[david c. ring, mark cohen] fractures of the hand

of the Handand Wrist

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New York London

Edited by

David C. RingMassachusetts General HospitalBoston, Massachusetts, U.S.A.

Mark S. CohenRush University Medical Center

Chicago, Illinois, U.S.A.

of the Handand Wrist

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Preface

Fractures of the hand and wrist are among the most common musculoskeletal

injuries sustained by orthopedic patients. In fact, most people will suffer from

such an injury at some point in their lives. Although treatment is typically

straightforward, several pitfalls exist that often require the attention of a

trained specialist.

Our international panel of expert hand surgeons provides insights into new

developments and techniques for both basic and more challenging management

and treatment problems. Discussion of hand and wrist fractures is broken down

into chapters focusing on distal phalanx fractures, fingertip crush injuries,

phalangial shaft fractures, metacarpal fractures, carpal fracture dislocations,

and scaphoid fractures. Special attention is given to challenging proximal inter-

phalangeal fracture-dislocations, including evolving concepts in fixation and

arthroplasty, and the treatment of distal radius fractures.

We hope we have created a readable text for easy reference or complete

review of the practical and up-to-date aspects of fracture care.

David C. Ring

Mark S. Cohen

iii

Editors’ Note

We hope that this book on hand and wrist fractures and dislocations will be useful

in the care of injured patients. Our co-authors were generous with their time and

talents, and we are sure that you will benefit, as we did, from their wisdom and

intelligence. We made no attempt to be comprehensive, but instead aimed for a

concise and practical review of current concepts. Few texts focus on skeletal

injury in the hand and wrist, and we hope this book will be a useful reference

for both straightforward and challenging problems.

David C. Ring

Mark S. Cohen

v

Contents

Preface . . . . iii

Editors’ Note . . . . v

Contributors . . . . ix

1. Distal Fingertip and Thumb Injuries . . . . . . . . . . . . . . . . . . . . . . . 1Adrian L. Butler and Mark Baratz

2. Phalanx Shaft Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Mark S. Cohen

3. Dislocations and Fracture Dislocations of the

Metacarpophalangeal and Proximal Interphalangeal Joints . . . . . 41Randy R. Bindra

4. Operative Management of Metacarpal Fractures . . . . . . . . . . . . . 75William B. Geissler and William O. McCraney

5. Carpal Dislocations and Fracture Dislocations . . . . . . . . . . . . . . . 91Santiago A. Lozano-Calderon and David C. Ring

6. Fractures of the Scaphoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115Satoshi Toh

7. Distal Radius Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137Karl-Josef Prommersberger and Thomas Pillukat

Index . . . . 189

vii

Contributors

Mark Baratz Division of Hand and Upper Extremity Surgery, Allegheny

General Hospital, Pittsburgh, Pennsylvania, U.S.A.

Randy R. Bindra Hand Surgery, University of Arkansas for Medical

Sciences, Little Rock, Arkansas, U.S.A.

Adrian L. Butler Philadelphia Hand Center, King of Prussia, Pennsylvania,

U.S.A.

Mark S. Cohen Department of Orthopedic Surgery, Rush University

Medical Center, Chicago, Illinois, U.S.A.

William B. Geissler Department of Orthopedic Surgery, University

of Mississippi Medical Center, Jackson, Mississippi, U.S.A.

Santiago A. Lozano-Calderon Department of Orthopedic Surgery,

Massachusetts General Hospital, Boston, Massachusetts, U.S.A.

William O. McCraney Department of Orthopedic Surgery, University

of Mississippi Medical Center, Jackson, Mississippi, U.S.A.

Thomas Pillukat Klinik fur Handchirurgie, Bad Neustadt, Germany

Karl-Josef Prommersberger Klinik fur Handchirurgie, Bad Neustadt,

Germany

David C. Ring Department of Orthopedic Surgery, Massachusetts General

Hospital, Boston, Massachusetts, U.S.A.

Satoshi Toh Department of Orthopedic Surgery, Hirosaki University School

of Medicine, Hirosaki, Aomori, Japan

ix

1

Distal Fingertip and Thumb Injuries

Adrian L. Butler

Philadelphia Hand Center, King of Prussia,Pennsylvania, U.S.A.

Mark Baratz

Division of Hand and Upper Extremity Surgery, Allegheny General Hospital,Pittsburgh, Pennsylvania, U.S.A.

INTRODUCTION

Distal fingertip and thumb injuries are among the most common hand injuries.

We audited the Internet-based National Occupational Health and Safety

Commission Worker’s Compensation Database and found that 32% of the

claims in 1999 and 2000 (approximately 70,000 of 220,000 claims) involved

the upper extremity. When considering only patients aged 30 or younger, 50%

of the claims involved the upper extremity (1). Among upper-extremity injuries,

the fingertip is the most commonly involved site.

Many fingertip injuries create open wounds and fractures of the distal

phalanx. The vast majority of these can be cared for in the emergency depart-

ment. Injuries requiring internal fixation or soft-tissue coverage for skin

defects may be more easily managed in an operating room. Particular attention

must be given to preserving the integrity of the nail bed and matrix as well as sen-

sation to the finger pulp. A complete understanding of the anatomy of the distal

phalanx is essential to care for these injuries.

1

ANATOMY

A distinctive feature of the finger is the nail plate. It provides a hard protective

surface as well as dorsal support of the terminal one-half of the distal phalanx.

This provides the finger with myriad functions such as picking, scratching,

scraping, and prying. The nail plate is composed of compact epidermal cells

that undergo macrocystosis (swelling), nucleolysis (loss of nuclei), and gradual

cell collapse and flattening. Toughness of the nail plate is derived through the

deposition of keratin (2–5). The fingernail grows from the germinal matrix

and over the nail bed (sterile matrix) at a rate of approximately 1 mm per

week (2,3).

The proximal and lateral nail folds and the distal groove surround the nail

and help mold the nail into shape. The proximal nail fold is termed the epony-

chium and includes the cuticle or perionyx. The lateral fold is the perionychium,

and the terminal groove is the hyponychium (Fig. 1).

The lunula—the junction of the nail plate and matrix—decreases in size

from the thumb to the small finger. The light color of the lunula results from

Eponychium(A)

(B)

Nailwall

Insertion ExtensorTendon

Dorsal roofNail

foldVentral floor

Distal

interphalangeal

joint

Lunula

Nail bed

Hyponychium

Periosteum

LAT. NAIL FOLD

(PARONYCHIUM)CUTICLE

(PERIONYX)

PROX. NAIL FOLD

(EPONYCHIUM)

LUNULA

NAIL BED NAIL MATRIX

HYPONYCHIUM

granulosa cell layer

NAIL PLATE

Figure 1 Illustration of fingertip anatomy.

2 Butler and Baratz

incomplete cornification and the fact that, proximally, the nail bed does not

adhere to the nail plate (5). The perionyx or cuticle is fixed to the nail

plate, and the nail plate to the nail bed. The extraordinary adherence of the

nail plate to the nail bed stems from a corneous substance that is produced

by the epidermis beneath the nail. More proximally, the nail plate is softer

and more flexible with a loose attachment at the germinal matrix and

lunula (2). This becomes important when dealing with nail plate avulsions.

When the nail plate is injured proximally, it can avulse from the germinal

matrix but remain firmly attached to the cuticle and nail bed. The nail bed

has, in turn, a strong attachment to the periosteum of the distal phalanx.

As a result, distal nail plate injuries will usually result in lacerations to the

underlying nail bed with partial or complete detachment of the nail plate.

The variable adherence of the nail plate from distal to proximal can be rel-

evant in treating fingertip amputations. In order to have a stable adherent

nail plate, at least 5 mm of healthy nail bed distal to the lunula is required (5).

Sensation to the fingertip is provided by the radial and ulnar digital nerves.

The pulp of the finger is highly vascular with many arterioles (rete arteriosum)

branching and extending distally off a transverse arterial arch. Two additional

arterial arches are present dorsally: one at the level of the germinal matrix

(arcus unguicularis proximalis) and a second at the middle of the nail bed

(arcus unguicularis distalis). Along the base of the nail is the transverse

arcus venosus, which provides the majority of the venous outflow of the distal

fingertip (2,3).

Discriminatory sensation is evaluated by “two-point” testing. Normal

two-point discrimination is 5 mm or less. This degree of sensitivity comes by

virtue of a high concentration of Meissner’s corpuscles which sense light touch

and low-frequency vibration. Pacinian and Merkel mechanoreceptors help

sense pressure and constant touch, respectively. Ruffini end organs are also

present and sense both skin stretch and heat. Threshold sensitivity may be

tested using the Semmes–Weinstein monofilament test (6,7). Normal fingertip

monofilament values range from 1.65 to 2.83 (8). This is a useful tool for both

detecting and following the recovery of a dysfunctional nerve. These mechano-

receptors are present within the fat of the pulp, which is held by retinacular

septae to the palmar periosteum of the phalanx. The ungual tuberosity is the

site of attachment of these septae. This spade-like structure is unique to the

terminal aspect of the distal phalanx in homonids (9). The pulp of the fingertip

is a soft, highly sensitive and immobile fat pad which helps to disperse

contact pressures.

Both the extensor and flexor tendons insert on the distal phalanx proximal

to the germinal matrix. When evaluating injuries to the distal phalanx, it is

important to test for the function of these tendons. The average distance from

the terminal extensor tendon insertion to the proximal edge of the germinal

nail matrix was found to be 1.2 mm in a study of 16 cadavers (10). Internal

fixation of the terminal tendon places the germinal matrix at risk.

Distal Fingertip and Thumb Injuries 3

FRACTURES OF THE DISTAL PHALANX

Schneider classified fractures of the distal phalanx into tuft, shaft, and base frac-

tures (11). Additional consideration must be given to fractures that extend into the

distal interphalangeal (DIP) joint and those that involve extensor and flexor

tendon avulsion fractures.

Tuft and Shaft Fractures

Closed fractures of the tuft and shaft of the distal phalanx can be treated

nonoperatively. Surgical intervention should be considered for widely displaced

transverse fractures of the distal phalanx shaft, severely angulated fractures, and

injuries with complex wounds.

The vast majority of closed tuft and shaft fractures of the distal phalanx are

well-aligned and stable. Treatment is for comfort only as immediate active use of

the finger without immobilization will not affect the result. Immobilization of the

DIP joint for three to four weeks is reasonable for comfort. Fractures of the distal

phalanx shaft should be splinted until the phalanx is no longer significantly

tender. This typically takes three to four weeks. Radiographic evidence of

healing will lag behind clinical signs of healing.

Some physicians favor routine drainage of a substantial subungual

hematoma, whereas others only do this in an attempt to relieve severe pain.

There is very little room under the nail plate for hematoma expansion. A substan-

tial hematoma can cause severe pain, and there is a small risk of fingertip necrosis

(4). Perforating the nail plate to drain the hematoma provides substantial pain

relief. An 18-gage needle can be used to bore a small hole in the nail plate.

When the subungual hematoma occupies greater than 50% of the sterile matrix,

consideration should be given to complete nail removal and sterile matrix repair.

Widely displaced fractures of the distal phalanx are uncommon, but are

more likely to result in nonunion. Widely displaced and angulated fractures

may benefit from closed reduction and percutaneous fixation with a small

Kirschner wire (Fig. 2). In many cases, it is necessary to have the wire cross

the DIP joint to achieve adequate stabilization of the fracture. Stiffness of the

DIP is an expected consequence of a high-energy injury to the distal phalanx.

Temporary pinning of the DIP does not add substantially to DIP joint stiffness

and allows the surgeon to achieve the goal of a stable, aligned, and pain-free

fingertip.

Fractures at the Base of the Distal Phalanx

Flexor Digitorum Profundus Tendon Avulsion Injuries

Avulsions of the extensor and flexor tendons off the distal phalanx are frequently

associated with fractures at the base of the distal phalanx. Avulsions of the flexor

digitorum profundus tendons were classified by Leddy and Packer (12). Type I

injuries are ruptures of the tendon insertion from the bone with retraction of

4 Butler and Baratz

the tendon into the palm. Type II and III injuries involve bone attached to the

avulsed tendon. In Type II avulsions, the tendon retracts to the level of the prox-

imal interphalangeal (PIP) joint where it is held in place by intact long vinculum.

In Type III injuries, a relatively large bone fragment catches on the A4 pulley

Figure 2 Unstable distal phalanx fractures benefit from percutaneous Kirschner wire

fixation. (A) A young man crushed his fingertip. (B) The result was an unstable transverse

fracture of the distal phalanx. (C) A single longitudinal Kirschner wire provided adequate

stability after closed manipulative reduction. (D) The wire should cross the DIP joint in

order to gain adequate purchase and prevent an extensor lag. Abbreviation: DIP, distal

interphalangeal.


limiting tendon retraction to the level of the middle phalanx. Smith (13) described

an uncommon variant, that is, the base of the distal phalanx is avulsed from the

phalanx and the tendon is avulsed from the bone.

Type I injuries can be treated with primary repair within two to three weeks

of injury. Past this point a myostatic contracture of the musculotendinous unit

occurs, and it may be difficult to reattach without flexion of the finger, a maneuver

that may result in a permanent flexion contracture. A separate incision is

frequently required to retrieve the retracted tendon from the palm. The tendon

must be passed back through the flexor tendon sheath and pulley system. A

2–0 monofilament suture is woven through the end of the avulsed tendon

using a Bunnell stitch. The sutures and tendon are advanced through the

pulleys. The tendon is secured to the distal phalanx by passing the sutures on

heavy, straight needles on either side of the waist of the distal phalanx or

through the bone. The needles, with sutures, are passed through the nail bed

and nail plate and tied over the nail with a button. Alternatively, suture

anchors may be used, but with caution; care should be taken to avoid extending

the fracture from palmar to dorsal while creating the drill holes. In addition, when

this method is used, it is important to avoid penetration of the dorsal cortex with

the suture anchor.

Type II injuries are managed in a similar fashion. Because the vincula have

not been ruptured and the tendon has retracted only to the level of the PIP joint,

primary repair without excessive finger flexion is often possible up to four weeks

postinjury.

Repair of a type III injury is performed with the same method (Fig. 3). The

repair can be supplemented with one or two 0.035- or 0.045-inch Kirschner wires.

Occasionally, the fragment is large enough to accept a screw, but it may be wise

to protect this with a suture or Kirschner wire (Fig. 4).

Type IV injuries are very rare. The bone fragment can be repaired or

excised prior to tendon reattachment. Chronic injuries may be best treated

without surgery or with primary DIP fusion or tenodesis.

Terminal Extensor Tendon Avulsion (Mallet) Injuries

Mallet injuries with an avulsed bone fragment can, in most cases, be managed

with splinting of the DIP joint. The finger is examined with attention to the

degree of flexion at the DIP joint, passive extension of the DIP joint, and the

position of the PIP joint of the injured finger and the adjacent fingers (Fig. 5).

A finger with loss of active DIP extension, full passive extension, and no

swan-neck deformity is treated with a splint that holds the DIP joint in extension

(14–17). A wide variety of prefabricated and custom-made splints can be used,

and the patient’s needs and preferences should be taken into account. Hyper-

extension of the DIP joint diminishes the blood supply to the dorsal skin,

which may contribute to a pressure sore, particularly when a dorsal splint is

used. The joint is splinted in extension, full time for six to eight weeks and at

6 Butler and Baratz

Figure 3 (Continued on next page) Example of an acute Leddy and Packer Type III flexor

digitorum tendon avulsion of the fifth digit. (A) Full extension is achievable; (B) however,

finger flexion is absent. (C) Radiographs demonstrate an avulsion fracture at the insertion

of the FDP. (D) The fracture fragment has retracted to the level of the A4 pulley. (E)

Repair was achieved by exposing the insertion site of the FDP, (F) advancing the FDP

from the A4 pulley back to its insertion site, and (G) suturing the tendon through the

boney fragment and distal phalanx over a dorsal button. A temporary Kirschner wire was

used to immobilize the DIP joint in extension to prevent a flexion contracture. Abbreviations:

DIP, distal interphalangeal; FDP, flexor digitorum profundus.


night for an additional six to eight weeks. Two splints can be provided, one for

bathing and a second for general use. Patients are instructed to support the tip

of the finger on the edge of a counter top during splint changes to maintain the

DIP joint in extension.

If extension is restored after six weeks of splinting, the finger is splinted at

night for six weeks and during the day while performing heavy tasks. The dur-

ation of splinting may be shortened in patients with stiff joints, such as elderly

patients and laborers. In patients with supple joints, and in injuries in which

the initiation of treatment is delayed, the splinting duration may be extended.

Fingers with a mallet and compensatory swan-neck deformity are treated with

a custom splint that maintains the DIP in full extension and the PIP in a slightly

flexed position (Fig. 6). The adequacy of joint positioning in the splint can be

confirmed with a lateral radiograph of the digit. In health-care workers, we

have had good success with a small thermoplastic splint that can be covered

with a glove or a clear, sterile adhesive wrap.

Mallet fractures can, in most instances, be treated with splint immobiliz-

ation using the same principles outlined above. We consider surgical treatment

for the subset of mallet fractures where more than 25% of the articular surface is

involved or the DIP joint is subluxated; however, we counsel patients that an

acceptable outcome can still be achieved with nonoperative treatment as

long as there is no compensatory swan-neck deformity. Splint immobilization

for this subset of injuries may result in a prominent dorsal bump, a modest

extensor lag, a partial loss of DIP flexion, and radiographic evidence of post-

traumatic arthritis. However, function is typically unimpeded, and the need

Figure 3 (Continued from previous page)

8 Butler and Baratz

Figure 4 Leddy Type III FDP avulsion repaired with screws. (A) The FDP insertion site is

avulsed as a single large fragment in a 28-year-old man. (B) A Brunner incision was used.

(C) The fracture fragment is stuck at the A4 pulley. (D) The articular surface of the middle

phalanx is visible through the fracture. (E) A secure repair was achieved with two screws,

but an unrecognized fracture of the dorsal cortex subsequently displaced. The fractures ulti-

mately healed without loss of reduction. Abbreviation: FDP, flexor digitorum profundus.

Figure 5 A bony mallet injury. (A) Lack of full extension of the DIP joint of the long

finger with slight hyperextension at the PIP joint (slight swan-neck deformity). (B) A

lateral radiograph demonstrates an avulsion fracture of the terminal extensor tendon

off the dorsal surface of the distal phalanx. Abbreviations: DIP, distal interphalangeal;

PIP, proximal interphalangeal.


for subsequent surgery is rare. This joint has a remarkable ability to remodel

following fracture.

Several surgical techniques have been used to treat mallet fractures

(18–20). Open reduction and internal fixation with screws or tension wires has

been associated with wound problems, infection, loss of fixation, and nail

deformity, but is still used by some surgeons (21,22).

Percutaneous dorsal extension block pinning is increasingly popular, and

good results have been reported (23,24). The DIP joint is flexed 908, and a

Kirschner wire is advanced at a 458 angle over the avulsed bone fragment and

into the dorsal aspect of the middle phalanx. The DIP joint is then extended,

and a second Kirschner wire is advanced longitudinally from distal to proximal

across the DIP joint (Fig. 7). Pins are left in place approximately four weeks.

At that time, the pins are removed and active exercises are initiated. A splint

may be worn for an additional two or three weeks.

Articular Injuries

An axial load across the DIP joint frequently produces an impaction or pilon

injury to the base of the distal phalanx. With a bending moment to the DIP

joint, a collateral ligament condylar avulsion may be produced. Alternatively,

there may be volar or dorsal subluxation of the joint (Fig. 8). An adequate

reduction can often be obtained and maintained with one or two transverse

Kirschner wires (Fig. 8). Occasionally, internal fixation with screws is

appropriate.

Fractures Associated with Wounds

Many distal phalanx fractures are open fractures with injury to the sterile matrix,

germinal matrix, or both. Although these are open fractures, infection is uncom-

mon, probably because of the rich blood supply in this area. However, antibiotic

Figure 6 (A) The patient depicted in Figure 5 was treated in a custom splint which

maintains the DIP joint in extension and PIP joint in slight flexion to account for the

tendency towards a swan-neck deformity. (B) A lateral radiograph with the finger in the

custom splint confirms adequate reduction of the mallet injury. Abbreviations: DIP,

distal interphalangeal; PIP, proximal interphalangeal.

10 Butler and Baratz

Figure 7 Percutaneous fixation of a bony mallet. (A) Inability to extend the DIP joint.

(B) Flexion of the bony mallet injury brings the avulsion fracture fragment into improved

alignment. (C) With the DIP joint flexed, a Kirschner wire was advanced from distal to

proximal into the dorsal aspect of middle phalanx at the level of the DIP joint. (D)

After confirming an adequate dorsal block to DIP extension. (E) A second Kirschner

wire was advanced distal to proximal across the DIP joint. (F and G) Reduction is verified

under image intensification. (H) In this case, pin caps were used to cover the ends of the

pins. Abbreviation: DIP, distal interphalangeal. Source: Photos courtesy of Alex Shin, MD.


coverage for staphylococcus and streptococcus with a single dose of 1 or 2 g of

intravenous cefazolin and tetanus prophylaxis given in the emergency department

may be prudent. Digital block anesthesia facilitates wound evaluation, debride-

ment, and irrigation.

The more proximal the fracture, soft-tissue injuries associated with distal

phalanx fractures are more severe. Tuft and shaft fractures frequently involve

injury to the nail bed because of its firm attachment to the periosteum of the

dorsal terminal distal phalanx. These injuries may benefit from removal of

the nail plate and repair of the nail bed with an absorbable suture (25), although

this is debatable. In many cases, suturing of the skin and nail bed will reduce the

fracture. In addition, repair of the nail bed also facilitates the subsequent

formation of a new smooth and esthetically appealing nail plate. However, if

the nail bed is irreparable, it may be difficult to cover the dorsum of the fingertip

after removal of the nail plate. In these circumstances, leaving the nail plate in

place may act as a biologic dressing.

When removed, the nail plate should be cleansed and inserted under the

eponychium to prevent adhesion between the germinal matrix and eponychial

fold and to provide protection and support of the fracture. One or two sutures

can be placed through the nail plate to prevent it from dislodging. Sutures

should be placed in a manner that facilitates their removal. If the nail plate is

absent or unusable, the foil from a suture pack may be substituted.

Figure 8 A 25-year-old woman had an impacted articular fracture after an injury playing

basketball. (A) There is impaction and comminution of the volar half of the articular

surface and dorsal subluxation of the joint. (B) A percutaneous reduction and fixation

was achieved.


Open fractures at the base of the distal phalanx usually involve injury to the

germinal matrix with the nail remaining firmly attached to the cuticle or perionyx

and distal to the nail bed. After irrigation and debridement, simple reduction of

the nail beneath the eponychium frequently results in fracture reduction

(26,27). However, this injury pattern is often rotationally unstable, and sup-

plementary fixation with a Kirschner wire is often required to obtain stability.

If injury to the nail bed is present, the nail plate should be removed, and the

nail bed repaired (25).

Open mallet fractures are treated using the method described by Doyle. The

joint is pinned in extension with a 0.045-inch Kirschner wire. The tendon and bone

are repaired to the distal phalanx with a pin, pull-out suture, or suture anchor.

SOFT-TISSUE COVERAGE

Fingertip amputations without exposed bone will heal by secondary intention

(Fig. 9); however, defects larger than 1 or 2 cm2 may benefit from soft-tissue

coverage as these may create a hook-nail deformity as the wound contracts

(3,4). Wounds larger than this or with exposed bone will heal, but may leave a

tender and easily reinjured fingertip. A major advantage of healing by secondary

intention is near-normal sensibility. Skin grafts and many local or regional flaps

will greatly reduce sensation.

Flaps used most frequently include the homodigital island flap and cross-

finger flap for the fingertips and a homodigital island or a modified Moberg for

the tip of the thumb. Thenar flaps are used occasionally in young patients

where the concern for a PIP joint flexion contracture is diminished. Local

advancement flaps, such as those described by Atasoy and Kutler, must be used

with caution as subcutaneous atrophy and fingertip sensitivity can result (28).

Thenar Flap

Thenar flaps are designed based on the flexible skin of the radial aspect of the

thenar eminence. This flap is ideal for fingertip injuries of the ring and small

fingers, but it is also useful for the long and index fingers. It is best suited for

younger patients with lax joints, such as young women. The flap should be

designed near the metacarpophalangeal (MP) joint crease. To minimize a

flexion contracture of the PIP joint, flexion should occur through the DIP joint

and MP joint of the finger. No more than 408 to 508 of flexion should occur at

the PIP joint. However, this can be difficult to control, and if more than 508 of

flexion is present at the proximal interphalangeal (IP) joint, an alternate

method of coverage should be considered as the joint is at increased risk for a

flexion contracture. The thumb should be palmarly abducted as this will minimize

the amount of flexion of the finger with the flap placed at the level of the MP joint.

The flap should be 1.5 to 2 times greater than the recipient area to ensure cov-

erage of the semicircular fingertip. The skin and subcutaneous tissue of the flap are


elevated off of the thenar musculature. Care should be taken to avoid injury to the

radial digital nerve and motor branch of median nerve. By designing an H-flap, it

may be possible to close the donor site. If primary closure is not possible, a full-

thickness graft is used to cover the donor site defect. This can be harvested from

the ulnar aspect of the hypothenar eminence or the medial aspect of the arm (29).

The flap is divided under a local anesthetic after 10 to 14 days.

In a review of 150 patients treated with the thenar flap, 96% good-to-

excellent results were obtained (30). Four percent of patients had a PIP joint

contracture and 3% reported transient donor site tenderness.

Cross-Finger Flap

Cross-finger flaps provide a predictable means to cover defects on the palmar

aspect of the digit. The choice of donor site for the cross-finger flap is commonly

Figure 9 Index fingertip amputation at two days (A and B), four weeks (C and D), and

eight weeks (E and F) after injury. Excellent cosmetic and functional results using healing

by secondary intention.


the long finger for the thumb, index, and ring fingers. The ring finger is usually a

donor for the small finger. The dorsal skin and subcutaneous tissue of the middle

phalanx of the donor finger is transferred to the palmar skin defect of the injured

fingertip. The base of the flap is adjacent to the tissue defect of the recipient digit.

The flap is elevated off the peritendinous fascia deep to the dorsal veins. Fingertip

coverage is more challenging than coverage for more proximal defects, particu-

larly for the long and ring fingers (Fig. 10). Covering the fingertip with tissue

from the adjacent finger requires flexing the injured finger so that transferred

tissue will reach the fingertip. Flexion can be minimized by designing an

oblique flap that angles toward the fingertip. Full-thickness skin grafts can be

Figure 10 Circular saw injury involving significant skin and soft-tissue loss to the volar

aspect of the middle and distal phalanxes of the ring and long fingers (A). Cross-finger

flaps were created using the dorsal skin of the middle phalanx of the index and small

fingers leaving peritenon over the now exposed extensor tendons (B). Split-thickness

skin grafts were then used to cover the peritenon (C). Adequate soft-tissue coverage

was achieved by reflection of the skin grafts volarly on a pedicle adjacent to the finger

to be grafted (D). Slight flexion of the ring finger PIP joint was required to advance the

finger flap from the shorter small finger to the distal tip of the ring finger. Abbreviation:

PIP, proximal interphalangeal.


used to cover the donor site and can be taken from the medial aspect of the

brachium. Flaps are divided at 10 to 14 days (31).

Homodigital Island Flap

The homodigital island flap is an excellent means to provide durable, sensate

coverage to the fingertip, particularly the ulnar aspect of the thumb, and radial

aspects of the index and long fingers. A paddle of skin and fat matching the

dimensions of the defect is harvested just proximal to the defect. The paddle is

raised with its nerve and vessel. Through a Bruner incision, the neurovascular

bundle is mobilized with the flap to the base of the proximal phalanx. The

combination of a mobilized neurovascular bundle and slight PIP joint flexion

allows the flap to be transposed to the distal defect (Fig. 11). Finger flexion

can be initiated immediately by using a dorsal block splint to prevent undue

tension on the bundle. The splint is discontinued after two weeks, and unrestricted

motion is permitted (32).

Moberg Flap

In 1946, Moberg described a palmar advancement flap for covering the tip of the

thumb. This flap includes the skin and subcutaneous tissue proximal to the defect

on the tip of the thumb. Midaxial incisions are made on the radial and ulnar

aspects of the thumb just dorsal to neurovascular bundle. The flap is elevated

Figure 11 A homodigital island flap was used to cover a fingertip soft-tissue defect

involving the radial and volar aspects of the index finger (A). After the radial neurovascu-

lar bundle was identified proximally (B), a full-thickness flap of skin and soft tissue was

then raised and advanced distally to cover the defect (C). Primary closure of the donor

site was not achieved, and a split-thickness skin graft was required (D).


off of the flexor sheath to the level of the MP joint. Flexion of the IP joint allows

the distal margin of the flap to reach the tip of the thumb MP joint (33). In a modi-

fication of the Moberg flap, the skin is incised at the MP joint converting the flap

to a neurovascular island flap. This allows the flap to reach the tip of the thumb

without the need for IP joint flexion (Fig. 12).

Free Toe Pulp Transfer

A free toe pulp flap from the great toe or the second toe can be used to cover

fingertip defects that cannot be covered by other means. The lateral border of

Figure 12 Partial thumb amputation (A and B) treated with a modified Moberg advance-

ment flap. After both neurovascular pedicles are identified and preserved, a pedicle of

tissue based on both these pedicles is advanced distally to cover the soft-tissue defect

(C and D). A skin graft is then used to cover the newly formed proximal skin defect

(E). Complete soft-tissue healing and nearly full ROM of the thumb MCP joint at six

months after injury (F and G). Abbreviations: MCP, metacarpophalangeal; ROM, range

of motion.


the great toe or the entire pulp of the second toe is harvested with its artery, vein,

and plantar collateral nerve. This is transferred to the defect accompanied by ana-

stamosis of the artery, vein, and nerve. The donor site is skin-grafted. Reported

results for this procedure have been variable. In one series of 12 patients,

partial or complete flap necrosis occurred in 38% of patients, cold intolerance

developed in 73%, occasional pain in 45%, and hypersensitivity in 36% (34).

In another series of eight patients, the only adverse outcome was cold intolerance

in 25% of patients (35). Few complications were observed at the toe donor site.

Average two-point discrimination improved to less than 9.8 mm.

CONCLUSION

Injuries to the distal phalanx are best managed when armed with an understand-

ing of the pertinent anatomy and options for treatment. Nonoperative treatment is

appropriate for most fractures, with the exception of articular fractures, widely

displaced shaft fractures, and fractures associated with avulsion of the flexor

digitorum profundus tendon. Open fractures require debridement and wound

care; care that can usually be provided in the emergency department. Advance-

ment flaps may be used to maintain digital length and provide a durable,

sensate fingertip.

REFERENCES

1. National Occupational Health and Safety Commission Worker’s Compensation Data

Base. http://nohs.info.au.com (accessed August 2004).

2. Zook EG. The perionychium: anatomy, physiology, and care of injuries. Clin Plast

Surg 1981; 8(1):21–31.

3. Verdan CE, Egloff DV. Fingertip injuries. Symp Pract Surg Hand 1981; 61(2):237–266.

4. Ditmars DM Jr. Fingertip and nailbed injuries. Occup Med 1989; 4(3):449–461.

5. Rosenthal EA. Treatment of fingertip and nail bed injuries. Symp Rehab After Hand

Surg 1983; 14(4):675–697.

6. Bell-Krotoski J. Advances in Sensibility Evaluation. Hand Clinics. Philadelphia:

Saunders, 1991.

7. Bell-Krotoski J. Sensibility Testing: State of the Art. Rehabilitation of the Hand.

3rd ed. St. Louis: Mosby, 1990.

8. Bell-Krotoski J. Light Touch–Deep Pressure Testing Using Semmes–Weinstein

Monofilaments. Rehabilitation of the Hand. 3rd ed. St. Louis: Mosby, 1990.

9. Shrewsbury MM, Johnson RK. Form, function, and evolution of the distal phalanx.

J Hand Surg 1983; 8:475–479.

10. Shum C, Bruno RJ, Ristic S, Rosenwasser MP, Strauch RJ. Examination of the

anatomic relationship of the proximal germinal nail matrix to the extensor tendon

insertion. J Hand Surg [Am] 2000; 25(6):1114–1117.

11. Schneider LH. Fractures of the distal phalanx. Hand Clinics 1988; 4:537–547.

12. Leddy LP, Packer JW. Avulsion of the profundus insertion in athletes. J Hand Surg

1979; 4:461–464.


13. Smith JH. Avulsion of a profundus tendon with simultaneous intraarticular fracture of

the distal phalanx—a case report. J Hand Surg 1981; 6:600–601.

14. Lester B, Jeong GK, Perry D, Spero L. A simple effective splinting technique for the

mallet finger. Am J Orthod 2000; 29:202–206.

15. Abouna JM, Brown H. The treatment of mallet finger: the results in a series of 148 -

consecutive cases and a review of the literature. Br J Surg 1968; 55:653–667.

16. Crawford GP. The molded polythene splint for mallet finger deformities. J Hand Surg

1984; 9A:231–237.

17. Stack HG. A modified splint for mallet finger. J Hand Surg 1986; 11B:263.

18. Bischoff R, Buechler U, De Roche R, Jupiter J. Clinical results of tension band

fixation of avulsion fractures of the hand. J Hand Surg 1994; 19A:1019–1026.

19. Damron TA, Engber WD. Surgical treatment of mallet finger fractures by tension band

technique. Clin Orthod 1994; 300:133–140.

20. Yamanaka K, Sasaki T. Treatment of mallet fractures using compression fixation pins.

J Hand Surg 1999; 24B:358–360.

21. Jupiter JB, Sheppard JE. Tension wire fixation of avulsion fractures in the hand. Clin

Orthod 1987; 214:113–120.

