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

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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

All clots and debris between the fracture fragments must be débrided to allow anatomic reduction of the fracture fragments.

Procedure

Step 1

image The fracture is exposed, and blood clots and periosteum are débrided from the fracture surface.

image Reduction of the fracture is achieved by longitudinal traction and rotation of the distal fragment toward the proximal fragment to close the fracture.

Step 1 Pearls

All debris must be cleared because even small amounts can prevent accurate reduction.

Step 2

image A small, pointed bone reduction clamp is used to hold the fracture in position (Fig. 49-5). Sometimes, two clamps are required to control rotation.

image Alternatively, artery forceps may be used.

image

FIGURE 49-5

Step 2 Pearls

Care must be taken to achieve anatomic reduction. Rotational reduction is confirmed by flexing the fingers using the tenodesis effect.

Reduction must be perfect. A very slight malreduction can translate into a rotational deformity.

Step 3

image Precompression of the fracture is achieved by using the pointed bone reduction clamp or artery forceps. This allows a bicortical screw to be inserted instead of a classic lag screw without compromising the compression across the fracture.

image Usually, a 1.5- or 1.3-mm screw is chosen, according to the size of the bone and fragment. Sometimes, for very small fragments, 1-mm screws may be used. Alternatively, for larger bones, 2-mm screws may be used. There should be at least a one-diameter distance from the edge of the fracture to the drill hole.

image The direction of the screw should be perpendicular to the fracture line for maximal compression. Screws should also be placed perpendicular to the rotational plane of the fracture (Fig. 49-6).

image The fracture is held in a precompressed position while the drill hole is made. With precompression, the fracture is not likely to slide and displace during tightening of the screws.

image

FIGURE 49-6

Step 3 Pearls

Precompression helps to interdigitate the fracture to lessen the risk for fracture displacement during screw placement.

Smaller screws should be used nearer the apex of the fracture fragments to lessen the risk for fractures.

Ensure that the drill is sharp and that irrigation is done during drilling to reduce the amount of heat produced and the risk for osteonecrosis.

Step 3 Pitfalls

Care should be taken not to overtighten and fracture the fragments.

Screws that are not perpendicular to the fracture plane may cause the fracture fragments to shear and displace.

Step 4

image The drill hole is countersunk so that the screw head will sit better. This will also lessen soft tissue irritation as well as ensuring that the direction of the screw is maintained, preventing the screw head from being pushed eccentrically when one side of it comes into contact with the phalanx, as is usually the case with a spiral or long oblique fracture.

Step 4 Pearls

Countersinking the drill hole will minimize soft tissue irritation and ensure maintenance of the alignment of the screw and, hence, the reduction.

Step 5

image A minimum of two, and, if possible, three, such screws are inserted, each perpendicular to the rotational plane of the fracture (Fig. 49-7).

image The fixation is checked using the mini C-arm to confirm the reduction, positioning, and length of the screws as well as the stability through the full range of motion of the finger.

image

FIGURE 49-7

Step 5 Pearls

Rotational alignment of the finger must be regularly checked with each screw inserted.

Step 5 Pitfalls

The screw length must be perfect. If too long, it may impinge on the flexor tendons. If too short, the fixation will become unstable.

The direction of the screw during insertion must be correctly aligned with the drill hole. Otherwise, the screw will push the distal cortex away and cause a loss of reduction of the fracture (Fig. 49-8A). Figure 49-8B shows screws readjusted with effective interfragmentary compression.

image

FIGURE 49-8

Step 6

image The periosteum is repaired using absorbable sutures in delayed cases.

image The extensor tendon is repaired using absorbable sutures, usually 4-0 size.

image The skin is repaired using interrupted nonabsorbable sutures, usually 5-0 size.

Postoperative Care and Expected Outcomes

image Immediate active assisted range-of-motion exercises are started.

image Sutures are removed at 12th to 14th postoperative day.

image Fracture healing is monitored at 2-, 6-, and 12-week intervals with radiographs.

image Progression to passive range-of-motion exercises and strengthening are started as the fracture heals.

image Figure 49-9: Good range of motion of the middle finger is achieved.

image

FIGURE 49-9

Pearls

Early range-of-motion exercise should be started.

Pain control with nerve block may sometimes be required for those who are unable to mobilize the interphalangeal joints because of pain.

Evidence

Black DM, Mann RJ, Constine RM, Daniels AU. The stability of internal fixation in the proximal phalanx. J Hand Surg [Am]. 1986;11:672-677.

Five commonly used techniques of internal fixation—dorsal plating, dorsal plating combined with an interfragmentary lag screw, two interfragmentary lag screws, tension-band technique, and crossed Kirschner wires—were tested for rigidity and apex palmar bending. The results showed that both of the techniques that used interfragmentary lag screws across the oblique osteotomies provided significantly more rigidity than did dorsal plating alone or the wired configurations. (Level IV evidence)

Ford DJ, el-Hadidi S, Lunn PG, Burke FD. Fracture of phalanges: results of internal fixation using 1.5 mm and 2 mm A.O. screws. J Hand Surg [Br]. 1987;12:28-33.

Thirty-six patients with 38 phalangeal fractures at various levels and with different configurations were treated with open reduction and internal fixation with mini AO screws. Results were satisfactory in 90% of the cases. (Level V evidence)

Kawamura K, Chung KC. Fixation choices for closed simple unstable oblique phalangeal and metacarpal fractures. Hand Clin. 2006;22:287-295.

The techniques of percutaneous K-wiring, tension band wiring, lag screw fixation, and plating for fixation of unstable oblique fractures of the proximal phalanx are reviewed. Lag screw fixation is considered the best choice for long oblique phalangeal fractures because this technique provides sufficient rigidity to allow early mobilization. (Level V evidence)

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