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Dorsal Fracture-Dislocations of the Proximal Interphalangeal Joint
EVIDENCE-BASED MEDICINE
Dorsal Fracture-Dislocations of the Proximal Interphalangeal Joint Ronald M. Gonzalez, DO,* Warren C. Hammert, MD* THE PATIENT A 27-year-old right-handed man injured his nondominant ring finger when he fell playing basketball. Owing to persistent pain, a hand surgeon evaluated him and radiographs were notable for a dorsal fracture-dislocation (DFD) of the middle phalanx base involving 45% of the articular surface. THE QUESTION What is the best treatment for an unstable middle phalanx base DFD and what are the guiding principles that direct the treatment of these injuries? CURRENT OPINION Surgical management of the proximal interphalangeal joint (PIP) DFD comprises a broad spectrum of treatment options that are categorized by the amount of the articular surface involved. Restoration of stability allowing early motion and a smooth articular surface are the goals of treatment.1 Hastings and Carroll2 established the most recognized classification in 1988 based on the percentage of articular surface involvement. Disruption of 30% or less of the articular surface is likely to be stable; 30% to 50% of articular surface involvement causes tenuous stability; and greater than 50% articular surface involvement is considered unstable.3 There is no gold standard for the treatment of unstable middle phalanx base articular fracture-dislocations. Treatment options include extension block pinning, closed reduction and percutaneous pinning, open reduction and internal fixation, traction devices and From the *Department of Orthopedics and Rehabilitation, Hand and Upper Extremity Surgery, University of Rochester, Rochester, NY. Received for publication August 13, 2015; accepted in revised form August 29, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Ronald M. Gonzalez, DO, 601 Elmwood Ave., Rochester NY 14642; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.08.023
external fixation, volar plate arthroplasty, and hemihamate reconstruction.4 THE EVIDENCE In a retrospective study of 41 patients by Nilsson and Rosberg,5 25 patients had radiographic signs of arthritis (61%). The final active motion was 66%, grip strength was 93%, and pinch strength was equal to that of the contralateral side. The mean QuickDASH (The Disabilities of Arm, Shoulder, and Hand) score was 9.1. Bear et al6 described 12 patients treated with extension block pinning, with the extent of articular surface involvement averaging 43%. Final motion was 84 at the PIP, and grip strength was equal to the uninvolved hand. The average QuickDASH scores were 5.7 and the visual analog score (VAS) for pain was 0.64 (scale, 0e10). One retrospective study of 16 patients with 18 fracture-dislocations presented by Waris and Alanen7 used closed reduction and extension block pinning with percutaneous reduction of the articular fragments using a Kirschner wire inserted through the middle phalanx. The mean articular step-off decreased from 2.1 mm to 0.5 mm. The average PIP range of motion (ROM) was 83 with a flexion contracture of 3 . The mean VAS for pain was 1 out of 10 and the mean DASH score was 4. de Hasbeth and colleagues8 reviewed 9 patients treated with extension block pinning and early motion beginning the day of surgery. Patients had an average of 106 of flexion and a flexion contracture of 4 with no pain an average of 28 days after surgery. Complications included 1 pin track infection treated with oral antibiotics and avascular necrosis of 1 of the proximal phalanx condyles in another patient. Vitale et al9 described 6 patients in which closed percutaneous reduction of the middle phalanx base fracture with pin fixation, and adjunct extension blocking pin of the PIP, was used in unstable DFDs of the PIP, with mean follow up at 18 months. Final ROM at the PIP of 1 to 73 and the DASH score
Ó 2015 ASSH
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Published by Elsevier, Inc. All rights reserved.
