Fractures of the Hand and Wrist

of the Hand and Wrist

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of the Hand and Wrist Edited by

David C. Ring Massachusetts General Hospital Boston, Massachusetts, U.S.A.

Mark S. Cohen Rush University Medical Center Chicago, Illinois, U.S.A.

New York London

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Informa Healthcare USA, Inc. 270 Madison Avenue New York, NY 10016 © 2007 by Informa Healthcare USA, Inc. Informa Healthcare is an Informa business No claim to original U.S. Government works Printed in the United States of America on acid‑free paper 10 9 8 7 6 5 4 3 2 1 International Standard Book Number‑10: 0‑8247‑2845‑9 (Hardcover) International Standard Book Number‑13: 978‑0‑8247‑2845‑8 (Hardcover) This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the consequences of their use. No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright. com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923, 978‑750‑8400. CCC is a not‑for‑profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Visit the Informa Web site at www.informa.com and the Informa Healthcare Web site at www.informahealthcare.com

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Preface

Fractures of the hand and wrist are among the most common musculoskeletal injuries sustained by orthopedic patients. In fact, most people will suffer from such an injury at some point in their lives. Although treatment is typically straightforward, several pitfalls exist that often require the attention of a trained specialist. Our international panel of expert hand surgeons provides insights into new developments and techniques for both basic and more challenging management and treatment problems. Discussion of hand and wrist fractures is broken down into chapters focusing on distal phalanx fractures, fingertip crush injuries, phalangial shaft fractures, metacarpal fractures, carpal fracture dislocations, and scaphoid fractures. Special attention is given to challenging proximal interphalangeal fracture-dislocations, including evolving concepts in fixation and arthroplasty, and the treatment of distal radius fractures. We hope we have created a readable text for easy reference or complete review of the practical and up-to-date aspects of fracture care. David C. Ring Mark S. Cohen

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Editors’ Note

We hope that this book on hand and wrist fractures and dislocations will be useful in the care of injured patients. Our co-authors were generous with their time and talents, and we are sure that you will benefit, as we did, from their wisdom and intelligence. We made no attempt to be comprehensive, but instead aimed for a concise and practical review of current concepts. Few texts focus on skeletal injury in the hand and wrist, and we hope this book will be a useful reference for both straightforward and challenging problems. David C. Ring Mark S. Cohen

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Contents

Preface . . . . iii Editors’ Note . . . . v Contributors . . . . ix 1. Distal Fingertip and Thumb Injuries Adrian L. Butler and Mark Baratz

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2. Phalanx Shaft Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Mark S. Cohen 3. Dislocations and Fracture Dislocations of the Metacarpophalangeal and Proximal Interphalangeal Joints . . . . . 41 Randy R. Bindra 4. Operative Management of Metacarpal Fractures . . . . . . . . . . . . . 75 William B. Geissler and William O. McCraney 5. Carpal Dislocations and Fracture Dislocations . . . . . . . . . . . . . . . 91 Santiago A. Lozano-Caldero´n and David C. Ring 6. Fractures of the Scaphoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Satoshi Toh 7. Distal Radius Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Karl-Josef Prommersberger and Thomas Pillukat Index . . . . 189

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Contributors

Mark Baratz Division of Hand and Upper Extremity Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, U.S.A. Randy R. Bindra Hand Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A. Adrian L. Butler U.S.A.

Philadelphia Hand Center, King of Prussia, Pennsylvania,

Mark S. Cohen Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A. William B. Geissler Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, Mississippi, U.S.A. Santiago A. Lozano-Caldero´n Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A. William O. McCraney Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, Mississippi, U.S.A. Thomas Pillukat

Klinik fu¨r Handchirurgie, Bad Neustadt, Germany

Karl-Josef Prommersberger Germany

Klinik fu¨r Handchirurgie, Bad Neustadt,

David C. Ring Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A. Satoshi Toh Department of Orthopedic Surgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan

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1 Distal Fingertip and Thumb Injuries Adrian L. Butler Philadelphia Hand Center, King of Prussia, Pennsylvania, U.S.A.

Mark Baratz Division of Hand and Upper Extremity Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, U.S.A.

INTRODUCTION Distal fingertip and thumb injuries are among the most common hand injuries. We audited the Internet-based National Occupational Health and Safety Commission Worker’s Compensation Database and found that 32% of the claims in 1999 and 2000 (approximately 70,000 of 220,000 claims) involved the upper extremity. When considering only patients aged 30 or younger, 50% of the claims involved the upper extremity (1). Among upper-extremity injuries, the fingertip is the most commonly involved site. Many fingertip injuries create open wounds and fractures of the distal phalanx. The vast majority of these can be cared for in the emergency department. Injuries requiring internal fixation or soft-tissue coverage for skin defects may be more easily managed in an operating room. Particular attention must be given to preserving the integrity of the nail bed and matrix as well as sensation to the finger pulp. A complete understanding of the anatomy of the distal phalanx is essential to care for these injuries.

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ANATOMY A distinctive feature of the finger is the nail plate. It provides a hard protective surface as well as dorsal support of the terminal one-half of the distal phalanx. This provides the finger with myriad functions such as picking, scratching, scraping, and prying. The nail plate is composed of compact epidermal cells that undergo macrocystosis (swelling), nucleolysis (loss of nuclei), and gradual cell collapse and flattening. Toughness of the nail plate is derived through the deposition of keratin (2– 5). The fingernail grows from the germinal matrix and over the nail bed (sterile matrix) at a rate of approximately 1 mm per week (2,3). The proximal and lateral nail folds and the distal groove surround the nail and help mold the nail into shape. The proximal nail fold is termed the eponychium and includes the cuticle or perionyx. The lateral fold is the perionychium, and the terminal groove is the hyponychium (Fig. 1). The lunula—the junction of the nail plate and matrix—decreases in size from the thumb to the small finger. The light color of the lunula results from

Eponychium

(A)

Insertion Extensor Tendon

Lunula Nailwall Nail bed

Dorsal roof Hyponychium

Ventral floor

Nail fold

Distal interphalangeal joint Periosteum

(B)

LAT. NAIL FOLD (PARONYCHIUM)

CUTICLE (PERIONYX)

LUNULA

PROX. NAIL FOLD (EPONYCHIUM)

NAIL PLATE

NAIL BED

NAIL MATRIX

HYPONYCHIUM granulosa cell layer

Figure 1 Illustration of fingertip anatomy.

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incomplete cornification and the fact that, proximally, the nail bed does not adhere to the nail plate (5). The perionyx or cuticle is fixed to the nail plate, and the nail plate to the nail bed. The extraordinary adherence of the nail plate to the nail bed stems from a corneous substance that is produced by the epidermis beneath the nail. More proximally, the nail plate is softer and more flexible with a loose attachment at the germinal matrix and lunula (2). This becomes important when dealing with nail plate avulsions. When the nail plate is injured proximally, it can avulse from the germinal matrix but remain firmly attached to the cuticle and nail bed. The nail bed has, in turn, a strong attachment to the periosteum of the distal phalanx. As a result, distal nail plate injuries will usually result in lacerations to the underlying nail bed with partial or complete detachment of the nail plate. The variable adherence of the nail plate from distal to proximal can be relevant in treating fingertip amputations. In order to have a stable adherent nail plate, at least 5 mm of healthy nail bed distal to the lunula is required (5). Sensation to the fingertip is provided by the radial and ulnar digital nerves. The pulp of the finger is highly vascular with many arterioles (rete arteriosum) branching and extending distally off a transverse arterial arch. Two additional arterial arches are present dorsally: one at the level of the germinal matrix (arcus unguicularis proximalis) and a second at the middle of the nail bed (arcus unguicularis distalis). Along the base of the nail is the transverse arcus venosus, which provides the majority of the venous outflow of the distal fingertip (2,3). Discriminatory sensation is evaluated by “two-point” testing. Normal two-point discrimination is 5 mm or less. This degree of sensitivity comes by virtue of a high concentration of Meissner’s corpuscles which sense light touch and low-frequency vibration. Pacinian and Merkel mechanoreceptors help sense pressure and constant touch, respectively. Ruffini end organs are also present and sense both skin stretch and heat. Threshold sensitivity may be tested using the Semmes – Weinstein monofilament test (6,7). Normal fingertip monofilament values range from 1.65 to 2.83 (8). This is a useful tool for both detecting and following the recovery of a dysfunctional nerve. These mechanoreceptors are present within the fat of the pulp, which is held by retinacular septae to the palmar periosteum of the phalanx. The ungual tuberosity is the site of attachment of these septae. This spade-like structure is unique to the terminal aspect of the distal phalanx in homonids (9). The pulp of the fingertip is a soft, highly sensitive and immobile fat pad which helps to disperse contact pressures. Both the extensor and flexor tendons insert on the distal phalanx proximal to the germinal matrix. When evaluating injuries to the distal phalanx, it is important to test for the function of these tendons. The average distance from the terminal extensor tendon insertion to the proximal edge of the germinal nail matrix was found to be 1.2 mm in a study of 16 cadavers (10). Internal fixation of the terminal tendon places the germinal matrix at risk.

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FRACTURES OF THE DISTAL PHALANX Schneider classified fractures of the distal phalanx into tuft, shaft, and base fractures (11). Additional consideration must be given to fractures that extend into the distal interphalangeal (DIP) joint and those that involve extensor and flexor tendon avulsion fractures. Tuft and Shaft Fractures Closed fractures of the tuft and shaft of the distal phalanx can be treated nonoperatively. Surgical intervention should be considered for widely displaced transverse fractures of the distal phalanx shaft, severely angulated fractures, and injuries with complex wounds. The vast majority of closed tuft and shaft fractures of the distal phalanx are well-aligned and stable. Treatment is for comfort only as immediate active use of the finger without immobilization will not affect the result. Immobilization of the DIP joint for three to four weeks is reasonable for comfort. Fractures of the distal phalanx shaft should be splinted until the phalanx is no longer significantly tender. This typically takes three to four weeks. Radiographic evidence of healing will lag behind clinical signs of healing. Some physicians favor routine drainage of a substantial subungual hematoma, whereas others only do this in an attempt to relieve severe pain. There is very little room under the nail plate for hematoma expansion. A substantial hematoma can cause severe pain, and there is a small risk of fingertip necrosis (4). Perforating the nail plate to drain the hematoma provides substantial pain relief. An 18-gage needle can be used to bore a small hole in the nail plate. When the subungual hematoma occupies greater than 50% of the sterile matrix, consideration should be given to complete nail removal and sterile matrix repair. Widely displaced fractures of the distal phalanx are uncommon, but are more likely to result in nonunion. Widely displaced and angulated fractures may benefit from closed reduction and percutaneous fixation with a small Kirschner wire (Fig. 2). In many cases, it is necessary to have the wire cross the DIP joint to achieve adequate stabilization of the fracture. Stiffness of the DIP is an expected consequence of a high-energy injury to the distal phalanx. Temporary pinning of the DIP does not add substantially to DIP joint stiffness and allows the surgeon to achieve the goal of a stable, aligned, and pain-free fingertip. Fractures at the Base of the Distal Phalanx Flexor Digitorum Profundus Tendon Avulsion Injuries Avulsions of the extensor and flexor tendons off the distal phalanx are frequently associated with fractures at the base of the distal phalanx. Avulsions of the flexor digitorum profundus tendons were classified by Leddy and Packer (12). Type I injuries are ruptures of the tendon insertion from the bone with retraction of

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Figure 2 Unstable distal phalanx fractures benefit from percutaneous Kirschner wire fixation. (A) A young man crushed his fingertip. (B) The result was an unstable transverse fracture of the distal phalanx. (C) A single longitudinal Kirschner wire provided adequate stability after closed manipulative reduction. (D) The wire should cross the DIP joint in order to gain adequate purchase and prevent an extensor lag. Abbreviation: DIP, distal interphalangeal.

the tendon into the palm. Type II and III injuries involve bone attached to the avulsed tendon. In Type II avulsions, the tendon retracts to the level of the proximal interphalangeal (PIP) joint where it is held in place by intact long vinculum. In Type III injuries, a relatively large bone fragment catches on the A4 pulley

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limiting tendon retraction to the level of the middle phalanx. Smith (13) described an uncommon variant, that is, the base of the distal phalanx is avulsed from the phalanx and the tendon is avulsed from the bone. Type I injuries can be treated with primary repair within two to three weeks of injury. Past this point a myostatic contracture of the musculotendinous unit occurs, and it may be difficult to reattach without flexion of the finger, a maneuver that may result in a permanent flexion contracture. A separate incision is frequently required to retrieve the retracted tendon from the palm. The tendon must be passed back through the flexor tendon sheath and pulley system. A 2– 0 monofilament suture is woven through the end of the avulsed tendon using a Bunnell stitch. The sutures and tendon are advanced through the pulleys. The tendon is secured to the distal phalanx by passing the sutures on heavy, straight needles on either side of the waist of the distal phalanx or through the bone. The needles, with sutures, are passed through the nail bed and nail plate and tied over the nail with a button. Alternatively, suture anchors may be used, but with caution; care should be taken to avoid extending the fracture from palmar to dorsal while creating the drill holes. In addition, when this method is used, it is important to avoid penetration of the dorsal cortex with the suture anchor. Type II injuries are managed in a similar fashion. Because the vincula have not been ruptured and the tendon has retracted only to the level of the PIP joint, primary repair without excessive finger flexion is often possible up to four weeks postinjury. Repair of a type III injury is performed with the same method (Fig. 3). The repair can be supplemented with one or two 0.035- or 0.045-inch Kirschner wires. Occasionally, the fragment is large enough to accept a screw, but it may be wise to protect this with a suture or Kirschner wire (Fig. 4). Type IV injuries are very rare. The bone fragment can be repaired or excised prior to tendon reattachment. Chronic injuries may be best treated without surgery or with primary DIP fusion or tenodesis. Terminal Extensor Tendon Avulsion (Mallet) Injuries Mallet injuries with an avulsed bone fragment can, in most cases, be managed with splinting of the DIP joint. The finger is examined with attention to the degree of flexion at the DIP joint, passive extension of the DIP joint, and the position of the PIP joint of the injured finger and the adjacent fingers (Fig. 5). A finger with loss of active DIP extension, full passive extension, and no swan-neck deformity is treated with a splint that holds the DIP joint in extension (14 –17). A wide variety of prefabricated and custom-made splints can be used, and the patient’s needs and preferences should be taken into account. Hyperextension of the DIP joint diminishes the blood supply to the dorsal skin, which may contribute to a pressure sore, particularly when a dorsal splint is used. The joint is splinted in extension, full time for six to eight weeks and at

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Figure 3 (Continued on next page) Example of an acute Leddy and Packer Type III flexor digitorum tendon avulsion of the fifth digit. (A) Full extension is achievable; (B) however, finger flexion is absent. (C) Radiographs demonstrate an avulsion fracture at the insertion of the FDP. (D) The fracture fragment has retracted to the level of the A4 pulley. (E) Repair was achieved by exposing the insertion site of the FDP, (F) advancing the FDP from the A4 pulley back to its insertion site, and (G) suturing the tendon through the boney fragment and distal phalanx over a dorsal button. A temporary Kirschner wire was used to immobilize the DIP joint in extension to prevent a flexion contracture. Abbreviations: DIP, distal interphalangeal; FDP, flexor digitorum profundus.

