Fractures Of Proximal Phalanx Research Articles

Effectiveness of Kirschner wire fixation for proximal phalangeal bone avulsion fracture caused by A2 circular trochlea injury of flexor digitorum tendon

To explore the mechanism, surgical method, and effectiveness of proximal phalangeal bone avulsion fracture caused by A2 circular trochlea injury of the flexor digitorum tendon. A retrospective analysis was conducted on the clinical data of 4 patients with proximal phalangeal bone avulsion fracture caused by A2 circular trochlea injury of flexor digitorum tendon admitted between May 2018 and September 2022. The patients were all male, the age ranged from 26 to 52 years, with an average of 33 years. The injured fingers included 1 case of middle finger and 3 cases of ring finger. The causes of injury were rock climbing of 2 cases and carrying heavy objects of 2 cases. Preoperative anteroposterior and lateral X-ray films and CT examination of the fingers showed a lateral avulsion fracture of the proximal phalanx, with a fracture block length of 15-22 mm and a width of 3-5 mm. The total active range of motion (TAM) of the injured finger before operation was (148.75±10.11)°. The grip strength of the middle and ring fingers was (15.50±2.88) kg, which was significantly lower than that of the healthy side (50.50±7.93) kg ( t=-8.280, P<0.001). The time from injury to operation was 2-7 days, with an average of 3.5 days. One Kirschner wire with a diameter of 1.0 mm was used for direct fixation through the fracture block, while two Kirschner wires with a diameter of 1.0 mm were used for compression fixation against the fracture block. The fracture healing was observed, and the TAM of the injured finger and the grip strength of the middle and ring fingers were measured. The finger function was evaluated according to the upper limb functional assessment trial standards of the Chinese Medical Association Hand Surgery Society. The incisions all healed by first intention after operation. All patients were followed up 6-28 months, with an average of 19 months. X-ray films showed that all avulsion fractures of proximal phalanx reached bony union, and the healing time ranged from 4 to 8 weeks, with an average of 4.6 weeks. At last follow-up, the grip strength of the middle and ring fingers was (50.50±7.76) kg, which significantly improved when compared with preoperative one ( t=-8.440, P<0.001). The TAM of the injured finger reached (265.50±2.08)°, and there was a significant difference when compared with preoperative one ( t=-21.235, P<0.001). According to the upper limb functional assessment trial standards of the Chinese Medical Association Hand Surgery Society, the finger function was all evaluated as excellent in 4 cases. Using Kirschner wire fixation through bone blocks and external compression fixation of bone blocks for treating proximal phalangeal bone avulsion fracture caused by A2 circular trochlear injury of the flexor digitorum tendon can achieve good effectiveness.

Comparison Between Intramedullary Nail and Percutaneous Pin Fixation in Proximal Phalanx Fractures.

Percutaneous pinning has been the predominant technique for fixation of proximal phalanx fractures, but stiffness is a reported complication. The introduction of intramedullary (IM) nail fixation of proximal phalanx fractures provides a stronger biomechanical fixation for amenable fracture patterns with the added benefit of not tethering the soft tissue. The goal of this study was to compare the surgical outcomes of IM nail and percutaneous pin fixation in isolated proximal phalanx fractures. A retrospective review was performed at our institution between the years 2018 and 2022 for patients treated for proximal phalanx fractures. Patients that underwent fixation with IM nails or percutaneous fixation for isolated extraarticular proximal phalanx fractures were included. Patients were excluded if they had concomitant hand fractures, tendon injury, or intraarticular extension. A total of 50 patients were included in this study. Twenty-eight patients received percutaneous pin fixation, and 22 patients underwent IM nail or screw fixation. There was no significant difference in injury patterns or demographics between these two groups. Patients that underwent IM nail fixation had a significantly quicker return to active motion, shorter duration of orthosis treatment, and fewer occupational therapy visits. In addition, patients in the IM fixation group had significantly improved range of motion (ROM) at 6 weeks postoperatively. This study demonstrates that patients receiving percutaneous pin or IM nail fixation have equivocal union and complication rates. The IM nail fixation group was able to have quicker return to mobilization, fewer required occupational therapy visits, and improved early ROM.