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DORSAL FRACTURE-DISLOCATIONS OF THE PIP JOINT
30 weeks). The average PIP ROM was 70 (acute, 70 ; chronic, 69 ) and the average DIP motion was 54 (acute, 56 ; chronic, 51 ). The mean DASH score was 5 (acute, 2; chronic, 6) and VAS score averaged 1.9 (acute, 1.4; chronic, 2.6). Ten patients complained of cold intolerance and 1 was dissatisfied because of ulnar deviation and underwent revision with silicone arthroplasty. The authors concluded that hemihamate arthroplasty is a viable treatment for acute and subacute or chronic injuries, with better outcomes in the acute setting. Yang et al16 described 11 patients treated with hemihamate arthroplasty for comminuted DFD. Average articular involvement was 58% and followup was 38 months. Active ROM for the PIP was 85 and DIP was 80 with a mean DASH of 5. The only complication was radiographic signs of graft absorption in 1 finger. In a systematic review, Freuh et al17 reviewed 177 studies of hemihamate autograft. Most surgeons consider hemihamate autograft beneficial for patients with acute fracture who have articular fracture involving greater than 50% of the joint. The average motion of the PIP was 77 . The complication rate was approximately 35% to include minor and major complications. Flexion contracture was seen in up to 10% of patients and there was minimal donor site morbidity.18
was 8. They reported no complications other than stiffness. Ikeda et al10 described 15 patients followed for an average of 14 months with average motion from 1 to 86 at the PIP and 0 to 77 at the distal interphalangeal (DIP) joint, after percutaneous pinning of the volar lip of the PIP, in DFDs. Cheah et al11 performed a retrospective review of 13 consecutive DFDs of the PIP treated with volar miniplate and screw fixation. The average arc of motion of the PIP joint was 75 , with grip strength averaging 85% of the unaffected side. Three patients had degenerative changes with minimal symptoms, and subjective outcomes included an average QuickDASH Score of 4. Ruland et al12 described 34 patients with both chronic and acute unstable DFD of the PIP treated with dynamic traction. An average of 16 months after surgery, the final arc of motion was 88 at the PIP joint and 60 at the DIP joint. They reported superficial pin track infection treated with oral antibiotics in 8 patients. In a prospective case series by Kubitskiy et al,13 10 patients were treated with external fixation for DFD of the PIP joint, comparing 2 cohorts: group 1 using a 2-pin technique and group 2 using a 4-pin technique. Groups 1 and 2 collectively averaged 83.5 of motion at the PIP joint. Group 1 had 80 of PIP motion and 51 DIP motion and group 2 had an average of 87 of PIP motion and 48 DIP motion. The average grip strength was 27 kg in group 1 and 37 kg in group 2. They reported 80% motion compared with the nonaffected hand, and a 90% union rate. One patient had early loss of reduction. There were no infections reported, restoration of the articular surface demonstrated a step-off in all patients but did not cause any adverse effects. Afendras et al14 reviewed 8 patients treated with hemihamate arthroplasty—4 acute and 4 subacute PIP fracture-dislocations—observing severe arthritis in 2 patients and mild arthritis in 2 patients a mean of 4 years after surgery. The arc of motion averaged 67 and grip strength averaged 91% of the unaffected side. Using VAS, pain at rest averaged 10 mm (range, 0e90 mm; 0 mm being best), 17 mm with activity, subjective grip strength 29 mm (range, 0e80 mm), hand function 24 mm (range, 0e80 mm), and subjective cosmetic result 16 mm (range, 0e70 mm). Only 1 patient was less than completely satisfied secondary to severe arthritis and pain. The mean QuickDASH was 19. Calfee et al15 described 22 patients treated with hemihamate arthroplasty for DFD of the PIP, 14 acute and 8 subacute or chronic (mean, < 6 weeks; J Hand Surg Am.
