fracture dislocations of the proximal...

FRACTURE DISLOCATIONS OF THE

PROXIMAL INTERPHALANGEAL

JOINT

BY RICHARD KANG, MD, AND PETER J. STERN, MD

Fracture dislocations of the proximal interphalangeal joint may occur by severaldifferent mechanisms of injury and are of 3 basic fracture patterns: palmar lipfractures, dorsal lip fractures, and pilon fractures. Proper treatment of these injuriesis predicated on maintenance of concentric reduction of the joint, restoration of jointstability, and institution of early motion. Anatomic reconstitution of the articularsurface, though ideal, is less important. Many methods are available to treat theseinjuries. Understanding the fracture within the context of a stability-based classifi-cation system helps to guide in the selection of the most appropriate treatment.

Copyright © 2002 by the American Society for Surgery of the Hand

Fracture dislocations of the proximal interphalan-geal joint are common injuries that, when inad-equately understood, can be confusing for the

physician to treat. Worse, inappropriate treatment canlead to a dysfunctional joint secondary to persistent pain,stiffness, and posttraumatic degenerative arthrosis. Athorough understanding of the biomechanics of the in-jured proximal interphalangeal joint, the principles of itstreatment, and the available treatment options is essen-tial to the proper management of these injuries.

FRACTURE TYPES AND MECHANISMS OF INJURY

Proximal interphalangeal joint (PIPJ) fracture dis-locations can be classified into 3 types based on

the fracture geometry of the base of the middle pha-

lanx: (1) palmar lip fractures, (2) dorsal lip fractures,and (3) pilon fractures (Fig 1). These fracture patternsare the result of characteristic mechanisms of injury.Pure hyperextension may cause an avulsion fracturefrom the base of the middle phalanx. More commonly,however, PIPJ fracture dislocations occur as a result ofan axial load, the specific fracture pattern dependingon the amount of flexion of the PIPJ at the time ofaxial loading.

Palmar lip fractures at the articular base of themiddle phalanx are the most frequently encounteredPIPJ fracture dislocation type (Fig 1A). With hyper-extension only, the palmar plate may rupture at itsdistal insertion on the middle phalanx, which canresult in pure dorsal dislocation of the middle phalanxon the proximal phalangeal head. Alternatively, thepalmar plate may avulse a fragment of bone from thepalmar lip of the middle phalanx; these fracture frag-ments vary in size and displacement, but are generallynot comminuted. Fracture dislocation of the PIPJowing to axial loading of the joint in some degree offlexion results in a fracture of the category coinedimpaction shear fractures.1 In this category, an axial

From the Department of Orthopaedic Surgery, University of Cincin-nati, Cincinnati, OH.Address reprint requests to Peter J. Stern, MD, 2800 Winslow Ave,Suite 401, Cincinnati, OH 45206. E-mail: [email protected]

Copyright © 2002 by the American Society for Surgery of the Hand1531-0914/02/0202-0004$35.00/0doi:10.1053/jssh.2002.33317

JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND � VOL. 2, NO. 2, MAY 2002 47

load across the PIPJ drives the middle phalangeal baseonto the proximal phalangeal head. Because of theflexed position of the PIPJ, the axial load creates apalmar to dorsal force gradient across the articularsurface of the base of the middle phalanx with greaterforce concentrated at its palmar aspect. The palmarbase of the middle phalanx is thus sheared off and,with continued displacement of the proximal phalan-geal head, the palmar fracture fragment is then im-pacted into the underlying metaphyseal bone, nearlyalways causing fracture comminution.2 This fracturepattern may involve up to 80% of the palmar aspect ofthe middle phalanx base; by definition, however, thedorsal cortex and some portion of the dorsal articular

surface of the base of the middle phalanx are spared.There may also be injury to the hyaline cartilage of thehead of the proximal phalanx.

Dorsal lip fractures of the middle phalanx occur inan analogous fashion as palmar lip fractures (Fig 1B)though they are less common. Hyperflexion of thePIPJ may result in rupture of the central tendonthrough its substance or its insertion; the centraltendon may also avulse a fragment of dorsal bone fromthe base of the middle phalanx. Axial load with thePIPJ in extension leads to a dorsal lip fracture of thebase of middle phalanx from an impaction shearmechanism similar to that described for palmar lipfractures.2

Pilon fractures of the PIPJ have been defined byStern et al3 as those in which both the palmar anddorsal cortical margins of the base of the middlephalanx are disrupted and the central articular surfaceis extensively comminuted and impacted into theunderlying metaphyseal bone (Fig 1C).3 They resultfrom a high-energy axial load applied to the PIPJ infull extension.

