Volar Base Fracture Dislocation of middle phalanx at the PIP

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Volar Base Fracture Dislocation of middle phalanx
at the PIP

• R2???

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Anatomy
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• Volar plate
• the strongest ligament
• connects the proximal phalanx to the middle
  phalanx on the palm side of the joint
• tightens as the joint is straightened and keeps
  the joint from hyperextending

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• Collateral ligament
• on each side of the PIP joint
• tighten when the joint is bent sideways and keep
  the joint stable from side to side

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Volar base fracture

• Unstable in relation to the percentage of
  articular surface involved

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Nonsurgical treatment

• Dynamic extension block splint
• lt 40 articular surface
• Beginning as flexed as 60 degrees
• Advancement of 10 ?/week for a total of 5 weeks
• ?PIP ROM 87 ?

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ORIF

• Volar fragment gt 40 of the joint surface
• Extension block pinning
• Volar plate arthroplasty
• Osteochondral reconstruction

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Eaton volar plate

• Pull-out suture and tied over a dorsal button

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Pilon fracture

• R3 ???

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Pilon fracture

• Involve complete articular surface of the base of
  P2 ( middle phalanx)
• Combined with metaphyseal compaction and bone
  loss
• Usually comminuted
• Highly unstable in every direction.

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Complication

• Stiffness with arcs of motion around 80 degrees

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Treatment

• Splinting
• Dynamic traction
• CRIF
• ORIF

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Dynamic traction

• Principle establish a foundation at the center
  of rotation in the head of P1
• Traction along the axis of P2 to hold the
  metaphyseal component of the fracture out to
  length.
• Allowing early motion to remodel the articular
  surface

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• Passive motion ? Active motion
• Active motion with the device in place
• ?Checked with fluoroscopy
• ?Congruent motion rather than hinge motion at the
  PIP joint
• ?Digital block

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• 14 pts, 2.5 yrs f/u Dynamic traction with pins
  and rubber bands
• ?PIP motion 74 degrees
• total active motion 196 degrees
• 8 pts Dynamic fixation with wires but not
  elasticity
• ?Final average motion 12 to 88 degrees
  following wire removal at 6 weeks
• 19 of 20 pts Dorsal spring mechanism
• Subjectively satisfied
• TAM 226 degrees
• Best results when the patients begin treatment
  acutely.

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Dynamic traction v.s. ORIF v.s. Splinting

• The results
• - 70- to 80-degree arc of motion
• - quality of articular surface restoration
• similar between dynamic traction and ORIF .
• Less complications with traction.

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Open Reduction with Internal and External
Fixation

• (1)Significant metaphyseal bone loss
• (2)Articular fragments at the base of P2 do
  not reduce sufficiently with traction alone
• small incision for cancellous bone graft
• fill the metaphyseal void and supporting a
  reduction of the articular fragments
• Transverse 0.035-inch K-wires
• ?placed at the subchondral level
• ?maintain the articular relationships
• The fracture must then be reduced at the
  metaphyseal level
• Stabilization sufficient to withstand the rigors
  of early motion.

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Authors preference

• Unilateral hinged external fixator with a manual
  adjustment for longitudinal traction.
• ?allow either free AROM with a gear dischengaged
  or passive range of motion (PROM) with the
  gearengaged

• Motion is initiated immediately

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• Repeated checks orientation of the device
• ?prevent malunion.
• The majority mistakes
• ?device to rotate along a different axis than the
  joint itself.
• Common errors
• device translated farther from the neutral axis
  of the bone at the P1 level than the P2 level
• pins entering the phalanges obliquely rather than
  true mid-axial plane.

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• Under a local anesthetic with the patient
  demonstrating true active PIP joint motion
• no tension in the skin around the pins
• ?pin tract infections.

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MIDDLE PHALANX FRACTURES
Longitudinal shaft fractures
intra-articular fractures of the head
transverse shaft fractures
oblique shaft fractures
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Surgical and Applied Anatomy

• Anatomy head, neck, shaft, and base

The insertions of the FDS, the FDP and the
components of the extensor apparatus typically
cause fractures in the distal ¼ of P2 to angulate
apex volar and in the proximal ¼ of P2 to
angulate apex dorsal
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Current Treatment Options
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Static Splinting

• dorsally applied 
• Motion rehabilitation should be initiated by 3
  weeks post-injury with interim splinting until
  clinical signs of healing are present  (but not
  longer than 6 weeks)

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Condylar Fractures of the Head
The second wire passed obliquely to the diaphysis
1. prevent lateral migration of the condyle 2.
controls the rotation of the fragment
open reduction with a lag screw fixation
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Unstable Shaft Fractures
transverse or short oblique patterns
Correct placement is from the  (A) collateral
recess distally to the opposite corner of the
metaphyseal base (B) restoration of the natural
neck to shaft curvature on the lateral.
long oblique or spiral shaft fractures
transverse placement of K-wires without joint or
tendon penetration
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Dorsal Base Fractures
volar articular fragment and the attached shaft
of P2 to sublux volarly and proximally
early extension block pinning more than 10 to
14 days ORIF with two 1.3 mm lag screws