- Email: [email protected]
The treatment of an osteochondral shearing fracture-dislocation of the head of the proximal phalanx: A case report
The Treatment of an Osteochondral Shearing FractureDislocation of the Head of the Proximal Phalanx: A Case Report Neil Harness, MD, Jesse B. Jupiter, MD, Boston, MA
We report the morphology and treatment of a proximal interphalangeal joint dislocation resulting in an injury to the articular surface of the proximal phalanx and avulsion of the radial collateral ligament from its proximal origin. A large osteochondral fragment was sheared from the radial articular surface of the proximal phalanx and remained displaced volarly after reduction of the joint. Plain radiographs and 2- and 3-dimensional computed tomography images were used to evaluate this unusual injury before surgery. Open reduction and internal fixation using a small K-wire and figure-of-eight wire technique restored the articular surface of the head of the proximal phalanx and gave a satisfactory functional result. (J Hand Surg 2004;29A:925–930. Copyright © 20042004 by the American Society for Surgery of the Hand.) Key words: Fracture, phalanx, interphalangeal, articular, osteochondral, fixation.
The treatment of osteochondral fractures involving the finger can be challenging. The fracture fragments are small and can be difficult to stabilize. This fracture does not represent the typical unicondylar fracture of the proximal phalanx1–3 but an osteochondral shearing injury to the articular surface. The 2 injuries are quite distinct in that the osteochondral fracture has a very thin layer of subchondral bone attached to the articular cartilage and is more difficult to treat than a standard unicondylar fracture. Many different
From the Harvard Combined Orthopaedic Residency, Harvard Medical School, and Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA. Received for publication February 16, 2004; accepted in revised form May 19, 2004. No benefits in any form have been received or will be received by a commercial party related directly or indirectly to the subject of this article. Reprint requests: Jesse B. Jupiter, MD, Dept of Orthopaedic Surgery, Massachusetts General Hospital, Hand and Upper Extremity Service, 15 Parkman St ACC 527, Boston, MA 02114. Copyright © 2004 by the American Society for Surgery of the Hand 0363-5023/04/29A05-0023$30.00/0 doi:10.1016/j.jhsa.2004.05.010
methods have been used with varying degrees of success.1,4 McElfresh and Dobyns4 advocated initially excision of osteochondral fragments in their series of 108 metacarpal head fractures (8 osteochondral fractures); however, most surgeons today advocate articular surface preservation. Intra-articular screws or K-wires, or both, can provide adequate fixation but may contribute to joint contracture.1,4 In an attempt to reduce the insult to the joint surface K-wires may be placed retrograde to just below the articular surface.5 In cases were very little subchondral bone is present, however, it may be necessary to transfix the joint with K-wires.6 To avoid the use of hardware altogether recent work has focused on the use of fibrin glue as a means of stabilizing small osteochondral fragments.2,7,8 Kumar and Satku6 reported recently on open reduction and stabilization of osteochondral fractures without fixation. They advocate accurate repair of the capsular rent and preservation of soft tissues to trap the fragment and allow early motion. The purpose of this report is to describe the morThe Journal of Hand Surgery
925
926
The Journal of Hand Surgery / Vol. 29A No. 5 September 2004
Figure 1. (A–C) Anteroposterior, lateral, and oblique radiographs show that the joint is reduced, with a small fragment volar to the PIP joint.
phology and treatment of an unusual proximal interphalangeal (PIP) joint dislocation with resultant osteochondral injury and radial collateral ligament avulsion that occurred in a young patient while wrestling. A unique fixation technique was used to maintain reduction of the small fragment using a single K-wire and a figure-of-eight wire loop.
