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

Published on 20/04/2015 by admin

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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

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