Proximal Interphalangeal Fracture-dislocations Research Articles

A 3-Dimensional Printed Dynamic External Fixator for the Treatment of Proximal Interphalangeal Fracture-Dislocations: A Biomechanical Study

This study evaluated the efficacy of a 3-dimensional printed dynamic external fixator for treating proximal interphalangeal (PIP) fracture-dislocations. The null hypothesis was that there would be no difference in maintaining PIP joint reduction between a 3-dimensional printed dynamic external fixator (3DPDEF) and the pins and rubbers traction system (PRTS). Ten cadaveric fingers underwent an oblique osteotomy at the base of the middle phalanx, recreating an unstable dorsal PIP fracture-dislocation. The percentages of compromised articular surface and middle phalanx dorsal displacement were measured. Both fixators were randomly placed on each digit and underwent 1,400 flexion-extension cycles. Efficacy, determined by joint reduction and maintenance of dorsal translation correction, was assessed using fluoroscopy before and after the cycles. The mean compromised articular surface was 50.8%. After osteotomy, PIP joint subluxation occurred at 37.8° flexion. Dorsal translation after osteotomies was 2.8 mm. After applying the 3DPDEF and the PRTS, it was 0 mm and 0.1 mm, respectively. During the cycles, all the joints remained stable and reduced. Dorsal displacement after cycles was-0.1 mm for the 3DPDEF and 0 mm for the PRTS. The mean translation difference between both fixators was 0.1 and 0 mm before and after the cycles. The translation differences before and after the cycles were 0.1 mm for both dynamic fixators. The 3DPDEF is a suitable option for PIP fracture-dislocations, providing stability comparable to that of the PRTS while offering benefits, such as easy placement, controlled distraction, and clear visualization of the articular surface. This external fixator, characterized by its efficacy, low cost, and simplicity of application, broadens the options available to address PIP fracture-dislocations.

Hemi-hamate arthroplasty for the management of chronic proximal interphalangeal joint fracture dislocations: Analysis of 21 cases in Indian population and review of the literature

BackgroundChronic fracture-dislocations involving the proximal interphalangeal (PIP) joint are challenging cases. We conducted this study to analyze the outcomes following hemi-hamate autograft reconstruction of such injuries and to compare our results with the existing literature. MethodsA retrospective analysis of 21 patients with chronic dorsal PIP fracture-dislocations that were managed with hemi-hamate autograft reconstruction was done. The average articular surface involvement was 64%. The average duration between injury and surgery was 9.4 weeks (range, 6–16). Quick DASH (Disabilities of Shoulder and Hand) scores, VAS (Visual Analog Scale) scores, range of motion of the PIP joints, DIP (distal interphalangeal) joints, and MCP (metacarpophalangeal) joints were measured during serial follow-up visits. ResultsUnion and graft incorporation was seen in all cases. The average Quick DASH score at four weeks post-surgery was 66 and it improved to eight at one year (p-value<0.05). The average VAS score at four weeks post-surgery was 7.66 and it improved to 2.09 at one year (p-value<0.05). The mean flexion of the MCP joint improved from 52.85° at the end of four weeks to 72.38° at one year (p-value<0.05). The average flexion at the PIP joint improved from 10.47° at the end of four weeks to 70.47° at one year (p-value<0.05). The average DIP flexion improved from 38.33° at the end of four weeks to 62.38° at one year (p-value<0.05). The average hand grip strength was 85% of the normal side. ConclusionHemihamate autograft reconstruction is a suitable procedure for the management of chronic PIP joint fracture-dislocations, especially in cases with extensive involvement of the articular surface. Level of evidenceIII.