SHORTCOMINGS OF THE EVIDENCE Most of the evidence is limited to retrospective or prospective case series, with limited number of patients and follow-up. Many studies have mixed cohorts with both acute and chronic injuries as well as pilon type fractures of the base of the middle phalanx, making it difficult to compare techniques. DIRECTIONS FOR FUTURE RESEARCH This is an uncommon injury and multiple centers would need to work together to recruit enough patients to compare treatments. Extension block or transarticular pinning might be considered the default treatment to which other treatments are compared given that it is relatively straightforward and cost effective because it can be done under local anesthesia with less operative time, fewer adverse events, and an easier recovery than more complex procedures. Important outcomes include subluxation, motion, and development of arthritis in the long term. OUR CURRENT CONCEPTS FOR THIS PATIENT In this patient, we prefer traction fixation using the external fixation with pins and rubber band techniques r
Vol. -, - 2015
DORSAL FRACTURE-DISLOCATIONS OF THE PIP JOINT
to extension block pinning because it avoids the transarticular pin. It offers the advantage of no donor site morbidity, decreased operative time, lower cost, and early motion. We favor hemihamate reconstruction in patients with greater than 50% of the articular surface involvement.19
9. Vitale MA, White NJ, Strauch RJ. A percutaneous technique to treate unstable dorsal fracture-dislocations of the proximal interphalangeal joint. J Hand Surg Am. 2011;36(9):1453e1459. 10. Ikeda M, Ishii T, Kobayashi Y, Mochida J, Saito I, Oka Y. Percutaneous pinning of the displaced volar plate avulsion fracture of the PIP joint. Hand Surg. 2009;14(2e3):113e119. 11. Cheah AE, Tan DM, Chong AK, Chew WY. Volar plating for unstable proximal interphalangeal joint fracture dislocations. J Hand Surg Am. 2012;37(1):28e33. 12. Ruland RT, Hogan CJ, Cannon DL, Slade JF. Use of dynamic distraction external fixation for unstable fracture-dislocations of the proximal interphalangeal joint. J Hand Surg Am. 2008;33(1):19e25. 13. Kubitskiy A, Soliman BA, Dowd MB, Curtin P. External fixation of the hand: a simple approach to comminuted proximal interphalangeal joint fractures. Hand Surg. 2014;19(1):85e89. 14. Afendras G, Abramo A, Mrkonjic A, Geijer M, Kopylov P, Tagil M. Hemi-hamate osteochondral transplantation in proximal interphalangeal dorsal fracture dislocations: a minimum 4 year follow-up in 8 patients. J Hand Surg Eur Vol. 2010;35(8):627e631. 15. Calfee RP, Keifhaber TR, Sommerkamp TG, Stern PJ. Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture-dislocations. J Hand Surg Am. 2009;34(7):1232e1241. 16. Yang DS, Lee SK, Kim KJ, Choy WS. Modified hemi-hamate arthroplasty technique for treatment of acute proximal interphalangeal joint fracture-dislocations. Ann Plast Surg. 2014;72(4):411e416. 17. Freuh FS, Calcagni M, Lindenblatt N. The hemi-hamate autograft arthroplasty in proximal interphalangeal joint reconstruction: a systematic review. J Hand Surg Eur Vol. 2015;40(1):24e32. 18. Capo JT, Hastings H II, Choung E, Kinchelow T, Rossy W, Steinberg B. Hemicondylar hamate replacement arthroplasty for proximal interphalangeal joint fracture dislocations: an assessment of graft suitability. J Hand Surg Am. 2008;33(5):733e739. 19. Tyser AR, Tsai MA, Parks BG, Means KR Jr. Biomechanical charateristics of hemi-hamate reconstruction versus volar plate arthroplasty in the treatment of dorsal fracture dislocations of the proximal interphalangeal joint. J Hand Surg Am. 2015;40(2):329e332.
REFERENCES 1. Calfee RP, Sommerkamp TG. Fracture-dislocation about the finger joints. J Hand Surg Am. 2009;34(6):1140e1147. 2. Hastings H II, Carroll C IV. Treatment of closed articular fractures of the metacarpophalangeal an proximal interphalangeal joints. Hand Clin. 1988;4(3):503e527. 3. Khouri JS, Bloom JM, Hammer WC. Current trends in the managment of proximal interphalangeal joint injuries of the hand. Plast Reconstr Surg. 2013;132(5):1192e1204. 4. Adams JE, Calfee RP, Vitale MA, Strauch RJ, Barron OA. Dorsal proximal interphalangeal joint fracture-dislocations: evaluation and treatment. Instr Course Lect. 2015;64:261e272. 5. Nilsson JA, Rosberg HE. Treatment of proximal interphalangeal joint fractures by the pins and rubbers traction system: a follow up. J Plast Surg Hand Surg. 2014;48(4):259e264. 6. Bear DM, Weichbrodt MT, Haung C, Hagberg WC, Balk ML. Unstable dorsal proximal interphalangeal joint fracture-dislocations treated with extension-block pinning. Am J Orthop. 2015;44(3): 122e126. 7. Waris E, Alanen V. Percutaneous, intermedullary fracture reduction and extension block pinning for dorsal proximal interphalangeal fracture-dislocations. J Hand Surg Am. 2010;35(12):2046e2052. 8. de Hasbeth KB, Neuhaus V, Mudgal CS. Dorsal fracture-dislocations of the proximal interphalangeal joint: evaluation of closed reduction and percutaneous Kirschner wire pinning. Hand (N Y). 2015;10(1): 88e93.
