Nonunion in Nonarticular Phalanx Fractures

35 Nonunion in Nonarticular Phalanx Fractures

A. Lee Osterman and Adam Strohl

35.1 Patient History Leading to the Specific Problem

A 25-year-old right-hand-dominant man presents with a left painful, stiff index finger. Four years earlier, he sustained a closed injury to the proximal phalanx that was treated elsewhere with open reduction and internal fixation. His injury resulted from an altercation in which he struck another individual. He underwent revision corrective osteotomy for malunion 1 year ago. Since then, he complains about persistent pain in the digit and inability to completely extend the digit. He acknowledges deformity of the digit, but tells you, “it is more straight than it was before last surgery.” Medical records do not indicate any history of infection.

35.2 Anatomic Description of the Patient’s Current Status

The patient has a 3-cm slightly hypertrophic, linear over the dorsum of the proximal phalanx of the left index finger. There is obvious ulnar deviation of 15 degrees at the proximal interphalangeal (PIP) joint. There is mild tenderness to palpation over the proximal phalanx without any gross instability, motion, or crepitus. No erythema, warmth, or drainage is seen. Capillary refill is present and there is no sensory deficit at the radial or ulnar tip of the finger.

Active range of motion (ROM): metacarpophalangeal (MCP): H30 to 80 degrees; PIP: 25 to 50 degrees; distal interphalangeal (DIP): 0 to 65 degrees.

Passive ROM: MCP: H50 to 85 degrees; PIP: 0 to 70 degrees; DIP: 0 to 65 degrees.

With finger flexion, the index finger overlaps the long finger (▶Table 35.1).

Radiographs of the left index finger reveal transverse lucency in the mid-diaphysis of the proximal phalanx (▶Fig. 35.1). There is no hardware present. The anteroposterior view shows ulnar translation as well as ulnar angulation (30 degrees) of the distal fragment. The lateral view shows dorsal angulation (45 degrees) of the distal fragment. Diagnosis is chronic nonunion of a left index finger nonarticular, proximal phalanx fracture.

35.3 Recommended Solution to the Problem

One must consider possible causes for nonunion of this fracture such as infection or inadequate fixation. In addition to the initial fracture and surrounding soft-tissue injury, this patient has already had two surgeries involving open reduction and internal fixation, which led to scar and tendon adhesions. Tenolysis and sometimes joint release maneuvers may need to be considered. Rigid fixation is important to allow early motion and prevent future adhesions, as well as careful consideration of approach and hardware position. Lateral, instead of dorsal, placement of hardware can prevent extensor tendon adhesion. The lateral approach will also allow adequate exposure of extensor and flexor tendons for tenolysis. If dorsal approach is chosen, then additional volar incision may be needed for additional procedures.

Table 35.1 Hand grip strength dynamometer testing