Choosing the proper implant for extra-articular fractures of proximal phalanges: A study on 75 cases

IntroductionPhalangeal fractures are the most common fractures of the hand and in particular the proximal phalanx of the long fingers is the most involved. These fractures can ben conservatively managed but, when the fracture pattern is considered unstable, surgical treatment is recommended. However, there is no consensus in literature about the proper surgical option for extra-articular proximal phalanx fractures. Material and methodsWe compared clinical and radiographical results after treatment of 75 cases of extra-articular proximal phalanx fractures using three different surgical techniques: closed reduction and internal fixation (CRIF) with Kirschner wires (G1 group), open reduction internal fixation (ORIF) with plates and screws or lag screws (G2 group), and closed reduction and intramedullary screw fixation (CRIMEF)(G3 group). ResultsWe found no significant differences in term of union rate and time to fracture healing between the three groups. However, we found a significant reduction in time to return at work and in TAM at the final follow-up examination in G3 group (treated with CRIMEF) when compared with both G1 and G2. No differences in complications rate were found between three groups. DiscussionThe surgical variability in the management of extra-articular phalanx fractures create lacks on standard guide for treatment. ConclusionsIn conclusion, our results showed good clinical and radiographical results with all the three surgical options. However, the closed reduction and internal fixation with intramedullary screws (CRIMEF) seems to be better in terms of time to return to work and TAM at the final follow-up, probably due to good primary stability and little risk of soft tissue adherence development.

Minimally invasive corrective derotational osteotomy for proximal phalanx malrotation.

Fractures of the phalanges may result in a challenging complication known as malrotation, which can adversely affect the functionality of the fingers during flexion, leading to scissoring. The standard surgical approach for correcting this condition involves open corrective osteotomy and derotation, often at the level of the metacarpal, which includes the use of different techniques for osteotomy and fixation. However, postoperative complications such as finger stiffness and hardware irritation are common. To overcome these limitations, we present a novel and minimally invasive corrective osteotomy technique for malunited proximal phalanx fractures with rotational malalignment, which offers several advantages, such as accelerated rehabilitation and no prominent hardware.

The Greco-Nice-Lag: Lag Screw and Double Nice Knot Fixation for Spiral Proximal Phalanx Fractures-Connecting the Shoulder to the Finger.

A colorful array of fixation options exists for the management of operative long oblique or spiral proximal phalanx fractures. These include lag screws, intramedullary devices, Kirschner wires, dorsal or lateral plating, and cerclage wiring. The "Nice double-suture knot," described by Boileau and colleagues, is a sliding, self-stabilizing knot initially created for tuberosity fixation in the shoulder. Nice knot cerclage has been described in shoulder arthroplasty, as well as for comminuted patella fractures. Here we describe a technique utilizing a single lag screw with 2 Nice knot cerclage sutures for the treatment of a spiral proximal phalanx fracture in a 65-year-old active smoker with osteopenia.

Bone Graft for Nonunion of Right Thumb Proximal Phalanx Fracture

Watch this full-length, narrated surgical video of a bone graft for a non-union of a right thumb proximal phalanx fracture. This was performed during a surgical mission in Honduras with the World Surgical Foundation.

Closed Reduction Percutaneous Pinning Versus Open Reduction With Plate and Screw Fixation in Management of Unstable Proximal Phalangeal Fractures: A Systematic Review and Meta-analysis.

Proximal phalanx fractures are common, with surgical fixation indicated for unstable fractures. Traditionally, closed reduction percutaneous pinning (CRPP) resulted in decreased stiffness and tendon irritation compared to open reduction internal fixation (ORIF). We hypothesized that more recent studies would have more similar outcomes to CRPP. The purpose of this study was to compare CRPP and ORIF in terms of range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and complications. Four electronic databases were queried from 2010 to present. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two independent reviewers performed a two-step review process to identify relevant articles. Patient demographics, total active motion (TAM), DASH, and complications were extracted. The methodological quality of each study included was assessed independently. Meta-analysis was performed for comparative trials. Fourteen studies met inclusion criteria including four comparative studies: Thirteen studies included TAM. The weighted average TAM was 228 ± 34° for CRPP and 223 ± 32° for ORIF (P = .07 with 95% confidence interval (CI), -0.5 to 10.5). Seven studies evaluated DASH scores; weighted average was 8.2 ± 8.9 for CRPP and 11.7 ± 6.5 for ORIF (P < .01 with 95% CI, 1.8-5.2). Two studies directly compared CRPP to ORIF, favoring ORIF for both TAM with d = 1.07 and DASH with d = 0.23. Rates of tenolysis or hardware removal were higher for ORIF (P < .01). New literature suggests more equipoise with regard to treatment of proximal phalanx fracture with CRPP versus ORIF. Meta-analysis, Level II.