JOINT STABILITY

Fractures of the base of the middle phalanx maylead to instability of the proximal interphalangeal

joint. Several anatomic and biomechanical factorsmust be considered in understanding the tendencytoward subluxation or dislocation of the middle pha-lanx on the head of the proximal phalanx. An under-standing of PIPJ stability is central to a functionallyuseful classification that is helpful in guiding appro-priate treatment of PIPJ fracture dislocations.

In palmar lip fractures, the normally cup-shapedbase of the middle phalanx is converted into one witha dorsal proximal to palmar distal orientation (Fig 2).Combining this anatomic alteration with the loss ofthe restraint of the palmar plate at the palmar base ofthe middle phalanx allows the central slip of theextensor tendon to subluxate or dislocate the base ofthe middle phalanx dorsally onto the head of theproximal phalanx. This tendency is facilitated by thepull of the flexor digitorum superficialis, which tiltsthe base of the middle phalanx dorsally about thearticular margin of the fracture.4 Restoration of sta-bility is predicated on reestablishing the palmar but-tress by restoring the articular geometry of the palmar

FIGURE 1. Proximal interphalangeal fracture dislocationtypes. (A) Palmar lip fracture with dorsal subluxation. A V-shaped gap can be appreciated between the head of theproximal phalanx and the intact dorsal base of the middlephalanx because of lack of articular congruency. (B) Dorsallip fracture with palmar subluxation. (C) Pilon fracture. Bothpalmar and dorsal cortical margins are fractured and thecentral articular fracture fragments are impacted and commi-nuted. (Adapted and reprinted with permission.1)

48 FRACTURE DISLOCATIONS OF THE PIP JOINT � KANG & STERN

base of the middle phalanx with respect to jointcongruency and concentricity.

Given that the primary variable in the earlier-mentioned scenario is the fracture itself, it stands toreason, then, that the size of the fracture fragment(s) isthe major determinant of stability of the injuredPIPJ. Though in large part true, equally important isthe determination of the clinical stability of the re-duced PIPJ fracture dislocation by physical examina-tion. After digital block anesthesia, the surgeon re-duces the PIPJ and watches for subluxation ordislocation while the patient actively extends thejoint. A true lateral radiograph of the PIPJ in full

extension is then obtained to confirm stability of thereduction. If the joint subluxates or dislocates, it isnecessary to identify the degree of flexion at whichthis occurs; use of fluoroscopy is especially helpful inthis determination.

In an analogous way, dorsal lip fractures may resultin subluxation or dislocation in a palmar direction.The pull of the flexor digitorum superficialis, nolonger opposed by the central slip of the extensortendon, acts to subluxate or dislocate the base of themiddle phalanx palmarward.

CLASSIFICATION

Based on fracture pattern and joint stability, aclassification system for fracture dislocations of

the proximal interphalangeal joint has been estab-lished that is useful with respect to selection of thebest option for treatment of these injuries (Table 1).1

Palmar Lip-Fracture ClassificationThis classification builds on previous ones that have

stratified PIPJ fracture dislocations according to thepercentage of fractured palmar articular surface at thebase of the middle phalanx.4,5 Fractures that involveless than 30% are usually, but not always, stable; 30%to 50% are of tenuous stability; and greater than 50%are unstable (Fig 3). By adding the assessment ofclinical stability to those based purely on anatomiccriteria, this classification divides palmar lip fracturesinto 3 functional groups: stable, tenuous, and un-stable.1

Stable fracture dislocations involve less than 30% ofthe palmar articular base of the middle phalanx, and,after reduction, the joint remains stable with the PIPJfully extended. Congruent reduction of the PIPJ

FIGURE 2. Mechanisms of instability in palmar lip fractures.The pull of the intact central slip of the extensor mechanismis able to subluxate or dislocate the base of the middlephalanx over the head of the proximal phalanx because of (1)the slope of the fractured base of the middle phalanx, (2) theloss of the palmar plate restraint, and (3) the tilting momentabout the fracture margin caused by the pull of the flexordigitorum superficialis. P1, proximal phalanx; P2, middle pha-lanx; EXT, central tendon; VP, palmar plate; FDS, flexordigitorum superficialis. (Adapted and reprinted with permis-sion.1)