22. Kronlage SC, Faust D. Open reduction and screw fixation of mallet fractures. J Hand

Surg 2004; 29(2):135–138.

23. Mazurek MT, Hofmeister EP, Shin AY, Bishop AT. Extension-block pinning for

treatment of displaced mallet fractures. Am J Orthod 2002; 31(11):652–654.

24. Hofmeister EP, Mazurek MT, Shin AY, Bishop AT. Extension block pinning for large

mallet fractures. J Hand Surg 2003; 28A(3):453–459.

25. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and

prognosis. J Hand Surg 1984; 9A(2):247–252.

26. Robins RHC. Fingertip injuries. Hand 1970; 2(2):119–125.

27. Allen MJ. Conservative management of fingertip injuries in adults. Hand 1980;

12(3):257–265.

28. Ma GF, Cheng JC, Chan KT, Chan KM, Leung PC. Fingertip injuries—a prospective

study on seven methods of treatment on 200 cases. Ann Acad Med Singapore 1982;

11(2):207–213.

29. Schenck RR, Cheema TA. Hypothenar skin grafts for fingertip reconstruction. J Hand

Surg 1984; 9A(5):750–753.

30. Melone CP, Beasley RW, Carstens JH. The thenar flap—an analysis of its use in 150

cases. J Hand Surg [Am] 1982; 7(3):291–297.

31. Tempest MN. Cross-finger flaps in the treatment of injuries to the fingertip. Plast

Reconstr Surg 1952; 9(3):205–222.

32. Bidulph SL. The neurovascular flap in fingertip injuries. Hand 1979; 11(1):59–63.

33. Moberg E. Aspects of sensation in reconstruction surgery of the upper extremity.

J Bone Joint Surg 1964; 46A:817–825.

34. Ratcliffe RJ, McGrouther DA. Free toe pulp transfer in thumb reconstruction. J Hand

Surg 1991; 16B:165–168.

35. Deglise B, Botta Y. Microsurgical free toe pulp transfer for digital reconstruction. Ann

Plast Surg 1991; 26(4):341–346.


2

Phalanx Shaft Fractures

Mark S. Cohen

Department of Orthopedic Surgery, Rush University Medical Center,Chicago, Illinois, U.S.A.

INTRODUCTION

Fractures involving the hand are the most common of all skeletal injuries,

estimated at 1.5 million per year in the U.S.A. Phalanx fractures are particularly

problematic due to the propensity for stiffness and functional loss. The goals of

phalanx fracture treatment are restoration of anatomy and most importantly the

adjacent articular surfaces if involved. For displaced injuries, a stable reduction

is optimal with the least amount of surgical trauma. Early mobilization of the

hand allows for a more rapid return of function. However, immediate rehabilita-

tion is not essential for a favorable clinical result. This chapter covers the

principles of phalanx fracture treatment, from simple to complex injuries, with

a special emphasis on the indications and techniques of operative intervention.

FRACTURE EVALUATION

When evaluating an individual with a phalanx fracture, it is important to obtain a

proper history. The mechanism of injury can provide important clues as to the

energy level and potential instability of the fracture. Patient factors such as age,

hand dominance, occupation, and activity level help to individualize a treatment

plan. Examination should include a clinical evaluation of the injured digit includ-

ing sensory testing. Proper radiographs typically require three views: frontal,

lateral, and oblique projections, centered and perpendicular to the injured bone.

Occasionally, the latter provides the best visualization of fracture displacement.

21

Next, one has to determine the “personality” of the fracture. This is defined as

the inherent instability of the injury. Although the history and radiographs provide

information, occasionally the personality of the fracture can only be defined follow-

ing an attempted reduction. Some fractures, although displaced, are of low energy

with minimal periosteal stripping. Once reduced, these can be stable through an

Figure 1 (A) Frontal radiograph of displaced middle and ring fingers proximal phalanx

shaft fractures. Fractures appear to be unstable. (B) One manipulation led to an anatomic

reduction in the frontal and (C) lateral planes. This reduction appeared stable through a

limited arc of motion. The fracture was immobilized for three weeks. (D) Final extension

and (E) flexion several weeks after immobilization discontinued. Often the “personality”

of the fracture can only be defined following reduction. This fracture was clearly of low

energy with minimal periosteal stripping. It was a reducible and stable injury.

22 Cohen

arc of active motion and do not necessarily require surgical intervention (Fig. 1). If

initially displaced fractures are treated with immobilization alone, it is imperative to

document that the digit is not rotated. This requires active or gently passive flexion of

the finger as rotation is difficult to assess in extension.

The principles of phalangeal fracture care differ substantially from those of

metacarpal injuries. Unstable phalanx fractures tend to angulate dorsally (oppo-

site of the metacarpal) as the tension side of the bone is located anteriorly (Fig. 2).

In addition, unlike metacarpal injuries, phalanx fractures are particularly prone to

Figure 2 Illustration depicting the typical pattern of displacement of proximal phalanx

shaft fractures. The tension side of the bone is anterior resulting in dorsal angulation.

This and shortening lead to relative laxity of the extensor mechanism resulting in an exten-

sor lag at the proximal interphalangeal joint. Unlike metacarpal fractures, shortening is

poorly tolerated in the phalanges.

Figure 3 Cross-section through the proximal phalanx of a digit. Note the close approxi-

mation of the gliding surface of the extensor tendon which blankets the dorsal cortex and

the flexor tendons anteriorly. These anatomic features make phalangeal fractures particu-

larly prone to adhesions and stiffness.

Phalanx Shaft Fractures 23

adhesions and stiffness. This is due to the anatomy whereby the bony skeleton is

enveloped by the gliding surfaces of the flexor and extensor tendons (Fig. 3). Fur-

thermore, fracture displacement is much less tolerated at the phalanx level than in

the metacarpals. Although shortening of up to 1 cm (without rotation) can be

accepted in metacarpal fractures without functional loss, this is not the case in

the digit. Shortening of only 1 mm following a proximal phalanx fracture leads

to a 128 extensor lag at the proximal interphalangeal joint (Fig. 2).

REDUCIBLE AND STABLE INJURIES

As a general rule, phalanx fractures will heal adequately by approximately three

weeks to allow for protected rehabilitation. Non- or very minimally displaced

fractures can be immobilized in a cast or splint during this time, followed by a

gentle mobilization program with interval protective splinting. Fractures which

are displaced but which are deemed stable once reduced can be treated similarly.

However, these fractures have to be followed carefully, with consideration given

to weekly evaluation during healing. Redisplacement can occur in a cast and

during follow-up visits, the cast or splint should be removed, and the alignment

and rotation of the digit documented in partial flexion.

In stable proximal phalanx fractures (in reliable patients), consideration can

be given to the use of a functional brace (Fig. 4). The orthosis maintains the meta-

carpophalangeal joint in maximum flexion while leaving the interphalangeal

joints free for early mobilization. In this way, the extensor tendon functions as

a tension band helping maintain reduction of the fracture. Again, fractures that

Figure 4 Hand-based functional splint which can be used for proximal phalanx fractures

which are deemed stable. With the metacarpophalangeal joint at 908, the extensor tendon

functions as a tension band helping maintain reduction while allowing unrestricted inter-

phalangeal joint motion.

24 Cohen

are initially displaced and treated by closed methods must be followed very

closely due to the potential for loss of reduction.

REDUCIBLE AND UNSTABLE INJURIES

The majority of displaced phalangeal fractures are reducible by closed manipu-

lation. However, initial displacement and periosteal stripping make the fracture

unstable, and displacement recurs once external pressure is released. The

simplest method of treating reducible but unstable phalanx fractures is percuta-

neous Kirschner wire fixation. For oblique and spiral fractures, the pins can be

inserted from medial and lateral taking care to obtain purchase in both fracture

fragments. For more transverse fracture patterns, intramedullary pins, placed

antegrade from proximal to distal through the metacarpal head or metacarpopha-

langeal joint, can be used as well. More comminuted injuries can be amenable to

a combination of pinning methods (Fig. 5). The advantage of closed pinning is

that it obviates the need for an open approach to the fracture. If not opened,

these fractures rarely lead to digital stiffness and morbidity despite several

weeks of immobilization.

Belsky and Eaton described a very useful method of pin fixation for

phalangeal fractures that allows for early mobilization of the interphalangeal

joints. Percutaneous pins (typically 0.045 in.) are placed intramedullary from

an antegrade approach to maintain fracture reduction (Fig. 6). Functional

bracing can then be used to protect the construct while allowing for interphalan-

geal joint rehabilitation. Even if the pins are through the metacarpophalangeal

joint (our preferred method) and thus the extensor digitorum tendon, active

interphalangeal joint extension is possible through the intrinsic extensor

system. This greatly facilitates recovery of motion and function. The technique

is particularly useful for unstable proximal phalangeal base fractures that

typically occur at the proximal metaphyseal–diaphyseal junction with dorsal

comminution (Fig. 6).

An alternative method for treating oblique and spiral reducible and unstable

phalanx fractures involves limited internal fixation with screws placed through

very small incisions. This is termed “closed reduction and internal fixation.”

Limited midaxial incisions are used, and the lateral band of the extensor mecha-

nism retracted dorsally (Fig. 7). Typically, fracture reduction is maintained with

provisional Kirschner wires which are exchanged for 1.3 or 1.5 mm screws. Two

screws are required for adequate stability. Self-tapping implants make this

method much easier, obviating the need for tapping of the screw track.

However, the technique requires careful attention to detail. Special care must

also be taken with titanium screws. Owing to their ductility (the degree of

plastic deformation prior to failure), there is a small margin for error, and exces-

sive force or improper placement can lead to screw breakage (Fig. 7). With

internal screw fixation, early mobilization and return of function are possible.


This minimally invasive technique limits the morbidity of formal open reduction

and internal fixation (adhesions, extensor tendon lag, etc.).

Occasionally, reducible but unstable fractures can be effectively treated

with external fixation. This method is typically reserved for open fractures and

those with severe comminution where pin and/or screw fixation is not possible.

Figure 5 (A) Frontal radiograph depicting unstable middle finger proximal phalanx frac-

ture with comminution. This fracture turned out to be reducible and unstable. (B) Antero-

posterior and (C) lateral radiographs following percutaneous pin fixation. Note the

combination of pin methods utilized for this fracture with oblique and intramedullary

implants. This percutaneous technique obviated the need for open reduction with its

associated morbidity.

26 Cohen

Figure 6 (A) Anteroposterior and (B) lateral radiographs of middle finger proximal

phalanx base fracture. These are typically associated with dorsal comminution. The frac-

ture was reducible with manipulation. (C) Frontal and (D) lateral radiographs following

antegrade intramedullary pin fixation through the metacarpophalangeal joint. (E) Clinical

photograph of hand-based functional orthosis. The volar splint attachment maintains the

interphalangeal joints in extension between exercises. This is removable allowing inter-

phalangeal joint motion with the pins in place. (F) Note full interphalangeal joint

flexion obtained two weeks following surgery. This technique allows fracture stabilization

with early digital motion. Active digital extension is maintained through the intrinsic

muscles.


However, external fixation can be effective in certain closed injuries. An example

would be a severely comminuted periarticular fracture (Fig. 8). In this way, the

fixator can provide ligamentotaxis to maintain the articular surface and help

neutralize (protect) any pins that are used. External fixation provides adequate

Figure 7 (A) Frontal radiograph depicting long oblique fracture of the proximal phalanx

of the small finger. This fracture was reducible and unstable. (B) Intraoperative photograph

showing limited midaxial incision. Note the lateral band of the extensor mechanism cour-

sing obliquely in the wound. (C) Lateral band has been retracted dorsally allowing screw

placement. (D) Anteroposterior and (E) lateral radiographs following internal fixation.

Two 1.3 mm screws and one central 1.5 mm screw were used. Note that the distal

screw head was sheared off during placement. Titanium implants have low ductility,

and screw breakage can occur with excessive force.

28 Cohen

Figure 8 (A) Anteroposterior radiograph of a diaphyseal middle phalanx fracture of the

ring finger with an associated comminuted and displaced fracture of the distal interphalan-

geal joint. This fracture was reducible and unstable. (B) Postoperative frontal and (C)

lateral radiographs following percutaneous placement of an external fixator and a pin.

The fixator crosses the distal joint providing ligamentotaxis and neutralization to maintain

the reduction of both fractures. (D) Clinical photograph of the digit with the fixator in

place. (E) With this method, the patient has unrestricted motion of the metacarpophalan-

geal and proximal interphalangeal joints during fracture healing.


stability to allow for unrestricted mobilization of adjacent joints. Owing to the

close opposition of the fingers, the technique is probably most applicable to

the index and small fingers, where the fixator can be applied along the borders

of the hand.

IRREDUCIBLE PHALANX INJURIES

Irreducible fractures of the phalanges are those that cannot adequately be reduced

by closed methods. These require open reduction which is typically followed by

internal fixation. For the proximal phalanx, a dorsal skin incision is most com-

monly employed. For the best exposure, a longitudinal split is made through

the center of the extensor mechanism (Fig. 9). Lateral extensor sparing exposures

are possible, but make reduction and stabilization much more difficult and have

not been shown to significantly alter ultimate motion and function.

Care is taken to next open the periosteum of the phalanx, which is surpris-

ingly thick and often intact or only partially torn. For long oblique and spiral frac-

tures, interfragmentary screw fixation is best, using 1.3 and/or 1.5 mm implants.

The technique requires precision and attention to detail to a much greater extent

than that in larger bones. It is often helpful to open the fracture to appreciate its

anatomy in planning screw fixation. Care is taken to place the provisional pins

perpendicular to the fracture for optimal stability. These are then exchanged

for self-tapping screws. As a general rule, one should not place a screw closer

than three screw widths from a fracture spike to prevent fragmentation

(Fig. 10). The tip of the depth gage should be directed to the far cortex opposite

the fracture to decrease the potential for choosing too short of a screw (Fig. 11). A

countersink is important not only to limit hardware prominence, but also more

importantly to decrease stress risers as the screw is tightened. This also provides

greater contact between the screw head and the bone improving compression and

stability. Following fixation, the periosteum and extensor mechanism are meticu-

lously repaired in separate layers (Fig. 9).

Occasionally, irreducible oblique or spiral fractures that seem relatively

simple actually have significant nondisplaced fracture lines visible upon inspec-

tion. This makes screw fixation inadequate. A very useful technique to use in

these circumstances involves a composite tension band wiring technique

termed the “sidewinder” method. This involves parallel or crossed Kirschner

wires supplemented with fine monofilament wire which is wrapped around the

pins providing compression and stability (Fig. 12). The wire is placed in such

a way as to provide four strands across the fracture. This technique can be

useful as well in cases where screw fixation has failed, such as when a screw

has stripped or a spike fractured. It allows for stable fixation with a very low-

profile construct. We have found threaded pins to be helpful when using this

method, decreasing the chance for pin migration and helping anchor the wire

around the tips of the pins.

30 Cohen

Figure 9 (A) Anteroposterior radiograph of a comminuted and displaced proximal

phalanx fracture of the middle finger. The fracture was irreducible by manipulation. (B)

Intraoperative photograph during open reduction and internal fixation with interfragmen-

tary compression screws. Exposure is provided by splitting the extensor tendon dorsally in

the midline. (C) Complete closure of the periosteum over the hardware. (D) Anatomic

repair of the extensor tendon. (E) Postoperative anteroposterior and (F) lateral radiographs

following reduction and screw fixation.


An alternative to the sidewinder tension wiring technique involves trans-

osseous wiring. In this technique, mostly used for transverse fractures and par-

ticularly useful in amputations, an oblique pin is supplemented with

monofilament wire placed proximal and distal to the fracture through the bone.

Figure 10 Diagram depicting the closest safe position for a screw relative to a fracture

edge (shaded hole). Screws placed less than three screw diameters from a cortical margin

risk fragmentation of the fracture spike.

Figure 11 Placement of the depth gauge away from the fracture in obliquely placed

screws. Placing the depth gage tip on the near cortex may underestimate optimal screw

length. By placing the tip of the gage away from the fracture, the correct screw measure-

ment is obtained. This is especially important with self-tapping screws which require the

screw tip through the opposite cortex for purchase.

32 Cohen

Figure 12 (Continued on next page) (A) Anteroposterior radiograph of an oblique dis-

placed proximal phalanx fracture in the small finger of an adolescent male. The fracture

was irreducible due to soft-tissue interposition. (B) Intraoperative photograph depicting

sidewinder composite wiring technique used to stabilize the fracture. Note the nondis-

placed longitudinal fracture lines running proximal and distal to the fracture. These

made the fracture irreparable with screw fixation alone. The tension band wire supports

the fracture comminution that was appreciated only during open reduction. (C) Repair

of the periosteum and (D) extensor tendon following internal fixation. Note complete

coverage of the hardware with periosteum.


The fracture is reduced, the pin advanced, and the wire tightened providing ade-

quate stability (Fig. 13).

Plate fixation of the phalanges is reserved for irreducible transverse or short

oblique fractures. In addition, one can consider plate fixation in more complex

injuries involving a crush component with comminution of the bone where

early tendon gliding and soft-tissue mobilization is preferred (Fig. 14). It must

be understood; however, that plate fixation of the phalanges is fraught with

Figure 12 (Continued from previous page) (E) Anteroposterior and (F) lateral radio-

graphs depicting sidewinder fixation. Note that the wire was applied to obtain four

strands across the fracture. (G) Finger flexion and (H) extension in dynamic brace designed

to improve the mechanical advantage of the extensor mechanism and decrease the

occurrence of an extensor lag at the proximal interphalangeal joint. (I) Final flexion and

(J) extension of the digit. Note the proximal interphalangeal joint extensor lag despite peri-

osteal and tendon repair and early motion in a dynamic splint. Full terminal extension is

difficult to obtain following open reduction and violation of the extensor tendon.

34 Cohen

complications. The plate is typically positioned dorsally in a potential space

between the extensor tendon and the bone. Extensor adhesions and motion loss

are not uncommon, and a subset of plated phalanges require a second-stage

procedure involving hardware removal and tenolysis once bony union has

occurred to recover mobility. Screws that are too long can lead to flexor

tendon embarrassment (Fig. 15).

Although lateral plate placement is less problematic theoretically, this has

not been proven to be significantly better than dorsal plating and is much more

difficult. Newer smaller 1.3 mm implants are less bulky and may decrease

extensor tendon complications (Fig. 16). Whatever implant is chosen, attempts

are made to close some periosteum over the plate if possible. When applied in

compression for transverse fractures, the plates should be prebent to allow for

uniform compression of the cortex opposite the plate. The exception would be

Figure 13 (A) Anteroposterior and (B) lateral radiographs of displaced and unstable dia-

physeal fracture of the middle phalanx. The fracture was not reducible by manipulation

requiring limited open reduction. (C) Postoperative anteroposterior and (D) lateral radio-

graphs depicting transosseous wiring used for fracture fixation.


Figure 14 (Continued on next page) (A) Clinical photograph and (B) frontal radiograph

following roller/crush injury resulting in multiple proximal phalanx fractures. The frac-

tures were irreducible by closed manipulation. (C) Intraoperative photograph revealing

open reduction and internal plate fixation of the fractures. A dorsal plate was used

for the middle finger with bone graft and lateral plates for the index and ring fingers.

(D) Frontal and (E) lateral radiographs following internal plate fixation. (F) Clinical

photograph of final extension and (G) flexion. Crush injury associated with irreducible

and comminuted fractures can be an indication for plate fixation of the phalanges where

early mobilization is imperative.

36 Cohen

a short oblique fracture which is first reduced and stabilized by a single lag screw.

In this situation, the plate functions mainly in neutralization and is not prebent but

applied in neutral fashion without eccentric drilling of the screw holes.

It must be emphasized that any open reduction of phalanx injuries comes at

a cost, mainly an increased risk for extensor tendon adhesions and stiffness. This

is especially true when larger implants such as plates are required. To improve the

mechanical advantage of the extensor mechanism, dynamic splints have been

Figure 15 (A) Lateral radiograph of a proximal phalanx fracture treated with a dorsal

plate. Note that one of the proximal screws is too long protruding well past the anterior

cortex. (B) Clinical photograph of attempted digital extension. Note the significant exten-

sor lag. This is not uncommon following dorsal plating of the proximal phalanx. (C)

Photograph of attempted flexion. Limitation of motion is due to rupture of the profundus

tendon due to the sharp tip of the protruding screw. Plate fixation of the phalanges is

technically demanding and fraught with potential complications.



suggested following open reduction (Fig. 12). However, even with lower-profile

constructs, such as sidewinder wiring, and the use of aggressive rehabilitation,

loss of terminal extension is common when the extensor mechanism is

surgically violated. Fortunately, recovery of flexion is more predictable and is

more important for function. In addition, a minor degree of extensor lag typically

leads to minimal functional difficulties.

BIBLIOGRAPHY

Belsky MR, Eaton RG, Lane LB. Closed reduction and internal fixation of proximal

phalanx fractures. J Hand Surg 1984; 9A:725–729.

Birndorf MS, Daley R, Greenwald DP. Metacarpal fracture angulation decreases

flexor mechanical efficiency in human hands. Plast Reconstr Surg 1997;

99(4):1079–1083.

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Clin Orthop 1996; 327:21–28.


3

Dislocations and Fracture Dislocationsof the Metacarpophalangeal andProximal Interphalangeal Joints

Randy R. Bindra

Hand Surgery, University of Arkansas for Medical Sciences, Little Rock,Arkansas, U.S.A.

INTRODUCTION

Fractures and dislocations of the metacarpophalangeal (MP) and proximal

interphalangeal (PIP) joints are most commonly seen in younger patients and

often related to sporting activities. Appropriate evaluation and timely interven-

tion are essential in order to ensure good outcomes and to avoid long-term

morbidity from pain and loss of motion. Although most dislocations can be

managed nonoperatively, operative intervention is usually indicated for larger

fractures associated with dislocations. Surgical intervention requires a good

knowledge of the anatomy and surgical approaches as well as familiarity with

instrumentation for the fixation of small fragments. An aggressive postoperative

rehabilitation program is essential for return to sport or preinjury level of activity.

METACARPOPHALANGEAL JOINT

Surgical Anatomy

The MP joint is a synovial joint with congruent articular surfaces that allow

multiplanar motion of flexion/extension, adduction/abduction/flexion, and

circumduction. Side–side stability is provided mainly by the collateral and

41

accessory collateral ligaments and to some extent by the lumbricals and the inter-

ossei. The metacarpal head is not a perfect sphere but rather a condyloid surface

wider volarly giving it a trapezoidal shape in its axial section. The collateral liga-

ments run from the fovea on the metacarpal head dorsally to the tubercle on the

volar-lateral base of the proximal phalanx and hence tighten during flexion. Con-

versely, the accessory collateral ligaments that originate just volar to the proper

collaterals and insert onto the volar plate are taut in extension. Dorsal displace-

ment of the phalanx is resisted by the volar plate that attaches loosely to the meta-

carpal neck proximally and has a thick firm attachment to the volar surface of the

proximal phalanx. The dorsal capsule is thin and loose to allow flexion of the MP

joint and provides relatively little stability to the joint. The thumb MP joint is

similar to those of the fingers, but has less side–side mobility and a large vari-

ation among individuals in its range of flexion-extension. Because of the lack

of adjacent support, the MP joints of the thumb and the border digits, index

and small, are most commonly injured.

Dislocation of the Metacarpophalangeal Joint

MP joints can be dislocated in a volar or dorsal direction as defined by the

relationship of the proximal phalanx to the metacarpal. The latter is the most

common resulting from hyperextension of the joint from falling on the

outstretched hand. Dorsal dislocations may be “simple,” in that they are reducible

by closed means. “Complex” dislocations require open reduction. Volar dislo-

cations are extremely rare with only a handful of case reports in literature and

are almost always complex.

Pathoanatomy

Hyperextension of the MP joint disrupts the volar plate, which commonly tears

from its weaker metacarpal attachment. Unless there is associated twisting of

the finger, the collateral ligaments remain intact. In a simple dislocation, the

phalanx remains in contact with the dorsal surface of the metacarpal. The deform-

ity is clinically obvious with the finger stuck in a claw position of extreme dorsi-

flexion at the MP joint. With continuation of the displacing forces, the metacarpal

head is pushed through the volar structures whereby it can get “buttonholed” in

the process as the volar plate displaces dorsal to the metacarpal head. The

proximal phalanx loses all contact with the metacarpal head and assumes a

position dorsal and parallel to the metacarpal with a less severe clinical

deformity. This type of dislocation, referred to as a complex MP dislocation, is

irreducible by closed means and was first described by Kaplan (1). The metacar-

pal head becomes wedged between the natatory ligament that supports the web

space dorsally and the superficial intermetacarpal ligament of the palmar fascia

anteriorly. In the small finger, the tendons of the flexor and abductor digiti

minimi are displaced ulnarly, and the long flexor tendons with the lumbricals

become positioned on the radial side of the metacarpal head. In index finger

42 Bindra

dislocations, the metacarpal head is caught between the flexor tendons ulnarly

and the lumbrical radially. The neurovascular bundles come to lie close to the

palmar skin tightly stretched across the front of the metacarpal head placing

them at risk of injury during a volar surgical approach. Less commonly, an osteo-

chondral fracture may be sheared off from the metacarpal head or phalanx base in

the process.

Volar dislocations are invariably irreducible with one of various anatomical

structures blocking reduction. These include interposition of the volar plate torn

from the base of the phalanx, the dorsal capsule detached from the metacarpal (2)

or the junctura tendinum between the ring and small finger extensors (3), and com-

binations of entrapment of the volar plate with the collateral or dorsal capsule (4).

Imaging

Radiographs in three planes, frontal, lateral, and oblique, are essential for the

evaluation and diagnosis of MP joint injuries. Lateral views may be difficult to

interpret because of overlapping adjacent digits. A widened joint space or an

interposed sesamoid bone implies volar plate interposition and a complex dislo-

cation (Fig. 1).

Closed Reduction

An attempt at closed reduction is usually justified. Local anesthetic infiltration

with or without sedation to promote muscle relaxation is all that is required in

most cases. Unlike the reduction maneuver common to all dislocations, the

Figure 1 Complex dorsal dislocation of the thumb metacarpophalangeal (MP) joint. The

appearance of sesamoid bones in the joint space suggests that the dislocation is complex.

Note the relative benign clinical appearance.

Metacarpophalangeal and Proximal Interphalangeal Joints 43

application of traction is contraindicated in this injury as it may create a negative

pressure and draw the volar plate into the joint causing a complex dislocation.

The wrist and interphalangeal joints are flexed to relax the flexor tendons and

with application of gentle compressive force the MP joint deformity is accentu-

ated by hyperextension followed by gentle flexion. If successful, the joint will

flex easily and a full arc of active motion is restored. If there is a “springy”

resistance to flexion and full MP joint flexion cannot be achieved, the dislocation

is a complex one and requires surgery.

Surgical Management

Kaplan’s original description of the injury included open reduction by a volar

approach (1). Although this exposure allows excellent visualization of the

anatomy, the risk of injury to the digital neurovascular bundle is extreme. A

dorsal approach is safer in this regard and has been reported to be effective in

surgical management of these injuries (5).

Volar approach: An oblique incision is centered across the volar promi-

nence of the metacarpal head. The incision is planned to allow distal and proxi-

mal extension in a zigzag fashion if required. The moment the skin incision is

made, the volar-displaced neurovascular bundle should be identified and

retracted. Palmar fascia fibers overlying the metacarpal head are released. The

A1 pulley must then be divided to relax the flexor tendons. Soft tissues are

retracted to either side of the head, and the volar plate is flipped out of the

joint with a hemostat. The joint is reduced with direct dorsal pressure on the

head. The joint is usually immediately stable. In cases of extreme instability,

the volar plate can be reattached with bone anchors to the metacarpal neck.

Dorsal approach: A longitudinal incision is made over the joint, and the

extensor mechanism is split longitudinally. If intact, the dorsal capsule is incised

as well. The volar plate is visualized overlying the metacarpal (Fig. 2). With

distraction applied to the joint, the volar plate is divided longitudinally and

with the help of a hemostat pushed back volarly. The proximal phalanx is then

flexed to reduce the joint. The extensor mechanism is repaired with a continuous

nonabsorbable suture.

Postoperative Management

Once the joint is reduced, stability is assessed through its range of motion. Unless

there is a significant collateral ligament injury, the joint is typically stable through

its normal arc. Following reduction, the patient can be fitted with a dorsal splint

blocking the last 308 of MP joint extension. Active motion is encouraged

within the splint. The splint is discontinued by the end of three weeks, and

active mobilization is encouraged. With collateral ligament instability, the MP

joint is immobilized for three weeks allowing interphalangeal joint motion alone.

44 Bindra

Fractures of the Metacarpophalangeal Joint

Fractures that are intraarticular to the MP joint involve either the head of the

metacarpal or the base of the proximal phalanx.

Fractures of the Metacarpal Head

There are several patterns of intraarticular fractures of the metacarpal head. The

index finger metacarpal head is the most prone to fracture and the thumb is the

least (6). The following are common fracture patterns.

Type 1: Oblique fractures of the metacarpal head exit into the joint making them

intraarticular injuries. These occur most commonly at the border metacarpals

(Fig. 3). The free joint fragments are usually shortened and rotated due to the

fracture geometry. The protruding metaphyseal spike of the proximal fragment

will cause obstruction of motion and stiffness is likely if not reduced.

Closed reduction by traction and derotation can be achieved in some cases,

but the reduction cannot be maintained without the application of some form of

traction or internal fixation. The most optimal method of stabilization of this

articular shear fracture is surgical fixation with interfragmentary lag screws

(Fig. 4). Fixation provides adequate stability to allow early motion out of a

protective splint. Surgical approach is dorsal by splitting or retracting the

extensor apparatus over the MP joint.

Figure 2 Dorsal surgical approach for open reduction of the case shown in Figure 1.

(A) Intraoperative photograph demonstrates the interposed soft tissue on the dorsum of

the metacarpal. (B) The soft tissue is mobilized and partly excised to allow the metacarpal

head to be delivered dorsally reducing the joint.


Type 2: Osteochondral fractures of the metacarpal head are the result of

direct trauma to the knuckle of the finger. The most common etiology is from

“fight-bite” injuries. These open fractures require urgent debridement and joint

lavage along with antibiotic coverage aimed at oral flora. The fracture fragments

Figure 3 (A) Oblique fracture of the metacarpal head of the index finger. The fracture is

unstable and the head is depressed along line of obliquity. (B) The fracture has been stabil-

ized with lag screws.

Figure 4 (A) An oblique fracture of the metacarpal head has been approached dorsally

between the proprius and communis extensor tendons of the index finger. (B) The

displaced fragment is elevated and fixed internally with two lag screws.

46 Bindra

are generally small and treated by excision. A large osteochondral fragment that

is devoid of soft-tissue attachments will not heal without fixation. These should

be fixed rigidly using a headless screw to avoid hardware prominence in the

joint (Fig. 5).

Type 3: Collateral ligament avulsion fractures off the metacarpal head are

rare. The collateral ligament more commonly fails at its phalangeal insertion.

Smaller, nondisplaced fragments will heal if treated with immobilization.

Displaced fragments may fail to unite or heal in a displaced position leading to

ligamentous laxity and joint instability. Open reduction and fixation with a lag

screw is recommended for all displaced avulsion fractures. Small fragments

that cannot be fixed can be excised followed by repair of the ligament to bone

using bone anchors or transosseous sutures.

Type 4: Vertical fractures of the metacarpal head are rare. In this pattern,

the metacarpal head is split in the longitudinal plane as a result of direct

trauma. The fracture may occur in the sagittal or coronal planes. Longitudinal

fractures in the sagittal plane may be depressed due to the compression force

of the injury. Careful examination of the radiographs will demonstrate an appar-

ent widening of the joint space in comparison to the neighboring joints (Fig. 6).

Displacement or depression of the joint surface is an indication for operative

treatment. Open reduction by a dorsal approach allows access to the articular

fragments. The depressed articular surface can be elevated easily leaving a

defect that must be filled with bone graft to prevent subsequent collapse. If

possible, lag screws should be placed transversely to buttress the elevated

articular surface (Fig. 7).

Figure 5 (A) Osteochondral transverse fracture of the metacarpal head of the long finger.

(B) The fracture is exposed by a dorsal extensor splitting incision and internally fixed with

a longitudinally placed headless screw.


Coronal shear factures of the metacarpal head occur as a result of a shearing

force from the base of the proximal phalanx and are associated with a subluxation

of the MP joint which follows the displacement of the fragment. Such fractures

are difficult to treat nonoperatively due to the associated joint subluxation.

Figure 6 (A) Posteroanterior (PA) and (B) lateral views demonstrating a vertical fracture

in the sagittal plane of the metacarpal head with depression of the articular surface recog-

nized by the widened joint space.

Figure 7 (A) The fracture is approached dorsally and (B) the depressed articular frag-

ment is elevated. (C) The defect is grafted and stable fixation is achieved with two lag

screws as demonstrated radiographically.

48 Bindra

Smaller dorsal coronal fractures with stable joints can be treated by simple exci-

sion of the fragment as the dorsal articular surface of the metacarpal head does

not articulate with the phalanx in the arc of functional motion. However, larger

fragments have to be internally fixed to support the base of the proximal phalanx.

Volar coronal fractures pose the biggest treatment challenge. The pull of

the flexor tendons and the lack of support of the base of the proximal phalanx

results in volar subluxation of the MP joint. Although the joint can be reduced

by traction, the volar fragment remains displaced as it has no soft-tissue attach-

ments (Fig. 8). Open reduction is mandatory and has to be performed through an

anterior approach as the fragment cannot be visualized through the usual dorsal

approach to the MP joint. An anterior approach to the joint involves a zigzag

incision in the palm centered over the distal palmar crease (Fig. 9). The interval

between the neurovascular bundle and the flexor tendon sheath is developed.