Case Report A 14-year-old right-handed high school wrestler sustained an injury to his right small finger while in competition. While he was attempting to grasp his opponent’s foot his small finger, which was extended, was stepped on and twisted. He dislocated his small finger PIP joint and had a closed reduction in the emergency room. The joint was splinted for comfort. Physical examination the day after injury showed circumferential swelling about the PIP joint with limited motion secondary to pain. There was no rotational malalignment and the PIP joint was reduced. Anteroposterior, lateral, and oblique views of the finger showed that the joint was reduced. A small fragment was evident volar to the PIP joint (Fig. 1A–C). Two-dimensional images showed a radial articular defect. Three-dimensional computed tomography scans showed a small osteochondral defect with displacement of the fragment volarly (Fig. 2). The patient had open reduction and internal fixation via a dorsal approach. The extensor tendon was
left intact and the joint was approached radial to the lateral band. The joint was hinged open easily on the radial side because of avulsion of the radial collateral ligament. This showed that the dorsoradial portion of the articular surface had been sheared off and was sitting free in the volar aspect of the joint. The fragment consisted of articular cartilage with a very thin layer (⬍1 mm) of subchondral bone. The fragment made up approximately 50% of the articular surface of the head of the proximal phalanx. The radial metaphysis was uninvolved; however, the radial collateral ligament had been avulsed from its proximal origin. The fragment remained attached to a small amount of soft tissue associated with the radial collateral ligament (Fig. 3). The fragment was manipulated carefully leaving all soft tissue attachments in place and then reduced back to the radial articular defect. The fragment was held in place with a 0.7-mm (0.028-in) K-wire. A second 0.7-mm K-wire was then placed obliquely from distal/radial to proximal/ulnar through the articular piece near its edge (Fig. 4). A 28-gauge stainless steel wire was then wrapped around it in a figure of eight, preventing dorsal displacement of the fragment (Figs. 5, 6). The initial K-wire was then removed, leaving the second K-wire in place. The volar plate acted to prevent volar subluxation of the large articular fragment and the ulnar edge of the fragment keyed into the adjacent articular surface. A small
Harness and Jupiter / Phalangeal Osteochondral Fracture Fixation
927
Figure 3. The small osteochondral fragment (black arrow) is displaced and rotated but remains attached to a small amount of soft tissue distally. For orientation the white arrow is on the dorsal surface of the proximal phalanx.
Figure 2. A 3-dimensional computed tomography image shows a small osteochondral defect in the head of the proximal phalanx with the fragment displaced volarly.
drill hole was placed on the radial aspect of the proximal phalanx for reattachment of the radial collateral ligament with 4-0 polyglactin 910. The construct was stable, and intraoperative and postsurgical radiographs confirmed that the joint was reduced (Fig. 7A, B). The wires were cut short and sterile dressings were applied. The finger was immobilized for 2 weeks followed by unrestricted active motion. The K-wire was removed 4 weeks after surgery. The small finger was buddy strapped until 6 weeks after surgery. Thereafter, buddy straps were used for sports only. There were no postsurgical complications. Radiographs taken 3 months after surgery showed the fracture was well healed. There was no evidence of malalignment or avascular necrosis. The small 28-gauge wire remained in its original position without evidence of migration. Follow-up examination at 1 year showed a total active digital motion of 250° (Fig. 8A, B). The patient’s PIP motion was from 0° extension to 100° flexion. The PIP joint was stable to radial and ulnar
stress while fully extended and flexed to 90°. The small finger had a mild abduction deformity of 5° at the PIP joint, which did not result in any functional deficit. There was no rotational malalignment. The incision was well healed with a prominence over the radial aspect of the PIP joint. Grip strength as measured with a dynamometer (Jaymar, Asimov Engineering, Los Angeles, CA) was 41 kg on the injured (right) side and 38 kg on the uninjured side. Radiographs taken at the 1-year follow-up examination showed no evidence of avascular necrosis or posttraumatic arthritis. The overall alignment of the PIP joint appeared normal. There was no abnormal translation or rotation. The patient had occasional aching discomfort in the small finger PIP joint when writing but did not have any complaints of hardware prominence. He did
Figure 4. Dorsal view of the articular surface. A provisional K-wire (white arrow) was used to hold the fragment in place while a second K-wire (black arrow) was placed through the fragment near its edge.
