CHAPTER
63

A skillful technician will achieve reproducible results in complicated surgery. On the other hand, complicated surgery performed by a poor technician yields catastrophic results. As a corollary, easy surgery is more popular but not necessarily the best for the patient’s problem.

When the reduction does not meet the criteria of acceptability1 (Table 63.1), surgery is recommended. Because articular fractures need an exacting reduction, most require surgery too. Finally, open fractures require emergent débridement and fixation. Patients with special needs (professional sportsmen, surgeons, etc.) may need surgery despite meeting the criteria referred to in Table 63.1 to shorten the recovery period. The presence of multiple fractures is in itself not an indication for surgery. However, it is quite common that one of them fails to meet the criteria of acceptability, making surgery necessary for all of them¹ (Fig. 63.1).

Open reduction and internal fixation, although attractive to surgeons, has a deleterious effect on the functional outcome of any digital fracture.^1–3 Hence if surgery is needed, the surgeon should determine the least invasive method that provides stable fixation to allow immediate range of motion. The surgical options are wide-ranging. Table 63.2 provides a summary of methods that meet most of my needs. Needless to say, the surgeon should be prepared to change plans according to the personality of the fracture and the intraoperative findings. I have achieved very satisfying results by using intramedullary headless cannulated screws for fractures of metacarpals and phalanges.⁴ A 1-mm K-wire is introduced through a nick in the skin, retrogradely (distal to proximal), and through the head of the metacarpal–proximal phalanx. This K-wire is used to reduce and align the fracture. Next, the K-wire is used as a guide for a double-threaded headless cannulated screw (as a rule, 2.-mm diameter for phalanges and 3 mm for metacarpals)⁴ (Fig. 63.2). The procedure is particularly indicated in transverse and short oblique fractures. Fixation can be performed in a matter of minutes, allowing immediate range of motion, with minimal trauma. The operation is not indicated when there is bone loss but can be used successfully in very complex scenarios (Fig. 63.3).

Phalangeal fractures, more so than metacarpal fractures, are prone to complications and bad results: lack of full range motion; loss of normal alignment; lack of union; and the catastrophic infection are among the most prevalent.

Ideally, a finger should recover an excellent result after any fracture, defined as more than 240 degrees of total active motion (TAM; active flexion of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints minus the extension deficits in these joints). However, loss of the normal arc motion is common. Incomplete range of motion can be related to poorly executed surgery; a noncooperative patient; combined injuries; and, very often, late initiation of active range of motion.

Table 63.1 Criteria of acceptability for phalangeal fractures depending on the location of the fracture

Table 63.2 Surgical options for fracture

An uncooperative patient will spoil any complex reconstruction. However, most cases of insufficient range of motion I see are related to faulty fixation, overinvasive fixation, or a dorsally placed plate. The latter is especially relevant, because it is axiomatic that any plate placed on the dorsal surface of the proximal phalanx will yield a poor functional result (Fig. 63.4).

Fig. 63.1 Multiple fractures can be dealt with by immobilization alone provided the criteria of acceptability are met after the reduction. (a,b) Significantly displaced fractures of the proximal phalanges of the fingers and base of the first metacarpal. All were reduced under local anesthesia in the office. Range of motion was started after 3 weeks. (c,d) Result at 6 weeks. (Copyright Dr. Piñal, 2015.)

Fig. 63.2 Intramedullary headless cannulated screw fixation technique (see text for details). (Copyright Dr. Piñal; reproduced from del Piñal F, Moraleda E, Rúas JS, et al. Minimally invasive fixation of fractures of the phalanges and metacarpals with intramedullary cannulated headless compression screws. J Hand Surg Am 2015;40[4]:692–700.)

Fig. 63.3 Multiple fracture, multifixation method in a patient who sustained a crush. (a,b) In addition to the obvious soft tissue defect and extensor tendon laceration of the ring and little finger and open fractures in all cases. Note the severe comminution of the head of the ring finger metacarpal. (c,d) Radiographs at 4 months. The injury was managed by a standard 3-mm HCS for the index finger, a 3-mm antegrade for the comminuted middle finger, a Y strut for the ring finger (and primary bone grafting of the defect), and a 4-mm HCS for the small finger. A free flap was used for coverage. (e,f) Clinical result at 2 years. (Copyright Dr. Piñal, 2015.)