The flexor tendons along with the intact flexor tendon sheath are reflected later-

ally off the volar plate by sharp dissection. The volar plate is then incised and

reflected distally. By maintaining traction on the digit to counteract displacing

forces, the fragment can be elevated to its normal position and fixed with tempor-

ary wires while the reduction is confirmed by radiography. At least two headless

screws or lag screws with the heads countersunk below the articular surface are

used. Joint stability is determined prior to closure. As visualization of the joint

surface is limited from the volar approach, intraoperative imaging is mandatory

to ensure that the joint is reduced and the articular congruity is restored (Fig. 10).

Figure 8 (A) Volar coronal fracture of the metacarpal head. Loss of joint space on the

posteroanterior (PA) view suggests joint subluxation that is confirmed with the (B)

oblique and (C) lateral views. The proximal phalanx follows the displaced volar articular

surface of the metacarpal head.


If secure fixation is achieved, protected motion can be early after the initial pain

and swelling are controlled. These fragments may develop late collapse due to

avascular necrosis.

Type 5: Transverse and comminuted metacarpal head fractures are usually

associated with significant comminution and are the result of violent injury to the

border metacarpals (Fig. 11). The injury is not uncommonly associated with sig-

nificant soft-tissue crushing and injury to the adjacent skeleton. Treatment in

these cases is dictated by the associated soft-tissue injury and often requires

open reduction and fixation (Fig. 12). Fixation of these fractures usually requires

some ingenuity using a combination of wires and screws and sometimes place-

ment of a neutralizing external fixator. Early mobilization may not be possible

in extremely comminuted and unstable fractures. Primary arthroplasty or arthrod-

esis may be considered in severe cases such as gun shot injuries where there is

significant loss of the articular surface of the joint.

Basal Fractures of the Proximal Phalanx

Fractures of the base of the proximal phalanx comprise 10% of all hand fractures

(7). These fractures can be classified into the following types.

Avulsion fractures: This is the commonest type and is usually sports-

related and results from avulsion of a variable-sized fragment off the volar-

lateral corner of the proximal phalanx (Fig. 13). Collateral avulsion from the

Figure 9 (A) The fracture is approached through a volar zigzag approach. (B) The volar

fragment is elevated with care to avoid stripping any tenuous soft-tissue attachments and

(C) fixed using screws directed dorsally. The screw heads are countersunk below the

articular surface.

50 Bindra

border digits can lead to significant symptoms of instability, whereas collateral

instability of the MP joint of inner digits may be asymptomatic in more sedentary

individuals. Anatomic reduction of the fragments should be the goal for all

collateral avulsion fractures in athletes or those with an active lifestyle and

Figure 10 (A) Frontal and (B) lateral radiographs postoperatively. The volar coronal

fracture has healed with minimal collapse of the volar fragment.

Figure 11 (A) Frontal and (B) oblique radiographs of a comminuted fracture of the

index metacarpal head caused by direct injury to the metacarpal head. The fracture was

irreducible by closed means and required open reduction.


injuries affecting border digits. Undisplaced or minimally displaced fragments

can be treated nonoperatively with immobilization in a hand-based splint.

Early motion with buddy taping to the adjacent digit may be considered by strap-

ping the digit to the one adjacent to the fracture. Thus, it is acceptable to strap the

long to the ring finger for a nondisplaced avulsion fracture from the ulnar corner

of the long finger proximal phalanx and to strap to the index finger for an avulsion

from the radial corner. If the fragment is displaced by more than 3 to 5 mm or

there is any joint subluxation, internal fixation must be considered regardless

of the size of the fragment as it is essential to restore integrity and correct

length of the ligament.

The border digits can be approached through a midaxial incision by dor-

sally reflecting the lateral band of the extensor apparatus to expose the fracture.

Avulsion fractures from the inner digits can be approached from a dorsal or volar

approach. Although the dorsal approach is easier to perform because of famili-

arity, the volar approach to the MP joint as described above is preferable as it

affords direct access to the fragment and allows better placement of a lag

screw compressing the fragment back to the phalanx (Fig. 14) (8). Depending

on the size of the fragment, one or two screws may be used for fixation. When

dealing with small fragments, careful drilling by hand using an oscillating

motion is preferable to powered drilling.

Compression fractures: The most common method of failure of the

proximal phalanx is a bending extraarticular fracture through the weaker

Figure 12 (A) Open reduction was performed using a dorsal approach. (B) After tempor-

ary fixation with Kirschner wires, (C) definitive fixation was performed using resorbable

radiolucent pins.

52 Bindra

Figure 13 (A) Frontal and (B) lateral radiographs of a radial collateral avulsion fracture

from the base of the proximal phalanx of the small finger. With a large fragment, displace-

ment can result in articular incongruity.

Figure 14 (A) Volar approach to the base of the proximal phalanx. (B) The flexor sheath

is left intact and reflected subperiosteally to expose the fracture (C and D). Care must be

taken to maintain the soft tissues attached to the fragment. (E) Fixation is achieved with

two lag screws.


metaphyseal bone. Less commonly, direct impact on the flexed MP joint drives

the metacarpal head into the phalangeal base resulting in an impaction fracture

with comminution and depression of the articular fragments (Fig. 15). Traction

alone is not effective in restoring congruity as articular fragments are displaced

into the metaphysis. Minor articular step-offs without angular deformity of the

phalanx may be treated nonoperatively, with early protected mobilization in a

removable splint. Surgical treatment is indicated when the articular surface frag-

ments are depressed more than 2 mm to prevent mechanical problems with MP

joint motion. Significant depression of the articular surface leads to rotational

deformity in flexion as the phalanx drops into a rotated position when the

depressed surface articulates with the radial head.

Preoperative workup with a computed tomography scan is helpful in

planning operative strategy. Open reduction of these injuries is challenging as

the fracture is comminuted and reduction requires careful elevation of tiny articu-

lar fragments. The base of the proximal phalanx can be exposed through a dorsal

tendon splitting incision and capsulotomy of the MP joint (Fig. 16). If the

metaphysis is largely intact, a dorsal metaphyseal window can be created

through which the articular surface is gently elevated back under vision. If

there is metaphyseal comminution, the cortical fragments are reflected to allow

access to the metaphysis from where articular fragments are gently elevated

back. The resulting metaphyseal defect is then packed with bone graft obtained

from the ipsilateral distal radius. An alternative such as allograft can be utilized

Figure 15 (A) Comminuted depressed fracture of the phalangeal base of the ring finger.

(B) Note the angular deformity of the phalanx at the metaphysis in addition to central

depression of the articular surface.

54 Bindra

at the discretion of the surgeon. The key to joint stability is packing the metaphy-

seal defect with bone graft. Additional stability is obtained by a buttress plate

applied to the lateral or dorsal surface of the phalanx although some authors

feel that internal fixation is not necessary (9). Early intermittent motion out of

a protective splint is started once the initial pain and swelling have subsided.

PROXIMAL INTERPHALANGEAL JOINT

Surgical Anatomy

The PIP joint functions as a hinge. The majority of motion is in the flexion-

extension plane with some allowance for minimal rotation and lateral movement

to allow some give when grasping objects of different shapes. The convex

surface of the proximal phalanx is only partially covered by the concave articular

surface of the middle phalanx. The proximal phalanx articular surface has two

condyles separated by a shallow sulcus into which fits a corresponding ridge

on the base of the middle phalanx providing some inherent bony stability.

Side-to-side stability of the joint is provided by collateral ligaments that run

from a notch just distal to the epicondyle of the proximal phalanx to insert onto

the anterior half of the lateral margin of the middle phalanx. The collateral liga-

ment has two distinct parts: a dorsal one that tightens during extension and a volar

one that tightens with flexion of the joint. Division of both these components can

Figure 16 (A) The metacarpophalangeal (MP) joint is exposed through a dorsal

approach to demonstrate articular incongruity. (B) The articular fragments have been elev-

ated with bone grafting of the metaphysis. (C) A lateral T-plate has been applied to correct

the metaphyseal angulation.


cause significant instability of the joint (10). An accessory collateral ligament

runs from the proximal phalanx to the lateral edge of the volar plate. The main

function of this ligament is to tension the volar plate and pull it proximally to

provide clearance for finger flexion. The volar plate is the third important stabi-

lizing structure and primarily prevents hyperextension of the joint. It is attached

distally to the base of the middle phalanx just volar to the articular surface. Proxi-

mally the volar plate gains attachment to bone by lateral extensions that attach to

the proximal phalanx just distal to and within the mouth of the second annular

pulley. The actual proximal edge of the plate remains free to move proximally

with digital flexion.

Dynamic stability of the PIP joint is provided by the central slip of the

extensor mechanism which is attached to the middle phalanx dorsally and the

flexor tendons that are held close to the joint by the third annular pulley attached

to the volar plate. In addition, the superficialis tendon also directly inserts by two

lateral slips on either side of the volar lateral edge of the middle phalanx over its

proximal third.

Proximal Interphalangeal Joint Fractures and Dislocations

Fractures may affect either the condyles of the proximal phalanx or the base of

the middle phalanx. The various fracture patterns are described below. Although

there are different patterns of injury, management principles are the same and are

discussed subsequently.

Condylar Fractures

Condylar fractures affect the younger population and are usually sports-related

(11). Sagittal fractures are caused by forced separation of the digits, whereas

coronal fractures can occur from impact on the joint in hyperflexion or in an

extended state. The small finger is most commonly involved and the long, the

least with equal incidence among the remaining digits (12).

Classification: Type 1: Unicondylar fracture with transverse metaphyseal

fracture occurs due to a combination of axial load with angular force and is stable

due to the transverse metaphyseal component. Unless initially displaced, these

fractures can be treated nonoperatively with early mobilization by buddy

taping to the digit adjacent to the fractured fragment.

Type 2: Unicondylar fracture with an oblique metaphyseal fracture of

varying length is by far the commonest accounting for one-half to two-thirds

of these fractures (Fig. 17). Owing to the obliquity of the metaphyseal fracture,

these fractures are highly unstable—even initially undisplaced fractures may

settle during the healing period and lead to an angular deformity of the digit.

Type 3: Bicondylar fractures with varying obliquity of the metaphyseal

component result in angular deformity that is less pronounced if there is equal

subsidence of both the fractured condyles. Stability of the fracture is determined

by the initial displacement and obliquity of the metaphyseal fracture component.

56 Bindra

Type 4: Coronal plane condyle fractures of the dorsal or volar part of the

phalanx head involve osteochondral fragments that are usually extremely

unstable injuries. If the fragment is displaced, there is associated joint subluxation

with proximal displacement of the middle phalanx.

Basal Fractures of the Middle Phalanx

Fractures of the base of the middle phalanx may or may not be associated with

dislocation of the PIP joint.

Type 1. Small avulsion fractures—volar or dorsal: These fractures

represent small fragments less than a third of the articular surface of the middle

phalanx base. The volar fracture is a relatively common injury occurring due to

a hyperextension force and represents an avulsion of the volar plate. Dorsal frac-

tures are less common and occur when the extended digit is suddenly bent by an

axial force causing an avulsion of the central slip of the extensor mechanism.

Type 2. Large avulsion fractures—volar or dorsal: When the size of

the detached fragment of the middle phalanx is more than 40% of the articular

surface, there is commonly associated joint instability and the PIP joint is

usually subluxated or dislocated dorsally. The joint instability is due to a combi-

nation of the loss of concavity of the middle phalanx base from displacement of

the volar lip and impaction of the articular surface along with disruption of

the collateral ligaments that remain attached to the volar fragment. Fracture

Figure 17 (A) A unicondylar fracture of the thumb proximal phalanx with an oblique

fracture line. (B) The fragment has collapsed resulting in a clinical angular deformity.

(C) Longitudinal alignment and articular congruity have been restored by open reduction

and screw fixation.


dislocations can be classified based on the degree of subluxation: A: ,25%, B:

25% to 50%, C: .50%. D: dislocated or on the amount of articular surface

involvement: Grade I: 0, II: 0% to 20% III: 20% to 40%, IV: .40% (13).

Type 3. Pilon fractures: Comminuted fractures that result in splaying of

the dorsal and volar cortices with compression of the central articular surface of

the middle phalanx are referred to as pilon fractures (14). Injury occurs due to

axial loading in neutral or hyperextension. Pilon fractures are highly comminuted

fractures with multiple small fragments that are often too small for internal

fixation (Fig. 18). The articular surface of the middle phalanx is disrupted and

if treated with immobilization without restoration of joint congruity and

alignment, results are poor with pain and stiffness of the joint.

Dislocations

Dislocations of the PIP joint can be classified by direction of the displaced middle

phalanx into dorsal, lateral, or volar.

Dorsal Dislocations

Dorsal dislocations of the PIP joint are by far the commonest type and occur as a

result of hyperextension injury to the digit. They may be associated with fractures

of the middle phalanx base anteriorly. The volar plate is avulsed from the base of

the middle phalanx usually with a small chip of bone. Larger avulsion fragments

Figure 18 (A) Posteroanterior (PA) and (B) lateral pilon fracture of the middle phalanx

base. There is comminution of the metaphysis with articular surface depression. (C and D)

Stability and joint congruity have been restored with open reduction and lag screw fixation

of the larger cortical fragments using a midlateral approach.

58 Bindra

are discussed below. The distal avulsion of volar plate in dorsal PIP dislocations

prevents entrapment of the plate within the joint in contrast to the MP joint in

which complex dislocations can occur due to volar plate entrapment within the

joint. In most dorsal dislocations, the volar plate maintains its attachments to

the proximal phalanx and its lateral attachments to the accessory collateral

ligament. These injuries are stable after closed reduction, and early motion is

encouraged providing hyperextension can be prevented by buddy taping or

dorsal block splinting. Postreduction films are essential to confirm concentric

reduction and exclude displaced bony fragments that may necessitate open

reduction (Fig. 19).

In more severe injuries, the collateral ligaments may also be ruptured at the

time of injury. Careful assessment of stability is essential after closed reduction of

the dorsal PIP joint. If the joint tends to dislocate when a position near full

extension is reached, extension block splinting should be used.

Lateral Dislocations

A more laterally directed force on the digit will cause the collateral ligament to

primarily fail. With continuing force, the volar plate is detached and the finger

dislocates laterally at the PIP joint (Fig. 20). The deformity is clinically very

Figure 19 (A) Dorsal dislocation of the ring finger PIP joint with small bone fragments

volar and dorsal to the PIP joint. (B) Closed reduction restored the volar plate avulsion

fracture, but there was an unexplained displaced dorsal fragment. The radial collateral

ligament was also clinically ruptured. (C) The joint was explored using a midlateral

approach and dislocated through the torn collateral ligament. (D) The dorsal fragment

was an osteochondral fragment consisting of almost the entire articular surface of the

middle phalanx. (E) This was restored and held with K-wires.


obvious. Closed reduction is usually successful and providing the joint can be

ranged without subluxation, early motion with buddy taping is permissible.

Primary ligament repair is advocated by some in athletes to ensure joint

stability, This can be achieved using a midlateral approach and repair with

bone anchors or transosseous sutures.

Volar Dislocation

Volar dislocations of the PIP joint are extremely uncommon. In an uncomplicated

volar dislocation, the central slip ruptures from the base of the middle phalanx

with or without a bony fragment (Fig. 21). In the more complex rotary

dislocation, there is an associated tear of the collateral ligament. The head of

the proximal phalanx can buttonhole between the lateral band and the central

slip which remains intact (15).

Simple volar dislocations can be reduced easily under digital block.

However, immobilization of the PIP joint in full extension for three to four

weeks is essential to allow healing of the central slip and prevention of a late

boutonniere deformity. Leaving the DIP joint free for active and passive

motions helps prevent volar subluxation of the lateral bands and extensor

mechanism imbalance. Complex rotary dislocations are irreducible and require

open reduction. A dorsal approach allows visualization of the interposed lateral

band. Once freed, the rent in the extensor apparatus is repaired and the joint is

reduced. Collateral ligament repair may be performed but is not absolutely

necessary. Early motion is commenced after surgery.

Figure 20 (A) Posteroanterior (PA) and (B) lateral views of proximal interphalangeal

(PIP) joint lateral dislocation in the ring finger. Note that the middle phalanx is aligned

with the proximal phalanx on the lateral view.

60 Bindra

Management of fracture dislocations require open reduction and fixation of

the displaced dorsal lip fragment and are discussed below.

Clinical Assessment

It is important to carefully examine a patient with a PIP joint injury. Malalign-

ment in the coronal plane usually suggests a depressed condyle fracture. The

PIP joint is swollen, and motion is invariably restricted. A significant dislocation

can be easily noted clinically, but minor subluxation is suspected when there is

severe restriction of joint motion. In a cooperative patient, it is often helpful to

try to pinpoint the area of maximal tenderness in order to localize the site of path-

ology. Continuity of the flexor and extensor tendons must be established by

asking the patient to gently move the digit in the desired direction.

Many patients with sporting injuries will have had the finger reduced or

splinted on the field prior to presentation to hospital. In such cases, it is very

helpful if information on the severity and original direction of displacement

can be gleaned from the patient. Thus, a joint that is normal on radiographs at

presentation may have been dislocated and management must be based on

history and physical findings.

Imaging

Evaluation of fractures around the PIP joint requires careful interpretation of

accurate PA, lateral, and oblique radiographs that are centered on the injured

Figure 21 (A) Simple volar dislocation with rupture of the central extensor slip.

(B) Volar fracture dislocation of the PIP joint with avulsion fracture of the central

extensor slip.


digit. Joint subluxation can only be adequately assessed on the true lateral view.

A coronal fracture of the proximal phalanx condyle can easily be missed if the

joint is stable. The only sign of the injury may be the presence of a double

projection in place of the normal single volar convexity of the proximal

phalangeal condyles.

Management of Condylar Fractures of the ProximalInterphalangeal Joint

Condylar fractures tend to cause joint incongruity and angular deformity of the

digit. Joint subluxation is less common and usually implies more severe injury

with associated ligamentous damage. Basal fractures of the proximal phalanx

and fracture dislocations follow the same management principles and are

discussed later.

Conservative Treatment

Nondisplaced fractures and joints stable after closed reduction can be treated

conservatively with immobilization in an intrinsic plus position. It is advisable

to repeat radiographs out of the splint after one week to ensure that there are

no signs of early collapse that can occur with almost two-thirds of oblique

unicondylar fractures. Buddy taping is an effective way of allowing protected

mobilization and can be started between two and three weeks. Most motion is

regained by six months, but swelling can persist for several months thereafter,

and some degree of residual swelling of the PIP joint is common. Patients

must be made aware of this at the time of presentation.

Some displaced bicondylar fractures are amenable to closed reduction by

traction. If a good reduction is achieved with less than a millimeter articular

displacement and normal rotational and angular alignment, immobilization

may be used. Usually, the displacement recurs when traction is released and

consideration may be given to application of continuous traction using

customized splinting or external fixation.

Operative treatment is indicated if closed reduction is not possible;

reduction cannot be maintained or is lost subsequently in the splint. Additional

surgery is also required if there is a middle phalanx volar fracture fragment

more than 40% of the articular surface or if the finger is unstable when extended

beyond 308.

Percutaneous Techniques

Fractures that are treated within a few days of presentation can be managed with

percutaneous techniques using either K-wires or miniature screws. The latter can

be inserted through specialized reduction clamps. The size of implant depends on

the fragment size, and good imaging is critical. Repeated blind attempts at

pinning may comminute small pieces or cause late collapse from thermal necro-

sis. In unicondylar fractures, a 0.6 or 0.9 mm K-wire is inserted into the fragment

62 Bindra

parallel to the articular surface through a stab incision. Using the wire as a joy-

stick, the fragment is realigned and the wire is driven through the opposite cortex.

Application of a clamp or forceps across the condyles externally will help to get

some compression across the fracture that cannot be achieved by the K-wiring

alone. A second wire may be passed in order to achieve rotational control. The

wires can be left outside the skin for removal at three weeks. Alternatively, a

small screw may be passed across the fracture using a targeting clap that

serves as a temporary fixation as well as a drill and screw guide. Newer cannu-

lated screws make the process even easier by allowing insertion of a screw

over a wire placed across the fracture.

Open Reduction

If treatment is delayed for more than 10 days, the organized hematoma and repair

tissue within the fracture may interfere with reduction. Anatomical reduction and

compression between the fractured fragments then requires open reduction. A

unicondylar fracture is approached through a midlateral incision defined by the

line joining the points formed by the flexion creases of the IP joints when the

digit is fully flexed (Fig. 22). Dissection is continued by elevation of the dorsal

skin flap to expose the lateral band of the extensor apparatus which is then

retracted dorsally with a skin hook after dividing the transverse retinacular

Figure 22 Steps in the operative management of unicondylar fractures. (A) The fracture

is exposed through a midlateral approach and a capsulotomy dorsal to the collateral liga-

ment. (B) A single K-wire is passed into the fragment after elevation. The K-wire is passed

through the opposite cortex for temporary fixation. (C) A small fragment screw is passed

across the fracture parallel to the K-wire. (D) The wire is then removed and replaced with a

second screw. (E) Final radiograph following internal fixation.


ligament. The collateral ligament is identified and a longitudinal capsulotomy is

made just dorsal to it. After washing out the joint hematoma, the articular surface

is visualized. The fractured condyle is mobilized with caution in order to avoid

stripping the collateral ligament and resultant loss of vascularity. A fine K-wire

inserted into the condyle will help with manipulation and reduction of the frac-

ture. Interposed granulation tissue is excised, and fracture surfaces can be com-

pressed by application of a reduction clamp whenever possible. The fracture is

temporarily fixed with a K-wire and a 1.5-mm screw is inserted parallel to it

after drilling. The K-wire is then removed and the wire track left is used for inser-

tion of a second screw. Screw length is critical and care must be taken to ensure

that the screw heads are well buried and that they do not protrude through the

opposite cortex to avoid impingement on either collateral ligament. Formal

repair of the transverse ligament of the extensor apparatus is not required. Post-

operatively, the finger is immobilized for comfort, and active motion with a pro-

tective splint is commenced after several days when the pain and swelling of

surgery are diminished.

Coronal condylar fractures pose the biggest management challenge.

Although clinical deformity is not immediately obvious due to limited motion,

a rotational deformity of the digit becomes obvious when mobility is regained

subsequently as the middle phalanx rotates when flexed onto a depressed

condyle. Displaced fractures lead to joint instability in flexion and left untreated

can lead to nonunion or malunion with significant joint stiffness. Nonoperative

treatment is ineffective as the condylar fragment has no soft-tissue attachment

and cannot be manipulated into position. The fracture is best exposed through

a lateral approach. The fragment is gently manipulated back into position and

can be fixed with a K-wire passed from dorsal to volar. The wire can be cut

close to bone and left buried with minimal risk of late migration. Alternatively,

the wire is passed through a stab incision from intact dorsal skin and can be left

outside for removal for three weeks. Screw fixation of these small fragments is

difficult but obviates problems associated with wires and provides better stability.

The screw is inserted from dorsal to volar using the lag screw technique (Fig. 23).

Again screw length is critical as a long screw will protrude through the articular

surface of the condyle on the volar surface and cause discomfort and impinge-

ment on flexion of the PIP joint.

Open reduction of bicondylar fractures requires good visualization and

access to the entire distal articular surface of the proximal phalanx. A curved

dorsal skin incision is made over the PIP joint and the extensor mechanism is

elevated in one of two ways. Either by making an incision between the lateral

band and extensor slip on either side or by creating a distally based V-shaped

flap with the apex of the V situated at the proximal third of the proximal

phalanx. A transverse capsulotomy will allow visualization of the joint. The

articular surface is first restored and provisionally held with a K-wire. The articu-

lar fragments are then stabilized to the shaft with an oblique K-wire. Although

this fixation will maintain reduction, it will not permit early motion, and

64 Bindra

consideration must be given to stable internal fixation with either a dorsal T-plate

or a laterally applied minicondylar plate. Although insertion of a lateral condylar

plate is technically more challenging, it causes less interference with the extensor

mechanism. The extensor tendon is repaired with nonabsorbable sutures.

Controlled active mobilization is started within a week.

Management of Dislocations and Fracture Dislocationsof the Proximal Interphalangeal Joint

In order to preserve motion that is imperative to normal hand function, the

goal of management of all PIP joint dislocations and fracture dislocations is to

restore joint alignment and to maintain adequate joint stability to allow early

functional range of motion exercises. Secondary goals are maintenance of

articular congruity and prevention of posttraumatic arthritis. The majority of

dislocations can be reduced by closed methods under digital block anesthesia

in the emergency room after which stability must be assessed through a range

of motion. All stable injuries and nondisplaced fractures can be managed

nonoperatively. When conservative measures fail, percutaneous techniques can

be employed to restore stability. Operative intervention for open reduction and

internal fixation are less frequently required and usually indicated for manage-

ment of late presentation.

Fractures that are associated with dislocation or subluxation of the PIP joint

usually involve the base of the middle phalanx. Volar lip fractures of the middle

Figure 23 (A) Unicondylar coronal fracture of the proximal phalanx. (B) The fracture

was stabilized with a single lag screw passed from dorsal to volar using a midlateral

approach.


phalanx which involve 40% or more of the articular surface are associated with

PIP joint instability and are a big management challenge.

Conservative Treatment

Closed reduction by traction and flexion of the PIP joint is successful in most cases

of PIP dislocations if seen within a few days after injury. Minor avulsion fractures

of the volar lip of the middle phalanx indicate volar plate avulsion and are a

common result of hyperextension injuries. Providing the joint is stable, these frac-

tures need no special management and the digit can be mobilized with buddy

taping to prevent hyperextension stress for three weeks. Splinting these injuries

in flexion is not necessary and will risk a flexion contracture of the joint.

In unstable injuries, the joint dislocates as the digit is brought into extension.

It is important to document the position at which this occurs. Immobilization of

the PIP joint in extreme flexion will stabilize the joint but lead to severe flexion

contracture and morbidity. If a position of more than 308 of flexion is necessary

to maintain reduction, consideration must be given to other methods of treatment.

A simple technique for treating dorsally unstable PIP joint fracture dislocation is

that of extension block splinting (16). This technique is applicable to cases where

closed reduction is achieved easily and where the fracture does not exceed 40% of

the articular surface of the middle phalanx. A splint is fashioned whose angle is

determined by the degree of flexion at which the PIP joint is stable. The flexion

angle is 108 more than the angle of stability determined by clinical examination

after closed reduction. The amount of flexion is reduced on a weekly basis by

about 25% and full extension is delayed for approximately six weeks.

Displaced chip fractures on the dorsum of the middle phalanx, however

small, are significant because they represent an avulsion of the central slip of

the extensor mechanism. Insufficiency of the central slip is not immediately

obvious because digital extension is maintained by the lateral bands. The triangu-

lar ligament holding the lateral bands eventually stretches causing the lateral

bands to subluxate volarly leading to hyperextension of the distal interphalangeal

joint and loss of ability to straighten the PIP joint—the boutonniere deformity.

The injured digit must be splinted with the PIP joint immobilized in full extension

for at least three weeks with the DIP joint free followed by gentle active

mobilization.

Percutaneous Techniques

The reduced but unstable PIP joint can easily be stabilized with a transarticular

pin. Although this technique may seem to be prone to stiffness, some authors

have reported results comparable to open reduction (17). An alternative technique

involves placement of a Kirschner wire as a block to PIP extension (18). The PIP

joint is reduced by applying manual traction and placing the joint into maximal

possible flexion. A smooth K-wire is then introduced percutaneously through the

center of the PIP joint to engage the distal articular surface of the proximal

phalanx. The wire is then driven obliquely into the shaft to engage the volar

66 Bindra

cortex of the proximal phalanx. The wire is left long outside the skin and effec-

tively forms a block to the last 308 of PIP extension. An extension-block K-wire

is more reliable than an extension blocking splint. The patient is put in a protec-

tive splint and instructed in pin care. Gentle active range of motion exercise is

started the next day and the wire is pulled after four weeks. It is essential to

monitor this pin closely, as a pin track infection may lead to a frank pyarthrosis.

Alternatively, continuous traction can be applied to the digit by applying

tension on a K-wire passed transversely across the middle phalanx. A 7.5 cm

radius circular frame is fashioned around the hand and incorporated into a

forearm splint (19). The amount of traction is adjusted by serial lateral radio-

graphs of the digit in the splint. The patient is instructed in passive motion of

the digit for 10 minutes every waking hour. The splint is discontinued after

three to five weeks. If adequate reduction of the articular surface of the middle

phalanx is not achieved by traction alone, the articular surface can be manipu-

lated percutaneously or by a small open incision. The fragments are then

stabilized by multiple small K-wires and traction is then applied (20).

Various forms of external fixators or K-wires have been described to treat

these injuries and consist of K-wires bent in tension (21), wires coiled into

springs (22), hinged device (23), force-couple devices (24), parallel spring-

framed systems (25), and pins and rubber (26). They are based on the concept

of providing stability by distraction of the soft tissues around the base of the

middle phalanx that stabilize and improve the alignment. It must be noted that

external fixation will not elevate all depressed and impacted fragments. Which-

ever form of external fixation is used, attempts should be made to elevate the

impacted fragments using a percutaneous blunt K-wire or freer dissector. External

fixators do have the advantage of avoiding soft-tissue stripping, soft-tissue dissec-

tion, and are not associated with the postoperative swelling seen after open

approaches. However, patients need to take care of the pin sites, and stiffness is

common. The simplest and most economic method is to create a low-profile

frame using K-wires as suggested by Haynes and Giddins (21). A wire is

placed across the proximal phalanx condyles, close to the axis of motion of the

PIP joint (Fig. 24). A second wire is passed transversely in the shaft of the

middle phalanx distal to the level of the fracture. The distal wire is then bent,

first 908 proximally, and then a second S-shaped bend is placed into the wire

and it is looped around the proximal transverse wire in such a way as to generate

tension and provide distraction to the joint. Early active motion is allowed with

this configuration and the wires are removed at three weeks. Postoperative radio-

graphs generally do show some widening of the middle phalanx base, but the

articular surfaces generally conform very well due to molding of the fragments

with motion (Fig. 25).

Open Reduction and Fixation

Operative fixation of fracture dislocations of the PIP joint involves reduction and

stabilization of the volar lip fracture of the middle phalanx thereby restoring joint


Figure 24 (A–F) proximal interphalangeal PIP joint fracture-dislocation treated with

distractor-external fixator. Creation of the distraction frame essentially involves bending

the distal wire to generate tension against the wire passed along the axis of the PIP

joint. Source: Courtesy of Dr. Grey Giddins.

Figure 25 (A) Lateral radiograph of a proximal interphalangeal (PIP) joint fracture-

dislocation. (B) This was treated by distraction external fixation frame created from

K-wires. (C) Note the remodeled articular surface of the middle phalanx following

active motion in distraction. Source: Courtesy of Dr. Grey Giddins.

68 Bindra

stability. A direct approach to the fragment can be undertaken using a volar

Bruner approach extending from the proximal digital crease to the distal

interphalangeal joint crease. The flexor tendon sheath is opened between the

A2 and A4 pulleys and reflected laterally. Often the sheath is torn in this

region and can be excised without any functional loss. The flexor tendons are

retracted to one side to expose the traumatized volar plate (Fig. 26). The plate

is mobilized by releasing its lateral attachments to the collateral ligaments and

reflected proximally. The attachments of the collateral ligaments to the base

of the middle phalanx are partially released in a volar to dorsal direction and

the digit is gently hyperextended until it is fully doubled over or “shotgunned.”

The volar fragment and the entire articular surfaces are then fully visualized.

Small comminuted fragments are removed and the major volar fragment

is elevated, reduced, and held either with a circumferential wire loop or with

two small screws passed from volar to dorsal (Fig. 27) (27). When the fragments

are small or too comminuted for fixation, an osteochondral graft obtained from

the dorsal lip of the hamate can be used to replace the volar lip of the middle

phalanx (28).

Pilon fractures can also be treated surgically but require considerable care

to avoid stripping soft-tissue attachments of small fragments. These fractures

may be better approached using a midlateral approach. By dividing the transverse

Figure 26 Volar approach for fixation of a large volar fracture of the middle phalanx

associated with dorsal proximal interphalangeal (PIP) joint subluxation. (A) The

flexor tendon sheath between the second and forth annular pulleys has been opened.

(B) The collateral ligaments have been released allowing the joint to be hyperexten-

ded and “shotgunned” open. (C) Reduction of the base of the middle phalanx articular

surface.


retinaculum, the lateral band of the extensor apparatus can be elevated giving

exposure to the fragments. Fixation is achieved using lag screws passed from

the dorsal cortex in the bare area between the two lateral bands.

A displaced larger dorsal fragment of the middle phalanx will result in joint

incongruity and instability from loss of the dorsal concavity of the middle

phalanx in addition to causing insufficiency of the extensor apparatus. Conserva-

tive treatment can be undertaken if the fragment is anatomically reduced with the

PIP joint in full extension. Separation more than 2 mm must not be accepted and

internal fixation with a pin or screw inserted from dorsal to volar percutaneously

or by open reduction.

SALVAGE

For those patients that present late where the articular surface of the middle

phalanx cannot be salvaged either due to displacement with healing or extensive

comminution, it is possible to restore some motion and stability by doing a volar

plate arthroplasty (29). This technique uses the volar plate to reconstitute the

volar aspect of the middle phalanx base. In order to create a volar plate arthro-

plasty, the joint is exposed with the usual volar approach retracting the flexor

tendons. When elevating the volar plate, it is essential to preserve length by divid-

ing it as far distally as possible right up to and including some volar periosteum of

the middle phalanx. The volar plate is then divided laterally along its attachment

to the collateral ligaments and reflected proximally. The PIP dislocation is then

Figure 27 (A) Anteroposterior and (B) lateral preoperative radiographs of a dorsal frac-

ture dislocation of the proximal interphalangeal (PIP) joint. (B) This was treated by open

reduction and fixation of the middle phalangeal fracture through a volar approach with

miniature screw fixation.