Osteochondral Autograft From the Hamate for Treating Partial Defect of the Proximal Interphalangeal Joint

The management of a proximal interphalangeal (PIP) joint fracture dislocation becomes more challenging when the joint surface is damaged because of severe comminution or inadequate treatment in the acute phase. The purpose of this study was to evaluate the clinical outcomes of an osteochondral autograft for the reconstruction of the joint surface in patients with a partial PIP joint defect. Twelve patients underwent osteochondral autograft surgery from May 2007 to July 2018. The average age at the time of surgery was 38 years (range, 21-67 years), and there were 10 men and 2 women. Plain radiographs and computed tomography scans showed a partial middle phalangeal base defect in all the cases. The surgeries were performed 2 weeks to 20 months after the fracture or a previous surgery. Partial hamate grafts were harvested to reconstruct volar lip (n= 7), middle portion (n= 2), and dorsal lip (n= 3) defects of the middle phalangeal base. Bone healing, postoperative range of motion, instability, and pain were evaluated. The average follow-up duration was 27.8 months (range, 12-53 months). Radiographic graft union was observed in all the patients 6-8 weeks after the surgery. The deformity was corrected in 11 patients. The active range of motion of the involved PIP joint was improved from 28.3° (range, 0°-60°) to 75.0° (range, 25°-95°). Complications were observed during follow-up, including degenerative arthritis (n= 2), instability (n= 3), and stiffness (n= 5). Various types of partial joint defects of the middle phalangeal base following a PIP fracture dislocation can be reconstructed using an osteochondral autograft from the hamate. The functional recovery is generally acceptable, with a well-restored joint architecture. Therapeutic IV.

An Analysis of Hamate Morphology Relevant to Hemi-Hamate Arthroplasty

Dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint can lead to joint incongruity from loss of the buttress function of the middle phalanx volar base. Hemi-hamate arthroplasty can reconstruct the volar articular surface of the middle phalangeal base where repair is not possible. We compared the anatomy of the hamate graft with the middle phalanx base. Forty unique skeletal specimens (40 hamates, 160 middle phalanges) were sampled. Anatomical features relevant to hemi-hamate reconstruction were measured, including the articular surface areas, the axial ridge angles, and the sagittal inclination angles of the hamate and the middle phalanx base specimens. Facets of the articular surfaces were classified as concave, convex, or flat. Calibrated measurements were made using digital photographs of the cadaveric specimens. Descriptive and univariate statistics were performed. There was greater variability in the distal hamate than in the middle phalanx base. The ring finger facet of the distal hamate was concave in 39 of 40 specimens, whereas the little finger facet was convex in 31 of 40 specimens. The hamate axial ridge angle (66.0° ± 3.7°) was significantly different from the middle phalanx base (90.4° ± 0.4°). The hamate articular sagittal inclination (3.2° ± 4.1°) was significantly different from the middle phalanx base (51.2° ± 1.3°). The hamate articular surface area (1.96 cm2) was significantly greater than the middle phalanx base (mean index/middle/ring finger= 0.85 cm2 and mean little finger= 0.59 cm2). The distal articular surface of the hamate is not anatomically identical to the middle phalanx base. The differences may still preclude anatomical reconstruction in the setting of a dorsal PIP fracture-dislocation, thereby affecting short- and long-term outcomes. Knowledge of the anatomical differences between the distal hamate and the middle phalanx base may improve graft harvest and inset during reconstruction.

The Relationship Between Hemihamate Graft Size and Proximal Interphalangeal Joint Flexion for Reconstruction of Fracture-Dislocations: A Biomechanical Study

