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Cerclage Fixation for Fracture Dislocation of the Proximal Interphalangeal Joint

Weiss, Arnold-Peter

Section Editor(s): Meals, Roy; Foulkes, Guy

Clinical Orthopaedics and Related Research: June 1996 - Volume 327 - Issue - p 21-28
Problem Fractures of the Hand and Wrist
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Dorsal fracture dislocations of the proximal interphalangeal joint remain 1 of the most difficult problems in which to obtain an excellent functional outcome. The use of minimally invasive internal fixation techniques improving the biologic healing response and yet providing fracture fragment stabilization has met with greater popularity in recent years. The results of 12 patients treated by the volar cerclage wiring technique are described. At average followup examination of 2.1 years, 11 of 12 patients were noted to have no degenerative joint changes with only 1 patient having evidence of early volar articular surface beaking. Average final active arc of motion at the proximal interphalangeal joint was 89 ° (range, 72 °-109 °). The average degree of extension loss at the proximal interphalangeal joint was 8 ° (range, 0 °-16 °). There were no complications involving implant failure, irritation, or infection. A description of the volar cerclage wire technique is presented. This technique provides the advantage of avoiding fracture fragment stripping, stable restoration of the articular surface, and palmar buttress of the middle phalanx at the proximal interphalangeal joint.

Guest Editors

From the Department of Orthopaedics, Brown University School of Medicine, Rhode Island Hospital, Providence, RI.

Reprint requests to Arnold-Peter C. Weiss, MD, University Orthopedics, Inc., 2 Dudley Street, Second Floor, Providence, RI 02905.

Dorsal fracture dislocation of the proximal interphalangeal joint remains 1 of the most difficult problems for the orthopaedic surgeon to treat successfully.10,11,14,18 This condition has an estimated incidence of 9 of 100,000 persons per year. It usually occurs during sports with an impact loading injury from a ball striking the tip of the extended finger or from an athlete jamming the finger.5 Immediate deformity, pain, and swelling are most commonly noted. The difficulties in treating this injury successfully generally rest on the fact that the fracture fragments are very small and therefore difficult to manipulate and transfix with fixation hardware. In addition, the proximal interphalangeal joint has the propensity to quickly become very stiff due to the fibroblastic response to injury in the surrounding collagenous structures. The propensity is accentuated if pain and instability persist.6,20

Many treatment methods have been advocated for this condition. When evaluating a dorsal fracture dislocation of the proximal interphalangeal joint, attention must first be directed to whether the joint itself appears to be stable. This determination is made during efforts at reduction. If the proximal interphalangeal joint cannot be reduced regardless of the fracture fragment size, the injury will most likely require stabilization. If the fracture dislocation can be reduced successfully and maintained through a certain arc of motion, simpler means of treatment are generally appropriate with fairly good success including extension block splinting and several methods of dynamic traction.12,22 These methods can be applied to fractures that involve as much as 40% of the middle phalanx palmar articular surface because some stabilizing ligamentous joint constraints are present in these cases.16 Individuals, who on lateral radiograph have a greater than 40% surface involvement of the middle phalanx articular surface, usually cannot be held in reduction except in extremes of flexion often leading to poor results due to flexion contracture. The quantity of volar margin fracturing and initial degree of displacement are not the sole determinants of stability. Patients with relatively insignificant fracture patterns can have a large degree of instability of the proximal interphalangeal joint with or without reduction, and patients with very large volar comminuted fractures can have excellent stability after reduction. One must never take the general guidelines as rules in a particular case.3

More severe cases that involve larger components of palmar margin fracturing and significant instability after trial reduction often require more technically demanding methods of treatment. A distraction and motion apparatus,15 a force-couple device designed by Agee,1 forms of both static and dynamic external fixation,7,8 and open reduction and internal fixation have been used successfully.19,23 All these techniques require sophisticated surgery for placement and maintenance to ensure that complications such as infection, implant loosening, and stiffness do not occur.

