal approach to the proximal phalanx
4 Skin incision Straight skin incision Fig 1.3-5 Make a straight skin incision, starting at the metacarpophalangeal joint, ending at the proximal interphalangeal (PIP) joint. Depending on the fracture geometry, the incision may be shorter. With this incision, vascularity and venous drainage are well preserved. If a longer incision is needed proximally, a curved skin incision may be indicated.
With the straight skin incision, early postoperative motion will prevent scarring between skin, tendon, and bone. However, the disadvantage of this incision is that any skin and tendon scarring will be in the same line.
Alternative: curved skin incision Fig 1.3-6 Alternatively, make a gently curved skin incision extending from the proximal phalangeal base to the PIP joint. The convexity of the incision is planned so that the scar does not involve the radial border of the index, or the ulnar border of the little finger. The fracture configuration and implant placement must be taken into account when planning the incision.
Fig 1.3-7 The advantage of the curved incision is that the skin and tendon scarring are not in the same line. The disadvantage is reduced vascularity at the apex of the curve, with a risk of necrosis and delayed skin healing.
Potential scar adhesion
Necrosis
15
Part I Surgical approaches
4 Skin incision (cont) Tendon splitting
Split the extensor tendon apparatus along the midline longitudinal fibers of the tendon. Avoid detaching the central slip insertion at the base of the middle phalanx as this could result in a secondary boutonnière deformity. The tendon incision is allowed to go as far distally as the bony ridge of the dorsal rim.
Fig 1.3-8a–b
Central slip insertion
a
b
Alternative incision Fig 1.3-9 Alternatively, the incision may be placed between the lateral band and the central slip of the extensor tendon.
16
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
1 Approaches 1.3 Dorsal approach to the proximal phalanx
4 Skin incision (cont) Fracture exposure Fig 1.3-10a–b Retract the tendon to expose the fracture site. Try to preserve the periosteum, which should be elevated only adjacent to the fracture line.
a
b
a
b
5 Wound closure Suturing the tendon Fig 1.3-11a–b After finishing the osteosynthesis, complete the procedure by closing the tendon incision using multiple fine mattress sutures, as shown in the illustrations, or with a running suture.
Video
Video 1.3-1 This video provides a demonstration of the dorsal approach to the proximal phalanx.
17
2.1 Proximal phalanx, base—articular fracture treated with an LCP T-plate and bone graft 1 Case description
a
a Fig 2.1-2a–d
Fig 2.1-1a–b A 59-year-old retired teacher suffered a multifragmentary articular fracture of the proximal phalanx of her ring finger, sustained while wrestling with a burglar. The AP and oblique x-rays showed a fracture at the base of the proximal phalanx.
b
b
c
d
Frontal and sagittal CT scans further showed the complex fracture.
107
Part II Cases
2 Indications
a
b
Fig 2.1-3a–b When vertical compression forces created by axial load are applied to the finger, multifragmentary intraarticular compression fractures can result. These fractures are very unstable. Typically, they involve centrally impacted multifragmentary fractures (a) or have T or Y-shaped fracture geometry (b). It is desirable to obtain stable fixation to allow early motion and to minimize the risk of degenerative joint disease.
3 Preoperative planning Equipment
Patient preparation and positioning
• LCP modular hand set 2.0 • 0.8 mm K-wires • Autogenous bone graft equipment.
Fig 2.1-4
Pronate the forearm on the hand table. Nonsterile pneumatic tourniquet. Prophylactic antibiotics are optional.
4 Surgical approach
a Fig 2.1-5 The surgical approach used was a dorsal approach (see chapter 1.1 Dorsal approach to the MCP joint of the finger).
108
b
Fig 2.1-6a–b
Intraoperative images show that a median incision was performed through the extensor tendon creating a central tendon split approach.
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
2 Proximal phalanx 2.1 Proximal phalanx, base—articular fracture treated with an LCP T-plate and bone graft
5 Reduction Direct reduction
Disimpact the fragments
a Fig 2.1-7
Compression fractures are not reducible by ligamentotaxis as the centrally impacted fragments are devoid of soft-tissue attachments. Direct reduction is therefore necessary. The key to fixing compression fractures is restoring the joint surface to as close to normal as possible, and supporting the reduction with a bone graft and internal fixation.
b
Fig 2.1-8a–b
Using a K-wire or dental pick, the fragments are disimpacted and pushed towards the head of the metacarpal, which is used as a template to ensure congruity of the articular surface of the phalanx. If a cartilage step-off greater than 1 mm remains, degenerative joint disease could follow. Since the metaphyseal cancellous bone is impacted, a void could be created by its disimpaction. This jeopardizes the fracture in two ways: • A very unstable situation exists in which the fragments can easily redisplace (collapse) • The healing process is delayed. The void should therefore be filled with cancellous bone taken from the distal radius.