928
The Journal of Hand Surgery / Vol. 29A No. 5 September 2004
Figure 5. Dorsal view of the articular surface. The fragment (white arrow) is held in place by a figure-of-eight tension band (black arrow). It was constructed using the second K-wire and a no. 28 – gauge stainless steel wire.
not return to wrestling but was able to snap the ball while playing center for his high school football team 7 months after the injury.
Discussion Osteochondral injuries to the digits, although rare, can have untoward consequences if not treated adequately. Osteochondral or chondral injuries may result from a prolonged force applied to a joint surface or from a sudden impact. Compressive forces applied to the joint surface may result in shearing stresses at the subchondral bone junction.2 During contact sports the PIP joint is particularly vulnerable to injury. It was found that ligament injuries are more common in wrestling, articular fractures in baseball, and fracture– dislocations in football.7 In some cases shearing fractures of the digits may occur in association with a collateral ligament injury.9 Cartilage defects in the articular surface may hasten the development of osteoarthritis.10 Although fibrocartilage may fill an osteochondral defect the joint surface will never display the original mechanical properties it once had.2 Although McElfresh and Dobyns4 advocated osteochondral fragment excision to prevent further damage to joint surfaces most surgeons today would favor reduction of these fragments with or without internal fixation.5,6,8,11,12 Traditional fixation techniques have used K-wires to either maintain the fragment reduced in a retrograde fashion or transfix the joint. If the fragment includes a small portion of the radial or ulnar metaphyseal bone a small screw may suffice; however, small central fragments are difficult to treat with these
techniques and may prevent early motion and lead to joint stiffness. To avoid problems associated with K-wires or intra-articular screws fibrin sealant has been used for fixation.8,11,12 Shah et al12 reported its use in 1 patient with a dorsoradial osteochondral defect in the head of the proximal phalanx. The fibrin sealant (Tisseel, Hemaseel, Haemacure Corp, Sarasota, FL) provided adequate fixation strength to allow early motion and healing by 3 months. Sugimoto8 reported on 15 patients with osteochondral injuries involving the digits, which were repaired with fibrin sealant. These cases included injuries to the distal interphalangeal joint, PIP joint, metacarpophalangeal joint, and carpometacarpal joints. Seven cases required supplemental K-wire fixation to maintain reduction. All of the osteochondral fractures healed by 3 to 6 weeks. Three patients had significant stiffness and 9 had excellent motion. Disadvantages of fibrin sealant include the need to prepare the solution 40 minutes before use to allow time for thrombin to cleave fibrinogen, the potential for hypersensitivity reactions in patients with an allergy to bovine protein, and the possibility of viral transmission (HIV, syphilis, hepatitis A and C) because fibrinogen and thrombin are harvested from pooled human plasma.12 We were able to characterize this unusual PIP
Figure 6. An illustration of the technique used to stabilize the large osteochondral fragment.
Harness and Jupiter / Phalangeal Osteochondral Fracture Fixation
929
Figure 7. (A,B) Postsurgical radiographs confirmed that the joint was reduced.
fracture dislocation with both plain radiographs and computed tomography. Three-dimensional computed tomography reconstructions were valuable in deter-
mining the location and extent of the osseous defect but underestimated the amount of articular surface involved.
Figure 8. (A,B) Clinical photos taken at the 9-month follow-up examination show full range of motion.
930
The Journal of Hand Surgery / Vol. 29A No. 5 September 2004
A satisfactory result was achieved with open reduction and internal fixation through a dorsal open approach. A K-wire and figure-of-eight wiring technique was used to stabilize the small fragment. Care was taken to maintain soft tissue attachments to the fragment to reduce the risk of avascular necrosis. Early range of motion (2 weeks) may have helped reduce the risk of capsular and extensor tendon scarring. The K-wire maintained the reduction of the fragment and was removed at 4 weeks after an adequate period of time for healing. Small osteochondral injuries involving the interphalangeal joints of the finger may be characterized accurately with plain radiographs and computed tomography images including 3-dimensional reconstructions. In addition they may be treated successfully without resultant osteonecrosis, contracture, or significant malalignment with the use of a small K-wire and figure-of-eight tension band technique.