For dorsal fracture dislocations that involve a large volar fragment, high degrees of comminution with its resulting instability, or joint surface impaction with the risk for secondary degenerative arthrosis, open reduction and internal fixation with or without external adjuncts are indicated to restore stability and cartilage congruity.6,19,23 Traditional techniques have used a miniscrew for fragments that are of substantial size and Kirschner wires (K wires) with or without tension band augmentation for fractures of smaller size or for comminution.6 Bone grafting techniques similar to those used in the complicated tibial plateau fracture may be used to maintain fragment height and internal stability during the healing process.6,18 Imperative to any technique of open reduction and internal fixation is the ability to undertake early active and passive motion exercises to the proximal interphalangeal joint without loss of joint congruity. Screw fixation would seem to hold a strong advantage in this regard because of its intrinsic stability. Unfortunately, a minority of dorsal fracture dislocations of the proximal interphalangeal joint have fragments that are large enough to accept miniscrew fixation. Iatrogenic fragmentation presents additional problems. The use of K wires, although extremely valuable in maintaining reduction, do not impart a significant amount of intrinsic stability and can develop problems with early active motion. In addition, the prominence of K wires can irritate or abrade soft tissue structures on both the extensor and flexor surfaces impairing digital function. The addition of a tension band technique to a transosseous K wire can provide needed additional support to the fracture construct but still has limitations regarding protrusion of the implant from the cortex.

The use of low profile internal fixation allowing as much postoperative biologic healing to occur yet maintaining enough biomechanical stability to commence early active and passive range of motion (ROM) has become increasingly popular during the past several years with the recognition that hardware alone infrequently provides the answer to complicated problems.4,9,13,17 The author describes a technique of cerclage wiring for severe simple and multifragmented volar margin fractures of the middle phalanx in patients who have suffered a dorsal fracture dislocation of the proximal interphalangeal joint. The advantages of this particular approach are that it (1) restores the articular surface, (2) provides excellent postoperative stability to the fracture fragments, (3) allows early active and passive ROM, (4) does not have implant protrusion, (5) allows aggressive edema management, and (6) offers the ability to place this fixation accurately with excellent visualization of the entire joint surface to ensure appropriate alignment, approximation, and compression of the fractured fragments. In addition, volar plate or silicone implant arthroplasty remain salvage options.2,21 The use of intraoperative fluoroscopy greatly aids the ability to assess both the stability and quality of reduction of the volar margin fracture fragments and joint surfaces.

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SURGICAL TECHNIQUE (VOLAR CERCLAGE WIRING)

After adequate general or regional anesthesia is applied, a volar zigzag incision from the metacarpophalangeal joint crease across the proximal interphalangeal joint crease to the distal interphalangeal joint will provide excellent exposure of the volar structures. The skin flap is mobilized exposing the subcutaneous tissues and flexor sheath. The digital neurovascular structures are mobilized from the flexor sheath apparatus. This step is essential so that during the shotgun exposure maneuver, the neurovascular bundle can sublux dorsally without tethering to avoid traction injury. After the flexor sheath anatomy has been exposed adequately, the entire sheath between the A-2 and A-4 pulleys can be excised. Alternatively, the sheath can be incised at 3 sides and retracted for later repair at the end of the operation. Occasionally, to allow appropriate exposure of the joint, a small portion of the A-2 and A-4 pulleys also requires resection so that adequate mobility of the flexor tendons can be provided. The flexor digitorum profundus and flexor digitorum sublimis tendons are retracted exposing the volar plate (Fig 1).

In general, the volar plate is intact with its distal attachment remaining firmly affixed to the volar fragment. The volar plate is incised transversely just proximal to the distal fragment leaving a small amount (1-2 mm) of the volar plate attached to the bony fragment itself. The main proximal portion of the volar plate can be retracted proximally exposing the volar aspect of the proximal interphalangeal joint. In nearly all cases, some recession of the collateral ligaments using sharp dissection is required (generally involving 1/3-1/2; of the volar attachment of the collateral ligaments at both the distal and proximal aspects). At this point, the proximal interphalangeal joint is gently distracted and a hyperextension maneuver is performed avoiding impaction of the middle phalanx base fragments. The neurovascular structures are watched during this maneuver on either side to ensure that they ca+n sublux easily in a dorsal fashion during the hyperextension maneuver. Once the proximal interphalangeal joint has been hyperextended approximately 130 °, the finger will maintain this alignment without distraction or force.

