Volar A1 pulley approach for fixation of avulsion fractures of the base of the proximal phalanx

Peri-articular fractures of the hand

Peri-articular fractures of the hand are common injuries. Long-term consequences can be relatively innocuous or severely disabling. Due to the specific anatomy of the hand, avulsion fractures are likely more common here than anywhere else in the body and often occur at or near joints. The management of peri-articular fractures of the hand requires consideration of both the articular reduction and the status of ligament and tendon attachments. In general, these fractures can be treated non-operatively. Operative treatment can be percutaneous or open and should be individualized.

Outcomes of a Trans-Web Approach to Fractures around the Finger Metacarpophalangeal Joint

Background: A fracture around the finger metacarpophalangeal joint (MCPJ) can be difficult to access. We developed a trans-web approach that could lead surgeons directly to this site. An incision across the web is believed to result in a web contracture. The aim of this study is to present the outcomes of the trans-web approach. Methods: This is a retrospective study of all patients in whom a trans-web approach was used to fix fractures around the MCPJ in the period from October 2008 and September 2020. The outcomes of the trans-web approach were evaluated by appearance of the scar, presence of pain in relation to the scar, grading web creep, range of motion at the MCPJ and degree of abduction and adduction of the finger. Any complications of surgery were also recorded. Results: This study included 10 patients with 11 fractures around the MCPJ (6 avulsion fractures and 5 extra-articular fractures). The mean follow-up was 5 months. Skin contractures did not occur in any avulsion fracture case where original or extended trans-web skin incisions were used. However, they occurred in 2 extra-articular cases treated via a trans-web plus a mid-lateral approach. The mean range of motion of the MCP joint in all the patients was 80° (range, 70°-95°). There was a 10° loss of abduction in one patient and temporary sensory disturbance in another patient. Both these patients had been treated with extended incisions. Conclusions: The trans-web incision is a useful approach for the open reduction of fractures around the finger MCPJ, especially in avulsion fractures of the lateral volar base of the proximal phalanx with minimal risk of scar contracture. The risk of scar contracture is higher when the trans-web incision is combined with a mid-lateral incision for extra-articular fractures. Levels of Evidence: Level IV (Therapeutic).

Dorsal and Volar Surgical Approaches to the Metacarpophalangeal Joint: A Comparative Anatomic Study

BACKGROUND

We compared 3 surgical approaches to the MP joint: a dorsal extensor tendon-splitting approach, a dorsal extensor tendon-reflecting parasagittal approach, and the volar A1 pulley approach. We quantitatively compared each of these approaches by measuring the amount of articular cartilage exposed on the base of the proximal phalanx. We hypothesize that visualization of the articular cartilage of the proximal phalangeal base is enhanced with the volar approach.

METHODS

The MP joints of the 32 available digits were randomly assigned to 1 of 3 surgical approaches: extensor tendon splitting (A), extensor tendon reflecting (B), or volar approach (C). After each approach, the visible articular surface of the base of the proximal phalanx was stained with methylene blue. The MP joints were then disarticulated, and the proximal phalanges were digitally mapped using a 3-dimensional digitizer. Three-dimensional computer software was used to analyze and calculate the dyed exposed surface area and total surface area of each specimen.

RESULTS

The mean % exposed joint surface area for the dorsal extensor splitting, dorsal extensor reflecting and volar approaches were 62%, 67% (over the dorsal side of the proximal phalanx) and 54% (over the volar side of the proximal phalanx), respectively. Multiple linear regression showed statistical significance for a smaller percentage of articular surface area exposed with the volar approach. However, this was not clinically significant. A significant association was found between location in the small finger and greater % exposed joint surface, compared to approaches in the index finger. In all volar approach specimens, the collateral insertion site was visible, but not in the dorsal approach specimens.

CONCLUSIONS

Knowledge of the limits of each exposure is essential for planning the most appropriate surgical approach. The A1 pulley approach provided greater access to the volar 50% of the joint and collateral ligament insertion without violating the extensor mechanism. The amount of joint surface visualized through all 3 approaches was not significantly different. However, based on the accessibility to the collateral ligament insertion site among three different approaches, we recommend the volar A1 pulley approach for treatment of avulsion fractures of the base of the proximal phalanx. For other injuries of the MP joint, including the intra-articular proximal phalanx base fractures, and metacarpal head fractures, the dorsal approaches are still indicated.