TABLE 1Classification of Proximal Interphalangeal Joint Fracture Dislocations

Fracture Type StabilityArticular Surface

Involvement Comment

Palmar lip fracture Stable �30% Reduced in full extensionTenuous 30%-50% Requires �30° of flexion to maintain reductionUnstable 30%-50% or �50% Requires �30° of flexion to maintain reduction

Dorsal lip fracture Stable �50% Reduced in full extensionUnstable Any percentage Palmar subluxation/dislocation in full extension

Pilon fracture Unstable 100% Grossly unstable

FRACTURE DISLOCATIONS OF THE PIP JOINT � KANG & STERN 49

should be shown by radiographs of the joint in thisposition.

Tenuous fracture dislocations of the PIPJ are thosein which 30% to 50% of the palmar lip is fracturedand, once reduced, are stable in reduction with lessthan 30° of flexion. If the joint requires more than 30°of flexion to maintain congruent reduction, it is con-sidered unstable.

Unstable PIPJ fractures dislocations include allfractures involving greater than 50% of the palmarjoint surface of the middle phalanx, as well as thoseinvolving 30% to 50% that require greater than 30°of flexion to maintain congruent reduction.

Dorsal Lip Fracture ClassificationDorsal lip fractures differ from palmar lip fractures

in that the position of maximal stability is in fullextension. Further, it is usually necessary to immobi-lize the PIPJ in this position to reestablish continuityof the central slip of the extensor mechanism. In fullextension, the PIPJ is either stable or unstable—thus,the tenuous group is eliminated.

Stable dorsal lip fractures are usually non- or min-imally displaced avulsion fractures from the dorsalbase of the middle phalanx involving up to 50% of thejoint surface. Positioned in full extension, the PIPJremains reduced with no evidence of palmar sublux-ation as shown by a true lateral radiograph.

Unstable dorsal lip fractures are any that permitpalmar subluxation or dislocation of the middle pha-langeal base with the middle phalanx in full exten-sion.

PRINCIPLES OF TREATMENT

O f paramount importance in the treatment ofproximal interphalangeal joint fracture disloca-

tions is the correction of joint subluxation or disloca-tion and the maintenance of concentric reduction.Based on multiple studies, the best functional resultsare obtained by treatments in which the normal glid-ing arc of motion of the base of the middle phalanxabout the head of the proximal phalanx is reestab-lished; with persistent subluxation of the PIPJ, mo-tion occurs by hinging at the fracture margin andportends a poor result.6-8 Treatment, therefore, mustbe directed at correction of PIPJ subluxation andrestoration of joint stability to permit a normal arc ofjoint motion. Whenever possible, early motion shouldbe instituted to minimize adhesions and contracturesand to enhance cartilage and soft-tissue healing. An-atomic reduction of the fractured articular surface,though desirable, is not a prerequisite for good PIPJfunction.3,9-11

TREATMENT OPTIONS

Treatment methods of proximal interphalangealjoint fracture dislocations are grouped into 5

broad categories: immobilization, protected motion,traction, open reduction and internal fixation, andbuttress reconstruction (Fig 4).

ImmobilizationStatic splinting or transarticular Kirschner wire

fixation may be used to immobilize the PIPJ in areduced position.4,12 Though a simple technique,there are 2 major disadvantages of immobilization.Prolonged immobilization (�3 wks) often leads tosignificant permanent stiffness and loss of range ofmotion. Furthermore, in unstable fractures, thismethod is frequently unable to reliably restore stabil-ity to the joint and recurrent subluxation or disloca-tion often results after cessation of immobilization.

