Fracture dislocation of the finger joints.

Fracture dislocations of the hand are difficult and often unforgiving injuries. Keys to treatment include early recognition, stable concentric reduction, and protected early active range of motion maintaining joint stability. The balance between stability and mobility is difficult to manage; therefore, surgeons need a wide array of treatments to tailor management to the specific fracture pattern. With appropriate treatment, residual stiffness and pain can be minimized. This Current Concepts review aims to provide up-to-date management for proximal interphalangeal, distal interphalangeal, and metacarpophalangeal joint fracture dislocations.

Morphometric analysis of potential osteochondral autografts for resurfacing unicondylar defects of the proximal phalanx in PIP joint injuries.

PURPOSE: This study was designed to morphometrically assess the base of the little and ring finger metacarpals as potential osteochondral donors to resurface distal condylar defects of the proximal phalanx. METHODS: The proximal phalanges were dissected from all 4 fingers in 10 cadaveric hands and the following measurements were obtained from the distal condylar surface: anteroposterior height, radial-ulnar width, and radius of curvature. Measurements were obtained from posteroanterior and lateral radiographic views, which were digitized and analyzed using digital imaging software. Comparable measurements were obtained from the base of the small and ring metacarpals. RESULTS: The anteroposterior dimension of both potential donor metacarpals was large enough to resurface the distal condyles of each of the proximal phalanges; however, this was not true for the radial-ulnar dimensions. The distal ulnar condyle of the long finger proximal phalanx was largest, measuring 4.9 (+/- 0.) mm dorsally and 6.2 (+/- 0.5) mm volarly in the radial-ulnar dimension. Only the small metacarpal base had sufficient stock in the radial-ulnar dimension (9.4 [+/- 1.7]) mm dorsally and 10.6 [+/- 2.0] mm volarly) to resurface this condyle. With respect to radius of curvature (ROC), the donor-to-recipient ROC ratio was 1.43 for the small metacarpal base versus 2.12 for the ring metacarpal base. Linear regression analysis revealed a stronger relationship in ROC between donor and recipient condyle when the small metacarpal base served as the donor (R = 0.96 vs R = 0.60). CONCLUSIONS: As determined from morphometric measurements of the 2 potential donor sites tested, the base of the small metacarpal provides the best match for resurfacing distal condylar defects of the proximal phalanges.

Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture-dislocations.

PURPOSE: Hemi-hamate resurfacing arthroplasty is a treatment alternative for the management of severe acute and chronic dorsal proximal interphalangeal (PIP) fracture-dislocations. This study was designed to determine whether this procedure would successfully restore function after such injuries. METHODS: Hemi-hamate reconstructions were performed on 33 patients (mean age, 34 years) who presented to 1 hand surgery practice with dorsal PIP fracture-dislocations. Eligible patients experienced unstable dislocations with comminuted metaphyseal fractures involving at least 50% of the volar middle phalangeal surface that was not amenable to open reduction and internal fixation. We evaluated 22 patients with 14 acute (<6 weeks) and 8 chronic (mean, 30 weeks) injuries at a mean of 4.5 years (range, 1-7 years). Functional outcomes were assessed by objective and subjective measures: joint alignment/motion/stability, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and visual analog scales (VAS) of pain and function. RESULTS: After hemi-hamate reconstruction, active PIP motion averaged 70 degrees (acute 71 degrees , chronic 69 degrees ) with a mean flexion contracture of 19 degrees (range, 0 degrees to 80 degrees ). Active distal interphalangeal motion averaged 54 degrees (acute 56 degrees , chronic 51 degrees ). The mean VAS score for digit pain was 1.4 (acute 0.7, chronic 2.5). The mean DASH score of 5 (acute 2, chronic 9) and VAS functional score of 1.9 (acute 1.4, chronic 2.6) indicated little functional impairment (acute 2, chronic 9). Grip strength averaged 95% of the opposite hand. Mean coronal plane angulation at the PIP joint was 3 degrees . Ten patients reported aching with cold temperatures. One dissatisfied patient underwent revision surgery. Chronic reconstructions were associated with increased VAS pain ratings (p = .02) and higher DASH scores (p = .06). CONCLUSIONS: Hemi-hamate reconstruction represents a valuable surgical procedure to address severe PIP joint fracture-dislocations. Reconstruction of chronic injuries by this method restores PIP function, albeit with more modest outcome performance. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Fracture-dislocation about the finger joints.