This approach provides excellent exposure of the articular cartilage at the distal aspect of the proximal phalanx and the proximal aspect of the middle phalanx. There often is some articular damage to 1 or both distal condyles of the proximal phalanx. Using a dental pick and careful manipulation, the volar margin fracture and its comminuted fragments can be aligned and elevated appropriately to reconstitute the articular surface. Occasionally, cancellous bone grafting under 1 or more of the fragments, accomplished by direct application or through the cortical window, aids in providing stability to the fragment reduction. Because the volar fragment of the middle phalanx tends to be large with the central fragments being small and often depressed, a compression maneuver to hold these central fragments in place is possible.

A piece of Number 24 gauge steel wire is formed into a loop and twisted on itself. The loop is closed so that it is just larger than the base of the middle phalanx. Sharp dissection is used to free approximately 1 to 2 mm of the periosteum circumferentially around the bony fragments of the middle phalanx. This maneuver will allow seating of the wire loop so that it can provide firm fixation to the bony fragments. The normal shape of the base of the middle phalanx with a reverse funnel contour also aids in fixation of the cerclage wire preventing any postoperative slippage even with early ROM. After fracture alignment, the loop wire is seated and gently tightened allowing a circumferential compression of all the fracture fragments together (Fig 2A). The twist portion of the loop wire should be placed so that it does not have any possible interference with either the flexor or extensor tendons. The preferred location is so that it ends lying flush to the cortex at the edge of the volar plate (Fig 2B). The proximal interphalangeal joint can be gently reduced, which requires a slight amount of distraction during the reduction maneuver to avoid any impaction of the fixed fragments. The finger should be taken through a full ROM to ensure that no abnormal jumping of the proximal interphalangeal joint occurs and that the joint moves smoothly without crepitus. Intraoperative radiographs are taken to ensure fracture reduction (Fig 3). Radial and ulnar stability also should be tested at this stage.

Repair of the volar plate will aid in reducing the risk of hyperextension and also will maintain its presence should it ever be required for a salvage volar plate arthroplasty if failure of the open reduction and internal fixation occurs. One problem frequently noted if the volar plate is repaired without modification is that there is significant bulk immediately underneath the flexor tendon that frequently imparts some resistance to full flexion of the digits. To avoid complete excision of the volar plate and yet avoiding excessive bulk, a V type resection of the volar plate can be performed (Fig 4). A central V is resected from the volar plate using a Number 15 blade keeping lateral tails for repair. This debulks the central portion of the volar plate allowing the flexor tendons to recess into this gap eliminating any mass effect during complete flexion. The lateral tips of the volar plate can be repaired to the small portion of the volar plate that was maintained intact to the volar margin fracture fragment itself. Maintaining the volar plate in this fashion allows it to be used for a volar plate arthroplasty as a salvage procedure. Testing of ROM and stability to a hyperextension stress is performed. The wound is irrigated copiously at each stage of the operative procedure. If the flexor tendon sheath has been saved, it is now repaired over the flexor tendons themselves. The skin is closed and a light compressive dressing is applied.

After 2 to 4 days of edema control, active and passive motion exercises are begun under the supervision of a therapist. Edema control, using elastic wrap, in between exercises is extremely important during the first 1 to 2 weeks postoperatively to aid patients in obtaining near full flexion and extension. Additional aids, such as dynamic splinting or buddy taping, are begun by 2 weeks postoperatively if any substantial resistance to full motion is encountered.

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RESULTS

From 1991 to 1995, 12 patients sustained dorsal fracture dislocations of the proximal interphalangeal joint with persistent subluxation of the joint after reduction that could not be maintained with extension block splinting. The average age of the patients was 27.3 years (range, 16-47 years). There were 10 males and 2 females. Patients presented an average of 6 days after injury (range, 1-16 days). All patients complained of significant pain and swelling at the proximal interphalangeal joint of the involved finger and the inability to undertake any significant flexion of the digit. Lateral radiographs of the proximal interphalangeal joint revealed persistent dorsal subluxation of the middle phalanx in all 12 cases with a single volar fragment in 2 cases, a major volar fragment with secondary comminution in 8 cases, and a volar margin fracture with central depression of the articular cartilage in 2 cases. Patients underwent open reduction and internal fixation using the cerclage wire technique at an average of 2 days after their initial evaluation. One patient had an augmentary K wire placed adjacent to the cerclage wire for additional fixation.