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Figure 3 (Continued from previous page)

night for an additional six to eight weeks. Two splints can be provided, one for bathing and a second for general use. Patients are instructed to support the tip of the finger on the edge of a counter top during splint changes to maintain the DIP joint in extension. If extension is restored after six weeks of splinting, the finger is splinted at night for six weeks and during the day while performing heavy tasks. The duration of splinting may be shortened in patients with stiff joints, such as elderly patients and laborers. In patients with supple joints, and in injuries in which the initiation of treatment is delayed, the splinting duration may be extended. Fingers with a mallet and compensatory swan-neck deformity are treated with a custom splint that maintains the DIP in full extension and the PIP in a slightly flexed position (Fig. 6). The adequacy of joint positioning in the splint can be confirmed with a lateral radiograph of the digit. In health-care workers, we have had good success with a small thermoplastic splint that can be covered with a glove or a clear, sterile adhesive wrap. Mallet fractures can, in most instances, be treated with splint immobilization using the same principles outlined above. We consider surgical treatment for the subset of mallet fractures where more than 25% of the articular surface is involved or the DIP joint is subluxated; however, we counsel patients that an acceptable outcome can still be achieved with nonoperative treatment as long as there is no compensatory swan-neck deformity. Splint immobilization for this subset of injuries may result in a prominent dorsal bump, a modest extensor lag, a partial loss of DIP flexion, and radiographic evidence of posttraumatic arthritis. However, function is typically unimpeded, and the need

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Figure 4 Leddy Type III FDP avulsion repaired with screws. (A) The FDP insertion site is avulsed as a single large fragment in a 28-year-old man. (B) A Brunner incision was used. (C) The fracture fragment is stuck at the A4 pulley. (D) The articular surface of the middle phalanx is visible through the fracture. (E) A secure repair was achieved with two screws, but an unrecognized fracture of the dorsal cortex subsequently displaced. The fractures ultimately healed without loss of reduction. Abbreviation: FDP, flexor digitorum profundus.

Figure 5 A bony mallet injury. (A) Lack of full extension of the DIP joint of the long finger with slight hyperextension at the PIP joint (slight swan-neck deformity). (B) A lateral radiograph demonstrates an avulsion fracture of the terminal extensor tendon off the dorsal surface of the distal phalanx. Abbreviations: DIP, distal interphalangeal; PIP, proximal interphalangeal.

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Figure 6 (A) The patient depicted in Figure 5 was treated in a custom splint which maintains the DIP joint in extension and PIP joint in slight flexion to account for the tendency towards a swan-neck deformity. (B) A lateral radiograph with the finger in the custom splint confirms adequate reduction of the mallet injury. Abbreviations: DIP, distal interphalangeal; PIP, proximal interphalangeal.

for subsequent surgery is rare. This joint has a remarkable ability to remodel following fracture. Several surgical techniques have been used to treat mallet fractures (18 –20). Open reduction and internal fixation with screws or tension wires has been associated with wound problems, infection, loss of fixation, and nail deformity, but is still used by some surgeons (21,22). Percutaneous dorsal extension block pinning is increasingly popular, and good results have been reported (23,24). The DIP joint is flexed 908, and a Kirschner wire is advanced at a 458 angle over the avulsed bone fragment and into the dorsal aspect of the middle phalanx. The DIP joint is then extended, and a second Kirschner wire is advanced longitudinally from distal to proximal across the DIP joint (Fig. 7). Pins are left in place approximately four weeks. At that time, the pins are removed and active exercises are initiated. A splint may be worn for an additional two or three weeks. Articular Injuries An axial load across the DIP joint frequently produces an impaction or pilon injury to the base of the distal phalanx. With a bending moment to the DIP joint, a collateral ligament condylar avulsion may be produced. Alternatively, there may be volar or dorsal subluxation of the joint (Fig. 8). An adequate reduction can often be obtained and maintained with one or two transverse Kirschner wires (Fig. 8). Occasionally, internal fixation with screws is appropriate. Fractures Associated with Wounds Many distal phalanx fractures are open fractures with injury to the sterile matrix, germinal matrix, or both. Although these are open fractures, infection is uncommon, probably because of the rich blood supply in this area. However, antibiotic

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Figure 7 Percutaneous fixation of a bony mallet. (A) Inability to extend the DIP joint. (B) Flexion of the bony mallet injury brings the avulsion fracture fragment into improved alignment. (C) With the DIP joint flexed, a Kirschner wire was advanced from distal to proximal into the dorsal aspect of middle phalanx at the level of the DIP joint. (D) After confirming an adequate dorsal block to DIP extension. (E) A second Kirschner wire was advanced distal to proximal across the DIP joint. (F and G) Reduction is verified under image intensification. (H) In this case, pin caps were used to cover the ends of the pins. Abbreviation: DIP, distal interphalangeal. Source: Photos courtesy of Alex Shin, MD.

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Figure 8 A 25-year-old woman had an impacted articular fracture after an injury playing basketball. (A) There is impaction and comminution of the volar half of the articular surface and dorsal subluxation of the joint. (B) A percutaneous reduction and fixation was achieved.

coverage for staphylococcus and streptococcus with a single dose of 1 or 2 g of intravenous cefazolin and tetanus prophylaxis given in the emergency department may be prudent. Digital block anesthesia facilitates wound evaluation, debridement, and irrigation. The more proximal the fracture, soft-tissue injuries associated with distal phalanx fractures are more severe. Tuft and shaft fractures frequently involve injury to the nail bed because of its firm attachment to the periosteum of the dorsal terminal distal phalanx. These injuries may benefit from removal of the nail plate and repair of the nail bed with an absorbable suture (25), although this is debatable. In many cases, suturing of the skin and nail bed will reduce the fracture. In addition, repair of the nail bed also facilitates the subsequent formation of a new smooth and esthetically appealing nail plate. However, if the nail bed is irreparable, it may be difficult to cover the dorsum of the fingertip after removal of the nail plate. In these circumstances, leaving the nail plate in place may act as a biologic dressing. When removed, the nail plate should be cleansed and inserted under the eponychium to prevent adhesion between the germinal matrix and eponychial fold and to provide protection and support of the fracture. One or two sutures can be placed through the nail plate to prevent it from dislodging. Sutures should be placed in a manner that facilitates their removal. If the nail plate is absent or unusable, the foil from a suture pack may be substituted.

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Open fractures at the base of the distal phalanx usually involve injury to the germinal matrix with the nail remaining firmly attached to the cuticle or perionyx and distal to the nail bed. After irrigation and debridement, simple reduction of the nail beneath the eponychium frequently results in fracture reduction (26,27). However, this injury pattern is often rotationally unstable, and supplementary fixation with a Kirschner wire is often required to obtain stability. If injury to the nail bed is present, the nail plate should be removed, and the nail bed repaired (25). Open mallet fractures are treated using the method described by Doyle. The joint is pinned in extension with a 0.045-inch Kirschner wire. The tendon and bone are repaired to the distal phalanx with a pin, pull-out suture, or suture anchor. SOFT-TISSUE COVERAGE Fingertip amputations without exposed bone will heal by secondary intention (Fig. 9); however, defects larger than 1 or 2 cm2 may benefit from soft-tissue coverage as these may create a hook-nail deformity as the wound contracts (3,4). Wounds larger than this or with exposed bone will heal, but may leave a tender and easily reinjured fingertip. A major advantage of healing by secondary intention is near-normal sensibility. Skin grafts and many local or regional flaps will greatly reduce sensation. Flaps used most frequently include the homodigital island flap and crossfinger flap for the fingertips and a homodigital island or a modified Moberg for the tip of the thumb. Thenar flaps are used occasionally in young patients where the concern for a PIP joint flexion contracture is diminished. Local advancement flaps, such as those described by Atasoy and Kutler, must be used with caution as subcutaneous atrophy and fingertip sensitivity can result (28). Thenar Flap Thenar flaps are designed based on the flexible skin of the radial aspect of the thenar eminence. This flap is ideal for fingertip injuries of the ring and small fingers, but it is also useful for the long and index fingers. It is best suited for younger patients with lax joints, such as young women. The flap should be designed near the metacarpophalangeal (MP) joint crease. To minimize a flexion contracture of the PIP joint, flexion should occur through the DIP joint and MP joint of the finger. No more than 408 to 508 of flexion should occur at the PIP joint. However, this can be difficult to control, and if more than 508 of flexion is present at the proximal interphalangeal (IP) joint, an alternate method of coverage should be considered as the joint is at increased risk for a flexion contracture. The thumb should be palmarly abducted as this will minimize the amount of flexion of the finger with the flap placed at the level of the MP joint. The flap should be 1.5 to 2 times greater than the recipient area to ensure coverage of the semicircular fingertip. The skin and subcutaneous tissue of the flap are

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Figure 9 Index fingertip amputation at two days (A and B), four weeks (C and D), and eight weeks (E and F) after injury. Excellent cosmetic and functional results using healing by secondary intention.

elevated off of the thenar musculature. Care should be taken to avoid injury to the radial digital nerve and motor branch of median nerve. By designing an H-flap, it may be possible to close the donor site. If primary closure is not possible, a fullthickness graft is used to cover the donor site defect. This can be harvested from the ulnar aspect of the hypothenar eminence or the medial aspect of the arm (29). The flap is divided under a local anesthetic after 10 to 14 days. In a review of 150 patients treated with the thenar flap, 96% good-toexcellent results were obtained (30). Four percent of patients had a PIP joint contracture and 3% reported transient donor site tenderness. Cross-Finger Flap Cross-finger flaps provide a predictable means to cover defects on the palmar aspect of the digit. The choice of donor site for the cross-finger flap is commonly

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the long finger for the thumb, index, and ring fingers. The ring finger is usually a donor for the small finger. The dorsal skin and subcutaneous tissue of the middle phalanx of the donor finger is transferred to the palmar skin defect of the injured fingertip. The base of the flap is adjacent to the tissue defect of the recipient digit. The flap is elevated off the peritendinous fascia deep to the dorsal veins. Fingertip coverage is more challenging than coverage for more proximal defects, particularly for the long and ring fingers (Fig. 10). Covering the fingertip with tissue from the adjacent finger requires flexing the injured finger so that transferred tissue will reach the fingertip. Flexion can be minimized by designing an oblique flap that angles toward the fingertip. Full-thickness skin grafts can be

Figure 10 Circular saw injury involving significant skin and soft-tissue loss to the volar aspect of the middle and distal phalanxes of the ring and long fingers (A). Cross-finger flaps were created using the dorsal skin of the middle phalanx of the index and small fingers leaving peritenon over the now exposed extensor tendons (B). Split-thickness skin grafts were then used to cover the peritenon (C). Adequate soft-tissue coverage was achieved by reflection of the skin grafts volarly on a pedicle adjacent to the finger to be grafted (D). Slight flexion of the ring finger PIP joint was required to advance the finger flap from the shorter small finger to the distal tip of the ring finger. Abbreviation: PIP, proximal interphalangeal.

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used to cover the donor site and can be taken from the medial aspect of the brachium. Flaps are divided at 10 to 14 days (31). Homodigital Island Flap The homodigital island flap is an excellent means to provide durable, sensate coverage to the fingertip, particularly the ulnar aspect of the thumb, and radial aspects of the index and long fingers. A paddle of skin and fat matching the dimensions of the defect is harvested just proximal to the defect. The paddle is raised with its nerve and vessel. Through a Bruner incision, the neurovascular bundle is mobilized with the flap to the base of the proximal phalanx. The combination of a mobilized neurovascular bundle and slight PIP joint flexion allows the flap to be transposed to the distal defect (Fig. 11). Finger flexion can be initiated immediately by using a dorsal block splint to prevent undue tension on the bundle. The splint is discontinued after two weeks, and unrestricted motion is permitted (32). Moberg Flap In 1946, Moberg described a palmar advancement flap for covering the tip of the thumb. This flap includes the skin and subcutaneous tissue proximal to the defect on the tip of the thumb. Midaxial incisions are made on the radial and ulnar aspects of the thumb just dorsal to neurovascular bundle. The flap is elevated

Figure 11 A homodigital island flap was used to cover a fingertip soft-tissue defect involving the radial and volar aspects of the index finger (A). After the radial neurovascular bundle was identified proximally (B), a full-thickness flap of skin and soft tissue was then raised and advanced distally to cover the defect (C). Primary closure of the donor site was not achieved, and a split-thickness skin graft was required (D).

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off of the flexor sheath to the level of the MP joint. Flexion of the IP joint allows the distal margin of the flap to reach the tip of the thumb MP joint (33). In a modification of the Moberg flap, the skin is incised at the MP joint converting the flap to a neurovascular island flap. This allows the flap to reach the tip of the thumb without the need for IP joint flexion (Fig. 12). Free Toe Pulp Transfer A free toe pulp flap from the great toe or the second toe can be used to cover fingertip defects that cannot be covered by other means. The lateral border of

Figure 12 Partial thumb amputation (A and B) treated with a modified Moberg advancement flap. After both neurovascular pedicles are identified and preserved, a pedicle of tissue based on both these pedicles is advanced distally to cover the soft-tissue defect (C and D). A skin graft is then used to cover the newly formed proximal skin defect (E). Complete soft-tissue healing and nearly full ROM of the thumb MCP joint at six months after injury (F and G). Abbreviations: MCP, metacarpophalangeal; ROM, range of motion.

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the great toe or the entire pulp of the second toe is harvested with its artery, vein, and plantar collateral nerve. This is transferred to the defect accompanied by anastamosis of the artery, vein, and nerve. The donor site is skin-grafted. Reported results for this procedure have been variable. In one series of 12 patients, partial or complete flap necrosis occurred in 38% of patients, cold intolerance developed in 73%, occasional pain in 45%, and hypersensitivity in 36% (34). In another series of eight patients, the only adverse outcome was cold intolerance in 25% of patients (35). Few complications were observed at the toe donor site. Average two-point discrimination improved to less than 9.8 mm.

CONCLUSION Injuries to the distal phalanx are best managed when armed with an understanding of the pertinent anatomy and options for treatment. Nonoperative treatment is appropriate for most fractures, with the exception of articular fractures, widely displaced shaft fractures, and fractures associated with avulsion of the flexor digitorum profundus tendon. Open fractures require debridement and wound care; care that can usually be provided in the emergency department. Advancement flaps may be used to maintain digital length and provide a durable, sensate fingertip.

