Executive Editor: Chris Colton

Authors: Fiesky Nuñez, Renato Fricker, Matej Kastelec, Terry Axelrod

Middle phalanx - PIP joint - lateral plateau compression fracture

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Glossary

1 Principles top

While dislocations and ligament injuries are common throughout the hand, they are most common at the proximal ... enlarge

Dislocations

While dislocations and ligament injuries are common throughout the hand, they are most common at the proximal interphalangeal (PIP) joint.
The spectrum of these injuries ranges from minor stretching (sprains) to complete disruptions of the ligaments.


Dislocations of the PIP joint are classified according to the direction of displacement of the middle phalanx... enlarge

Dislocations of the PIP joint are classified according to the direction of displacement of the middle phalanx. They can be palmar, dorsal, lateral, or lateral rotatory.


The collateral ligament usually tears at one of two locations. enlarge

Ligament injuries

The collateral ligament usually tears at one of two locations:
a) at its attachment to the proximal phalanx
b) at its attachment to the volar plate and middle phalanx.
Often, these injuries are accompanied by a partial lesion of the volar plate.


Lateral subluxation can be accompanied by a condylar fracture, or a plateau fracture (either as an avulsion fracture, or as ... enlarge

Accompanying fractures

Lateral subluxation can be accompanied by a condylar fracture, or a plateau fracture (either as an avulsion fracture, or as an impaction fracture).


A combination of lateral angulation and axial loading of the finger results in eccentric longitudinal compression forces on ... enlarge

Mechanism of the injury – plateau compression fracture

A combination of lateral angulation and axial loading of the finger results in eccentric longitudinal compression forces on one condyle of the middle phalanx, leading to impaction fracture.
Often dorsal instability, or dorsal rotatory instability, is a result.

2 Reduction top

Apply traction to the finger, with the PIP joint in slight flexion, to relax the flexor tendons and the lateral band. enlarge

Closed reduction of dislocation

In cases of associated dislocation, start by reducing the dislocation.
Apply traction to the finger, with the PIP joint in slight flexion, to relax the flexor tendons and the lateral band.


Then, maintaining the traction, deviate the finger laterally... enlarge

Then, maintaining the traction, deviate the finger laterally...


...and rotate towards the contralateral side. enlarge

...and rotate towards the contralateral side.

In the majority of cases, the collateral ligament regains its natural anatomical position after reduction.


Use a 2.5 mm drill bit to create an entry portal just distal to the fracture zone, to permit disimpaction. enlarge

Create a metaphyseal entry portal

Use a 2.5 mm drill bit to create an entry portal just distal to the fracture zone, to permit disimpaction.


Insert a K-wire, a dental pick, or a tiny curette, into the drill hole. Disimpact the fragments and push them towards the ... enlarge

Disimpact the fragments

Insert a K-wire, a dental pick, or a tiny curette, into the drill hole. Disimpact the fragments and push them towards the head of the proximal phalanx, which can be used as a template to ensure congruity of the articular surface of the middle phalanx.
If a cartilage step-off greater than 1 mm remains, degenerative joint disease is likely to follow.

As the metaphyseal cancellous bone is disimpacted, a void may be created.
This jeopardizes the fracture in two ways:

  • It is a very unstable situation in which the fragments may easily redisplace (collapse)
  • the healing process is delayed.

3 Bone graft top

Harvest the bone graft from the distal radius. A suitable and safe place for the harvest is just proximal to Lister’s tubercle. enlarge

Harvest site

Cancellous autograft will be necessary to support the articular fragments and fill the void. The graft will also assist the healing process.

Harvest the bone graft from the distal radius. A suitable and safe place for the harvest is just proximal to Lister’s tubercle.


Make a 2 cm long incision proximal to the Lister’s tubercle. Retract the tendons of the second compartment radially, and the ... enlarge

Harvesting

Make a 2 cm long incision proximal to the Lister’s tubercle. Retract the tendons of the second compartment radially, and the extensor pollicis longus (EPL) in an ulnar direction.


Use a chisel to cut three sides of a square. Hinge up the dorsal cortical flap. After harvesting cancellous bone, replace ... enlarge

Use a chisel to cut three sides of a square. Hinge up the dorsal cortical flap. After harvesting cancellous bone, replace the “lid” and suture the periosteum and the skin incision.


Fill the whole fracture cavity with compacted bone graft, using a blunt dissector. enlarge

Insert graft into cavity

Fill the whole fracture cavity with compacted bone graft, using a blunt dissector.

The bone graft increases the potential for bone regeneration and healing, and mechanically supports the subchondral bone, helping to avoid its collapsing.

4 Fixation top

If a large fragment is present, maintain its reduction using a position screw. enlarge

Larger fragment

If a large fragment is present, maintain its reduction using a position screw.


In case of a small cavity, one option is to insert a position screw from dorsal to palmar, just at the distal edge of the ... enlarge

Small cavity

In case of a small cavity, one option is to insert a position screw from dorsal to palmar, just at the distal edge of the bone graft. This screw will serve to buttress the graft.


Another option for small cavities is to insert a K-wire to protect the reduction. The K-wire crosses the PIP joint obliquely ... enlarge

Alternative small cavity option

Another option for small cavities is to insert a K-wire to protect the reduction.
The K-wire crosses the PIP joint obliquely and holds it in 20-30 degrees of flexion.

v1.0 2008-11-08