- Email: [email protected]
Irreducible palmar dislocation of the distal interphalangeal joint of the finger
Irreducible palmar dislocation of the distal interphalangeal joint of the finger A case of irreducible palmar dislocation of the distal interphalangeal (DIP) joint is reported. The cause of irreducibility was an entrapment of the extensor tendon in front of the head of the middle phalanx. (J HAND SURG 1987;12A:I077-9.)
Goro Inoue, M.D ., and Noboru Maeda, M.D., Nagoya, Japan
Dislocation at the distal interphalangeal (DIP) joint is usually reducible by simple traction. A few cases of irreducible dorsal dislocations of the DIP joint have been described, but to our knowledge, no cases of irreducible palmar dislocations of the DIP joint have been reported. In our patient an entrapment of the extensor tendon in front of the head of the middle phalanx caused irreducible dislocation of the DIP joint.
Case report A 50-year-old woman sustained a rotation injury to her left long finger when her glove was caught by a weaving machine at work. At a nearby clinic she was diagnosed as having a mallet finger and was referred to our hospital. Examination showed slight swelling and deformity of the DIP joint and marked swelling of the proximal interphalangeal (PIP) joint. The patient was unable to extend the DIP joint but was able to flex it. Neurovascular status of the finger was intact. X-ray films revealed palmar dislocation of the DIP joint without evidence of bone injury (Fig. I) . Closed reduction was attempted with digital block anesthesia, but this was unsuccessful. Open reduction was done through a curved longitudinal incision on the dorsal aspect of the finger. The head of the middle phalanx was found to have been driven dorsally through the extensor mechanism between its lateral extensor tendons , which were stripped from the middle phalanx. The extensor mechanism, the distal pha-
From the Department of Orthopaedic Surgery, Division of Hand Surgery, Nagoya University, School of Medicine, Nagoya, Japan. Received for publication March 2, 1987; accepted in revised form April 16, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint request: Goro Inoue, M.D., Instructor in Orthopaedics , Department of Orthopaedic Surgery, Division of Hand Surgery, Nagoya University, School of Medicine, 1-1-20 Daiko-minami , Higashi-ku, Nagoya 461, Japan.
Fig. 1. X-ray film showing palmar dislocation of the DIP joint. Note the marked swelling of the PIP joint.
langeal insertion of which remained intact, was displaced downwards under the middle phalanx, thus preventing reduction (Fig. 2, A). At the PIP joint, the arciform fibers were tom so that the two lateral extensor tendons were displaced volarly (Fig. 2, B). The palmar plate , as well as the radial and ulnar collateral ligaments of the DIP joint, were disrupted. Reduction was easily accomplished by using a hook to pull out the extensor mechanism in front of the middle phalanx with the PIP joint in flexion (Fig . 2, C) . Both collateral ligaments were repaired. The finger was splinted in the functional position of semi flexion for 2 weeks before exercises were started . One year postoperatively, the patient had an active range of motion (ROM) of 10° to 95° of flexion of the PIP joint and 5° to 25° of flexion of the DIP joint. X-ray films showed that there was no narrowing of the joint space.
Discussion Because of the stability of the DIP joint provided by the flexor and extensor tendons , strong collateral ligaments, short lever arm , and the snug fit of the skin, dislocations of the DIP joint are uncommon. There are THE JOURNAL OF HAND SURGERY
1077
1078
The Journal of HAND SURGERY
Inoue and Maeda
Fig. 2. A, Axial view of palmar dislocation of the DIP joint with complete disruption of both collateral ligaments and the palmar plate. Note the intact extensor terminal tendon in front of the head of the middle phalanx. B, Instrument holds both lateral extensor tendons. which have displaced downwards. C, Appearance after reduction of the dislocation shows normal configurations of the extensor mechanism.
