1 Principles topenlarge
Complete cartilage removal
Complete cartilage removal is important to provide for maximum contact between the opposing subchondral bone plates. With compression, generated by the fixation technique, frictional forces are generated between the subchondral bone plates, which maximizes strength and stability of the fixation, providing maximum patient comfort and allowing early removal of postoperative cast support.
The implant positioning in the middle phalanx is in the proximal epiphyseal region. The distal end of the plates should not impinge on the proximal attachment of the distal interphalangeal joint capsule and should be positioned abaxially to avoid the extensor process. The distal plate screw should engage a substantial portion of the palmar/plantar eminence fragment provide maximum strength of the fixation.
It is important, that the screws through the distal aspect of the plates engage the eminence fragments to provide for reestablishment of the palmar/plantar support and to reduce the fractures on the palmar/plantar aspect of the middle phalanx.
Alignment of the proximal articular fracture components indirectly establishes alignment of the distal articular fractures except in cases of major comminution at the distal interphalangeal joint.
Two plates are necessary to neutralize the bending forces acting across the pastern joint and provide transarticular compression to encourage arthrodesis.
AO teaching videos
Multifragment fracture fixation using two 3-hole pastern arthrodesis LCPs and independent lag screws
Middle phalanx fracture arthrodesis using two 3-hole 4.5 LC-DCPs and lag screws
2 Preparation and approach topenlarge
3 Reduction and fixation of the major central axial eminence fragment topenlarge
In most cases, the proximal articular surface of the middle phalanx is reconstructed with the joint dorsally luxated to allow direct visualization of the major fracture fragments.
Alignment is generally achieved through a combination of flexion and extension of the digit and placement of large pointed reduction forceps to engage the major eminence fragments from dorsal to palmar/plantar.
Once the major central axial eminence fragment is reduced a 4.5 mm cortex screw is placed in lag fashion from dorsal to palmar/plantar to compress the reduced fracture fragments.
4 Plate preparation topenlarge
A combination of PIP plates and/or 4-5 hole narrow LCP are used in most cases. Other plate constructs have been used successfully, including narrow, 4.5 mm DCPs and LC/DCPs.
The technique for fixation with DCP or LC/DCP is described for uniaxial eminence fractures as an example. For more details click here.
The plates are contoured to approximate the dorsal surface of the distal proximal phalanx and proximal middle phalanx with the stacked combi-hole into the plate positioned over the proximal end of middle phalanx.
The distal end of the plate is then bent slightly to ensure that the middle phalangeal plate screw is directed into the major substance of the eminence fragment.
5 Reduction and Fixation topenlarge
Reduction and placement of the first plate
Usually, the second eminence fracture can be reduced with a pointed reduction forceps. Once reduced, either a 5.5 mm or a 5.0 mm locking head screw is positioned through the distal hole of the first plate. This screw is located abaxial to the first screw and engages the major eminence fracture fragment that has not been stabilized by the axial lag screw.
Application of the second plate
The second plate is applied on the opposite abaxial side and, the distal screw engages the eminence fragment.
Fixation to the proximal phalanx
The middle and proximal phalanges are realigned and the plates fixed to the proximal phalanx using 5.5 mm cortex screws placed in a load position in the second hole proximal to the joint.
The remaining holes are filled with locking screws with both juxta-articular locking screws placed bicortically and the proximal most locking screw in a four hole plate monocortically.
Note: If DCPs or LC-DCPs are used only 4.5 mm or 5.5 mm cortex screws are used in all plate holes.
There are cases where it is beneficial to put an additional screw into major fracture fragments. This screw is placed through a stab incision with careful intraoperative radiographic or fluoroscopic control to ensure precise positioning.
Note: This fracture was repaired with a 4-hole and a 3-hole narrow DCP with 5.5 mm cortex and 4.5 mm cortex screws.
The final construct configuration is checked with appropriate imaging to ensure appropriate length and positioning of all implants.
It is important that screws of appropriate length are used and that they do not protrude significantly beyond the palmar/plantar cortex of the proximal and middle phalanges.
Note: This was repaired with a 4-hole PIP and a 3-hole DCP in addition to a 5.5mm cortex screw.