70 Bindra

reduced by inserting a dissector into the joint and using it as a lever. In delayed

cases, it may be necessary to excise scar tissue within the joint, partially release

the contracted collateral ligaments or do a careful dorsal capsular release. It is

essential to fully reduce the PIP joint and ensure that it can be fully flexed

prior to creating the arthroplasty. A 2 mm wide trough is then created along

the entire length of the volar margin of the middle phalanx for attachment of

the volar plate. A pullout wire placed through the distal volar plate is passed

through two drill holes at either edge of the trough and brought out on the

dorsum of the finger where it can be tied over a button. The joint is temporarily

pinned for two to three weeks, and active motion with dorsal block splinting is

started thereafter.

It must be emphasized that recurrent dorsal dislocation may occur even

after a properly performed volar plate arthroplasty. This is most commonly due

to inadequate bone remaining on the volar aspect of the middle phalanx to func-

tion as a hinge. With loss of the stabilizing effect of the concave base of the

middle phalanx, the dorsal pull of the central slip and superficialis tendon

create a rotational force that tends to subluxate the middle phalanx base. In

this case, joint stability requires restoration of a functional palmar buttress on

the base of the middle phalanx. This can be accomplished with an osteochondral

hamate graft as noted above.

SUMMARY

There are several different types of injuries affecting the MP and PIP joints. Some

are simple and easily treatable. The management of more severe injuries requires

knowledge of injury pathomechanics for recognition, surgical anatomy for open

reduction, and skill with internal fixation of small fragments. The basic prin-

ciples, however, do not change. The joint must be reduced, stabilized, and the

articular surface realigned with the least invasive methods possible. When

closed reduction is not successful, percutaneous or open techniques must be

attempted.

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23. Krakauer JD, Stern PJ. Hinged device for fractures involving the proximal interpha-

langeal joint. Clin Orthop Relat Res 1996; 327:29–37.

24. Agee JM. Unstable fracture dislocation of the proximal interphalangeal joint:

treatment with a force couple splint. Clin Orthop Relat Res 1987; 214:101–112.

25. Fahmy NRM. The Stockport Serpentine Spring System for the treatment of displaced

comminuted intraarticular phalangeal fractures. J Hand Surg 1990; 15B:303–311.

26. Suzuki Y, Matsunaga T, Sato S, Yokoi T. The pins and rubbers traction system for

treatment of comminuted intraarticular fractures and fracture-dislocations in the

hand. J Hand Surg 1994; 19B:98–107.

72 Bindra

27. Weiss APC. Cerclage fixation for fracture dislocation of the proximal interphalangeal

joint. Clin Orthop Relat Res 1996; 327:21–28.

28. Williams RMM, Kiefhaber TM, Sommerkamp TG, Stern PJ. Treatment of unstable

dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft.

J Hand Surg 2003; 28A:856–865.

29. Eaton RG, Malerich MM. Volar plate arthroplasty of the proximal interphalangeal

joint: a review of ten years’ experience. J Hand Surg 1980; 5A:260–268.


4

Operative Management ofMetacarpal Fractures

William B. Geissler and William O. McCraney

Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson,Mississippi, U.S.A.

INTRODUCTION

The hand is an instrument of both performance and protection. Accidents invari-

ably occur, resulting in fractures of the metacarpals and phalanges. The economic

cost of hand injuries is staggering. It is estimated that one-third of all injuries

involve the upper extremity. This involves 16 million patients per year in the

U.S. alone. It is estimated that 1.5 million hand fractures occur annually in the

U.S., which results in 16 million lost work days, 2 billion dollars in lost

wages, and 4 billion in costs to industry annually in the U.S. (1).

There are potential and specific problems and complications that may occur

with fractures of the hand. Hand fractures generally involve small fragments,

which may be difficult to anatomically reduce and securely repair. There is a

high risk for tendon and joint adhesions, due to the close association of both

the flexor and extensor tendons to the bone. This may result in joint stiffness

and permanent loss of motion. Surgical incision carries the risk of function-

limiting scar formation. The physician must always balance the potential

benefit of increased biomechanical stability that may be gained through surgical

management against the risk of potential scarring and stiffness.

Fracture fixation need not be absolutely rigid, but must be reliable and allow

for early rehabilitation. If surgical intervention is recommended, the implant

75

selected must provide sufficient structure stability to allow immediate active range

of motion in order to offset the increased risk of scarring and stiffness associated

with fracture exposure and fixation. Early fracture stabilization and rehabilitation

are utilized in an effort to reduce the elements of fracture disease—meaning the

stiffness and atrophy associated with prolonged immobilization.

It is important to remember that the majority of hand fractures are closed,

simple, and stable. The vast majority of hand fractures do not require operative

management. The intact, intrametacarpal ligaments prevent shortening of a frac-

tured metacarpal more than 3 to 4 mm (2). Most hand fractures demonstrate

minimal displacement, defined as less than 1 to 2 mm of translation and less

than 108 of angulation, and absence of rotational malalignment or substantial

visual deformity. These fractures can be treated with a brief period of immobil-

ization (or with protective splints that allow some motion—extension block

splints, for example) followed by active exercises (3–8).

Fractures with greater displacement, rotational malalignment, or substan-

tial deformity, multiple fractures, and fracture associated with greater soft-

tissue injury should be considered for operative stabilization. Second and fifth

metacarpal fractures are more likely to shorten as they only have the suspensory

effect of only one intrametacarpal ligament. It has been shown that approximately

78 of extensor lag develops in the finger for each 2 mm of residual metacarpal

shortening after fracture healing (9). The unbalanced pull of the extrinsic

flexor tendons and intrinsic muscles may cause dorsal angulation of the distal

fragment of metacarpal fractures (10,11). Angulation greater than 308, shortening

of more than 4 mm, or a combination of these two, interferes with the normal

intrinsic muscle dynamics of the hand and may cause weakness, clawing, and

potential cramping (10–12). Specifically, the metacarpals do not tolerate malro-

tation. It has been shown that 58 of malrotation may translate up to 1.5 cm of

digital finger overlap during flexion (8,13).

EXTRAARTICULAR BASE FRACTURES

The majority of extraarticular metacarpal base fractures are stable. Most fractures

are impacted, which results in a stable fracture configuration. However, when

associated soft-tissue trauma occurs, this can disrupt the intrinsic capsular liga-

ments and the fracture may become unstable, particularly when multiple metacar-

pal base fractures are involved. When multiple extraarticular base fractures are

present, open reduction and internal fixation are recommended (7,14) (Fig. 1).

A dorsal incision may be made, centered between the involved metacarpals,

and dissection is carried down to the base of the metacarpal. When fractures

involve the base or distal portion of the metacarpal, generally plate fixation is rec-

ommended. Plates are named for their anatomic shape and due to the proximal

location of the fractures, a T-shaped plate or mini-condylar plate may be utilized.

It is important to remember that when a T-plate is used it is important to place the

screws in the T-portion of the plate first. If the screws are placed first in the

76 Geissler and McCraney

longitudinal portion of the plate, the T-section of the plate may be kicked up and

not sit fully congruent on the base of the metacarpal. When the screw is then

placed in the T-portion after the longitudinal screws are already placed, this

screw may displace the fracture as it is being seated if the plate is not congruent

on the bone. For this reason, when a T-plate is utilized, always place the screws

on the T-portion first before the longitudinal section. This also aids in com-

pression of the fracture site.

INTRAARTICULAR METACARPAL BASE FRACTURES

Intraarticular metacarpal base fractures are most common in the small finger

metacarpal. The vast majority of these are stable and adequately aligned. The

extent of articular injury and, in particular, articular surface impaction may not

be apparent on plain radiographs, and computed tomography may more accu-

rately define the fracture. The articular fragments are small and difficult to

handle. If operative treatment is elected, it is wise to provide some means of

distracting the small finger metacarpal with respect to the carpus (a small external

fixator between the metacarpal and hamate may be useful in this regard), the frag-

ments are elevated and the resulting metaphyseal defect grafted with cancellous

bone from the distal radius, and the fragments are stabilized with small Kirschner

Figure 1 Open reduction internal fixation is recommended when multiple extraarticular

metacarpal base fractures are present. (A) A PA radiograph demonstrates extraarticular

base fractures of the index through small metacarpals. (B) A PA radiograph demonstrates

fixation of the multiple base metacarpal fractures. Each metacarpal fracture was stabilized

with a mini-condylar plate due to the position of the fracture near the base of the metacar-

pal. Abbreviation: PA, posteroanterior.

Operative Management of Metacarpal Fractures 77

wires, and—on rare occasions—with screws. It has not been clearly demonstrated

that operative fixation is superior to nonoperative treatment.

CARPAL–METACARPAL FRACTURE DISLOCATIONS

Carpal–metacarpal fracture dislocations are the result of high-energy trauma

(Fig. 2). The fifth metacarpal is most frequently involved (15). The fifth metacar-

pal carpal joint is a concave, convex saddle-type joint. This joint allows 208 to

308 of flexion extension at the base and allows the small finger to oppose the

thumb. Carpal–metacarpal fracture dislocations are classified as epiphyseal,

two-part, three-part, and comminuted.

Radiographically, a 308 oblique pronated view outlines the fifth metacarpal

base. This is very useful to gain further detail about the amount of displacement

of a fracture dislocation of the fifth carpal–metacarpal joint. The 308 oblique

supinated view particularly outlines the index and long metacarpal base and

the potential amount of articular displacement.

Two-part carpal–metacarpal fracture dislocations of the small metacarpal

are frequently unstable due to the pull of the extensor carpi ulnaris tendon. The

fracture tends to translate proximally due to the pull of the tendon on the

oblique slope of the fracture line. The fracture is easily reduced by longitudinal

traction and if the fracture fragment is small, two Kirschner wires may be placed

transversely from the fifth metacarpal through the fragment into the base of the

fourth metacarpal (Fig. 3). This adds further stability to the fracture configuration

by placing the pins into the base of the fourth metacarpal as well. It is particularly

important to note when placing Kirschner wires on the ulnar side of the hand, to

make an incision and insert the Kirschner wires through a soft-tissue protector, or

utilize an oscillating drill to prevent branches of the dorsal sensory branch of the

ulnar nerve becoming wrapped around the Kirschner wires as they are being

inserted. This avoids the potential for neuritis of the dorsal sensory branch of

the ulnar nerve.

Figure 2 Multiple carpal–metacarpal dislocations are uncommon. (A) A PA radiograph

showing dislocation of the carpal–metacarpal joints. (B) The dislocations were reduced by

open reduction and stabilized by Kirschner wire fixation.


Three-part intraarticular fractures may be stabilized either by K-wire,

T-plate, mini-condylar plate, or external fixation if there is extensive comminu-

tion present (Fig. 4). When Kirschner wires are utilized, they are placed through

the intraarticular fragments and advanced into the base of the fourth metacarpal

Figure 3 Two-part carpal–metacarpal fracture dislocations are relatively unstable. (A)

A PA radiograph showing the small radial-based fragment. The small metacarpal is at

risk to displace proximally secondary to pull of the extensor carpi ulnaris. (B) With

gentle longitudinal traction, the metacarpal was reduced and two Kirschner wires were

placed across the fracture site into the base of the fourth metacarpal for added stability.

Figure 4 (A) A PA radiograph demonstrating a two-part carpal–metacarpal fracture

dislocation. The fracture fragment is relatively large enough to accept screw fixation.

(B) A PA radiograph showing the fracture reduced by plate stabilization. Lag screw fix-

ation is utilized to capture the relatively large fragment at the base of the fifth metacarpal.


Figure 5 (A) A PA radiograph showing a comminuted fracture of the base of the fifth

metacarpal. (B) Due to the amount of comminution, the fracture was stabilized by

K-wire jail. Notice how the transverse Kirschner wire stabilizes the articular surface,

but also is advanced into the fourth metacarpal for added stability.

Figure 6 (A) Frequently, fractures of the base of the metacarpal may be associated with a

head fracture of the adjacent digit as demonstrated in this PA radiograph. (B) A PA radio-

graph demonstrating fixation of the metacarpal head fracture to the ring finger and Kirsch-

ner wire fixation to the base of the fifth metacarpal fracture.


for added stability (Fig. 5). It is important to remember that when a fracture of the

metacarpal base is identified on X ray, the head of the adjoining metacarpal must

be closely evaluated. Fractures of the head and base adjoining metacarpal frac-

tures frequently coexist (8) (Fig. 6).

METACARPAL SHAFT FRACTURES

The vast majority of isolated metacarpal shaft fractures are stable. Border meta-

carpal fractures are less stable due to lack of soft-tissue support. Transverse frac-

tures may angulate with the apex dorsally. This is due to the pull of intrinsic

musculature, causing the metacarpal head to flex. Owing to the mobility of the

saddle joint of the hamate, it is possible to accept up to 208 of angulation to trans-

verse fractures of the shaft of the ring and small metacarpals. The carpal–meta-

carpal joints of the index and long fingers are relatively immobile. Owing to the

lack of mobility to the index and long metacarpals, patients may not tolerate the

presence of a flexed metacarpal head in the palm, particularly with gripping. For

this reason, only 58 to 108 of angulation may be accepted for the index and long

metacarpals (16).

Most transverse isolated metacarpal fractures are stable. Because the cam

effect of the metacarpal head (the metacarpal head is wider anteriorly and the

collateral ligaments tighten in flexion) can lead to stiffness of the metacarpopha-

langeal (MP) joint if it is immobilized in extension, metacarpal fractures are

usually immobilized in a splint with the MP joints immobilized at approximately

708 of flexion. The interphalangeal joints are splinted in extension (17–19).

Multiple modes of fixation are available for unstable transverse metacarpal

fractures. Kirschner wire stabilization is particularly useful in patients who would

like to avoid the scar associated with internal fixation (Fig. 7). In an unstable fifth

metacarpal fracture, two Kirschner wires are placed transversely proximal and

two Kirschner wires are placed distal to the fracture line due to the motion at

the base of the fourth and fifth metacarpals. The pins are left outside the skin

and removed in the office approximately three to four weeks later. Digital

range of motion can be initiated while the pins are in place, but the disadvantage

of this is a potential increase in the risk of pin track infection.

Plate fixation can be useful in contact athletes or in patients that want to

return to work as quickly as possible (Fig. 8). For the metacarpals, 2-mm

plates are recommended. Four cortices both proximal and distal to the fracture

line are required for adequate fracture stability (7,8). Immediate digital range

of motion may be started after plate fixation, and strengthening is usually initiated

at four weeks postoperatively. Particularly, in the contact sport athlete, the patient

may be cleared to return to play in the first several weeks wearing a fracture brace

if it is felt adequate fracture stability has been achieved with plate fixation.

A number of surgical approaches have been recommended when multiple

metacarpal fractures are present (20). The easiest is a vertical incision centered

between the two metacarpal bones that are fractured. If fractures exist for the


index through small metacarpals, two longitudinal incisions may be made. One is

between the index and long fingers, and the second is between the ring and small

fingers. Alternatively, an oblique dorsal incision can be made or a straight trans-

verse incision may be made on the dorsum of the hand to approach multiple meta-

carpal fractures. The interval between the extensor digitorum communis tendons

is utilized. The periosteum is elevated and if plate fixation is utilized, it is import-

ant to close the periosteum over the plate to decrease extensor tendon irritation

from the plate itself. Unlike fractures of the phalanges, plate fixation of the meta-

carpals is very well tolerated, as the extensor tendons are not as closely adhered to

the bone as compared to the phalanges.

Lag screws are the implant of choice for spiral fractures of the metacarpals

(Fig. 9). To utilize a lag screw, the fracture line needs at least twice the diameter

of the bone (7,8,21–24). A minimum of two screws is required. One screw may

be placed perpendicular to the shaft, which helps prevent translation of the frac-

ture, and a second screw is placed perpendicular to the fracture to provide com-

pression of the fracture. Alternatively, the two screws may be placed bisecting the

angle of the fracture and the shaft (7,8,21–24). It is recommended that 2.0 or

1.5 mm screws be used if lag screw fixation is utilized for a spiral metacarpal

fracture (7,8,21–24).

Figure 7 (A) A PA radiograph showing a displaced fracture of the fifth metacarpal at the

junction of the middle and distal thirds. (B) Under fluoroscopy, the fracture was percuta-

neously reduced and stabilized. Two Kirschner wires were placed both proximal and distal

to the fracture site for stability. The advantage of percutaneous fixation is it is very

cosmetic which may be desirable in the female patient.


Oblique metacarpal fractures have a tendency to shorten along the oblique

slope of the fracture line, particularly the index and small metacarpals, due to the

lack of support of the transverse metacarpal ligament. With an oblique metacar-

pal fracture, the fracture line is usually too short for lag screw fixation alone and a

single lag screw needs to be neutralized by a plate. It is recommended that 2.0 or

1.5 mm screws and plates be used. Usually, the fracture is compressed by the lag

screw and once fracture stability is achieved, a T-plate or L-plate is then placed

on the dorsum of the metacarpal. Four cortices, both proximal and distal to the

fracture line, are required for adequate stability (7,8,21–24).

Figure 8 (A) Lateral radiograph showing a displaced transverse fracture of the long

metacarpal. (B) The fracture was stabilized by plate fixation. The patient was allowed

to return to sports in two weeks following suture removal in a playing cast.


When considering when to use a lag screw to stabilize a bone fragment, the

fracture fragment should be at least three times the diameter of the screw (7,8).

During open reduction, stabilization by a screw is preferable to a Kirschner

wire. The advantage of a screw over a wire is that it can compress the fracture

to provide added stability. If the fragment is large enough to place a Kirschner

wire, then it is usually large enough to compress with a screw. A 0.45 Kirschner

wire is equal in diameter to a 1.1 mm drill bit. Therefore, if the surgeon can get a

0.45 Kirschner wire into a bone fragment, this is the same size as the drill bit for

the 1.5 mm screw. The Kirschner wire can be removed and fixation can be

Figure 9 (A) PA radiographs showing spiral fractures involving the long and ring meta-

carpals. (B) Clinical radiograph showing the amount of rotation of the involved long and

ring digits secondary to rotation of the fracture fragments. (C) A PA radiograph demon-

strating lag screw fixation of the spiral fractures involving the long and ring metacarpals.

Lag screw fixation is the implant of choice in spiral metacarpal fractures.


improved by utilizing the screw. Similarly, a 0.065 Kirschner wire is equal in

diameter to a 1.5 mm drill bit. The 1.5 mm drill bit is utilized for placement of

a 2.0 mm screw. If the fracture fragment is large enough to support a 0.065

Kirschner wire, it is usually large enough for the fixation for improved stabiliz-

ation with a 2.0 mm screw.

METACARPAL NECK FRACTURES

Fractures of the metacarpal neck are very common (Boxer’s fracture). This is

usually the result of a direct impact from a clenched fist. It is important to be

wary of open injuries either to the fracture site or the joint itself. Excessive

palmar tilt to the distal head fragment can occur secondary to the pull of the

extrinsic flexor tendon. It is controversial how much angulation to accept to

the ring and small metacarpals. Most authors recommend accepting up to 308

to 408 of greater angulation. There should be no rotation or clawing deformity

to the finger. Owing to the more rigid carpal–metacarpal joint to the index and

long fingers, up to only 108 of angulation may be acceptable for metacarpal

head fractures that involve the index and long metacarpals (16,25,26).

Several methods of fixation have been recommended for metacarpal neck

fractures. These include transverse pinning of the metacarpal head into the adja-

cent metacarpal and intramedullary pinning. The latter is particularly appealing

because it keeps the wires away from the relatively mobile skin near the MP

joints thereby limiting the risk of pin track infection and also limits interference

with the extensor tendons.

For fractures that involve comminution, plate fixation with either a mini-

condylar plate or a T-plate may be an option as well (Fig. 10).

Figure 10 (A) A PA radiograph demonstrating a comminuted fracture to the metacarpal

neck of the fifth metacarpal. (B) The fracture was stabilized by a mini-condylar plate due

to the amount of comminution.


METACARPAL HEAD FRACTURES

Intraarticular fractures involving the metacarpal head are uncommon. These

fractures have been classified as vertical, horizontal, oblique sagittal, and

comminuted. A Brewerton (27) radiographic view is recommended to view

the articular detail of the metacarpal head (Fig. 11). This view is obtained

by flexing the metacarpal phalangeal joint and placing the dorsum of the

Figure 11 (A) Brewerton radiographic view showing the articular detail of the metacar-

pal heads. (B) A PA radiograph revealing the displaced intraarticular fracture to the long

metacarpal head. (C) The displaced intraarticular fracture was stabilized by lag screw fix-

ation. The fracture was approached by splitting the extensor digitorum communis tendon

and exposing the articular surface. Close attention was made to preserve the collateral liga-

ments, so it would not affect the blood supply to the metacarpal head.


hand flat on a cassette. This view outlines the articular surface to the

metacarpals.

The metacarpal head is approached by a dorsal incision. The central

slip of the extensor digitorum communis tendon may be split or may be

accessed between the sagittal band and the extensor tendon, particularly

between the long and ring metacarpals. In fractures involving the index

and small metacarpal head, the interval between the extensor digitorum com-

munis and extensor indicis proprius is utilized for the index finger and the

interval between the extensor digitorum communis and extensor digiti

minimi is utilized for the small finger. It is important to keep the soft-

tissue fragments attached to the bone fragments to prevent avascular necrosis.

Kirschner wires, lag screw fixation, or potentially headless cannulated screws

or plate fixation have all been recommended for comminuted intraarticular

fractures of the metacarpal head (Fig. 11). In very rare instances, metacarpal

phalangeal joint arthroplasty may be utilized in elderly patients with exten-

sive comminution (28).

CONCLUSIONS

Symptoms resulting from tendon adhesions and joint contracture are the most

common complications associated with hand fractures. Stiffness has been

directly correlated with the severity of the initial fracture and the presence

and severity of initial soft-tissue injuries and excessive immobilization greater

than four weeks. If internal fixation is considered, it must be adequately

strong enough to support early rehabilitation in order to prevent tendon adhe-

sions and joint contractures from forming. The worst scenario is to consider

open reduction internal fixation with poor stability that requires excessive

immobilization rather than early range of motion. Following the principles out-

lined in this chapter may potentially decrease the complication rate from these

very difficult fractures.

REFERENCES

1. Kelsey JL, Pastides H, Kreiger N, Harris C, Chernow RA. Upper Extremity Dis-

orders: A Survey of their Frequency and Cost in the United States. St. Louis:

Mosby, 1980.

2. Eglseder WA Jr, Juliano PJ, Roure R. Fractures of the fourth metacarpal. J Orthop

Trauma 1997; 11:441–445.

3. Barton NJ. Fractures of the hand. J Bone Joint Surg 1984; 66B:159–167.

4. Corley FG Jr, Schenck RC Jr. Fractures of the hand. Clin Plast Surg 1996;

23:447–462.

5. Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal

shaft fractures. J Am Acad Orthop Surg 2000; 8:111–121.


6. Stern PJ. Management of fractures of the hand over the last 25 years. J Hand Surg

2000; 25A:817–823.

7. Freeland AE, Geissler WB. Plate fixation of metacarpal shaft fractures. In: Blair WF,

Steyers CM, eds. Techniques in Hand Surgery. Baltimore: Williams and Wilkins,

1996:255–264.

8. Freeland AE, Jabaley ME. Open reduction internal fixation: metacarpal fractures. In:

Strickland JW, ed. Mater Techniques in Orthopedic Surgery: The Hand. Philadelphia:

Lippincott-Raven, 1998:3–33.

9. Strauch RJ, Rosenwasser MP, Lunt JC. Metacarpal shaft fractures: the effect of short-

ening on the extensor mechanism. J Hand Surg 1998; 23A:519–523.

10. Smith RJ. Balance and kinetics of the fingers under normal and pathologic conditions.

Clin Orthop 1974; 104:92–111.

11. Smith RJ. Intrinsic muscles of the fingers: function, dysfunction, and surgical recon-

struction. Instr Course Lect 1975; 24:200–220.

12. Birndorf MS, Daley R, Greenwald DP. Metacarpal fracture angulation

decreases mechanical efficiency in human hands. Plast Reconstr Surg 1997;

99:1079–1085.

13. Royle SG. Rotational deformity following metacarpal fracture. J Hand Surg 1990;

15B:124–125.

14. Freeland AE. Hand Fractures: Repair, Reconstruction, and Rehabilitation. Philadel-

phia: Churchill-Livingstone, 2000.

15. Lawlis JF III, Gunther SF. Carpometacarpal dislocations. J Bone Joint Surg 1991;

73A:42–58.

16. Ashkenaze DM, Ruby L. Metacarpal fractures and dislocations. Orthop Clin North

Am 1992; 23:19–33.

17. Burkhalter WE. Hand fractures. In: Green WB, ed. Instructional Course Lectures

XXXIX. Park Ridge: American Academics of Orthopaedics Surgeons, 1990.

18. Viegas SF, Tencer A, Woodard P, Williams CR. Functional bracing of fractures of the

second through fifth metacarpals. J Hand Surg 1987; 12A:139–143.

19. Konradsen L, Neilson PT, Albrecht-Beste E. Functional treatment of metacarpal

fractures: 100 randomized cases with or without fixation. Acta Orthop Scand 1990;

61:531–534.

20. Littler JW. Hand, wrist, and forearm incisions. In: Littler JW, Cramer LM, Smith JW,

eds. Symposium on Reconstructive Hand Surgery. St. Louis: Mosby, 1974.

21. Dabezies EJ, Schutte JP. Fixation of metacarpal and phalangeal fractures with minia-

ture plates and screws. J Hand Surg 1986; 11A:283–288.

22. Hastings H. Unstable metacarpal and phalangeal fracture treatment with screws and

plates. Clin Orthop 1987; 214:37–52.

23. Melone CP. Rigid fixation of phalangeal and metacarpal fractures. Orthop Clin North

Am 1986; 17:421–435.

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the proximal phalanges and metacarpals in adults. J Hand Surg 1986; 11B:103–

108.

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immobilization necessary? J Hand Surg 1989; 14B:165–167.

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27. Lane CS. Detecting occult fractures of the metacarpal head: the Brewerton view.

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langeal joint. Hand Clin 1994; 10:303–314.


5

Carpal Dislocations and FractureDislocations

Santiago A. Lozano-Calderon and David C. Ring

Department of Orthopedic Surgery, Massachusetts General Hospital, Boston,Massachusetts, U.S.A.

INTRODUCTION

Dislocations and fracture dislocations of the carpus are uncommon injuries.

Fracture dislocations of the radiocarpal joint are considered as a type of distal

radius fracture (1). The most common carpal dislocation is the dorsal perilunate

dislocation (2–6), named because the carpus dislocates dorsally around the

lunate, with the lunate remaining in its normal relationship with the distal

radius in most cases, and occasionally dislocating volarward. Perilunate injuries

follow a predictable circular progression of injury from the radial to the ulnar side

of the wrist with variations in the injury pattern arising from the fact that at each

point failure can occur through either ligament or bone (2,7). Other types of

carpal dislocations, including midcarpal, axial, and isolated carpal dislocations

and fracture dislocations, are rare (2).

Current concepts of carpal dislocations are derived from relatively few ret-

rospective case series, some anatomical observations, and collective experience

or wisdom. There is substantial variation in the reported radiological and clinical

outcomes (8), and there are many debatable issues in the management of these

uncommon injuries. It is clear, however, that even with early, accurate diagnosis

and appropriate treatment, substantial permanent wrist dysfunction should be

expected in most cases.

91

EPIDEMIOLOGY AND MECHANISM OF INJURY

Carpal dislocations and fracture dislocations occur in young patients with strong

bone that are involved in relatively high-energy injuries such as motor vehicle

collisions and high-energy falls (from a height, during sports, downstairs, etc.)

(2,9,10). Most patients are relatively young adult males: average 32 years of

age, range 16 to 78 years; 94% males (3,10–15).

Perilunate injuries are thought to occur with forceful wrist hyperextension,

ulnar deviation, and intercarpal supination. The spectrum of injury observed

reflects the injury forces and failure through ligament or bone at each anatomical

area. The proposal by Mayfield and colleagues that perilunate instability pro-

gresses from radial to ulnar around the lunate in four stages is consistent with

observed injury patterns: Stage 1 is injury to the scapholunate interosseous liga-

ment; Stage II adds dorsal dislocation of the capitate with respect to the lunate;

Stage III adds injury to the lunotriquetral ligament; and in Stage IV, the hand

and wrist return to normal alignment with the radius and the lunate dislocates

volarly (Fig. 1) (7,16,17).

At each stage, there are alternative bony or ligamentous injuries.

Progressing from radial to ulnar around the lunate these include: (i) radial

Figure 1 Mayfield described four stages of perilunate dislocation. The first stage is

rupture of the scapholunate interosseous ligament. Next the capitolunate joint dislocates

through the space of Poirier. The third stage is rupture of the lunotriquetral ligament.

Finally the lunate completely dislocates and the remainder of the wrist returns to

normal alignment with the radius. Source: From Ref. 7.

92 Lozano-Calderon and Ring

styloid fracture as an alternative to radiocarpal ligament injury; (ii) scaphoid

fracture instead of scapholunate interosseous ligament injury; (iii) capitate frac-

ture instead of capitolunate dislocation; and (iv) triquetral fracture instead of

lunotriquetral interosseous ligament injury (Fig. 2).

The injury mechanisms for rare carpal dislocations and fracture dislo-

cations are incompletely understood (18). The Mayo group has proposed the

reverse perilunar dislocation concept, suggesting that some perilunate injuries

may progress from ulnar to radial, resulting in relatively more severe ulnar

than radial injury. Following the example of Mayfield and colleagues, they

demonstrated a progression of reverse perilunar dislocations in cadavers. Three

stages were described: Stage 1 adds a tear of the lunotriquetral ligament; Stage 2

adds disruption of the palmar ulnar leash complex as well as the dorsal radiocar-

pal ligament and the dorsal intercarpal ligament; and Stage 3 adds a tear of

the scapholunate ligament with consequent perilunate dislocation (Fig. 3).

These injuries are thought to occur in extension of the wrist but with associated

hyperpronation at the moment of impact (19).

CLASSIFICATION

The first classification system for carpal dislocations and fracture dislocations

was proposed by Green and O’Brien in 1978 (18,20) in an attempt to help

resolve some of the inconsistencies and controversies in the literature. Their

most important contribution was a system that recognized perilunate dislocations,

lunate dislocations, and fracture dislocations as part of a continuum of injuries

with similar mechanisms. They proposed six groups based on the radiographic

Figure 2 Each of the areas of injury in a perilunate dislocation can occur either through

bone (the so-called greater arc) or through ligaments (the lesser arc). Source: From Ref. 2.

Carpal Dislocations and Fracture Dislocations 93

appearance of the injury: (i) dorsal perilunate and volar lunate dislocations;

(ii) dorsal transscaphoid perilunate dislocation; (iii) volar perilunate/dorsal

lunate dislocations; (iv) variants including four subgroups [transradial styloid

perilunate dislocation (subgroup A), naviculo-capitate syndrome (subgroup B),

transtriquetral fracture dislocation (subgroup C), and miscellaneous injuries

(subgroup D)]; (v) isolated rotatory scaphoid subluxation, which is divided in

subgroups A and B, acute scaphoid subluxation, and recurrent scaphoid subluxa-

tion, respectively; and (vi) total dislocation of the scaphoid (Table 1).

Figure 3 A reverse Mayfield progression has been described progressing from the luno-

triquetral ligament through the space of Poirier and then through the scapholunate liga-

ment. Source: Courtesy of Mayo Foundation 2002.

Table 1 Green’s and O’Brien’s Classification for Carpal Dislocations

Classification of Carpal Dislocations: (Green and O’Brien, 1978)

Dorsal perilunate/volar lunate dislocationa

Dorsal transscaphoid perilunate dislocationa

Volar perilunate/dorsal lunate dislocation

Variants

Transradial styloid perilunate dislocationa

Naviculocapitate syndrome

Transqtriquetral fracture-dislocation

Miscellaneous

Isolated rotatory scaphoid subluxation

Acute subluxation

Recurrent subluxation

Total dislocation of the scaphoid

aMost common patterns of injury.


Mayfield and colleagues modified this classification system after several

cadaveric studies contributed to an improved understanding of the mechanism

of injury. Their system has become the most widely accepted and utilized

system for classifying carpal dislocations and fracture dislocations. They classi-

fied carpal dislocations and fracture dislocations into four groups: (i) dislocations

and fracture dislocations of the lesser arc; (ii) dislocations and fracture dislo-

cations of the greater arc; (iii) variants; and (iv) radiocarpal dislocations and

fracture dislocations (16,17).

Lesser arc injuries—pure dislocations—include perilunate dislocations

and lunate dislocations (2,7,10). Greater arc injuries—perilunate fracture

dislocations (21–23)—include transscaphoid perilunate fracture dislocations

(fracture of the scaphoid rather than rupture of the scapholunate interosseous

ligament); trans-scapho-capitate fracture dislocations (fractures of the scaphoid

and capitate, instead of scapholunate and lunate–capitate ligament ruptures);

trans-scapho-capitate-hamate-triquetral fracture dislocations (fractures of the

scaphoid, capitate, hamate, and triquetrum instead of ligament rupture between

the lunate and these bones); and lastly, the volar transscaphoid perilunate fracture

dislocation (Fig. 4). The most prevalent of these injuries is the trans-scapho-

perilunate fracture dislocation (6,7,10,11,24–27). It has been proposed that

greater arc injuries result when greater forces are experienced by the wrist

during extension than during ulnar deviation and intercarpal supination (2,16).