Protected MotionWith protected motion, the PIPJ is permitted to

move in an arc through which the joint remainsconcentrically reduced, but is restricted from positionsin which it is unstable. In those cases requiring onlyprotection from hyperextension, buddy taping may be

FIGURE 3. Classification of palmar lip fractures. Stable frac-tures involve less than 30% of the palmar base of the middlephalanx and show no tendency to subluxation in full exten-sion. Tenuous fractures involve 30% to 50% of the base andremain concentrically reduced with less than 30° of flexion.Unstable fractures include all those involving greater than50% of the articular surface, as well as those involving 30%to 50% that require greater than 30° of flexion to maintainreduction. (Adapted and reprinted with permission.1)


used. A figure of 8 splint is the most simple methodto treat a stable PIPJ fracture dislocation when aslight degree of flexion (ie, a PIPJ extension block) isrequired to maintain reduction. Both of these methodsare advantageous in that they permit early motion.

McElfresh et al5 introduced the dorsal extensionblock splint—a short arm cast with an alumafoamdorsal PIPJ extension-blocking outrigger to permitunrestricted active flexion of the reduced PIPJ whileblocking extension just short of the point at which thejoint begins to subluxate dorsally. This splinting tech-nique, as well as later modifications thereof,6,13 main-tains joint reduction during fracture consolidation andsoft-tissue healing while encouraging early motion.Whether the dorsal blocking splint is forearm-, hand-,or digit-based, the critical component is the dorsalalumafoam over the proximal phalanx, the PIPJ, andthe middle phalanx. The proximal phalanx must bewell secured to the splint with tape to prevent over-extension of the PIPJ such as occurs if the proximalphalanx is allowed to pull away from the splint.Additionally, the splint must be bent at the PIPJ suchthat the middle phalanx is dorsally blocked fromextending past the point at which subluxation occursas confirmed by a true lateral radiograph.

By using the same concept, Viegas14 proposed ex-tension block pinning to achieve the same effect. Afterreduction, the PIPJ is held at 90° of flexion, and apercutaneous Kirschner wire is then placed into thehead of the proximal phalanx in a distal dorsal to

proximal palmar direction, approximately 30° to thelong axis of the bone; thus, the wire acts as a mechan-ical block to extension while allowing active flexion.

TractionMany traction methods or devices have been devel-

oped that effectively maintain PIPJ reduction afterfracture dislocation. Nearly all use longitudinal trac-tion either alone or in combination with a palmarlydirected force to maintain reduction, and most permitactive or passive PIPJ motion. Robertson et al15 de-scribed a static traction system that uses 1 pinthrough the distal aspect of the middle phalanx toapply traction across the PIPJ while 2 other pins, 1through the neck of the proximal phalanx and 1through the base of the middle phalanx, pull in op-posite directions, to correct dorsal subluxation.Schenck10 devised a system in which longitudinaltraction is applied to a transosseus wire through thedistal aspect of the middle phalanx via a rubber bandattached to a movable component on an arcuate splint,thus, allowing passive PIPJ motion. Morgan et al9

combined these 2 methods in a technique that pro-vides traction and relocation forces with passive PIPJmotion. One transosseous wire is placed through thedistal aspect of the middle phalanx and 1 through theaxis of PIPJ rotation in the head of the proximalphalanx. Both wires are then attached via rubberbands to an arcuate frame such that the distal wireprovided longitudinal traction and the proximal wire

FIGURE 4. Treatment algo-rithm for proximal interpha-langeal joint fracture disloca-tions.


provided a relocation force; movement of both aboutthe arcuate frame permits passive motion of the PIPJ.Agee16 developed an ingenious linkage of 3 Kirschnerwires and a rubber band to create a force couple thateffects PIPJ reduction by simultaneously levering thebase of the middle phalanx palmarly and lifting thehead of the proximal phalanx dorsally. This forcecouple maintains joint reduction through a full activerange of motion. Hastings and Ernst17 and Kasparynand Hotchkiss18 have designed dynamic external fix-ators that simultaneously provide longitudinal trac-tion, maintain joint reduction, and permit passive andactive motion.8

Open Reduction and Internal FixationOpen reduction and internal fixation is a viable

option for treatment of PIPJ fracture dislocationswhen there is little or no comminution and the frac-ture fragments are large enough to accommodate fix-ation. Lag screws, Kirschner wires, tension banding,cerclage wiring, and pull-out sutures have all beenadvocated alone or in combination.19-23 The use of

interfragmentary compression screw technique has be-come more practical with the availability of smallerself-tapping screws with low profile heads. With openreduction and internal fixation, cancellous bone graftmust often be used to fill a metaphyseal void left afterelevation of a depressed fracture fragment.8,19,22 Theuse of a hyperextension gunstock volar approach to thePIPJ can provide superb joint visualization, thoughstable fixation, usually by miniscrews or cerclage wire,is important for early motion.20

