Dorsal Fracture–Dislocations of the Proximal Interphalangeal Joint

The proximal interphalangeal joint is frequently injured in sports when the digit sustains an axial load and hyperextension force against a ball or other player. Presentation of the “jammed finger” to the hand surgeon is often delayed. However, the coach or manager may underplay the injury, and the pressure on the athlete to continue in competition is often high. The challenge to the surgeon is multiple: a comminuted intra-articular fracture of the middle phalangeal base with dorsal joint subluxation, underappreciated damage to the contralateral side of the joint, delay from the time of injury, and a patient who is often young and demands not just return to activities of daily living but a return to high function and competitive sport. When faced with this challenge, the surgeon tries to achieve restoration of an anatomical articular surface with joint stability and a robust long-term outcome for the patient.

In the best-case scenario, rigid anatomical fixation and early mobilization are achieved. A meticulous volar approach, carefully elevating the articular surface, packing of bone graft, and rigid fixation with screws or a buttress plate can allow a stable articulation and predictable functional outcome. Often, however, a reconstructive option is required. The preferred strategy depends on the patient's age, functional demands, and surgeon's skill set and experience. Hastings described the hemihamate autograft at the annual meeting of the Society for Surgery of the Hand in 1999 as a salvage procedure for comminuted intra-articular fractures of the proximal interphalangeal joint with clinical results published in 2003.[1] Since then, the technique has become popularized as it is a useful tool in the armamentarium for the hand surgeon treating this complex injury.

Certainly, the use of a hemihamate osteochondral graft can lead to a stable enlocated joint allowing an early functional range of motion. Early results in small series have shown excellent union rates and good functional outcomes.[2] The hemihamate autograft is an excellent option in many cases, but is it always the answer? Concerns arise due to reports of early arthritis and the lack of substantial long-term results with this technique.[3] [4] Recent studies have shown significant differences in morphology between the middle phalangeal base and distal hamate depending on the digit and the individual. Certainly, a “one-size-fits-all” approach for all fingers in every patient seems overly simplistic; a perfect graft match is unrealistic, but graft choice should be individualized. A hamate with perfectly matched facets for an index finger middle phalanx is unlikely to fit as well in the smaller little finger and vice versa. The ideal graft for the patient selection should be tailored to the individual.

In my practice, I have found excellent outcomes in the index and middle fingers compared with the little finger following hemihamate reconstruction. This led us to study our practice. What was clear at the time of the hamate harvest was the mismatch in facet shapes of the hamate; the facet for the ring finger was often concave, whereas the facet for the little finger was often convex. We have studied 3-Tesla magnetic resonance imaging scans of hands to identify another suitable graft choice. We found that the distal capitate had some advantages: the facets are often equal in shape, usually flat or convex. In some digits, this proved a closer match to the shape of the middle phalangeal base. In addition, the smaller articular surface–cortex angles led to the potential for less overstuffing of the joint, with overstuffing a potential concern for flexor tendon bowstringing.[5] Our recommendation was a close study of the imaging and contralateral imaging (radiographs or advanced imaging) to choose the best graft for the individual patient. A recent case report illustrates the first published use of hemicapitate grafting as an option for this injury in the ring finger with an excellent range of motion and a pain-free congruent joint at short-term follow-up.[6]

An ‘outside-the-box’ approach helped Hastings report the use of the hemihamate autograft. Perhaps we should look beyond the box to the rest of the carpus. Some surgeons have even looked to the feet for inspiration to find a better solution for this injury.[7] Further cadaveric and biomechanical studies will allow us to assess contact surface areas and loading characteristics between the distal articular surfaces of the capitate and the proximal phalangeal head. Further consideration should be made to the donor site and the potential consequence on carpal loads, instability, and postoperative pain when choosing the ideal graft.

Technology may hold the answer. For forearm deformity correction, we often use computed tomography scans of the injured and contralateral “normal” side with computer-aided design when planning surgery. Perhaps software has a similar role in planning reconstructive surgery in proximal interphalangeal injuries. 3D printing is already successfully used in orthopaedic surgery, allowing intra- and postoperative planning. 3D printing of the ‘injured’ side and the carpal bones may allow a trial run to decide on the most precise match for the injury before reaching the operating theater.

Dorsal fracture–dislocations of the proximal interphalangeal joint remain a challenging injury to treat. Hemihamate harvest has expanded our options. For some cases, a “hemicapitate” may be a better choice. We look forward to further research to help our patients return to the rigors of their occupations and sporting activities.

Publication History

Article published online:
29 March 2023

• References

• 1 Williams RM, Kiefhaber TR, Sommerkamp TG, Stern PJ. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg Am 2003; 28 (05) 856-865
• 2 Frueh FS, Calcagni M, Lindenblatt N. The hemi-hamate autograft arthroplasty in proximal interphalangeal joint reconstruction: a systematic review. J Hand Surg Eur Vol 2015; 40 (01) 24-32
• 3 Afendras G, Abramo A, Mrkonjic A, Geijer M, Kopylov P, Tägil M. Hemi-hamate osteochondral transplantation in proximal interphalangeal dorsal fracture dislocations: a minimum 4 year follow-up in eight patients. J Hand Surg Eur Vol 2010; 35 (08) 627-631
• 4 Calfee RP, Kiefhaber TR, Sommerkamp TG, Stern PJ. Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture-dislocations. J Hand Surg Am 2009; 34 (07) 1232-1241
• 5 Bond EC, Matenga M. B M MacLean S. Hamate vs. capitate grafting for proximal interphalangeal joint fracture-dislocation: an MRI-based study of 35 hands. J Hand Surg Eur Vol 2022; 47 (07) 755-760
• 6 Jerome JT.J. Hemi-capitate arthroplasty for dorsal fracture-dislocations of the proximal interphalangeal joint: surgical technique and illustrative case. JOIO 2023; DOI: 10.1007/s43465-023-00853-2.
• 7 Nizzero D, Tang N, Leong J. A novel technique for proximal interphalangeal joint fracture-dislocations: the second toe middle phalanx osteochondral graft. J Hand Surg Eur Vol 2021; 46 (09) 941-945