Among Mayfield and colleagues’ Group 3 or variant injuries are fracture

dislocations that involve the radial styloid, the scapho-capitate syndrome (simul-

taneous fracture of the scaphoid and the capitate without lunate dislocation—

most likely just a reduced transscaphoid, transcapitate perilunate dislocation),

and the isolated dislocation of any carpal bone. The first subgroup, radial

styloid fracture dislocations, is the most common entity in this subset.

Watson and Jeffrey (2) proposed a classification with five injury types:

(i) perilunate dislocation, (ii) radiocarpal dislocation, (iii) midcarpal dislocation,

(iv) axial-carpal dislocation; and (v) isolated carpal injuries (2). The strength

of this system is its ability to account for all described carpal dislocations and

fracture dislocations according to the anatomic pattern of trauma.

Figure 4 The patterns of greater arc injury. Source: From Ref. 7.


Cooney and colleagues suggested classifying carpal dislocations and

fracture dislocations into five groups: (i) dorsal perilunate dislocations or lesser

arc injuries; (ii) transcarpal fracture dislocation or greater arc injuries, which

includes transstyloid, transscapho, scapho-capitate, and transtriquetral fracture

dislocation types; (iii) radiocarpal dislocations and fracture dislocations; (iv)

longitudinal or axial dislocations and fracture dislocations; and (v) isolated

carpal bone dislocations and fracture dislocations (Table 2).

DIAGNOSIS

Published case series of perilunate injuries emphasize a substantial percentage of

delayed diagnosis, between 25% and 43% (6,10,26,28,29). Factors that may

contribute to the potential for delayed diagnosis include: (i) association with

severe or life-threatening injuries that require emergent treatment; (ii) alcohol

intoxication and alcohol abuse; and (iii) misinterpretation of radiographs.

Clinical Diagnosis

A thorough secondary survey after primary resuscitation of a critically injured

patient with serial repeat examinations as the patient recovers will help to limit

the potential for a carpal dislocation or fracture dislocation to be overlooked.

During the inspection, the involved limb should be evaluated for open wounds

or penetrating trauma. These are uncommon, but in addition to the need for more

expedient operative treatment, they are also associated with diminished results

(10). Most injuries are associated with obvious deformity, pain, swelling, and

ecchymosis. Some patients may have instability or crepitation during palpation.

There is a substantial risk of acute carpal tunnel syndrome in association

with carpal dislocations and fracture dislocations. Careful evaluation of light

touch sensation and intrinsic hand muscle strength are important. Patients

should also be warned about the risk of developing acute carpal tunnel syndrome

after leaving the emergency room following reduction as this problem can

develop hours to days after the injury.

Table 2 Cooney et al.’s Classification for Carpal Dislocations

Dorsal perilunate dislocations or Lesser arc injuries

Transcarpal fracture dislocations or Greater arc injuries

Transstyloid injuries

Transscaphoid injuries

Scaphocapitate injuries

Transtriquetral

Radiocarpal dislocations

Longitudinal or axial dislocations

Isolated carpal bone dislocations

Source: From Ref. 11.


Radiographic Diagnosis

Perilunate injuries and even complete lunate dislocations can be overlooked

initially. Wrist anatomy is complex, and careful interpretation of good quality

radiographs is helpful in making a timely and accurate diagnosis. At a

minimum, good quality posteroanterior (PA) and lateral radiographs should

be obtained. Additional oblique views and radiographs made with the wrist in

traction may be beneficial.

It can be difficult to get good quality radiographs in an injured and uncom-

fortable patient. The PA view is made with the volar surface of the hand, wrist,

and forearm flat on the film, usually with the shoulder abducted 908, the elbow at

908, the wrist in neutral radioulnar deviation, and the forearm supported in neutral

rotation. The beam is focused on the midcarpus and is triggered at a distance of

40 inches, perpendicular to the hand. Proper alignment is confirmed as longitudi-

nal alignment of the axes of the middle finger, third metacarpal, and the radius

(30–32) (Fig. 5). The lateral projection is made with the hand, wrist, and

forearm placed perpendicular to the cassette. Alignment in neutral wrist flexion

is necessary and it is monitored by ensuring that the longitudinal axes of the

third metacarpal, capitate, and radius are aligned (Fig. 6). Appropriate rotation

can be confirmed in the film by the fact that the distal pole of the scaphoid

is located between the palmar surface of the capitate and the palmar surface of

the trapezium; the volar margin of the pisiform is between the volar surface

of the capitate and the volar tip of the distal pole of the scaphoid (30–32); and

the inferior pole of the lunate is between the capitate and the inferior pole

of the scaphoid.

Figure 5 In a posteroanterior radiograph of a normal wrist, the axes of the long finger

metacarpal, capitate, and radius shaft should align.


Interpretation of the radiographs should include careful evaluation of the

carpal arcs emphasized by Gilula and Weeks (33). He described two arcs that

correspond to the articular surfaces of the radiocarpal joint (proximal arc) and

the midcarpal joint (distal arc) in the PA radiograph. The continuous

and smooth shape of both arcs is an indirect sign of adequate positioning of

the carpal bones. Any alteration in this continuous pattern is an indication

of malalignment of one or more carpal bones. The proximal arc is formed by

the proximal articular surfaces of the scaphoid, the lunate, and the triquetrum.

The distal arc is formed by the articular surface of the head of the capitate,

the trapezium’s proximal articular surface, and the proximal articular surface

of the hamate (33) (Fig. 7).

In perilunate dislocations, the carpal height will be reduced, and an

overlap between the proximal and distal rows (lunate and capitate) will

obscure the midcarpal space. The carpal ratio (measurement of carpal height)

is calculated as the longitudinal length of the carpus (measured from the

distal articular radial surface to the capitate-third metacarpal junction),

divided by the longitudinal length of the metacarpal longitudinal length (2,7)

(Fig. 8). The average value is: 0.54 (range: 0.51–0.57) (34). An alternative

method for quantifying carpal height was developed to account for the fact

that many wrist radiographs do not include the entire third metacarpal. The

modified carpal height ratio is calculated as the ratio of the height of the

carpus to the height of the long axis of the capitate (Fig. 9). The normal

value of this modified ratio is 1.57, ranging from 1.52 to 1.62. A reduction in

the intercarpal space and an overlap of the carpal bones were described as

the “crowded carpal sign” by Klein and Webb (35).

Other things to look for on the PA radiograph include: (i) the lunate having

a triangular rather than a trapezoidal shape and overlaps with the capitate in both

Figure 6 The axes of the long finger metacarpal, capitate, and radial shaft should also

align on a lateral radiograph with the wrist in neutral flexion.


perilunate and lunate dislocations; (ii) the so-called “Terry Thomas” sign or

widening of the scapholunate space; and (iii) the “Scaphoid Ring” sign caused

by volar flexion and rotation of the scaphoid so that the distal pole is viewed

along its central axis, and the cortex forms a ring (PA view) (Fig. 10). Finally,

associated fractures of the radial styloid, scaphoid, capitate, triquetrum, and/or

hamate may be seen.

Figure 8 The carpal height ratio is measured as the quotient of the height of the carpus

from the lunate facet of the distal radius to the distal end of the capitate and the length of

the long finger metacarpal. It averages 0.54.

Figure 7 Gilula is credited with describing arcs defined by the proximal and distal articu-

lar surfaces of the proximal carpal row and the proximal articular surfaces of the distal

carpal row. Abnormal disjunction or overlap of the arcs is suspicious for ligament injury.


In the lateral view, the relationships of the radius, lunate, and capitate should be

carefully evaluated. In perilunate dislocations and fracture dislocations, the articular

relation between the radius and the lunate is maintained, but the capitate is dislocated

dorsally from its articulation with the lunate. When the lunate is completely dislo-

cated, the relationship between the capitate and radius is relatively normal, and the

Figure 9 A modified carpal height ratio is useful when the entire third metacarpal is not

included on the radiograph. The modified carpal height ratio is the quotient of the height of

the carpus over the height of the capitate. Its average value is 1.57.

Figure 10 Findings in X rays (antero-posterior projection) characteristic of perilunate

dislocations and fracture dislocations. (1) Broken Gilula’s arcs, (2) Terry Thomas sign

(scapholunate disruption), (3) crowded carpus sign, (4) triangular shape of the lunate,

(5) scaphoid signet ring sign (where the distal pole of the scaphoid looks like a

ring because it is seen on end), (6) reduced carpal height, (7) associated fractures.

Source: Template courtesy of Taleisnik.


lunate is dislocated volarly or dorsally according to the type of injury. Complete

volar dislocation is sometimes overlooked when the lunate is assumed to be the pisi-

form. The “empty” or “spilled teacup sign” has been used to emphasize the charac-

teristic appearance of the lunate when it is completely dislocated and rotated on a

hinge of intact volar radiocarpal capsule and ligament (Fig. 11B).

The normal capitolunate angle is 08 and any value above 158 is considered

abnormal. This angle is measured by drawing a line through the longitudinal axis

of the capitate and another one perpendicular to the axis of the lunate. The normal

scapholunate angle is less than 608 and any value above 808 is considered abnor-

mal. Values between 608 and 808 are considered borderline. This angle is

Figure 11 Complete lunate dislocation can occur in a volar (A, B) or a dorsal direction

(C, D), but dorsal is rare. Source: From Ref. 2.


obtained by drawing longitudinal lines through the longitudinal axes of the

scaphoid and the lunate on a proper lateral radiograph. The radiolunate angle

normally is 08 and any value greater than 158 is abnormal. This is measured as

the angulation between a line drawn through the longitudinal axis of the radius

and a perpendicular line to the longitudinal axis of the lunate (Fig. 12).

Radiographs taken while traction is applied to the wrist are useful for the

assessment of osseous and articular compromise. In complex injuries, computed

tomography may be useful to further characterize the injury, particularly any

associated fractures.

TREATMENT

Proposed treatments have included closed reduction and cast immobilization;

closed reduction, percutaneous pin fixation, and cast immobilization; and open

reduction and internal fixation. Factors associated with worse results include

delayed treatment, injuries associated with an open wound, and nonanatomic

reduction (2,10,26).

These are uncommon injuries and the best available evidence is from

large retrospective case series. There are no prospective clinical trials to

guide management of these injuries.

Treatment Techniques

Closed Manipulative Reduction

For acute injuries, a closed, manipulative reduction should be performed soon

after the dislocation is identified to limit the risk of acute carpal tunnel syndrome,

Figure 12 A patient with a transscaphoid perilunate fracture dislocation was treated with

open reduction. (A) The scaphoid was repaired with a screw. (B) The intercarpal and

midcarpal articulations were pinned temporarily with percutaneously inserted wires.


and to allow planning of operative repair at a more convenient time. Delayed

diagnosis usually necessitates open reduction.

Muscle relaxation facilitates manipulative reduction. In the emergency

room, this can be accomplished with a combination of conscious sedation (the

administration of short-acting benzodiazepine sedatives and narcotics to an

awake patient) with or without local or regional anesthesia (intraarticular

anesthesia, Bier block, or peripheral nerve block). The ideal setting for closed

manipulative reduction is the operating room where either a brachial plexus

block or pharmacological paralysis can be administered.

In either setting, muscle relaxation can be facilitated by finger-trap traction.

After anesthesia administration, the fingers are placed in the traps and the arm is

suspended with the elbow at a 908 angle. Weight of 5 to 15 kg of is suspended

from the brachium on a well-padded strap for about 10 minutes.

When muscle relaxation is established, the finger traps are removed to

allow manipulation. For a perilunate or volar lunate dislocation, with axial trac-

tion, the wrist is fully extended and then flexed with the thumb placed over the

lunate volarly (36). In this manner, the lunate is held in position with respect

to the radius, whereas the capitolunate joint and other carpal articulations are

reduced. An image intensifier is useful in order to confirm reduction while the

patient is still under optimal anesthesia. It is also much easier to get a good

quality lateral radiograph because it can be adjusted under direct radiographic

monitoring. If an image intensifier is not available, plain radiographs are obtained

as described above.

Closed Reduction and Cast Immobilization

The traditional recommendation for immobilization after closed manipulative

reduction was an above-elbow, thumb spica cast (4,6,11,20,25,28,37,38). It has

been recommended that the wrist be placed in as much flexion as it was when

reduction was achieved, and the forearm in some pronation to help realign the

scaphoid; however, this would increase the potential for acute carpal tunnel syn-

drome. After four weeks, the long-arm cast is replaced by a cast that immobilizes

the wrist and thumb, but not the elbow (a below-elbow, or short arm, thumb

spica cast) for an additional four weeks. After eight weeks of cast immobilization,

exercises to improve wrist motion and strength are initiated.

This protocol can result in reasonable short-term results (11,20). The series

of Cooney et al. included nine patients treated with closed reduction within a

week of injury and cast immobilization. Using the modified Mayo wrist score

(11), the results for patients treated with manipulative reduction and casting

had results comparable to patients treated percutaneously or with open operative

treatment.

This was the most popular method of treatment until approximately the late

1970s when concern regarding residual carpal malalignment led most authors to

prefer more invasive treatments (20,22,24,39–41). Adkison and Chapman (24)

reported that 68% of their patients had inadequate carpal alignment after


closed treatment. The results of closed treatment of fracture dislocations (greater

arc injuries) are particularly poor (2,7).

Closed Reduction and Percutaneous Pinning

Several case reports and case series advocate percutaneous fixation of the carpal

bones in order to improve the alignment of the carpal bones after closed reduction

(10,26,42). Raab et al. (42) compared small series of athletes with perilunate dis-

locations treated with either closed reduction and percutaneous pinning (five

patients) or open reduction and internal fixation (five patients). They noted a

more rapid return to sport in patients treated percutaneously (five weeks after

pinning compared to 10 weeks with open treatment), but it makes no sense

why this would be so other than the fact that the surgeon allowed the former

group to play sooner. Very little detail was presented regarding the function or

radiographic result, and the follow-up was very short.

Percutaneous pinning is technically demanding, particularly when fractures

are present. This technique should be done only if complete anatomic reduction

of the lunate, the capitate, and the scaphoid, including associated fractures, can be

achieved by closed reduction. It can be difficult to realign the carpal bones with

manipulative reduction alone (7,43). It may prove useful to insert temporarily

smooth Kirschner wires (0.062 inch diameter) into the lunate and the scaphoid

in order to directly correct rotational and angular malalignment. Next the sca-

phoid is pinned to the lunate and the capitate with several smooth Kirschner

wires (usually 0.045 inch diameter). Kirschner wires between the triquetrum

and lunate are also inserted. The pins can be trimmed so that they remain

under the skin to be removed at a second operative procedure or they can be

bent and trimmed outside the skin for later removal in the office. Traditionally,

the wrist is immobilized with a thumb spica, above-elbow cast for six weeks fol-

lowed by a below-elbow thumb spica cast for four weeks. It may not be necessary

to include the elbow, and the thumb in the cast and practice varies. The pins are

removed between 8 and 12 weeks after surgery.

The authors strongly feel that percutaneous fixation of displaced, unstable

scaphoid and capitate fractures cannot be adequately monitored with image inten-

sification alone. Wrist arthroscopy can provide adequate visualization to confirm

reduction; however, arthroscopic-assisted, percutaneous treatment of perilunate

fracture dislocations should be considered experimentally at this time.

Open Reduction and Internal Fixation

Open reduction and internal fixation is the only option for patients with delayed

diagnosis, inadequate reduction, acute carpal tunnel syndrome, and open wounds.

It is currently the treatment of choice for all types of carpal dislocations and fracture

dislocations (3,10,13,22,24,44). Open reduction facilitates alignment of the carpus

and provides direct assessment and repair of each injury component. It also allows

for removal of small osteochondral fragments which are not uncommon in

these injuries.


Various operative approaches have been suggested including volar, dorsal,

or combined exposures. Sotereanos et al. (13) reviewed the existing literature, but

did not find a clear advantage to one of these approaches.

Whatever approach is selected, intraoperative traction can facilitate

treatment, particularly with delayed treatment or whenever the wrist remains

dislocated. Intraoperative traction can be provided by sterile finger-trap traction,

which can be applied horizontally to facilitate the operative exposure. Alterna-

tively, an external fixator can be applied across the wrist and used to apply trac-

tion. This external fixator can then be kept in place after the surgery as an

alternative to a cast (1). This is particularly useful when treating acute injuries

where avoiding constrictive circumferential casts and dressings may help limit

swelling and finger stiffness.

The volar approach to perilunate injuries has several advantages including:

(i) an extended release of the carpal tunnel; (ii) potential access to the stouter,

more important volar aspect of the triquetrolunate interosseous ligament; and

(iii) repair of volar radiocarpal ligament injury. Disadvantages include: (i) the

preference of most surgeons to limit incision of the important volar radiocarpal

capsule leading to a more limited view of the carpus through the traumatic rent

in the capsule with consequently greater difficulty judging alignment and fre-

quent inability to see or repair the volar triquetrolunate ligament; (ii) no access

to the stouter, more important dorsal aspect of the scapholunate interosseous liga-

ment; and (iii) inadequate assessment of carpal fractures and technical difficulties

in their reduction and fixation.

The dorsal capsule is felt to be less important and is therefore more

readily incised in whatever manner the surgeon feels is most useful (transverse,

longitudinal, and oblique orientations have been described). The decision on cap-

sular incision is often facilitated by the nature of the traumatic capsular injury. A

very broad exposure (sufficient to see a scaphoid fracture and the lunotriquetral

joint) is obtained by mobilizing the extensor pollicis longus from the third

dorsal compartment transposing it radially into the subcutaneous tissues,

followed by elevation of the second and fourth dorsal compartments off of the

distal radius.

A 0.062-inch Kirschner wire is inserted into the lunate as a “joystick” to

realign the bone. The realigned lunate is then stabilized to the distal radius

with a 0.045 or 0.062-inch Kirschner wire. The scaphoid is realigned in a

similar fashion and then pinned to the capitate.

Most surgeons provide definitive stabilization with temporary smooth

Kirschner wires between the scaphoid and lunate, the triquetrum and lunate,

and the scaphoid and capitate (Fig. 12). Additional wires are often used. Tempor-

ary screws can also be used (Figs. 13 and 14). When screws are placed between

the scaphoid and lunate, and the lunate and triquetrum, the midcarpal joint can be

allowed to move sooner. One disadvantage of Kirschner wires is the risk of infec-

tion if they are left out of the skin (or if swelling results in them protruding

through the skin). The use of buried Kirschner wires or screws requires a


second surgery for implant removal. The wires or screws are left in place for at

least two to three months. Wires are protected with a cast, and the wrist is not

allowed to move for the entire time. With screws, wrist motion and exercises

are usually initiated within a month of surgery.

Figure 13 (A) A posteroanterior radiograph of a transscaphoid perilunate fracture dislo-

cation. The lunate is triangular in shape. (B) On the lateral capitolunate, dislocation is

apparent. (C) Upon dorsal exposure, dislocation of the carpus is apparent. (D) External fix-

ation and open reduction were accomplished. (E) A fracture of the scaphoid was reduced

dorsally and secured with a volar percutaneous screw. (F) The triquetrolunate interval was

temporarily secured with a screw.


Figure 14 A 40-year-old man injured his wrist in a motor cycle accident. (A) A PA

radiograph showed a transstyloid perilunate dislocation. (B) Complete dislocation of the

lunate was seen on the lateral radiograph. (C) The radial styloid fracture and the triquetro-

lunate and scapholunate intervals were secured with screws and the corresponding

ligaments secured with suture anchors. (D) The short radiolunate ligaments were also

repaired with a suture anchor. (E) A PA radiograph after screw removal shows good

carpal alignment. (F) The lateral radiograph also shows good alignment. (G) Good

function was obtained, (H) although the wrist was quite stiff. Abbreviation: PA,

posteroanterior.


The accessible portions of the interosseous ligaments can be repaired either

with small suture anchors or drill holes in the bones. The ligaments usually

remain attached to the lunate and need to be reattached to the scaphoid and

lunate (2). Some authors recommend repair of the volar portion of the triquetro-

lunate ligament because it is the stoutest portion of that ligament, but we believe

there is insufficient access to do this in most patients.

When the carpal bones are realigned and stabilized, the ligaments usually

line up into their correct positions, and may heal without direct repair. Although

the current preferred treatment is direct open repair, the advantages of this over

realignment and stabilization are unproven.

Associated Fractures

A fracture of the scaphoid can be reduced through a dorsal incision and repaired

with a countersunk dorsally inserted screw or a volar, percutaneously inserted

screw (Fig. 13). Fracture of the capitate is repaired from dorsal with a counter-

sunk screw. Fractures of the radial styloid and triquetrum can be stabilized

with Kirschner wires or screws (Fig. 14). Ulnar styloid fractures are approached

through a direct ulnar incision and repaired with a tension band wiring technique

(45). In some patients with extreme instability, temporary immobilization of the

wrist with a plate can be useful (Fig. 15). Some fractures are so complex that an

acute proximal row carpectomy is merited (Fig. 16).

PROGNOSIS/RESULTS

The data available to guide treatment and prognosis are of limited quality, a fact

that is not surprising given the relatively infrequency of these injuries. Most

studies are case reports or case series that combined different types of injuries

and different treatment options. Other problems are the short follow-up of

most of these patients and the various evaluation techniques and instruments

used in these studies.

Garcia-Elias et al. (26), in their retrospective review of 91 cases, reported a

statistically significant impact on clinical outcomes while using a modified

Witvoet and Allieu score (46), when treatment was delayed longer than one

week, reduction was not maintained appropriately, and the lunate had a signifi-

cant rotational component (26). Herzberg et al. (10) found a difference in

terms of clinical and radiological outcomes if treatment was delayed greater

than 45 days or if injury was open. The anatomical pattern of injury had a

more limited affect on the outcome.

Data that demonstrate an association between open injures and worse

prognosis (2,8,10,26) likely reflect greater displacement and more significant

soft-tissue damage. Series from Herzberg et al. in 1993 addressed this issue

after evaluating clinical outcomes of 166 patients with a modified Green and

O’Brien score instrument. They found a statistically significant correlation

between poor outcomes and open lesions.


Figure 15 A 25-year-old man sustained complex injuries to the hand and wrist. (A) This

injury oblique radiograph demonstrates a transscaphoid perilunate injury. (B) A lateral

radiograph suggests fracture dislocation of the index through small carpometacarpal

joints as well. (C) Anteroposterior and lateral radiographs demonstrate screw fixation of

the scaphoid and temporary plate fixation of the carpus. (D) Anteroposterior and lateral

radiographs after plate removal demonstrate healing and good alignment. (E) Half of

his wrist flexion and extension were regained. (F) His function is very good.


Figure 16 A 38-year-old man had a complex, widely displaced transscaphoid, transtri-

quetral perilunate fracture dislocation. (A) Fracture fragments extend well proximal in

the forearm. (B) The lunate is widely dislocated and fractured. (C) An acute proximal

row carpectomy was elected. The distal radioulnar joint was unstable. (D) The radial

styloid was secured with Kirschner wires and the wrist immobilized with an external

fixator. (E) The final radiographic result was good. (F) Reasonable function was restored

given the complexity of the injury.


Russell (6) reviewed 59 patients with wrist dislocations and fracture dislo-

cations and found an association between nonanatomical reduction and dimin-

ished wrist function. In Pai’s series of 20 patients, diminished results were

observed in patients that did not have initial anatomic reduction or presented

with malunion or secondary degenerative arthritis. Herzberg et al. (10) reported

better outcomes in patients that achieved anatomic reduction and adequately

maintained it independent of the fixation method. Altissimi et al. (25), in their

analysis of 19 cases, found worse results in patients that did not have initial ade-

quate and stable reduction. In general, they progressed to chronic stability and

secondary degenerative arthritis. Lastly, one of the largest series confirming

this association of good outcomes and initial adequate reduction is the series of

Garcia-Elias (91 patients) where good outcomes were statistically significantly

related to the carpal alignment (26). This concern of anatomic reduction is par-

ticularly true in fracture dislocations, where nonunion and avascular necrosis

are also associated with nonanatomic reduction, as reported in series and case

reports (5,6,10,25,26).

The influence of surgical technique is less well established. As a general

rule, it seems that techniques that achieve and maintain anatomical reduction

are correlated with better results (3,10,22,24,44,47).

Older series suggested worse outcomes in patients with fracture dislo-

cations (6,13,25,38,48); however, more recent and larger series have not born

this out (10,13,49). Herzberg et al.’s review of 166 patients and Garcia-Elias’

review of 91 patients found no correlation between clinical outcomes and type

of lesion.

COMPLICATIONS

Median Neuropathy

Rates of incidence for median neuropathy in association with carpal dislocations

and fracture dislocations range from 11% to 45% in various series

(20,24,26,28,44,48). Median nerve symptoms resolved in most patients even

when the carpal tunnel was not released; however, we believe that carpal

tunnel release is merited in the presence of any median nerve symptoms or

dysfunction and should be strongly considered for all high-energy injuries with

substantial swelling even when median nerve dysfunction is not present.

Avascular Necrosis

It is quite impressive that avascular necrosis is extremely uncommon after these

injuries in spite of the dislocation, soft-tissue injury, and inherently limited

blood supply to the carpal bones. When this rare complication presents, it

seems to depend on the initial degree of displacement and the injury to the

capsular flap where the lunate usually attaches (10,11,13,26,27,48). Avascular

necrosis seems most frequent in perilunate fracture dislocations treated closed


leading to scaphoid nonunion and avascular necrosis of the proximal

pole (11,26,50).

Late Complications/Salvage Procedures

The most common late complication is arthrosis. Salvage options include total or

partial wrist arthrodesis and proximal row carpectomy. Patients must be willing

to sacrifice motion and be exposed to the risks of surgery for the goal of

pain relief (51–54).

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Am 2000; 82A(4):578–592.


6

Fractures of the Scaphoid

Satoshi Toh

Department of Orthopedic Surgery, Hirosaki UniversitySchool of Medicine, Hirosaki, Aomori, Japan

INTRODUCTION

Scaphoid fractures are prevalent in young, active people. There is often a strong

desire to return to sports or work. Delayed diagnosis and nonunion of the

scaphoid are fairly common as well, probably as a result of several factors,

including the difficulty of radiographic diagnosis of nondisplaced fractures and

underestimation of the injury by the patient.

The goal of treatment is solid union in good alignment. Malalignment

[either malunion (1) or nonunion with malalignment] contributes to a dorsal inter-

calated segmental instability (DISI) deformity (2–4) that may be followed by

carpal collapse and eventual osteoarthrosis (5–7)—the so-called scapholunate

advanced collapse (SLAC) (8) or scaphoid nonunion advanced collapse

(SNAC) wrist (9).

The development of countersunk, variable pitched screws (such as the

Herbert screw) improved fixation of scaphoid fractures (10). Percutaneous

screw insertion—which we and others developed with the standard Herbert

screw—has been greatly facilitated by the development of cannulated screws. Per-

cutaneous screw fixation has become an accepted alternative to cast immobiliz-

ation for the treatment of nondisplaced fractures of the scaphoid and allows

patients to avoid prolonged cast immobilization (11–18). Arthroscopic-assisted

percutaneous fixation of displaced scaphoid fractures is also increasingly common.

115

MECHANISM AND EPIDEMIOLOGY

Fracture of the scaphoid is usually the result of a fall onto the outstretched hand

resulting in hyperextension and ulnar deviation of the wrist (19). Injuries that

cause forceful wrist extension (e.g., sports activities and car accidents) may

also cause scaphoid fractures. In Japan, from the late 1980s, we have seen an

increase in wrist flexion scaphoid fractures due to the increasing popularity of

punching game machines (20,21). In these punching games, as in Karate or fight-

ing, the wrist is in slight palmar flexion and slight radial deviation. With radial

deviation and flexion, the waist of the scaphoid is impacted between the

distal and volar edge of the radius and the trapezium and trapezoid over the

radioscaphocapitate ligament (21).

Fracture of the scaphoid is the most frequent carpal fracture and occurs

most commonly in young active individuals. The average age of occurrence in

athletes has been reported as being approximately 17 years of age (22). This is

similar to our observations in Japan of a peak during high school age, between

15 and 18 years, with an increasing overall prevalence that may be related to

the growing popularity of sports and punching game machines (20,21).

DIAGNOSIS

There is some tendency for the diagnosis of fracture of the scaphoid to be delayed

because of misdiagnosis or because patients do not see a doctor immediately after

injury. The latter seems particularly common in children, some of whom may be

reluctant to tell their parents about their use of a punching machine or fighting. A

delayed presentation is also common among athletes because members of sports

clubs or teams do not want to lose their position. In addition, the clinical

symptoms are not usually severe, and may resemble a wrist sprain—something

an athlete may have experienced numerous times and may not be particularly

concerned about. Many patients with delayed presentations are found to have

nonunion (23).

When examining a patient with wrist pain, detecting the tender spot is the

most important finding on examination. Tenderness with palpation of the

scaphoid radially in the so-called anatomical snuffbox (between the extensor

pollicis longus dorsally and the abductor pollicis longus and extensor pollicis

longus volarly), volarly at the distal pole of the scaphoid, and with axial

compression of the thumb are all useful palpatory examination maneuvers for

scaphoid fracture. Provocative maneuvers of the wrist, such as the scaphoid

shift test reported by Watson et al. (24), which originally was initially described

to check for scapholunate dissociation or rotatory instability of the scaphoid, are

also helpful to diagnose this fracture.

The radiographic examination should consist of posteroanterior (PA),

lateral, and semipronated and semisupinated oblique views. A view of the

116 Toh

scaphoid with the wrist in ulnar deviation is useful because it extends the

scaphoid, making its longitudinal axis more perpendicular to the X-ray

beam. Nondisplaced fractures can be very subtle and difficult to see on plain

radiographs.

When a fracture is suspected based upon the injury mechanism and

examination, but the radiographs are interpreted as normal, a suspected or

occult scaphoid fracture is diagnosed. The management of suspected scaphoid

fractures has traditionally consisted of two weeks of cast or splint immobilization

followed by repeat radiographical and clinical examination. In the vast majority

of patients, the repeat examination will resolve the issue. When suspicion for

fracture persists after repeat evaluation, the use of a bone scan has largely been

replaced by the use of magnetic resonance imaging (MRI), depending on its

availability and relative cost.

It is not yet clear whether attempts to triage suspected scaphoid fractures

in the acute setting with more sophisticated diagnostic tests are worthwhile. It

takes a few days after a fracture before a bone scan will be useful. MRI is not

usually immediately available, but it can be obtained within a few days in

many centers. Worldwide, an MRI is generally difficult to obtain in any

circumstance, let alone in a timely fashion. Computed tomography (CT) is

more readily available in some centers, but may not be best for suspected

fractures because nondisplaced fractures can be very subtle on CT, can have

a similar appearance to vascular channels, and may be distorted by volume

averaging. Given that most suspected scaphoids are not true scaphoid

fractures, any costs of advanced radiological interventions will have to be

balanced by the potential costs due to lost work, although even a wrist

sprain usually requires a few weeks of rest.

Diagnosis of displacement is very important. Fracture displacement (or

instability) is strongly associated with nonunion. The lines of Gilula should be

checked for irregularity (25) and in the lateral view, the rotation of the lunate

with respect to the radius are evaluated. The diagnosis of fracture displacement

or instability is usually made as follows (Fig. 1):

1. One millimeter or greater gap or translation at the fracture site.

2. Radiolunate angle greater than 108 to 158 on a true lateral radiograph

(third metacarpal in line with the radial shaft; lower margin of the

pisiform between the lower margins of the capitate and the distal

pole of the scaphoid).

3. Carpal height ratio (CHR) of the affected side is less than the opposite

side and the discrepancy is 0.03 or greater (26).

4. Scaphoid length is shorter on the affected side and the discrepancy is

1 mm or greater (27).

CT and MRI provide very detailed depictions of the scaphoid and

may be more useful for diagnosing displacement. CT is cheaper, more

Fractures of the Scaphoid 117

readily available, and perhaps superior for bone imaging, at least as far as dis-

placement and other fracture detail are concerned (28,29). The best scan plane

for evaluating the scaphoid fracture is along the long axis of the scaphoid.

Scans in line with the longitudinal axis plane can be obtained by placing

the patient in the prone position with the arm overhead, fully pronated, and

flat on the table, and the forearm passing through the gantry at a 458

angle (30). A “coronal plane” scan in this axis is obtained by supinating the

forearm 908 (Fig. 2). Alternatively, a high-resolution scan can be obtained

and reformatted in selected planes using image manipulation software.

Any gapping or angular or translational displacement suggests instability of

the fracture.

CLASSIFICATION

Herbert’s classification is widely recognized and useful (10). The modification of

this system, described by Filan and Herbert in 1996, omitted Type B5 (commin-

uted fractures) and Type C (delayed union) because they did not form natural

groups. All fractures diagnosed more than six weeks after the initial injury

were classified as Type D (nonunion) in the newer system, reflecting concerns

about delayed diagnosis (Fig. 3).

Figure 1 Diagnosis of scaphoid fracture displacement. The following radiographic

factors indicate fracture instability. (A) One millimeter or greater translation or gap at

the fracture site on any view. (B) Greater than 158 dorsal angulation of the lunate with

respect to the radius. (C) When the carpal height ratio (CHR) of the affected side is

less than the opposite side by at least 0.03. The CHR is defined as L2 divided by L1.

(D) If the scaphoid length is greater than 1 mm and shorter than the affected side. Abbrevi-

ation: CHR, carpal height ratio.