REFERENCES 1. National Occupational Health and Safety Commission Worker’s Compensation Data Base. http://nohs.info.au.com (accessed August 2004). 2. Zook EG. The perionychium: anatomy, physiology, and care of injuries. Clin Plast Surg 1981; 8(1):21 –31. 3. Verdan CE, Egloff DV. Fingertip injuries. Symp Pract Surg Hand 1981; 61(2):237–266. 4. Ditmars DM Jr. Fingertip and nailbed injuries. Occup Med 1989; 4(3):449–461. 5. Rosenthal EA. Treatment of fingertip and nail bed injuries. Symp Rehab After Hand Surg 1983; 14(4):675–697. 6. Bell-Krotoski J. Advances in Sensibility Evaluation. Hand Clinics. Philadelphia: Saunders, 1991. 7. Bell-Krotoski J. Sensibility Testing: State of the Art. Rehabilitation of the Hand. 3rd ed. St. Louis: Mosby, 1990. 8. Bell-Krotoski J. Light Touch–Deep Pressure Testing Using Semmes–Weinstein Monofilaments. Rehabilitation of the Hand. 3rd ed. St. Louis: Mosby, 1990. 9. Shrewsbury MM, Johnson RK. Form, function, and evolution of the distal phalanx. J Hand Surg 1983; 8:475–479. 10. Shum C, Bruno RJ, Ristic S, Rosenwasser MP, Strauch RJ. Examination of the anatomic relationship of the proximal germinal nail matrix to the extensor tendon insertion. J Hand Surg [Am] 2000; 25(6):1114–1117. 11. Schneider LH. Fractures of the distal phalanx. Hand Clinics 1988; 4:537–547. 12. Leddy LP, Packer JW. Avulsion of the profundus insertion in athletes. J Hand Surg 1979; 4:461–464.

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13. Smith JH. Avulsion of a profundus tendon with simultaneous intraarticular fracture of the distal phalanx—a case report. J Hand Surg 1981; 6:600–601. 14. Lester B, Jeong GK, Perry D, Spero L. A simple effective splinting technique for the mallet finger. Am J Orthod 2000; 29:202–206. 15. Abouna JM, Brown H. The treatment of mallet finger: the results in a series of 148 consecutive cases and a review of the literature. Br J Surg 1968; 55:653– 667. 16. Crawford GP. The molded polythene splint for mallet finger deformities. J Hand Surg 1984; 9A:231–237. 17. Stack HG. A modified splint for mallet finger. J Hand Surg 1986; 11B:263. 18. Bischoff R, Buechler U, De Roche R, Jupiter J. Clinical results of tension band fixation of avulsion fractures of the hand. J Hand Surg 1994; 19A:1019–1026. 19. Damron TA, Engber WD. Surgical treatment of mallet finger fractures by tension band technique. Clin Orthod 1994; 300:133 –140. 20. Yamanaka K, Sasaki T. Treatment of mallet fractures using compression fixation pins. J Hand Surg 1999; 24B:358–360. 21. Jupiter JB, Sheppard JE. Tension wire fixation of avulsion fractures in the hand. Clin Orthod 1987; 214:113–120. 22. Kronlage SC, Faust D. Open reduction and screw fixation of mallet fractures. J Hand Surg 2004; 29(2):135–138. 23. Mazurek MT, Hofmeister EP, Shin AY, Bishop AT. Extension-block pinning for treatment of displaced mallet fractures. Am J Orthod 2002; 31(11):652–654. 24. Hofmeister EP, Mazurek MT, Shin AY, Bishop AT. Extension block pinning for large mallet fractures. J Hand Surg 2003; 28A(3):453–459. 25. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and prognosis. J Hand Surg 1984; 9A(2):247–252. 26. Robins RHC. Fingertip injuries. Hand 1970; 2(2):119–125. 27. Allen MJ. Conservative management of fingertip injuries in adults. Hand 1980; 12(3):257–265. 28. Ma GF, Cheng JC, Chan KT, Chan KM, Leung PC. Fingertip injuries—a prospective study on seven methods of treatment on 200 cases. Ann Acad Med Singapore 1982; 11(2):207–213. 29. Schenck RR, Cheema TA. Hypothenar skin grafts for fingertip reconstruction. J Hand Surg 1984; 9A(5):750–753. 30. Melone CP, Beasley RW, Carstens JH. The thenar flap—an analysis of its use in 150 cases. J Hand Surg [Am] 1982; 7(3):291–297. 31. Tempest MN. Cross-finger flaps in the treatment of injuries to the fingertip. Plast Reconstr Surg 1952; 9(3):205–222. 32. Bidulph SL. The neurovascular flap in fingertip injuries. Hand 1979; 11(1):59–63. 33. Moberg E. Aspects of sensation in reconstruction surgery of the upper extremity. J Bone Joint Surg 1964; 46A:817–825. 34. Ratcliffe RJ, McGrouther DA. Free toe pulp transfer in thumb reconstruction. J Hand Surg 1991; 16B:165–168. 35. Deglise B, Botta Y. Microsurgical free toe pulp transfer for digital reconstruction. Ann Plast Surg 1991; 26(4):341–346.

2 Phalanx Shaft Fractures Mark S. Cohen Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.

INTRODUCTION Fractures involving the hand are the most common of all skeletal injuries, estimated at 1.5 million per year in the U.S.A. Phalanx fractures are particularly problematic due to the propensity for stiffness and functional loss. The goals of phalanx fracture treatment are restoration of anatomy and most importantly the adjacent articular surfaces if involved. For displaced injuries, a stable reduction is optimal with the least amount of surgical trauma. Early mobilization of the hand allows for a more rapid return of function. However, immediate rehabilitation is not essential for a favorable clinical result. This chapter covers the principles of phalanx fracture treatment, from simple to complex injuries, with a special emphasis on the indications and techniques of operative intervention. FRACTURE EVALUATION When evaluating an individual with a phalanx fracture, it is important to obtain a proper history. The mechanism of injury can provide important clues as to the energy level and potential instability of the fracture. Patient factors such as age, hand dominance, occupation, and activity level help to individualize a treatment plan. Examination should include a clinical evaluation of the injured digit including sensory testing. Proper radiographs typically require three views: frontal, lateral, and oblique projections, centered and perpendicular to the injured bone. Occasionally, the latter provides the best visualization of fracture displacement. 21

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Next, one has to determine the “personality” of the fracture. This is defined as the inherent instability of the injury. Although the history and radiographs provide information, occasionally the personality of the fracture can only be defined following an attempted reduction. Some fractures, although displaced, are of low energy with minimal periosteal stripping. Once reduced, these can be stable through an

Figure 1 (A) Frontal radiograph of displaced middle and ring fingers proximal phalanx shaft fractures. Fractures appear to be unstable. (B) One manipulation led to an anatomic reduction in the frontal and (C) lateral planes. This reduction appeared stable through a limited arc of motion. The fracture was immobilized for three weeks. (D) Final extension and (E) flexion several weeks after immobilization discontinued. Often the “personality” of the fracture can only be defined following reduction. This fracture was clearly of low energy with minimal periosteal stripping. It was a reducible and stable injury.

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Figure 2 Illustration depicting the typical pattern of displacement of proximal phalanx shaft fractures. The tension side of the bone is anterior resulting in dorsal angulation. This and shortening lead to relative laxity of the extensor mechanism resulting in an extensor lag at the proximal interphalangeal joint. Unlike metacarpal fractures, shortening is poorly tolerated in the phalanges.

arc of active motion and do not necessarily require surgical intervention (Fig. 1). If initially displaced fractures are treated with immobilization alone, it is imperative to document that the digit is not rotated. This requires active or gently passive flexion of the finger as rotation is difficult to assess in extension. The principles of phalangeal fracture care differ substantially from those of metacarpal injuries. Unstable phalanx fractures tend to angulate dorsally (opposite of the metacarpal) as the tension side of the bone is located anteriorly (Fig. 2). In addition, unlike metacarpal injuries, phalanx fractures are particularly prone to

Figure 3 Cross-section through the proximal phalanx of a digit. Note the close approximation of the gliding surface of the extensor tendon which blankets the dorsal cortex and the flexor tendons anteriorly. These anatomic features make phalangeal fractures particularly prone to adhesions and stiffness.

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adhesions and stiffness. This is due to the anatomy whereby the bony skeleton is enveloped by the gliding surfaces of the flexor and extensor tendons (Fig. 3). Furthermore, fracture displacement is much less tolerated at the phalanx level than in the metacarpals. Although shortening of up to 1 cm (without rotation) can be accepted in metacarpal fractures without functional loss, this is not the case in the digit. Shortening of only 1 mm following a proximal phalanx fracture leads to a 128 extensor lag at the proximal interphalangeal joint (Fig. 2).

REDUCIBLE AND STABLE INJURIES As a general rule, phalanx fractures will heal adequately by approximately three weeks to allow for protected rehabilitation. Non- or very minimally displaced fractures can be immobilized in a cast or splint during this time, followed by a gentle mobilization program with interval protective splinting. Fractures which are displaced but which are deemed stable once reduced can be treated similarly. However, these fractures have to be followed carefully, with consideration given to weekly evaluation during healing. Redisplacement can occur in a cast and during follow-up visits, the cast or splint should be removed, and the alignment and rotation of the digit documented in partial flexion. In stable proximal phalanx fractures (in reliable patients), consideration can be given to the use of a functional brace (Fig. 4). The orthosis maintains the metacarpophalangeal joint in maximum flexion while leaving the interphalangeal joints free for early mobilization. In this way, the extensor tendon functions as a tension band helping maintain reduction of the fracture. Again, fractures that

Figure 4 Hand-based functional splint which can be used for proximal phalanx fractures which are deemed stable. With the metacarpophalangeal joint at 908, the extensor tendon functions as a tension band helping maintain reduction while allowing unrestricted interphalangeal joint motion.

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are initially displaced and treated by closed methods must be followed very closely due to the potential for loss of reduction.

REDUCIBLE AND UNSTABLE INJURIES The majority of displaced phalangeal fractures are reducible by closed manipulation. However, initial displacement and periosteal stripping make the fracture unstable, and displacement recurs once external pressure is released. The simplest method of treating reducible but unstable phalanx fractures is percutaneous Kirschner wire fixation. For oblique and spiral fractures, the pins can be inserted from medial and lateral taking care to obtain purchase in both fracture fragments. For more transverse fracture patterns, intramedullary pins, placed antegrade from proximal to distal through the metacarpal head or metacarpophalangeal joint, can be used as well. More comminuted injuries can be amenable to a combination of pinning methods (Fig. 5). The advantage of closed pinning is that it obviates the need for an open approach to the fracture. If not opened, these fractures rarely lead to digital stiffness and morbidity despite several weeks of immobilization. Belsky and Eaton described a very useful method of pin fixation for phalangeal fractures that allows for early mobilization of the interphalangeal joints. Percutaneous pins (typically 0.045 in.) are placed intramedullary from an antegrade approach to maintain fracture reduction (Fig. 6). Functional bracing can then be used to protect the construct while allowing for interphalangeal joint rehabilitation. Even if the pins are through the metacarpophalangeal joint (our preferred method) and thus the extensor digitorum tendon, active interphalangeal joint extension is possible through the intrinsic extensor system. This greatly facilitates recovery of motion and function. The technique is particularly useful for unstable proximal phalangeal base fractures that typically occur at the proximal metaphyseal – diaphyseal junction with dorsal comminution (Fig. 6). An alternative method for treating oblique and spiral reducible and unstable phalanx fractures involves limited internal fixation with screws placed through very small incisions. This is termed “closed reduction and internal fixation.” Limited midaxial incisions are used, and the lateral band of the extensor mechanism retracted dorsally (Fig. 7). Typically, fracture reduction is maintained with provisional Kirschner wires which are exchanged for 1.3 or 1.5 mm screws. Two screws are required for adequate stability. Self-tapping implants make this method much easier, obviating the need for tapping of the screw track. However, the technique requires careful attention to detail. Special care must also be taken with titanium screws. Owing to their ductility (the degree of plastic deformation prior to failure), there is a small margin for error, and excessive force or improper placement can lead to screw breakage (Fig. 7). With internal screw fixation, early mobilization and return of function are possible.

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Figure 5 (A) Frontal radiograph depicting unstable middle finger proximal phalanx fracture with comminution. This fracture turned out to be reducible and unstable. (B) Anteroposterior and (C) lateral radiographs following percutaneous pin fixation. Note the combination of pin methods utilized for this fracture with oblique and intramedullary implants. This percutaneous technique obviated the need for open reduction with its associated morbidity.

This minimally invasive technique limits the morbidity of formal open reduction and internal fixation (adhesions, extensor tendon lag, etc.). Occasionally, reducible but unstable fractures can be effectively treated with external fixation. This method is typically reserved for open fractures and those with severe comminution where pin and/or screw fixation is not possible.

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Figure 6 (A) Anteroposterior and (B) lateral radiographs of middle finger proximal phalanx base fracture. These are typically associated with dorsal comminution. The fracture was reducible with manipulation. (C) Frontal and (D) lateral radiographs following antegrade intramedullary pin fixation through the metacarpophalangeal joint. (E) Clinical photograph of hand-based functional orthosis. The volar splint attachment maintains the interphalangeal joints in extension between exercises. This is removable allowing interphalangeal joint motion with the pins in place. (F) Note full interphalangeal joint flexion obtained two weeks following surgery. This technique allows fracture stabilization with early digital motion. Active digital extension is maintained through the intrinsic muscles.

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Figure 7 (A) Frontal radiograph depicting long oblique fracture of the proximal phalanx of the small finger. This fracture was reducible and unstable. (B) Intraoperative photograph showing limited midaxial incision. Note the lateral band of the extensor mechanism coursing obliquely in the wound. (C) Lateral band has been retracted dorsally allowing screw placement. (D) Anteroposterior and (E) lateral radiographs following internal fixation. Two 1.3 mm screws and one central 1.5 mm screw were used. Note that the distal screw head was sheared off during placement. Titanium implants have low ductility, and screw breakage can occur with excessive force.

However, external fixation can be effective in certain closed injuries. An example would be a severely comminuted periarticular fracture (Fig. 8). In this way, the fixator can provide ligamentotaxis to maintain the articular surface and help neutralize (protect) any pins that are used. External fixation provides adequate

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Figure 8 (A) Anteroposterior radiograph of a diaphyseal middle phalanx fracture of the ring finger with an associated comminuted and displaced fracture of the distal interphalangeal joint. This fracture was reducible and unstable. (B) Postoperative frontal and (C) lateral radiographs following percutaneous placement of an external fixator and a pin. The fixator crosses the distal joint providing ligamentotaxis and neutralization to maintain the reduction of both fractures. (D) Clinical photograph of the digit with the fixator in place. (E) With this method, the patient has unrestricted motion of the metacarpophalangeal and proximal interphalangeal joints during fracture healing.