Intra-Articular Antegrade Intramedullary Screw Fixation for Proximal Phalanx Fractures: Impact of Articular Surface Defects on Joint Contact Pressures.

Intramedullary headless screw fixation is increasingly used for fixation of proximal phalanx fractures. However, the impact of screw entry defects on joint contact pressures is not well defined and may have implications for arthrosis. The objective of this cadaveric biomechanical study was to assess joint contact pressures at the metacarpophalangeal (MCP) joint before and after passage of 2 sizes of antegrade intramedullary fixation. Seven fresh frozen cadaver specimens without arthritis or deformity were included in this study. Antegrade intramedullary screw fixation of proximal phalanx fracture was simulated using an intra-articular technique. Flexible pressure sensors were inserted into the MCP joints and cyclic loading was performed. Peak contact pressures were determined and averaged across loading cycles for each finger in the native state, with 2.4- and 3.5-mm drill defects in line with the medullary canal. Peak pressure increased with the size of the drill hole defect. Contact pressure increases were greater in extension, with peak contact pressures increased by 24% for the 2.4-mm defect and 52% for the 3.5-mm defect. Increase in peak contact pressure was statistically significant with a 3.5-mm articular defect. Contact pressures were not consistently increased for the 2.4-mm defect. Testing in flexion of 45° resulted in reduced contact pressure for these defects. Our study demonstrates that antegrade intramedullary fixation of proximal phalanx fractures can increase MCP joint peak contact pressures, particularly in an extended joint position. Effect increases with defect size. This has implications for the management of proximal phalanx fractures using this technique.

Surgical Technique: Lateral Plate Osteosynthesis of Proximal Phalanx Fractures.

Dorsal plate fixation of proximal phalanx (PP) fractures is a conventional approach but interferes with the extensor mechanism and results in stiffness. Biomechanical studies have shown that laterally placed plates on the proximal phalanges are equally stable and rigid. This technique obviates the issue of tendon adhesion and may result in better postoperative range of motion and lower secondary procedures such as removal of implant and tenolysis. The low adoption of this technique may be related to lack of familiarity with the surgical approach. We describe our surgical technique with lateral plating of PP fractures and present our case that lateral plate osteosynthesis is an acceptable surgical fixation option for PP fractures, which extends the hand surgeon's armamentarium for more challenging and comminuted fractures.

What's New in Hand and Wrist Surgery.

What's New in Hand and Wrist Surgery.

Extra Periosteal Sliding Plate, a New Surgical Technique for the Treatment of Fractures of the First Metacarpal and Proximal Phalanx

Background: One of the most important objectives when performing an open reduction of a fracture is to achieve a stable internal fixation with minimal damage of the periosteum to preserve irrigation in the fracture site and thus promote adequate healing. Minimally Invasive plate osteosynthesis (MIPO) follow this key technical point with great effectiveness and efficiency, however, a reduction technique with these characteristics for the management of hand fractures has not yet been widely described for the management of hand fractures. Methods: The authors technique proposes a new surgical technique “extra-periosteal sliding plate” fixation for first metacarpal and proximal phalanx fractures. Data are obtained from 9 patients from June 2022 to January 2023 and a threemonth postoperative follow-up is performed where functionality and rehabilitation results are evaluated. Results: In total nine patients underwent to the described technique achieving adequate fracture stability and total bone healing with favorable functional outcomes without sequelae. Conclusion: Extra-periosteal sliding plate fixation is considered a great surgical option for the management of hand fractures, specially in those patients with severe trauma in whom vascular and soft tissue integrity must be preserved, providing suitable functional outcomes.

Double Barrel Screw Fixation for Proximal Phalanx Fracture.