118 Toh

TREATMENT CONSIDERATIONS

Acute unstable fractures (Type B) and delayed and nonunion fractures (Type D)

are indications for operative intervention. Scaphoid fractures that are part of a

more complex injury pattern (perilunate fracture dislocation, or combined

distal radius and scaphoid fracture) are also best treated operatively. For acute

Figure 2 CT of the scaphoid. (A) The patient lies prone and the wrist crosses the

gantry at a 458 angle. (B) This sagittal image depicts a displaced fracture of the scaphoid

waist in a 36-year-old man who presented three months after the initial injury with non-

union. (C) This coronal image depicts a proximal pole nonunion in a 20-year-old man

who presented 11 months after the initial injury. (D) Percutaneous screw fixation using

dorsal approach at 11 months after the initial injury. (E) PA radiograph four months

after the operation revealed solid bony fusion. Abbreviations: CT, computed tomography;

PA, posteroanterior.


stable fractures (Type A), conservative treatment achieves a high union rate and

excellent wrist function, but requires prolonged cast immobilization. According

to Leslie’s paper, six to eight weeks were required for fractures of the distal

pole, 8 to 12 weeks for fractures of the waist, and 12 to 20 weeks for fractures

proximal pole (31). However, in practice, there is substantial variation in these

times and even in the type of cast used. Dias et al. (32) have shown that radio-

graphs cannot reliably determine union, so the time of immobilization will be

determined mostly by the surgeon’s preference, radiographic appearance, and

clinical findings.

An alternative to immobilization is to insert a screw into the scaphoid

percutaneously, and forego cast immobilization. Percutaneous fixation can be

used with displaced fractures if wrist arthroscopy is used to monitor and

ensure adequate reduction. Percutaneous fixation may also be appropriate for

some patients with Type D1 fractures (fibrous union) when good alignment is

present, and a bone graft is felt to be unnecessary (Fig. 4). This may be more

reliable in relatively recent fractures. For long-standing nonunions, it remains

Figure 3 Classification of scaphoid fractures according to Herbert. (A) The original

Herbert classification. Type A fractures are stable acute fractures including: A1, fracture

of scaphoid tubercle; A2, incomplete or nondisplaced fracture through the scaphoid

waist. Type B fractures are acute and unstable including: B1, distal oblique fracture; B2,

complete fracture of the waist; B3, proximal pole fracture; B4, trans-scaphoid-perilunate

fracture dislocation; and Type B5 comminuted fractures. Type C comprised delayed

unions and Type D established nonunions either stable/fibrous (D1) or unstable pseudo-

arthrosis (D2). (B) The modified Herbert classification of Filan and Herbert omitted

Type B5 fractures and Type C fractures, which were now included as a type of D1 fracture.

Type A fractures are defined as presenting within six weeks of the initial injury. Additional

subtypes of nonunion were added.

120 Toh

somewhat unclear how to define a fracture as a stable or fibrous union. It has also

not been demonstrated that percutaneous treatment is effective for all stable

nonunions, regardless of age. Although the concept is worthy of further study,

caution is warranted.

For Type D1 nonunions which require curettage and type D2 nonunions

which require bone grafting to correct the length and deformity such as DISI,

open reduction from a volar approach and screw fixation is recommended

(Fig. 5). In the more advanced types of nonunions—in particular, multiply

operated patients or nonunions associated with avascular necrosis of the proximal

pole—vascularized bone grafting from the distal radius or other salvage

operations such as partial carpal fusion or proximal row carpectomy are indicated

depending on the case (Fig. 6) (33–36).

Figure 4 Percutaneous fixation of a delayed union of the scaphoid. (A) PA radiograph of

a waist fracture in a 53-year-old man. The fracture line was not clear. (B) PA view one

month after the initial injury. The fracture line was more clearly identifiable. (C) PA

view three months after the initial injury shows an established nonunion. (D and E)

Oblique and lateral radiographs eight months after operative treatment with percutaneous

screw fixation through a dorsal approach shows union. Abbreviation: PA, posteroanterior.


OPERATIVE TECHNIQUES

Percutaneous Screw Fixation Using Image Intensifier

Anesthesia

Alternatives for anesthesia include general or regional anesthesia. The latter

can be administered as an intravenous regional anesthesia (Bier block) or as a

brachial plexus block.

Figure 5 Nonunion with pseudoarthrosis (Type D2). (A and B) Oblique and lateral

radiographs of a waist fracture in a 15-year-old boy immediately after the initial injury.

The fracture was treated in a cast. (C and D) Radiographs two months later revealed

bony absorption and widening of the fracture site, shortening of length of the scaphoid,

and dorsal rotation of the lunate.

Type A Type B Type D1 Type D2-4

Cast Percutaneous

screw fixation w/o

open reduction

ORIF ORIF w/ BG

Vascularized BG

Other salvage op.

Patients w/

special

background

Good

reduction

Poor

reduction

Type B4

**

****

Figure 6 Algorithm of treatment options depending on Filan and Herbert classification.�Patient who does not want long-term immobilization, or who wants to return to sports activi-

ties as soon as possible or whose fracture is combined with another fracture such as distal end

of the radius. ��Cases of delayed fibrous union when good alignment can be achieved and a

bone graft is unnecessary. ��Comminuted fracture open reduction and internal fixation with

screw. Abbreviations: BG, bone grafting; ORIF, open reduction and internal fixation.

122 Toh

Approaches

There are two approaches for percutaneous screw insertion: volar and dorsal. In

the volar approach, the trapezium hinders insertion of the screw in the proper

location of the scaphoid. Some authors recommend removal of the foot process

of the trapezium to gain access to the entry location to target the axis of the

scaphoid. It is easier to place the screw in the central axis of the scaphoid

using a dorsal approach (37–39). The dorsal approach is particularly useful for

small fractures of the proximal pole (10).

Volar approach: A 1-cm transverse or longitudinal skin incision is often

made over the scaphotrapezium joint (Fig. 7). The joint is identified, and its

capsule is incised transversely. The beak of the trapezium is resected if this

proves helpful for screw placement.

Wrist arthroscopy can be used to confirm displacement and to monitor

reduction. The fracture cannot be seen through the radiocarpal portals, but is well

visualized via midcarpal portals. If the fracture is displaced or unstable, a reduction

Figure 7 A 1-cm transverse skin incision over the scaphotrapezium joint is used for

volar percutaneous screw fixation.


is performed either by manipulating the wrist into extension and radial deviation, or

using Kirschner wires inserted into each fragment as “joysticks” to manipulate the

fracture. Alternatively, a single wire can be placed in the distal pole of the scaphoid,

used to manipulate the fracture, then driven across the fracture site for provisional

stabilization. The reduction may be evaluated using wrist arthroscopy.

When using a noncannulated screw, the fracture is first stabilized tempor-

arily by a Kirschner wire inserted ulnarward and parallel to the intended line of

the screw. Then the wire is pulled volarward to rotate the scaphoid, and a second

wire is inserted along the intended line of the screw (Fig. 8). Using the second

Figure 8 Percutaneous screw fixation. Volar approach. (A) The fracture is stabilized

with a temporary Kirschner wire. The wire is pulled volarward to rotate the scaphoid.

(B) A guide pin for the cannulated screw is then inserted along the intended line of the

screw. (C) Image intensifier views from the operation. The arrow indicates a guide pin.

(D) Using the second wire as a guide pin, a cannulated screw is inserted. With the original

Herbert screw, after removal of the second wire, the screw is inserted free-hand. (E and F)

Radiographs after screw insertion.

124 Toh

wire as a guide pin, a cannulated screw is inserted (Fig. 8D). With the original

Herbert screw, after removal of the second wire, the screw is inserted free-

hand. If there is no problem with stability of the fracture site, the first Kirschner

wire is removed (Fig. 8E and F).

When using a cannulated screw, a second wire is only needed to secure a

displaced fracture. For nondisplaced fractures, an incision of more than a few

millimeters is not necessary, although it might be used to excise part of the

trapezium to facilitate screw passage. In most cases, the wire is placed across

the fracture and the screw is placed over it. It can be difficult to pass the screw

pass the trapezium and obtain good positioning. A more radial starting point

and partial excision of the trapezium may help. Alternatives include drilling

the wire for the screw through the trapezium and either passing a countersink

over the wire as a way of resecting part of the edge of the trapezium or even

passing the screw through the trapezium.

Dorsal approach: This is an elegant technique that results in the wire

being automatically inserted along the central axis of the scaphoid. It was

originally reported by Slade who performed this technique keeping the hand

vertically (16,40). The author performs it in a horizontal position (Fig. 9).

After flexion and ulnar deviation followed by forearm pronation, the image

intensifier is used to obtain a good perpendicular view of the long axis of the

scaphoid. The scaphoid is visualized as two rings: distal and proximal

(Fig. 10). The guide wire is then inserted perpendicularly through the centers

of the two rings. After inserting only the tip of the wire and confirming its

position proper (Fig. 11), the guide wire is advanced to the volar side

(Fig. 12). Then the screw is inserted (Fig. 13). If instability exists at the fracture

site, reduction is obtained as described above and a Kirschner wire is used for

stabilization of the fracture site before inserting the guide wire.

Figure 9 Percutaneous screw fixation. Dorsal approach. Position of the hand and wrist.

Slade performed this technique keeping the hand in a vertical position (A) and the author

used a horizontal position (B).


Implants

Many cannulated screws are available and each has advantages and disadvan-

tages for osteosynthesis of scaphoid fractures. The screw which we prefer to

use now is a double-thread screw developed by Dr. Tanaka of Japan. The charac-

teristic of this screw system is that the diameter of the guide wire is 1.2 mm

thicker than that of the other cannulated screws, and the screw is self-drilling

and self-tapping (Fig. 14). This is essentially a cannulated self-tapping double-

headed, countersunk, variable pitched screw (like a Herbert screw), and other

screws of this type are available.

Figure 10 Percutaneous screw fixation. Dorsal approach. Views of the insertion point of

the guide wire. After ulnar deviation (A) and flexion followed by forearm pronation, the

image intensifier is used to obtain a good perpendicular view of the long axis of the

scaphoid. The scaphoid is visualized as two rings: distal and proximal (B).

Figure 11 Percutaneous screw fixation. Dorsal approach. The guide wire is then inserted

perpendicularly through the centers of the two rings (A). After inserting only the tip of the

wire (B), its proper positioning is confirmed (C).

126 Toh


Patients are immobilized for comfort for two to three weeks (Figs. 2 and 15).

After removal of the cast or splint, wrist range of motion exercises is initiated.

Once bony union is established and the patient had regained at least 80% of

wrist motion and grip power compared to the opposite, uninjured wrist, resump-

tion of sports activity is permitted, usually around three months after the

operation (Fig. 16).

Figure 13 Percutaneous screw fixation. Dorsal approach. Then the screw is inserted

free-hand. PA (A) and lateral (B) radiographs reveal good screw position. The hole of

the cannulated screw is seen in the position of the wrist which is the same as for insertion

of the guide wire (C). Abbreviation: PA, posteroanterior.

Figure 12 Percutaneous screw fixation. Dorsal approach. PA (A) and lateral (B) image

intensifier views reveal that the wire is inserted along the central axis of the scaphoid.

Abbreviation: PA, posteroanterior.


Figure 14 Author’s preferred screw. The double-thread screw was developed by

Dr. Tanaka of Japan. Its characteristics are that the diameter of the guide wire (A) is

1.2 mm thicker than that of the other cannulated screws and it is, therefore, stronger,

and the screw is self-drilling and self-tapping (B).

Figure 15 Case with Type A2. This is an 18-year-old male with a scaphoid waist frac-

ture. Posteroanterior (A) and lateral (B) radiographs at 26 months after the surgery

revealed good bony fusion. Good functional results were also achieved (C and D).

128 Toh

Results

From 1988 to date, 103 patients (91 men and 12 women), all with follow-up times

over six months, had percutaneous fixation of a fractured scaphoid in our center.

The average age was 29 years (range 11 to 73 years). Thirty-two patients had

Figure 16 Patient with Type D1 nonunion. (A and B) A waist fracture in a 19-year-old

man was treated by percutaneous screw fixation using dorsal approach at 30 days after

the initial injury. PA radiograph (A) and CT scan (B). (C–E: ) Three months later,

good bony fusion was revealed in PA (C) and lateral radiographs and CT scan (E).

(F and G) Due to achievement of about 80% of ROM and grip power of the opposite

healthy side, resumption of sports activity was permitted. Abbreviations: CT, computed

tomography; PA, posteroanterior; ROM, range of motion.


acute stable fractures, 47 had acute unstable fractures, and 24 had delayed fibrous

union according to the modified Herbert’s classification. The duration from injury

to operative treatment in the fibrous union group averaged 104 days (range 42 to

316 days) (Fig. 17). We used standard Herbert screws in 49 patients and

cannulated screws of various types in 54 patients.

One of the 103 cases achieved bony fusion but revealed symptomatic

malunion. One patient with delayed union used sonic accelerated fracture

healing system (SAFHS) (low-intensity pulsed ultrasound) and achieved union

without a second operation. In three patients, union was not achieved—one

nonunion healed after a subsequent open surgery with bone grafting (Fig. 18). In

the remaining 98 cases, union and good wrist function were documented.

Figure 17 Patient with Type D1 nonunion. In this 14-year-old boy, the duration between

injury and to operation was 107 days. Oblique (A) and lateral (B) radiographs revealed

Type D1 nonunion. (C and D) Percutaneous screw (Herbert–Whipple) fixation was per-

formed. PA (A) and lateral (B) radiographs revealed good bony fusion. Abbreviation:

PA, posteroanterior.

130 Toh

The four persistent nonunions, delayed unions, and malunions seemed to be

related to technical problems in the initial operations. For example, one patient

(Fig. 18) operated two months after the injury had inadequate reduction, resulting

in nonunion. Four months later, a second operation was performed using the

Russe method (41). The graft harvested from the iliac crest was remodeled to

match the shape of the inside of the scaphoid because of severe bone absorption

Figure 18 Nonunion after percutaneous screw fixation. In this 19-year-old male, the

initial operation was performed two months after the injury. Unfortunately, the fracture

was not reduced perfectly before fixation was performed (A), resulting in nonunion (B).

Four months later, a second operation was performed following the Russe method

(C). PA (D) and lateral (E) radiographs five months later revealed good bony fusion.

The range of motion of the wrist (89%) and grip power (90%) were almost acceptable.

Abbreviation: PA, posteroanterior.


(Fig. 18). Six months after the second operation, the wrist motion and grip

strength were satisfactory.

Open Reduction and Internal Fixation with Bone Grafting

For cases that require curettage and bone grafting to correct length and angular

deformity, we use open reduction, structural bone grafting, and internal fixation

from a volar approach. As reported by Fernandez (27), for nonunion with

malalignment, we use a wedge-shaped graft to correct the scaphoid length and

malalignment including DISI deformity. Alternatively, one can fill the opening

wedge defect anteriorly with pure cancellous graft, using the screw for primary

structural support. This simplifies the technical aspects of the procedure.

Preoperative Planning

Using PA radiographs of both the injured and uninjured wrists in maximum ulnar

deviation, the length of the scaphoids are calculated (Fig. 19). From this, the size

and shape of the grafted bone is planned preoperatively.

Operative Procedure

A zigzag skin incision is performed on the volar side of the wrist. The flexor carpi

radialis (FCR) sheath is used to gain deeper exposure. The wrist capsule is

incised. The fracture site is opened, and the nonunion site with the fibrous

tissue is resected until the previously sclerotic fracture surfaces are fresh and

able to bleed. Using two Kirschner wires as joysticks, the gap of the nonunion

site is opened and resected. In a case with DISI deformity, the rotation of the

Figure 19 Preoperative planning for cases with established nonunion. Using the PA

radiographs of both the opposite uninjured wrist (A) and the injured wrist in maximum

ulnar deviation (B), the length of the scaphoids were calculated. PA radiograph

seven months after the open reduction and bone grafting revealed good bony fusion

(C). Abbreviation: PA, posteroanterior.

132 Toh

lunate is corrected using a spring made by inserting a Kirschner wire in the lunate

(42). Alternatively, the lunate can be temporarily pinned to the radius in proper

alignment. The position is maintained during the bone grafting. A silicone

block is used as a trial spacer, and a tricortical corticocancellous bone graft is

obtained in the same size and shape as this silicone block (Fig. 20).

After grafting the bone, a Kirschner wire is inserted to stabilize both the

proximal and distal fragments and grafted bone. Then a guide wire is inserted

in the same manner as the percutaneous methods from volar or dorsal side. We

prefer to use a volar graft and dorsal percutaneous screw insertion.


The wrist is usually immobilized in a cast for four weeks. After removal of the

cast, wrist range of motion exercises is initiated. If a Kirschner wire has been

inserted to stabilize the alignment of the lunate, it is removed six weeks after

the operation. Resumption of sports activity is managed as for percutaneous

treatment.

Results

From 1984 to 2003, we performed open reduction and screw fixation with bone

grafting for 109 patients with Type D nonunions. Ages ranged from 12 to 64

years (average 26 years). The duration from injury averaged 29 months (range

six weeks to 487 months). In five of the 109 cases, union was not achieved.

The reasons for failure were inadequate screw length, incorrect screw position,

and improper size of grafted bone. In two of these five failed cases, an additional

Figure 20 Open reduction and volar wedged bone graft technique. (A) Volar approach

for nonunion of the scaphoid. Using two Kirschner wires as joysticks, the gap of the

nonunion site is opened and resected. (B) In a case with DISI deformity, the rotation of

the lunate is corrected using a spring made by inserting a Kirschner wire in the lunate.

The position is maintained during the bone grafting. (C) A silicon block is used as a

trial spacer, and tricortical corticocancellous bone graft is obtained in the same size and

shape as this silicon block. Abbreviation: DISI, dorsal intercalated segmental instability.


bone graft was performed, and good bony union was achieved. In the remaining

three cases, patients did not desire further operation. In the remaining 104 cases,

union and good wrist function were achieved.

Pitfalls and Pearls

Poor results seem to be related to inadequate reduction, screw position, or screw

length. Trumble et al. (43) reported that the time to union was significantly

shorter when the screw had been placed in the central third of the proximal

pole of the scaphoid. The insertion techniques for the original Herbert screw

were somewhat difficult for less-experienced surgeons. However, cannulated

screws have been developed to resolve this problem. In the volar approach, the

trapezium hinders insertion of the screw in the proper location of the scaphoid.

Direct visualization of the fracture site using arthroscopy may make open

exposures unnecessary for displaced fractures and stable nonunions (44–46).

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134 Toh

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136 Toh

7

Distal Radius Fractures

Karl-Josef Prommersberger and Thomas Pillukat

Klinik fur Handchirurgie, Bad Neustadt, Germany

INTRODUCTION

Fractures of the distal radius are extremely common injuries, which are steadily

becoming a public health issue. Although it was once believed that all patients

with distal radius fractures did relatively well, regardless of the treatment, it is

now well-recognized that undertreated distal radius fractures may be often

associated with poor results. The primary goals of treatment should be restoration

of pain-free hand and wrist function and prevention of long-term disability.

EPIDEMIOLOGY

In the 1970s and 1980s, fractures of the distal radius were estimated to account

for upwards of one-sixth of all fractures seen in the emergency room (1,2).

Some have suggested that they may account for approximately 25% of all

long-bone fractures (3).

Fractures of the distal radius are associated with osteoporosis. They are

more common in women than in men with an incidence increasing rapidly

after menopause and reaching a maximum between 60 and 69 years (4–10).

The most common injury mechanism is a fall from a standing height (11,12).

Hegeman et al. (13) assessed the bone mineral density (BMD) of the

lumbar spine and hip in 94 women (mean age, 69 years) with a distal radius frac-

ture. A low BMD was found in 85% of the patients, and osteoporosis was diag-

nosed in 51%. Ring and Jupiter (14) suspected that fracture of the distal radius is

typically a fracture of relative fit osteoporotic individuals. Looking at the survival

137

among elderly patients after fractures of the distal radius, Rozental et al. (15)

found at seven years after the fracture that survival rates after distal radius frac-

tures were notably lower than those expected for individuals of the same age and

gender in standard populations. Men were twice as likely to die as women and did

so almost twice as quickly. In addition, in older males, a recent study found that a

fracture of the distal radius was associated with a risk of hip fractures statistically

significantly greater than in women (16). As the population ages, fractures of the

distal radius may become a significant challenge to the orthopedic surgeon and

the health care system.

CLASSIFICATION

Despite the fact that the observations of Colles, Barton, Smith, and Pouteau were

made solely from postmortem specimens, their descriptions of fracture mor-

phology have served as guidelines for treating surgeons over 150 years and may

still provide a comfortable base for communication among clinicians (17). Classi-

fication systems for fractures of the distal radius have focused on the direction of

fracture displacement, the radiographic appearance, the mechanism of injury, the

articular joint surface involvement, and the degree of comminution (5,18–26).

We have found the classification system of Fernandez (26) extremely helpful in

decision-making in our clinical practice and the arbeitsgemeinschaft fur osteo-

synthesefragen/association for the study of internal fixation (AO/ASIF) Compre-

hensive Classification of Fractures (23) useful in preparing scientific papers.

The Comprehensive Classification of Fractures (AO/ASIF Classification)

The Comprehensive Classification of Fractures (or AO classification) divided

fractures of the distal radius into three types: extraarticular fractures (type A),

partial articular fractures (type B), and complete articular fractures (type C).

Further divisions into groups and subgroups are based upon patterns and severity

of articular and metaphyseal comminution. Observer reliability and reproducibil-

ity is adequate for the three basic types of the classification but was less reliable

when analyzing the groups and subgroups (27–31).

Fernandez’ Classification

Fernandez divided distal radius fractures into five major types (Fig. 1). Type I

fractures are bending fractures of the metaphysis in which one cortex fails to

tension stress and the opposite cortex shows a certain degree of comminution.

Type II fractures are shearing fractures of the joint surface. Type III fractures

are compression fractures of the joint surface with impaction of the subchondral

and metaphyseal cancellous bone. Type IV fractures are avulsion fractures of

ligament attachments, including ulnar and radial styloid fractures associated

with radiocarpal fracture dislocations. Type V fractures result from high-energy

138 Prommersberger and Pillukat

injuries and involve combinations of bending, compression, shearing, and

avulsion mechanism and often bone loss.

Figure 1 Fernandez’ classification for fractures of the distal radius.

Distal Radius Fractures 139

Distal Radioulnar Joint

In 1996, Fernandez and Jupiter (32) established a prognosis- and treatment-

oriented classification of distal radioulnar joint injuries associated with fractures

of the lower end of the radius. Depending on the residual stability of the distal

radioulnar joint (DRUJ) after reduction and stabilization of the radius, three

basic types of DRUJ lesions were differentiated. Type I are stable DRUJ

lesions, which means that the joint is clinically stable and the radiographs show

articular congruity. Type II are unstable DRUJ lesions with clinical and radio-

graphic evidence of subluxation or dislocation of the ulnar head. Type III are

potentially unstable lesions due to extension of distal radius fracture in the

sigmoid notch or due to a fracture of the ulnar head.

FUNCTIONAL AND RADIOGRAPHIC ANATOMY

The distal radius articulates with both the proximal carpal row and the head of the

ulna. The radiocarpal articular surface is divided into the scaphoid and lunate

fossae. These two concave articular surfaces are separated from each other by

a bony dorsal-volar ridge, the crista radii (33). The articular surface of the

distal radius inclines volarward in the sagittal plane an average of 108 to 128

(34–41) and inclines ulnarward in the frontal plane an average of 228 (42–45).

The sigmoid notch is a concave structure that articulates with the ulnar head

(46). The shape and the orientation of the sigmoid notch of the radius vary in

relation to the ulnar variance (47). With rotation of the radius about the ulna,

the ulnar head translates volarly in supination and dorsally in pronation (48–50).

The ulnar side of the wrist is supported by the triangular fibrocartilage

complex (TFCC), which articulates with both the lunate and the triquetrum.

The TFCC and radioulnar ligaments were attached to the ulnar edge of the

distal radius and may be injured in lunate fossa fractures, and disruptions of

distal radioulnar joint (51–53). The radial border of the TFCC is attached

along the entire margin of the lunate fossa of the distal radius and onto

its border with the sigmoid notch. The TFCC originates from the base of the

ulnar styloid.

Although the volar metaphyseal surface of the distal radius is relatively flat,

the dorsal aspect of the distal end of the radius is convex with specific areas for

anchoring the extensor retinaculum. The first dorsal extensor compartment

tendons run through a groove on the radial styloid. The extensor pollicis

longus (EPL) is routed around Lister’s tubercle, which functions as a fulcrum.

Ligamentotaxis for reduction of fractures of the distal radius is possible

because of dorsal and volar radiocarpal ligaments (54). The volar ligaments trans-

mit more force to fracture fragments around the distal radius than do the dorsal

ligaments when traction is applied across the wrist joint.

Several investigators, such as Medoff and Kopylov (55), Pechlaner (56),

and Rikli and Regazzoni (57), have realized that the distal metaphyseal and


articular regions of the radius and the ulna represent structural units or

“columns.” Rikli and Regazzoni described an ulnar column comprising the

distal ulna, TFCC, and distal radioulnar joint; an intermediate column made up

of the lunate fossa and sigmoid notch of the radius; and a lateral column including

the scaphoid fossa and radial styloid process. Medoff and Pechlaner divided frac-

tures of distal radius into five fracture components: the radial column, which is

comprised three orthogonally oriented cortical surfaces; the dorsal and the

volar rim, and the intra-articular and ulnar split. These concepts have added sub-

stantially to our understanding of methods for achieving operative stability of

complex fractures and have lead to the development of implants designed specifi-

cally for the anatomy of the various columns.

The radiographic anatomy of the distal radius and its relationship to the

distal end of the ulna can be evaluated using four measurements: the volar tilt,

the ulnar inclination, the radial length, and the ulnar variance (Fig. 2). To

provide reliable data, a standardized radiographic technique is essential.

Because the elbow and shoulder positions affect the relationship between the

distal radius and the ulna, the standard posterior–anterior view of the wrist

should be obtained with the elbow flexed 908 and the shoulder abducted 908

with the forearm and wrist in a neutral position. The hand is placed palm flat

on the cassette without any flexion, extension, or deviation. A correct position

of the examination shows the edge or the entire groove of the extensor carpi

ulnaris tendon is at or radial to the fovea at the base of the ulnar styloid. The

lateral view of the wrist is taken with the elbow flexed 908 and adducted

against the trunk with the forearm and wrist in neutral position whilst a vertical

X-ray beam enters radially and exits ulnarly at the level of the distal pole of the

scaphoid (58). A correct position of the examination shows the volar surface of

the pisiform located at the midpoint between the volar surface of the distal

pole of the scaphoid and volar surface of the capitate head. For both, the postero-

anterior (PA) view and the lateral of the wrist at least 5 cm of the distal radius

have to be included to allow for accurate assessment of the long axis of the radius.

Radial length, also called radial height or length of the radial styloid, is

defined as the distance between two lines perpendicular to the long axis of the

radius, one passing through the distal tip of the radial styloid and the other

passing through the most distal aspect of the ulnar articular surface of the

radius. The average is 11 to 12 mm (34,40). This distance is less useful in asses-

sing relative radial shortening, because it reflects loss of ulnar inclination of the

articular surface of the distal radius and not the position of the distal articular

surface of the radius relative to the articular surface of the distal ulna.

The ulnar variance describes the relative positions of the distal articular sur-

faces of the radius and the ulna. All methods used to measure ulnar variance have

shown to be highly reliable with respect to intra- and interobserver variations

(59,60). Therefore, clinicians may use whichever technique he or she prefers

when measuring ulnar variance. According to Gelberman et al. (61), the measure-

ment can be obtained as the difference along the line of the longitudinal axis of


the forearm between a perpendicular line at the ulnar edge of the lunate facet of

the distal radius articular surface and another perpendicular at the distal articular

surface of the ulnar head. A difference of 2 mm in length between the radius and

the ulna is considered normal (62). A positive ulnar variance occurs when the

articular surface of the ulna is distal to the distal articular surface of the radius.

Post-traumatic positive ulnar variance due to radial shortening can cause ulnar

impaction with degenerative tears of the TFCC and the luno-triquetral ligament

(51–53,63).

Figure 2 Radiographic anatomy of the distal radius. (A) The volar tilt is determined by a

line (Z) perpendicular to the long axis (X) of the radius, as determined by a line through the

center of its medullary space at 2 cm (B) and 5 cm (A)proximal to the radiocarpal joint and

a line (Y) joining the most distal parts of the dorsal and the volar rims of the radial articular

surface. (B) Radial length is defined as the distance (D–E) between two lines perpendicu-

lar to the long axis of the radius, one passing through the distal tip of the radial styloid and

the other passing through the most distal aspect of the ulnar articular surface of the radius

(C). The degree of ulnar inclination is derived by an intersection of a line formed between

the radial styloid and the sigmoid notch (Y) and one perpendicular to the long axis of the

radius (Z). (C) According to Gelberman et al. (61), the ulnar variance is determined as the

difference along the line of the longitudinal axis of the forearm between a perpendicular

line at the ulnar edge of the lunate facet of the distal radius articular surface and

another perpendicular at the distal articular surface of the ulnar head.


The volar tilt, also known as dorsal tilt, dorsal angle, volar tilt, and volar

slope, is determined by a line joining the most distal parts of the dorsal and the

volar rims of the radial articular surface. The degree of the volar tilt is derived

by an intersection of the line of volar tilt and one perpendicular to the long

axis of the radius, as determined by a line through the center of its medullary

space at 2 and 5 cm proximal to the radiocarpal joint (41).

The ulnar inclination, also called radial inclination or radial tilt, describes

the angulation of the distal radial articular surface in relationship with the long

axis of the radius in the frontal view. It is determined by a line perpendicular

to the long axis of the radius and a line formed between the radial styloid and

the distal sigmoid notch (64).

When evaluating the extent of deformity caused by an extraarticular frac-

ture of the distal radius, comparing the radiologic criteria outlined above to those

of the opposite uninjured side will clarify the extent of displacement (65). For

intra-articular fractures, several investigators have shown that computed tomo-

graphy (CT) scans improve the sensitivity of measurement of articular surface

gapping, improved the accuracy of detection of comminution, and altered

proposed treatment plans within observers (66–70). In addition, CT appears to

be a superior diagnostic modality for detecting and quantifying sigmoid notch

fracture step-off and articular gapping as well as subluxation and dislocation of

the distal radioulnar joint (71–73).

In most distal radius fractures, standard radiographs of the wrist in two

plains will be adequate to control the reduction and to measure the final radiologi-

cal result at the time of fracture union. In a study of Chern et al. (74), sonogra-

phically guided monitoring compared well with conventional radiographic

techniques during closed reduction of extraarticular distal radial fractures.

However, after open reduction and internal fixation of the distal radius screw

position relative to the articular surface may be difficult to determine on standard

PA and lateral radiographs taken perpendicular to the long axis of the forearm in

both the frontal and the sagittal planes, in part because of the failure of standard

radiographic views to compensate for the normal inclination and tilt of the distal

radius articular surface. In addition, the dorsal plate often obscures the articular

surface itself on both PA and lateral views. Boyer et al. (75) have shown the

so-called anatomic tilt PA and lateral radiographs of the distal radius to be an

accurate and clinically useful tool for the evaluation of both the presence and

location of screw penetration of the articular surface after dorsal plating. Distinc-

tive to volar fixed-angle plating of the distal radius, the optimal position of the

distal fixed-angle support is in the subchondral bone immediately proximal to

the articular surface. Standard radiographic imaging of the distal radius during

placement of a volar fixed-angle plate does not provide adequate visualization

of the subchondral bone–distal support interface. To address this specific issue

of whether volar hardware placed at the immediate subchondral bone level has

effectively avoided the radiocarpal joint, Smith and Henry (76) described a 458

pronated oblique view of the distal radius. If there are concerns in regard to


screw penetration in the articular surface of the distal radius, CT scanning may be

helpful (77) (Fig. 3).

BIOMECHANICS

Normal wrist biomechanics depend upon maintenance of the anatomical position

of the distal end of the radius with respect to the carpus and the distal end of the

ulna. Normal wrist motion consists of greater than 1208 of wrist flexion and

extension, 508 of wrist radial and ulnar deviation, and 1508 of forearm rotation

at the DRUJ (78). The distal radius carries 80% of the axial load through the

wrist, and the distal ulna carries 20% (79).

In clinical and laboratory studies, multidirectional deformity of the distal

radius caused alterations of the radiocarpal joint, the midcarpal joint, and the

distal radioulnar joint (80). The osseous deformity affects the normal mechanics

of the radiocarpal joint producing a limitation of the extension-flexion arc of

motion. In addition, the malalignment affects the normal load transmission

through the radiocarpal joint, but also across the whole wrist joint. Dorsal

tilting of radial surface shifts axial loading through the wrist dorsally and

ulnarly and decreases the joint contact area. The pressure distribution on the

radial articular surfaces becomes more concentrated (81–84) and may represent

a prearthritic condition of the wrist joint (85).

Furthermore, shortening of the radius and dorsal tilting of the articular

surface increase the force borne by the ulna. The load through the ulna increases

from 21% to 67% of the total load as the angulation of the distal radius fragment

increases from 108 of volar tilt to 458 of dorsal tilt (86). Lengthening of the ulna

by 2.5 mm increases the force borne by the ulna from 18.4% to 41.9% of the total

axial load (79).

Malalignment of the surface of the distal radius in both the sagittal and

coronal planes may result in a decreased mechanical advantage of the flexor

tendons as they pass through the carpal tunnel (87), diminishing grip strength.

In addition, median nerve compression neuropathy can also be encountered as

a result of the deformity of the distal radius (88–94).

At the midcarpal level, dorsal tilt of the distal radius may lead to a compen-

satory flexion deformity as an adaptive response to the dorsally rotated proximal

carpal row (95), an extrinsic midcarpal dynamic instability (96), and a fixed

carpal malalignment in dorsiflexion (97).

Angular and shortening deformity of the distal radius may cause incongruity

of the distal radioulnar joint and reduction of radioulnar contact area (98).