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stability to allow for unrestricted mobilization of adjacent joints. Owing to the close opposition of the fingers, the technique is probably most applicable to the index and small fingers, where the fixator can be applied along the borders of the hand.

IRREDUCIBLE PHALANX INJURIES Irreducible fractures of the phalanges are those that cannot adequately be reduced by closed methods. These require open reduction which is typically followed by internal fixation. For the proximal phalanx, a dorsal skin incision is most commonly employed. For the best exposure, a longitudinal split is made through the center of the extensor mechanism (Fig. 9). Lateral extensor sparing exposures are possible, but make reduction and stabilization much more difficult and have not been shown to significantly alter ultimate motion and function. Care is taken to next open the periosteum of the phalanx, which is surprisingly thick and often intact or only partially torn. For long oblique and spiral fractures, interfragmentary screw fixation is best, using 1.3 and/or 1.5 mm implants. The technique requires precision and attention to detail to a much greater extent than that in larger bones. It is often helpful to open the fracture to appreciate its anatomy in planning screw fixation. Care is taken to place the provisional pins perpendicular to the fracture for optimal stability. These are then exchanged for self-tapping screws. As a general rule, one should not place a screw closer than three screw widths from a fracture spike to prevent fragmentation (Fig. 10). The tip of the depth gage should be directed to the far cortex opposite the fracture to decrease the potential for choosing too short of a screw (Fig. 11). A countersink is important not only to limit hardware prominence, but also more importantly to decrease stress risers as the screw is tightened. This also provides greater contact between the screw head and the bone improving compression and stability. Following fixation, the periosteum and extensor mechanism are meticulously repaired in separate layers (Fig. 9). Occasionally, irreducible oblique or spiral fractures that seem relatively simple actually have significant nondisplaced fracture lines visible upon inspection. This makes screw fixation inadequate. A very useful technique to use in these circumstances involves a composite tension band wiring technique termed the “sidewinder” method. This involves parallel or crossed Kirschner wires supplemented with fine monofilament wire which is wrapped around the pins providing compression and stability (Fig. 12). The wire is placed in such a way as to provide four strands across the fracture. This technique can be useful as well in cases where screw fixation has failed, such as when a screw has stripped or a spike fractured. It allows for stable fixation with a very lowprofile construct. We have found threaded pins to be helpful when using this method, decreasing the chance for pin migration and helping anchor the wire around the tips of the pins.

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Figure 9 (A) Anteroposterior radiograph of a comminuted and displaced proximal phalanx fracture of the middle finger. The fracture was irreducible by manipulation. (B) Intraoperative photograph during open reduction and internal fixation with interfragmentary compression screws. Exposure is provided by splitting the extensor tendon dorsally in the midline. (C) Complete closure of the periosteum over the hardware. (D) Anatomic repair of the extensor tendon. (E) Postoperative anteroposterior and (F) lateral radiographs following reduction and screw fixation.

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Figure 10 Diagram depicting the closest safe position for a screw relative to a fracture edge (shaded hole). Screws placed less than three screw diameters from a cortical margin risk fragmentation of the fracture spike.

An alternative to the sidewinder tension wiring technique involves transosseous wiring. In this technique, mostly used for transverse fractures and particularly useful in amputations, an oblique pin is supplemented with monofilament wire placed proximal and distal to the fracture through the bone.

Figure 11 Placement of the depth gauge away from the fracture in obliquely placed screws. Placing the depth gage tip on the near cortex may underestimate optimal screw length. By placing the tip of the gage away from the fracture, the correct screw measurement is obtained. This is especially important with self-tapping screws which require the screw tip through the opposite cortex for purchase.

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Figure 12 (Continued on next page) (A) Anteroposterior radiograph of an oblique displaced proximal phalanx fracture in the small finger of an adolescent male. The fracture was irreducible due to soft-tissue interposition. (B) Intraoperative photograph depicting sidewinder composite wiring technique used to stabilize the fracture. Note the nondisplaced longitudinal fracture lines running proximal and distal to the fracture. These made the fracture irreparable with screw fixation alone. The tension band wire supports the fracture comminution that was appreciated only during open reduction. (C) Repair of the periosteum and (D) extensor tendon following internal fixation. Note complete coverage of the hardware with periosteum.

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Figure 12 (Continued from previous page) (E) Anteroposterior and (F) lateral radiographs depicting sidewinder fixation. Note that the wire was applied to obtain four strands across the fracture. (G) Finger flexion and (H) extension in dynamic brace designed to improve the mechanical advantage of the extensor mechanism and decrease the occurrence of an extensor lag at the proximal interphalangeal joint. (I) Final flexion and (J) extension of the digit. Note the proximal interphalangeal joint extensor lag despite periosteal and tendon repair and early motion in a dynamic splint. Full terminal extension is difficult to obtain following open reduction and violation of the extensor tendon.

The fracture is reduced, the pin advanced, and the wire tightened providing adequate stability (Fig. 13). Plate fixation of the phalanges is reserved for irreducible transverse or short oblique fractures. In addition, one can consider plate fixation in more complex injuries involving a crush component with comminution of the bone where early tendon gliding and soft-tissue mobilization is preferred (Fig. 14). It must be understood; however, that plate fixation of the phalanges is fraught with

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Figure 13 (A) Anteroposterior and (B) lateral radiographs of displaced and unstable diaphyseal fracture of the middle phalanx. The fracture was not reducible by manipulation requiring limited open reduction. (C) Postoperative anteroposterior and (D) lateral radiographs depicting transosseous wiring used for fracture fixation.

complications. The plate is typically positioned dorsally in a potential space between the extensor tendon and the bone. Extensor adhesions and motion loss are not uncommon, and a subset of plated phalanges require a second-stage procedure involving hardware removal and tenolysis once bony union has occurred to recover mobility. Screws that are too long can lead to flexor tendon embarrassment (Fig. 15). Although lateral plate placement is less problematic theoretically, this has not been proven to be significantly better than dorsal plating and is much more difficult. Newer smaller 1.3 mm implants are less bulky and may decrease extensor tendon complications (Fig. 16). Whatever implant is chosen, attempts are made to close some periosteum over the plate if possible. When applied in compression for transverse fractures, the plates should be prebent to allow for uniform compression of the cortex opposite the plate. The exception would be

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Figure 14 (Continued on next page) (A) Clinical photograph and (B) frontal radiograph following roller/crush injury resulting in multiple proximal phalanx fractures. The fractures were irreducible by closed manipulation. (C) Intraoperative photograph revealing open reduction and internal plate fixation of the fractures. A dorsal plate was used for the middle finger with bone graft and lateral plates for the index and ring fingers. (D) Frontal and (E) lateral radiographs following internal plate fixation. (F) Clinical photograph of final extension and (G) flexion. Crush injury associated with irreducible and comminuted fractures can be an indication for plate fixation of the phalanges where early mobilization is imperative.

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Figure 14 (Continued from previous page)

a short oblique fracture which is first reduced and stabilized by a single lag screw. In this situation, the plate functions mainly in neutralization and is not prebent but applied in neutral fashion without eccentric drilling of the screw holes. It must be emphasized that any open reduction of phalanx injuries comes at a cost, mainly an increased risk for extensor tendon adhesions and stiffness. This is especially true when larger implants such as plates are required. To improve the mechanical advantage of the extensor mechanism, dynamic splints have been

Figure 15 (A) Lateral radiograph of a proximal phalanx fracture treated with a dorsal plate. Note that one of the proximal screws is too long protruding well past the anterior cortex. (B) Clinical photograph of attempted digital extension. Note the significant extensor lag. This is not uncommon following dorsal plating of the proximal phalanx. (C) Photograph of attempted flexion. Limitation of motion is due to rupture of the profundus tendon due to the sharp tip of the protruding screw. Plate fixation of the phalanges is technically demanding and fraught with potential complications.

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Figure 16 (A) Anteroposterior and (B) lateral radiographs of a displaced transverse fracture of the middle finger proximal phalanx with comminution. The fracture was irreducible by closed methods. (C) Frontal and (D) lateral radiographs following dorsal plate fixation with low-profile 1.3-mm implant. These smaller implants are less bulky and may limit extensor tendon complications following dorsal plating of the phalanges.

suggested following open reduction (Fig. 12). However, even with lower-profile constructs, such as sidewinder wiring, and the use of aggressive rehabilitation, loss of terminal extension is common when the extensor mechanism is surgically violated. Fortunately, recovery of flexion is more predictable and is more important for function. In addition, a minor degree of extensor lag typically leads to minimal functional difficulties. BIBLIOGRAPHY Belsky MR, Eaton RG, Lane LB. Closed reduction and internal fixation of proximal phalanx fractures. J Hand Surg 1984; 9A:725 –729. Birndorf MS, Daley R, Greenwald DP. Metacarpal fracture angulation decreases flexor mechanical efficiency in human hands. Plast Reconstr Surg 1997; 99(4):1079 –1083.

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Breddam M, Hansen TB. Subcapital fractures of the fourth and fifth metacarpal treated without splinting and reposition. Scand J Plast Reconstr Surg 1995; 29(3):269–270. Buchler U, Gupta A, Ruf S. Corrective osteotomy for post-traumatic malunion of the phalanges in the hand. J Hand Surg [Br] 1996; 21(1):33– 42. Cullen JP, Parentis MS, Chinchilli VM, Pellegrini VD Jr. Simulated Bennett fracture treated with closed reduction and percutaneous pinning: a biomechanical analysis of residual incongruity of the joint. J Bone Joint Surg [Am] 1997; 79(3):413–420. DeJonge JJ, Kingma J, Van Der Lei B, Klasen HJ. Phalangeal fractures of the hand: an analysis of gender and age-related incidence and aetiology. J Hand Surg 1994; 19B:168–170. Emmett JE, Breck LW. A review of analysis of 11,000 fractures seen in a private practice of orthopaedic surgery, 1937 –1957. J Bone Joint Surg 1958; 40A:1169–1175. Firoozbakhsh KK, Moneim MS, Doherty W, Naraghi FF. Internal fixation of oblique metacarpal fractures: a biomechanical evaluation by impact loading. Clin Orthop 1996; 325:296– 301. Fitoussi F, Ip WY, Chow SP. External fixation for comminuted phalangeal fractures: a biomechanical cadaver study. J Hand Surg [Br] 1996; 21(6):760– 764. Gonzales MH, Hall RF. Intramedullary fixation of metacarpal and proximal phalangeal fractures of the hand. Clin Orthop 1996; 327:47–54. Hornbach EE, Cohen MS. Closed reduction and percutaneous pinning of fractures of the proximal phalanx. J Hand Surg 2001; 26B:45 –49. Kahler DM. Fractures and dislocations of the base of the thumb. J South Orthop Assoc 1995; 4(1):69–76. Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000; 8:111 –121. Lester B, Mallik A. Impending malunions of the hand: treatment of subacute, malaligned fractures. Clin Orthop 1996; 327:55–62. Liaw Y, Kalnins G, Kirsch G. Combined fourth and fifth metacarpal fracture and fifth carpometacarpal joint dislocation. J Hand Surg [Br] 1995; 20(2):249– 252. Lins RE, Myers BS, Spinner RJ, Levin LS. A comparative mechanical analysis of plate fixation in a proximal phalangeal fracture model. J Hand Surg [Am] 1996; 21A(6):1059 –1064. Manueddu CA, Della Santa D. Fasciculated intramedullary pinning of metacarpal fractures. J Hand Surg [Br] 1996; 21(2):230–236. Ouellette EA, Freeland AE. Use of the minicondylar plate in metacarpal and phalangeal fractures. Clin Orthop 1996; 327:38–46. Pelto-Vasenius K, Hirvensalo E, Rokkane P. Absorbable pins in the treatment of hand fractures. Ann Chir Gynaecol 1996; 85(4):353– 358. Sochart DH, Paul AS. A simple external fixator for use in metacarpal and phalangeal fractures: a technique paper. J Orthop Trauma 1995; 9(4):333–335. Swanson TV, Szabo RM, Anderson DD. Open hand fractures: prognosis and classification. J Hand Surg 1991; 16A:101– 107. Toronto R, Donovan PJ, Macintyre J. An alternative method of treatment for metacarpal fractures in athletes. Clin J Sport Med 1996; 7(1):4–8. Vandenberk P, DeSmet L, Fabry G. Finger fractures in children treated with absorbable pins. J Pediatr Orthop, Part B 1996; 5(1):27 –30. Weiss AP. Cerclage fixation for fracture dislocation of the proximal interphalangeal joint. Clin Orthop 1996; 327:21–28.

3 Dislocations and Fracture Dislocations of the Metacarpophalangeal and Proximal Interphalangeal Joints Randy R. Bindra Hand Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A.