J Hand Surg Am.
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Dorsal Fracture-Dislocations of the Proximal Interphalangeal Joint Ronald M. Gonzalez, DO,* Warren C. Hammert, MD* THE PATIENT A 27-year-old right-handed man injured his nondominant ring finger when he fell playing basketball. Owing to persistent pain, a hand surgeon evaluated him and radiographs were notable for a dorsal fracture-dislocation (DFD) of the middle phalanx base involving 45% of the articular surface. THE QUESTION What is the best treatment for an unstable middle phalanx base DFD and what are the guiding principles that direct the treatment of these injuries? CURRENT OPINION Surgical management of the proximal interphalangeal joint (PIP) DFD comprises a broad spectrum of treatment options that are categorized by the amount of the articular surface involved. Restoration of stability allowing early motion and a smooth articular surface are the goals of treatment.1 Hastings and Carroll2 established the most recognized classification in 1988 based on the percentage of articular surface involvement. Disruption of 30% or less of the articular surface is likely to be stable; 30% to 50% of articular surface involvement causes tenuous stability; and greater than 50% articular surface involvement is considered unstable.3 There is no gold standard for the treatment of unstable middle phalanx base articular fracture-dislocations. Treatment options include extension block pinning, closed reduction and percutaneous pinning, open reduction and internal fixation, traction devices and From the *Department of Orthopedics and Rehabilitation, Hand and Upper Extremity Surgery, University of Rochester, Rochester, NY. Received for publication August 13, 2015; accepted in revised form August 29, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Ronald M. Gonzalez, DO, 601 Elmwood Ave., Rochester NY 14642; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.08.023
external fixation, volar plate arthroplasty, and hemihamate reconstruction.4 THE EVIDENCE In a retrospective study of 41 patients by Nilsson and Rosberg,5 25 patients had radiographic signs of arthritis (61%). The final active motion was 66%, grip strength was 93%, and pinch strength was equal to that of the contralateral side. The mean QuickDASH (The Disabilities of Arm, Shoulder, and Hand) score was 9.1. Bear et al6 described 12 patients treated with extension block pinning, with the extent of articular surface involvement averaging 43%. Final motion was 84 at the PIP, and grip strength was equal to the uninvolved hand. The average QuickDASH scores were 5.7 and the visual analog score (VAS) for pain was 0.64 (scale, 0e10). One retrospective study of 16 patients with 18 fracture-dislocations presented by Waris and Alanen7 used closed reduction and extension block pinning with percutaneous reduction of the articular fragments using a Kirschner wire inserted through the middle phalanx. The mean articular step-off decreased from 2.1 mm to 0.5 mm. The average PIP range of motion (ROM) was 83 with a flexion contracture of 3 . The mean VAS for pain was 1 out of 10 and the mean DASH score was 4. de Hasbeth and colleagues8 reviewed 9 patients treated with extension block pinning and early motion beginning the day of surgery. Patients had an average of 106 of flexion and a flexion contracture of 4 with no pain an average of 28 days after surgery. Complications included 1 pin track infection treated with oral antibiotics and avascular necrosis of 1 of the proximal phalanx condyles in another patient. Vitale et al9 described 6 patients in which closed percutaneous reduction of the middle phalanx base fracture with pin fixation, and adjunct extension blocking pin of the PIP, was used in unstable DFDs of the PIP, with mean follow up at 18 months. Final ROM at the PIP of 1 to 73 and the DASH score
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
DORSAL FRACTURE-DISLOCATIONS OF THE PIP JOINT