A variety of fixation options exist for treatment of unstable proximal phalanx fractures. Variables which require consideration include the strength of fixation, the invasiveness of the technique and the postoperative rehabilitation protocol. Here we present a minimally invasive technique for dual headless compression screw fixation of proximal phalanx fractures which reduces extensor tendon violation and allows early motion in the immediate postoperative period.

Proximal phalanx fracture treated with extension block Splint: An observational study at a tertiary care centre

Proximal phalangeal fractures are common fractures of the hand. The fracture are difficult to treat because of vicinity of 2 important joints and presence of tight osseofascious tunnel. The purpose of this study was to evaluate the efficacy of extension block splint in the management of selective proximal phalangeal fracture of hand. 21 Patients with proximal phalangeal fractures were treated by extension block splint and evaluated prospectively. Patient were followed up after 1 week, 3 weeks, and thereafter on monthly basis. Average follow up period was 9.8 months and outcomes were assessed by Belsky’s criteria. In our study, 76.19% patients had excellent outcomes, 19.04% had good, 4.76% had poor outcomes. 2 patients had extensor lag which subsided at further follow up at 1 year. The results of this prospective study shows that with careful selection of patients extension block splint is a simple, safe and effective technique for managing proximal phalanx fracture of hand.

Translated article] Comparison of three different minimally invasive intramedullary screw for proximal phalanx fractures. A biomechanical study

Background and objectivePhalangeal fractures are the most common hand fractures. In the last years, intramedullary compression screw (IMHCS) for instable transverse or short oblique proximal P1 fractures have been described. Although both anterograde (intraarticular or trans-articular) and retrograde IMHCS techniques have shown good results, no comparison between anterograde and retrograde screw in P1 fractures has been published. We sought to determine stability with retrograde IMHCS and anterograde IMHCS, both trans-articular and intra-articular technique, in a cadaveric transverse proximal P1 fracture model, at two different levels. Material and methodsWe performed a biomechanical study in 30 fresh-frozen human cadaveric P1 fracture model. Fracture was performed at 9-mm from the metacarpo-phalangeal (MCP) joint in 15 specimens, whereas it was done at 15mm in the other 15. In turn, in each group, five fractures were stabilised with an anterograde intra-articular IMHCS, five with anterograde trans-articular IMHCS and other five with retrograde IMHCS. ResultsAnterograde IMHCS fixation in 9-mm P1 fractures (both trans- and intra-articular technique, 62.74N and 70.86N, respectively) was found to be more stable than retrograde IMHCS one (32.72N) (p=0.022). Otherwise, retrograde IMHCS fixation was found to be more stable in more distal P1 fractures (90.52N retrograde vs. 57.64N trans-articular vs. 42.92N intra-articular; p=0.20). ConclusionsAnterograde IMHCS fixation in proximal transverse P1 bone cut in a cadaveric model provides more stability than retrograde IMHCS, while retrograde screw provides more stability when the bone cut is located more distal.

Comparing treatment of proximal phalangeal fractures with intramedullary screws versus plating

PurposePhalangeal fractures are the most common injuries in humans and account for approximately 10% of all fractures. With plate fixation, anatomic reduction is achievable in most cases, but extension lag is seen in up to 67%. Intramedullary headless screw offers treatment of unstable proximal phalangeal fractures using a minimally invasive procedure with very few complications. One of the major disadvantages of this technique is the transarticular screw position, damaging the articular surface and thus preventing very proximal fractures from being treated with a distally inserted screw. In this study, we present a modified approach to the fixation of the proximal phalangeal fractures and compare outcomes with plate osteosynthesis.Materials and methodsTwenty-nine patients with 31 comparable fractures of the proximal phalanx were treated either with a plate (14) or with minimal invasive cannulated compression screw (17). Pain, strength, range of motion (ROM), work disability and QuickDASH score were assessed.ResultsTAM was significantly better in the screw group. The extension lag was worse in the plate group. Plate removal had to be performed in 13 of 14 the cases, while the screw had to be removed in only 3 cases. The average duration of work disability was 9.9 weeks in the plate group, compared to 5.6 weeks in the screw group.ConclusionMinimally invasive screw osteosynthesis not only has the advantage of significantly shorter work disabilities, but also shows remarkably improved postoperative range of motion. In contrast to plate osteosynthesis, removal of the screw is only necessary in exceptional cases. With the antegrade screws position, even difficult fractures close to the base can be treated without destroying any articular surface. In proximal phalanx fractures with both options of plate or single-screw osteosynthesis, we recommend minimal invasive cannulated screw osteosynthesis.

