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AVULSION FRACTURES FROM THE BASE OF THE PROXIMAL PHALANGES OF THE FINGERS
AVULSION FRACTURES FROM THE BASE OF THE PROXIMAL PHALANGES OF THE FINGERS D. J. SHEWRING and R. H. THOMAS From the Department of Orthopaedic Surgery, University Hospital of Wales, Cardiff, UK
Thirty-three patients with avulsion fractures from the base of the proximal phalanges were treated during a 6-year period. All eight fractures treated conservatively failed to unite and subsequently required surgery. The remaining 25 patients were treated with primary internal fixation using a single lag screw through a palmar approach. Surgery gave excellent results in all cases and all patients achieved a full range of movement within 3 weeks. Journal of Hand Surgery (British and European Volume, 2003) 28B: 1: 10–14 reduced with a skin hook and secured with a selftapping titanium lag screw. A 1.2 or 1.7 mm screw is used, depending upon the size of the fragment. The soft tissues are repaired with a running absorbable stitch prior to closure of the skin and the hand is immobilized in a palmar slab in the position of comfort. Patients are seen on the fourth post-operative day and
INTRODUCTION Avulsion fractures from the base of the proximal phalanges occur through the pull of the collateral ligaments and are usually caused by a fall onto the outstretched hand. Such injuries are well recognized at the metacarpophalangeal joint of the thumb (Lee, 1963; Kozin and Bishop, 1994) but similar injuries affecting the fingers are less common and have received scant attention. Previous studies have often grouped these fractures along with those of the thumb, or with other avulsion fractures such as the mallet finger (Bischoff et al., 1994; Jupiter and Sheppard, 1985). The purpose of this prospective study was to compare the outcomes of conservative and operative treatment of these fractures in the fingers and to describe a technique of surgical fixation through a palmar, rather than a dorsal (Hastings, 1986; Hastings and Carroll, 1988) approach. PATIENTS AND METHODS Over a 6-year period, a total of 33 patients with these fractures presented to the hand trauma service in Cardiff. There were 25 men and eight women, with a mean age of 26 (range, 15–44) years. The majority of injuries (22) were sustained during sporting activities, with the remainder occurring as the result of a simple fall. All fractures affected either the ulnar side of the index or the radial side of the little fingers, suggesting an abduction injury (Fig 1). The fragments involved 12–28% of the joint surface. Twenty-five patients were treated within 5 days of injury by primary internal fixation using a single lag screw inserted through a palmar approach. Operative technique (Fig 2) A palmar incision is made and the digital nerve is protected. The finger flexor sheath and palmar plate are mobilized subperiosteally with sharp dissection off the metacarpal shaft and head and the base of the proximal phalanx. The fragment is identified and care is taken when dissecting to stay palmar to it, in order to preserve the attachment of the collateral ligament. The fracture is
Fig 1 A displaced avulsion fracture from the radial side of the base of the little finger proximal phalanx. 10
AVULSION FRACTURES OF THE FINGER MCP JOINT
are then referred to the Hand Therapists for a resting thermoplastic splint and mobilization which commenced immediately. Radiographs are taken at the first postoperative visit and at 3 months. Eight patients, including two adolescents, aged 15 and 16, chose conservative treatment and were initially treated with ‘‘neighbour strapping’’ to the adjacent digit. The proximal interphalangeal joints were then mobilized under the supervision of the Hand Therapists, but the metacarpophalangeal joints were immobilized in 701 flexion with a thermoplastic splint. The fractures were monitored with radiographs taken at 2 week intervals for 6 weeks and then monthly.
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RESULTS All patients treated with primary internal fixation achieved a full range of movement by 3 weeks and most had achieved almost full flexion of the digits by 10 days when the sutures were removed. All fractures had united by 3 months, at which point the patients were discharged. There was no loss of fixation and no patient required screw removal. One patient, a woman aged 22, developed pain and swelling in the hand at 4 weeks, despite having previously regained a full range of movement with minimal post-operative symptoms. No cause was found
Fig 2 Technique of fracture fixation: (a) the incision is marked, (b) the flexor mechanism and palmar plate are retracted. The fragment, attached to the collateral ligament, can be opened like a book and cleaned, (c) the fragment is reduced and held with a skin hook and (d) fixed with a self-tapping lag screw.
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THE JOURNAL OF HAND SURGERY VOL. 28B No. 1 FEBRUARY 2003
Fig 2 (continued ).
for this and the symptoms resolved completely over a 3 week period. Conservative treatment was less satisfactory. There were no signs of union, either clinically or radiographically, by 2 months in any of these patients (Fig 3). Seven of these patients were subsequently treated with internal fixation without bone graft. At operation all these fractures were found to be mobile. This secondary surgery was more difficult than primary fixation due to loss of the fracture interdigitations but there was no loss of fixation and union occurred in all cases. One patient, a 43-year-old woman declined surgery. One year after the injury there was a persisting non-union with ongoing symptoms of pain, and instability which can be assessed by abducting the fully flexed metacarpophalangeal joint. Surgery was again refused.
