32 Middle/Proximal Phalanx (Pinning)
Abstract
Operative options for the phalanx fractures include many types of surgery including closed or open reduction and percutaneous pinning.
32.1 Description
Most phalangeal fractures are managed by splint immobilization, especially when the fracture is stable. Due to tendinous forces exerted on these fractures, certain fracture patterns require operative fixation for stability. Operative options include closed reduction and percutaneous pinning (CRPP), open reduction and pinning (ORP), open reduction and internal fixation (ORIF), and static or dynamic external fixation (Ex-fix). This chapter will discuss the percutaneous pinning of phalangeal fractures. In general, most pinnings are performed using Kirschner wires (K-wires).
32.2 Key Principles
The first key principle is achieving adequate reduction, which is best done under fluoroscopic guidance. Every effort should be made to obtain such a reduction by closed means because CRPP is generally preferred over ORP. The second principle is to provide “adequate” fracture stability. K-wire fixation is not rigid, but it can still provide enough stability to allow some early postoperative range of motion. The use of more than one K-wire provides better rotational stability, especially when transverse or oblique wires are utilized. Single axial and intramedullary K-wires are more stable when the size of the K-wire is large enough to “fill up” the medullary cavity. Another principle is to avoid placing the K-wire through the joint. Crossing the distal interphalangeal (DIP) joint of the fingers and the interphalangeal (IP) joint of the thumb is more tolerated than crossing the proximal interphalangeal (PIP) joint because the resulting stiffness of the former joints is usually mild and is less disabling from the functional point of view. Crossing of the DIP, IP, or PIP joints should be done with joint fully extended. However, crossing the metacarpophalangeal (MP) joint should be done with the joint flexed to avoid shortening of the collateral ligaments and intrinsic muscles.
In the management of fractures, the early institution of postoperative mobilization is always preferred to prevent stiffness. Although this principle also applies for fractures of the middle and proximal phalanges, several factors should be taken into consideration such as age, concurrent tendon injuries, neurovascular injuries or soft tissue loss, the presence of ischemia or severe crush of the fractured digit, and the reliability of the patient. Young children with phalangeal fractures are typically immobilized in a cast after surgery. A common fracture pattern in industrial workers is transverse fractures of the middle phalanx with concurrent extensor tendon injury. An axial K-wire crossing the extended DIP joint is necessary because of concurrent extensor tendon injury. In fractured crushed digits with concurrent ischemia, early exercises are not advised. Finally, general principles of open fracture management should be applied such as early operative intervention, debridement, irrigation, and adequate antimicrobial coverage.
32.3 Expectations
Following the above principles can generally lead to good postoperative results and function. Management of fractured digits in children generally results in a better outcome when compared to adults due to quicker fracture healing, being less prone to stiffness, and the greater potential for remodeling. One exception in children is the phalangeal neck fractures that are known to have a high complication rate including stiffness, nonunion, malunion, and avascular necrosis of the phalangeal head. Open phalangeal fractures with comminution or concurrent tendon and soft tissue injury are considered as poor prognostic factors and therefore the prognosis is generally guarded. Chow et al 1 studied 245 open digital fractures prospectively and demonstrated that the presence of concurrent extensor tendon injury or extensive skin loss had a major effect resulting in a poor outcome in 48% of patients. The worst effect was from concurrent flexor tendon injury resulting in a poor outcome in 86% of patients, defined as total active motion (TAM) of less than 180 degrees.
32.4 Indications
Adequate reduction by closed or open methods is a prerequisite prior to fracture pinning. Phalangeal fractures can be broadly classified into extra-articular and intra-articular fractures. Extra-articular fractures include neck, shaft, and base fractures. Intra-articular fractures include condylar fractures and base intra-articular fractures with or without fracturedislocation. Intra-articular base fracture and/or fracture dislocation of PIP joint can be treated by dynamic external fixation, provided the ligamentotaxis effect allows adequate concentric reduction. Alternatively, other methods such as transarticular or dorsal block pinning, interfragmentary screw fixation, hemi-hamate arthroplasty, or volar plate arthroplasty may be utilized.
32.5 Contraindications
CRPP is contraindicated when closed fracture reduction is not achieved.
Intra-articular fractures of the volar base of the middle phalanx with more than 40% involvement of the articular surface should not be treated by dynamic external fixation; rather alternative methods should be used.
32.6 Special Considerations
Preoperative evaluation of the patient’s age, medical history, occupation, hand dominance, and compliance with postoperative rehabilitation is essential. Date and mechanism of injury as well as associated injuries will play an important role in the decision-making process. Associated flexor or extensor tendon injuries may require early mobilization and hence rigid fixation is preferred. Adequacy of reduction and fixation of intra-articular fractures should be confirmed intraoperatively under fluoroscopy to ensure stability of the fixation in order to allow early protected movement.
32.7 Special Instructions, Positioning, and Anesthesia
Majority of phalangeal fractures can be operated under local digital block anesthesia allowing for intra-operative testing of adequacy of reduction and fixation under fluoroscopy.
Patient is placed supine with the hand on an arm board.
Upper arm or digital tourniquet minimizes postreduction swelling and loss of digital landmarks, which would make the accurate placement of percutaneous pinning more difficult. Awake patients may not tolerate upper arm tourniquet of more than 20 minutes; intravenous sedation may be used as a supplement.
32.8 Individual Fractures Discussing Tips, Key Procedural Steps, and Expected Outcomes
32.8.1 Extra-Articular Fractures
Neck Fractures
Phalangeal neck fractures of the middle phalanx are more common than those of the proximal phalanx. They are usually seen in children but also occur in adults. Al-Qattan 2 classified these fractures into three types: type I (undisplaced), type II (displaced but with some bone-to-bone contact), and type III (displaced with no bone-to-bone contact). Type II fractures are usually treated with closed reduction and axial K-wire fixation. Another technique of K-wire fixation is the K-wire “lever” technique. The displaced phalangeal head is usually dorsally displaced similar to the distal segment of a Colles’ fracture. Hence, a percutaneous K-wire may be placed dorsally into the fracture side and used as a “joystick” to reduce the fracture and then the wire is advanced into the medullary cavity of the proximal segment (i.e., diaphysis) to maintain the reduction. This method of K-wire fixation is similar to the Kapandji’s intrafocal technique of K-wire fixation of Colles’ fractures. Type III fractures are usually open injuries and the existing laceration may be used for reduction prior to K-wire fixation. These fractures have a high complication rate including delayed union, malunion, nonunion, avascular necrosis of the phalangeal head, and stiffness of the joint involved.
Related posts:
34 Fixation of Uni and Bicondylar Phalangeal Fractures
31 Distal Phalanx Fractures: Percutaneous Pinning and Open Reduction Internal Fixation
36 Proximal Interphalangeal Joint Fracture-Dislocation
39 Limited-Open Retrograde Intramedullary Headless Screw Fixation of Metacarpal Fractures
38 Metacarpal Fracture Open Reduction and Internal Fixation (ORIF)
37 Metacarpals (Pinning)
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