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Internal Fixation of Unstable Fracture Dislocations of the Proximal Interphalangeal JointFrom the Victorian Hand Surgery Associates, Cliveden Hill Hospital, 29 Simpson Street, East Melbourne, Victoria 3002, Australia Correspondence: Mr Stephen K.Y. Tham FRACS 29 Simpson St, East Melbourne, Victoria, 3002, Australia. Tel.: +61 3 94832588; fax: +61 3 94832575 E-mail: stham{at}bigpond.net.au
We report a group of 14 patients with fracture dislocations of the proximal interphalangeal joint with fracture fragments of adequate size to allow reduction of the proximal interphalangeal joint and internal mini screw fixation of the bone fragment attached to the palmar plate to the base of the middle phalanx. Three years after surgery, (range 25–52 months) the average total active range of motion of the proximal interphalangeal joint was 100° (range 65–115°) for the acute group (operation within 14 days of injury, n = 7) and 86° (range 60–110°) for the chronic group (operation on average 46 days after injury, range 21–120 days, n = 7). Longer delay from injury was associated with a decreased total range of motion (P = 0.028). Further subluxation occurred in three chronic group patients, one required further surgery. The key to successful treatment of this injury is the re-establishment of joint congruity and early mobilization. With appropriate patient selection, pain free, satisfactory range of motion can be achieved. There is a risk of persistent subluxation or dislocation, particularly if treatment is delayed.
Key Words: proximal interphalangeal joint • fracture dislocation • internal fixation
Unstable fracture dislocations of the proximal interphalangeal joint have an estimated incidence of 9 per 100,000 per year (Weiss, 1996). This injury presents a significant surgical challenge, due to the relative difficulty in achieving both anatomical reduction and fixation stable enough to facilitate early mobilization (Deitch et al., 1999; Weiss and Hastings, 1993). Various treatments have been described for complex intraarticular fractures or fracture dislocations of the proximal interphalangeal joint which employ transarticular skeletal traction (Agee, 1987; Hynes and Giddins, 2001; Johnson et al., 2004; Schenck, 1994; Suzuki et al., 1994) or closed reduction with temporary Kirschner wire (K-wire) fixation (Newington et al., 2001). These techniques may only be used in acute injuries. They necessitate repeated assessment to confirm the accuracy of reduction and employ a cumbersome external frame. There is also a significant incidence of pin-site infection (Bain et al., 1998; Duteille et al., 2003). Joint and fracture reduction is often incomplete. Open reduction and internal fixation of the palmar fragment has previously been reported in a pilot study using the AO/ASIF 2 mm screw (Green et al., 1992). This study presents the results of a subgroup of these injuries, both acute and chronic, treated between September 1997 and December 1999 by internal fixation of the palmar fragment using a 1.2 mm Leibinger® screw (Stryker-Leibinger, Berkshire, UK) with temporary K-wire stabilization of the proximal interphalangeal joint.
Seventeen patients underwent surgical treatment for fracture dislocation of a single proximal interphalangeal joint each over a 2 year period from September 1997 to December 1999 (Table 1). Three patients were not available for review; one patient declined to attend and two patients were overseas. Of the fourteen patients available for review, seven patients were treated acutely (interval from surgery less than 14 days) and seven underwent delayed treatment (interval from surgery greater than 14 days, average 46 days after injury). Preoperative X-rays confirmed the fracture configuration and the severity of the injury (Fig 1).
In acute injuries, closed reduction was attempted initially and fracture reduction and stability assessed using intraoperative radiography. Generally, fractures involving more than 30% of the articular surface were unstable (Hastings and Carroll, 1988; Weiss, 1996). A decision to proceed with internal fixation was made if there was a failure of closed reduction and the joint surface remained incongruous, or the joint remained unstable after reduction and the bone fragment attached to the volar plate ligament was considered large enough for internal fixation. Patients who presented more than 2 weeks after injury proceeded directly to internal fixation provided the bone fragment attached to the volar plate ligament was large enough for internal fixation. Surgery was performed through a volar zigzag incision. The A3 pulley was incised and reflected radial-wards, the flexor tendons were retracted and two longitudinal incisions were made in the volar plate (Fig 2). This allowed identification of the proximal interphalangeal joint and left the volar plate still attached to the fragment. A transverse incision of the periosteum distal to the fracture fragment allowed its complete mobilization.