Radial shortening in relation to the distal part of the ulna can increase the

strain in the TFCC (99) and result in a disruption of the deep portion of the

dorsal radioulnar ligament (100). These factors may limit the arc of forearm

rotation (101,102).

Fellmann et al. (103) found that an anatomical reduction of acute distal

radial fracture correlated with a significantly better range of motion, whereas


Figure 3 (Continued on next page) Open reduction and internal fixation of a dorsally

angulated, comminuted distal radius fracture with 908 to 908 plates position. (A) An

intraarticular fracture of the distal radius was stabilized with an external fixator. (B and

C) Preoperative CT demonstrated substantial intraarticular and metaphyseal comminution.

(D and E) The postoperative radiographs demonstrate the situation after open reduction

and internal fixation with a 908 to 908 plating with one plate applied lateral to the radial

styloid and use of a volar fixed-angle plate without bone grafting. On the anteroposterior

view, the articular surface of the radius seems to be well restored. However, there may be

some concerns whether the distal pegs have effectively avoided the radiocarpal joint. In

addition, the distal pegs and screws obscure the articular surface on the lateral view. (F

and G) Postoperative CT demonstrates that screw penetration in the articular surface of

the distal radius was avoided. To diminish side effects from the hardware, the software

program for CT has to be modified. Abbreviation: CT, computed tomography.


McQueen and Caspers (104) found that motion was significantly worse in wrists

with dorsal angulation of more than 128. Jenkins and Mintowt-Czyz (105) and

Cooney et al. (106) reported that decreased grip strength had a close relationship

with the severity of residual fracture deformity. Aro and Koivunen (107) found

that the functional end result was unsatisfactory in only 4% of the patients

with an acceptable anatomic result, compared with 25% of the patients with

minor shortening and 31% of the patients with gross shortening of the radius.

TREATMENT

General Considerations

In spite of the anatomic and biomechanic rationale supporting attempts to restore

the alignment of the fractured distal radius, the need for anatomic reduction



remains controversial, and several studies have championed one side or the other.

Furthermore, in spite of the explosion of new implants designed specifically for

internal fixation of distal radius fractures, the role of traditional treatment

methods such as closed reduction and casting, percutaneous K-wire pinning,

and/or external fixation must also be considered (108).

In a prospective study, Anzarut et al. (109) looked at the radiological and

patient-reported functional outcomes in 74 patients who were at least 50 years

of age with conservatively treated distal radius fractures. The average dorsal/volar tilt measured by a radiologist was 3.48 dorsal; overall 47 patients (64%)

were considered to have an acceptable radiographic reduction (dorsal tilt ,108

or volar tilt ,208). Acceptable radiographic reduction was not associated with

better generic physical or mental health status, lesser degrees of upper-extremity

disability, or greater satisfaction with outcomes than was unacceptable reduction.

The average score on the DASH (disabilities of the arm, shoulder, and hand)

was 24 (SD 17). Forty-four (60%) of the 74 patients were satisfied with their

functional status six months after injury. The DASH score averaged 27

(SD 19) in patients judged to have unacceptable dorsal/volar tilt and 22

(SD 16) in patients with an acceptable radiographic result.

In a prospective, randomized study of 57 patients older than 60 years of age

with unstable, extraarticular fractures of the distal radius, Azzopardi et al. (110)

looked at the outcome of immobilization in a cast alone compared with that using

supplementary, percutaneous pinning. At one year, the mean volar/dorsal tilt,

radial length, and ulnar inclination were significantly better in patients treated

using percutaneous wire fixation than in patients by immobilization in a cast

alone, but ulnar variance was not. Nonetheless, there was no significant differ-

ence in functional outcome in terms of pain, range of movement, grip strength,

activities of daily living, and the SF-36 score except for an improvement of the

range of motion in ulnar deviation in the percutaneous wire group. The authors

concluded that percutaneous pinning of unstable, extraarticular fractures of the

distal radius provides an improvement in the radiological parameters compared

with immobilization in cast alone, but this does not correlate with an improved

functional outcome in the investigated population of elderly people.

Harley et al. (111) evaluated augmented external fixation versus percuta-

neous pinning and casting for unstable fractures of the distal radius in a prospec-

tive fashion with a one-year radiographic and clinical follow-up period. Their

hypothesis was that external fixation with augmentation would provide superior

results compared with percutaneous pinning and casting. Fifty patients younger

than 65 years of age were randomized into these treatment groups. Over 80%

of the fractures were classified as AO/ASIF C2 or C3 and there was a similar dis-

tribution of fracture types in each group. The use of augmented external fixation

did not improve the mean radiographic outcome with respect to radial length,

ulnar inclination, and volar tilt. Improved articular surface reduction was noted

with the use of an external fixator but overall only three patients were recognized

to have steps or gaps greater than 2 mm. No significant differences in mean


DASH scores, total range of motion, and grip strength were found between

the groups. However, all three patients diagnosed with a chronic regional pain

syndrome had external fixation.

Kreder et al. (112) conducted a prospective, randomized study comparing

open reduction and internal fixation with indirect reduction and percutaneous

fixation for treatment of displaced intra-articular fractures of the distal radius.

Internal fixation, usually involving an arthrotomy, was performed either

through an extended carpal tunnel approach on the volar side or between the

third and fourth compartments on the dorsum of the wrist. If necessary, fixation

by small- or mini-fragment plates and screws was supplemented with K-wires or

an external fixator. Percutaneous fixation was limited to percutaneous K-wires,

cannulated or regular small- or mini-fragment screws, and/or external skeletal

fixation. An arthrotomy was not performed. A total of 179 adult patients were fol-

lowed for two years with careful patient-related and physician-related outcome

assessments. There were no statistically significant differences in the radiological

restoration of anatomical features or the range of movement between the two

groups. However, during the study period, patients treated with indirect reduction

and external fixation had a more rapid return of function and a better functional

outcome as those who underwent open reduction and internal fixation, provided

that the intraarticular step and gap deformity were minimized.

The Cochrane Musculoskeletal Injuries Trial Registry reviewed 44

“eligible” trials, such as those mentioned above, over a 13-year period compris-

ing a total of 3193 patients with 3197 fractures. They concluded that there is

neither enough evidence to tell whether surgery gives a better result nor which

type of surgery is best for most types of fractures. In other words, there is

neither “one way” nor “one implant” to treat fractures of the distal radius and

often different ways of treatment lead to similar results.

The relationship between anatomy and function of the distal radius may be

more notable in active, healthy patients and after high-energy injury. Substantial

malalignment will lead to carpal malalignment and distal radioulnar joint dys-

function. Associated problems such as carpal fractures or ligament injuries,

acute carpal tunnel syndrome, and hand swelling and stiffness are important

sources of dysfunction after distal radius fractures. Furthermore, many of our

treatments can lead to problems.

To achieve the goal of restoring the distal radius as a base for optimal hand

and wrist function, we consider three questions: (i) Who is the patient? Infirm or

healthy? High-demand or low-demand? Good bone/high-energy versus poor

bone/low energy? (ii) What is the extent and pattern of articular involvement?

(iii) What is the integrity of metaphyseal support?

The first question highlights the role of the patient interview and examin-

ation. The history and physical examination should include age, occupation,

daily activity level, and general medical condition. The population of healthy

older people is expanding rapidly. Many of these patients remain active well

into their eighth decade, some of them pursuing activities such as skiing, golf,


or tennis. On the other hand, most of the older persons have at least one chronic

medical condition and many have multiple medical conditions. Keeping in mind

that in the elderly the bone of the distal radius is weaker and thus not only more

likely to fracture but also more likely to collapse with plaster immobilization, the

aggressiveness with which we treat the fracture must be tempered by the patient’s

functional limits and general medical condition rather than by the patient’s age.

Therefore, we have found it helpful for treatment purposes to divide adult patients

with fracture of the distal radius into two groups: the physiological young and/or

active and the physiological old and/or inactive. In addition to age and activity,

the physical examination should define the urgency of treatment by inspecting

the wrist for wounds, tendon, and nerve function, with special attention to the

function of the median nerve.

The second question addresses the extent of fractures involving the articu-

lations between the radius and the proximal carpal row, and the radius with the

ulnar head. As shown by Kreder et al. (112), the final outcome on distal radius

fractures following fracture union depends primarily on residual joint stability

and the presence or absence of post-traumatic arthritis of the DRUJ. For the

radiocarpal joint surface of the distal radius, it is generally accepted that a

greater than 2 mm step-offs or gaps seen on plain radiographs is likely to lead

to an unacceptable outcome. In a retrospective study, Knirk and Jupiter (113)

investigated the effect of residual radiocarpal incongruity after intra-articular

fractures of the distal end of the radius in young adults. At a mean follow-up

of 6.7 years, there was radiographic evidence of post-traumatic arthritis in 28

(65%) of the fractures. Accurate articular restoration was the most critical

factor in achieving a successful result. Of the 24 fractures that healed with

residual incongruity of the radiocarpal joint, arthritis was noted in 91%,

whereas of the 19 fractures that healed with a congruous joint, arthritis developed

in only 11%. In addition, radial styloid fractures with the fracture line ending at

the scapholunate gap should be suspected of the concurrence of the distal radial

fracture with a scapholunate dissociation (114).

The third question directs the surgeon to determine the metaphyseal

support. If the volar metaphysis is involved, the fracture may be reducible but

will never maintain reduction. Those dorsal fractures with involvement of

greater then one-third of the sagittal diameter of the radius metaphysis may redis-

place despite excellent close reduction, because those fractures are inherently

unstable. Extensive metaphyseal comminution with involvement of both the

dorsal and volar metaphysis makes it more difficult to restore the alignment of

the distal fragments and leaves them with little or no bone-to-bone contact to

help prevent loss of alignment despite external fixation with or without ancillary

K-wires or internal fixation with a single dorsal or volar plate.

Treatment options for fractures of the distal radius can be divided into non-

operative or operative treatment. The surgical options of treatment of distal radial

fractures can be categorized into three main tools that may be used individually

or in combination to obtain optimal stability: percutaneous pinning, external


fixation, and internal fixation. Whether patients have a nondisplaced fracture

requiring a minimal degree of immobilization or a markedly displaced fracture

requiring open reduction and internal fixation, all patients need to be instructed

and encouraged to perform hand and finger exercises, such as the “six pack” of

exercises described by Dobyns and Linscheid (115). Most patients can perform

these on their own, but some may benefit from supervised hand therapy. Shoulder

and elbow motion should also be encouraged and maintained during healing,

especially in the elderly.

Nondisplaced Distal Radius Fractures

Nondisplaced and minimally displaced distal radius fractures can be treated with

a removable prefabricated splint of the wrist, leaving the elbow, fingers, and

thumb free to avoid stiffness. O’Connor et al. (116) conducted a study in

which 66 adult patients with minimally displaced distal radial fractures were ran-

domly assigned to treatment with either a plaster cast or a lightweight removable

splint. Outcome assessment by clinical and radiological evaluation, and an inde-

pendent physiotherapy assessment showed greater satisfaction, few treatment-

related problems, and a superior functional assessment score at six weeks for

the removable splint compared to the cast.

A prefabricated, functional brace can also recommended for those patients

with displaced fractures which need closed manipulation as reported in a prospec-

tive, randomized study by Tumia et al. (117). A total of 339 patients were placed

into two groups, those with minimally displaced fractures not requiring manipu-

lation and those with displaced fractures which needed manipulation. Treatment

was by either a conventional Colles’ plaster cast or with a prefabricated func-

tional brace. Similar results were obtained in both groups with regard to the

reduction and to pain scores but the brace provided better grip strength in the

early stage of treatment. This was statistically significant after five weeks for

both manipulated and nonmanipulated fractures. There was no significant differ-

ence in the functional outcome between the two treatment groups. However,

younger patients and those with less initial displacement had better functional

results.

Displaced Distal Radius Fractures

On the basis of the large body of clinical and experimental evidence, we believe

that an attempt at anatomic reduction of most distal radius fractures is warranted.

However, if substantial displacement is present—defined as intra-articular dis-

placement greater than 2 mm, metaphyseal angulation greater than 208, or meta-

physeal shortening from a collapse greater than 3 mm—there is a high risk for

secondary displacement during the immobilization period (118). In a prospective

study, Nesbitt et al. (119) evaluated the radiographic outcome of unstable distal

radius fractures in 50 patients with three or more instability factors as described

by Lafontaine et al. (120) treated by closed reduction and sugar tong splinting.


At four weeks after reduction, only 46% of these unstable distal radius fractures

maintained an adequate reduction. Of the 54% of fractures that failed to maintain

an adequate reduction, age was the only statistically significant predictor of sec-

ondary displacement. In our experience, secondary displacement is associated

with a suboptimal outcome and sequelae in active or “physiologically young”

patients. Again, when developing a treatment program the treating physician

must always bear in mind the patient’s functional demands and general

(medical) condition.

Closed Reduction

A good long-term prognosis after closed reduction and casting can be expected

when there is limited displacement. There are essentially two different techniques

for obtaining closed reduction, direct manipulation of the distal radius fragment,

and longitudinal traction through the hand, wrist, and fracture site. It has been

suggested that longitudinal traction results in a better reduction, is less painful,

and has a lower rate of redisplacement than direct manipulation. Earnshaw et al.

(121) compared these two methods in a prospective, randomized controlled

trial. Two hundred and twenty-five patients that displaced Colles’ fractures

were randomized to treatment with closed reduction with either finger-trap trac-

tion or manual manipulation. All underwent cast immobilization. The fractures

were assessed radiographically by measurement of the ulnar inclination, volar

tilt, and radial shortening before reduction, immediately after reduction, and at

one and five weeks after reduction. No significant differences were found

between the alignment of the fractures in the two treatment groups at any time.

However, the percentages of fractures in an acceptable alignment (,108 dorsal

tilt and radial shortening ,5 mm) were only 27% and 32% at five weeks after

finger-trap traction and manual manipulation, respectively.

The greatest challenge of closed treatment of dorsally displaced fractures of

the distal radius is maintaining the position obtained by reduction of the fracture.

The Cotton-Loder position with extreme volar flexion and ulnar deviation of the

wrist might be mechanically effective in restoring volar tilt; however, this pos-

ition can be dangerous, causing excessive median nerve compression and may

also contribute to hand stiffness because it is difficult to close the fist with the

wrist in this position. Our recommended position of immobilization for a dorsally

tilted metaphyseal fracture is that of a neutral position with respect to extension/flexion, and a slight ulnar deviation of the wrist. Although an argument can be

made for immobilization of Colles’ fractures in a sugar tong splint or a long-

arm cast, we favor immobilization in a below-elbow cast or a prefabricated, func-

tional brace because we feel that stability of the fracture determines maintenance

of reduction far more than the method of immobilization. If displacement of the

fracture would influence the patient and surgeon to consider operative care, radio-

graphs should be used to monitor the fracture prior to the establishment of early

healing that would make manipulative reduction more difficult (i.e., within

two weeks). The patient should be warned that loss of reduction may occur.


If redisplacement during the immobilization period occurs, remanipulation has

been shown to have little value (122)—again most likely a reflection of the

inherent instability of the fracture—and operative treatment should be con-

sidered. Jupiter et al. (123) achieved excellent and good results with open

reduction and internal fixation in 18 of 20 patients aged 60 years and older

who presented to their institution with a radius fracture made complex by

virtue of displacement after closed reduction and cast or external fixation

immobilization.

Closed Reduction and Percutaneous K-Wire Fixation

Percutaneous pinning alone is contraindicated in extraarticular fractures with

marked metaphyseal comminution, in soft osteoporotic bone, and in fractures

with severe shortening. It can be recommended for reducible extraarticular or

simple intraarticular fractures without metaphyseal comminution and with

good bone stock (Fig. 4). A variety of different techniques have been described

in the literature. These include pins placed through the radial styloid, crossing

pins from the radial and ulnar sides of the distal fragment into the distal shaft,

intrafocal pinning as advocated by Kapandji (124), and transulnar pinning with

or without transfixation of the DRUJ. In a prospective study on 96 patients

with extraarticular or intra-articular dorsally displaced fractures of the distal

radius, Lenoble et al. (125) compared the radiological and clinical outcome

after transstyloid fixation and immobilization with Kapandji fixation and early

mobilization. Pain and reflex dystrophy were more frequent after Kapandji fix-

ation and early mobilization, but the range of movement was better although

this became statistically significant after six weeks. The radiological reduction

was better soon after Kapandji fixation, but there was some loss of reduction

and increased radial shortening during the first three postoperative months. The

clinical result at two years follow-up was similar in both groups. Percutaneous

fixation techniques may be more reliable when supplemented with additional

stabilization from bone grafts, bone graft substitutes, calcium phosphate bone

cement, or external fixation (126).

To avoid injury to the sensory branch of the radial nerve, it has been

suggested that the K-wires be inserted through a small skin incision after blunt

dissection with a small hemostat down to the bone. Alternatively, an oscillating

wire driver can be used. The wires can be either cut beneath the skin or cut to lie

outside the skin. To minimize the risk of pin infection, we prefer to cut off the

wires just below the skin and then bent it back to the bone. However, this requires

an operative procedure to remove the wires six to eight weeks later. In the rare

situation of a deep infection after percutaneous pinning, operative treatment

including removal of the pins is necessary. However, pin track infections are

usually superficial and can be treated with wound care and antibiotics. Ruschel

and Albertoni (127) observed six complications in 29 unstable extraarticular

distal radius fractures treated by intrafocal Kapandji pinning. Four patients


developed reflex sympathetic dystrophy (RSD), one patient had a superficial

K-wire infection, and another patient had radial nerve superficial branch

paresthesia.

External Fixation

External fixation remains a valuable option in the management of fractures of the

distal radius (Fig. 5). Depending on the specific mechanical features inherent in

Figure 4 (A–C) K-wire fixation of a distal radius fracture.


the fracture pattern, external fixation may act as a joint distractor, neutralization

frame, buttress, or even for compression. In acute fractures, an external fixator is

mainly used with joint distraction to obtain an indirect reduction of comminuted

fractures by applying tension on the capsuloligamentous structures attached to

the distal radius and after the device is statically locked to maintain fracture frag-

ment alignment. Attention is important not only in the recognition of indications,

functions, and limitations of the external fixation, but also on the application of a

specific external fixator. It has been recognized that excessive distraction is

harmful to the hand and median nerve and can created stiffness and develop

Figure 5 (A–D) External fixation for an unstable fracture of the distal end of the radius.


sympathetic reflex dystrophy. In addition, distraction alone does not provide ana-

tomical reduction in every case, especially in those fractures with intra-articular

fragments and severe comminution. Finally, distraction alone often cannot

prevent a secondary collapse. Therefore, several authors have advocated

limited open reduction, supplementary pin fixation, or bone grafting in addition

to external fixation (128–132). Others have tried to create dynamic fixators that

maintain length and alignment but allow for wrist flexion and extension (133–

135). By avoiding wrist traction, investigators hoped to avoid wrist stiffness,

finger stiffness, or nonunion, all secondary to overdistraction. Overdistraction

of the wrist can be avoided by applying a “nonbridging” fixator which does

not span the wrist joint. The distal pins of a nonbridging external fixator are

placed in the distal fracture fragments directly, permitting at least a limited arc

of wrist motion (136). In a prospective comparison of spanning and nonspanning

external fixators, McQueen (137) has found improved radiological results, grip,

and wrist flexion in the nonspanning group at all stages of review. However,

the results by Krishnan et al. (138), also comparing static bridging and

dynamic nonbridging external fixation in a prospective randomized study, did

not demonstrate a statistically significant difference in the radiological and clini-

cal outcomes achieved with these two treatments.

External fixation can also be used for temporary fixation in severe open

fractures until the soft-tissue situation allow an open reduction and internal fix-

ation and as a neutralization frame to unload and protect a fracture that has

more tenuous internal fixation due to fracture complexity or osteoporosis.

Limited Open Reduction and Internal Fixation

The choice of surgical approach is dependent on the type of fracture, direction of

displacement, associated injuries (if any) and now, where volar locking plates for

the fixation of dorsally displaced distal radius fractures are available, in many

fractures on the preference of the treating surgeon. Pneumatic tourniquet

control is strictly recommended for all open procedures.

Dorsal approach: A lazy-S or a straight longitudinal dorsal midline

incision is made from the midcarpus proximally centered over the radius, extend-

ing between 8 and 10 cm (139). The third extensor compartment is opened, with

the EPL tendon mobilized proximally and distally so that it can be transposed.

The fourth and the second dorsal compartments are elevated with sharp sub-

periosteal dissection. Some surgeons prefer to resect the terminal branch of

the posterior interosseous nerve. The fourth compartment extensor tendons are

then retracted ulnarward, and the second and third compartments radialward.

Using a T-plate for fixation of the radius fracture, Lister’s tubercle is ronguered

flush with the shaft, while it is preserved when using a Pi-plate or two small

plates. With extraarticular fractures or shearing dorsal fracture dislocation, the

dorsal wrist capsule can be preserved because the accuracy of the reduction

can easily be confirmed by the interdigitation of the fracture lines and by


fluoroscopic control. To reduce the fragments under direct vision for complex

intra-articular fractures with impacted articular fragments as well as for fractures

associated with carpal bone or ligament injuries, the dorsal wrist capsule is

opened by an incision along the dorsal rim of the distal radius, exploring the

underlying proximal carpal row and the articular surface of the distal radius.

After reduction and fixation of the fracture, the capsulotomy—if performed—is

closed with side-to-side sutures and the extensor retinaculum is reapproximated,

leaving the EPL tendon subcutaneous.

Volar approaches: The most commonly used volar exposure of the distal

radius is the distal part of the Henry (140) approach between the flexor carpi

radialis and the radial artery. A longitudinal incision from the wrist flexion

crease proximally, extending 5 to 8 cm is used. The flexor carpi radialis tendon

and the flexor tendons are retracted ulnarly, thus protecting the median nerve,

while the radial artery is retracted radially. The pronator quadratus is identified

and with an L-shaped incision at its most radial and distal attachment elevated

off of the radius with sharp dissection and retracted ulnarly. The volar carpal liga-

ments should not be incised. If a carpal tunnel release is necessary, a separate

incision on the ulnar side of the palm should be made so that the volar cutaneous

branch of the median nerve is not transected by connecting the incisions. After

reduction and fixation of the fracture, the implant is covered by suturing the

pronator quadratus to the edge of the brachioradialis.

An extension of this approach can provide access to the articular surface

and to the dorsal aspect of the radius (141). The first extensor compartment is

opened and the brachioradialis tendon is released from its attachment at the

distal radius to enable reduction of the radial styloid. To visualize the intra-

articular fragments and the dorsal die-punch, the proximal shaft fragment must

be pronated “out of the way” with a bone clamp. This gives free—intrafocal—

access to the articular fragments through the fracture plane. After indirect

reduction of these fragments against the proximal carpal row, the shaft fragment

is supinated back in place.

With more complex volarly displaced fractures, particularly with involve-

ment of the volar die-punch fragment, and to avoid two incisions—if a carpal

tunnel release is planned—in volar shearing fractures, a different approach is

chosen. An incision is outlined to extend from the midpalm obliquely crossing

the wrist flexor crease and extending proximally for 6 to 10 cm. The flexor reti-

naculum is opened at its ulnar border. The space between the ulnar vascular struc-

tures and the flexor tendons is dissected. The ulnar neurovascular bundle together

with the flexor carpi ulnaris tendon are retracted ulnarly, whereas the flexor

tendons, median nerve, and radial artery are retracted radially, exposing the pro-

nator quadratus. After elevating the muscle from the radius, an excellent exposure

of the medial side of the radius is given.

Approach to the radial styloid: In some circumstances, a specific

approach to the radial styloid may be useful. This can be done with a longitudinal


incision between the first and second extensor compartments. Throughout the

whole procedure, care must be taken to protect the branches of the superficial

radial nerve and lateral antebrachial cutaneous nerves. The exposure includes

subperiosteal elevation of the extensor compartments, which are then retracted

away from the fracture site. If the exposure is extended distally to the tip of

the radial styloid, then the dorsal branch of the radial artery is at risk.

Limited open reduction and internal fixation: The concept of limited

open reduction is defined as a selective surgical exposure of fracture fragments

in association with closed reduction and in conjunction with arthroscopic treat-

ment of distal radius fractures. Articular and metaphyseal fragments which

remain displaced after closed reduction are approached through limited incisions

in an effort to achieve anatomic reduction with minimal soft-tissue disruption

devascularization of the fragments. The choice of surgical approach depends

on the location of the displaced fragment. The limited incision allows only the

use of small implants such as wires, tension bands, and small buttress plates.

The following fractures cannot be managed by limited open reduction: irre-

ducible metaphyseal fractures, shearing marginal fractures of the joint surfaces,

irreducible intra-articular fractures, radiocarpal fracture dislocations, redisplaced

fractures after closed reduction, fractures associated with carpal or DRUJ injuries

which need to be addressed operatively, and fractures associated with soft-tissue

lesions. The choice of surgical approach depends on the location and direction of

displacement of the fracture fragments, but also on the implant that the surgeon

prefers to use for stabilization of the fracture. In addition, soft-tissue problems as

well as associated carpal and DRUJ injuries may influence the choice of the sur-

gical approach. Volarly displaced fractures have to be approached through volar

exposures. But dorsally angulated fractures can be approached dorsally or volarly

using a volar fixed-angle plate fixation (Fig. 6). Volar incisions are also appropri-

ate for primary repair of a torn wrist capsule in radiocarpal fracture dislocations

and whenever median nerve decompression is indicated.

Combined dorsal and volar exposure and fixation: Complex articular

and metaphyseal fractures of the distal radius may merit a combined dorsal and

volar exposure and plate fixation (142,143). A single dorsal or volar plate may not

provide adequate stability, and the distal fragments may displace in the direction

opposite to the plate. The combined dorsal and volar plate can cradle the articular

fragments, compressing them together and providing improved support at the

metaphyseal level (Fig. 7).

Distraction plating: As an alternative for double plating, internal dis-

traction plating can also be used for the treatment of highly comminuted distal

radius fractures especially in the elderly patient (144). The technique involves

the use of 3.5 or 2.7 dynamic compression plates. The instrumentation is

applied in distraction dorsally from the radial diaphysis, bypassing the


comminuted segment, and fixed to the long metacarpal (Fig. 8). A disadvantage

of this technique is the need for a second operation to remove the plate.

Implants for Internal Fixation

An innumerable and ever-increasing variety of implants for internal fixation of

fractures of the distal radius continue to appear, largely as a result of the attempts

by many different companies to corner a part of this market. This together with a

Figure 6 Fixation of a dorsally displaced distal radius fracture with a volar fixed-angle

device. (A and B) Radiographs of a 40-year-old man showing an extraarticular dorsally

displaced distal radius fracture. (C and D) Postoperative radiographs demonstrating

anatomic reconstruction of the distal radius using a volar fixed-angle plate and screws.


Figure 7 (Continued on next page) Combined dorsal and volar plate fixation of a

complex fracture of the distal radius. (A) Radiograph of a type V complex distal radius

fracture according to Fernandez in an elderly woman. (B and C) Preoperative CT scans

reveal the severity of both intraarticular and metaphyseal comminution with involvement

of the radial column, the central articular surface, the dorsal and the volar rim, and a split of

the ulnar facet. In addition, CT scans demonstrate degenerative changes at the tip of the

radial styloid. (D and E) Postoperative radiographs showing an acceptable reduction

and restoration of radial length after open reduction, bone grafting, and volar and dorsal

plate fixation. However, the dorsal plate obscures the articular surface on the frontal

view. (F–H) Postoperative computed tomography scans confirm an acceptable realign-

ment of the severely comminuted articular surface. Abbreviation: CT, computed

tomography.


steady stream of case series (level 4 evidence) claiming excellent results in the

treatment of distal radial fractures using one special plate or another may be tire-

some (145–156). Nonetheless, we believe that there have been some important

developments. One was the inauguration of fixed-angle plate fixation and the

other the development of the fragment specific fixation. Walz et al. (157) com-

pared the loss of reduction after internal fixation of distal radius fractures in

elderly patients following plate fixation with a conventional T-plate with that fol-

lowing fixed-angle plate fixation. The two groups were comparable with respect

to age and fracture type, but there were more women in the group with the fixed-

angle plate fixation. A loss of reduction was found in 12 of the 30 patients treated

with a conventional T-plate (40%), whereas a loss of reduction was observed only

in two out of 44 patients (4.5%), which were treated with a fixed-angle device. In

a biomechanical study, Dodds et al. (158) compared the fragment-specific fix-

ation with low-profile modular implants and the augmented external fixation

for intraarticular distal radius fractures. In the four-part fracture pattern,



Figure 8 (Continued on next page) Internal distraction plating of distal radius fracture.

(A) Radiograph of a 25-year-old, right-handed patient, who was injured in a motorcycle

accident, with a fracture of the distal third of the ulna, and an open highly comminuted

intraarticular distal radius fracture type V according to Fernandez. (B) Notice the fracture

fragments in the wound. (C) These radiographs demonstrate the open reduction and

internal fixation of the distal ulna fracture combined with repair of the laceration of the

FDP V tendon, and the external fixation of the distal radius fracture. After the external fix-

ation of the distal radius fracture, the distal radioulnar joint was still grossly unstable and

was temporarily stabilized with an outlier of the external fixator. Notice the persisting

gross deformity of the distal radius. (D) A postoperative PA radiograph demonstrates

bridge plate fixation with ancillary Kirschner wires. (E) Five months postoperatively,

the patient presented with a broken plate which was then removed. (F and G) Final clinical

and radiographical examination 13 months after the injury showed an arc of motion of

wrist extension/flexion of 45/508, wrist ulnar/radial deviation of 20/108, and a

forearm supination/pronation of 70/808.


fragment-specific fixation was shown to be significantly more stable when com-

pared with static augmented external fixation. Meanwhile, it has been shown in

several clinical and laboratory studies that these ultrathin modular implants

that can be shaped to customize fixation for different fragment configurations



provide an extremely high degree of stability allowing active, unresisted motion

exercises within a week of surgery even in unstable intraarticular fractures of the

distal radius.

Again, we believe that there is not one best method or one superior implant

to treat fractures of the distal radius and that often different ways of treatment

result in a similar outcome. The treating physician must always bear in mind

that the primary goal in the treatment of distal radius fractures is to restore

hand and wrist function and to prevent long-term disability. On the other hand,

recognizing that distal radius fractures are associated with a high rate of compli-

cations and frequently poor results should lead us to be more aggressive in the

original case of these fractures.

ASSOCIATED INJURIES

As a result of the original trauma, distal radius fractures can be associated with

several soft-tissue and bony injuries. Injuries associated with fractures of the

distal radius are open fractures, nerve injuries, lesions of the distal radioulnar

joint with or without fractures of the distal ulnar, and injuries to the carpal liga-

ments and bones. Associated injuries often lead to more problems than the distal

radius fracture itself and might have a negative effect on the final outcome, par-

ticularly if they are missed initially. Associated injuries can influence decision-

making on whether to operate on a distal radius fracture or not as well as how

to fix the fracture.

Open Fractures

Open fractures of the distal radius are unusual. However, all open fractures—

whether there is a massive skin injury or a pinpoint—are indications for emer-

gency operative treatment of the injury. Preoperative cultures are advised as

the first step of the treatment plan followed by broad-spectrum antibiotic

therapy, debridement, and irrigation of the wound with saline solution.

Decision-making how to deal with the fracture itself depends on the wound situ-

ation on the one hand—result of a low- or high-energy trauma, suitable cleaned or

not, open for less or more than eight hours—and the fracture stability. If there is

any doubt about the wound situation, the wound is left open and closed seconda-

rily, and the fracture is fixed with use of an external fixator. If the wound could be

suitably cleaned and the fracture is unstable, we are not afraid to stabilize the

fracture with an internal fixation or a combined internal and external fixations.

Nerve Injuries

Although ulnar nerve dysfunction is less frequent, symptoms of median nerve

dysfunction is the most common problem associated with acute distal radius frac-

tures (90,159–164). However, in general, they were resolved, if a satisfactory

reduction of the fracture is obtained. Therefore, we recommend immediate


reduction for all distal radius fractures with neurologic symptoms, but do not rou-

tinely release the carpal tunnel, even in patients with fractures, which require

operative treatment unless there is previous history of carpal tunnel syndrome

or a massive swelling, so that compartment syndrome must be considered.

Carpal Injuries

Resulting from a similar injury mechanism, intraarticular and extraarticular frac-

tures of the distal radius are often accompanied by soft-tissue and bony injuries

within the carpus. Initially, these injuries are often missed because the attention is

drawn to the obvious deformity of the distal radius, but may in part be responsible

for continued discomfort even after a seemingly well-healed fracture (165).

Therefore, our treatment plan for the setting of distal radius fracture suspected

to be associated with a carpal ligament disruption calls for diagnostics of the

carpal ligaments (166). Special attention is mandatory in the evaluation of the

carpal architecture after reduction of the distal radius fracture, particularly in

intra-articular fracture with the fracture line entering the ridge between the

scaphoid and lunate fossa (114). Traction radiograms may be helpful to detect

complete scapholunate ligament tears because the scaphoid translates distally

under traction, if the ligament is completely disrupted (167). If there are

further concerns, a CT with intraarticular injection of gadolinium or an MRI

with intravenous gadolinium should be recommended in distal radius fractures

which do not require operative treatment and arthroscopy or direct visualization

of the carpal ligaments in distal radius fractures requiring surgical treatment.

