Modified extension-block K-wire fixation technique for the treatment of bony mallet finger

Reverse Ishiguro Extension Block Technique as an Alternative for Irreducible Osseous Mallet Finger

Subacute or late-presenting unstable osseous mallet finger might be hard to reduce and, therefore, remain subluxed when using the traditional Ishiguro technique. In such cases, we suggest it is best to prioritize correction of joint subluxation over step-by-step adherence to the traditional Ishiguro technique. Specifically, we contend that carrying out the procedure in reverse order typically results in an easier and more stable reduction of both joint and fracture.

Delta Wiring Technique to Treat Bony Mallet Finger: No Need of Transfixation Pin

Extension-block pinning is a popular surgical treatment method for mallet fractures but is associated with several pitfalls. Transfixation Kirschner wires used in the extension-block pinning technique may cause iatrogenic nail bed injury, bone fragment rotation, chondral damage, or osteoarthritis. The objective of this study was to determine the result of the delta wiring technique in mallet fractures with fracture fragment involving more than one-third of the distal phalanx articular surface. The authors are reporting 5 cases of mallet fractures treated with delta wiring technique with good functional and radiologic outcomes. Radiologic outcomes were evaluated on the basis of postoperative and follow-up x-rays and functional outcomes were evaluated using Crawford's criteria. Five patients (4 males, 1 female) with a mean age of 26.8 years (range, 20 to 33 y) were included. The mean time between the injury and surgery was 5 days (range, 3 to 7 d), and the mean follow-up period was 8.6 months (range, 8 to 10 mo). Radiographic bone union was achieved in all patients within an average of 6.4 weeks (range, 6 to 7 wk). At the final follow-up, the distal interphalangeal joint had an average degree of flexion of 73 degrees (range, 70 to 75 degrees) and an average extension deficit of 5.40 (range, 0 to 8 degrees). According to Crawford's criteria, 1 patient had excellent results and 4 patients had good results. No patient reported pain at the final follow-up with a visual analog scale score mean of 0.6 (range, 0 to 2). Satisfactory clinical and radiologic outcomes were obtained with the delta wiring technique. Future prospective and randomized studies are justified to confirm the efficacy of this technique.

Tips Under the Skin: A Simple Modification of Extension Block Pinning for Mallet Fractures

Pins exposed out of the skin after surgery for mallet fractures keep patients from washing their hands. The authors buried the tips of all pins under the skin while performing extension block pinning for 14 patients with mallet fractures. The patients were allowed to wash their hands 4 to 5 days postoperatively, without any dressing or splinting. The pins were removed at a mean of 8 weeks postoperatively. Solid union was achieved in all 14 fractures. No pull-out or subsidence of the pin was observed. No patient developed infection or other pin-related complications. Mean extension lag at final follow-up was 4°. [Orthopedics. 2018; 41(2):e299-e302.].

Correlation between extension-block K-wire insertion angle and postoperative extension loss in mallet finger fracture

INTRODUCTION

Extension-block pinning represents a simple and reliable surgical technique. Although this procedure is commonly performed successfully, some patients develop postoperative extension loss. To date, the relationship between extension-block Kirschner wire (K-wire) insertion angle and postoperative extension loss in mallet finger fracture remains unclear.

HYPOTHESIS

We aimed to clarify this relationship and further evaluate how various operative and non-operative factors affect postoperative extension loss after extension-block pinning for mallet finger fracture.

MATERIALS AND METHOD

A retrospective study was conducted to investigate a relationship between extension block K-wire insertion angle and postoperative extension loss. The inclusion criteria were: (1) a dorsal intra-articular fracture fragment involving 30% of the base of the distal phalanx with or without volar subluxation of the distal phalanx; and (2) <3 weeks delay from the injury without treatment. Extension-block K-wire insertion angle and fixation angle of the distal interphalangeal (DIP) joint were assessed using lateral radiograph at immediate postoperative time. Postoperative extension loss was assessed by using lateral radiograph at latest follow-up. Extension-block K-wire insertion angle was defined as the acute angle between extension block K-wire and longitudinal axis of middle phalangeal head. DIP joint fixation angle was defined as the acute angle between the distal phalanx and middle phalanx longitudinal axes.