In acute injuries, joint reduction was achieved by traction and holding the joint flexed, usually at 15–30° flexion. A 1.l mm K-wire was used to secure the proximal interphalangeal joint in flexion. It was inserted dorsally, abutting the middle phalanx and penetrating the margin of the articular surface of the proximal phalanx. Where this was not possible, a transarticular wire was used. The proximal interphalangeal joint reduction was confirmed with intraoperative radiography. In chronic cases, both collateral ligaments were released to facilitate joint reduction. Trial reduction of the volar plate fracture was then performed and checked radiologically. The fracture was held with a single Leibinger® Mini-fragment 1.2 mm self-tapping titanium cortical screw (Fig 3). The A3 pulley was repaired before skin closure. The joint was further protected in a plaster splint placed over the dorsum of the proximal interphalangeal joint.
In this series, the K-wire was removed, on average, at 12 days (range 4–21 days) after surgery. Our current practise is to remove the wires within 1 week in acute injuries and 2 weeks in chronic injuries. Following removal of the K-wire, the finger was placed in a hand-based dorsal extension block splint at 20° proximal interphalangeal joint flexion. Hand therapy was started with passive and active assisted flexion exercises and finger oedema control. If progress was slow after 2 weeks of therapy, intermittent use of a dynamic finger flexion device with rubber band traction to the distal palmar crease was introduced. At 4 weeks, the extension block splint was discarded and the joint allowed to extend. At 6 weeks, a dynamic extension splint, or safety pin splint, was used to correct any residual flexion contracture. The number of days between injury and surgery and the preoperative mobility were assessed by (retrospective) reference to the clinical notes by one of the two senior authors and recorded. At review, patients were issued with a questionnaire in which they recorded return to work and sport, pain and overall satisfaction. They also underwent clinical examination by an orthopaedic registrar. Assessment of proximal interphalangeal joint range of motion was done before surgery and proximal and distal interphalangeal joint range of motion at review using a goniometer. Finger overlap on flexion, indicating angulation or rotation deformities, was also recorded at review. AP and lateral radiographs of the proximal interphalangeal joint were taken and joint incongruity assessed. In this study, a good result was defined as total active range of motion of the proximal interphalangeal joint of greater than 80° (Fig 4) with joint incongruity of l mm or less at the fracture site and minimal, or no, pain. A poor result was a range of motion of this joint less than 80° and/or clinically significant pain, sufficient to affect the patient’s lifestyle.
Using total active range of motion as an outcome measure, the relationship between a delay of more than 14 days between injury and surgery and outcome was analysed using a two-sample Wilcoxon rank-sum test (with a P value equal to or less than 0.05 being statistically significant). The relationship between the duration of delay and outcome was analysed using the Pearson Product Moment Correlation test. Normality was assessed using the Kolmogorov–Smirnov test.