a few case reports in the literature that describe irreducible dorsal dislocations of the DIP joint. Four causes of irreducibility have been described as follows: (1) entrapment of the flexor tendon,1.5 (2) palmar plate interposition,5-7 (3) a buttonhole tear in the palmar plate,S and (4) a displaced intra-articular osteochondral fracture. 9 Irreducible palmar dislocation of the DIP joint has not been previously described, although Zielinski lO reported one case of the irreducible palmar fracturedislocation of the DIP joint. In most cases palmar dislocation of the DIP joint is reducible by simple traction because the extensor tendons and the collateral ligaments and palmar plate are usually avulsed. The mechanism of injury of this case is not clear, but it probably involved the following combination of forces: (1) a flexion force to the PIP joint, which pro-
duced a rupture of the arciform fiber, permitting the lateral extensor tendons to displace downwards, and (2) a rotation force to the DIP joint, which produced a stripping of the extensor mechanism from the middle phalanx, and rupture of the collateral ligaments and palmar plate, permitting the head of the middle phalanx to drive dorsally through the extensor mechanism between its lateral extensor tendons.
REFERENCES I. Pohl AL. Irreducible dislocation of a distal interphalangeal joint. Br J Plast Surg 1976;29:227-9. 2. Rayan GM, Elias LS. Irreducible dislocation of the distal interphalangeal joint caused by long flexor tendon entrapment. Orthopedics 1981 ;4:35-7. 3. Iftikhar TB. Long flexor tendon entrapment causing open
Vol. 12A, No.6 November 1987
4. 5.
6.
7.
irreducible dorsoradial dislocation of distal interphalangeal joint of the finger. Orthop Rev 1982;11:117-9. Murakami Y. Irreducible dislocation of the distal interphalangeal joint. J HAND SURG 1985;IOB:231-2. Salamon PB, Gelberman RH. Irreducible dislocation of the interphalangeal joint of the thumb. J Bone Joint Surg [Am] 1978;60:400-1. Palmer AK, Linscheid RL. Irreducible dorsal dislocation of the distal interphalangeal joint of the finger. J HAND SURG 1977;2:406-8. Phillips lH. Irreducible dislocation of a distal interpha-
Irreducible palmar dislocation of DIP joint
langeal joint: Case report and review of literature. Clin Orthop 1981;154:188-90. 8. Selig S, Schein A. Irreducible buttonhole dislocations of the fingers. J Bone Joint Surg [Am] 1940;22:436-41. 9. Stripling WD. Displaced intra-articular osteochondral fracture: Cause for irreducible dislocation of the distal interphalangeal joint. J HAND SURG 1982;7:77-8. 10. Zielinski CJ. Irreducible fracture-dislocation of the distal interphalangeal joint: A case report. J Bone Joint Surg [Am] 1983;65: 109-10.
Sub condylar fossa reconstruction for malunion of fractures of the proximal phalanx in children Subcondylar fractures of the proximal or middle phalanx occur at the neck of the phalanx, usually as a result of a crush injury, and almost exclusively in the pediatric age group. The distal fragment rotates dorsally and the degree of displacement may be misjudged if a true lateral radiograph is not obtained. If malunion occurs, there is a block to flexion. Subcondylar fossa reconstruction by removal of bone through a palmar approach removes this bony block. Three patients are presented in whom this procedure allowed an average increase in flexion of 41. 7°. (J HAND SURG 1987;12A:I079-82.)
Barry P. Simmons, M.D., and Theodore T. Peters, M.D., Boston, Mass. and Tulsa, Okla.
S
ubcondylar fractures of the proximal and middle phalanges are relatively uncommon and are seen almost exclusively in children (Fig. 1). Dixon and Moon l reported five cases, Leonard and Dubravcik2 reported 38 cases, and Barton3 found 20 cases in a series of 203 children with phalangeal fractures. A crushing From the Department of Orthopedic Surgery, Harvard Medical School, and the Department of Orthopedic Surgery, Children's Hospital Medical Center, Brigham and Women's Hospital, Boston, Mass. Received for publication Nov. 19, 1986; accepted in revised form April 16, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Barry P. Simmons, M.D., Department of Orthopedic Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.