Fig. 63.4 “Frozen finger.” This patient had a lack of active extension and lack of active flexion at presentation and the telltale sign in the lateral radiograph: a dorsally placed plate (arrows). (Copyright Dr. Piñal, 2015.)

Incomplete range of motion is much more common in phalangeal than metacarpal fractures, because the former is surrounded by tendons and has a minimal gliding layer. Restrictive adhesions are common and require tenolysis. Tenolysis is sometimes offered as a simple solution for dealing with the adhesions, but my experience has often not shown this to be the case. Extensor tenolysis rarely yields a normal result (260 degrees of total active motion), particularly if multiple fingers are involved.5 By the same token, when flexor tendons are involved, an excellent result is rarely possible, and there is an unknown (but real) risk of flexor tendon rupture during or after the operation, a catastrophic situation. Again, the surgeon must resist the temptation to place a plate dorsally in a proximal phalanx. Although easier, technically speaking, the plates destroy the gliding layer and create massive adhesions that are nearly impossible to resolve. Tenolysis in an uncooperative patient is highly discouraged, because the possibility of complications is high and the likelihood of improvement nil. These factors have led me to become increasingly concerned regarding patients with adhesions after digital fractures, and I recommend all readers not to approach tenolysis lightly. Lack of full range of motion after a tenolysis is poorly accepted and is a major cause of patient dissatisfaction. All this underscores the importance of doing things right from the beginning.

Delay in starting active range of motion in a phalangeal fracture for more than 3 or 4 weeks will unavoidably yield a poor result because of adhesions. Early range of motion should be encouraged in stable fractures using functional braces.1 Others require immobilization, because they are not as stable, but they will still heal in 3 weeks. However, if the fracture characteristics arouse concerns of not healing by 3 to 4 weeks (basically because of poor contact or comminution), surgery is recommended. Delayed healing will cause hypertrophic callus and more inflammation, entrapping the flexor and extensor tendons over large surfaces. By the same token, if the surgeon decides to operate on a fracture, surgery must be followed by immediate range of motion. As a rule, open reduction and internal fixation followed by immobilization is nonsensical.

Malunions

Malunions should not occur if the basic tenets of fracture management are applied. As stated earlier, low or no toler ance for deformity in phalangeal fractures (see Table 63.1) will reward the surgeon with mostly good results. By the same token, corrections that appear to fall within the acceptable limits on radiographs after reduction may develop into a major deformity and the need for corrective osteotomy if left unaddressed. It is important to highlight that malunions are often associated with delayed healing, and this in turn creates an adhesion issue, thus compounding the problem exponentially. The need for secondary surgery and a poor functional result will be nearly guaranteed if the surgeon is not prepared to perform a complex surgical reconstruction (discussed later). It is therefore of utmost importance to achieve healing of the digit in the customary 3 or 4 weeks. The surgeon must do everything possible to procure stability to permit full range of motion as soon as possible.

Metacarpal fractures, as opposed to phalangeal fractures, are much more tolerant of deformity, particularly in less-demanding individuals. However, they can be a source of problems as well. A 50-degree flexion deformity in the neck of the fifth metacarpal may be considered as highly successful to the surgeon but can be unbearable for a patient if the injury occurred at work. For this reason, I am very reluctant to leave radiological deformities unaddressed. Furthermore, the fact that a generous soft tissue layer protects them makes the metacarpals less prone to extensor and flexor adhesions after localized trauma. However, after major trauma, the bed becomes heavily scarred and devascularized—the fat disappears. In this setting, adhesions are impossible to solve unless a gliding layer is restored again⁶ (Fig. 63.5).

Fig. 63.5 (a) In exhausted beds tenoarthrolysis is doomed to fail, because the scarred tissue will not permit tendon gliding. The surgeon should wrap the scarred tendons with adipofascial flaps. Plain radiographs (b) and computed tomography (c) show that volar angulation of the malunited or nonunited third through fifth metacarpals has compounded the problem of the hyperextension of the MPJs. (d) Preoperatively the lack of flexion of the MPJs is evident. In a single-stage procedure the metacarpals were aligned with plates, arthrolysis of all MPJs was performed, and the extensor was freed from scarred tissue. A lateral arm adipofascial flap was used to wrap the tendons. (e) Result at 1 year. (Copyright Dr. Piñal, 2015.)