Fracture-dislocations in the small joints of the fingers are challenging injuries. The surgeon must choose an appropriate treatment based on fracture pattern, joint stability, and injury chronicity. Fracture-dislocations of the proximal interphalangeal joint are notoriously unforgiving, with potential long-term sequelae of residual pain and stiffness. Similar injuries in the distal interphalangeal joint are more tolerant of fracture displacement and even joint subluxation. Dorsal dislocations of the metacarpophalangeal joint may be associated with shearing fractures of the metacarpal head but are most notable for the volar plate interposition that may block closed reduction.

Thorn-induced Alternaria flexor tenosynovitis of the hand.

A thorn puncture to the hand is a common, usually minor childhood injury. A 6-year-old boy developed Alternaria tenosynovitis as a complication of thorn penetration into the digital flexor tendon sheath. He was successfully treated with tenosynovectomy and a prolonged course of itraconazole.

Dynamic external fixation of unstable fractures of the distal part of the radius. A prospective, randomized comparison with static external fixation.

A prospective, randomized study was done to compare the results of dynamic external fixation (the Clyburn device) with those of static external fixation (the AO/ASIF device) in the treatment of fifty unstable fractures of the distal part of the radius. Mobilization of the wrist from neutral to 30 degrees of flexion was begun in the dynamic-fixator group at approximately two weeks, and full motion, allowing 30 degrees of extension, was started at approximately four weeks. The external fixation frames in both groups were kept in place for approximately ten weeks. Mobilization of the wrist in the dynamic-fixator group provided little gain in the mean motion of the wrist at the time of the removal of the fixator or at the one, six, or twelve-month evaluation. The static-fixator group had greater flexion of the wrist and radial deviation at the early and late follow-up examinations, while the dynamic-fixator group demonstrated only greater ulnar deviation one month after the fixator had been removed. Motion of the wrist in the dynamic-fixator group resulted in a statistically significant loss of radial length compared with that in the static-fixator group (four millimeters compared with one millimeter, p < 0.001). Complications were more frequent in the dynamic-fixator group. As evaluated with a modification of the scoring system of Gartland and Werley, 92 percent of the results at one year were excellent or good in the static-fixator group and 76 percent, in the dynamic-fixator group. The results of this study cannot support the concept of early mobilization with a dynamic external fixator for the treatment of unstable fractures of the distal part of the radius.

The pulp plasty: a composite graft for complete syndactyly fingertip separations.

Composite grafts of skin and subcutaneous fat harvested from the glabrous non-weight-bearing areas of the foot were used to graft 34 fingertips after separation of 23 complete syndactyly webs in 13 patients. Simple complete syndactylies accounted for 17% and complex complete syndactylies accounted for 83%; synonychia was encountered in 70%. Follow-up averaged 13.9 months (minimum, 2 months, maximum 33 months). All patients had 100% take of the composite graft. Subjective gradings were 94% good, 6% fair, and there were no poor results. This technique provides a relatively normal contour and satisfactory pad to the fingertip.

The scaphoid allograft: a new operation for treatment of the very proximal scaphoid nonunion or for the necrotic, fragmented scaphoid proximal pole.

This is a preliminary report of eight cases in which an allograft was used to replace half of the scaphoid. The indications for the procedure include the following: (1) Severe necrosis with fragmentation of the proximal pole, (2) Very proximal pole nonunion with small (less than 20% of the bone), unreconstructable proximal fragments, and (3) One case of severely comminuted intra-articular fracture of the scaphotrapezial joint and basal joint of the thumb caused by a gunshot wound. The Herbert scaphoid screw was used to provide rigid fixation. Follow-up ranged from 8 to 30 months. The result was good in six of eight patients. It should be emphasized that this is a preliminary report of the early experience with a new operation for salvage of difficult scaphoid fracture problems.