Fig 2.1-9 A defect was present following reduction of the impacted articular surface of the patient’s finger.
109
Part II Cases
5 Reduction (cont) Bone graft
Lister’s tubercle Fig 2.1-10 Harvest the graft material from the distal radius. A good and safe place is proximal and slightly radial to Lister’s tubercle.
Harvesting
2 cm
Fig 2.1-11 Make a 2 cm longitudinal incision proximal to Lister’s tubercle. Retract the tendons of the second compartment radially, and the extensor pollicis longus in an ulnar direction.
110
Fig 2.1-12 Use a chisel to cut three sides of a small square. Lift the dorsal radial cortex as a flap. After harvesting cancellous bone, replace the “lid” and suture the periosteum and the skin incision.
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
2 Proximal phalanx 2.1 Proximal phalanx, base—articular fracture treated with an LCP T-plate and bone graft
5 Reduction (cont) Impact the graft
Fig 2.1-13
Use a pusher instrument to impact the bone graft and fill the whole fracture cavity. Confirm reduction using image intensification.
6 Fixation Plate selection and application
a
b
Fig 2.1-14a–b Select a suitable plate, such as an LCP T-plate (a) or (T-shaped) LCP condylar plate (b). The plate is placed dorsally on the phalanx, as proximally as possible, without interfering with the joint. Ensure that the plate is centered on the long axis of the diaphysis. For this patient, an LCP T-plate 2.0 was used and will be demonstrated.
111
Part II Cases
6 Fixation (cont) Bending and contouring the plate for T and Y-shaped articular fractures
Bending and contouring the plate for multifragmentary articular fractures
a
a
b
b Fig 2.1-15a–b The dorsal surface of the proximal phalanx is gently convex. In T and Y-shaped articular fractures, the plate should therefore be slightly overcontoured so that when the screws are tightened, compression can be exerted on the opposite cortex and is generated evenly across the whole fracture surface (a). If the plate is not adequately contoured to follow this convexity and the geometry at the base of the phalanx, tightening of the screws will result in fracture distraction creating a gap in the opposite cortex (b).
Fig 2.1-16a–b In multifragmentary fractures, it is important to contour the plate to perfectly fit the bone (a). Neither compression nor distraction forces should occur through screw tightening, as the reduction would again be compromised (b).
However, this can only be applied in fractures with large fragments, never in small-fragment multifragmentary fractures, as the reduction could be compromised or collapse.
If compression is exerted on the multifragmentary zone in the sagittal plane by overbending the plate, angulation of the finger will result.
Pitfall: angulation
Drill proximal hole
Fig 2.1-17a–b
a
112
b
When a locking head screw is used, use a threaded drill guide and carefully drill a first hole for a screw through the transverse part of the plate with a 1.5 mm drill bit (for a 2.0 mm screw). Repeat for the second hole in the transverse part.
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
2 Proximal phalanx 2.1 Proximal phalanx, base—articular fracture treated with an LCP T-plate and bone graft
6 Fixation (cont) Measure proximal screw length
10
20
80
Pitfall: tendons and vessels
Fig 2.1-18
Be sure not to injure the flexor tendons and digital artery and nerve.
Screw selection
b
Headless
c
Locking
d
There is a wide variety of screws available for the treatment of fractures, and screw selection can depend on the indications, the selected plate, or even the manufacturer. For example, cortex screws (a–b) can be self-tapping, which facilitates screw insertion without the need for using a tap after drilling, headless screws (c) are mainly used in intraarticular fractures, while the threads of a locking head screw (d) engage into the threads of a locking hole for angular stable plate fixation. While the illustrations in this publication provide a guide to screw selection, the surgeon should nevertheless always ensure they are familiar with the specific recommended screws and specifications of any implant being used. Fig 2.1-20a–d
Use a depth gauge to determine screw length.
Insert proximal screw
Cortex
a
Fig 2.1-19
Fig 2.1-21 Insert the first proximal screw. Ensure that it engages the far cortex but does not protrude into the fibro-osseous flexor digital channel, where the flexor tendons run. Insert a second screw into the opposite end of the transverse plate section, in the same fashion, alternately tightening both screws.