Low Infection Rate for Hand Fractures Managed with Surgical Fixation under Wide-Awake Local Anesthesia with No Tourniquet in Minor Surgery.

The purpose of this study was to review the rate and type of infectious complications after surgical fixation of hand fractures managed under wide-awake local anesthesia with no tourniquet (WALANT) in minor procedure rooms outside the main operating room. A two-surgeon retrospective chart review was performed of patients who received surgical fixation of hand fractures under WALANT in minor surgery from March of 2014 to March of 2019. patients, with distal phalanx ( n = 16), middle phalanx ( n = 7), proximal phalanx ( n = 11), or metacarpal ( n = 26) fractures, were included in the study. The average patient age was 37 years, with a higher proportion of male patients (51:7). Two patients had two fractures each. Thirty of the 58 cases were already open fractures. Fixation was performed using either plates and screws (25 of 58) or nonburied Kirschner wires (31 of 58). Thirty-six percent of patients (21 of 58) were treated with prophylactic antibiotics. One patient developed postoperative cellulitis. The only case of osteomyelitis occurred in a patient with risk factors known to increase rates of infectious complications (open fracture, smoking history, and >24 hours from injury to treatment). No infectious complications occurred in those who sustained closed fractures. Although the minor surgery environment varies significantly from that of the main operating room, infection rates after surgical fixation of hand fractures using WALANT in this setting remain low (3.4 percent), with no documented infections in fractures that were referred closed and opened surgically for operative fixation. Therapeutic, IV.

Physiotherapeutic rehabilitation following JESS Fixator-treated proximal phalanx fracture along with isolated medial malleolar fracture - A case report

Physiotherapeutic rehabilitation following JESS Fixator-treated proximal phalanx fracture along with isolated medial malleolar fracture - A case report

Traction splinting (EAVAST protocol) versus operative fixation of proximal phalanx fractures: a comparative study of patient outcomes

Introduction: Phalangeal fractures are common, frequently deformed and unstable, and are regularly managed operatively. However, closed methods of reduction are increasing. This study aimed to compare functional outcomes for a non-operative cohort using a skin traction method developed by the Nepean Hospital, Sydney, Australia, termed ‘early active vector adjustable skin traction’ or EAVAST, compared to operatively managed patients as a potential alternative for the management proximal phalanx fractures. Methods: A prospective cohort study of patients who underwent operative fixation or traction using the EAVAST protocol between January 2018 and January 2020. Patients were managed on a case-by-case basis by fracture type and mechanism of injury. Functional outcomes were assessed at three months post intervention using total active motion, mean strength and QuickDASH scores. Measurements were conducted by independent clinicians with patients wearing gloves to blind the assessor to signs of intervention. Results: Of 38 patients identified for inclusion in the study, 15 underwent operative fixation and 23 underwent traction. There were no significant differences found between the two groups for all outcome measures. The mean total active motion, mean strength and QuickDASH scores for the traction and operative groups were 90.8 per cent versus 90.7 per cent (P = 0.97), 84 per cent versus 79 per cent (P = 0.58) and 1.48 versus 2.5 (P = 0.54), respectively. Conclusions: We found no clinically or statistically significant difference between EAVAST protocol and operative management of proximal phalanx fractures. Future study is now warranted, ideally a multi-centre prospective randomised controlled trial with blinded assessment of outcomes in-cluding a cost–benefit analysis comparing standardised operative and traction techniques.

Nonpathological phalangeal fractures in cattle: 17 cases (2004-2020).