Buttress ReconstructionTwo unique methods have been designed for the

treatment of unstable palmar lip fractures: palmarplate arthroplasty and hamate osteochondral autograftarthroplasty. Described by Eaton and Malerich,24 pal-mar plate arthroplasty involves advancement of thepalmar plate into the defect at the base of the middlephalanx to resurface the damaged articular surface andto restrain dorsal subluxation of the joint (Fig 5A).24

The procedure and useful modifications have beenwell described in the literature.24-26 However, 3

FIGURE 5. Eaton palmar plate arthroplasty. (A) The palmar plate is advanced into the fracture defect in the base of the middlephalanx to resurface the articular surface and to restrain dorsal subluxation. (B) Dorsal subluxation may recur if advancementof the palmar plate is unable to adequately fill the void left by the palmar lip fracture. By filling this space with a slip of flexordigitorum superficialis (C) or bone graft or fracture fragments (D), the cup-shaped geometry of the middle phalangeal base andthe palmar buttressing effect is reestablished. VP, palmar plate; P1, proximal phalanx; P2, middle phalanx; EXT, central tendon;FDS, flexor digitorum superficialis. (Adapted and reprinted with permission.1)


points warrant mention here. First, the PIPJ is subjectto recurrent dorsal subluxation particularly if the pal-mar defect is not adequately filled by the thickness ofthe advanced palmar plate.4,24 This occurs as the headof the proximal phalanx forces the palmar plate intothe fracture defect in the base of the middle phalanxthus allowing dorsal subluxation of the joint (Fig 5B).It is thus essential to provide unyielding support tothe palmar plate arthroplasty by filling any distalbony void. Although a slip of flexor digitorum super-ficialis may be used to this effect (Fig 5C), it is betterperformed with bony fracture fragments or bone graft(Fig 5D).1 Second, redislocation is a real concern,especially when greater than 50% of the base of themiddle phalanx is fractured.27 Finally, a dynamic ex-ternal fixator can be used in conjunction with a palmarplate arthroplasty to initiate early range of motion.1

In an effort to reconstruct the palmar buttress inunstable palmar lip fractures, Hastings et al28 haveproposed a novel approach by using the anatomicsimilarity in contour between the palmar articularsurface of the base of the middle phalanx and thehamate articulation with the bases of the 4th and 5thmetacarpals (Fig 6).28 The PIPJ is first exposedthrough a volar approach to allow visualization of thefractured palmar articular base of the middle phalanx(Fig 6B). A dorsal approach is then used to expose thearticulation between the hamate and the 4th and 5thmetacarpals (Fig 6C). A small straight osteotome isthen used to remove a rectangular segment of hamateat its distal articular margin centered between the 4thand 5th metacarpals. The width and depth of thearticular surface of the segment should match thewidth and depth of the palmar lip defect of the base ofthe middle phalanx, and the height of the segmentshould be sufficient to permit secure fixation withsmall (�1.0-1.5 mm) screws. The palmar base of themiddle phalanx is then sculpted with a small os-teotome and rongeur to allow close fit of the hamateosteochondral autograft at its articular, cortical, andcancellous surfaces (Fig 6D). The graft is oriented suchthat its original dorsal surface becomes the new pal-mar surface and is trimmed at its radial and ulnarmargins to reconstruct the outline of the palmar mid-dle phalangeal base as viewed en face. Two smallcompression screws are then placed in a palmar todorsal direction to fix the graft to the defect (Fig 6E).Care should be taken in fitting the graft to the defect

to ensure that the cup-shaped sagittal profile of thearticular base of the middle phalanx is recreated (Fig6D and F). Properly performed, this technique pro-vides immediate stability to the joint, thus, permit-ting early motion (Fig 6G and H).

TREATMENT OF PALMAR LIP FRACTURES

The goals of treatment of palmar lip fractures areto obtain and maintain concentric reduction of

the joint to reestablish joint stability and a normalgliding arc of motion of the articular base of themiddle phalanx about the head of the proximalphalanx. Use of the stability-based classificationsystem for palmar lip fractures as outlined earlier,simplifies selection of an appropriate treatment mo-dality.

