Open Reduction and Internal Fixation for Dorsal Fracture-dislocation of the Proximal Interphalangeal Joint

Abstract

Purpose The purpose of this study was to investigate and compare the clinical and radiological results of ORIF with inter-fragment screw or buttress plate fixation of acute PIP joint fracture dorsal dislocation.

Patients and Methods Between January 2007 to December 2016, nineteen patients – 14 men and 5 women with an average age of 40.9 (19 to 64) years – were included in this study; 9 patients underwent small sized interfragmentary screw fixation and 10 patients underwent small buttress plating. The average follow-up period was 45.1 (13 to 78) months. Clinical assessment included measurement of range of motion (ROM) of the proximal and distal interphalangeal joint (PIP, DIP), grip and pinch strength, and pain with use of the Visual Analog Scale (VAS). At the postoperative X-ray, articular step off, gap, and degree of dorsal subluxation was measured, and maintenance of the reduction, fracture union, and the presence of degenerative changes were assessed.

Results All patients achieved solid unions without instability. The overall average range of motion of PIP joint were from 9° to 85° (10–83° in the screw group, 8–87° in the plate group without significant difference). However, the screw group (average: 53°) presented more flexion in the distal interphalangeal joint than the plate group (average: 34°). Plate fixation can cause limited DIP flexion. Six of the ten patients from the plate group, underwent implant removal and two of these patients required PIP joint arthrolysis due to the PIP flexion contracture of more than 30°. Three of the nine patients in screw group underwent implant removal and two of the three patients required PIP joint arthrolysis.

Conclusion Mini plate and screw fixation of acute PIP joint fracture dorsal dislocation can achieve comparable favorable clinical and radiographic outcomes through stable fixation and early range of motion exercise. Screw fixation, if possible, is probably preferable to plate fixation because of better DIP joint ROM and lower incidence of hardware removal. If there is a need for plate fixation the use of a short plate is recommended to avoid joint stiffness.

Zusammenfassung

Ziel In dieser Studie wurden die klinischen und radiologischen Ergebnisse nach Schraubenosteosynthesen mit den Ergebnissen von Plattenosteosynthesen von dorsalen Luxationsfrakturen des Fingermittelgelenkes (PIP-Gelenk) verglichen.

Patienten und Methoden Zwischen Januar 2007 und Dezember 2016 wurden 19 Patienten – 14 Männer und 5 Frauen mit einem durchschnittlichen Alter von 40,9 (19–64) Jahren in die Studie eingeschlossen. Bei 9 Patienten erfolgte eine Schrauben-, bei 10 Patienten eine Plattenosteosynthese. Die Nachuntersuchungszeit betrug im Schnitt 45,1 (13 bis 78) Monate. Die klinische Untersuchung umfasste die Messung des Bewegungsumfangs des Mittel- und Endgelenkes (PIP- und DIP-Gelenk), der Grobgriff- und Spitzgriffkraft sowie der Schmerzen mittels visuellen Analogskala (VAS). Die postoperativen Röntgenbildern wurde bzgl. Frakturheilung, Repositionsverlust, degenerativen Veränderungen und der Größe verbliebener Stufen- und Spaltbildungen ausgewertet.

Ergebnisse Bei allen Patienten kam es zur knöchernen Heilung ohne Zeichen einer Instabilität des PIP-Gelenkes. Die durchschnittliche Beweglichkeit aller PIP-Gelenke betrug 0–9–85°, für die Schraubengruppe 0–10–83°und für die Plattengruppe 0–8–87°, ohne dass ein signifikanter Unterschied bestand. Im DIP-Gelenk wiesen Patienten der Schraubengruppe eine bessere Flexion auf. Bei 6 der 10 Patienten mit Plattenosteosynthese musste die Platte entfernt werden, gleichzeitig erfolgte bei 2 eine Lösung des PIP-Gelenkes aufgrund einer Beugekontraktur von mehr als 30°. Bei 3 der 9 Patienten mit Schraubenosteosynthese erfolgte ebenfalls die Entfernung des Osteosynthesematerials, 2 erhielten zusätzlich eine Lösung des PIP-Gelenkes.

Schlussfolgerung Schrauben- und Plattenosteosynthesen dorsaler Mittelgelenksluxationsfrakturen erzielen vergleichbar gute klinische und radiologische Ergebnisse und erlauben eine Frühmobilisation bei stabiler Situation. Aufgrund der besseren Beweglichkeit im DIP-Gelenk und da weniger häufig das Osteosynthesematerial entfernt werden muss, ist – wenn möglich – die Schraubenosteosynthese zu bevorzugen. Bedarf es einer Plattenosteosynthese, sollte die Platte möglichst kurz sein, um Bewegungseinschränkungen des DIP-Gelenkes zu vermeiden.

