*Department of Orthopaedic and Traumatology Surgery, İstanbul Taksim Research and Training Hospital, Istanbul
†Department of Orthopaedic and Traumatology Surgery, Cukurova University, Adana, Turkey
The authors declare that they have nothing to disclose.
Address correspondence and reprint request to Ayhan Kiliç, MD, Department of Orthopaedic and Traumatology Surgery, İstanbul Taksim Research and Training Hospital, Taksim Egitim ve Arastirma Hastanesi, Siraselviler cad. No: 112, 34433, Beyoglu, Istanbu, Turkey. E mail: firstname.lastname@example.org.
Several open and closed surgical techniques have been reported in the treatment of displaced phalangeal neck fractures. The most common fixation is provided by a Kirschner wire, which is placed in a retrograde manner through the interphalangeal joint in extension. Although it provides a stable fixation, it may lead to joint stiffness and cartilage damage. The purpose of this report is to describe a new fixation technique for phalangeal neck fractures in 2 cases, which may provide stable fixation and prevent cartilage damage and joint stiffness.
Phalangeal neck fractures are frequently seen in children, whereas rarely seen in adults.1 Management of these fractures is difficult and thus can lead to joint stiffness, delay union, and malunions. Although type I neck fractures can be treated adequately with splinting for 3 to 4 weeks, displaced fractures are usually unstable and require reduction and fixation.1–3 Intact collateral ligaments cause rotation of the distal fragment in the type 2 and 3 phalangeal neck fractures, which makes it difficult to maintain adequate reduction without internal fixation.3,4 The most common fixation for phalangeal neck fractures is provided by a Kirschner wire (K-wire), which is placed in a retrograde manner through the interphalangeal joint in extension. Although retrograde K-wire fixation that crosses the joint provides a stable fixation, it may cause joint stiffness and articular damage.
In this paper, a new fixation technique for type 3 phalangeal neck fractures in 2 cases, which may provide stable fixation and prevent cartilage damage and joint stiffness, is described.
A 21-year-old male patient presented to the emergency room with a deformity, swelling, and painfully restricted motion at the level of interphalangeal joint of the thumb. Rotational deformity associated with hyperextension was observed during physical examination and neurovascular structures were intact. The plain radiographs of the affected hand revealed a severe dorsally displaced type 3 neck fracture of the proximal phalanx of the thumb (Fig. 1).
Closed reduction under sedation was performed applying longitudinal traction, followed by immobilization using a forearm cast in a functional position. However, upon detection of the reduction loss in plain radiographs at first week follow-up control, the patient underwent surgical treatment.
A 28-year-old female patient presented to the emergency service with pain and flexion disturbance in the right fifth finger following a low-energy trauma (Fig. 2). Initial examination revealed slight swelling and tenderness on the dorsal side of the interphalangeal joint of the right fifth finger. Slight rotational deformity was also observed on initial examination. The active range of motion was 0-degree extension and complete inability of flexion, as well as 0-degree extension and 45-degree flexion at the dorsal side of the interphalangeal and proximal interphalangeal joints, respectively; thus, the range was evidently limited. The plain radiographs revealed displaced type 3 neck fracture of the middle phalanx of the fifth finger. Closed reduction was performed as in the previous case. Because of inadequate reduction, the patient underwent surgery with the technique, which is described below.