Stable Palmar Lip FracturesThese fractures involve less than 30% of the palmar

articular surface of the middle phalangeal base andclinical testing shows that the PIPJ remains congru-ently reduced throughout a full arc of motion. There-fore, treatment is focused on maximizing motion.Treatment options include static splinting, buddytaping, figure of 8 splint, and extension block splint.In 1 study, static splinting is not recommended forthe treatment of stable palmar lip fractures because itsuse has been associated with increased stiffness whencompared with buddy taping; its use has also beenassociated with loss of flexion and flexion contrac-ture.29 This same study also showed that displacementand nonunion of the palmar lip fracture fragment hadno bearing on the outcome of stable palmar lip frac-tures. Stable palmar lip fractures in which the PIPJdoes not exhibit a tendency to hyperextend are treatedwith buddy taping to prevent re-injury while encour-aging immediate motion. If the palmar lip fractureallows PIPJ hyperextension (which may result in aswan neck deformity if left uncorrected), we prefer touse a figure of 8 splint or a dorsal blocking splint thatpermits full active flexion but prevents the last 10° to15° of extension to facilitate palmar plate healing.After 3 weeks, the splint is adjusted to allow anadditional 10° of extension per week.

Tenuous Palmar Lip FracturesThese fractures involve 30% to 50% of the palmar

articular surface of the middle phalanx base and clin-


FIGURE 6. Hamate osteochondral autograft arthroplasty. (A) Radiographs show an unstable palmar lip fracture. (B) Over 50%of palmar base of the middle phalanx was fractured resulting in a large defect (arrow). P1, proximal phalanx; P2, middle phalanx.(C) The hamate articulation with the bases of the 4th and 5th metacarpal is anatomically similar to the articular surface of thepalmar base of the middle phalanx. H, hamate; 4, 4th metacarpal base; 5, 5th metacarpal base. (D) The hamate osteochondralautograft was used to reestablish the cup-shaped geometry of the base of the middle phalanx. (E) Two small lag screws (1.0mm) were used to secure the hamate osteochondral autograft to the defect in the palmar base of the middle phalanx.Intraoperatively, congruent joint reduction in full extension has been restored. (F) Radiographs taken 2 months after hamateosteochondral autograft show a stable proximal interphalangeal joint with excellent anatomic restoration of the articular contourof the base of the middle phalanx. (G and H) Excellent active range of motion of the proximal interphalangeal joint was achieved.(Reprinted with permission.1)


ical testing shows that the PIPJ maintains concentricreduction with less than 30° of flexion. Treatment isdirected at maintaining concentric joint reductionwhereas the palmar fracture fragments consolidate torestore the palmar buttress. Treatment options in-clude static splint, transarticular pin, figure of 8splint, extension block splint, extension block pin,traction devices, dynamic external fixation, and openreduction and internal fixation. Immobilization bystatic splint or transarticular pin is effective in restor-ing stability to the joint, but is too frequently asso-ciated with postimmobilization stiffness and is notrecommended. Traction, dynamic external fixation,and open reduction and internal fixation are unneces-sarily complex and require surgical intervention withall of its attendant risks.

We prefer the simple but effective method of ex-tension block splinting for treatment of tenuous pal-mar lip fractures.5,6,13 Regardless of the specific splintdesign used (ie, forearm-, hand-, or digit-based), the

proximal phalanx should be securely bound to thesplint to prevent the digit from pulling away from thesplint and inadvertently permitting more than thedesired degree of extension at the PIPJ (Fig 7). Oncethe fracture dislocation has been reduced, and thedorsal blocking splint applied, it is important toconfirm with true lateral radiographs that the PIPJ isconcentrically reduced at the point of maximum ex-tension allowed by the splint. Dorsal subluxation ofthe middle phalanx must be corrected by increasingthe flexion angle of the splint. If greater than 30° offlexion is required to achieve and maintain reduction,the fracture dislocation should be reclassified as un-stable, and an appropriate treatment method selected.The limit of extension on the splint should be in-creased 10° weekly with radiographic confirmation ofjoint reduction at each change. If subluxation recurs atany interval, the splint is restored to its previousangle. Once the PIPJ has attained full stable extension(usually 6-8 wks), the splint is discontinued, and

Figure 6. (Continued)


buddy taping used to protect the joint for anotherseveral weeks.