References 1. Becton JL, Christian JD, Goodwin N, Jacson JG. A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg 1975; 57A:698 –700. 2. Buckwalter JA, Mow VC, Ratcliffe A. Restoration of injured or degenerated articular cartilage. J Am Acad Orthop Surg 1994;4(2):192–201.
3. Weiss A-PC, Hastings HI. Distal unicondylar fractures of the proximal phalanx. J Hand Surg 1993;18A:594 –599. 4. McElfresh EC, Dobyns JH. Intra-articular metacarpal head fractures. J Hand Surg 1983;8:383–393. 5. Stern P. Fractures of the metacarpals and phalanges. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery. New York: Churchill Livingstone, 1999:711–771. 6. Kumar VP, Satku K. Surgical management of osteochondral fractures of the phalanges and metacarpals: a surgical technique. J Hand Surg 1995;20:1028 –1031. 7. McCue FC, Honner R, Johnson MC, Gieck JH. Athletic injuries of the proximal interphalangeal joint requiring surgical treatment. J Bone Joint Surg 1970:52A:937–956. 8. Sugimoto Y. Basic and clinical studies on osteochondral fragment fixation using fibrin adhesive system (FAS) in cases of fracture. Nippon Seikeigeka Gakkai Zasshi—Journal of the Japanese Orthopaedic Association 1985;59(12): 1059 –1072. 9. Stener B. Skeletal injuries associated with rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Bone Joint Surg 1964;46B:361–365. 10. Mankin H, Mow V, Buckwalter J. Articular cartilage repair and osteoarthritis. In: Buckwalter JA, Einhorn TA, Simon SR, eds. Orthopaedic basic science. Chicago: American Academy of Orthopaedic Surgeons, 2000:472– 488. 11. Kaplonyi G, Zimerman I, Frenyo AD, Farkas T, Nemes G. The use of fibrin adhesive in the repair of chondral and osteochondral injuries. Injury 1988;19:267–272. 12. Shah MA, Ebert AM, Sanders WE. Fibrin glue fixation of a digital osteochondral fracture: case report and review of the literature. J Hand Surg 2002;27A:464 – 469.
We report the morphology and treatment of a proximal interphalangeal joint dislocation resulting in an injury to the articular surface of the proximal phalanx and avulsion of the radial collateral ligament from its proximal origin. A large osteochondral fragment was sheared from the radial articular surface of the proximal phalanx and remained displaced volarly after reduction of the joint. Plain radiographs and 2- and 3-dimensional computed tomography images were used to evaluate this unusual injury before surgery. Open reduction and internal fixation using a small K-wire and figure-of-eight wire technique restored the articular surface of the head of the proximal phalanx and gave a satisfactory functional result. (J Hand Surg 2004;29A:925–930. Copyright © 20042004 by the American Society for Surgery of the Hand.) Key words: Fracture, phalanx, interphalangeal, articular, osteochondral, fixation.