113
Part II Cases
6 Fixation (cont)
114
Pitfall: screw convergence
Drill for distal screw
Fig 2.1-22
Conflict of tips of the screws in the transverse part of the plate and joint penetration must be avoided.
Fig 2.1-23
Measure distal screw length
Insert distal screw
Fig 2.1-24
Fig 2.1-25
Use a depth gauge to determine screw length.
Use a threaded drill guide and 1.5 mm drill bit to prepare a neutral screw hole at the distal end of the plate. As shown here, a locking head screw can also be inserted at the most distal plate hole. In multifragmentary fractures, compression from eccentric drilling is not recommended.
Insert a 2.0 mm self-tapping screw and tighten it. Drilling is neutral and therefore there is no axial compression when the screw is tightened.
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
2 Proximal phalanx 2.1 Proximal phalanx, base—articular fracture treated with an LCP T-plate and bone graft
6 Fixation (cont) Complete the fixation
a
b
Fig 2.1-26a–b
To complete the fixation, drill for another more proximal diaphyseal screw (a) and insert a standard screw in neutral position (b). When placing a standard cortex screw, a standard drill sleeve is used.
a Fig 2.1-27a–b
b
The fracture fixation was conducted using a dorsally applied LCP T-plate 2.0 (a). Note that an interfragmentary screw was also inserted across the articular fragments to help support the reduction (b).
a Fig 2.1-28a–b
b
The extensor mechanism was then carefully
closed.
115
Part II Cases
6 Fixation (cont)
a
b
Fig 2.1.29a–b
Postoperative AP and oblique x-rays.
7 Rehabilitation Aftercare
Follow-up
See the patient after 2–5 days to change the dressing. After 10 days, remove the sutures and confirm with x-rays that no secondary displacement has occurred.
Functional exercises
Fig 2.1-30 While the patient is in bed, use pillows to keep the hand elevated above the level of the heart to reduce swelling. For ambulating patients, put the arm in a sling and elevate above the heart.
Fig 2.1-31 As pain and swelling recede, early active controlled digital range of motion exercises (six-pack exercises) gently progress. The importance of mobilization must be emphasized to the patient and rehabilitation should be supervised by a physical therapist.
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Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
2 Proximal phalanx 2.1 Proximal phalanx, base—articular fracture treated with an LCP T-plate and bone graft
8 Outcome
a Fig 2.1-32a–d
a Fig 2.1-33a–d
b
c
d
Postoperative AP and lateral x-rays at the 4-year follow-up.
b
c
d
There was anatomical reduction of the articular surface and an excellent functional result.
117
Part II Cases
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Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
2.2 Proximal phalanx, base—articular fracture treated with a minicondylar plate and bone graft 1 Case description
a
b
c
Fig 2.2-1a–c
A 37-year-old female architect sustained direct trauma to her left middle finger. The clinical appearance showed an angulated and rotated deformity.
Fig 2.2-2a–b
a
b
On inspection of the oblique and lateral x-rays, a multifragmentary intraarticular fracture became apparent.
119
Part II Cases
2 Indications
a
b
Fig 2.2-3a–b When vertical compression forces created by axial load are applied to the finger, multifragmentary intraarticular compression fractures can result. These fractures are very unstable. Typically, they involve centrally impacted multifragmentary fractures (a) or have T or Y-shaped fracture geometry (b). It is desirable to obtain stable fixation to allow early motion and to minimize the risk of degenerative joint disease.
3 Preoperative planning Equipment
• • • • •
120
Modular hand set 1.5 Minicondylar plate 1.5 0.8 mm K-wires Pointed reduction forceps Autogenous bone graft equipment.
Patient preparation and positioning
Fig 2.2-4 Pronate the forearm on the hand table. Nonsterile pneumatic tourniquet. Prophylactic antibiotics are optional.
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
2 Proximal phalanx 2.2 Proximal phalanx, base—articular fracture treated with a minicondylar plate and bone graft
4 Surgical approach
a Fig 2.2-5 The surgical approach used was a midaxial approach (see chapter 1.2 Midaxial approach to the proximal phalanx).
b
Fig 2.2-6a–b
The interval between the common extensor tendon and lateral band was identified.