DISCUSSION These fractures occur as the result of the finger being forced into abduction, usually during a fall. The detachment of the collateral ligament renders the metacarpophalangeal joint unstable and, if union is not achieved, this persists. The fragments may involve a significant amount of articular surface leading to joint incongruity, if the fragment remains displaced. Since these fractures result from an avulsion rather than an impaction mechanism, there is no comminution of the fragment and the joint surfaces are not buckled or otherwise deformed, which aids fracture fixation. Hastings and Carroll (1988) described 11 collateral ligament avulsion fractures from the base of the proximal phalanges of the fingers, nine of which were Salter III fractures in skeletally immature patients. Ten
AVULSION FRACTURES OF THE FINGER MCP JOINT
13
Fig 3 (a) Undisplaced fracture in a 16 year old, (b) radiograph at 2 months showing no signs of union.
Fig 4 Pre- and post-operative radiographs of a 20-year-old dental student illustrating optimal placement of a screw into the small fragment. Insertion of the screw from a dorsal approach would not have been possible.
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of these fractures were treated with wires (eight) or screws (two), using a dorsal extensor tendon splitting approach and a transverse dorsal capsulotomy. They reported good results, although with a reduced final range of movement of the metacarpophalangeal and proximal interphalangeal joints. One patient required an extensor tenolysis for adhesions. Schubiner and Mass (1989) described ten cases of metacarpophalangeal joint collateral ligament rupture, six of which had fragments avulsed from the base of the proximal phalanx, two from the metacarpal head. In all cases surgery was performed with satisfactory results, but the surgical approach was not mentioned. Bischoff et al. (1994), in their series of 100 various avulsion fractures of the hand, described six fractures of the base of the proximal phalanx treated with tension band fixation. All patients achieved a full range of movement but again the surgical approach was not specified. Previous authors (Hastings, 1986; Hastings and Carroll, 1987) have advocated that these fractures are approached through a dorsal tendon splitting incision but we feel that a palmar approach allows better visualization and easier reduction of the fracture fragment. Insertion of a single lag screw is straightforward and optimal placement of the screw, into what is often a very small fragment, is possible (Fig 4). Furthermore, violation of the plane between the extensor mechanism and the dorsal periosteum of the proximal phalanx is avoided and would explain the early achievement of full flexion in our series. Our conservative treatment for these fractures resulted in high rates of nonunion and ongoing symptoms, despite immobilization of the metacarpophalangeal joint for up to 8 weeks. The high rate of nonunion may be explained by the pull of the collateral ligament on the fragment. Conservative treatment prevents early
THE JOURNAL OF HAND SURGERY VOL. 28B No. 1 FEBRUARY 2003
mobilization since the fracture may displace as the collateral ligament tightens with flexion of the metacarpophalangeal joint. When the fractures initially treated conservatively were later secured with a lag screw, union occurred without the need for bone graft. It is our view that this indicates that these fractures will unite readily, if adequate stability is provided. Thus, some delay in fixation does not appear to affect the outcome, allowing referral to a surgeon familiar with techniques of fixation of small fragments and with the anatomy of the hand. References Bischoff R, Buechler U, De Roche R, Jupiter J (1994). Clinical results of tension band fixation of avulsion fractures of the hand. Journal of Hand Surgery, 19A: 1019–1026. Kozin SH, Bishop AT (1994). Tension wire fixation of avulsion fractures at the thumb metacarpophalangeal joint. Journal of Hand Surgery, 19A: 1027– 1031. Hastings H (1987). Unstable metacarpal and phalangeal fracture treatment with screws and plates. Clinical Orthopaedics and Related Research, 214: 37–52. Hastings H, Carroll C (1988). Treatment of closed articular fractures of the metacarpophalangeal and proximal interphalangeal joints. Hand Clinics, 4: 503–527. Jupiter JB, Sheppard JE (1987). Tension wire fixation of avulsion fractures in the hand. Clinical Orthopaedics and Related Research, 214: 113–120. Lee MLH (1963). Intra-articular and peri-articular fractures of the phalanges. Journal of Bone and Joint Surgery, 45B: 103–109. Schubiner JM, Mass DP (1989). Operation for collateral ligament ruptures of the metacarpophalangeal joints of the fingers. Journal of Bone and Joint Surgery, 71B: 388–389.
