1 Principles topenlarge
These are rare unicondylar fractures that occur in the coronal plane and are
associated with palmar, or dorsal, dislocations.
If the PIP joint is dislocated dorsally, a coronal dorsal fracture is present. If the PIP joint is dislocated palmarly, a coronal palmar fracture is associated.
Typically these fractures are the results of sports injuries, occurring as a
result of axial loading associated with hyperflexion or hyperextension.
Condylar fractures tend to be very unstable and should usually be treated operatively. If conservative treatment is attempted, secondary displacement leads to angulation of the finger.
These fractures are rare, but difficult to treat. There is an increased risk of joint stiffness resulting from these fractures.
It is wise to use magnifying loupes in these procedures. Gentle and precise handling throughout the procedure is mandatory.
2 Reduction topenlarge
Anatomical reduction mandatory
Articular fractures must be reduced anatomically, otherwise, the articular
cartilage may be damaged, leading to painful degenerative joint disease and
This illustration shows how displacement may lead to abrasion and shearing of the articular cartilage, and also to instability.
Closed reduction of the dislocation
Apply traction to the finger with the PIP joint in partial flexion, and exert dorsal pressure on the displaced condyle in order to reduce the dislocation.
Apply traction to the finger with the PIP joint in extension and exert palmar pressure on the displaced condyle in order to reduce the dislocation.
In dorsal fragments
In dorsal fragments, part of the fracture line on the lateral aspect of the
head is covered by the collateral ligament.
Flexing the PIP joint will draw back the collateral ligament, which can be further retracted with a hook to expose the dorsal fragment.
In palmar fragments
In palmar dislocations, the collateral ligament complex is torn or partially torn. In most cases, the remnant of the collateral ligament can be retracted gently to reveal the palmar condylar fracture line.
Reduce the fracture
In order to gain better visualization of the fracture, use a syringe to
clear out blood clot with a jet of Ringer lactate.
Gently reduce the fragment with a dental pick. Be careful to avoid fragmentation.
The opposite joint surface of the middle phalanx can be used as a template for reduction.
Small dorsal articular defect
If a small articular fragment is present, it can be excised. This will not compromise stability or flexion of the PIP joint.
Small palmar articular incongruency
Any incongruency on the palmar side is critical and can impede movement. It must be anatomically reduced and fixed.
3 Fixation topenlarge
Location of the drill holes
On the lateral intraarticular aspects of the condyles, there is a small ridge on each side. These are uniquely suited for screw placement, as the screws can be buried deep to the edge of the cartilage without violating the joint surface and avoiding causing irritation.
Drill a gliding hole as perpendicularly to the fracture plane as possible,
using a 1.0 mm drill bit for a 1.0 mm screw.
Use a 0.8 mm drill bit to drill a thread hole in the opposite fragment, just through the far (trans) cortex.
In a dorsal fragment, fixation is from dorsal to palmar.
In a palmar fragment, fixation is from palmar to dorsal.
Insert lag screw
Insert the lag screw. Carefully tighten the screw to achieve interfragmentary compression.