In a technical variation of extension block splint-ing, extension block pinning, as advocated by Vie-gas,14 may be used to treat tenuous palmar lip frac-tures. Active flexion of the PIPJ is encouraged duringthe 4- to 6-week period that the extension block pinis in place. Thereafter, active and passive range ofmotion exercises are used to regain full extension.

Unstable Palmar Lip FracturesThis group of fractures involves all those involving

greater than 50% of the palmar articular surface of themiddle phalanx base and those involving 30% to 50%,which require more than 30° of flexion to maintainconcentric reduction of the PIPJ. Treatment is aimed atrestoring the stabilizing cup-shaped geometry of the baseof the middle phalanx by reconstructing its palmar de-ficiency, which is responsible for the instability of thesefractures. Treatment options include open reduction andinternal fixation, palmar plate arthroplasty, and hamateosteochondral autograft arthroplasty. Traction or dy-namic external fixation may also be used alone or inconjunction with any of the earlier-mentioned methods.

When fracture fragments are of sufficient size to accom-modate fixation with screws, Kirschner wires, tensionband wires, cerclage wires, or pull-out wires, open re-duction and internal fixation20 should be used to restorethe palmar buttress. Frequently, however, one findssmall, comminuted, and impacted fragments that re-quire alternative techniques. In cases with one relativelylarge fragment volarly and comminution of the middleaspect of the joint, cerclage wiring, as described byWeiss, can provide a stable construct providing inter-fragmentary compression and allowing early range ofmotion22 (Fig 8).

If traction across the PIPJ is able to effect bothfracture alignment by ligmentotaxis and concentricjoint reduction, traction or dynamic external fixationmay be used to maintain concentric joint reductionwhile the fracture heals. When this is unsuccessful,restoration of stable geometry to the base of themiddle phalanx requires a reconstructive proceduresuch as palmar plate arthroplasty or hamate osteo-chondral autograft arthroplasty. Immediately afterrestoration or reconstruction of the palmar base of themiddle phalanx, dynamic external fixation may be

FIGURE 7. When using anextension block splint, theproximal phalanx must befirmly affixed to the splintwith tape to prevent loss ofextension blocking by pullingaway of the finger from thesplint.


used to maintain joint reduction, protect the healingbone and soft tissues, and institute early active andpassive range of motion exercises.

TREATMENT OF CHRONIC DORSAL FRACTURE

DISLOCATIONS

Palmar lip fractures with associated dorsal PIPJ dis-locations that are missed, neglected, or incorrectly

treated lead to chronic dorsal fracture dislocations. Insuch cases, joint flexion is limited to that allowed byhinging or pivoting of the middle phalangeal base aboutthe dorsal margin of the fracture resulting in articularerosion and joint stiffness. In deciding treatment for achronic PIPJ fracture dislocation, it is first necessary todetermine whether or not the remaining articular sur-faces have undergone significant degenerative changesbased on radiographic assessment. With significant post-traumatic arthrosis, silicone implant arthroplasty30,31 orarthrodesis32 may be better options. If the remainingarticular surface quality is good, the goals of treatmentare, once again, to obtain and to maintain concentricPIPJ reduction to restore functional motion. Donaldsonand Millender33 performed open reduction through alateral approach by clearing the palmar retrocondylarspace of proximal phalanx of scar and adhesions, dorsal

capsulotomy, and extensor tenolysis. Stability was main-tained by a transarticular pin placed with the joint at 90°of flexion for less than 2 weeks. Then, a dorsal extensionblock splint at 60° was initiated allowing active flexion;the angle was gradually decreased over a 4-week periodafter which immobilization was discontinued. Othershave used corrective osteotomy34 or palmar plate arthro-plasty24 to reestablish the cup-shaped geometry of thebase of the middle phalanx to restore stability to thejoint. Zemel et al34 proposed corrective osteotomy inwhich the palmar articular surface and the central de-pressed articular fragments are levered back into positionand supported by distal radius bone graft. Our preferredmethod is palmar plate arthroplasty because it simulta-neously resurfaces the palmar articular surface of themiddle phalanx, restores the palmar buttress, and tight-ens the palmar plate. Though current experience is lim-ited, we have also successfully used hamate osteochondralautograft arthroplasty for chronic dorsal fracture disloca-tions of the PIPJ.

