49: Open Reduction and Internal Fixation of Phalangeal Shaft Spiral or Long Oblique Fractures

Procedure 49 Open Reduction and Internal Fixation of Phalangeal Shaft Spiral or Long Oblique Fractures



Winston Y.C. Chew



Indications




image Instability as indicated by the following:


• Rotational deformity causing scissoring

• Shortening resulting in extensor tendon dysfunction

• Angulation resulting in pseudoclawing for the proximal phalanx and swan-neck–like deformity for the middle phalanx

• Significant pain restricting range of motion

• Displacement during conservative treatment

image Fractures with intra-articular extension resulting in joint incongruity


image Open fractures



Examination/Imaging



Clinical Examination




image Deformity in the form of shortening, rotation, and angulation of the finger (Fig. 49-1)


image Limited range of motion of the affected joint, especially the joint distal to the fracture


image

FIGURE 49-1



Imaging




image Standard anteroposterior (Fig. 49-2A) and lateral views (Fig. 49-2B) of the affected finger will often give the diagnosis.


image Oblique views may sometimes be required to give a better understanding of the fracture displacement and degree of comminution, if any.


image

FIGURE 49-2



Surgical Anatomy




image The extensor tendons, consisting of both the extrinsic and intrinsic tendons, form a finely balanced complex over the finger (Fig. 49-3A).


image The central slip inserts to the base of the middle phalanx, and care should be taken not to violate this insertion during exposure.


image The fibrous flexor sheath with its flexor tendons is closely applied to the volar surface of the phalanges (Fig. 49-3B). Hence, all screws must not protrude beyond the cortex, especially on the volar aspect, to avoid attrition of the flexor tendons.


image

FIGURE 49-3



Positioning




image The patient should be positioned supine with a hand extension table.


image The hand should be easily accessible to the mini C-arm for fluoroscopic control during surgery.



Exposures




image For the proximal phalanx, the fracture is exposed through a direct dorsal longitudinal incision, splitting the extensor tendon in the midline (Fig. 49-4).


image For the middle phalanx, the fracture is exposed through a direct dorsal longitudinal incision, and the lateral slips of the extensor tendon are mobilized by incising the triangular ligament in the midline and extending distally by splitting the tendon in the midline to its insertion into the distal phalanx.


image The periosteum is incised and elevated. This layer is more prominent if fracture repair is delayed by a few days.


image

FIGURE 49-4



Pearls


Related posts:

28: Pronator Teres Rerouting 34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity 32: Crossed Intrinsic Tendon Transfer 38: Reconstruction for Congenital Thumb Hypoplasia 65: Arthroscopic Treatment for Septic Arthritis 89: Total Wrist Fusion

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Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 49: Open Reduction and Internal Fixation of Phalangeal Shaft Spiral or Long Oblique Fractures

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