Surgical exposures of the hand

Surgical approaches to the hand are commonly executed in the treatment of fractures, ligament injuries, and less commonly in the resection of bony tumors. Careful design and execution of these surgical approaches translates into superior functional and aesthetic outcomes. We have provided a thorough review of commonly used approaches to the hand by evaluating each of these approaches in the context of core principles including safety, versatility, preservation of stability, and aesthetic outcomes.

Treatment of phalangeal fractures

Treatment of phalangeal fractures depends on the characteristics of the fracture, condition of the soft tissue envelope, associated injuries, patient functional requirements, and surgeon familiarity and comfort with various techniques. Most phalangeal fractures can be treated successfully with nonoperative means. Surgery is considered to treat unstable injuries, articular incongruity, concomitant soft tissue damage, or other situations in which restoration of anatomy and preservation of function are achieved only via operative stabilization. Careful soft tissue handling and early mobilization are premises on which surgical phalangeal fracture treatment is based.

Volar A1 pulley sparing technique for fixation of avulsion fractures of the base of the proximal phalanx

For open reduction and internal fixation of the displaced avulsion fractures of the base of the proximal phalanx of the fingers, the volar A1 pulley approach was introduced instead of the dorsal approach. Although this procedure is quite useful, the A1 pulley and volar plate need to be divided. As a less invasive alternative, the authors developed the volar A1 pulley sparing technique and treated six patients with the median follow-up period of 14 months. All fractures healed without displacement, and all patients regained full range of motion without any evidence of instability. The volar A1 pulley sparing technique is minimally invasive and provides good visualization of the fracture site without damage to the metacarpophalangeal joint and flexor tendon structure.

Application of a trans-web approach to plating technique for an extra-articular fracture of the proximal phalanx

We report the case of an extra-articular fracture at the base of the proximal phalanx of the ring finger treated by plate and screw fixation using a modified trans-web approach. The combination of trans-web and mid-lateral approach provided a wide operative field and adequate visualization without marked damage to the soft tissues, and the operative outcome was excellent.

Trans-web approach for fixation of avulsion fractures of the proximal phalangeal base: report of two cases

Although displaced fractures of the lateral aspect of the base of the proximal phalanx can be treated surgically, previously described approaches to the fracture are not necessarily easily performed. We describe a trans-web approach to the metacarpophalangeal joint and report 2 clinical cases. This technique allows the fracture fragments to be reduced and fixed with minimal risk of damage to the adjacent structures.

Irreducible fracture dislocation of a finger metacarpophalangeal joint: a case report

A case of unusual displacement in a finger, with an avulsion fragment from the dorsal metacarpal head of the finger displaced in the palmar direction under the volar plate is described. An 18-year-old woman presented with complaint of difficulty flexing the metacarpophalangeal (MP) joint of the right little finger after a fall onto the outstretched hand. Three-dimensional computed tomography (CT) was useful for diagnosing this condition. Use of both palmar and dorsal approaches was needed to reduce the displacement and to fix the bones with a single screw. Bone union was achieved, and the patient has been asymptomatic for more than 10 months.

Volar plating for intra-articular fracture of the base of the proximal phalanx

Comminuted fractures involving the articular surface of the base of the proximal phalanx are relatively rare and pose a challenging problem for hand surgeons because of the difficulty in achieving an accurate reduction and secure fixation of the articular surface. These fractures usually comprise a volar base fracture associated with a central depression of the articular surface. We describe a technique for open reduction and plate fixation of intra-articular fractures of the base of the proximal phalanx through a volar A1 pulley approach. Compared with the dorsal approach, this technique offers the advantages of direct visualization of the volar base fragment and the depressed central fragment, allowing for a more accurate reduction and rigid internal fixation using a volar buttress plate. In addition, there is no interference with extensor apparatus. Although our experience is limited to 4 patients, we have had a positive experience with this technique. The technique is useful for internal fixation of intra-articular fractures of the base of the proximal phalanx.