5 Reduction Direct reduction
Disimpact the fragments
a Fig 2.2-7 Compression fractures are not reducible by ligamentotaxis, as the centrally impacted fragments are devoid of soft-tissue attachments. Direct reduction is therefore necessary. The key to fixing compression fractures is restoring the joint surface to as close to normal as possible, and supporting the reduction with a bone graft and internal fixation.
b
Fig 2.2-8a–b
Using a K-wire or dental pick, the fragments are disimpacted and pushed towards the head of the metacarpal, which is used as a template to ensure congruity of the articular surface of the phalanx. If a cartilage step-off greater than 1 mm remains, degenerative joint disease may follow. Since the metaphyseal cancellous bone is impacted, a void may be created by its disimpaction. This jeopardizes the fracture in two ways: • There is a very unstable situation in which the fragments can easily redisplace (collapse) • The healing process is delayed. The void should therefore be filled with cancellous bone taken from the distal radius. 121
Part II Cases
5 Reduction (cont) Bone graft
Lister’s tubercle Fig 2.2-9 Harvest the graft material from the distal radius. A good and safe place is proximal and slightly radial to Lister’s tubercle.
Harvesting
2 cm
Fig 2.2-10
Make a 2 cm longitudinal incision proximal to Lister’s tubercle. Retract the tendons of the second compartment radially, and the extensor pollicis longus in an ulnar direction.
122
Fig 2.2-11 Use a chisel to cut three sides of a small square. Lift the dorsal radial cortex as a flap. After harvesting cancellous bone, replace the “lid” and suture the periosteum and the skin incision.
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
2 Proximal phalanx 2.2 Proximal phalanx, base—articular fracture treated with a minicondylar plate and bone graft
5 Reduction (cont) Impact the graft
Option: K-wire
At this point, a K-wire can be inserted and used for temporary stabilization if needed.
Fig 2.2-12
Use a pusher instrument to impact the bone graft and fill the whole fracture cavity. Confirm reduction using image intensification.
Fig 2.2-13a–b
Intraoperative images of the reduction. intraoperative traction view shows incomplete articular reduction. b Anatomical reduction of the fracture by pointed reduction forceps. a The
a
b
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Part II Cases
6 Fixation Plate selection
Fig 2.2-14
For this patient, a minicondylar plate was chosen.
Determine location of drill hole
Fig 2.2-15
In order to determine the position of the first drill hole it can be very helpful to turn the plate over and use it as a template.
Trim the plate
Fig 2.2-16
The plate used as a template to determine the correct drill hole position.
Pearl: cut the blade transversely Recommended
Adapt the plate length to fit the length of the proximal phalanx. Avoid sharp edges, which can be injurious to the tendons. It is ideal to have at least two plate holes either proximal or distal to the fracture available for fixation, given that usually an additional plate hole is placed over the fracture zone with no screw inserted. At least two screws should be inserted into the diaphysis.
a
b
Fig 2.2-17a–b
When cutting the blade on the flat, it will compress and widen very slightly as it is cut (a). This makes its maximal width very slightly larger than 1.5 mm and may not fit in the 1.5 mm hole that has been drilled. Therefore, cut the blade on its edge (to deform it through its narrower dimension) to the correct length. The resultant tip is somewhat arrow-shaped (b).
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2 Proximal phalanx 2.2 Proximal phalanx, base—articular fracture treated with a minicondylar plate and bone graft
6 Fixation (cont) Contouring the plate
Fig 2.2-18 Use pliers to contour the plate so that it fits exactly to the anatomy of the base of the proximal phalanx. The plate was designed for condylar fractures and is precontoured to fit around a condyle. It has to be adapted for the less curved shape of the base of the proximal phalanx.
Drilling
a
b
Fig 2.2-19a–b Drill a 1.5 mm transverse hole through the base of the proximal phalanx adjacent to the joint surface as a track for the blade of the plate (a). The drill hole needs to be dorsal enough as to leave enough space for the plate’s most proximal screw hole (b).
Measure for length of the blade
Fig 2.2-20 Measure the length of the drill hole using a measuring device. Cut the blade to the determined length, so that it just fills the drill hole.
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6 Fixation (cont) Plate application
Align the plate with the diaphysis
Fig 2.2-21 Introduce the blade into the drill hole. Gently push with the thumb until the plate is fully seated.
Fig 2.2-22 Before inserting the first (distal) screw, ensure that the plate is in line with the phalangeal diaphysis in the sagittal plane by rotating it around the axis of the blade.