The purpose of this study was to determine the relationship between hemihamate graft size and proximal interphalangeal (PIP) joint flexion in a biomechanical fracture-dislocation model. We simulated middle finger PIP fracture-dislocations in 5 cadaver hands by resecting 50% of the palmar articular surface of the middle phalanx (P2) base. Fluoroscopy was used to confirm dorsal subluxation of the middle phalanx base after resection. A 10-mm osteochondral hamate graft was contoured to reconstruct the volar lip of the middle phalanx and was progressively downsized by 2-mm increments for each trial. A computer-controlled articulator and jig simulated active flexion and extension of the fingers. Maximum PIP flexion was measured at each graft size using fluoroscopy and digital imaging software. Clinically significant flexion block was defined as PIP flexion less than 90°. The actual mean size of the volar defect created was 52% (3.5 mm) of the middle phalanx articular surface, which created instability and dorsal subluxation in all tested fingers. After hemihamate reconstruction, all specimens were stable throughout flexion and extension for all graft sizes. A flexion block of 90° occurred at a mean graft size of 191% of the defect (6.5 mm). With regard to the volar lip of the P2, grafts that projected an average 0.8 mm past the native volar lip position had 98° (range, 84°-107°) maximum PIP flexion. Grafts that projected an average of 3.1 mm past the native volar lip position had 90° (range, 69°-100°) maximum PIP flexion. Linear regression modeling incorporating all of the results predicted flexion block tooccur at a graft size as small as 166% of the 50% volar P2 defect. In this model, for every 50% (1.7-mm) increase in graft size relative to the defect, PIP flexion decreased by approximately 6°. Nonanatomical hemihamate grafts produce a PIP flexion block at extreme sizes, predicted to occur at greater than 166% of a 50% P2 base articular defect in our model. This suggests that relatively large grafts can be used for reconstruction of PIP fracture-dislocations without substantial biomechanical block to PIP flexion. We suggest sizing no larger than 3 mm past the native P2 volar lip position to avoid an important mechanical block to PIP flexion. The information from this study helps surgeons understand how large a hemihamate graft can be used for P2 volar base reconstruction before having a negative impact on PIP flexion.

Mid-Term Outcomes After Open Reduction Internal Fixation of Proximal Interphalangeal Joint Dorsal Fracture-Dislocations Through a Volar, Shotgun Approach and a Review of the Literature.

Background:Proximal interphalangeal (PIP) fracture dislocations remain a complex injury pattern to treat. There are several treatment methods available aimed to restore stability, preserve range of motion, and reconstitute the articular surface. This study looked at the mid-term clinical and radiographic results of open reduction internal fixation through a shotgun approach of comminuted PIP fracture dislocations.Methods:A retrospective review was conducted of all PIP fracture dislocations treated through a volar, shotgun approach at a single institution over a 15-year period. Patients identified were contacted and asked to return to the office for clinical and radiographic evaluation. Patient reported outcomes were assessed with the Michigan hand questionnaire (MHQ) and visual analog scale (VAS) for pain.Results:5 patients returned to the office for further evaluation with average follow-up of 69 months (range, 33-133 months). 3 patients were found to have post traumatic arthritis on radiographs. 1 case had recurrent instability and one case had a deep infection, both necessitating further surgical intervention. Average PIP arc of motion was found to be 79°. Average VAS score of 0 and MHQ result of 95 (out of a possible score of 100) indicating no residual pain and excellent functionality of the affected hand.Conclusion:Open reduction internal fixation of comminuted PIP fracture dislocations utilizing the volar, shotgun approach provides excellent mid-term functional results despite the high incidence of post traumatic arthritis.

Unstable PIP Fracture-Dislocations

Purpose: Multiple techniques exist as part of the armamentarium for the management of Proximal Interphalangeal (PIP) joint fracture-dislocations. Of these, unstable lesions with hard reduction are the most complicated to handle. This study aims to compare the biomechanical results obtained with volar plate arthroplasty (VPA) and the hemihamate arthroplasty (HHA). Materials and Methods: We used 20 fingers from 8 cadaveric hands. We created a 50% defect on the base of the middle phalanges to simulate an unstable fracture-dislocation. The 2 techniques were assigned randomly to the different fingers (10 for each technique). A biomechanical harness was used to carry all PIP joints from extension to complete flexion. The amount of dorsal translation of the subluxation was recorded digitally at full extension. We recorded the angle at which subluxation occurred for each specimen. Results: The average of dorsal displacement of the middle phalanx did not show statistical significant difference (0.02 mm for the HHA and 0.01 mm for the VPA). All the fingers with VPA coursed with flexion contracture as opposed to the HHA. Conclusions: The VPA and the HHA are current techniques used for the management of unstable PIP fracture-dislocations. The 2 procedures manage to maintain reduction throughout the range of flexo-extension. Surgeons must choose between a little more invasive technique with double incision, hamate block bone graft with potential discomfort in the donor area and screw fixation on the recipient middle phalanx not leading to flexion contracture (HHA); versus a single surgical approach technique -dorsal or ventral- which provides stability but may course with certain flexion contracture.