Fourteen patients with 14 single finger injuries were reviewed, on average, 39 months after surgery (range 25–52 months, S.D. 8.7 months, n = 14). There were 13 men and one woman (patient 2) with an average age of 30 (range 15–43) years. The dominant hand was involved in 11 patients. The ring finger was most commonly involved (8 patients). The most common cause of this injury was ball sports (Weiss and Hastings, 1993). Thirteen injuries were caused in this way, seven fingers having been injured playing Australian-rules football. The average interval from injury to surgery was 21 (range 3–46) days. Seven patients were operated on within 14 days of the injury (mean 7, range 3–14 days). Seven patients underwent surgery more than 2 weeks after the injury (mean 46, range 21–46 days). The fractures involved between 25 and 60% of the palmar articular surface of the base of middle phalanx. The dorsal articular surface remained in continuity with the shaft of the middle phalanx in all of the cases. The average proximal interphalangeal joint flexion deformity was 6° (range 0–30°) and the mean flexion arc was 100° (range 65–115°). The mean total active range of motion was 94° (range 60–110°). This compares with an overall preoperative median active total range of motion of 23° (range 10–34°) for the acute group and 37° (range 21–44°) for the chronic group. Seven patients could fully extend their proximal interphalangeal joints and five patients achieved full flexion (115°). Only one patient had a flexion deformity of greater than 20°. There were no significant coronal angulation or rotation deformities. However, a distal interphalangeal joint extension lag was observed in two chronic patients, both of 15°, and in one acute patient, of 10°. In the other 12 fingers, distal interphalangeal joint range of motion was normal. A good result was achieved in 11 patients (79%). A poor result was observed in 3 patients, two with chronic injuries and one with an acute injury. Longer delay from the time of injury to the time of surgery was associated with a decreased total range of motion (P = 0.028) and decreased flexion (P = 0.038). When comparing the two groups, the acute group achieved a mean total active range of motion of 110° (range 65–115°) while the chronic group reached a mean of 86° (range 60–110°, S.D. 17.7). This difference was statistically significant (P = 0.038). There was no association between decreased range of motion and increasing age of the patient but the average age in this series was only 30 (range 15–43) years. Three patients were observed to have loss of reduction (two subluxations and one dislocation) on assessment of X-rays at the initial postoperative review at 7 to 14 days. All were from the chronic group, with an interval to surgery of 33, 40 and 49 days compared to a range of 3 to 14 days in the acute group. The patient with the dislocation (patient 9) required further surgery, with repeat open reduction and internal fixation and bone graft initially, then soft tissue release 9 months later. In addition, one acute patient was found to have subluxation at initial postoperative review but he was not available for long-term review and is not included in this study. There were no deep or superficial infections or neurovascular complications. None of the patients went on to have a joint fusion or replacement. There were no difficulties with instrumentation and only one patient had a screw removed during a revision, for reasons unrelated to the hardware (patient 9). Follow-up radiographs demonstrated minor residual dorsal subluxation and joint incongruity (<0.5 mm) in 12 patients. Two of the three patients from the chronic group with loss of reduction at initial follow-up radiographs showed significant joint incongruity (between 1 and 1.5 mm) associated with joint subluxation. There was no instance of advanced degenerative change. The most common complaint was occasional stiffness associated with weather changes in seven patients. Five of these patients also reported mild pain. In three patients, this was only occasional with some sporting activities and, in two patients, it was more frequently, including at work. The latter two patients (patients 12 and 13) worked as a courier and a sales/repairman but were able to continue heavy lifting. None of the patients reported using analgesic medication for pain. Two patients (patients 9 and 13), responding to the questionnaire, reported that the pain and loss of finger range of motion as a result of their injury impacted on their work, or recreational, activities. For these patients, work was sometimes made difficult due to the inability to hold carpentry tools, or due to loss of index finger dexterity affecting ability to pick up screws and hold a screwdriver. However, both continued in their chosen professions without any major job modifications. No patients had given up or changed employment at final review because of their finger injury. The remaining 13 patients had no long-term limitations on recreational activities. Subjectively, 12 patients were pleased with the end result while two patients were dissatisfied with the surgery. These were the same two patients discussed immediately above and were two of the seven chronic patients whose surgery was delayed.