INTRODUCTION Fractures and dislocations of the metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints are most commonly seen in younger patients and often related to sporting activities. Appropriate evaluation and timely intervention are essential in order to ensure good outcomes and to avoid long-term morbidity from pain and loss of motion. Although most dislocations can be managed nonoperatively, operative intervention is usually indicated for larger fractures associated with dislocations. Surgical intervention requires a good knowledge of the anatomy and surgical approaches as well as familiarity with instrumentation for the fixation of small fragments. An aggressive postoperative rehabilitation program is essential for return to sport or preinjury level of activity. METACARPOPHALANGEAL JOINT Surgical Anatomy The MP joint is a synovial joint with congruent articular surfaces that allow multiplanar motion of flexion/extension, adduction/abduction/flexion, and circumduction. Side – side stability is provided mainly by the collateral and 41

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accessory collateral ligaments and to some extent by the lumbricals and the interossei. The metacarpal head is not a perfect sphere but rather a condyloid surface wider volarly giving it a trapezoidal shape in its axial section. The collateral ligaments run from the fovea on the metacarpal head dorsally to the tubercle on the volar-lateral base of the proximal phalanx and hence tighten during flexion. Conversely, the accessory collateral ligaments that originate just volar to the proper collaterals and insert onto the volar plate are taut in extension. Dorsal displacement of the phalanx is resisted by the volar plate that attaches loosely to the metacarpal neck proximally and has a thick firm attachment to the volar surface of the proximal phalanx. The dorsal capsule is thin and loose to allow flexion of the MP joint and provides relatively little stability to the joint. The thumb MP joint is similar to those of the fingers, but has less side– side mobility and a large variation among individuals in its range of flexion-extension. Because of the lack of adjacent support, the MP joints of the thumb and the border digits, index and small, are most commonly injured. Dislocation of the Metacarpophalangeal Joint MP joints can be dislocated in a volar or dorsal direction as defined by the relationship of the proximal phalanx to the metacarpal. The latter is the most common resulting from hyperextension of the joint from falling on the outstretched hand. Dorsal dislocations may be “simple,” in that they are reducible by closed means. “Complex” dislocations require open reduction. Volar dislocations are extremely rare with only a handful of case reports in literature and are almost always complex. Pathoanatomy Hyperextension of the MP joint disrupts the volar plate, which commonly tears from its weaker metacarpal attachment. Unless there is associated twisting of the finger, the collateral ligaments remain intact. In a simple dislocation, the phalanx remains in contact with the dorsal surface of the metacarpal. The deformity is clinically obvious with the finger stuck in a claw position of extreme dorsiflexion at the MP joint. With continuation of the displacing forces, the metacarpal head is pushed through the volar structures whereby it can get “buttonholed” in the process as the volar plate displaces dorsal to the metacarpal head. The proximal phalanx loses all contact with the metacarpal head and assumes a position dorsal and parallel to the metacarpal with a less severe clinical deformity. This type of dislocation, referred to as a complex MP dislocation, is irreducible by closed means and was first described by Kaplan (1). The metacarpal head becomes wedged between the natatory ligament that supports the web space dorsally and the superficial intermetacarpal ligament of the palmar fascia anteriorly. In the small finger, the tendons of the flexor and abductor digiti minimi are displaced ulnarly, and the long flexor tendons with the lumbricals become positioned on the radial side of the metacarpal head. In index finger

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dislocations, the metacarpal head is caught between the flexor tendons ulnarly and the lumbrical radially. The neurovascular bundles come to lie close to the palmar skin tightly stretched across the front of the metacarpal head placing them at risk of injury during a volar surgical approach. Less commonly, an osteochondral fracture may be sheared off from the metacarpal head or phalanx base in the process. Volar dislocations are invariably irreducible with one of various anatomical structures blocking reduction. These include interposition of the volar plate torn from the base of the phalanx, the dorsal capsule detached from the metacarpal (2) or the junctura tendinum between the ring and small finger extensors (3), and combinations of entrapment of the volar plate with the collateral or dorsal capsule (4). Imaging Radiographs in three planes, frontal, lateral, and oblique, are essential for the evaluation and diagnosis of MP joint injuries. Lateral views may be difficult to interpret because of overlapping adjacent digits. A widened joint space or an interposed sesamoid bone implies volar plate interposition and a complex dislocation (Fig. 1). Closed Reduction An attempt at closed reduction is usually justified. Local anesthetic infiltration with or without sedation to promote muscle relaxation is all that is required in most cases. Unlike the reduction maneuver common to all dislocations, the

Figure 1 Complex dorsal dislocation of the thumb metacarpophalangeal (MP) joint. The appearance of sesamoid bones in the joint space suggests that the dislocation is complex. Note the relative benign clinical appearance.

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application of traction is contraindicated in this injury as it may create a negative pressure and draw the volar plate into the joint causing a complex dislocation. The wrist and interphalangeal joints are flexed to relax the flexor tendons and with application of gentle compressive force the MP joint deformity is accentuated by hyperextension followed by gentle flexion. If successful, the joint will flex easily and a full arc of active motion is restored. If there is a “springy” resistance to flexion and full MP joint flexion cannot be achieved, the dislocation is a complex one and requires surgery. Surgical Management Kaplan’s original description of the injury included open reduction by a volar approach (1). Although this exposure allows excellent visualization of the anatomy, the risk of injury to the digital neurovascular bundle is extreme. A dorsal approach is safer in this regard and has been reported to be effective in surgical management of these injuries (5). Volar approach: An oblique incision is centered across the volar prominence of the metacarpal head. The incision is planned to allow distal and proximal extension in a zigzag fashion if required. The moment the skin incision is made, the volar-displaced neurovascular bundle should be identified and retracted. Palmar fascia fibers overlying the metacarpal head are released. The A1 pulley must then be divided to relax the flexor tendons. Soft tissues are retracted to either side of the head, and the volar plate is flipped out of the joint with a hemostat. The joint is reduced with direct dorsal pressure on the head. The joint is usually immediately stable. In cases of extreme instability, the volar plate can be reattached with bone anchors to the metacarpal neck. Dorsal approach: A longitudinal incision is made over the joint, and the extensor mechanism is split longitudinally. If intact, the dorsal capsule is incised as well. The volar plate is visualized overlying the metacarpal (Fig. 2). With distraction applied to the joint, the volar plate is divided longitudinally and with the help of a hemostat pushed back volarly. The proximal phalanx is then flexed to reduce the joint. The extensor mechanism is repaired with a continuous nonabsorbable suture. Postoperative Management Once the joint is reduced, stability is assessed through its range of motion. Unless there is a significant collateral ligament injury, the joint is typically stable through its normal arc. Following reduction, the patient can be fitted with a dorsal splint blocking the last 308 of MP joint extension. Active motion is encouraged within the splint. The splint is discontinued by the end of three weeks, and active mobilization is encouraged. With collateral ligament instability, the MP joint is immobilized for three weeks allowing interphalangeal joint motion alone.

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Figure 2 Dorsal surgical approach for open reduction of the case shown in Figure 1. (A) Intraoperative photograph demonstrates the interposed soft tissue on the dorsum of the metacarpal. (B) The soft tissue is mobilized and partly excised to allow the metacarpal head to be delivered dorsally reducing the joint.

Fractures of the Metacarpophalangeal Joint Fractures that are intraarticular to the MP joint involve either the head of the metacarpal or the base of the proximal phalanx. Fractures of the Metacarpal Head There are several patterns of intraarticular fractures of the metacarpal head. The index finger metacarpal head is the most prone to fracture and the thumb is the least (6). The following are common fracture patterns. Type 1: Oblique fractures of the metacarpal head exit into the joint making them intraarticular injuries. These occur most commonly at the border metacarpals (Fig. 3). The free joint fragments are usually shortened and rotated due to the fracture geometry. The protruding metaphyseal spike of the proximal fragment will cause obstruction of motion and stiffness is likely if not reduced. Closed reduction by traction and derotation can be achieved in some cases, but the reduction cannot be maintained without the application of some form of traction or internal fixation. The most optimal method of stabilization of this articular shear fracture is surgical fixation with interfragmentary lag screws (Fig. 4). Fixation provides adequate stability to allow early motion out of a protective splint. Surgical approach is dorsal by splitting or retracting the extensor apparatus over the MP joint.

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Figure 3 (A) Oblique fracture of the metacarpal head of the index finger. The fracture is unstable and the head is depressed along line of obliquity. (B) The fracture has been stabilized with lag screws.

Type 2: Osteochondral fractures of the metacarpal head are the result of direct trauma to the knuckle of the finger. The most common etiology is from “fight-bite” injuries. These open fractures require urgent debridement and joint lavage along with antibiotic coverage aimed at oral flora. The fracture fragments

Figure 4 (A) An oblique fracture of the metacarpal head has been approached dorsally between the proprius and communis extensor tendons of the index finger. (B) The displaced fragment is elevated and fixed internally with two lag screws.

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are generally small and treated by excision. A large osteochondral fragment that is devoid of soft-tissue attachments will not heal without fixation. These should be fixed rigidly using a headless screw to avoid hardware prominence in the joint (Fig. 5). Type 3: Collateral ligament avulsion fractures off the metacarpal head are rare. The collateral ligament more commonly fails at its phalangeal insertion. Smaller, nondisplaced fragments will heal if treated with immobilization. Displaced fragments may fail to unite or heal in a displaced position leading to ligamentous laxity and joint instability. Open reduction and fixation with a lag screw is recommended for all displaced avulsion fractures. Small fragments that cannot be fixed can be excised followed by repair of the ligament to bone using bone anchors or transosseous sutures. Type 4: Vertical fractures of the metacarpal head are rare. In this pattern, the metacarpal head is split in the longitudinal plane as a result of direct trauma. The fracture may occur in the sagittal or coronal planes. Longitudinal fractures in the sagittal plane may be depressed due to the compression force of the injury. Careful examination of the radiographs will demonstrate an apparent widening of the joint space in comparison to the neighboring joints (Fig. 6). Displacement or depression of the joint surface is an indication for operative treatment. Open reduction by a dorsal approach allows access to the articular fragments. The depressed articular surface can be elevated easily leaving a defect that must be filled with bone graft to prevent subsequent collapse. If possible, lag screws should be placed transversely to buttress the elevated articular surface (Fig. 7).

Figure 5 (A) Osteochondral transverse fracture of the metacarpal head of the long finger. (B) The fracture is exposed by a dorsal extensor splitting incision and internally fixed with a longitudinally placed headless screw.

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Figure 6 (A) Posteroanterior (PA) and (B) lateral views demonstrating a vertical fracture in the sagittal plane of the metacarpal head with depression of the articular surface recognized by the widened joint space.

Coronal shear factures of the metacarpal head occur as a result of a shearing force from the base of the proximal phalanx and are associated with a subluxation of the MP joint which follows the displacement of the fragment. Such fractures are difficult to treat nonoperatively due to the associated joint subluxation.

Figure 7 (A) The fracture is approached dorsally and (B) the depressed articular fragment is elevated. (C) The defect is grafted and stable fixation is achieved with two lag screws as demonstrated radiographically.

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Smaller dorsal coronal fractures with stable joints can be treated by simple excision of the fragment as the dorsal articular surface of the metacarpal head does not articulate with the phalanx in the arc of functional motion. However, larger fragments have to be internally fixed to support the base of the proximal phalanx. Volar coronal fractures pose the biggest treatment challenge. The pull of the flexor tendons and the lack of support of the base of the proximal phalanx results in volar subluxation of the MP joint. Although the joint can be reduced by traction, the volar fragment remains displaced as it has no soft-tissue attachments (Fig. 8). Open reduction is mandatory and has to be performed through an anterior approach as the fragment cannot be visualized through the usual dorsal approach to the MP joint. An anterior approach to the joint involves a zigzag incision in the palm centered over the distal palmar crease (Fig. 9). The interval between the neurovascular bundle and the flexor tendon sheath is developed. The flexor tendons along with the intact flexor tendon sheath are reflected laterally off the volar plate by sharp dissection. The volar plate is then incised and reflected distally. By maintaining traction on the digit to counteract displacing forces, the fragment can be elevated to its normal position and fixed with temporary wires while the reduction is confirmed by radiography. At least two headless screws or lag screws with the heads countersunk below the articular surface are used. Joint stability is determined prior to closure. As visualization of the joint surface is limited from the volar approach, intraoperative imaging is mandatory to ensure that the joint is reduced and the articular congruity is restored (Fig. 10).

Figure 8 (A) Volar coronal fracture of the metacarpal head. Loss of joint space on the posteroanterior (PA) view suggests joint subluxation that is confirmed with the (B) oblique and (C) lateral views. The proximal phalanx follows the displaced volar articular surface of the metacarpal head.

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Figure 9 (A) The fracture is approached through a volar zigzag approach. (B) The volar fragment is elevated with care to avoid stripping any tenuous soft-tissue attachments and (C) fixed using screws directed dorsally. The screw heads are countersunk below the articular surface.

If secure fixation is achieved, protected motion can be early after the initial pain and swelling are controlled. These fragments may develop late collapse due to avascular necrosis. Type 5: Transverse and comminuted metacarpal head fractures are usually associated with significant comminution and are the result of violent injury to the border metacarpals (Fig. 11). The injury is not uncommonly associated with significant soft-tissue crushing and injury to the adjacent skeleton. Treatment in these cases is dictated by the associated soft-tissue injury and often requires open reduction and fixation (Fig. 12). Fixation of these fractures usually requires some ingenuity using a combination of wires and screws and sometimes placement of a neutralizing external fixator. Early mobilization may not be possible in extremely comminuted and unstable fractures. Primary arthroplasty or arthrodesis may be considered in severe cases such as gun shot injuries where there is significant loss of the articular surface of the joint. Basal Fractures of the Proximal Phalanx Fractures of the base of the proximal phalanx comprise 10% of all hand fractures (7). These fractures can be classified into the following types. Avulsion fractures: This is the commonest type and is usually sportsrelated and results from avulsion of a variable-sized fragment off the volarlateral corner of the proximal phalanx (Fig. 13). Collateral avulsion from the

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Figure 10 (A) Frontal and (B) lateral radiographs postoperatively. The volar coronal fracture has healed with minimal collapse of the volar fragment.

border digits can lead to significant symptoms of instability, whereas collateral instability of the MP joint of inner digits may be asymptomatic in more sedentary individuals. Anatomic reduction of the fragments should be the goal for all collateral avulsion fractures in athletes or those with an active lifestyle and

Figure 11 (A) Frontal and (B) oblique radiographs of a comminuted fracture of the index metacarpal head caused by direct injury to the metacarpal head. The fracture was irreducible by closed means and required open reduction.

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Figure 12 (A) Open reduction was performed using a dorsal approach. (B) After temporary fixation with Kirschner wires, (C) definitive fixation was performed using resorbable radiolucent pins.

injuries affecting border digits. Undisplaced or minimally displaced fragments can be treated nonoperatively with immobilization in a hand-based splint. Early motion with buddy taping to the adjacent digit may be considered by strapping the digit to the one adjacent to the fracture. Thus, it is acceptable to strap the long to the ring finger for a nondisplaced avulsion fracture from the ulnar corner of the long finger proximal phalanx and to strap to the index finger for an avulsion from the radial corner. If the fragment is displaced by more than 3 to 5 mm or there is any joint subluxation, internal fixation must be considered regardless of the size of the fragment as it is essential to restore integrity and correct length of the ligament. The border digits can be approached through a midaxial incision by dorsally reflecting the lateral band of the extensor apparatus to expose the fracture. Avulsion fractures from the inner digits can be approached from a dorsal or volar approach. Although the dorsal approach is easier to perform because of familiarity, the volar approach to the MP joint as described above is preferable as it affords direct access to the fragment and allows better placement of a lag screw compressing the fragment back to the phalanx (Fig. 14) (8). Depending on the size of the fragment, one or two screws may be used for fixation. When dealing with small fragments, careful drilling by hand using an oscillating motion is preferable to powered drilling. Compression fractures: The most common method of failure of the proximal phalanx is a bending extraarticular fracture through the weaker

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Figure 13 (A) Frontal and (B) lateral radiographs of a radial collateral avulsion fracture from the base of the proximal phalanx of the small finger. With a large fragment, displacement can result in articular incongruity.

Figure 14 (A) Volar approach to the base of the proximal phalanx. (B) The flexor sheath is left intact and reflected subperiosteally to expose the fracture (C and D). Care must be taken to maintain the soft tissues attached to the fragment. (E) Fixation is achieved with two lag screws.