Fig. 63.6 (a,b) This patient sustained a crush injury that resulted in comminuted phalangeal fractures and an open palmar wound with devascularization of the fourth and fifth finger. The common digital arteries were found to be avulsed and consequently repaired. (c,d) Because of the amount of comminution (arrows) and the extent of cortical shattering, the fractures were primarily bone grafted. (e) Plates placed laterally allowed immediate range of motion. (f,g) Result at 4 months. (Copyright Dr. Piñal, 2015.)

The surgeon should do everything possible to achieve healing in the customary 3 to 4 weeks. In my practice this includes providing rigid fixation with the minimal possible devascularization, liberal use of cancellous bone graft, and provision of good soft tissue cover and vascularized bone graft for the worst cases. I use this armamentarium with the sensible radicalism mentioned previously—that is, if I have any doubt that the patient may experience a delayed healing, I opt for a more aggressive treatment. For example, a fracture may heal with a plate, but if there is cortical comminution, the healing is going to be slow and interfere with the result. Thus I would add cancellous bone graft (Fig. 63.6).

It is important to understand that surgery may convert a somewhat misaligned yet potentially healing fracture into a nonunion because of the negative effect that exposure has on the blood supply. Salvage of any nonunion may require “exceptional” surgery if a good result is to be obtained. I typically combine new fixation and vascularized bone graft to speed healing (Fig. 63.7).

Infection and Osteomyelitis

After any fixation, the appearance of infection is a major disaster. Fortunately, the infection rate in phalangeal fractures is very low. In fact, it has been calculated to be 2% in open fractures and less if closed.⁶ Although some of them can be treated by removal of the hardware and antibiotic therapy, amputation is also quite prevalent.^2,6,7 Established infection in the tubular bones of the hand resulted in an amputation rate approaching 50% in a study by Reilly et al.⁷

The management of infection depends on whether there is bony stability and whether there is associated combined soft tissue loss (Table 63.3). In the “ideal” case of infection with bone continuity, hardware removal and oral antibiotics will cure the problem. The issue becomes increasingly complicated if the soft tissue cover is insufficient or the fixation is tenuous.

In my experience, most severe infections occur as a combination of open fracture and poor coverage, as after a crush. It is axiomatic that if the soft tissues are left unattended (i.e., they are not radically débrided and good cover is not provided at the time of initial treatment), infection is unavoidable. Infection in the setting of poor coverage does not clear until the bone is radically débrided and a good soft tissue provided (which is what the surgeon should have done in the first place). Even if, after a heroic surgical operation, amputation is avoided, infection will rarely clear without a high price: a major loss of motion and/or arthrodesis of a neighboring joint (Fig. 63.8).

Fig. 63.7 (a) This patient sustained an open crush and was managed by plating. According to the report the intrinsic muscles were devitalized and had to be debrided. All these unfavorable factors lead to an atrophic nonunion and hardware failure. (b) To overcome an exhausted bed (with no healing potential) apart from a new fixation, vascularized tissue with osteogenic potential was planned (the cannulated screws in the medullary canal). (c) A wedge-shaped flap from the medial femoral condyle was harvested and fixed in position with lag screws (d). In the same surgery tenolysis and capsulotomies (second through fourth fingers) were added to treat the stiff hand. (e,f) Immediate range of motion was begun and a full functional result was achieved at 3 weeks. (g) Radiograph at 4 months, showing the amount of new bone formed by the corticoperiosteal flap. (Copyright Dr. Piñal, 2015.)

I have had positive experience using vascularized bone graft taken from the toe metatarsal for long defects and the phalanx for medium and small defects.8 As in most cases of infection in the fingers there is a need of soft tissue cover; there is no role for the medial femoral condyle corticoperiosteal flap.

Table 63.3 Management of infected digital fractures

Fig. 63.8 (a) This patient had a replantation elsewhere of the index and middle finger. He presented for a second opinion because he was scheduled for a secondary amputation. Multiple draining sinuses were present in the middle finger and in the radial aspect of the index finger (white arrows). (b) Radiographs of the index finger revealed a radial abscess and a partially healed fracture ulnarly. A massive abscess was present in the middle finger with the distal proximal phalanx acting as a sequestrum. (c) After débridement, the middle finger had a through-and-through soft tissue defect and a bone defect that involved most of the middle phalanx and the distal interphalangeal joint. (d) A vascularized second toe proximal phalanx spanned the bony ends. Minimal fixation was used to stabilize this vascularized bone graft. The index hardware was left in place because it was away from the infection. However, the bone was débrided, cancellous bone was applied, and a local flap (a hatchet flap) was used for coverage. No other surgery had been performed. (e,f) Functional range of motion of the proximal interphalangeal joint was achieved. (g) Plain radiographs showed complete bone healing at 1 year. Infection has not recurred after 6 years. (Copyright Dr. Piñal, 2015.)

