53: Metacarpophalangeal and Proximal Interphalangeal Joint Collateral Ligament Avulsion Fractures

Published on 19/04/2015 by admin

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Procedure 53 Metacarpophalangeal and Proximal Interphalangeal Joint Collateral Ligament Avulsion Fractures

Randy R. Bindra, Micah K. Sinclair

imageSee Video 39: Metacarpal Shaft Fractures

Indications

image Displaced collateral ligament with or without associated joint subluxation or dislocation

image Large avulsion fragment with articular incongruity

image Displaced and interposed fracture fragment within joint

image Border digit injury such as radial border of index finger or ulnar collateral ligament of thumb metaphalangeal (MP) joint

image Injury in athletes

Examination/Imaging

Clinical Examination

image Unilateral swelling and bruising of the injured joint

image Lateral deviation deformity of digit due to loss of collateral ligament integrity (Fig. 53-1)

image Pain with restricted range of motion

image Gentle testing of collateral ligaments to ensure integrity, which may require local anesthetic block. Avoid excessive force to prevent displacement of fragment (Fig. 53-2)

image Patient asked to flex and extend the uninjured joints distal to the injury to evaluate the continuity of the flexor and extensor tendons

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FIGURE 53-1

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FIGURE 53-2

Imaging

image Posteroanterior, oblique, and true lateral films of the digit for proximal interphalangeal (PIP) joint injuries. At the PIP joint, the most common avulsion fracture is a unicondylar fracture (Fig. 53-3).

image Posteroanterior, oblique, and true lateral films of the hand for metacarpophalangeal (MCP) joint injuries (Fig. 53-4).

image In the immature skeleton, ligament avulsion injuries occur at the growth plate with a fragment of the epiphysis (Fig. 53-5).

image Brewerton view provides a tangential view of the metacarpal head, demonstrating the area of origin of the collateral ligament, which will help to reveal small avulsion fragments from the metacarpal head.

image Computed tomography scanning is useful in cases of suspected involvement of the articular surface for evaluation of joint congruity.

image

FIGURE 53-3

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FIGURE 53-4

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FIGURE 53-5

Surgical Anatomy

image MCP joint collateral ligaments are more commonly avulsed at their distal insertion. An avulsed fragment from the base of the proximal phalanx is lateral and volar to the midaxis.

image Rarely, in more severe injuries, with pure ligamentous avulsions or smaller fragment avulsions, the avulsed ligament lies superficial to the extensor apparatus.

image If avulsed without bone or with a small fragment, the ulnar collateral ligament of the thumb MP joint can come to lie superficial to the adductor aponeurosis (Stener lesion).

Positioning

image The patient is positioned supine with the arm on a hand table.

image The forearm is pronated, and the hand is placed on a towel roll. The surgeon is seated facing the injured side of the digit.

image A tourniquet is used for the procedure.

Positioning Equipment

Intraoperative imaging is critical in this procedure. The mini C-arm is draped sterilely, placed at the axillary side of the table, and brought in when needed during the case.

Exposures

Metacarpophalangeal Joint

image The MCP joint of the thumb and borders of the hand (ulnar side of small and radial side of index finger) can be easily accessed through a lateral approach.

image Cutaneous nerves are located in the subcutaneous plane and must be identified and preserved.

image The oblique fibers of the extensor hood cover the MCP joint and will need to be incised longitudinally for access to the joint; they require meticulous repair on completion.

image Access to the MP collateral avulsion fracture for nonborder digits is achieved by a volar approach that allows reduction and fixation with compression.

image With a volar approach, the digital neurovascular bundle is at risk for injury and must be identified and carefully retracted away from the flexor tendon sheath.

image A Bruner zigzag skin incision is made centered over the proximal digital crease (Fig. 53-6).

image The flexor sheath is kept intact (Fig. 53-7

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