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metaphyseal bone. Less commonly, direct impact on the flexed MP joint drives the metacarpal head into the phalangeal base resulting in an impaction fracture with comminution and depression of the articular fragments (Fig. 15). Traction alone is not effective in restoring congruity as articular fragments are displaced into the metaphysis. Minor articular step-offs without angular deformity of the phalanx may be treated nonoperatively, with early protected mobilization in a removable splint. Surgical treatment is indicated when the articular surface fragments are depressed more than 2 mm to prevent mechanical problems with MP joint motion. Significant depression of the articular surface leads to rotational deformity in flexion as the phalanx drops into a rotated position when the depressed surface articulates with the radial head. Preoperative workup with a computed tomography scan is helpful in planning operative strategy. Open reduction of these injuries is challenging as the fracture is comminuted and reduction requires careful elevation of tiny articular fragments. The base of the proximal phalanx can be exposed through a dorsal tendon splitting incision and capsulotomy of the MP joint (Fig. 16). If the metaphysis is largely intact, a dorsal metaphyseal window can be created through which the articular surface is gently elevated back under vision. If there is metaphyseal comminution, the cortical fragments are reflected to allow access to the metaphysis from where articular fragments are gently elevated back. The resulting metaphyseal defect is then packed with bone graft obtained from the ipsilateral distal radius. An alternative such as allograft can be utilized

Figure 15 (A) Comminuted depressed fracture of the phalangeal base of the ring finger. (B) Note the angular deformity of the phalanx at the metaphysis in addition to central depression of the articular surface.

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Figure 16 (A) The metacarpophalangeal (MP) joint is exposed through a dorsal approach to demonstrate articular incongruity. (B) The articular fragments have been elevated with bone grafting of the metaphysis. (C) A lateral T-plate has been applied to correct the metaphyseal angulation.

at the discretion of the surgeon. The key to joint stability is packing the metaphyseal defect with bone graft. Additional stability is obtained by a buttress plate applied to the lateral or dorsal surface of the phalanx although some authors feel that internal fixation is not necessary (9). Early intermittent motion out of a protective splint is started once the initial pain and swelling have subsided.

PROXIMAL INTERPHALANGEAL JOINT Surgical Anatomy The PIP joint functions as a hinge. The majority of motion is in the flexionextension plane with some allowance for minimal rotation and lateral movement to allow some give when grasping objects of different shapes. The convex surface of the proximal phalanx is only partially covered by the concave articular surface of the middle phalanx. The proximal phalanx articular surface has two condyles separated by a shallow sulcus into which fits a corresponding ridge on the base of the middle phalanx providing some inherent bony stability. Side-to-side stability of the joint is provided by collateral ligaments that run from a notch just distal to the epicondyle of the proximal phalanx to insert onto the anterior half of the lateral margin of the middle phalanx. The collateral ligament has two distinct parts: a dorsal one that tightens during extension and a volar one that tightens with flexion of the joint. Division of both these components can

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cause significant instability of the joint (10). An accessory collateral ligament runs from the proximal phalanx to the lateral edge of the volar plate. The main function of this ligament is to tension the volar plate and pull it proximally to provide clearance for finger flexion. The volar plate is the third important stabilizing structure and primarily prevents hyperextension of the joint. It is attached distally to the base of the middle phalanx just volar to the articular surface. Proximally the volar plate gains attachment to bone by lateral extensions that attach to the proximal phalanx just distal to and within the mouth of the second annular pulley. The actual proximal edge of the plate remains free to move proximally with digital flexion. Dynamic stability of the PIP joint is provided by the central slip of the extensor mechanism which is attached to the middle phalanx dorsally and the flexor tendons that are held close to the joint by the third annular pulley attached to the volar plate. In addition, the superficialis tendon also directly inserts by two lateral slips on either side of the volar lateral edge of the middle phalanx over its proximal third. Proximal Interphalangeal Joint Fractures and Dislocations Fractures may affect either the condyles of the proximal phalanx or the base of the middle phalanx. The various fracture patterns are described below. Although there are different patterns of injury, management principles are the same and are discussed subsequently. Condylar Fractures Condylar fractures affect the younger population and are usually sports-related (11). Sagittal fractures are caused by forced separation of the digits, whereas coronal fractures can occur from impact on the joint in hyperflexion or in an extended state. The small finger is most commonly involved and the long, the least with equal incidence among the remaining digits (12). Classification: Type 1: Unicondylar fracture with transverse metaphyseal fracture occurs due to a combination of axial load with angular force and is stable due to the transverse metaphyseal component. Unless initially displaced, these fractures can be treated nonoperatively with early mobilization by buddy taping to the digit adjacent to the fractured fragment. Type 2: Unicondylar fracture with an oblique metaphyseal fracture of varying length is by far the commonest accounting for one-half to two-thirds of these fractures (Fig. 17). Owing to the obliquity of the metaphyseal fracture, these fractures are highly unstable—even initially undisplaced fractures may settle during the healing period and lead to an angular deformity of the digit. Type 3: Bicondylar fractures with varying obliquity of the metaphyseal component result in angular deformity that is less pronounced if there is equal subsidence of both the fractured condyles. Stability of the fracture is determined by the initial displacement and obliquity of the metaphyseal fracture component.

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Figure 17 (A) A unicondylar fracture of the thumb proximal phalanx with an oblique fracture line. (B) The fragment has collapsed resulting in a clinical angular deformity. (C) Longitudinal alignment and articular congruity have been restored by open reduction and screw fixation.

Type 4: Coronal plane condyle fractures of the dorsal or volar part of the phalanx head involve osteochondral fragments that are usually extremely unstable injuries. If the fragment is displaced, there is associated joint subluxation with proximal displacement of the middle phalanx. Basal Fractures of the Middle Phalanx Fractures of the base of the middle phalanx may or may not be associated with dislocation of the PIP joint. Type 1. Small avulsion fractures—volar or dorsal: These fractures represent small fragments less than a third of the articular surface of the middle phalanx base. The volar fracture is a relatively common injury occurring due to a hyperextension force and represents an avulsion of the volar plate. Dorsal fractures are less common and occur when the extended digit is suddenly bent by an axial force causing an avulsion of the central slip of the extensor mechanism. Type 2. Large avulsion fractures—volar or dorsal: When the size of the detached fragment of the middle phalanx is more than 40% of the articular surface, there is commonly associated joint instability and the PIP joint is usually subluxated or dislocated dorsally. The joint instability is due to a combination of the loss of concavity of the middle phalanx base from displacement of the volar lip and impaction of the articular surface along with disruption of the collateral ligaments that remain attached to the volar fragment. Fracture

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dislocations can be classified based on the degree of subluxation: A: ,25%, B: 25% to 50%, C: .50%. D: dislocated or on the amount of articular surface involvement: Grade I: 0, II: 0% to 20% III: 20% to 40%, IV: .40% (13). Type 3. Pilon fractures: Comminuted fractures that result in splaying of the dorsal and volar cortices with compression of the central articular surface of the middle phalanx are referred to as pilon fractures (14). Injury occurs due to axial loading in neutral or hyperextension. Pilon fractures are highly comminuted fractures with multiple small fragments that are often too small for internal fixation (Fig. 18). The articular surface of the middle phalanx is disrupted and if treated with immobilization without restoration of joint congruity and alignment, results are poor with pain and stiffness of the joint. Dislocations Dislocations of the PIP joint can be classified by direction of the displaced middle phalanx into dorsal, lateral, or volar. Dorsal Dislocations Dorsal dislocations of the PIP joint are by far the commonest type and occur as a result of hyperextension injury to the digit. They may be associated with fractures of the middle phalanx base anteriorly. The volar plate is avulsed from the base of the middle phalanx usually with a small chip of bone. Larger avulsion fragments

Figure 18 (A) Posteroanterior (PA) and (B) lateral pilon fracture of the middle phalanx base. There is comminution of the metaphysis with articular surface depression. (C and D) Stability and joint congruity have been restored with open reduction and lag screw fixation of the larger cortical fragments using a midlateral approach.

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are discussed below. The distal avulsion of volar plate in dorsal PIP dislocations prevents entrapment of the plate within the joint in contrast to the MP joint in which complex dislocations can occur due to volar plate entrapment within the joint. In most dorsal dislocations, the volar plate maintains its attachments to the proximal phalanx and its lateral attachments to the accessory collateral ligament. These injuries are stable after closed reduction, and early motion is encouraged providing hyperextension can be prevented by buddy taping or dorsal block splinting. Postreduction films are essential to confirm concentric reduction and exclude displaced bony fragments that may necessitate open reduction (Fig. 19). In more severe injuries, the collateral ligaments may also be ruptured at the time of injury. Careful assessment of stability is essential after closed reduction of the dorsal PIP joint. If the joint tends to dislocate when a position near full extension is reached, extension block splinting should be used. Lateral Dislocations A more laterally directed force on the digit will cause the collateral ligament to primarily fail. With continuing force, the volar plate is detached and the finger dislocates laterally at the PIP joint (Fig. 20). The deformity is clinically very

Figure 19 (A) Dorsal dislocation of the ring finger PIP joint with small bone fragments volar and dorsal to the PIP joint. (B) Closed reduction restored the volar plate avulsion fracture, but there was an unexplained displaced dorsal fragment. The radial collateral ligament was also clinically ruptured. (C) The joint was explored using a midlateral approach and dislocated through the torn collateral ligament. (D) The dorsal fragment was an osteochondral fragment consisting of almost the entire articular surface of the middle phalanx. (E) This was restored and held with K-wires.

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Figure 20 (A) Posteroanterior (PA) and (B) lateral views of proximal interphalangeal (PIP) joint lateral dislocation in the ring finger. Note that the middle phalanx is aligned with the proximal phalanx on the lateral view.

obvious. Closed reduction is usually successful and providing the joint can be ranged without subluxation, early motion with buddy taping is permissible. Primary ligament repair is advocated by some in athletes to ensure joint stability, This can be achieved using a midlateral approach and repair with bone anchors or transosseous sutures. Volar Dislocation Volar dislocations of the PIP joint are extremely uncommon. In an uncomplicated volar dislocation, the central slip ruptures from the base of the middle phalanx with or without a bony fragment (Fig. 21). In the more complex rotary dislocation, there is an associated tear of the collateral ligament. The head of the proximal phalanx can buttonhole between the lateral band and the central slip which remains intact (15). Simple volar dislocations can be reduced easily under digital block. However, immobilization of the PIP joint in full extension for three to four weeks is essential to allow healing of the central slip and prevention of a late boutonniere deformity. Leaving the DIP joint free for active and passive motions helps prevent volar subluxation of the lateral bands and extensor mechanism imbalance. Complex rotary dislocations are irreducible and require open reduction. A dorsal approach allows visualization of the interposed lateral band. Once freed, the rent in the extensor apparatus is repaired and the joint is reduced. Collateral ligament repair may be performed but is not absolutely necessary. Early motion is commenced after surgery.

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Figure 21 (A) Simple volar dislocation with rupture of the central extensor slip. (B) Volar fracture dislocation of the PIP joint with avulsion fracture of the central extensor slip.

Management of fracture dislocations require open reduction and fixation of the displaced dorsal lip fragment and are discussed below. Clinical Assessment It is important to carefully examine a patient with a PIP joint injury. Malalignment in the coronal plane usually suggests a depressed condyle fracture. The PIP joint is swollen, and motion is invariably restricted. A significant dislocation can be easily noted clinically, but minor subluxation is suspected when there is severe restriction of joint motion. In a cooperative patient, it is often helpful to try to pinpoint the area of maximal tenderness in order to localize the site of pathology. Continuity of the flexor and extensor tendons must be established by asking the patient to gently move the digit in the desired direction. Many patients with sporting injuries will have had the finger reduced or splinted on the field prior to presentation to hospital. In such cases, it is very helpful if information on the severity and original direction of displacement can be gleaned from the patient. Thus, a joint that is normal on radiographs at presentation may have been dislocated and management must be based on history and physical findings. Imaging Evaluation of fractures around the PIP joint requires careful interpretation of accurate PA, lateral, and oblique radiographs that are centered on the injured

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digit. Joint subluxation can only be adequately assessed on the true lateral view. A coronal fracture of the proximal phalanx condyle can easily be missed if the joint is stable. The only sign of the injury may be the presence of a double projection in place of the normal single volar convexity of the proximal phalangeal condyles. Management of Condylar Fractures of the Proximal Interphalangeal Joint Condylar fractures tend to cause joint incongruity and angular deformity of the digit. Joint subluxation is less common and usually implies more severe injury with associated ligamentous damage. Basal fractures of the proximal phalanx and fracture dislocations follow the same management principles and are discussed later. Conservative Treatment Nondisplaced fractures and joints stable after closed reduction can be treated conservatively with immobilization in an intrinsic plus position. It is advisable to repeat radiographs out of the splint after one week to ensure that there are no signs of early collapse that can occur with almost two-thirds of oblique unicondylar fractures. Buddy taping is an effective way of allowing protected mobilization and can be started between two and three weeks. Most motion is regained by six months, but swelling can persist for several months thereafter, and some degree of residual swelling of the PIP joint is common. Patients must be made aware of this at the time of presentation. Some displaced bicondylar fractures are amenable to closed reduction by traction. If a good reduction is achieved with less than a millimeter articular displacement and normal rotational and angular alignment, immobilization may be used. Usually, the displacement recurs when traction is released and consideration may be given to application of continuous traction using customized splinting or external fixation. Operative treatment is indicated if closed reduction is not possible; reduction cannot be maintained or is lost subsequently in the splint. Additional surgery is also required if there is a middle phalanx volar fracture fragment more than 40% of the articular surface or if the finger is unstable when extended beyond 308. Percutaneous Techniques Fractures that are treated within a few days of presentation can be managed with percutaneous techniques using either K-wires or miniature screws. The latter can be inserted through specialized reduction clamps. The size of implant depends on the fragment size, and good imaging is critical. Repeated blind attempts at pinning may comminute small pieces or cause late collapse from thermal necrosis. In unicondylar fractures, a 0.6 or 0.9 mm K-wire is inserted into the fragment

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parallel to the articular surface through a stab incision. Using the wire as a joystick, the fragment is realigned and the wire is driven through the opposite cortex. Application of a clamp or forceps across the condyles externally will help to get some compression across the fracture that cannot be achieved by the K-wiring alone. A second wire may be passed in order to achieve rotational control. The wires can be left outside the skin for removal at three weeks. Alternatively, a small screw may be passed across the fracture using a targeting clap that serves as a temporary fixation as well as a drill and screw guide. Newer cannulated screws make the process even easier by allowing insertion of a screw over a wire placed across the fracture. Open Reduction If treatment is delayed for more than 10 days, the organized hematoma and repair tissue within the fracture may interfere with reduction. Anatomical reduction and compression between the fractured fragments then requires open reduction. A unicondylar fracture is approached through a midlateral incision defined by the line joining the points formed by the flexion creases of the IP joints when the digit is fully flexed (Fig. 22). Dissection is continued by elevation of the dorsal skin flap to expose the lateral band of the extensor apparatus which is then retracted dorsally with a skin hook after dividing the transverse retinacular

Figure 22 Steps in the operative management of unicondylar fractures. (A) The fracture is exposed through a midlateral approach and a capsulotomy dorsal to the collateral ligament. (B) A single K-wire is passed into the fragment after elevation. The K-wire is passed through the opposite cortex for temporary fixation. (C) A small fragment screw is passed across the fracture parallel to the K-wire. (D) The wire is then removed and replaced with a second screw. (E) Final radiograph following internal fixation.

