1 Principles topenlarge
Comminuted fractures are rarely isolated injuries, as they usually result
from high-energy trauma (crushing). Soft-tissue lesions are frequently
associated with the potential risk of edema, fibrotic reactions and eventual
For these reasons, these injuries are usually treated by ORIF, in order to provide sufficient stability for immediate mobilization, reducing the risk of joint stiffness and tendon adhesions.
Depending on the forces acting on the bone, two kinds of comminuted fractures are common: small fragment comminution, or wedge fractures.
Small fragment comminution
Even in the hand, which is well vascularized, small fragment comminution means poor soft-tissue attachment to the fragments and, thereby, compromised vascularity.
The degree and type of comminution depends on the forces and energy acting on the finger. In some cases, a large wedge fragment may result from the injury. In such cases, vascularity has not usually been significantly compromised.
2 Reduction topenlarge
Gaining length by traction
Length can be gained by traction applied either manually by the surgeon, by a finger trap, or with pointed reduction forceps.
Reduce rotation and angulation
Manipulate the fragments with pointed reduction forceps in order to reduce rotation and restore correct angulation.
3 Check alignment topenlarge
At this stage, after provisional fixation, it is advisable to check the
alignment and rotational correction by moving the finger through a range of
Rotational alignment can only be judged with the fingers in a degree of flexion, and never in full extension. Malrotation may manifest itself by overlap of the flexed finger over its neighbor. Subtle rotational malalignments can often be judged by tilting of the leading edge of the fingernail, when the fingers are viewed end-on.
If the patient is conscious and the regional anesthesia still allows active movement, the patient can be asked to extend and flex the finger.
Any malrotation is corrected by direct manipulation and later fixed.
Using the tenodesis effect when under anesthesia
Under general anesthesia, the tenodesis effect is used, the surgeon fully flexing the wrist to produce extension of the fingers, and fully extending the wrist to cause flexion of the fingers.
Alternatively, the surgeon can exert pressure against the muscle bellies of the proximal forearm to cause passive flexion of the fingers.
4 Fixation topenlarge
Select a straight plate that is long enough to have at least 2 holes on each side of the wedge fragment. Apply the plate laterally and center it on the shaft axis of the phalanx in the lateral projection.
Using a drill guide and 1.1 mm drill bit, carefully drill a neutral first screw hole through a plate hole directly adjacent to the wedge fragment.
Use a depth gauge to determine screw length.
Insert first screw
Insert the first screw in a neutral position. Do not yet completely tighten it, to avoid displacement.
Insert second screw
Drill for a neutral second screw through the plate hole adjacent to the
opposite end of the wedge fragment. Measure for screw length, and insert the
Now tighten both screws alternately.
Insert remaining screws
Fill the remaining screw holes on each side of the wedge fragment in a similar fashion. The most proximal and most distal screws should be inserted at a divergent angle, thereby increasing stability.
Option: approximating screw
In some cases it may be desirable to approximate the wedge fragment to the plate in order to strengthen the construct. Insert a short neutral monocortical screw, and carefully tighten it.