The treatment of osteochondral fractures involving the finger can be challenging. The fracture fragments are small and can be difficult to stabilize. This fracture does not represent the typical unicondylar fracture of the proximal phalanx1–3 but an osteochondral shearing injury to the articular surface. The 2 injuries are quite distinct in that the osteochondral fracture has a very thin layer of subchondral bone attached to the articular cartilage and is more difficult to treat than a standard unicondylar fracture. Many different
From the Harvard Combined Orthopaedic Residency, Harvard Medical School, and Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA. Received for publication February 16, 2004; accepted in revised form May 19, 2004. No benefits in any form have been received or will be received by a commercial party related directly or indirectly to the subject of this article. Reprint requests: Jesse B. Jupiter, MD, Dept of Orthopaedic Surgery, Massachusetts General Hospital, Hand and Upper Extremity Service, 15 Parkman St ACC 527, Boston, MA 02114. Copyright © 2004 by the American Society for Surgery of the Hand 0363-5023/04/29A05-0023$30.00/0 doi:10.1016/j.jhsa.2004.05.010
methods have been used with varying degrees of success.1,4 McElfresh and Dobyns4 advocated initially excision of osteochondral fragments in their series of 108 metacarpal head fractures (8 osteochondral fractures); however, most surgeons today advocate articular surface preservation. Intra-articular screws or K-wires, or both, can provide adequate fixation but may contribute to joint contracture.1,4 In an attempt to reduce the insult to the joint surface K-wires may be placed retrograde to just below the articular surface.5 In cases were very little subchondral bone is present, however, it may be necessary to transfix the joint with K-wires.6 To avoid the use of hardware altogether recent work has focused on the use of fibrin glue as a means of stabilizing small osteochondral fragments.2,7,8 Kumar and Satku6 reported recently on open reduction and stabilization of osteochondral fractures without fixation. They advocate accurate repair of the capsular rent and preservation of soft tissues to trap the fragment and allow early motion. The purpose of this report is to describe the morThe Journal of Hand Surgery
925
926
The Journal of Hand Surgery / Vol. 29A No. 5 September 2004
Figure 1. (A–C) Anteroposterior, lateral, and oblique radiographs show that the joint is reduced, with a small fragment volar to the PIP joint.
phology and treatment of an unusual proximal interphalangeal (PIP) joint dislocation with resultant osteochondral injury and radial collateral ligament avulsion that occurred in a young patient while wrestling. A unique fixation technique was used to maintain reduction of the small fragment using a single K-wire and a figure-of-eight wire loop.
Case Report A 14-year-old right-handed high school wrestler sustained an injury to his right small finger while in competition. While he was attempting to grasp his opponent’s foot his small finger, which was extended, was stepped on and twisted. He dislocated his small finger PIP joint and had a closed reduction in the emergency room. The joint was splinted for comfort. Physical examination the day after injury showed circumferential swelling about the PIP joint with limited motion secondary to pain. There was no rotational malalignment and the PIP joint was reduced. Anteroposterior, lateral, and oblique views of the finger showed that the joint was reduced. A small fragment was evident volar to the PIP joint (Fig. 1A–C). Two-dimensional images showed a radial articular defect. Three-dimensional computed tomography scans showed a small osteochondral defect with displacement of the fragment volarly (Fig. 2). The patient had open reduction and internal fixation via a dorsal approach. The extensor tendon was
left intact and the joint was approached radial to the lateral band. The joint was hinged open easily on the radial side because of avulsion of the radial collateral ligament. This showed that the dorsoradial portion of the articular surface had been sheared off and was sitting free in the volar aspect of the joint. The fragment consisted of articular cartilage with a very thin layer (⬍1 mm) of subchondral bone. The fragment made up approximately 50% of the articular surface of the head of the proximal phalanx. The radial metaphysis was uninvolved; however, the radial collateral ligament had been avulsed from its proximal origin. The fragment remained attached to a small amount of soft tissue associated with the radial collateral ligament (Fig. 3). The fragment was manipulated carefully leaving all soft tissue attachments in place and then reduced back to the radial articular defect. The fragment was held in place with a 0.7-mm (0.028-in) K-wire. A second 0.7-mm K-wire was then placed obliquely from distal/radial to proximal/ulnar through the articular piece near its edge (Fig. 4). A 28-gauge stainless steel wire was then wrapped around it in a figure of eight, preventing dorsal displacement of the fragment (Figs. 5, 6). The initial K-wire was then removed, leaving the second K-wire in place. The volar plate acted to prevent volar subluxation of the large articular fragment and the ulnar edge of the fragment keyed into the adjacent articular surface. A small
Harness and Jupiter / Phalangeal Osteochondral Fracture Fixation
927
Figure 3. The small osteochondral fragment (black arrow) is displaced and rotated but remains attached to a small amount of soft tissue distally. For orientation the white arrow is on the dorsal surface of the proximal phalanx.