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ligament. The collateral ligament is identified and a longitudinal capsulotomy is made just dorsal to it. After washing out the joint hematoma, the articular surface is visualized. The fractured condyle is mobilized with caution in order to avoid stripping the collateral ligament and resultant loss of vascularity. A fine K-wire inserted into the condyle will help with manipulation and reduction of the fracture. Interposed granulation tissue is excised, and fracture surfaces can be compressed by application of a reduction clamp whenever possible. The fracture is temporarily fixed with a K-wire and a 1.5-mm screw is inserted parallel to it after drilling. The K-wire is then removed and the wire track left is used for insertion of a second screw. Screw length is critical and care must be taken to ensure that the screw heads are well buried and that they do not protrude through the opposite cortex to avoid impingement on either collateral ligament. Formal repair of the transverse ligament of the extensor apparatus is not required. Postoperatively, the finger is immobilized for comfort, and active motion with a protective splint is commenced after several days when the pain and swelling of surgery are diminished. Coronal condylar fractures pose the biggest management challenge. Although clinical deformity is not immediately obvious due to limited motion, a rotational deformity of the digit becomes obvious when mobility is regained subsequently as the middle phalanx rotates when flexed onto a depressed condyle. Displaced fractures lead to joint instability in flexion and left untreated can lead to nonunion or malunion with significant joint stiffness. Nonoperative treatment is ineffective as the condylar fragment has no soft-tissue attachment and cannot be manipulated into position. The fracture is best exposed through a lateral approach. The fragment is gently manipulated back into position and can be fixed with a K-wire passed from dorsal to volar. The wire can be cut close to bone and left buried with minimal risk of late migration. Alternatively, the wire is passed through a stab incision from intact dorsal skin and can be left outside for removal for three weeks. Screw fixation of these small fragments is difficult but obviates problems associated with wires and provides better stability. The screw is inserted from dorsal to volar using the lag screw technique (Fig. 23). Again screw length is critical as a long screw will protrude through the articular surface of the condyle on the volar surface and cause discomfort and impingement on flexion of the PIP joint. Open reduction of bicondylar fractures requires good visualization and access to the entire distal articular surface of the proximal phalanx. A curved dorsal skin incision is made over the PIP joint and the extensor mechanism is elevated in one of two ways. Either by making an incision between the lateral band and extensor slip on either side or by creating a distally based V-shaped flap with the apex of the V situated at the proximal third of the proximal phalanx. A transverse capsulotomy will allow visualization of the joint. The articular surface is first restored and provisionally held with a K-wire. The articular fragments are then stabilized to the shaft with an oblique K-wire. Although this fixation will maintain reduction, it will not permit early motion, and

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Figure 23 (A) Unicondylar coronal fracture of the proximal phalanx. (B) The fracture was stabilized with a single lag screw passed from dorsal to volar using a midlateral approach.

consideration must be given to stable internal fixation with either a dorsal T-plate or a laterally applied minicondylar plate. Although insertion of a lateral condylar plate is technically more challenging, it causes less interference with the extensor mechanism. The extensor tendon is repaired with nonabsorbable sutures. Controlled active mobilization is started within a week. Management of Dislocations and Fracture Dislocations of the Proximal Interphalangeal Joint In order to preserve motion that is imperative to normal hand function, the goal of management of all PIP joint dislocations and fracture dislocations is to restore joint alignment and to maintain adequate joint stability to allow early functional range of motion exercises. Secondary goals are maintenance of articular congruity and prevention of posttraumatic arthritis. The majority of dislocations can be reduced by closed methods under digital block anesthesia in the emergency room after which stability must be assessed through a range of motion. All stable injuries and nondisplaced fractures can be managed nonoperatively. When conservative measures fail, percutaneous techniques can be employed to restore stability. Operative intervention for open reduction and internal fixation are less frequently required and usually indicated for management of late presentation. Fractures that are associated with dislocation or subluxation of the PIP joint usually involve the base of the middle phalanx. Volar lip fractures of the middle

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phalanx which involve 40% or more of the articular surface are associated with PIP joint instability and are a big management challenge. Conservative Treatment Closed reduction by traction and flexion of the PIP joint is successful in most cases of PIP dislocations if seen within a few days after injury. Minor avulsion fractures of the volar lip of the middle phalanx indicate volar plate avulsion and are a common result of hyperextension injuries. Providing the joint is stable, these fractures need no special management and the digit can be mobilized with buddy taping to prevent hyperextension stress for three weeks. Splinting these injuries in flexion is not necessary and will risk a flexion contracture of the joint. In unstable injuries, the joint dislocates as the digit is brought into extension. It is important to document the position at which this occurs. Immobilization of the PIP joint in extreme flexion will stabilize the joint but lead to severe flexion contracture and morbidity. If a position of more than 308 of flexion is necessary to maintain reduction, consideration must be given to other methods of treatment. A simple technique for treating dorsally unstable PIP joint fracture dislocation is that of extension block splinting (16). This technique is applicable to cases where closed reduction is achieved easily and where the fracture does not exceed 40% of the articular surface of the middle phalanx. A splint is fashioned whose angle is determined by the degree of flexion at which the PIP joint is stable. The flexion angle is 108 more than the angle of stability determined by clinical examination after closed reduction. The amount of flexion is reduced on a weekly basis by about 25% and full extension is delayed for approximately six weeks. Displaced chip fractures on the dorsum of the middle phalanx, however small, are significant because they represent an avulsion of the central slip of the extensor mechanism. Insufficiency of the central slip is not immediately obvious because digital extension is maintained by the lateral bands. The triangular ligament holding the lateral bands eventually stretches causing the lateral bands to subluxate volarly leading to hyperextension of the distal interphalangeal joint and loss of ability to straighten the PIP joint—the boutonnie`re deformity. The injured digit must be splinted with the PIP joint immobilized in full extension for at least three weeks with the DIP joint free followed by gentle active mobilization. Percutaneous Techniques The reduced but unstable PIP joint can easily be stabilized with a transarticular pin. Although this technique may seem to be prone to stiffness, some authors have reported results comparable to open reduction (17). An alternative technique involves placement of a Kirschner wire as a block to PIP extension (18). The PIP joint is reduced by applying manual traction and placing the joint into maximal possible flexion. A smooth K-wire is then introduced percutaneously through the center of the PIP joint to engage the distal articular surface of the proximal phalanx. The wire is then driven obliquely into the shaft to engage the volar

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cortex of the proximal phalanx. The wire is left long outside the skin and effectively forms a block to the last 308 of PIP extension. An extension-block K-wire is more reliable than an extension blocking splint. The patient is put in a protective splint and instructed in pin care. Gentle active range of motion exercise is started the next day and the wire is pulled after four weeks. It is essential to monitor this pin closely, as a pin track infection may lead to a frank pyarthrosis. Alternatively, continuous traction can be applied to the digit by applying tension on a K-wire passed transversely across the middle phalanx. A 7.5 cm radius circular frame is fashioned around the hand and incorporated into a forearm splint (19). The amount of traction is adjusted by serial lateral radiographs of the digit in the splint. The patient is instructed in passive motion of the digit for 10 minutes every waking hour. The splint is discontinued after three to five weeks. If adequate reduction of the articular surface of the middle phalanx is not achieved by traction alone, the articular surface can be manipulated percutaneously or by a small open incision. The fragments are then stabilized by multiple small K-wires and traction is then applied (20). Various forms of external fixators or K-wires have been described to treat these injuries and consist of K-wires bent in tension (21), wires coiled into springs (22), hinged device (23), force-couple devices (24), parallel springframed systems (25), and pins and rubber (26). They are based on the concept of providing stability by distraction of the soft tissues around the base of the middle phalanx that stabilize and improve the alignment. It must be noted that external fixation will not elevate all depressed and impacted fragments. Whichever form of external fixation is used, attempts should be made to elevate the impacted fragments using a percutaneous blunt K-wire or freer dissector. External fixators do have the advantage of avoiding soft-tissue stripping, soft-tissue dissection, and are not associated with the postoperative swelling seen after open approaches. However, patients need to take care of the pin sites, and stiffness is common. The simplest and most economic method is to create a low-profile frame using K-wires as suggested by Haynes and Giddins (21). A wire is placed across the proximal phalanx condyles, close to the axis of motion of the PIP joint (Fig. 24). A second wire is passed transversely in the shaft of the middle phalanx distal to the level of the fracture. The distal wire is then bent, first 908 proximally, and then a second S-shaped bend is placed into the wire and it is looped around the proximal transverse wire in such a way as to generate tension and provide distraction to the joint. Early active motion is allowed with this configuration and the wires are removed at three weeks. Postoperative radiographs generally do show some widening of the middle phalanx base, but the articular surfaces generally conform very well due to molding of the fragments with motion (Fig. 25). Open Reduction and Fixation Operative fixation of fracture dislocations of the PIP joint involves reduction and stabilization of the volar lip fracture of the middle phalanx thereby restoring joint

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Figure 24 (A –F) proximal interphalangeal PIP joint fracture-dislocation treated with distractor-external fixator. Creation of the distraction frame essentially involves bending the distal wire to generate tension against the wire passed along the axis of the PIP joint. Source: Courtesy of Dr. Grey Giddins.

Figure 25 (A) Lateral radiograph of a proximal interphalangeal (PIP) joint fracturedislocation. (B) This was treated by distraction external fixation frame created from K-wires. (C) Note the remodeled articular surface of the middle phalanx following active motion in distraction. Source: Courtesy of Dr. Grey Giddins.

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stability. A direct approach to the fragment can be undertaken using a volar Bruner approach extending from the proximal digital crease to the distal interphalangeal joint crease. The flexor tendon sheath is opened between the A2 and A4 pulleys and reflected laterally. Often the sheath is torn in this region and can be excised without any functional loss. The flexor tendons are retracted to one side to expose the traumatized volar plate (Fig. 26). The plate is mobilized by releasing its lateral attachments to the collateral ligaments and reflected proximally. The attachments of the collateral ligaments to the base of the middle phalanx are partially released in a volar to dorsal direction and the digit is gently hyperextended until it is fully doubled over or “shotgunned.” The volar fragment and the entire articular surfaces are then fully visualized. Small comminuted fragments are removed and the major volar fragment is elevated, reduced, and held either with a circumferential wire loop or with two small screws passed from volar to dorsal (Fig. 27) (27). When the fragments are small or too comminuted for fixation, an osteochondral graft obtained from the dorsal lip of the hamate can be used to replace the volar lip of the middle phalanx (28). Pilon fractures can also be treated surgically but require considerable care to avoid stripping soft-tissue attachments of small fragments. These fractures may be better approached using a midlateral approach. By dividing the transverse

Figure 26 Volar approach for fixation of a large volar fracture of the middle phalanx associated with dorsal proximal interphalangeal (PIP) joint subluxation. (A) The flexor tendon sheath between the second and forth annular pulleys has been opened. (B) The collateral ligaments have been released allowing the joint to be hyperextended and “shotgunned” open. (C) Reduction of the base of the middle phalanx articular surface.

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Figure 27 (A) Anteroposterior and (B) lateral preoperative radiographs of a dorsal fracture dislocation of the proximal interphalangeal (PIP) joint. (B) This was treated by open reduction and fixation of the middle phalangeal fracture through a volar approach with miniature screw fixation.

retinaculum, the lateral band of the extensor apparatus can be elevated giving exposure to the fragments. Fixation is achieved using lag screws passed from the dorsal cortex in the bare area between the two lateral bands. A displaced larger dorsal fragment of the middle phalanx will result in joint incongruity and instability from loss of the dorsal concavity of the middle phalanx in addition to causing insufficiency of the extensor apparatus. Conservative treatment can be undertaken if the fragment is anatomically reduced with the PIP joint in full extension. Separation more than 2 mm must not be accepted and internal fixation with a pin or screw inserted from dorsal to volar percutaneously or by open reduction. SALVAGE For those patients that present late where the articular surface of the middle phalanx cannot be salvaged either due to displacement with healing or extensive comminution, it is possible to restore some motion and stability by doing a volar plate arthroplasty (29). This technique uses the volar plate to reconstitute the volar aspect of the middle phalanx base. In order to create a volar plate arthroplasty, the joint is exposed with the usual volar approach retracting the flexor tendons. When elevating the volar plate, it is essential to preserve length by dividing it as far distally as possible right up to and including some volar periosteum of the middle phalanx. The volar plate is then divided laterally along its attachment to the collateral ligaments and reflected proximally. The PIP dislocation is then

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reduced by inserting a dissector into the joint and using it as a lever. In delayed cases, it may be necessary to excise scar tissue within the joint, partially release the contracted collateral ligaments or do a careful dorsal capsular release. It is essential to fully reduce the PIP joint and ensure that it can be fully flexed prior to creating the arthroplasty. A 2 mm wide trough is then created along the entire length of the volar margin of the middle phalanx for attachment of the volar plate. A pullout wire placed through the distal volar plate is passed through two drill holes at either edge of the trough and brought out on the dorsum of the finger where it can be tied over a button. The joint is temporarily pinned for two to three weeks, and active motion with dorsal block splinting is started thereafter. It must be emphasized that recurrent dorsal dislocation may occur even after a properly performed volar plate arthroplasty. This is most commonly due to inadequate bone remaining on the volar aspect of the middle phalanx to function as a hinge. With loss of the stabilizing effect of the concave base of the middle phalanx, the dorsal pull of the central slip and superficialis tendon create a rotational force that tends to subluxate the middle phalanx base. In this case, joint stability requires restoration of a functional palmar buttress on the base of the middle phalanx. This can be accomplished with an osteochondral hamate graft as noted above.

SUMMARY There are several different types of injuries affecting the MP and PIP joints. Some are simple and easily treatable. The management of more severe injuries requires knowledge of injury pathomechanics for recognition, surgical anatomy for open reduction, and skill with internal fixation of small fragments. The basic principles, however, do not change. The joint must be reduced, stabilized, and the articular surface realigned with the least invasive methods possible. When closed reduction is not successful, percutaneous or open techniques must be attempted.

