Avulsion fractures from the base of phalanges of the fingers

Recent and chronic sprains of the First Metacarpo-Phalangeal Joint

Sprains of the first metacarpo-phalangeal joint (MCPJ) are a common form of hand injury that mainly affects the ulnar collateral ligament. Although the diagnosis is made on the physical findings, radiographs must be obtained and ultrasonography or magnetic resonance imaging (MRI) is necessary in some cases. If the joint is unstable or a bony fragment is displaced, surgery must be performed within 4 weeks after the injury. Beyond this interval, ligament reconstruction is the preferred treatment. The objective of this article is to provide evidence, from both older and recent studies, that guides the choice of the best treatment in clinical practice. To this end, we will address the following questions: (1) What is a Stener lesion? (history and pathophysiology); (2) In addition to the physical examination, what other investigations are appropriate in doubtful cases? (with special attention to the indications of ultrasonography and MRI); (3) What are the clinical and radiological criteria for performing surgery in patients with acute first MCPJ sprains? (4) What reconstruction procedures are appropriate in patients with acute or chronic MCPJ sprains?

Mini hook plate fixation for thumb ulnar collateral ligament avulsion fracture: A technical report

Ulnar collateral ligament (UCL) injuries of the thumb sometimes occur with avulsion fracture. Avulsion fractures generally require open reduction and internal fixation to restore stability of the metacarpophalangeal (MP) joint of the thumb. Although several surgical techniques have been reported, UCL avulsion fractures are still challenging hand injuries to treat and to obtain stable fixation that allows early finger motion because of small size of fragment. This report describes two cases of thumb UCL avulsion fractures that were successfully treated with two-hole mini hook plates by adapting 1.5-mm variable angle locking hand plates. This method allowed for early postoperative rehabilitation and provided stability of the thumb MP joint and satisfactory clinical outcomes. Altogether, hook plate fixation could be an alternative technique for thumb UCL avulsion fracture.

The Nonoperative Management of Hand Fractures in United Kingdom

Hand fractures (excluding small avulsion fractures and scaphoid fractures) almost always unite with bone. The role of the hand surgeon is not to achieve bone union but to achieve stability in an adequate position, often with some displacement, and maintenance of good soft tissue gliding. This article establishes that many fractures treated operatively do no better and often could not realistically do better than with good nonoperative treatment. Yet many are treated surgically to satisfy surgical egos, the desire to produce excellent radiographs, or just the mistaken belief that current surgical techniques can improve on nonoperative treatment.

[Treatment of phalangeal fractures using the mini-hook plate. An alternative for surgical fixation of small phalangeal bone fragments?]

BACKGROUND

Fixation of the small bony fragments of the phalanges is often difficult. In this study a clinical and radiological evaluation was carried out after operative treatment using the mini-hook plate.

PATIENTS AND METHODS

Between 2003 and 2006 a total of 36 fractures were treated operatively using the mini-hook plate. Of the patients 24 had an basal avulsion fracture of the distal phalanx and 11 patients (12 fractures) had other bony avulsion fractures of the phalanges. The patients were evaluated clinically and radiologically as well as using the disabilities of the arm, shoulder and hand (DASH) questionnaire.

RESULTS

A total of 29 patients with 30 fractures were examined. The mean follow-up was 13.6 months. The mean range of motion in the affected finger joint was 60.3 ° and the mean DASH score was 2.8 points. Postoperatively five nail growth defects, one infection and one secondary dislocation of the implant were observed.

CONCLUSION

Using the mini-hook plate, preservation of the joint and stable internal fixation with no need for temporary arthrodesis is possible; however, prerequisites are experience and skill of the surgeon with a difficult surgical technique.

The non-operative management of hand fractures

Most hand fractures can be treated non-operatively. Some hand fractures, such as open injuries or markedly displaced intra-articular fractures, are almost always treated operatively. The treatment of many fractures, such as proximal interphalangeal joint fracture subluxations or spiral phalangeal fractures, is unclear. The aim of this review is to establish those injuries where the outcome of non-operative treatment is unlikely to be improved with surgery. This may help to prevent unnecessary surgery, concentrate work on finding the sub-groups that may benefit from surgery and to establish which injuries do so well with non-operative treatment that the only valuable clinical research in future will be large cohort studies of non-operative treatment or randomized controlled trials comparing operative and non-operative treatments. The relevant fractures are spiral metacarpal fractures, transverse metacarpal shaft and neck (boxer's) fractures, base of proximal phalanx avulsion fractures, thumb metacarpophalangeal joint ulnar and radial collateral ligament injuries and bony mallet injuries. For the majority of these injuries, current knowledge suggests that the outcome of non-operative treatment cannot reliably be improved upon with surgery.

Management of difficult intra-articular fractures or fracture dislocations of the proximal interphalangeal joint

Intra-articular fractures or fracture dislocations of the proximal interphalangeal joint are difficult clinically because the bone and soft tissue structures are small and intricate. Suboptimal treatment of intra-articular fractures typically leads to functional impairment of the hand. This article reviews the current methods of treatment, together with the senior author's experience in treating difficult proximal interphalangeal joint fractures and dislocations. Besides conservative treatments, surgical treatments include open or closed reduction with traditional Osteosynthesis, such as K-wires, screws or plates. Among recent developments are the percutaneous application of thin cannulated compression screws and novel dynamic external fixators. After a preferred minimally invasive treatment with stable reconstruction of the articular surface, sufficient aftercare is necessary to improve surgical outcomes.

Operative treatment for volar plate avulsion fractures of the fingers

We present our experience with 14 volar plate avulsion fractures of the fingers that were treated by excision or internal fixation and discuss the factors affecting the operative techniques and results. Fourteen cases were divided into two groups: the volar plate avulsions with excision (eight cases) and the volar plate avulsions with fixation (six). We compared clinical factors between fracture groups and between fixation methods. Fractures treated with fixation had the larger fragment, a shorter preoperative period, and the larger articular surface involvement than fractures treated with excision. Postoperative pain, average age, patients' satisfaction measured by VAS, DASH scores, grip, and pinch strength were not different between two groups. All fixated fractures healed and the time to union did not differ based on fixation method. The true size of the fracture fragment was larger than expected based on the X-ray and the fragments were usually rotated by pull of the volar plate or ligament. The size and shape of the avulsed fragment might be important factors to determine the treatment method, but the results after operation were not significantly different whether the fragment was excised or fixed.

The hook plate technique for fixation of phalangeal avulsion fractures

BACKGROUND

Avulsion fractures of the phalanges involve small osseous fragments that are usually attached to structures that are necessary for stability or movement of the joint. Satisfactory healing of the fracture to preserve joint function may require open reduction and internal fixation, which can be difficult because of the small size of the fragments.

METHODS

We used a hook plate fashioned from a 1.3-mm Synthes titanium plate in thirteen patients with a phalangeal avulsion fracture. Four patients had an avulsion fracture of the volar plate with dorsal proximal interphalangeal joint dislocation, four had a dorsal avulsion fracture of the extensor central slip from the middle phalanx, three had a flexor digitorum profundus avulsion fracture from the distal phalanx, and two had an avulsion fracture of the phalangeal insertion of the collateral ligament.

RESULTS

Union without complications was achieved in all cases. After an average duration of follow-up of seventeen months, all patients had a good to excellent result and the average total interphalangeal motion was 149°.

CONCLUSIONS

This indirect fixation technique produces stable fixation allowing early active finger motion.