The mechanism of fracture dislocation of the proximal interphalangeal joint is initiated by a combination of axial loading and tension on the volar plate, usually from a ball impacting on the tip of the finger (Weiss and Hastings, 1993). When the hyperextension force predominates, there is an avulsion type fracture and, when there is greater axial loading, there is a tendency towards comminution, as the volar lip is crushed between the proximal phalangeal head and the middle phalanx metaphysis (Kiefhaber and Stern, 1998). It is now widely accepted that the loss of the basal buttress creates the necessary instability for a dorsal migration of the middle phalanx. Therefore, its restoration is an important part of treatment. The variable nature of the force of the injury gives rise to the variance in fracture presentation such that no single treatment modality is suitable for all proximal interphalangeal joint fractures. Regardless, the key to treatment is the same: establishment of joint congruity (Glickel and Barron, 2000; Hastings and Carroll, 1988; Wilson and Rowland, 1966). Without it, results are unpredictable and persistent subluxation is a common sequel. Rather than gliding, the incongruent joint hinges, giving rise to limited range of motion and to point loading, which increases the risk of post-traumatic arthritis. The advantage of treating these injuries by internal stable fixation of the fracture fragment is early active motion, preservation of the volar plate attachment, restoration of joint congruity and reduced risk of subluxation. The use of screw fixation for proximal interphalangeal joint fractures was first reported in 1966 (Wilson and Rowland, 1966). Despite encouraging results, enthusiasm waned because of difficulties with oversized instrumentation. Further advances in screw design have enabled more accurate reduction with lower intraoperative risk of fragmentation of the volar component. The Leibinger® screw (Stryker-Leibinger, Berkshire, UK) used in this series is well suited for proximal interphalangeal joint fractures because of its small diameter (1.2 mm), low head profile and self-tapping design. However, the technique described is not suitable for every case and this is not a technique for use by novices. Our experience is similar to that of previous authors (Deitch et al., 1999), who estimated that 47% of proximal interphalangeal joint fracture dislocations have significant comminution requiring alternative operative techniques. These include volar plate arthroplasty (Dionysian and Eaton, 2000). Conversely, between 35% and 50% of proximal interphalangeal joint fracture dislocations contain unstable large fragments which are suitable for internal fixation with this technique (Kiefhaber and Stern, 1998). As a guide, the fragment should be at least twice the diameter of the intended screw hole (Jupiter and Sheppard, 1985). However, closed reduction with extension block splint should first be attempted in all acute cases. Alternatively closed reduction with temporary Kirschner wire fixation may be considered (Newington et al., 2001). A single dorsal K-wire provides immediate postoperative stability, but close monitoring for any subluxation is important. Where possible, the surgeon should abut the K-wire on the middle phalanx dorsally and enter the proximal phalanx at the joint margin, to minimize articular injury. Occasionally, a transarticular K-wire was necessary. Ongoing controversy surrounds the optimal time for K-wire removal. In our experience, early removal allows commencement of hand therapy but increases the risk of dorsal subluxation, particularly with chronic cases, where there remains a tendency for dorsal subluxation. In this series, there were three subluxations, all in the chronic group. Therefore, we recommend shifting the balance towards stabilization by leaving K-wires in longer in chronic cases, to maintain joint congruity in the expectation that scar tissue will reduce the risk of subluxation. Because of the delay of early mobilization, there is a risk of greater stiffness which may require tenolysis and capsulotomy later. Currently, we remove the wires within 1 week in acute injuries and 2 weeks in chronic injuries. Once the K-wire is removed, early mobilization is started. The benefits of early passive motion of the proximal interphalangeal joint are, perhaps, best illustrated by Stern in his series of pilon fractures, which showed significant cartilage remodelling (Stern et al., 1991). The definite advantage of early active movement was also demonstrated in an earlier series using an extension block splint (McElfresh et al., 1972). A similar dorsal splint, but hand based, and early active and active-assisted mobilization was used in this series. Our results show that this technique of internal fixation may be used in a selected group of patients with unstable proximal interphalangeal joint fracture dislocations. The technique is indicated in proximal interphalangeal joint fracture dislocations where closed, and subsequently stable, reduction cannot be achieved in fingers in which the bone fragment attached to the volar plate ligament is large enough to be internally fixed and is not comminuted. Pain free, satisfactory range of motion can be achieved, particularly when surgery is carried out within 14 days of injury. After a delay of over 14 days, internal fixation still has an advantage because the treatment options are limited in these patients. However, this treatment carries a risk of persistent subluxation or recurrent dislocation in this group of patients.
Ian Grant would like to thank the British Society for Surgery of the Hand and the British Association of Plastic Surgery for grants to support his fellowship with the Victorian Hand Surgery Associates. We also acknowledge Dr David Horman who performed the follow-up clinical assessments. Manuscript received April 28, 2004. Accepted for publication May 10, 2005.
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Journal of Hand Surgery (British and European Volume), Vol. 30, No. 5,
492-498 (2005) This article has been cited by other articles:
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Abstract
INTRODUCTION