Drill distal hole
Insert distal screw
a Fig 2.2-23 Use a 1.1 mm drill bit to prepare the first neutral screw hole at the distal end of the plate. In multifragmentary fractures, compression from eccentric drilling is not recommended.
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b
Fig 2.2-24a–b
Measure the screw length and insert a self-tapping 1.5 mm screw. Drilling is neutral and therefore there is no axial compression when the screw is tightened.
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
2 Proximal phalanx 2.2 Proximal phalanx, base—articular fracture treated with a minicondylar plate and bone graft
6 Fixation (cont) Insert proximal screw
Complete the fixation
Fig 2.2-25 The proximal screw is inserted next in a neutral position. The screw should just engage the far cortex. Note, be careful to avoid screw protrusion through the far cortex, as ligament injury can result from friction during movement.
a
d
b
Fig 2.2-26 Insert further screws into the diaphyseal holes in a neutral position to finalize the fixation. In some indications, an oblique screw can be placed through the oblong hole of the plate with the purpose of increasing the stability of fixation.
c
e
Fig 2.2-27a–e
Intraoperative images of the plate application (a–d). The intraoperative x-ray shows the oblique screw through the oblong hole of the plate (e). This screw should just engage the far cortex at the base of the phalanx.
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7 Rehabilitation Aftercare
Functional exercises
Fig 2.2-28 While the patient is in bed, use pillows to keep the hand elevated above the level of the heart to reduce swelling. For ambulating patients, put the arm in a sling and elevate above the heart. Fig 2.2-29 As pain and swelling recede, early active controlled digital range of motion exercises (six-pack exercises) gently progress. The importance of mobilization must be emphasized to the patient and rehabilitation should be supervised by a physical therapist.
Follow-up
See the patient after 2–5 days to change the dressing. After 10 days, remove the sutures and confirm with x-rays that no secondary displacement has occurred.
8 Outcome
a
128
b
Fig 2.2-30a–b The 1-year follow-up showed an excellent functional result with restoration of normal anatomical alignment.
Manual of Fracture Management—Hand Jesse B Jupiter, Fiesky Nuñez, Renato Fricker
2.3 Proximal phalanx, base—vertical shearing fracture treated with lag screws 1 Case description
a
b
Fig 2.3-1a–b A 33-year-old industrial engineer suffered a complex vertical shearing fracture of the base of the proximal phalanx of his right thumb (plus other injuries) while playing sport. The AP and oblique x-rays show the shearing fracture of the thumb.
2 Indications
Fig 2.3-2 The mechanism of this fracture is a combination of compression and shearing forces. The patient usually presents with angular deviation and malrotation.
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3 Preoperative planning Equipment
• • • •
Patient preparation and positioning
Modular hand set 1.5 and 2.0 1.3 mm or 1.5 mm, and 2.0 mm screws 0.8 mm K-wire Pointed reduction forceps.
Fig 2.3-3
Pronate the forearm on the hand table. Nonsterile pneumatic tourniquet. Prophylactic antibiotics are optional.
4 Surgical approach
Fig 2.3-4
The surgical approach used was a dorsoulnar approach (see chapter 1.12 Dorsoulnar approach to the MCP joint of the thumb).
a
b
Fig 2.3-5a–b The intraoperative images show that, due to the location of the fracture, the approach taken was between the extensor tendon and the aponeurosis of the adductor pollicis.
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2 Proximal phalanx 2.3 Proximal phalanx, base—vertical shearing fracture treated with lag screws
5 Reduction Reduction by ligamentotaxis
Direct reduction
Fig 2.3-6
Fig 2.3-7
Often, the fracture can be reduced by applying traction via finger traps.
For more accurate reduction, small pointed reduction forceps are used gently to manipulate the fracture. Application of excessive force can result in fragmentation. Check reduction using image intensification. Note, anatomical reduction is important to prevent chronic instability or posttraumatic degenerative joint disease.
Fig 2.3-8
Direct reduction was applied by using pointed reduction forceps.
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6 Fixation Preliminary fixation by K-wire
Screw placement
x
x
x = Screw head diameter
x x x
Fig 2.3-9
Preliminarily fix the fragments by inserting a K-wire. Be careful to place it in such a way that it will not conflict with later screw placement.
Fig 2.3-10 Do not insert screws too close to the fracture apex or the subchondral bone. A minimal distance from the fracture line, equal to the screw head diameter, must be observed. Screw length needs to be adequate for the screw to penetrate and purchase in the opposite (trans) cortex.