Received: 11 January 2002 Accepted after revision: 11 July 2002 Mr D. J. Shewring, Consultant Hand Surgeon, Department of Trauma and Orthopaedics, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, U.K. E-mail: [email protected] r 2003 The British Society for Surgery of the Hand. Published by Elsevier Science Ltd. All rights reserved. doi: 10.1054/jhsb.2002.0842, available online at http://www.sciencedirect.com
Thirty-three patients with avulsion fractures from the base of the proximal phalanges were treated during a 6-year period. All eight fractures treated conservatively failed to unite and subsequently required surgery. The remaining 25 patients were treated with primary internal fixation using a single lag screw through a palmar approach. Surgery gave excellent results in all cases and all patients achieved a full range of movement within 3 weeks. Journal of Hand Surgery (British and European Volume, 2003) 28B: 1: 10–14 reduced with a skin hook and secured with a selftapping titanium lag screw. A 1.2 or 1.7 mm screw is used, depending upon the size of the fragment. The soft tissues are repaired with a running absorbable stitch prior to closure of the skin and the hand is immobilized in a palmar slab in the position of comfort. Patients are seen on the fourth post-operative day and
INTRODUCTION Avulsion fractures from the base of the proximal phalanges occur through the pull of the collateral ligaments and are usually caused by a fall onto the outstretched hand. Such injuries are well recognized at the metacarpophalangeal joint of the thumb (Lee, 1963; Kozin and Bishop, 1994) but similar injuries affecting the fingers are less common and have received scant attention. Previous studies have often grouped these fractures along with those of the thumb, or with other avulsion fractures such as the mallet finger (Bischoff et al., 1994; Jupiter and Sheppard, 1985). The purpose of this prospective study was to compare the outcomes of conservative and operative treatment of these fractures in the fingers and to describe a technique of surgical fixation through a palmar, rather than a dorsal (Hastings, 1986; Hastings and Carroll, 1988) approach. PATIENTS AND METHODS Over a 6-year period, a total of 33 patients with these fractures presented to the hand trauma service in Cardiff. There were 25 men and eight women, with a mean age of 26 (range, 15–44) years. The majority of injuries (22) were sustained during sporting activities, with the remainder occurring as the result of a simple fall. All fractures affected either the ulnar side of the index or the radial side of the little fingers, suggesting an abduction injury (Fig 1). The fragments involved 12–28% of the joint surface. Twenty-five patients were treated within 5 days of injury by primary internal fixation using a single lag screw inserted through a palmar approach. Operative technique (Fig 2) A palmar incision is made and the digital nerve is protected. The finger flexor sheath and palmar plate are mobilized subperiosteally with sharp dissection off the metacarpal shaft and head and the base of the proximal phalanx. The fragment is identified and care is taken when dissecting to stay palmar to it, in order to preserve the attachment of the collateral ligament. The fracture is
Fig 1 A displaced avulsion fracture from the radial side of the base of the little finger proximal phalanx. 10
AVULSION FRACTURES OF THE FINGER MCP JOINT
are then referred to the Hand Therapists for a resting thermoplastic splint and mobilization which commenced immediately. Radiographs are taken at the first postoperative visit and at 3 months. Eight patients, including two adolescents, aged 15 and 16, chose conservative treatment and were initially treated with ‘‘neighbour strapping’’ to the adjacent digit. The proximal interphalangeal joints were then mobilized under the supervision of the Hand Therapists, but the metacarpophalangeal joints were immobilized in 701 flexion with a thermoplastic splint. The fractures were monitored with radiographs taken at 2 week intervals for 6 weeks and then monthly.
11
RESULTS All patients treated with primary internal fixation achieved a full range of movement by 3 weeks and most had achieved almost full flexion of the digits by 10 days when the sutures were removed. All fractures had united by 3 months, at which point the patients were discharged. There was no loss of fixation and no patient required screw removal. One patient, a woman aged 22, developed pain and swelling in the hand at 4 weeks, despite having previously regained a full range of movement with minimal post-operative symptoms. No cause was found
Fig 2 Technique of fracture fixation: (a) the incision is marked, (b) the flexor mechanism and palmar plate are retracted. The fragment, attached to the collateral ligament, can be opened like a book and cleaned, (c) the fragment is reduced and held with a skin hook and (d) fixed with a self-tapping lag screw.
12
THE JOURNAL OF HAND SURGERY VOL. 28B No. 1 FEBRUARY 2003
Fig 2 (continued ).
for this and the symptoms resolved completely over a 3 week period. Conservative treatment was less satisfactory. There were no signs of union, either clinically or radiographically, by 2 months in any of these patients (Fig 3). Seven of these patients were subsequently treated with internal fixation without bone graft. At operation all these fractures were found to be mobile. This secondary surgery was more difficult than primary fixation due to loss of the fracture interdigitations but there was no loss of fixation and union occurred in all cases. One patient, a 43-year-old woman declined surgery. One year after the injury there was a persisting non-union with ongoing symptoms of pain, and instability which can be assessed by abducting the fully flexed metacarpophalangeal joint. Surgery was again refused.
