Angulation in Nonarticular Phalanx Fractures

37 Angulation in Nonarticular Phalanx Fractures

Berthold Bickert

37.1 Patient History Leading to the Specific Problem

A 19-year-old man presented with an angular deviation of his left index finger toward the long finger. In early childhood, at the age of 2 years, he had suffered an injury to his left hand when it was caught in the V-belt drive of a sawmill on his parents’ farm. His left thumb was completely destroyed and had to be amputated. It could be reconstructed 3 years later by a free microvascular great toe transplantation. The proximal phalanx of the left index finger had suffered an open phalangeal neck fracture and was treated by K-wire fixation.

37.2 Anatomic Description of the Patient’s Current Status

The left thumb-toe shows an almost normal appearance with full sensitivity and function. The index finger has an angulation of 15 degrees, near the proximal interphalangeal (PIP) joint, toward the ulnar side, impeding the function of the long finger (▶Fig. 37.1). Additionally, there is a significant lack of extension in the index PIP joint, with active and passive motion being limited to 0 to 40 to 65 degrees (extension–flexion).

37.3 Recommended Solution to the Problem

In complex hand injuries, it may be difficult for the hand surgeon to shift his focus of interest from the major problem (thumb amputation) to the minor one (open phalangeal neck fracture or the index finger). Yet, early correction of what is possible may improve late function.

Actual treatment should first address the impairment of the long finger by the deviated index finger and then the function of the index finger itself. The index finger can be improved either by an attempt of flexor and extensor tenoarthrolyses (17 years after injury) or by corrective PIP joint arthrodesis.

As the patient has got used to the limited—and appreciates the remaining—PIP joint motion of the index finger, he only wants the long finger to be freed from the impairment by the index finger. So a corrective osteotomy at the neck of the proximal phalanx of the index finger has been consented.

Fig. 37.1 (a) Lateral angulation of the left index finger in a 19-year-old young man after a V-belt injury and K-wire osteosynthesis at the age of 2 years. (Also note the thumb that had been reconstructed by microvascular great toe-to-thumb transplantation at the age of 5 years.) X-rays show the lateral angulation at the fracture site at the phalangeal neck of the index finger in (b) posteroanterior and (c) lateral views.