Open Reduction and Internal Fixation of Phalangeal Fractures

William B. Geissler, MD

Jarrad A. Barber, MD

Dr. Geissler or an immediate family member has received royalties from Acumed, LLC and Arthrex, Inc., Medartis, Integra; is a member of a speakers’ bureau or has made paid presentations on behalf of Acumed, LLC and Arthrex, Inc., Medartis, Integra; and serves as a paid consultant to or is an employee of Acumed, LLC and Medartis, Integra. Neither Dr. Barber nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

INTRODUCTION

Stable anatomic reduction of a phalangeal fracture with early functional recovery is the goal of internal fixation of hand fractures. Open reduction and internal fixation (ORIF) of hand fractures has become increasingly popular, particularly over the past three decades, secondary to improved implant material, designs, surgical technique, radiographic availability, and the demand by the general public for anatomic fracture restoration. ORIF of hand fractures presents a significant challenge to the surgeon, however, because of the difficulty of managing small fracture fragments without causing devascularization. Open reduction without stable fixation increases the risk of adhesions and scarring adjacent to the fracture. Percutaneous techniques offer the advantages of stable fracture fixation and earlier rehabilitation while minimizing the risk of fragment devascularization and surgical scarring. This is particularly true in the proximal and middle phalanx, where the flexor and extensor tendons are close to the bone.

PATIENT SELECTION

Indications

Most phalangeal fractures are treated nonsurgically. Displaced unstable fractures may require surgical stabilization, however, particularly if the fracture is rotated. In multiple phalangeal or metacarpal fractures or open fractures, stabilization should be considered. “Less is more” in phalangeal fractures because of the high propensity for stiffness from the close association of the flexor and extensor tendons.

Phalangeal Condylar Fractures

Phalangeal condylar fractures were initially classified by London in 1971.¹ Type I fractures were considered stable and nondisplaced, type II fractures were unstable, and type III fractures were bicondylar. London found that bicondylar fractures were common athletic injuries. Stark² noted that unicondylar fractures of the proximal phalanx were often missed because the patient can usually bend the finger initially after injury. Affected athletes frequently have a history of a finger dislocation that was reduced by a trainer or coach, and they present to the clinic in a semiacute state; they continue to experience pain and deformity of the finger as the fracture displaces.

Weiss and Hastings³ noted that unicondylar fractures tend to be common sports injuries that occur when a ball impacts the slightly flexed outstretched digits with high velocity, spreading the digits and resulting in an oblique volar fracture pattern. In their series of 38 patients with unicondylar fractures of the proximal phalanx, they found that the location of an avulsed condylar fracture tends to be the outermost fingers of the hand, and the condyle toward the midline is the most frequently fractured. They also found that when the condyle away from the midline was fractured, either a compressive mechanism (with the finger away from the midline) or a tension mechanism (with the fingers deviating toward the midline) was the most likely cause.

Indications

Unicondylar fractures of the phalanges are very unstable. Weiss and Hastings³ noted that in five of seven patients with nondisplaced condylar fractures managed nonsurgically, the fractures displaced during treatment. They specified that nonsurgical treatment of these fractures requires very close follow-up to reduce the high likelihood of displacement. At least two Kirschner wires (K-wires) are required for stable fixation of unicondylar fractures of the phalanx. A single K-wire does not provide adequate stability because K-wires splint and do not compress the fracture site as does screw fixation. Mini-screws provide compression at the fracture site, and a single screw centered in the condylar fragment may provide sufficient stability. K-wires and mini-screws may be used in combination, and two mini-screws may be used in larger fracture fragments. Full recovery of proximal interphalangeal (PIP) joint motion is the exception, not the rule, following unicondylar fractures of the phalanx. Stable fixation does seem to correlate with recovery of motion at the PIP joint. Usually, some loss of extension is present, resulting in a flexion contracture.

In 2006, I presented my technique for percutaneous headless cannulated mini-screw fixation as an option for
intra-articular unicondylar fractures and selected bicondylar fractures of the phalanx.⁴ The advantage of headless screws is that they fit entirely within the bone fragment, minimizing irritation to the collateral ligament compared with mini-screws with conventional heads. In addition, percutaneous insertion minimizes soft-tissue dissection and scarring, compared with a mini-open approach. This results in less restriction from joint and tendon adhesions and greater range of motion. Insertion of a cannulated screw allows precise placement of the screw over the guidewire and simplifies the procedure.