Condylar malunions are managed by a dorsal approach and after creating a distally based extensor flap that contains most of the central band and part of the lateral bands. The joint is flexed and the malunion comes easily into view. After stable fixation, active flexion exercises are encouraged, whereas the extensor repair is strong enough to allow active assisted exercises (Fig. 63.9). What is key at the time of mobilization and fixation of the displaced fragment is to understand that aggressive maneuvers may lead to fragment devascularization and, in turn, necrosis. Radiographs of a previously perfect result may reveal a collapsed joint—a disaster that only can be solved in young individuals by a joint transfer or an arthrodesis.

Malunion after impacted fracture dislocation of the base of the middle phalanx is more common. Unless properly performed radiographs are taken, the diagnosis will be missed. Unfortunately, this is common, but most cases are amenable to reconstruction. I favor a shotgun approach to fully see the deformity. Then, by using ultrathin bone instruments (dental picks and 1.0-mm rongeurs) the fracture is re-created and fixation with 1.3-mm screws or cerclage wire is carried out.9 I have had very good results in previously nonoperated patients with this approach (Fig. 63.10). Conversely, I have had mostly disappointing results when patients have been “aggressively” operated previously (i.e., screws, plates, or combined approaches). In this situation there is an enormous amount of scarring, and the risk of devascularization of the fragments is very high. I believe most of these cases will end up requiring a salvage operation, which I would recommend from the outset in some individuals.

Fig. 63.9 (a) The Chamay approach for treatment of the malunion of the head of the proximal phalanx permits a pristine view of the problem (arrow indicates extension slip). (b) The malunited condyle has been reduced and fixed rigidly. (c) The extensor tendon slip is repaired with a continuous 5–0 nylon suture. This enables immediate active flexion and active assisted extension exercises. (Copyright Dr. Piñal, 2015.)

Fig. 63.10 (a) This 32-year-old physiotherapist was seen 7 weeks after sustaining a basketball injury to her middle finger. She had been immobilized for 3 weeks but presented because of a minimal range of motion and deformity. (b,c) In the original radiographs in the posteroanterior view, some clinodactyly is already evident. In the lateral view the apparently aligned middle phalanx is revealed to actually be dorsal to the dorsal axis of the proximal phalanx and the impacted fragment can be imagined in the base of the middle phalanx (arrows). Notice also the widening of the base of the middle phalanx. All these radiological signs are pointers to a major joint disruption. (d,e) Intraoperative view of the impacted fragments and after mobilization and reduction. Bone graft was packed under the fragments and the fracture fixed with a cerclage wire. (f,g) Result at 3 years. (Copyright Dr. Piñal, 2015.)

Some patients are seen for unsalvageable joint trauma or previously failed surgery that are already beyond reconstruction. For those patients the only alternative is an arthrodesis, a prosthesis, or a vascularized joint transfer.10 I do not believe a prosthesis has a role in the PIP joint for active patients. I have a fair experience (nearly 50 cases) in transferring PIP joints from the second toe to the PIP joint of fingers and in MCP joint reconstruction (both metatarsophalangeal and PIP joints). My results can be summarized as follows: When the injury is isolated to the joint and there is minimal scarring, a very good result can be expected. However, when there is multitissue damage (flexor tendon, previous flaps, or late reconstructions) a moderate (30–50 degrees of active range of motion) result can be anticipated. In most published series the cases are mixed, and it is difficult for the reader to determine the real benefit of the joint transfer in young individuals (Fig. 63.11).

Carpus Fractures

The scaphoid is the most commonly fractured bone in the carpus and the most difficult to handle. Furthermore, being a bone mostly covered by cartilage, the blood supply has limited entryways, and mismanaged fractures have a high rate of nonunions and delayed union. The introduction by Herbert and Fisher¹¹ of the double-threaded screw marked a benchmark in the treatment of scaphoid fractures. A high success rate was reported for fractures and nonunions alike.¹¹ Some factors that are known to carry a poor prognosis for healing have been found to be a clear indication for surgery:

• Proximal pole fractures

• Displaced fractures (more than a 1 mm)

• Delayed presentation (more than 4 weeks)

As for other fractures, to shorten the recovery period, patients in certain types of professions benefit from surgery despite it not being, technically speaking, medically indicated.