RESULTS

Seventy-five patients were included. The correlation analysis revealed that extension-block K-wire insertion angle had a negative correlation with postoperative extension loss, whereas fracture size and time to operation had a positive correlation (correlation coefficient for extension block K-wire angle: -0.66, facture size: +0.67, time to operation: +0.60). When stratifying patients in terms of negative and positive fixation angle of the DIP joint, the independent t-test showed that mean postoperative extension loss is -3.67° and +4.54° (DIP joint fixation angles of <0° and ≥0°, respectively, P=0.024). When stratifying patients in terms of extension-block K-wire insertion angle (30°, 30°-40°, >40°), ANOVA showed significantly less postoperative extension loss for higher insertion angles (>40°) than for medium insertion angles (30°-40°). Mean postoperative extension loss difference between higher insertion angle (>40°) and medium insertion angle (30°-40°) was 11° (P=0.002).

DISCUSSION

Using an insertion angle of the extension-block K-wire of 40°-45° and a slightly hyperextended position of the DIP joint may help reducing postoperative extension loss.

LEVEL OF EVIDENCE

Therapeutic level III.

Surgical and Nonsurgical Management of Mallet Finger: A Systematic Review

PURPOSE

The current literature describes multiple surgical and nonsurgical techniques for the management of mallet finger injuries, and there is no consensus on the indications for surgical treatment. The objective of this study was to determine, through a literature review, if any conclusions can be drawn concerning the indications for surgery in mallet finger injuries; the treatment outcomes of surgical versus nonsurgical management; the most effective methods of surgical and nonsurgical treatment; and the most common treatment complications of mallet finger injuries.

METHODS

A systematic review of multiple databases was performed. English language clinical studies evaluating therapeutic interventions for mallet fingers that reported objective, standardized outcome measures were included. Basic science studies, cadaveric studies, conference abstracts, level V evidence studies, studies lacking statistical data, and tendinous injuries other than mallet fingers were excluded. Salvage procedures and studies evaluating exclusively chronic lesions were also excluded.

RESULTS

Forty-four studies that reported clinical outcomes for the treatment of mallet finger injuries, 22 evaluating surgical treatments and 17 studies investigating nonsurgical treatments were included. The average distal interphalangeal joint extensor lag was 5.7° after surgical treatment and 7.6° after nonsurgical treatment. Complication rates of surgical and nonsurgical interventions were comparable (14.5% and 12.8%, respectively). Five studies directly compared the outcomes of surgical with nonsurgical management, with mixed results and recommendations.

CONCLUSIONS

Both surgical and nonsurgical treatments of mallet finger injuries lead to excellent clinical outcomes. Insufficient evidence is available to determine when surgical intervention is indicated. Based on our literature review, it appears that these treatments are equivalent and should be individualized to the patient.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Minimally invasive finger fracture management: wide-awake closed reduction, K-wire fixation, and early protected movement

We prefer wide-awake finger fracture reduction, closed percutaneous K-wire fixation, and early protected movement to treat phalangeal fractures. This approach allows intraoperative visualization of active movement after K-wire fixation with the possibility of adjustments during the case. It also negates the need for extensive dissection with subsequent scar formation between the tendons and the bone. It provides the same advantages that are provided by early protected movement after flexor tendon repair.

Hand fractures: a review of current treatment strategies

Fractures of the tubular bones of the hand are common and potentially debilitating. The majority of these injuries may be treated without an operation. Surgery, however, offers distinct advantages in properly selected cases. We present a review of hand fracture management, with special attention paid to advances since 2008. The history and mechanisms of these fractures are discussed, as are treatment options and common complications. Early mobilization of the fractured hand is emphasized because soft tissue recovery may be more problematic than that of bone.