Figure 2. A 3-dimensional computed tomography image shows a small osteochondral defect in the head of the proximal phalanx with the fragment displaced volarly.
drill hole was placed on the radial aspect of the proximal phalanx for reattachment of the radial collateral ligament with 4-0 polyglactin 910. The construct was stable, and intraoperative and postsurgical radiographs confirmed that the joint was reduced (Fig. 7A, B). The wires were cut short and sterile dressings were applied. The finger was immobilized for 2 weeks followed by unrestricted active motion. The K-wire was removed 4 weeks after surgery. The small finger was buddy strapped until 6 weeks after surgery. Thereafter, buddy straps were used for sports only. There were no postsurgical complications. Radiographs taken 3 months after surgery showed the fracture was well healed. There was no evidence of malalignment or avascular necrosis. The small 28-gauge wire remained in its original position without evidence of migration. Follow-up examination at 1 year showed a total active digital motion of 250° (Fig. 8A, B). The patient’s PIP motion was from 0° extension to 100° flexion. The PIP joint was stable to radial and ulnar
stress while fully extended and flexed to 90°. The small finger had a mild abduction deformity of 5° at the PIP joint, which did not result in any functional deficit. There was no rotational malalignment. The incision was well healed with a prominence over the radial aspect of the PIP joint. Grip strength as measured with a dynamometer (Jaymar, Asimov Engineering, Los Angeles, CA) was 41 kg on the injured (right) side and 38 kg on the uninjured side. Radiographs taken at the 1-year follow-up examination showed no evidence of avascular necrosis or posttraumatic arthritis. The overall alignment of the PIP joint appeared normal. There was no abnormal translation or rotation. The patient had occasional aching discomfort in the small finger PIP joint when writing but did not have any complaints of hardware prominence. He did
Figure 4. Dorsal view of the articular surface. A provisional K-wire (white arrow) was used to hold the fragment in place while a second K-wire (black arrow) was placed through the fragment near its edge.
928
The Journal of Hand Surgery / Vol. 29A No. 5 September 2004
Figure 5. Dorsal view of the articular surface. The fragment (white arrow) is held in place by a figure-of-eight tension band (black arrow). It was constructed using the second K-wire and a no. 28 – gauge stainless steel wire.
not return to wrestling but was able to snap the ball while playing center for his high school football team 7 months after the injury.
Discussion Osteochondral injuries to the digits, although rare, can have untoward consequences if not treated adequately. Osteochondral or chondral injuries may result from a prolonged force applied to a joint surface or from a sudden impact. Compressive forces applied to the joint surface may result in shearing stresses at the subchondral bone junction.2 During contact sports the PIP joint is particularly vulnerable to injury. It was found that ligament injuries are more common in wrestling, articular fractures in baseball, and fracture– dislocations in football.7 In some cases shearing fractures of the digits may occur in association with a collateral ligament injury.9 Cartilage defects in the articular surface may hasten the development of osteoarthritis.10 Although fibrocartilage may fill an osteochondral defect the joint surface will never display the original mechanical properties it once had.2 Although McElfresh and Dobyns4 advocated osteochondral fragment excision to prevent further damage to joint surfaces most surgeons today would favor reduction of these fragments with or without internal fixation.5,6,8,11,12 Traditional fixation techniques have used K-wires to either maintain the fragment reduced in a retrograde fashion or transfix the joint. If the fragment includes a small portion of the radial or ulnar metaphyseal bone a small screw may suffice; however, small central fragments are difficult to treat with these
techniques and may prevent early motion and lead to joint stiffness. To avoid problems associated with K-wires or intra-articular screws fibrin sealant has been used for fixation.8,11,12 Shah et al12 reported its use in 1 patient with a dorsoradial osteochondral defect in the head of the proximal phalanx. The fibrin sealant (Tisseel, Hemaseel, Haemacure Corp, Sarasota, FL) provided adequate fixation strength to allow early motion and healing by 3 months. Sugimoto8 reported on 15 patients with osteochondral injuries involving the digits, which were repaired with fibrin sealant. These cases included injuries to the distal interphalangeal joint, PIP joint, metacarpophalangeal joint, and carpometacarpal joints. Seven cases required supplemental K-wire fixation to maintain reduction. All of the osteochondral fractures healed by 3 to 6 weeks. Three patients had significant stiffness and 9 had excellent motion. Disadvantages of fibrin sealant include the need to prepare the solution 40 minutes before use to allow time for thrombin to cleave fibrinogen, the potential for hypersensitivity reactions in patients with an allergy to bovine protein, and the possibility of viral transmission (HIV, syphilis, hepatitis A and C) because fibrinogen and thrombin are harvested from pooled human plasma.12 We were able to characterize this unusual PIP
Figure 6. An illustration of the technique used to stabilize the large osteochondral fragment.
