Surgical Treatment of a Neglected Thumb Volar Plate Injury in an 11-Year-Old Girl: A Case Report

BACKGROUND Volar plate injuries are rare and difficult to diagnose and treat. Only a few cases have been described on the thumb, especially in children, that resulted in swan-neck type deformity. Conservative treatment has been suggested as first-line management, but surgical reconstruction utilizing flexor digitorum superficialis tenodesis has been described for refractive cases. Only a few attempted surgical repairs of the volar plate have been reported, since it is a technically demanding procedure. CASE REPORT We present the case of a neglected thumb volar plate injury in an 11-year-old girl after a thumb hyperextension injury. The patient presented 2 months after her injury with functional disability of her thumb. Magnetic resonance imaging had been performed, with no signs of volar plate injury, and she was consequently treated with an extension-blocking splint, with no effect. Clinical examination raised the suspicion of a thumb volar plate injury, which was confirmed during surgical exploration. Therefore, fixation with a bone anchor was performed, and the metacarpophalangeal joint was immobilized in 20° flexion with a percutaneously inserted Kirschner wire. After splinting for 3 weeks, the patient had 10 sessions of physical therapy. At 6-week follow-up, she presented with excellent active and passive range of motion and absence of pain. CONCLUSIONS Magnetic resonance imaging did not have high sensitivity. Six weeks after surgery, full range of motion was achieved, with no stiffness or tenderness at the first metacarpophalangeal joint, suggesting that a thumb volar plate injury had been managed surgically with a suture anchor with excellent results.

Swan neck deformity due to chronic radial collateral ligament injury of the little finger proximal interphalangeal joint

We present seven cases of a relatively rare swan neck deformity resulting from chronic radial collateral ligament (RCL) injury of the proximal interphalangeal (PIP) joint in the little finger. All patients were middle-aged women (mean 51 years old, range 42-55), and the duration between the initial injury and surgery was 20 years (range 5-40). The chief complaint was painful snapping of the PIP joint. All patients had hyperextension and ulnar deviation of the PIP joint with mobile swan neck deformities that had not improved with conservative treatment. Radiographs revealed osteoarthritis and ulnar deviation of the PIP joints in all cases. We describe a method for reconstruction of both the palmar plate and the RCL of the affected PIP joint using a distally-based ulnar slip of flexor superficialis tendon. The prevention of PIP joint hyperextension was critical for successful resolution of symptoms; the aim of RCL augmentation was to prevent the recurrence of the deformity.

LEVEL OF EVIDENCE

IV.

Post-traumatic Raynaud's phenomenon following volar plate injury

Post-traumatic Raynaud's phenomenon following non-penetrating or non-repetitive injury is rare. We report a case of Raynaud's phenomenon occurring in a single digit 3 months following volar plate avulsion injury. Daily episodes of painless pallor of the digit occurred for 1 month upon any exposure to cold, resolving with warm water therapy. Symptoms resolved after the initiation of hand therapy, splinting, and range-of- motion exercises.

Volar long locking compression plate fixation for distal radius fractures with metaphyseal and diaphyseal extension

Comminuted distal radial fractures with metaphyseal and diaphyseal extension are uncommon and remain a challenge to treat. The purpose of this study was to assess the radiographic and functional outcomes of treatment with the volar long locking compression plate (LCP) system for distal radius fractures with metaphyseal and diaphyseal extension. This retrospective study was performed on 22 consecutive patients who were treated with open reduction and internal fixation with the application of a 2.4-mm-extra-long LCP volar distal radius plate. Patients were evaluated based on clinical signs and radiography studies. The average time to fracture union was 16 weeks. The volar tilt was restored to a mean of 10.1°. The radial length and radial inclination were restored to a mean of 12.8 mm and 23.6° at final follow-up, respectively. The mean loss of radial length was -1.0 mm at final follow-up as compared with the contralateral extremity. The average ulnar variance was positive 0.1 mm at final follow-up with a congruent distal radioulnar joint. The degree of collapse after fixation between immediate postoperative and final follow-up visit was -0.1 mm. Using the demerit-point system of the Gartland and Werley rating system, 14 results were rated as excellent, 5 as good and 1 as fair. DASH scores averaged 10.1 points. Based on our experience, the volar long LCP is useful in the management of comminuted fractures of the distal radius, in which there is proximal extension into the diaphysis and can avoid or minimize the complications of external fixation or dorsal bridging distraction plate.

The "local dorsal adipofascial flap" for volar digital defects: a case report

The coverage of volar digital defects can be achieved by a variety of surgical options. Although frequently used and reliable, these procedures entail the need for a second stage for flap release, meticulous dissection, sacrifice of a digital artery of the uninvolved digit, or delayed mobilization resulting in digital stiffness. The ideal surgical procedure for such defects should be a simple, single-stage surgery that allows early mobilization and return to function and at the same time avoiding unnecessary donor site morbidity from an uninvolved digit. The "local dorsal adipofascial flap" is a simple procedure that does not need a secondary procedure for flap release and affords early range of motion and return to function. We used this new flap technique in two digits with volar defects in a single patient. At ten months after flap coverage, the fingers were fully functional with good healing of the "local dorsal adipofascial flap."

Volar plate repair for posttraumatic hyperextension deformity of the proximal interphalangeal joint

Traditionally, flexor digitorum superficialis tenodesis has been recommended for surgical correction of posttraumatic proximal interphalangeal (PIP) joint hyperextension deformity resulting from recurrent volar plate (VP) disruption. In contrast, VP repair has been used sparingly to restore joint stability, because of concerns regarding excessive scarring, insufficient substance, and the often long time between injury and repair. In the study reported here, we critically evaluated the long-term functional outcome of isolated VP repairs for chronic dorsal instability of the PIP joint performed over an 18-year period. Twenty-five patients underwent surgery for hyperextension deformity of the PIP joint. Mean time from injury to repair was 8.2 years. All patients complained of painful locking of the PIP joint in extension. Precise repair of the VP was performed by meticulous scar lysis and advancement to the anatomical site of insertion while avoiding the adjacent nutrient vessels. Follow-up evaluation included completion of the DASH (Disabilities of the Arm, Shoulder, and Hand) questionnaire and digital mobility, strength, and radiographic assessment. At a mean follow-up of 8 years, we found consistent alleviation of pain, restoration of joint stability, mean arc of motion ranging from 6 degrees to 92 degrees of flexion, and grip strength returned to within 90% of the contralateral side. All patients returned to unrestricted activities.

An unusual dorsal fracture-dislocation of the proximal interphalangeal joint

A case of dorsal fracture-dislocation of the proximal interphalangeal joint in which the volar plate had been pulled from its distal attachment without bony or cartilaginous attachments and the lip of the volar plate had also been detached separately and was obstructing full flexion of the joint is presented. A tentative mechanism of causation of this unusual variant of a common injury is suggested.