TREATMENT OF DORSAL LIP FRACTURES

As with palmar lip fractures, the goals of treatmentof dorsal lip fractures are to obtain and maintain

concentric reduction of the joint to reestablish joint

FIGURE 8. In highly comminuted fractures of the base of the middle phalanx, a 22-gauge steel cerclage wire can be used tostabilize the fragments by providing circumferential compression with wire tightening.


stability. In addition, continuity of the central slip of theextensor apparatus must be reestablished.

Stable FracturesThe PIPJ does not show palmar subluxation with

stable dorsal lip fractures. Therefore, the primary treat-ment goal is to reestablish continuity of the central slip.Though the fracture fragment may vary in size, most arenot significantly comminuted and will heal with osseousor stable fibrous union. At issue, however, is the amountof fragment separation acceptable with respect to com-promise of central slip function.

In our experience, stable dorsal lip fractures withless than 2 mm of fragment separation may be treatedby immobilization of the PIPJ in extension by splintor transarticular Kirschner wire with acceptable re-sults. Duration of immobilization should be 3 to 4weeks, after which a dynamic extension splint shouldbe placed to permit active flexion. At 6 weeks, passiveflexion and strengthening exercises should be initi-ated. It should be noted that immobilization must notinclude the distal interphalangeal joint, which shouldbe started immediately on active and passive range-of-motion exercises.

In dorsal lip fractures with fragment displacementgreater than 2 mm, unacceptable extensor lag mayresult unless treated with open reduction and internalfixation. Fixation options include Kirschner wireswith or without a tension band wire, loop wire, pull-out suture, suture anchor, or lag screws; with stablefixation, immediate postoperative motion is initiated.

Unstable FracturesIf the PIPJ is subluxated or dislocated anteriorly

after closed reduction, it is by definition unstable.Treatment is directed at obtaining and maintainingconcentric joint reduction to restore integrity of thecentral slip. If the fracture fragments are large enough,this is achieved by open reduction and internal fixa-tion. Highly comminuted fractures may be treated byclosed reduction and percutaneous pinning with thePIPJ in full extension to allow consolidation of thefracture fragments and the insertion of the central slipif the dorsal buttress of the base of the middle phalanxis restored by reduction of the joint. When this is notthe case, some investigators have proposed fragmentelevation with bone grafting,4,35 or central slip sutureinto the fracture bed. These methods have been asso-ciated with considerable postoperative stiffness; use of

a dynamic external fixator has been advocated to limitstiffness and PIPJ contracture.8,17 Alternatively, incases in which the fracture fragment is displaced lessthan 2 mm and moves with the base of the middlephalanx, traction and immediate motion have beenused successfully to correct joint subluxation and re-store joint stability with minimal extensor lag.9

TREATMENT OF PILON FRACTURES

P ilon fractures involve both palmar and dorsal lipfractures with extensive central depression and

comminution and are unstable. The goal of treatmentis to reestablish a concentric gliding arc of motion ofthe base of the middle phalanx about the head of theproximal phalanx. To achieve this goal, the proximaland middle phalanges must be collinear and the pal-mar and dorsal fracture fragments must realign toreapproximate the cup-shaped geometry of the base ofthe middle phalanx. Exact anatomic reduction of thejoint surface is far less important than the institutionof early motion. Traction accomplishes these pre-requisites and has been shown to be effective in treat-ing pilon fractures.3,9,10

Although any of the traction methods described maybe used successfully to treat pilon fractures, certain prin-ciples apply to all. Splint immobilization is to be dis-couraged Traction is a reasonable alternative and is ourtreatment of choice. It should effect collinear alignmentof the proximal and middle phalanges with no angula-tion in the coronal plane as well as good overall align-ment of the fracture fragments in the sagittal plane asshown by radiographs. The traction method chosenshould permit immediate mobilization of the joint.Traction is discontinued at 6 weeks when the fracturefragments have consolidated; aggressive range-of-motionexercises are continued. Treated as such, these fracturesfrequently remodel,3 resulting in an acceptable arc ofmotion with minimal pain.

Although not contraindicated, we have found openreduction and internal fixation risky, and complica-tions such as loss of reduction, stiffness, and infectioncan arise.

ACKNOWLEDGMENT

The authors thank T. R. Kiefhaber, MD, for sharinghis photographs and illustrations.


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