Fig. I. A typical subcondylar or phalangeal neck fracture of the proximal phalanx is seen on this true lateral x-ray film. Note that the condyles are rotated dorsally. This displacement and subsequent new bone formation will block flexion unless proper reduction is achieved.
THE JOURNAL OF HAND SURGERY
1079
Goro Inoue, M.D ., and Noboru Maeda, M.D., Nagoya, Japan
Dislocation at the distal interphalangeal (DIP) joint is usually reducible by simple traction. A few cases of irreducible dorsal dislocations of the DIP joint have been described, but to our knowledge, no cases of irreducible palmar dislocations of the DIP joint have been reported. In our patient an entrapment of the extensor tendon in front of the head of the middle phalanx caused irreducible dislocation of the DIP joint.
Case report A 50-year-old woman sustained a rotation injury to her left long finger when her glove was caught by a weaving machine at work. At a nearby clinic she was diagnosed as having a mallet finger and was referred to our hospital. Examination showed slight swelling and deformity of the DIP joint and marked swelling of the proximal interphalangeal (PIP) joint. The patient was unable to extend the DIP joint but was able to flex it. Neurovascular status of the finger was intact. X-ray films revealed palmar dislocation of the DIP joint without evidence of bone injury (Fig. I) . Closed reduction was attempted with digital block anesthesia, but this was unsuccessful. Open reduction was done through a curved longitudinal incision on the dorsal aspect of the finger. The head of the middle phalanx was found to have been driven dorsally through the extensor mechanism between its lateral extensor tendons , which were stripped from the middle phalanx. The extensor mechanism, the distal pha-
From the Department of Orthopaedic Surgery, Division of Hand Surgery, Nagoya University, School of Medicine, Nagoya, Japan. Received for publication March 2, 1987; accepted in revised form April 16, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint request: Goro Inoue, M.D., Instructor in Orthopaedics , Department of Orthopaedic Surgery, Division of Hand Surgery, Nagoya University, School of Medicine, 1-1-20 Daiko-minami , Higashi-ku, Nagoya 461, Japan.
Fig. 1. X-ray film showing palmar dislocation of the DIP joint. Note the marked swelling of the PIP joint.
langeal insertion of which remained intact, was displaced downwards under the middle phalanx, thus preventing reduction (Fig. 2, A). At the PIP joint, the arciform fibers were tom so that the two lateral extensor tendons were displaced volarly (Fig. 2, B). The palmar plate , as well as the radial and ulnar collateral ligaments of the DIP joint, were disrupted. Reduction was easily accomplished by using a hook to pull out the extensor mechanism in front of the middle phalanx with the PIP joint in flexion (Fig . 2, C) . Both collateral ligaments were repaired. The finger was splinted in the functional position of semi flexion for 2 weeks before exercises were started . One year postoperatively, the patient had an active range of motion (ROM) of 10° to 95° of flexion of the PIP joint and 5° to 25° of flexion of the DIP joint. X-ray films showed that there was no narrowing of the joint space.
Discussion Because of the stability of the DIP joint provided by the flexor and extensor tendons , strong collateral ligaments, short lever arm , and the snug fit of the skin, dislocations of the DIP joint are uncommon. There are THE JOURNAL OF HAND SURGERY
1077
1078
The Journal of HAND SURGERY
Inoue and Maeda
Fig. 2. A, Axial view of palmar dislocation of the DIP joint with complete disruption of both collateral ligaments and the palmar plate. Note the intact extensor terminal tendon in front of the head of the middle phalanx. B, Instrument holds both lateral extensor tendons. which have displaced downwards. C, Appearance after reduction of the dislocation shows normal configurations of the extensor mechanism.