The average followup examination was 2.1 years. Final anteroposterior (AP) and lateral radiographs of the proximal interphalangeal joints demonstrated no evidence of articular degeneration in 11 cases and minimal volar fracture articular surface beaking indicating early degenerative arthrosis in 1 case. No patients complained of pain during ROM in the proximal interphalangeal joint although 1 patient complained of the sensation of a slight click at approximately 30 ° flexion. Followup radiographs also revealed no recurrence of dorsal subluxation of the middle phalanx and no loss of fixation of the cerclage wire. Average final active ROM at the proximal interphalangeal joint was 89 ° (range, 72 °-109 °) with final passive ROM being 98 ° (range, 93 °-112 °). The average degree of terminal extension loss at the proximal interphalangeal joint was 8 ° (range, 0 °-16 °) actively. There were no infections and no patients required surgical removal of the cerclage wires.

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DISCUSSION

Fracture dislocations of the proximal interphalangeal joint are 1 of the most challenging problems encountered by the orthopaedic surgeon because of the high propensity toward functional loss.6,20 A rational approach to the treatment of these fractures is essential so that overall final function can be maximized. The main tenets in treatment involve determining whether the fracture dislocation can be stably reduced with congruent joint surfaces and maintained in this type of position during postreduction rehabilitation. If this type of treatment is possible, it will nearly always provide the best functional outcome. Unfortunately, a great number of these fractures are not amenable to limited treatment including isolated extension block splinting.12 Nevertheless, an attempt at simpler means of obtaining reduction and appropriate stability during a minimal motion arc is always warranted.

In patients who remain with marked instability at the proximal interphalangeal joint and loss of congruous contour between the articular surfaces of that joint, more definitive forms of treatment are required. Some form of external fixation or traction can provide excellent reduction to the digit and may allow both forced passive and voluntary active motion to occur to the proximal interphalangeal joint.7,8,15 One must always consider the possible complication of pin tract infection with these techniques because fixation for at least a 3 to 4-week period, and often longer, is generally the rule. This complication can be minimized with appropriate pin care and a propensity toward using this technique in border digits avoiding any significant crowding with adjacent digits.

An equally attractive alternative is that of open reduction and internal fixation using a low profile technique. Cerclage wiring has been long used in the treatment of specific long bone and axial skeletal fractures with excellent functional results equal or superior to more complicated forms of internal fixation.4,9,13,17 Incorporating principles of minimally invasive internal fixation for improved biologic bone healing and cerclage wiring provides distinct advantages. Operative exposure for this surgical fixation method is relatively simple and efficient. Visualization of the fracture fragments is excellent and affords the ability to position the fracture fragments exactly in appropriate alignment. Cerclage wiring provides excellent compression of the fracture fragments among themselves in the appropriate reduced position and is an extremely low profile, nonsoft tissue binding fixation method.

The ability to retain the volar plate postoperatively with the inclusion of a V plasty allows less bulk formation along the flexor surface with early ROM yet provides more immediate hyperextension resistence after repair of the V plastied volar plate. Although no evidence of implant failure was found in the current series of patients, the theoretical advantage of repairing the volar plate after addressing the fracture dislocation is that it can be used in a secondary volar plate arthroplasty thereby not burning any bridges. To accomplish the surgical technique with relative ease, care must be given to the soft tissue requirements for obtaining adequate exposure and allowing the shotgun approach to be performed without undue tension. Meticulous fracture fragment manipulation with a fine dental pick type instrument and as much of a no touch technique combined with bone grafting of defects and excellent rigid fixation as provided by a cerclage wire provides substantial advantages for the patient.

The results of the author's first 12 patients treated by this technique have been encouraging regarding the lack of secondary arthrosis at the joint and the final functional arc of motion which, although not normal, provides relatively good function after this severe injury. It seems that failure of the cerclage wire itself or subsequent loosening with fracture displacement is not a prevalent problem. This observation is made despite the fact that early ROM exercises or use activities are started in the early postoperative period. Because no external hardware is present using this technique, efforts at manipulation by the therapist and at successful edema control can be instituted to improve final motion without any substantial problems.

This complex fracture requires a well thought out, carefully executed exposure, fracture reduction, and minimal fixation techique for improvement in overall functional outcome. Following the principles provided, the majority of these cases can be treated by the described minimal fixation technique with little fear of subsequent fracture malunion or joint discongruity.

Fig 1

Fig 1

Fig 2A-B

Fig 2A-B

Fig 3A-C

Fig 3A-C

Fig 4

Fig 4

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References

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Section Description

SECTION I

SYMPOSIUM

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