Screw size selection
Screw length pitfalls
Thread hole
Gliding hole
1.5 mm
2.0 mm
1.1 mm
1.5 mm
1.0 mm
1.3 mm
0.8 mm
1.0 mm
Ensure that a screw of the correct length is used. Too short screws do not have enough threads to engage the far cortex properly, a problem that increases when self-tapping screws are used due to the geometry of their tips. Too long screws endanger the soft tissues, especially tendons and neurovascular structures; with self-tapping screws, the sharp cutting flutes are especially dangerous, and great care has to be taken that the flutes do not protrude beyond the cortical surface.
Fig 2.3-11
The exact size of the diameter of the screw used will be determined by the fragment size and the fracture configuration. There are various gliding hole and thread hole drill sizes for the different screws.
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2 Proximal phalanx 2.3 Proximal phalanx, base—vertical shearing fracture treated with lag screws
6 Fixation (cont) Drilling and alternative preliminary fixation
1.5 mm
Drill for distal screw
2.0 mm
Fig 2.3-12
Leaving the reduction forceps in place, drill a gliding hole as perpendicular to the fracture plane as possible, using a 2.0 mm drill bit for a 2.0 mm screw. Insert a 2.0 mm drill sleeve into the gliding hole. Use a 1.5 mm drill bit to drill a threaded hole in the opposite fragment, just through the far (trans) cortex. Leave the drill bit in the drill hole preliminarily to hold the reduction, if no K-wire has already been used for this purpose.
Fig 2.3-13 Drill a gliding hole for a second lag screw close to the distal apex of the fracture line. This screw, too, should be placed as perpendicularly to the fracture plane as possible, using a 1.3 mm drill bit for a 1.3 mm screw. Insert a 1.3 mm drill sleeve into the gliding hole. Then drill a threaded hole in the opposite fragment, just through the far (trans) cortex.
Insert proximal screw
Insert distal screw
a Fig 2.3-14
Leaving the second drill bit in situ, insert the proximal lag screw. Do not completely tighten it at this time. The screw should just penetrate the opposite (trans) cortex.
b
Fig 2.3-15a–b
Now insert the distal lag screw. This screw should also just penetrate the opposite cortex. Alternate tightening of the two lag screws helps to avoid tilting of the fragment, and applies even compression forces across the whole fracture surface. Check using image intensification. Reduction must be anatomical. Two screws must be used to offset any vertical shear forces that will displace the fracture. 133
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6 Fixation (cont) Use of lag screws
a
Pitfall: positioning
b
Fig 2.3-16a–b
Be sure to insert the screw as a lag screw, with a gliding hole in the near (cis) cortex, and a threaded hole in the far (trans) cortex (a). Inserting a screw across a fracture plane that is threaded in both cortices (position screw) will hold the fragments apart and apply no interfragmentary compression (b).
a
b
Fig 2.3-17a–b Small fracture fragments require perfect positioning of the screws (a). Vertical-type fragments may be subject to shear forces (b). The screws should be inserted from the smaller articular fragment into the diaphyseal and base fragment to guarantee perfect screw position. Note that one screw alone is often not able to withstand the rotational and axial shearing forces that occur during rehabilitation.
Fig 2.3-18
The articular surface was reduced under direct view and secured with two lag screws, one being a 2.0 mm screw adjacent to the joint and the other a 1.5 mm screw in a more distal location.
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2 Proximal phalanx 2.3 Proximal phalanx, base—vertical shearing fracture treated with lag screws
6 Fixation (cont)
a
Fig 2.3-19a–b
Intraoperative x-rays of the lag screw fixations.
b
7 Rehabilitation Aftercare
Follow-up
See the patient after 2–5 days to change the dressing. After 10 days, remove the sutures and confirm with x-rays that no secondary displacement has occurred.
Fig 2.3-20
While the patient is in bed, use pillows to keep the hand elevated above the level of the heart to reduce swelling. For ambulating patients, put the arm in a sling and elevate above the heart.
Splint
Functional exercises
A removable splint is initially recommended for such lag screw fixations to prevent the patient from strong flexion or grasping activities.
Fig 2.3-21
As pain and swelling recede, controlled flexion and extension exercises for the thumb gently progress. The importance of mobilization must be emphasized to the patient and rehabilitation should be supervised by a physical therapist.
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8 Outcome
a
b
c
d
Fig 2.3-22a–d At the 6-month follow-up, the shearing fracture had united and there was excellent functional recovery.
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