DISCUSSION These fractures occur as the result of the finger being forced into abduction, usually during a fall. The detachment of the collateral ligament renders the metacarpophalangeal joint unstable and, if union is not achieved, this persists. The fragments may involve a significant amount of articular surface leading to joint incongruity, if the fragment remains displaced. Since these fractures result from an avulsion rather than an impaction mechanism, there is no comminution of the fragment and the joint surfaces are not buckled or otherwise deformed, which aids fracture fixation. Hastings and Carroll (1988) described 11 collateral ligament avulsion fractures from the base of the proximal phalanges of the fingers, nine of which were Salter III fractures in skeletally immature patients. Ten
AVULSION FRACTURES OF THE FINGER MCP JOINT
13
Fig 3 (a) Undisplaced fracture in a 16 year old, (b) radiograph at 2 months showing no signs of union.
Fig 4 Pre- and post-operative radiographs of a 20-year-old dental student illustrating optimal placement of a screw into the small fragment. Insertion of the screw from a dorsal approach would not have been possible.
14
of these fractures were treated with wires (eight) or screws (two), using a dorsal extensor tendon splitting approach and a transverse dorsal capsulotomy. They reported good results, although with a reduced final range of movement of the metacarpophalangeal and proximal interphalangeal joints. One patient required an extensor tenolysis for adhesions. Schubiner and Mass (1989) described ten cases of metacarpophalangeal joint collateral ligament rupture, six of which had fragments avulsed from the base of the proximal phalanx, two from the metacarpal head. In all cases surgery was performed with satisfactory results, but the surgical approach was not mentioned. Bischoff et al. (1994), in their series of 100 various avulsion fractures of the hand, described six fractures of the base of the proximal phalanx treated with tension band fixation. All patients achieved a full range of movement but again the surgical approach was not specified. Previous authors (Hastings, 1986; Hastings and Carroll, 1987) have advocated that these fractures are approached through a dorsal tendon splitting incision but we feel that a palmar approach allows better visualization and easier reduction of the fracture fragment. Insertion of a single lag screw is straightforward and optimal placement of the screw, into what is often a very small fragment, is possible (Fig 4). Furthermore, violation of the plane between the extensor mechanism and the dorsal periosteum of the proximal phalanx is avoided and would explain the early achievement of full flexion in our series. Our conservative treatment for these fractures resulted in high rates of nonunion and ongoing symptoms, despite immobilization of the metacarpophalangeal joint for up to 8 weeks. The high rate of nonunion may be explained by the pull of the collateral ligament on the fragment. Conservative treatment prevents early
THE JOURNAL OF HAND SURGERY VOL. 28B No. 1 FEBRUARY 2003
mobilization since the fracture may displace as the collateral ligament tightens with flexion of the metacarpophalangeal joint. When the fractures initially treated conservatively were later secured with a lag screw, union occurred without the need for bone graft. It is our view that this indicates that these fractures will unite readily, if adequate stability is provided. Thus, some delay in fixation does not appear to affect the outcome, allowing referral to a surgeon familiar with techniques of fixation of small fragments and with the anatomy of the hand. References Bischoff R, Buechler U, De Roche R, Jupiter J (1994). Clinical results of tension band fixation of avulsion fractures of the hand. Journal of Hand Surgery, 19A: 1019–1026. Kozin SH, Bishop AT (1994). Tension wire fixation of avulsion fractures at the thumb metacarpophalangeal joint. Journal of Hand Surgery, 19A: 1027– 1031. Hastings H (1987). Unstable metacarpal and phalangeal fracture treatment with screws and plates. Clinical Orthopaedics and Related Research, 214: 37–52. Hastings H, Carroll C (1988). Treatment of closed articular fractures of the metacarpophalangeal and proximal interphalangeal joints. Hand Clinics, 4: 503–527. Jupiter JB, Sheppard JE (1987). Tension wire fixation of avulsion fractures in the hand. Clinical Orthopaedics and Related Research, 214: 113–120. Lee MLH (1963). Intra-articular and peri-articular fractures of the phalanges. Journal of Bone and Joint Surgery, 45B: 103–109. Schubiner JM, Mass DP (1989). Operation for collateral ligament ruptures of the metacarpophalangeal joints of the fingers. Journal of Bone and Joint Surgery, 71B: 388–389.
Received: 11 January 2002 Accepted after revision: 11 July 2002 Mr D. J. Shewring, Consultant Hand Surgeon, Department of Trauma and Orthopaedics, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, U.K. E-mail: [email protected] r 2003 The British Society for Surgery of the Hand. Published by Elsevier Science Ltd. All rights reserved. doi: 10.1054/jhsb.2002.0842, available online at http://www.sciencedirect.com