To characterize clinical findings and outcomes for cattle with nonpathological phalangeal fractures. 17 cattle with nonpathological phalangeal fractures. Medical records of a teaching hospital were reviewed to identify cattle treated for nonpathological phalangeal fracture between May 2004 and May 2020. Information extracted from the records of study-eligible animals included signalment, history, clinical and diagnostic imaging findings, treatment, and survival to hospital discharge. Long-term outcome was assessed by telephone communication with owners. 9 bulls and 8 heifers or cows (age range, 1 to 7 years) of various breeds and uses were evaluated. Five of the 9 bulls were bucking stock, which were overrepresented in the study population. Seven animals had 8 distal phalanx fractures; 10 animals had 11 proximal phalanx fractures. Eight animals were treated by application of a hoof block on the unaffected adjacent digit, 7 animals were treated with a distal limb (n = 6) or transfixation pin (1) cast in addition to a hoof block, 1 animal was treated with a hoof trim to elevate and alleviate weight bearing on the affected digit, and 1 animal was euthanized immediately after diagnosis. Sixteen animals survived to hospital discharge. Follow-up was obtained for 12 animals, of which 9 returned to functionable use and 3 were culled. Results suggested cattle with a nonpathological phalangeal fracture have a favorable prognosis for return to function following application of a hoof block to the unaffected adjacent digit with or without a distal limb cast.

You Can Handle It: Pediatric Hand Injuries from Toddlers to Teens

As so many of children’s interactions with the world are through their hands, it is no surprise that hand injuries are a common pediatric complaint. Fractures of the hand and wrist account for 2.3% of pediatric emergency department visits, with a peak incidence in the teenage years, coinciding with participation in sports or fights. Hand injuries may be subtle, and appropriate recognition, treatment, and referral are vital for preventing long-term morbidity.After a focused history, providers should inspect for edema, ecchymosis, laceration, or deformity and assess all joints for motor function in addition to active and passive range of motion. The examiner should evaluate sensation and capillary refill, particularly distal to the injury. Any sensorimotor abnormality should raise concern for tendon or nerve involvement. Bony anatomy should be meticulously palpated, with any point tenderness or crepitus evaluated for fracture.The distal phalanx is frequently fractured in toddlers, with peak incidence at 2 years of age. The mechanism is often a crush injury, such as in a doorframe, resulting in a nail bed hematoma, laceration, or amputation. A subungual hematoma with an intact nail plate may be managed with supportive care when it involves less than 50% of the nail surface, or with trephination when it involves greater than 50%. Nail bed lacerations may be anesthetized with a digital block. After nail plate removal and copious irrigation, the laceration should be repaired with absorbable sutures. Glue may be an acceptable alternative but is not appropriate in all situations, particularly a contaminated wound. After repair, the nail fold may be stented open with the native nail, aluminum suture packaging, or nonadherent gauze; however, whether this maneuver improves outcomes awaits ongoing research. Antibiotic drug therapy should be considered for a nail bed laceration with an associated fracture that is contaminated or has significant bone exposure. Tetanus prophylaxis should be administered when indicated.When a nail bed laceration is suspected, radiographs should be obtained: a fracture is present in approximately half of cases, frequently a “tuft fracture” of the distal phalanx. Most fractures can be managed with a finger splint; however, fractures with significant displacement may require future operative management. Seymour fractures are Salter-Harris type I or II fractures of the distal phalanx in which the nail bed becomes entrapped between fracture fragments. These are best visualized on lateral radiographs and should be treated as an open fracture with antibiotics and evaluation by a hand specialist. Complications of Seymour fractures include malunion, nail bed deformity, and osteomyelitis. Treatment within 24 hours is associated with improved outcomes.Amputated fingertips should be wrapped in saline-soaked gauze, placed in a plastic bag, and stored in an ice water slurry, with reimplantation attempted as soon as possible. Amputations that are grossly contaminated, require significant debridement, have exposed bone, or have significant tissue loss warrant evaluation by a hand specialist.Injuries to the middle and proximal phalanxes are associated with athletics and peak between ages 10 and 14 years. Nondisplaced or minimally displaced fractures may be managed with a finger splint or buddy taping. Patients undergoing buddy taping should be counseled on the importance of compliance to avoid skin breakdown and loss of fixation or joint mobility. Painful or unstable proximal phalanx fractures should be placed in an ulnar or radial gutter splint with intrinsic plus positioning (wrist in 20°–30° extension, metacarpophalangeal joints in 70°–90° of flexion, and interphalangeal joints in full extension). A hand specialist should evaluate fractures that are displaced, malrotated, angulated, or involve the physis or joint. A Salter-Harris type II fracture of the proximal phalanx is common, occurring most often in the fifth finger, usually resulting from an abduction injury. Called an “extra-octave fracture,