Schlüsselwörter

Proximales Interphalangealgelenk - dorsale Luxationsfrakturen - offene Reposition und interne Fixierung - Platten- und Schraubenosteosynthese

Key words

Proximal interphalangeal joint - dorsal fracture dislocation - open reduction and internal fixation - plate and screw fixation

• References

• 1 E.Adams J, Calfee PP, Vatale MA. et al. Dorsal Proximal Interphalangeal Joint Fracture-Dislocation: Evaluation and Treatment. Valle CJD. Instructional course lectures. Rosemont IL: Amer Acad Of Orthopaedic; 2015
• 2 Williams RM, Kiefhaber TR, Sommerkamp TG. et al. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg Am 2003; 28: 856-865
• 3 Pillukat T, Kalb K, Fuhrmann R. et al. Reconstruction of the middle phalangeal base of the finger using an osteocartilaginous autograft from the hamate. Oper Orthop Traumatol 2019; 31: 393-407
• 4 Kim HJ, Lee HJ, Kim PT. et al. Modified Transosseous Wiring Technique for Neglected Fracture-Dislocation of the Proximal Interphalangeal Joint. Clin Orthop Surg 2019; 11: 220-225
• 5 Ng C, Oliver C. Fractures of the proximal interphalangeal joints of the fingers. J Bone  Joint Surg B 2009; 91: 705-712
• 6 Aladin A, Davis TR. Dorsal fracture-dislocation of the proximal interphalangeal joint: a comparative study of percutaneous Kirschner wire fixation versus open reduction and internal fixation. J Hand Surg Br 2005; 30: 120-128
• 7 Barksfield RC, Bowden B, Chojnowski AJ. Hemi-hamate arthroplasty versus transarticular Kirschner wire fixation for unstable dorsal fracture-dislocation of the proximal interphalangeal joint in the hand. Hand Surg 2015; 20: 115-119
• 8 Basar H, Basar B, Basci O. et al. Comparison of treatment of oblique and spiral metacarpal and phalangeal fractures with mini plate plus screw or screw only. AOTS 2015; 135: 499-504
• 9 Ikeda M, Kobayashi Y, Saito I. et al. Open reduction and internal fixation for dorsal fracture dislocations of the proximal interphalangeal joint using a miniplate. THUES 2011; 15: 219-224
• 10 Green A, Smith J, Redding M. et al. Acute open reduction and rigid internal fixation of proximal interphalangeal joint fracture dislocation. J Hand Surg Am 1992; 17: 512-517
• 11 Lee JY, Teoh LC. Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results. J Hand Surg Br 2006; 31: 138-146
• 12 Ford DJ, el-Hadidi S, Lunn PG. et al. Fractures of the phalanges: results of internal fixation using 1.5 mm and 2 mm A. O. screws. J Hand Surg Br 1987; 12: 28-33
• 13 Hamilton SC, Stern PJ, Fassler PR. et al. Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations. J Hand Surg Am 2006; 31: 1349-1354
• 14 Ikeda M, Kobayashi Y, Saito I. et al. Open reduction and internal fixation for dorsal fracture dislocations of the proximal interphalangeal joint using a miniplate. THUES 2011; 15: 219-224
• 15 Federer AE, Guerrero EM, Dekker TJ. et al. Open Reduction Internal Fixation With Transverse Volar Plating for Unstable Proximal Interphalangeal Fracture-Dislocation: The Seatbelt Procedure. Hand (N Y) 2018;
• 16 Chew WY, Cheah AE. Volar plate and screw fixation for dorsal fracture-dislocation of the proximal interphalangeal joint: case report. J Hand Surg Am 2010; 35: 928-930
• 17 Cheah AE, Tan DM, Chong AK. et al. Volar plating for unstable proximal interphalangeal joint dorsal fracture-dislocations. J Hand Surg Am 2012; 37: 28-33
• 18 Caggiano NM, Harper CM, Rozental TD. Management of Proximal Interphalangeal Joint Fracture Dislocations. Hand Clin 2018; 34: 149-165
• 19 Waris E, Alanen V. Percutaneous, Intramedullary Fracture Reduction and Extension Block Pinning for Dorsal Proximal Interphalangeal Fracture–Dislocations. J Hand Surg Am 2010; 35: 2046-2052
• 20 Ruland RT, Hogan CJ, Cannon DL. et al. Use of dynamic distraction external fixation for unstable fracture-dislocations of the proximal interphalangeal joint. J Hand Surg Am 2008; 33: 19-25
• 21 Lee LS, Lee HM, Hou YT. et al. Surgical outcome of volar plate arthroplasty of the proximal interphalangeal joint using the Mitek micro GII suture anchor. J Trauma 2008; 65: 116-122
• 22 Seno N, Hashizume H, Inoue H. et al. Fractures of the base of the middle phalanx of the finger classification, management and long-term results. J Bone Joint Surg B 1997; 79: 758-763
• 23 Watson HK, Weinzweig J. Stiff Joints. Cohen MS, Green DP, Hotchkiss RN. et al. Green‘s Operative hand surgery. Seventh edition. Aufl. Philadelphia. 2017
• 24 Cheah AEJ, Chong AK. Soft-tissue coverage of the hand. Current Orthopaedic Practice 2012; 23: 336-345
• 25 Duncan RW, Freeland AE, Jabaley ME. et al. Open hand fractures: an analysis of the recovery of active motion and of complications. J Hand Surg Am 1993; 18: 387-394