Avulsion fractures from the base of phalanges of the fingers

Avulsion fractures of the phalanges are among challenging problems encountered in the hand surgery. These fractures are characterized by existence of small bone fragments usually attached to a collateral ligament. They mostly occur in metacarpophalangeal and proximal interphalangeal joints. Bony gamekeeper's thumb is one of the well-known. Inadequate reduction and healing of these fractures may lead to joint deformity, chronic instability and posttraumatic arthritis. Existence of very small bone fragments and involvement of joint surface are the obvious factors predisposing to technical problems in reposition and fixation of these fractures. Avulsion fractures are intraarticular according to their configuration and need anatomic reduction. AO principles depending on stable fixation and compression have difficulties to be applied to these fractures owing the inconvenience of the osteosynthesis materials and implants available are designed for fracture fixation of larger bones. Fixation may result in further comminution of the fragments.

Intra-articular fractures of the hand: treatment by open reduction and internal fixation

OBJECTIVE

This study was designed to evaluate the results of open reduction and internal fixation of intra-articular fractures of the hand.

DESIGN

Retrospective review.

SETTING

Patients were treated at 2 university hospital settings by 2 hand surgeons.

PATIENTS/PARTICIPANTS

Twenty-eight patients with displaced intra-articular fractures of the hand treated with mini-screw/plate fixation were identified from databases maintained by two hand surgeons. There were 23 men and 5 women, with an average age of 35 (range, 18-68) years.

INTERVENTION

Titanium mini-plate and screw set was used in all cases.

MAIN OUTCOME MEASUREMENTS

Total active motion of the digit scored according to the Belsky and Gingrass systems.

RESULTS

Twenty-two patients (79%) had excellent or good results, and 6 patients (21%) had poor results. All 5 thumb fractures healed without complication and had excellent results. For the lesser digits, 9 had excellent, 8 had good, and 6 had poor clinical outcomes. Poor outcomes were identified in patients with comminuted (P = 0.01) or open (P < 0.001) fractures. Other complications included superficial infection and hardware prominence, both of which occurred in patients with distal phalanx dorsal lip fractures (P = 0.01).

CONCLUSIONS

Open reduction and internal fixation of articular fractures of the joints of the hand seems to be an effective treatment method for these difficult fracture patterns. We identified excellent or good outcomes in 79% of our patient group. Patients with open or comminuted fractures were found to have poor results.

Evaluation of wrist and hand handicap and postoperative outcome in rheumatoid arthritis

Functional instruments in rheumatology should use standardized procedures and should be quantifiable, valid, reliable, and responsive/sensitive to change. For most assessment tools, these aspects have been considered and tested. One of the most important questions in assessing hand involvement in patients with RA is what the single assessment should be used for. There could be a substantial difference should hand assessment be done in a routine way in a hand practice or should it be performed within scientific studies on disease progression or the effect of operative interventions. Among other points, answering this question has a significant impact on the time the patient has to spend with the tests and on the time the hand therapist or hand surgeon is involved with it. In addition to aspects such as accuracy, reliability, and validity, therefore, in some evaluation tools the time needed to perform the clinical examination and assessment of hand function has also been considered to be of importance. In addition, it has to be considered that description of the anatomic status, measurements of impairment, and assessment of disability cannot simply be replaced by each other, and even measurements of single aspects often are not sufficient. It has been stated, therefore, that the combination of different discrete hand-function assessment methods provides a more complete picture of hand ability. Moreover, although better responsiveness of disability outcome measures over impairment measures has been demonstrated previously (eg, in patients treated for Colle fracture), the relationship between disability and impairment measures is not clearly established. Although some studies reported significant correlations between impairment and disability tests, other studies showed only poor or moderate correlations between disability scores, impairment, and disease activity measures when rheumatoid hands were assessed. It has been concluded that the relationship between impairment and disability is not straightforward. The new ICF-model addresses these two levels of health-related quality of life by different concepts of assessment. Because impairment reflects the consequences of the disease at the organ level, whereas disability reflects the consequences of the disease for functional performance and activity, for comprehensive assessment of hand handicap, measurement of disability is more comprehensive and closer to the patient's needs for performing ADLs.