Unfortunately, what was not underlined when the procedure was presented was that the technique is exacting and without room for error. The risk of causing devastating damage to the joint is even higher if inexperience is combined with the now in vogue percutaneous approach. Understanding the complex scaphoid anatomy is key to avoiding complications.¹² The industry has a major role in pushing the product, which may have overwhelmingly negative effects for the joint (Fig. 63.12).

Fig. 63.11 This 28-year-old man was seen for irreversible degeneration of the PIP joint after sustaining a “sprain,” which was operated secondarily elsewhere with resulting pain and stiffness. (a,b) A PIP joint was transferred, and the result is shown at 5 years. The dots outline the skin monitor. (The screw in the middle phalanx is unrelated to the joint transfer [c]). (Copyright Dr. Piñal, 2015.)

Fig. 63.12 This patient was seen 8 months after a prior percutaneous screw fixation of a middle third displaced scaphoid fracture. Nonhealing and radius surface destruction is evident. An arthroscopic radioscapholunate arthrodesis was performed to salvage this catastrophic scenario. (Copyright Dr. Piñal, 2015.)

When the scaphoid has failed to unite by a certain time after the fracture (6–12 weeks), the possibility of healing without intervention is nil. The nonunited scaphoid requires treatment in symptomatic patients, and it is probable that asymptomatic “patients” should also undergo reconstruction to avoid development of the scaphoid nonunion advanced collapse (SNAC) wrist. However, surgery is controversial in truly asymptomatic patients, because a clear progression to degeneration is not certain, whereas patients may become symptomatic if the surgery is unsuccessful. Scaphoid nonunion on its own is the topic of several books, so summarizing it is a difficult endeavor. There are myriad techniques, but the basic modifiers are the blood supply of the proximal pole, the location of the fracture, the loss of length of the scaphoid, and the degree of degeneration of the joint. Table 63.4 summarizes my current management protocol of scaphoid nonunion.

The presence of blood supply in the proximal fragment is a sine qua non condition to proceed to reconstruction. I have found that if the proximal fragment is avascular, there is no way to achieve healing of the cartilage cover (though the bone may heal). An exceptional reconstructive operation may be indicated apart from a salvage operation.¹³ The problem is that the definition of vascularity is subjective. Part of the confusion relates to the fact that authors (surely unconsciously) stretch the term to their benefit to glorify the virtues of a proposed technique. However, I have tried nearly every technique, and I have reached the conclusion that when the scaphoid is necrotic (i.e., fragmented, “toothpaste” aspect with yellowish deposits), healing is impossible. However, a hypovascular scaphoid (the bone may not have bleeding points but has normal bony structure at surgery) deserves an attempt at reconstruction, independently of the imaging result. Any hypovascular fracture benefits from vascularized bone transplant, and the scaphoid is no exception. Finally, if the scaphoid has good blood supply, then nonvascularized bone graft is enough.

The location of the fracture is important for the approach and the method of fixation. Ideally all reconstructions should be fixed with screws, but a small fragment may not have enough volume to harbor the screw without further fragmentation. K-wires may be the only feasible method in this scenario. Another major breakthrough in the management of the scaphoid has been the introduction by Ho of the arthroscopy in scaphoid nonunion.¹⁴ This method is particularly useful in hypovascular proximal poles, because the surgeon does not disturb the remaining blood supply and bone can be added into the nonunion (Fig. 63.13).

If the scaphoid is deformed and flexed, the so-called humpback deformity, the surgeon must restore the length. Otherwise, the wrist joint mechanics will be distorted and degeneration will ensue. Again there are several methods: a nonvascularized wedge graft, a pedicled volar graft,¹⁵ and a distant medial femoral condyle flap are among the most popular.¹⁶ I do not hesitate, if the defect is long and any of the unfavorable modifiers are present, to proceed directly to a vascularized transfer. This may be considered overkill, but if one minimizes dissection at the time of flap harvesting, the donor site sequelae are negligible, and the benefit of the blood supply undeniable (Fig. 63.14).

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