PROCEDURE

Surgical Technique

Condylar fractures of the phalanx usually can be treated with closed reduction within 7 to 10 days following injury (Figure 1). Under fluoroscopy, a dental pick, K-wire, or hypodermic needle can be used to assist reduction if closed manipulation fails to anatomically reduce the fracture fragment. Once the fracture is reduced, a pointed reduction clamp or a specialized fracture reduction jig may be used to provide provisional fixation (Figure 2, A). The fracture reduction is evaluated under fluoroscopy in both the PA and lateral views. The condyles should align concentrically on the lateral view. A displaced condylar fracture that is not anatomically reduced will appear as a double convexity (Touchy sign) when viewed laterally. Once the fracture is anatomically reduced and confirmed under fluoroscopy, one or two K-wires are inserted. One guidewire is placed in the central aspect of the condylar fragment parallel to the articular surface, just distal to the origin of the collateral ligament (Figure 2, B). This will be the guidewire used for screw insertion. A second guidewire is placed eccentrically into the condylar fragment to prevent rotation during drilling and screw insertion. The key is to place both guidewires through the opposite cortex and the skin of the digit so that if the guidewire breaks, it can be easily removed.

FIGURE 1 Phalangeal condylar fracture. A, Clinical photograph shows a displaced fracture of the middle phalanx of the long finger, resulting in ulnar deviation of the digit. B, PA radiograph shows the displaced fracture angulation from the base of the middle phalanx of the long finger.

The skin is nicked with the tip of a No. 11 blade over the central guidewire (Figure 3, A). Then blunt dissection is carried down to the bone surface with a hemostat. In unicondylar fractures, only the near cortex needs to be reamed with a cannulated drill because the metaphyseal bone is relatively soft (Figure 3, B). In fractures that have a more proximal or distal extension involving a portion of the diaphysis of the phalanx, both cortices should be drilled, to avoid blow-out of the opposite cortex as the screw is inserted. Typically, the screw length is 8 to 10 mm. The screw is inserted over the guidewire so that it sets entirely inside the bone on both the PA and lateral radiographs (Figure 3, C through F). A second headless cannulated screw is placed if the fracture line extends toward the diaphysis (Figures 4 and 5). The second mini-screw is usually inserted on the opposite side from the initial screw. This allows the smaller-diameter lead portion of the screw to cross the fracture site and engage the smaller remaining cortex of the condylar fragment, decreasing the chance of fragmentation. Following screw placement, the stability of the fracture is judged by performing range of motion of the finger under fluoroscopy.

A small adhesive bandage is placed over the insertion site. Usually, no sutures or splint is required.

Postoperative Care and Rehabilitation

Immediate range-of-motion exercises are initiated, and strengthening exercises are typically started 4 to 6 weeks following surgery (Figure 6). Athletes typically return to competition within 1 week with the finger buddy taped to the adjacent digit in a skilled player.

FIGURE 2 Reduction of a phalangeal condylar fracture. A, Photograph demonstrates anatomic reduction of the fracture with closed manipulation. A specialized reduction clamp is used to hold the provisional reduction, and a guidewire is placed for the headless cannulated screw. B, PA fluoroscopic view shows the anatomic reduction of the fracture with placement of the guidewire through the reduction clamp.

FIGURE 3 Fixation of a phalangeal condylar fracture. A, Intraoperative photograph depicts incision of the skin with the tip of a No. 11 blade over the guidewire. B, The guidewire is placed across the finger and exits the opposite cortex and the skin. The near cortex is reamed with a cannulated reamer. C, The headless cannulated screw is placed over the guidewire to stabilize the fracture. The fracture is then anatomically reduced and stabilized. D, The ulnar deviation of the digit has been corrected. PA (E) and lateral (F) fluoroscopic views show the placement of the headless cannulated screw within the bone and anatomic restoration of the fracture.

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