Harness and Jupiter / Phalangeal Osteochondral Fracture Fixation
929
Figure 7. (A,B) Postsurgical radiographs confirmed that the joint was reduced.
fracture dislocation with both plain radiographs and computed tomography. Three-dimensional computed tomography reconstructions were valuable in deter-
mining the location and extent of the osseous defect but underestimated the amount of articular surface involved.
Figure 8. (A,B) Clinical photos taken at the 9-month follow-up examination show full range of motion.
930
The Journal of Hand Surgery / Vol. 29A No. 5 September 2004
A satisfactory result was achieved with open reduction and internal fixation through a dorsal open approach. A K-wire and figure-of-eight wiring technique was used to stabilize the small fragment. Care was taken to maintain soft tissue attachments to the fragment to reduce the risk of avascular necrosis. Early range of motion (2 weeks) may have helped reduce the risk of capsular and extensor tendon scarring. The K-wire maintained the reduction of the fragment and was removed at 4 weeks after an adequate period of time for healing. Small osteochondral injuries involving the interphalangeal joints of the finger may be characterized accurately with plain radiographs and computed tomography images including 3-dimensional reconstructions. In addition they may be treated successfully without resultant osteonecrosis, contracture, or significant malalignment with the use of a small K-wire and figure-of-eight tension band technique.
References 1. Becton JL, Christian JD, Goodwin N, Jacson JG. A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg 1975; 57A:698 –700. 2. Buckwalter JA, Mow VC, Ratcliffe A. Restoration of injured or degenerated articular cartilage. J Am Acad Orthop Surg 1994;4(2):192–201.
3. Weiss A-PC, Hastings HI. Distal unicondylar fractures of the proximal phalanx. J Hand Surg 1993;18A:594 –599. 4. McElfresh EC, Dobyns JH. Intra-articular metacarpal head fractures. J Hand Surg 1983;8:383–393. 5. Stern P. Fractures of the metacarpals and phalanges. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery. New York: Churchill Livingstone, 1999:711–771. 6. Kumar VP, Satku K. Surgical management of osteochondral fractures of the phalanges and metacarpals: a surgical technique. J Hand Surg 1995;20:1028 –1031. 7. McCue FC, Honner R, Johnson MC, Gieck JH. Athletic injuries of the proximal interphalangeal joint requiring surgical treatment. J Bone Joint Surg 1970:52A:937–956. 8. Sugimoto Y. Basic and clinical studies on osteochondral fragment fixation using fibrin adhesive system (FAS) in cases of fracture. Nippon Seikeigeka Gakkai Zasshi—Journal of the Japanese Orthopaedic Association 1985;59(12): 1059 –1072. 9. Stener B. Skeletal injuries associated with rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Bone Joint Surg 1964;46B:361–365. 10. Mankin H, Mow V, Buckwalter J. Articular cartilage repair and osteoarthritis. In: Buckwalter JA, Einhorn TA, Simon SR, eds. Orthopaedic basic science. Chicago: American Academy of Orthopaedic Surgeons, 2000:472– 488. 11. Kaplonyi G, Zimerman I, Frenyo AD, Farkas T, Nemes G. The use of fibrin adhesive in the repair of chondral and osteochondral injuries. Injury 1988;19:267–272. 12. Shah MA, Ebert AM, Sanders WE. Fibrin glue fixation of a digital osteochondral fracture: case report and review of the literature. J Hand Surg 2002;27A:464 – 469.