Extension Block Pinning for Unstable Proximal Interphalangeal Joint Dorsal Fracture Dislocations

To evaluate the outcomes of extension block pinning used to treat unstable dorsal fracture dislocations of the proximal interphalangeal (PIP) joint. The factors affecting the functional outcome were analyzed. A series of 53 patients with 55 dorsal fracture dislocations of the PIP joint treated with closed reduction and extension block pinning were retrospectively reviewed. Additional percutaneous intramedullary fracture reduction (16 cases) or open fracture reduction (4 cases) had been performed. The radiological and clinical evaluations were included. At a mean follow-up of 5.2 years (range, 1.0-10.6 years), 39 patients with 41 injured fingers were evaluated. The fracture fragments involved 30% to 69% (mean, 50%) of the articular surface of the middle phalanx. The mean range of motion was 80° (range, 35° to 115°) at the PIP joint with a mean extension loss of 6° (range, 0° to 50°) excluding 2 joints that were salvaged with arthrodesis. The mean range of motion of the distal interphalangeal joint was 68° (range, 5° to 90°). The mean visual analog scale for digit pain was 1.5/10. The reduction of the joint was achieved intraoperatively in all cases. However, after the hardware removal, recurrent minimal subluxation was observed in 12 cases (29%). Recurrent subluxation was associated with increased residual pain. The length of follow-up time had a positive correlation, whereas the patient age had a negative correlation with the range of motion of the injured PIP joint. The extension block pinning technique is a simple and valuable technique for treating unstable dorsal PIP fracture-dislocation injuries producing satisfactory long-term results.

Hemi-Hamate Arthroplasty Provides Functional Reconstruction of Acute and Chronic Proximal Interphalangeal Fracture–Dislocations

Hemi-Hamate Arthroplasty Provides Functional Reconstruction of Acute and Chronic Proximal Interphalangeal Fracture–Dislocations

Hemi-Hamate Arthroplasty Provides Functional Reconstruction of Acute and Chronic Proximal Interphalangeal Fracture–Dislocations

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. 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. 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). 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. Therapeutic IV.

Use of Dynamic Distraction External Fixation for Unstable Fracture-Dislocations of the Proximal Interphalangeal Joint

Unstable fracture-dislocations of the proximal interphalangeal (PIP) joint remain a difficult management problem, often leading to residual pain, stiffness, and recurrent instability. In a military setting, an easily applied, simple to operate, and inexpensive device becomes an attractive option. The purpose of this clinical investigation was to retrospectively review use of dynamic distraction external fixation (DDEF) for unstable fracture-dislocations and pilon injuries of the PIP joint in an active-duty population. The fixator is assembled under a local anesthetic from three 1.4-mm (0.045-inch) K-wires and rubber bands. It uses the principles of a lever and ligamentotaxis to assist and maintain reduction. Thirty-four members of the Armed Services, 27 men and 7 women (average age, 30 y), had DDEF for pilon fractures and unstable fracture-dislocations of the PIP joint. A retrospective review of these individuals was conducted. Final range of motion was determined from the clinical records at the final visit. There were 26 PIP fracture-dislocations (3 chronic, average 6 weeks) and 8 PIP pilon injuries. The average follow-up period was 16 months (range, 6-84 months). The final arc of motion at the PIP joint averaged 88 degrees , and the average distal interphalangeal joint arc of motion was 60 degrees . Eight patients experienced superficial pin-track infections that were easily controlled with oral antibiotics. There were no cases of septic arthritis or osteomyelitis requiring intravenous antibiotics or premature fixator removal. Loss of reduction did not occur. All patients returned to their prior level of activity and duties. Our results are comparable with other techniques used in the management of unstable PIP joint fracture-dislocations. Easily applied and simple to operate, DDEF is a valuable addition to the hand surgeon's armamentarium. We recommend its use for both primary and adjunctive treatment of acute and chronic unstable PIP joint fracture-dislocations and for primary treatment of PIP pilon injuries. Therapeutic IV.