30 weeks). The average PIP ROM was 70 (acute, 70 ; chronic, 69 ) and the average DIP motion was 54 (acute, 56 ; chronic, 51 ). The mean DASH score was 5 (acute, 2; chronic, 6) and VAS score averaged 1.9 (acute, 1.4; chronic, 2.6). Ten patients complained of cold intolerance and 1 was dissatisfied because of ulnar deviation and underwent revision with silicone arthroplasty. The authors concluded that hemihamate arthroplasty is a viable treatment for acute and subacute or chronic injuries, with better outcomes in the acute setting. Yang et al16 described 11 patients treated with hemihamate arthroplasty for comminuted DFD. Average articular involvement was 58% and followup was 38 months. Active ROM for the PIP was 85 and DIP was 80 with a mean DASH of 5. The only complication was radiographic signs of graft absorption in 1 finger. In a systematic review, Freuh et al17 reviewed 177 studies of hemihamate autograft. Most surgeons consider hemihamate autograft beneficial for patients with acute fracture who have articular fracture involving greater than 50% of the joint. The average motion of the PIP was 77 . The complication rate was approximately 35% to include minor and major complications. Flexion contracture was seen in up to 10% of patients and there was minimal donor site morbidity.18
was 8. They reported no complications other than stiffness. Ikeda et al10 described 15 patients followed for an average of 14 months with average motion from 1 to 86 at the PIP and 0 to 77 at the distal interphalangeal (DIP) joint, after percutaneous pinning of the volar lip of the PIP, in DFDs. Cheah et al11 performed a retrospective review of 13 consecutive DFDs of the PIP treated with volar miniplate and screw fixation. The average arc of motion of the PIP joint was 75 , with grip strength averaging 85% of the unaffected side. Three patients had degenerative changes with minimal symptoms, and subjective outcomes included an average QuickDASH Score of 4. Ruland et al12 described 34 patients with both chronic and acute unstable DFD of the PIP treated with dynamic traction. An average of 16 months after surgery, the final arc of motion was 88 at the PIP joint and 60 at the DIP joint. They reported superficial pin track infection treated with oral antibiotics in 8 patients. In a prospective case series by Kubitskiy et al,13 10 patients were treated with external fixation for DFD of the PIP joint, comparing 2 cohorts: group 1 using a 2-pin technique and group 2 using a 4-pin technique. Groups 1 and 2 collectively averaged 83.5 of motion at the PIP joint. Group 1 had 80 of PIP motion and 51 DIP motion and group 2 had an average of 87 of PIP motion and 48 DIP motion. The average grip strength was 27 kg in group 1 and 37 kg in group 2. They reported 80% motion compared with the nonaffected hand, and a 90% union rate. One patient had early loss of reduction. There were no infections reported, restoration of the articular surface demonstrated a step-off in all patients but did not cause any adverse effects. Afendras et al14 reviewed 8 patients treated with hemihamate arthroplasty—4 acute and 4 subacute PIP fracture-dislocations—observing severe arthritis in 2 patients and mild arthritis in 2 patients a mean of 4 years after surgery. The arc of motion averaged 67 and grip strength averaged 91% of the unaffected side. Using VAS, pain at rest averaged 10 mm (range, 0e90 mm; 0 mm being best), 17 mm with activity, subjective grip strength 29 mm (range, 0e80 mm), hand function 24 mm (range, 0e80 mm), and subjective cosmetic result 16 mm (range, 0e70 mm). Only 1 patient was less than completely satisfied secondary to severe arthritis and pain. The mean QuickDASH was 19. Calfee et al15 described 22 patients treated with hemihamate arthroplasty for DFD of the PIP, 14 acute and 8 subacute or chronic (mean, < 6 weeks; J Hand Surg Am.
SHORTCOMINGS OF THE EVIDENCE Most of the evidence is limited to retrospective or prospective case series, with limited number of patients and follow-up. Many studies have mixed cohorts with both acute and chronic injuries as well as pilon type fractures of the base of the middle phalanx, making it difficult to compare techniques. DIRECTIONS FOR FUTURE RESEARCH This is an uncommon injury and multiple centers would need to work together to recruit enough patients to compare treatments. Extension block or transarticular pinning might be considered the default treatment to which other treatments are compared given that it is relatively straightforward and cost effective because it can be done under local anesthesia with less operative time, fewer adverse events, and an easier recovery than more complex procedures. Important outcomes include subluxation, motion, and development of arthritis in the long term. OUR CURRENT CONCEPTS FOR THIS PATIENT In this patient, we prefer traction fixation using the external fixation with pins and rubber band techniques r