Closed reduction of the fracture was performed with gradual longitudinal traction under fluoroscopy control and the dorsally displaced head was pushed gently in the palmar direction (Fig. 3). After maintaining the alignment, a stab incision was made along the radial border of the phalanx metaphysis, 5 mm proximal to the metacarpophalangeal joint. Through the stab incision made, the near cortex was penetrated in a 45-degree angle relative to the shaft axis to create the entry point (Fig. 3A). The prebent K-wire of size 035 to 0.045 inch with its 3-mm end bent even sharper was introduced from the entry point and driven along the intramedullary canal to the fracture line (Fig. 3B). Particular attention was paid to avoid multiple attempts of K-wire passage, which may cause significant damage to the articular cartilage. At this stage, the wire was advanced gently into subchondral bone of the distal segment, leaving the metacarpal head free (Fig. 3C). The residual displacement of the fracture was reduced by turning the K-wire around its long axis through an angle of 180 degrees to produce the shift of the distal fragment and reduce it (Fig. 3D). Thereafter a second cross pin (0.035 to 0.045 inch) was introduced antegradely from the ulnar side and advanced into the distal fragment (Fig. 3E). Final fluoroscopic views are taken in anteroposterior, lateral, and 45-degree oblique planes and position of the K-wires was checked to confirm the absence of penetration of articular cartilage, which may lead to joint stiffness (Figs. 4, 5). The lower metaphyseal end of the pin is then cut and the skin dressed (Fig. 6). A volar splint was applied and passive range of motion exercises was begun immediately. After 2 weeks, the cast was removed and patients were allowed for active motion. In both patients the wires were removed in the fourth week, after union was achieved (Fig. 7). At final follow-up, active range of motion of the metacarpophalangeal and interphalangeal joints was recorded, and the percentage normal total active motion of all finger joints was documented by comparison with the contralateral normal finger (Fig. 8).
Neck fracture of the proximal phalanx is a relatively uncommon injury and occurs almost exclusively in children. Closed reduction and percutaneous K-wire fixation are still the recommended treatment options for unstable fractures.5 Although K-wire fixation is considered simple and less invasive compared with most other techniques, the methods of reduction and K-wire fixation of these fractures are technically demanding and require special attention to avoid several technical pitfalls. Probability of significant damage to articular cartilage and iatrogenic intra-articular fracture due to multiple penetrations of metacarpal head and irritation of the extensor tendons, which may lead to joint stiffness, delay union, and malunions, are the main restrictions of these fixations. In this paper, a new antegrade fixation technique for unstable proximal phalangeal neck fracture, which may prevent cartilage damage, joint stiffness, and provide a stable fixation, is reported.
Many closed techniques have been previously described in pediatric population; however, there are few reports about adults.1,3–10 Al-Qattan1 reported poor outcomes of type II fractures treated with closed reduction and splinting in pediatric patients. Therefore, displaced unstable (type II/III) pediatric phalangeal neck fractures of the proximal phalanx are usually treated with K-wire fixation, which crosses and immobilizes the proximal interphalangeal joint.1,2 Some authors described good outcomes about using longitudinal K-wires inserted through the articular cartilage, without complication.11 Londner et al7 reported 11 excellent and 2 good results among the 13 phalangeal neck fractures treated with an intrafocal pinning technique in children.
Unlike pediatric patients, transarticular fixation is not well tolerated in adults and thus results in joint stiffness.10 Previous studies also revealed that closed reduction and percutaneous K-wires driven across the flexed metacarpophalangeal joint noted significant stiffness at all finger joints because of the irritation of the extensor tendon in zone 5.12,13 Gonzalez et al14 described a joint-free fixation technique (intramedullary fixation) for phalangeal shaft fractures, which provides excellent results with a low complication rate.
As mentioned above, several fixation techniques were described for phalangeal neck fractures; however, joint stiffness seems to be the main problem especially in adults even if it is treated with open or closed procedures. To our knowledge, there is only 1 technique described by Al-Qattan5 for phalangeal neck fracture in adults that may avoid joint stiffness. Although placing the K-wire in antegrade manner avoids the surrounding joints and allows early active mobilization of all finger joints, only 1 K-wire may be inadequate for providing rotational stability and maintaining the reduction.5 In our technique, 2 K-wires consisting of 1 straight and 1 prebent were placed antegradely. To our opinion, 2 K-wires may provide both more rotational stability and rigid fixation compared with 1 wire, and it is crucial for postoperative early rehabilitation.
In conclusion, phalangeal neck fractures of the proximal phalanx in adults are rare and there is a lack of information about the optimal technique for fixing unstable type II/III fractures. Our technique for unstable fractures emphasizes that antegrade advancement of the K-wires keeping the articular cartilage intact may provide a stable reduction and fixation and allows a reliable postoperative rehabilitation protocol including early active mobilization of all finger joints to obtain a satisfactory outcome.
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