Treatment of Unstable Dorsal Proximal Interphalangeal Fracture/Dislocation using a Hemi-Hamate Autograft

Purpose: To evaluate clinical and radiology assessments of the treatment outcomes of an unstable dorsal proximal interphalangeal (PIP) fracture and dislocation by hemi-hamate autograft. Materials and Methods: Six patients underwent a hemi-hamate autograft for the treatment of an unstable dorsal PIP fracture dislocation of which the articular involvement of the PIP joint was ＞50%, or an unstable joint despite the lesser degree of involvement. The clinical results were evaluated from the following: postoperative patient satisfaction, range of motion, stability and grip strength. The radiographs were evaluated for the union, and graft incorporation, and/or collapse. Results: All patients were satisfied with the results and the range of motion of the PIP joint was 81 degrees (75-100 o ). In all cases, stability of the PIP joint was restored. The average grip strength was 82% (75-90%) of the uninjured side. Bone union was achieved in all patients. Conclusion: A hemi-hamate autograft is effective for reconstructing the cup-shaped contour of the articular surface, and for recovering the functional range of motion of the PIP joint after an unstable dorsal proximal interphalangeal (PIP) fracture and dislocation. However, more study will be needed through a mid-term and long-term follow up.

Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft

Purpose: This retrospective study was designed to evaluate the clinical and radiographic results of a hemi-hamate autograft for the treatment of comminuted dorsal proximal interphalangeal (PIP) joint fracture/dislocations. Methods: Thirteen consecutive patients underwent hemi-hamate autograft for the treatment of an unstable dorsal PIP fracture dislocation. The fractured middle phalangeal base was debrided and the defect was replaced using a size-matched portion of the dorsal/distal hamate osteoarticular surface and was secured with miniscrews. The average middle phalangeal volar lip involvement on initial radiographs was 60% (range, 40% to 80%). The average time to surgery was 45 days (range, 2–175 d). Range of motion, stability, and grip strength were measured at a mean follow-up evaluation of 16 months. Radiographs were evaluated for union, graft incorporation, and/or collapse. Subjective data, satisfaction, and return to work were obtained on 12 of the 13 patients at a mean follow-up evaluation of 17 months. Results: The average arc of motion at the PIP joint was 85° (range, 65° to 100°). The distal interphalangeal (DIP) joint average arc of motion was 60° (range, 35° to 80°). Average grip strength was 80% of the uninjured side. Bony union was achieved in all patients. One graft showed ulnar collapse but graft resorption was not noted. Except for 2 patients with recurrent dorsal subluxation there were no complications. The average pain level was 1.3 (as rated on a visual analog scale of 0–10). Eleven of 12 patients were very satisfied with their function and one was somewhat satisfied; one patient was lost to follow-up. Conclusions: When greater than 50% of the volar base of the middle phalanx is fractured in a PIP fracture/dislocation or the joint remains unstable despite a lesser degree of involvement, a hemi-hamate autograft should be considered. This procedure reconstructs the cup-shaped contour of the middle phalangeal articular surface and facilitates a stable, functional arc of motion at the PIP joint. Additionally, in our experience the procedure renders minimal disability and has a low complication rate.