Vol. -, - 2015
DORSAL FRACTURE-DISLOCATIONS OF THE PIP JOINT
to extension block pinning because it avoids the transarticular pin. It offers the advantage of no donor site morbidity, decreased operative time, lower cost, and early motion. We favor hemihamate reconstruction in patients with greater than 50% of the articular surface involvement.19
9. Vitale MA, White NJ, Strauch RJ. A percutaneous technique to treate unstable dorsal fracture-dislocations of the proximal interphalangeal joint. J Hand Surg Am. 2011;36(9):1453e1459. 10. Ikeda M, Ishii T, Kobayashi Y, Mochida J, Saito I, Oka Y. Percutaneous pinning of the displaced volar plate avulsion fracture of the PIP joint. Hand Surg. 2009;14(2e3):113e119. 11. Cheah AE, Tan DM, Chong AK, Chew WY. Volar plating for unstable proximal interphalangeal joint fracture dislocations. J Hand Surg Am. 2012;37(1):28e33. 12. Ruland RT, Hogan CJ, Cannon DL, Slade JF. Use of dynamic distraction external fixation for unstable fracture-dislocations of the proximal interphalangeal joint. J Hand Surg Am. 2008;33(1):19e25. 13. Kubitskiy A, Soliman BA, Dowd MB, Curtin P. External fixation of the hand: a simple approach to comminuted proximal interphalangeal joint fractures. Hand Surg. 2014;19(1):85e89. 14. Afendras G, Abramo A, Mrkonjic A, Geijer M, Kopylov P, Tagil M. Hemi-hamate osteochondral transplantation in proximal interphalangeal dorsal fracture dislocations: a minimum 4 year follow-up in 8 patients. J Hand Surg Eur Vol. 2010;35(8):627e631. 15. Calfee RP, Keifhaber TR, Sommerkamp TG, Stern PJ. Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture-dislocations. J Hand Surg Am. 2009;34(7):1232e1241. 16. Yang DS, Lee SK, Kim KJ, Choy WS. Modified hemi-hamate arthroplasty technique for treatment of acute proximal interphalangeal joint fracture-dislocations. Ann Plast Surg. 2014;72(4):411e416. 17. Freuh FS, Calcagni M, Lindenblatt N. The hemi-hamate autograft arthroplasty in proximal interphalangeal joint reconstruction: a systematic review. J Hand Surg Eur Vol. 2015;40(1):24e32. 18. Capo JT, Hastings H II, Choung E, Kinchelow T, Rossy W, Steinberg B. Hemicondylar hamate replacement arthroplasty for proximal interphalangeal joint fracture dislocations: an assessment of graft suitability. J Hand Surg Am. 2008;33(5):733e739. 19. Tyser AR, Tsai MA, Parks BG, Means KR Jr. Biomechanical charateristics of hemi-hamate reconstruction versus volar plate arthroplasty in the treatment of dorsal fracture dislocations of the proximal interphalangeal joint. J Hand Surg Am. 2015;40(2):329e332.
REFERENCES 1. Calfee RP, Sommerkamp TG. Fracture-dislocation about the finger joints. J Hand Surg Am. 2009;34(6):1140e1147. 2. Hastings H II, Carroll C IV. Treatment of closed articular fractures of the metacarpophalangeal an proximal interphalangeal joints. Hand Clin. 1988;4(3):503e527. 3. Khouri JS, Bloom JM, Hammer WC. Current trends in the managment of proximal interphalangeal joint injuries of the hand. Plast Reconstr Surg. 2013;132(5):1192e1204. 4. Adams JE, Calfee RP, Vitale MA, Strauch RJ, Barron OA. Dorsal proximal interphalangeal joint fracture-dislocations: evaluation and treatment. Instr Course Lect. 2015;64:261e272. 5. Nilsson JA, Rosberg HE. Treatment of proximal interphalangeal joint fractures by the pins and rubbers traction system: a follow up. J Plast Surg Hand Surg. 2014;48(4):259e264. 6. Bear DM, Weichbrodt MT, Haung C, Hagberg WC, Balk ML. Unstable dorsal proximal interphalangeal joint fracture-dislocations treated with extension-block pinning. Am J Orthop. 2015;44(3): 122e126. 7. Waris E, Alanen V. Percutaneous, intermedullary fracture reduction and extension block pinning for dorsal proximal interphalangeal fracture-dislocations. J Hand Surg Am. 2010;35(12):2046e2052. 8. de Hasbeth KB, Neuhaus V, Mudgal CS. Dorsal fracture-dislocations of the proximal interphalangeal joint: evaluation of closed reduction and percutaneous Kirschner wire pinning. Hand (N Y). 2015;10(1): 88e93.
J Hand Surg Am.
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Vol. -, - 2015