Treatment plans for distal radius fractures associated with carpal bone or

ligament injuries must take into account the stability of the distal radius fracture

and the severity of the carpal injury. Nondisplaced carpal fractures usually

require no additional treatment because the methods used for immobilization

of the radius are sufficient. Because it takes a long time to heal the scaphoid

even in a nondisplaced fracture, internal fixation of the scaphoid may be rec-

ommended in the setting of distal radius fracture combined with a nondisplaced

scaphoid fracture to allow mobilization of the wrist joint after healing of the distal

radius fracture (168) (Fig. 9). Although partial nondissociative carpal ligament

lesions may heal uneventfully during the immobilization time required for

healing of the distal radius fracture, dissociative lesions require aggressive treat-

ment. This includes reduction of the carpal malalignment, ligament repair, and

temporary K-wire stabilization (Fig. 10).

Associated DRUJ Lesions

The stability of the DRUJ depends on the congruity of the sigmoid notch and the

ulnar head, the integrity of the TFCC and the capsular, as well as on the stability

of the ulnar styloid. Therefore, assessment of the DRUJ requires that the radius is

adequately restored with respect to length and shape and that the anatomic


relationship of the sigmoid notch and the ulnar head is re-established. According

to Fernandez and Jupiter (32), associated lesions of the DRUJ are categorized as

stable, unstable, and potentially unstable. Type I lesions with the DRUJ clinically

stable and radiographically congruent allow early forearm rotation and do not

require special external support. Type II lesions with the joint clinical and radio-

graphic evidence of subluxation or even dislocation require operative treatment.

Tension band or interosseous wire is recommended to fix the ulnar styloid frag-

ment when its avulsion at the base is causing DRUJ instability. If the instability of

the DRUJ is caused by a massive tear of TFCC, the TFCC lesions may be treated

with arthroscopic or open repair. Immobilization with the forearm in neutral pos-

ition for six weeks is indispensable. For those type III DRUJ lesions, in which the

fracture of the ulnar head could be rigidly fixed with plate and screws (169)

(Fig. 11), functional aftercare with early active forearm rotation is possible.

Type III lesions with instability of the DRUJ due to dorsally displaced dorsoulnar

fragment of the distal radius require exact anatomic reduction of the sigmoid

notch to gain DRUJ stability (170).

Figure 9 Radius fracture associated with fracture of the scaphoid. (A) An oblique radio-

graph of a diaphyseal radius fracture with extension in the radiocarpal joint associated with

a transverse fracture of the scaphoid. (B) Postoperative radiograph showing reconstruction

of the metaphyseal radius fracture with three transverse lag screws, additional lag screw

fixation of the radial styloid fragment, and neutralization plating of the diaphyseal

radius fracture as well as Herbert screw fixation of the scaphoid fracture through an

extended volar approach.


Figure 10 Fracture of the distal radius associated with a complete scapholunate ligament

rupture. (A and B) Radiographs, after closed reduction and immobilization in a cast,

showing partial insufficient reduction and a step-off between the scaphoid and the

lunate fossae suspicious for scapholunate ligament tear. (C and D) Radiographs, after

open reduction and internal fixation with a 908 to 908 plating using fixed-angle devices

and stabilization of the scapholunate injury with two additional K-wires.


Figure 11 Distal radius fracture associated with fracture of the ulna head. (A and B)

Dorsally displaced intraarticular fracture of the distal radius associated with a fracture

of the ulna head and a fracture at the base of the ulnar styloid in an elderly woman.

(C and D) After open reduction and volar fixed-angle plate fixation, the distal radioulnar

joint (DRUJ) was grossly unstable. The ulna head fracture was treated with blade plate

fixation. Because of persisting instability of the DRUJ, stabilization of the ulnar styloid

fracture was provided with K-wire and tension band wiring.


COMPLICATIONS

Although it was once widely believed that patients with fracture of the distal

radius generally do very well regardless of the radiological result, it is now

appreciated that fractures of the distal radius fractures are susceptible to

several complications, many of which will lead to poor clinical results. In a

study of 565 Colles’ fractures, Cooney et al. (106) found a complication rate

of 31%. The main complications were median neuropathy, finger stiffness,

RSD, degenerative changes at the radiocarpal and distal radioulnar joints,

malunion, nonunuion, and tendon ruptures.

Reflex Sympathetic Dystrophy

RSD (complex regional pain syndrome type I) is a complex of symptoms charac-

terized by diffuse pain, usually with associated swelling, vasomotor instability,

and severe functional impairment of the extremity. RSD presents with very

varied symptoms and signs occurring in different combinations and intensity.

The incidence of RSD after fractures of the distal radius has been variably

reported at between 0.02% and 32% (171–175). The higher estimates of the

prevalence of RSD most likely reflect a broader definition of the problem, includ-

ing patients with stiffness and swelling that are more related to anxiety, fear, and

other psychological difficulties associated with treatment and recovery from

injury. With a more strict definition—one that requires objective evidence of a

role of sympathetic nerves in the pain via measurement of the response to a

stellate ganglion block—the prevalence of true RSD is very low.

If RSD is suspected, prompt intervention is recommended to prevent many

of the problems of this serious complication. RSD may be present in the patient

who has increasing finger stiffness associated with an inordinate amount of pain,

or paresthesias, and swelling during fracture healing. These might be caused by

tight dressings, casts, or splints. Removal of a dressing or cast to relieve pressure,

elevation of the swollen hand, and intensive physiotherapy are mostly adequate to

prevent the development of full RSD. However, in the severe condition, more

aggressive intervention with sympathetic blocks, appropriate medication, and

physiotherapy is necessary. Recognition and treatment of acute carpal tunnel

syndrome may also abort the development of RSD.

Nonunion

Although nonunions of fractures of the ulnar styloid process associated with

distal radius fractures are quite common and mostly do not cause symptoms, non-

unions of distal radius fractures are an extremely rare occurrence and are usually

symptomatic (176–181). In a study of more than 2000 fractures of the distal end

of the radius, Bacorn and Kurtzke (182) reported a nonunion rate of 0.2%.

Watson-Jones (183) reported one case of distal radius nonunion of 3199 fractures.

In 1998, Segalman and Clark (184) presented a series of 12 distal radius


nonunions in 11 patients treated during a 24-year period. Recently, we reported

on our experience with 23 nonunions of the distal radius (185).

Some investigators have speculated that delay and arrest in healing of a

fracture of the distal radius may have become more common since surgical treat-

ment of distal radius fractures has become more popular (186). Indeed, factors

associated with fracture treatment may contribute to the failure of fractures of

the distal radius to unite, including inadequate immobilization, inadequate

fixation during open reduction, and excessive distraction during application of

an external fixator. In addition, some medical conditions and some drugs may

disturb the bone metabolism and, therefore, may delay or even prevent fracture

healing. Segalman and Clark (184) reported 15 comorbid medical condition in

their 11 patients with 12 distal radius nonunions including diabetes mellitus,

peripheral vascular disease, peripheral neuropathy, and psychiatric disorders,

alcoholism, hypothyroidism, morbid obesity, and scleroderma. The most striking

association of the five patients treated for radial fracture nonunion by Smith and

Wright (187) was that all patients were heavy smokers. Tobacco previously has

been implicated in an increase in the nonunion rate in patients having spinal

fusion and limited intercarpal arthrodesis. In addition, three of the five patients

reported by Smith and Wright were heavy alcohol abusers. Alcoholism may

negatively affect compliance of the patients during fracture treatment.

A distal radial fracture nonunion should be suspected clinically if there is

continuing pain after remobilization of the wrist associated with an advancing

deformity. The pain is related to the use of the hand and shows no sign of improv-

ing. The diagnosis may be confirmed by showing movement at the fracture site on

lateral radiographs with the wrist in flexion and extension. If there is any doubt

regarding the radiographic signs of fracture union, a CT scan should be

recommended (188).

Because of the rarity of nonunion after fracture of the distal end of the

radius, it is not surprising that there is no consensus on the optimum mode of

operative treatment. A small, osteoporotic distal fragment, associated soft-tissue

contracture with radial deviation of the carpus and hand, and atrophic status at

the site of the nonunion are features that can make surgical correction of a

distal radial nonunion difficult and has led some authors to recommend total

wrist fusion (180,184,189). Several series describe surgical attempts to gain

union (179,186,190,191).

Segalman and Clark (184) used the extent of the metaphyseal subchondral

bone supporting the articular surface distal to the site of the nonunion as a criterion

to determine the appropriate treatment. They suggested that surgical attempts to

gain bony union are worthwhile when at least 5 mm of subchondral bone

beneath the lunate facet of the distal radius is available for application of implants.

For nonunions with less than 5 mm of subchondral bone supporting the articular

surface distal to the nonunion site, they recommend total wrist arthrodeses.

We compared the results of reconstruction of distal radial fracture nonunions

in 10 patients in whom the distal fragment had less than 5 mm of subchondral bone


supporting the articular surface distal to the site of the nonunion with those of

reconstruction of nonunions of the distal radius in 13 patients with a larger

distal fragment (185). The overall functional and radiographic outcomes were

similar, but more postoperative complications were observed in the patients

with small fragments than in the patients with large fragments. On the basis of

this experience, and because the radiocarpal and midcarpal articulations are

often uninvolved, we think that an attempt to maintain functional mobility of

the wrist by obtaining anatomic realignment of the distal fragment and union of

the fracture seems warranted. Total wrist arthrodeses should be reserved as a

final resort.

Malunion

In spite of advances in the treatment of fractures of the distal radius, malunion is

still a common complication. Malunion of the distal radius usually occurs follow-

ing conservative treatment; however, now that internal fixation of fractures of the

distal radius has become more commonplace, we are seeing an increasing number

of radial malunions after operative treatment.

Malunion of the distal end of the radius may be extraarticular with a meta-

physeal angulation, loss of length relative to the ulna, and rotational deformity of

the distal fragment (192). In addition, the distal fragment may be translated in

either the sagittal or the frontal plane (193). Distal radial malunion may be

intra-articular with a step-off or a gap at the radiocarpal and/or the distal radio-

ulnar joint or both, intra-articular and extraarticular.

It may be true that not all nonanatomically aligned fractures of the distal

radius result in a poor functioning outcome. However, in our experience many

patients with malunited fractures of the distal end of the radius complain of

decreased range of wrist motion and forearm rotation, weakness and pain,

especially on the ulnar side of the wrist, where an ulnocarpal impaction as a

result of radial shortening often exists. Many patients, both men and women,

complain of the cosmetic deformity. In a small number of patients, there may

be a carpal tunnel syndrome caused by the deformity of the wrist. All these com-

plaints are related to the disorder of the wrist joint caused by the deformity at the

radiocarpal level, the distal radioulnar joint, and the midcarpal level.

Treatment options for symptomatic malunion of the distal radius must take

into account the patient’s motivation, the functional demands of the patient, and

the anatomy of the deformity. Newer fixation devices allowing more stable fixation

of osteoporotic bone have made consideration of the bone quality less important.

Intervention to correct symptomatic malunions may be categorized into four broad

areas: procedures aimed at restoring anatomic relationships, procedures aimed

solely at gaining a functional improvement, procedures aimed at eliminating

pain, and procedures that combined two or more of the above approaches.

Procedures aimed at eliminating pain are wrist denervation and arthrodesis.

Arthrodesis may involve the total wrist joint or only radius, scaphoid, and lunate


(194–196). From the different procedures aimed solely at gaining a functional

improvement on forearm rotation, we have had very satisfactory results with

Bowers hemiresection interpositional arthroplasty (197,198). Procedures aimed

at restoring anatomic relationships between the distal end of the radius and the

carpus as well as the distal end of the ulna are primarily osteotomies of the

distal radius and the ulna.

The aim of a radial corrective osteotomy is to improve wrist function and

diminish pain by restoring the anatomic position of the distal end of the radius in

relation to the carpus and to the distal end of the ulna. Therefore, corrective

osteotomy is considered whenever there is a radiological malunion, but under-

taken only when there is a substantial likelihood that improved radiological align-

ment will lead to improvement in symptoms and function. It is important to

distinguish symptomatic and asymptomatic malunions. There are no fixed radio-

logical parameters to determine the indication for corrective osteotomy.

Poor general health and marked degenerative changes of the radiocarpal

joint are contraindications for radial osteotomy. Additional contraindications

include fixed carpal malalignment, evidence of a sympathetic reflex dystrophy,

limited function of the fingers, as well as severe osteoporosis. A slight instability

of the distal radioulnar joint is not a contraindication for radial osteotomy,

because the corrective osteotomy reestablishes, in general, its stability. Also a

marked instability of the distal radioulnar joint is no contraindication for radial

osteotomy, but requires a simultaneous procedure on the ulnar side of the wrist

(198–201). There is no upper age limit for osteotomy of the distal radius pro-

vided that there is adequate bone quality and impaired wrist function. Regarding

distal radial malunion in children, due to the remodeling capacity of the distal

radial metaphysis, osteotomy is rarely necessary.

Ideally, radial corrective osteotomy should be performed as soon after the

fracture as it is decided that the patient meets the criteria and the swelling is sub-

sided. Jupiter and Ring (202) evaluated the time of intervention comparing two

groups of patients who had had a corrective osteotomy of the distal radius.

One group had had the surgery an average of eight weeks after the initial

injury, and a comparable group had had the osteotomy an average of 40 weeks

after the fracture. The overall functional and radiographic outcomes were

similar, but earlier intervention reduced the total duration of disability and the

time until the patient returned back to work was significantly shorter in patients

out of the early-intervention group.

Preoperative work-up includes an exact evaluation of the clinical situation

and the radiological findings. The indication for corrective osteotomy is usually

based on plain radiographs of the injured wrist. Comparison of the opposite side

is helpful to determine ulnar variance and the inclination in the frontal and sagit-

tal planes. A CT may be helpful to detect degenerative changes and malalignment

of the distal radioulnar joint as well as rotational deformity of the distal radius

(192). An arthroscopy of the wrist may be indicated to assess the articular carti-

lage and the ligaments. Preoperative drawing of the planned surgical intervention


showing the level of osteotomy, the angle of correction, and the change in ulnar

variance is important. Nowadays, the preoperative planning of the surgical inter-

vention is often done on a computer (193,203–205).

Most surgeons feel that the approach to expose the distal part of the radius

depends on the direction of the deformity using a classic volar Henry approach

for volarly tilted malunions and a dorsal incision between the third and fourth

dorsal compartments for dorsally angulated malunions as outlined by Fernandez

(206–208). Because of formation of callus and remodeling at the site of the frac-

ture localized upon the dorsal aspect of the radius in dorsal malunions, visual

alignment of cortical surfaces may be difficult and inaccurate by using a dorsal

approach. In addition, the morbidity of dorsal plates such as extensor tendon com-

plications has been well documented (209–212). In 1937, Campbell (213–215)

published a technique in which the radius is osteotomized through a radial

approach. Now that newer plates designed specifically for the volar fixation of

dorsally unstable distal radius fractures by incorporating buttress pins and

screws that lock to the plate are available, the idea to correct dorsally tilted mal-

union through a volar or a radial approach has become more popular (216–220).

However, there are many facts which may influence the approach to the distal

radius for corrective osteotomy.

For corrective osteotomy of a dorsal malunion of the distal radius following

volar plate fixation, the radius can easily be approached using the prior incision. If

the distal fragment of the radius following dorsal plating is displaced in the direction

opposite to the plate or if the fracture is overcorrected a second approach on the

volar aspect of the radius may be needed. In the rare situation where an additional

procedure on the carpal ligaments or on the ulnar side of the wrist is required sim-

ultaneously with the radial corrective osteotomy, the radius should be approached

dorsally. Corrective osteotomy should include correction of malrotation of the

radius along with correction of angular deformities and radial shortening. Correct

rotational alignment of the distal radius with respect to the radial diaphysis can

easily be achieved by application of a buttress plate on the volar aspect of the

radius. In patients with a soft-tissue problem associated with distal radius malunion,

such as extensor pollicis longus or flexor pollicis longus rupture, the soft-tissue

problem may influence the choice of the approach to the radius (Fig. 12).

The osteotomy can be performed either at the prior fracture site or at a

different site. In many cases, it is technically easier to perform the osteotomy

proximal to the original fracture site. However, this can result in a severe hump-

back deformity of the distal radius and/or a dislocation of the DRUJ. The hump-

back deformity with the long axis of the carpus volar to the long axis of the radius

may disturb force transmission and can lead to a refracture after hardware

removal. Such problems can be avoided by locating the osteotomy as close to

the original fracture site as possible and by exact preoperative planning of the

center of rotation. The center of rotation can lie in, on, or outside the margins

of the radial cortex (221). When a limited lengthening is needed, the center of

rotation lies on the bone margins, and an incomplete opening-wedge osteotomy


Figure 12 (Continued on next page) Dorsally tilted malunion of the distal radius follow-

ing volar plating associated with rupture of the flexor pollicis longus tendon. (A and B)

Dorsal malunion of the distal radius following volar plating of a dorsally displaced fracture

with a nonlocking device. (C and D) Intraoperative views showing the rupture of the flexor

pollicis longus tendon and the loose distal screws. (E) Intraoperative view showing the

reconstruction of the flexor pollicis longus tendon and the reconstruction of the distal

radius with osteotomy, bone grafting, and volar fixed-angle plate fixation. (F and G)

Radiographs, after corrective osteotomy. Notice the large cortical iliac bone graft. (H

and I) Radiological appearance of the wrist four months after corrective surgery

showing the radius healed with an acceptable reduction and restoration of the length.


is enough. This situation is encountered in many volar malunions. When the

radius needs to be largely lengthened, the center of rotation is away from the

bone and a complete osteotomy is required. This situation is rarely given in

volarly angulated malunion but in most dorsal malunion.

It is important to restore the anatomic relationship between the distal radius

and the distal ulna. Radial shortening up to 12 mm can be corrected with a radial

osteotomy alone. If radial lengthening is complicated by soft-tissue contracture,

complete tenotomy or z-lengthening of the brachioradialis tendon may be helpful

(222). Although callotaxis is an useful technique to achieve satisfactory radial

length for young patients with growth arrest, combined radius–ulna osteotomy

can be recommended for elderly people (223,224).



Mostly, the defect created by the open-wedge osteotomy is filled with

corticocancellous or with cancellous bone graft harvested from the iliac crest.

Some investigators have reported about the use of bone substitute (225,226).

Hemicallotaxis is also described for correction of the radial deformity (227). In

most volarly angulated malunions in the sagittal plane, the graft will form a

triangular shape with its apex placed dorsally. For dorsally tilted malunions, a

double trapezoidal-shaped graft is needed to fill the gap. In 1988, Watson and

Castle (228) picked by a technique described by Durman in 1935 (229) cutting

the graft longitudinally from the distal end of the proximal fragment of the

radius. Campbell (213) harvested the graft from the distal ulna. Whatever is

used to fill the osteotomy gap, the large cancellous bone surface of the osteotomy

of the distal radius guarantees a fast integration of the bone graft, respectively, the

bone substitution and a fast consolidation (230).

Every technique used for fixation of the distal radius in acute radius

fractures, such as pinning and plating, can also be used to stabilize the distal

radius in corrective osteotomy. However, decision-making how to fix the

radius should take into account the quality of the bone graft and the interval

between the injury and the corrective osteotomy. To avoid implant failure, the

used plate should be strong, especially in a longstanding malunion and if the

bone graft is very tiny. Another option for stabilization of the site of the correc-

tive osteotomy is an external fixator with pins placed in the distal fragment (227).

This allows postoperative adjustment should the restoration of length or

alignment prove to be inadequate.

More than 100 papers on radial corrective osteotomy were published over

the last three decades. All of them show that corrective osteotomy improves wrist

and forearm motion as well as grip strength and diminishes pain. In a study pub-

lished in 2002, we were able to show that patients with no or only a minor residual

deformity after corrective osteotomy had significantly better results than those

with a gross residual deformity (231).

Recently, we published a study on corrective osteotomy for intra-articular

malunion of the distal part of the radius (232). We found that intra-articular

osteotomy can be performed with acceptable safety and efficacy. The results of

intra-articular corrective osteotomy are comparable with those of osteotomy

for the treatment of extraarticular malunion. However, the indication is limited

by both chronology and the type of injury. It is preferable to reserve such a pro-

cedure for those malunited fractures that have a relative simple intraarticular

component. CT scans are absolutely necessary to plan the surgical procedure.

Tendon Injury

Tendon injury associated with fractures of the distal radius is uncommon.

However, an unique complication that can occur in extraarticular distal radius

fractures is spontaneous rupture of the EPL tendon. This more commonly

occurs within four to eight weeks of the fracture (233–235).


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Index

Amputation

index fingertip, 14

thumb, 17

AO Classification. See Comprehensive

Classification of Fractures

(AO/ASIF Classification)

Arcs, 99

Articular injuries, 10, 12

ASIF Classification. See Comprehensive

Classification of Fractures

(AO/ASIF Classification)

Avascular necrosis

carpal dislocations, 111–112

Avulsion fractures, 49–51

open reduction, 52

radial collateral

small finger, 53

Avulsion injuries

digitorum tendon, 5–6

flexor digitorum profundus

tendon, 4–5

terminal extensor tendon

distal and fingertip

injuries, 5–6

Bone grafting

internal fixation

scaphoid fractures, 132–135

Bony mallet

percutaneous fixation, 11

Carpal

crowded sign, 98

height ratio, 99, 100

Carpal dislocations, 91–114

avascular necrosis, 111–112

classification, 93–96

clinical diagnosis, 96

closed reduction

and cast immobilization,

103–104

manipulation, 102–103

and percutaneous pinning, 104

complications, 111–112

Cooney’s classification, 96

diagnosis, 96–102

epidemiology, 92–93

Green and O’Brien’s

classification, 94

open reduction and internal fixation,

104–107

prognosis, 108–110

radiographic diagnosis, 97–98

treatment, 102–105

Carpal injuries

distal radius fractures, 164

Carpal-metacarpal fracture dislocations,

78–80

Cast immobilization


Circular saw injury, 15

189

Classification

AO/ASIF, 138

Cooney’s, 96

Fernandez, 138–139

Green and O’Brien’s, 94

Herbert’s

scaphoid fractures, 118, 120

Closed reduction

carpal dislocations, 102–103,

103–104, 104

distal radius fractures, 151–152

internal fixation, 26

metacarpophalangeal joint, 43–44

and percutaneous K-wire fixation


Comminuted and displaced proximal

phalanx fractures

middle finger, 31

Comminuted depressed fractures

phalangeal base of ring finger, 54

Comminuted fractures

fifth metacarpal, 80

index metacarpal head, 51

Comprehensive Classification of

Fractures (AO/ASIF

Classification), 138

Compression fractures, 52–54

Condylar fractures

PIP joint, 56–57

Cooney’s classification

carpal dislocations, 96

Cross-finger flaps, 14–16

Crowded carpal sign, 98

Crush injury

multiple proximal phalanx

fractures, 35–36

Cuticle, 3

Diaphyseal middle phalanx fractures

ring finger, 29

Digitorum tendon avulsion, 5–6

DIP. See Distal interphalangeal (DIP) joint

Discriminatory sensation, 3

Dislocations. See also Carpal dislocations

carpal-metacarpal fracture, 78–80

lunate

complete, 101

[Dislocations]

metacarpophalangeal joint, 42

MP joints, 41–74

multiple carpal-metacarpal, 78

PIP joint, 41–74, 58–59

Displaced and unstable diaphyseal

fractures

middle finger, 35

Displaced fractures

distal radius, 150–163


long metacarpal, 83

middle finger, 31, 38

proximal phalanx shaft, 22

Distal and fingertip injuries, 1–20

anatomy, 2–3

distal phalanx fractures

base, 4–5

incidence, 1

terminal extensor tendon avulsion

(mallet) injuries, 5–6

Distal interphalangeal (DIP)

joint, 4, 5, 6, 9, 10, 11, 13

Distal phalanx fractures, 4–5

distal and fingertip injuries

base, 4–5

tuft and shaft fractures, 4–5

unstable, 5

Distal radioulnar joint fractures, 140

Distal radius fractures, 137

associated injuries, 163–167

biomechanics, 144–146


closed reduction, 151–152

and percutaneous K-wire fixation,

152–153

combined dorsal and volar exposure

and fixation, 157

complications, 168–175

displaced, 150–163

distraction plating, 157–158

DRUJ injuries, 164–167

epidemiology, 137–138

external fixation, 153–158

dorsal approach, 155–156

radial styloid approach, 156–157

volar approach, 156

190 Index

[Distal radius fractures]

functional and radiographic anatomy,

140–144

implants for internal fixation,

158–163

malunion, 170–175

nondisplaced

treatment, 150

nonunion, 168–170

open reduction and internal fixation,

145–146, 157

tendon injuries, 175


Distraction plating


Extensor pollicis longus (EPL), 140

Extensor tendons, 3

External fixation



radial styloid approach, 156–157

volar approach, 156

FDP. See Flexor digitorum profundus

(FDP) tendon

Fernandez classification, 138–139

Fifth metacarpal

comminuted fractures, 80

displaced fractures, 82

Fight-bite injuries, 46

Finger

index

metacarpal fractures, 46

long

metacarpal, 98

metacarpal head fractures, 47

middle

comminuted and displaced proximal

phalanx fracture, 31

displaced and unstable diaphyseal

fractures, 35

displaced proximal phalanx shaft

fractures, 22

displaced transverse fractures, 38

proximal phalanx base

fracture, 26–28

[Finger]

ring


fractures, 22

phalangeal base

comminuted depressed fracture, 54

small

oblique displaced proximal phalanx

fractures, 33–34

radial collateral avulsion

fractures, 53

Fingertip. See also Distal and fingertip

injuries

sensation, 3

Fixation. See also External fixation

internal

closed reduction, 26


open reduction, 104–107,

145–146, 157

percutaneous

bony mallet, 11

percutaneous K-wire


Flaps

cross-finger, 14–16

homodigital island, 13, 16

moberg, 16–17

thenar, 13–14

Flexor digitorum profundus (FDP)

tendon, 7, 9

avulsion injuries, 4–5

Flexor tendons, 3

Fracture dislocations, 91–114

transscaphoid perilunate, 102, 106,

107, 109, 110

two-part carpal-metacarpal, 79

Fractures. See also Fractures under

distal radius; metacarpal;

phalanx; scaphoid

avulsion, 49–51

comminuted


index metacarpal head, 51


phalanx

middle finger, 31

Index 191

[Fractures]

comminuted depressed

phalangeal base of ring finger, 54

compression, 52–54

condylar

PIP joint, 56–57

diaphyseal middle finger, 35

diaphyseal middle phalanx

ring finger, 29

displaced middle and ring fingers

proximal phalanx shaft, 22

displaced transverse

long metacarpal, 83

middle finger, 38

distal phalanx, 4–5

distal and fingertip injuries, 4–5

distal radioulnar joint, 140

mallet, 9–10

metacarpal, 45–50

index finger, 46

operative management, 75–90,

76–77, 77–78

extraarticular base, 76–77

intra-articular base, 77–78

metacarpal head, 86–87

metacarpal neck, 85

metacarpal shaft, 81–85

MP joints, 41–74

nondisplaced distal radius

treatment, 150


small finger, 33–34

osteochondral transverse

metacarpal head of long

finger, 47

PIP joint, 41–74

proximal phalanx, 37

displacement pattern, 23


small finger, 53

screws, 32

spiral

metacarpals, 84

tuft and shaft

distal phalanx fractures, 4–5

vertical

metacarpal head, 48

[Fractures]

volar coronal, 51

metacarpal head, 49

wounds, 10–11

Free toe pulp transfer, 17–18

Greater arc injury

patterns, 95

Green and O’Brien’s classification


Hand-based functional splints

proximal phalanx fractures, 24

Hematoma

subungual, 4

Herbert’s classification

scaphoid fractures, 118, 120

Homodigital island flaps, 13, 16

Implants

internal fixation


Index finger

metacarpal fractures, 46

Index fingertip amputation, 14

Index metacarpal head

comminuted fracture, 51

Internal fixation

bone grafting


closed reduction, 26

implants


open reduction


distal radius fractures,

145–146, 157

Lag screws

metacarpal head

oblique fracture, 46

vertical fracture, 48

Lister’s tubercle, 142

Long finger

metacarpal, 47, 98

Long metacarpal


192 Index

Lunate dislocations

complete, 101

Lunula, 2–3

Mallet fractures, 9–10

Mallet injuries


Malunion


Median neuropathy


Meissner’s corpuscles, 3

Metacarpal

fractures, 45–50, 85, 86–87

comminuted, 80

index, 51

displaced, 82

displaced transverse, 83

index finger, 46

long finger, 47

operative management, 75–90

extra-articular base, 76–77

intra-articular base, 77–78

shaft, 81–85

vertical, 48

long finger, 98

Metacarpophalangeal (MP) joints, 13

articular incongruity, 55


dislocations, 41–74, 42

dorsal approach, 44

fractures, 41–74

hyperextension, 42

imaging, 43

pathoanatomy, 42–43

postoperative management, 44

surgical anatomy, 41–42

surgical management, 44

volar approach, 44

Middle finger


phalanx fracture, 31

displaced and unstable diaphyseal

fractures, 35


fractures, 22


[Middle finger]

proximal phalanx base fracture, 27

proximal phalanx fracture with

comminution, 26

Middle phalanx

basal fractures, 57–58

volar fractures, 69

Moberg flap, 16–17

MP. See Metacarpophalangeal

(MP) joints

Multiple carpal-metacarpal

dislocations, 78

Nail

distal groove, 2

folds, 2

plate, 2

Nerve injuries


Nondisplaced distal radius fractures

treatment, 150

Oblique displaced proximal phalanx

fractures

small finger, 33–34

Oblique fractures

metacarpal head of index finger, 46

Open fractures


Open reduction

avulsion fractures, 52

and internal fixation


distal radius fractures,

145–146, 157

internal fixation with bone grafting

scaphoid fractures, 132–133,

132–135

Osteochondral transverse fractures

metacarpal head of long finger, 47

Percutaneous fixation

bony mallet, 11

Percutaneous K-wire fixation

closed reduction


Percutaneous pinning


Index 193

Percutaneous screw fixation using

image intensifier



implants, 126–127

postoperative, 127–132

Phalanx. See also Proximal phalanx

middle


fractures, 29

volar fractures, 69

ring finger


fracture, 54

shaft fractures, 21–40

evaluation, 21–22

irreducible, 30–31

vs. metacarpal injuries, 23

proximal, 22

reducible and stable injuries, 24

reducible and unstable injuries,

25–26

Pinning

percutaneous


Proximal interphalangeal (PIP)

joint, 5

clinical assessment, 61

condylar fractures, 56–57


conservative treatment, 62

open reduction, 63–65

percutaneous techniques, 62–63

dislocations, 58–59

conservative treatment, 66

and fractures, 41–74

management, 65–66

open reduction and fixation,

67–70

percutaneous techniques, 66–67

dorsal dislocations, 58–59

dorsal fracture dislocation, 70

fracture dislocation

distractor-external fixator, 68

imaging, 61–62

lateral dislocations, 59–60

salvage, 70–71

[Proximal interphalangeal (PIP) joint]

surgical anatomy, 55–56

volar dislocation, 60–61

Proximal phalanx


cross-section, 23

displaced shaft fractures

middle and ring fingers, 22

fractures, 37

oblique fracture, 28

shaft fractures

displacement pattern, 23

volar approach, 53

Pseudoarthrosis

nonunion, 122

Radial collateral avulsion

fractures

small finger, 53

Radius. See Distal radius fractures

Reduction. See also Closed reduction;

open reduction

closed manipulation


Reflex sympathetic dystrophy (RSD)


Rete arteriosum, 3

Reverse Mayfield progression, 94

Ring finger


fractures, 22

phalangeal base


fracture, 54

Ring sign

scaphoid, 99

signet, 101

Roller/crush injury

multiple proximal phalanx fractures,

35–36

RSD. See Reflex sympathetic dystrophy

(RSD)

Scaphoid fractures, 115–136

diagnosis, 116–118

Herbert’s classification, 118, 120

mechanism and epidemiology, 116

194 Index

[Scaphoid fractures]

open reduction and internal fixation

with bone grafting, 132–135

operative, 132–133

pitfalls, 134

postoperative, 133

preoperative, 132

percutaneous screw fixation

using image intensifier,

122–124


implants, 126–127

postoperative, 127–132

screws, 128

volar approach, 122–125


Scaphoid ring sign, 99

Screws, 128

fractures, 32

lag, 46, 48

Sensation

discriminatory, 3

Sidewinder method, 30

Sigmoid notch, 142

Sign

crowded carpal, 98

scaphoid ring, 99

signet ring, 101

spilled teacup, 101

Terry Thomas, 99

Signet ring sign, 101

Small finger


fractures, 33–34


fractures, 53

Soft-tissue coverage, 13–15

Spilled teacup sign, 101

Spiral fractures

metacarpals, 84

Splints

hand-based functional

proximal phalanx

fractures, 24

Tendons

digitorum, 5–6

extensor, 3

flexor, 3

flexor digitorum profundus, 4–5

injuries, 175

terminal extensor, 5–6

Terminal extensor tendon avulsion

(mallet) injuries


Terry Thomas sign, 99

TFCC. See Triangular fibrocartilage

complex (TFCC)

Thenar flaps, 13–14

Thumb

partial amputation, 17

Transosseous wiring, 30

Transscaphoid perilunate fracture

dislocations, 102, 106, 107,

109, 110

Transverse arcus venosus, 3

Triangular fibrocartilage complex

(TFCC), 142

Tuft and shaft fractures

distal phalanx fractures, 4–5

Two-part carpal-metacarpal fracture

dislocations, 79

Two-point testing, 3

Unstable middle finger proximal phalanx

fracture with comminution, 26

Vertical fractures

metacarpal head

lag screws, 48

Volar coronal fractures, 51

metacarpal head, 49

Volar zigzag approach

volar coronal fractures, 49

Wounds

fractures, 10–11

Wrist

long finger metacarpal, 98

Index 195

[david c. ring, mark cohen] fractures of the hand

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