a few case reports in the literature that describe irreducible dorsal dislocations of the DIP joint. Four causes of irreducibility have been described as follows: (1) entrapment of the flexor tendon,1.5 (2) palmar plate interposition,5-7 (3) a buttonhole tear in the palmar plate,S and (4) a displaced intra-articular osteochondral fracture. 9 Irreducible palmar dislocation of the DIP joint has not been previously described, although Zielinski lO reported one case of the irreducible palmar fracturedislocation of the DIP joint. In most cases palmar dislocation of the DIP joint is reducible by simple traction because the extensor tendons and the collateral ligaments and palmar plate are usually avulsed. The mechanism of injury of this case is not clear, but it probably involved the following combination of forces: (1) a flexion force to the PIP joint, which pro-
duced a rupture of the arciform fiber, permitting the lateral extensor tendons to displace downwards, and (2) a rotation force to the DIP joint, which produced a stripping of the extensor mechanism from the middle phalanx, and rupture of the collateral ligaments and palmar plate, permitting the head of the middle phalanx to drive dorsally through the extensor mechanism between its lateral extensor tendons.
REFERENCES I. Pohl AL. Irreducible dislocation of a distal interphalangeal joint. Br J Plast Surg 1976;29:227-9. 2. Rayan GM, Elias LS. Irreducible dislocation of the distal interphalangeal joint caused by long flexor tendon entrapment. Orthopedics 1981 ;4:35-7. 3. Iftikhar TB. Long flexor tendon entrapment causing open
Vol. 12A, No.6 November 1987
4. 5.
6.
7.
irreducible dorsoradial dislocation of distal interphalangeal joint of the finger. Orthop Rev 1982;11:117-9. Murakami Y. Irreducible dislocation of the distal interphalangeal joint. J HAND SURG 1985;IOB:231-2. Salamon PB, Gelberman RH. Irreducible dislocation of the interphalangeal joint of the thumb. J Bone Joint Surg [Am] 1978;60:400-1. Palmer AK, Linscheid RL. Irreducible dorsal dislocation of the distal interphalangeal joint of the finger. J HAND SURG 1977;2:406-8. Phillips lH. Irreducible dislocation of a distal interpha-
Irreducible palmar dislocation of DIP joint
langeal joint: Case report and review of literature. Clin Orthop 1981;154:188-90. 8. Selig S, Schein A. Irreducible buttonhole dislocations of the fingers. J Bone Joint Surg [Am] 1940;22:436-41. 9. Stripling WD. Displaced intra-articular osteochondral fracture: Cause for irreducible dislocation of the distal interphalangeal joint. J HAND SURG 1982;7:77-8. 10. Zielinski CJ. Irreducible fracture-dislocation of the distal interphalangeal joint: A case report. J Bone Joint Surg [Am] 1983;65: 109-10.
Sub condylar fossa reconstruction for malunion of fractures of the proximal phalanx in children Subcondylar fractures of the proximal or middle phalanx occur at the neck of the phalanx, usually as a result of a crush injury, and almost exclusively in the pediatric age group. The distal fragment rotates dorsally and the degree of displacement may be misjudged if a true lateral radiograph is not obtained. If malunion occurs, there is a block to flexion. Subcondylar fossa reconstruction by removal of bone through a palmar approach removes this bony block. Three patients are presented in whom this procedure allowed an average increase in flexion of 41. 7°. (J HAND SURG 1987;12A:I079-82.)
Barry P. Simmons, M.D., and Theodore T. Peters, M.D., Boston, Mass. and Tulsa, Okla.
S
ubcondylar fractures of the proximal and middle phalanges are relatively uncommon and are seen almost exclusively in children (Fig. 1). Dixon and Moon l reported five cases, Leonard and Dubravcik2 reported 38 cases, and Barton3 found 20 cases in a series of 203 children with phalangeal fractures. A crushing From the Department of Orthopedic Surgery, Harvard Medical School, and the Department of Orthopedic Surgery, Children's Hospital Medical Center, Brigham and Women's Hospital, Boston, Mass. Received for publication Nov. 19, 1986; accepted in revised form April 16, 1987. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Barry P. Simmons, M.D., Department of Orthopedic Surgery, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.
Fig. I. A typical subcondylar or phalangeal neck fracture of the proximal phalanx is seen on this true lateral x-ray film. Note that the condyles are rotated dorsally. This displacement and subsequent new bone formation will block flexion unless proper reduction is achieved.
THE JOURNAL OF HAND SURGERY
1079