AOTrauma Webinar:  Why Do Patients Get Infection?

May 30, 2017 14:00 CET

Main Presenter: Olivier Borens, MD (Switzerland)
Chat Moderator: Stephen Kates, MD (USA)

Surgical site infections after trauma are debilitating and costly. They are feared by the surgeon and the patient alike. The incidence of this complication can be decreased by proper preoperative, intraoperative, and postoperative management.
The goal of this webinar is to present easy-to-use tools and strategies that will lead to a decrease in the incidence of infection.

More information and registration...

Infection

Executive Editor: Chris Colton

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

Proximal phalanx - Simple transverse fractures

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Glossary

1 Principles top

Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Fractures of the diaphysis can be transverse, oblique, spiral, or comminuted. Reduction is achieved by traction and digital manipulation. When the fracture is stable, it can be treated nonoperatively.


Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

If the fracture is irreducible, ORIF is indicated.
Other indications for ORIF are open fractures, or soft-tissue lacerations.

2 Reduction top

Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Indirect reduction by traction

Reduction can be obtained by traction and flexion of the metacarpophalangeal joint exerted by the surgeon.
Confirm reduction under image intensification.
Often, these fractures are stable after reduction, in which case, nonoperative treatment is indicated.


Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Direct reduction

Direct reduction is necessary when the fracture can not be reduced by traction and flexion, or is unstable.
When indirect reduction is not possible, this is usually due to interposition of parts of the extensor apparatus.
Use two pointed reduction forceps for direct reduction.


Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Preliminary fixation

Insert a K-wire for provisional fixation.

3 Check alignment top

At this stage, after provisional fixation, it is advisable to check the alignment and rotational correction by moving the ... enlarge

Identifying malrotation

At this stage, after provisional fixation, it is advisable to check the alignment and rotational correction by moving the finger through a range of motion.
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.


Under general anesthesia, the tenodesis effect is used, the surgeon fully flexing the wrist to produce extension of the ... enlarge

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 ... enlarge

Alternatively, the surgeon can exert pressure against the muscle bellies of the proximal forearm to cause passive flexion of the fingers.

4 Fixation top

Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Bending and contouring the plate

If the plate is perfectly contoured to follow the geometry of the concavity of the phalanx, tightening the screws will result in a gap in the opposite cortex.
The solution to this is slightly to overbend the plate so that when axial compression is exerted by the plate, the compression occurs evenly over the whole fracture surface.


Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Plate application

Select a plate with at least 5 holes, and center it over the fracture.
Ensure that the plate is centered on the long axis of the diaphysis in the lateral view.


Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Pitfall

If the plate is not properly aligned in the lateral view, the screws may not cross the medullary canal and may not have sufficient purchase. Secondary fractures may result.


Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Drilling

Using a drill guide, carefully drill a first hole with a 1.1 mm drill bit.


Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Measurement

Use a depth gauge to determine screw length.


Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Screw insertion

Insert the first screw in a neutral position. Ensure that it engages the far cortex. Failure accurately to measure the required screw length risks failure to engage the far cortex properly, weakens the fixation, and incurs the risk of implant failure.


Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Insert second screw

Insert a second screw in neutral position on the same side of the fracture after the same fashion as above.


Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Insert third screw eccentrically

Drill eccentrically for the third screw, through the proximal hole on the other side of the fracture. Measure for screw length, and insert a screw.
Tightening this screw will compress the fracture axially.


Simple transverse fracture of proximal phalanx – Compression plate fixation enlarge

Complete fixation

Complete the fixation with the insertion of a neutral fourth screw, after the fashion of the first two screws.

v1.0 2008-11-08