REFERENCES 1. Kaplan EB. Dorsal dislocation of the metacarpophalangeal joint of the index finger. J Bone Joint Surg 1957; 39A:1081–1086. 2. Vandeweyer E, Zygas P, Libotte M. Palmar metacarpophalangeal joint dislocation. J Hand Surg 1998; 23B:546–547. 3. Patel MR, Bassini L. Irreducible palmar metacarpophalangeal joint dislocation due to juncture tendinum interposition: a case report and review of the literature. J Hand Surg 2000; 25A:166–172. 4. Betz RR, Brown EZ, Perry GB, et al. The complex volar metacarpophalangeal joint dislocation: a case report and review of the literature. J Bone Joint Surg 1982; 64A:1374– 1375.

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5. Bohart PG, Gelberman RH, Vandell RF, et al. Complex dislocations of the metacarpophalangeal joint: operative reduction by Farabeuf’s dorsal incision. Clin Orthop 1982; 164:208–210. 6. McElfresh EC, Dobyns JH, O‘Brien ET. Management of fracture-dislocation of the proximal interphalangeal joints by extension-block splinting. J Bone Joint Surg [Am] 1972; 54(8):1705–1711. 7. Hove LM. Fractures of the hand. Scand J Plast Reconstr Surg 1993; 27:317– 319. 8. Shewring DJ, Thomas RA. Avulsion fractures from the base of the proximal phalanges of the fingers. J Hand Surg 2003; 28B:10–14. 9. Strickler M, Nagy L, Buchler U. Rigid internal fixation of basal fractures of the proximal phalanges by cancellous bone grafting only. J Hand Surg 1999; 26B: 455 –458. 10. Minamikawa Y, Horii E, Amadio PC, et al. Stability and constraint of the proximal interphalangeal joint. J Hand Surg 1993; 18A:198–204. 11. Weiss APC, Hastings H. Distal unicondylar fractures of the proximal phalanx. J Hand Surg 1993; 18A:594–599. 12. London PS. Sprains and fractures involving the interphalangeal joints. Hand 1971; 3:155 –158. 13. Schenck R. Classification of fractures and dislocations of the proximal interphalangeal joint. Hand Clin 1994; 10:179– 185. 14. Stern PJ, Roman RJ, Kiefhaber TR, McDonough JJ. Pilon fractures of the proximal interphalangeal joint. J Hand Surg [Am] 1991; 16(5):844–850. 15. Grant IR. Irreducible rotational anterior dislocation of the proximal interphalangeal joint A spin drier injury. J Hand Surg 1993; 18B:648–651. 16. McElfresh EC, Dobyns JH. Intra-articular metacarpal head fractures. J Hand Surg 1983; 8A:383–393. 17. Aladin A, Davis TR. Dorsal fracture-dislocation of the proximal interphalangeal joint: a comparative study of percutaneous Kirschner wire fixation versus open reduction and internal fixation. J Hand Surg 2005; 30B:120–128. 18. Viegas SF. Extension block pinning for proximal interphalangeal joint fracture dislocations: preliminary report of a new technique. J Hand Surg 1992; 17A:896–901. 19. Schenck RR. Dynamic traction and early passive movement for fractures of the proximal interphalangeal joint. J Hand Surg 1986; 11A:850–858. 20. Sarris I, Goitz RJ, Sotereanos DG. Dynamic traction and minimal internal fixation for thumb and digital pilon fractures. J Hand Surg 2004; 29A:39 –43. 21. Haynes MC, Giddins GEB. Dynamic external fixation for pilon fractures of the interphalangeal joints. J Hand Surg 2001; 26B:122–124. 22. Johnson D, Tiernan E, Richards AM, Cole RP. Dynamic external fixation for complex intra-articular phalangeal fractures. J Hand Surg 2004; 29B:76 –81. 23. Krakauer JD, Stern PJ. Hinged device for fractures involving the proximal interphalangeal joint. Clin Orthop Relat Res 1996; 327:29–37. 24. Agee JM. Unstable fracture dislocation of the proximal interphalangeal joint: treatment with a force couple splint. Clin Orthop Relat Res 1987; 214:101–112. 25. Fahmy NRM. The Stockport Serpentine Spring System for the treatment of displaced comminuted intraarticular phalangeal fractures. J Hand Surg 1990; 15B:303– 311. 26. Suzuki Y, Matsunaga T, Sato S, Yokoi T. The pins and rubbers traction system for treatment of comminuted intraarticular fractures and fracture-dislocations in the hand. J Hand Surg 1994; 19B:98 –107.

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27. Weiss APC. Cerclage fixation for fracture dislocation of the proximal interphalangeal joint. Clin Orthop Relat Res 1996; 327:21– 28. 28. Williams RMM, Kiefhaber TM, Sommerkamp TG, Stern PJ. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg 2003; 28A:856–865. 29. Eaton RG, Malerich MM. Volar plate arthroplasty of the proximal interphalangeal joint: a review of ten years’ experience. J Hand Surg 1980; 5A:260 –268.

4 Operative Management of Metacarpal Fractures William B. Geissler and William O. McCraney Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, Mississippi, U.S.A.

INTRODUCTION The hand is an instrument of both performance and protection. Accidents invariably occur, resulting in fractures of the metacarpals and phalanges. The economic cost of hand injuries is staggering. It is estimated that one-third of all injuries involve the upper extremity. This involves 16 million patients per year in the U.S. alone. It is estimated that 1.5 million hand fractures occur annually in the U.S., which results in 16 million lost work days, 2 billion dollars in lost wages, and 4 billion in costs to industry annually in the U.S. (1). There are potential and specific problems and complications that may occur with fractures of the hand. Hand fractures generally involve small fragments, which may be difficult to anatomically reduce and securely repair. There is a high risk for tendon and joint adhesions, due to the close association of both the flexor and extensor tendons to the bone. This may result in joint stiffness and permanent loss of motion. Surgical incision carries the risk of functionlimiting scar formation. The physician must always balance the potential benefit of increased biomechanical stability that may be gained through surgical management against the risk of potential scarring and stiffness. Fracture fixation need not be absolutely rigid, but must be reliable and allow for early rehabilitation. If surgical intervention is recommended, the implant 75

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selected must provide sufficient structure stability to allow immediate active range of motion in order to offset the increased risk of scarring and stiffness associated with fracture exposure and fixation. Early fracture stabilization and rehabilitation are utilized in an effort to reduce the elements of fracture disease—meaning the stiffness and atrophy associated with prolonged immobilization. It is important to remember that the majority of hand fractures are closed, simple, and stable. The vast majority of hand fractures do not require operative management. The intact, intrametacarpal ligaments prevent shortening of a fractured metacarpal more than 3 to 4 mm (2). Most hand fractures demonstrate minimal displacement, defined as less than 1 to 2 mm of translation and less than 108 of angulation, and absence of rotational malalignment or substantial visual deformity. These fractures can be treated with a brief period of immobilization (or with protective splints that allow some motion—extension block splints, for example) followed by active exercises (3 – 8). Fractures with greater displacement, rotational malalignment, or substantial deformity, multiple fractures, and fracture associated with greater softtissue injury should be considered for operative stabilization. Second and fifth metacarpal fractures are more likely to shorten as they only have the suspensory effect of only one intrametacarpal ligament. It has been shown that approximately 78 of extensor lag develops in the finger for each 2 mm of residual metacarpal shortening after fracture healing (9). The unbalanced pull of the extrinsic flexor tendons and intrinsic muscles may cause dorsal angulation of the distal fragment of metacarpal fractures (10,11). Angulation greater than 308, shortening of more than 4 mm, or a combination of these two, interferes with the normal intrinsic muscle dynamics of the hand and may cause weakness, clawing, and potential cramping (10 – 12). Specifically, the metacarpals do not tolerate malrotation. It has been shown that 58 of malrotation may translate up to 1.5 cm of digital finger overlap during flexion (8,13). EXTRAARTICULAR BASE FRACTURES The majority of extraarticular metacarpal base fractures are stable. Most fractures are impacted, which results in a stable fracture configuration. However, when associated soft-tissue trauma occurs, this can disrupt the intrinsic capsular ligaments and the fracture may become unstable, particularly when multiple metacarpal base fractures are involved. When multiple extraarticular base fractures are present, open reduction and internal fixation are recommended (7,14) (Fig. 1). A dorsal incision may be made, centered between the involved metacarpals, and dissection is carried down to the base of the metacarpal. When fractures involve the base or distal portion of the metacarpal, generally plate fixation is recommended. Plates are named for their anatomic shape and due to the proximal location of the fractures, a T-shaped plate or mini-condylar plate may be utilized. It is important to remember that when a T-plate is used it is important to place the screws in the T-portion of the plate first. If the screws are placed first in the

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Figure 1 Open reduction internal fixation is recommended when multiple extraarticular metacarpal base fractures are present. (A) A PA radiograph demonstrates extraarticular base fractures of the index through small metacarpals. (B) A PA radiograph demonstrates fixation of the multiple base metacarpal fractures. Each metacarpal fracture was stabilized with a mini-condylar plate due to the position of the fracture near the base of the metacarpal. Abbreviation: PA, posteroanterior.

longitudinal portion of the plate, the T-section of the plate may be kicked up and not sit fully congruent on the base of the metacarpal. When the screw is then placed in the T-portion after the longitudinal screws are already placed, this screw may displace the fracture as it is being seated if the plate is not congruent on the bone. For this reason, when a T-plate is utilized, always place the screws on the T-portion first before the longitudinal section. This also aids in compression of the fracture site.

INTRAARTICULAR METACARPAL BASE FRACTURES Intraarticular metacarpal base fractures are most common in the small finger metacarpal. The vast majority of these are stable and adequately aligned. The extent of articular injury and, in particular, articular surface impaction may not be apparent on plain radiographs, and computed tomography may more accurately define the fracture. The articular fragments are small and difficult to handle. If operative treatment is elected, it is wise to provide some means of distracting the small finger metacarpal with respect to the carpus (a small external fixator between the metacarpal and hamate may be useful in this regard), the fragments are elevated and the resulting metaphyseal defect grafted with cancellous bone from the distal radius, and the fragments are stabilized with small Kirschner

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wires, and—on rare occasions—with screws. It has not been clearly demonstrated that operative fixation is superior to nonoperative treatment.

CARPAL – METACARPAL FRACTURE DISLOCATIONS Carpal – metacarpal fracture dislocations are the result of high-energy trauma (Fig. 2). The fifth metacarpal is most frequently involved (15). The fifth metacarpal carpal joint is a concave, convex saddle-type joint. This joint allows 208 to 308 of flexion extension at the base and allows the small finger to oppose the thumb. Carpal – metacarpal fracture dislocations are classified as epiphyseal, two-part, three-part, and comminuted. Radiographically, a 308 oblique pronated view outlines the fifth metacarpal base. This is very useful to gain further detail about the amount of displacement of a fracture dislocation of the fifth carpal – metacarpal joint. The 308 oblique supinated view particularly outlines the index and long metacarpal base and the potential amount of articular displacement. Two-part carpal – metacarpal fracture dislocations of the small metacarpal are frequently unstable due to the pull of the extensor carpi ulnaris tendon. The fracture tends to translate proximally due to the pull of the tendon on the oblique slope of the fracture line. The fracture is easily reduced by longitudinal traction and if the fracture fragment is small, two Kirschner wires may be placed transversely from the fifth metacarpal through the fragment into the base of the fourth metacarpal (Fig. 3). This adds further stability to the fracture configuration by placing the pins into the base of the fourth metacarpal as well. It is particularly important to note when placing Kirschner wires on the ulnar side of the hand, to make an incision and insert the Kirschner wires through a soft-tissue protector, or utilize an oscillating drill to prevent branches of the dorsal sensory branch of the ulnar nerve becoming wrapped around the Kirschner wires as they are being inserted. This avoids the potential for neuritis of the dorsal sensory branch of the ulnar nerve.

Figure 2 Multiple carpal –metacarpal dislocations are uncommon. (A) A PA radiograph showing dislocation of the carpal –metacarpal joints. (B) The dislocations were reduced by open reduction and stabilized by Kirschner wire fixation.

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Figure 3 Two-part carpal –metacarpal fracture dislocations are relatively unstable. (A) A PA radiograph showing the small radial-based fragment. The small metacarpal is at risk to displace proximally secondary to pull of the extensor carpi ulnaris. (B) With gentle longitudinal traction, the metacarpal was reduced and two Kirschner wires were placed across the fracture site into the base of the fourth metacarpal for added stability.

Three-part intraarticular fractures may be stabilized either by K-wire, T-plate, mini-condylar plate, or external fixation if there is extensive comminution present (Fig. 4). When Kirschner wires are utilized, they are placed through the intraarticular fragments and advanced into the base of the fourth metacarpal

Figure 4 (A) A PA radiograph demonstrating a two-part carpal –metacarpal fracture dislocation. The fracture fragment is relatively large enough to accept screw fixation. (B) A PA radiograph showing the fracture reduced by plate stabilization. Lag screw fixation is utilized to capture the relatively large fragment at the base of the fifth metacarpal.

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Figure 5 (A) A PA radiograph showing a comminuted fracture of the base of the fifth metacarpal. (B) Due to the amount of comminution, the fracture was stabilized by K-wire jail. Notice how the transverse Kirschner wire stabilizes the articular surface, but also is advanced into the fourth metacarpal for added stability.

Figure 6 (A) Frequently, fractures of the base of the metacarpal may be associated with a head fracture of the adjacent digit as demonstrated in this PA radiograph. (B) A PA radiograph demonstrating fixation of the metacarpal head fracture to the ring finger and Kirschner wire fixation to the base of the fifth metacarpal fracture.

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for added stability (Fig. 5). It is important to remember that when a fracture of the metacarpal base is identified on X ray, the head of the adjoining metacarpal must be closely evaluated. Fractures of the head and base adjoining metacarpal fractures frequently coexist (8) (Fig. 6). METACARPAL SHAFT FRACTURES The vast majority of isolated metacarpal shaft fractures are stable. Border metacarpal fractures are less stable due to lack of soft-tissue support. Transverse fractures may angulate with the apex dorsally. This is due to the pull of intrinsic musculature, causing the metacarpal head to flex. Owing to the mobility of the saddle joint of the hamate, it is possible to accept up to 208 of angulation to transverse fractures of the shaft of the ring and small metacarpals. The carpal – metacarpal joints of the index and long fingers are relatively immobile. Owing to the lack of mobility to the index and long metacarpals, patients may not tolerate the presence of a flexed metacarpal head in the palm, particularly with gripping. For this reason, only 58 to 108 of angulation may be accepted for the index and long metacarpals (16). Most transverse isolated metacarpal fractures are stable. Because the cam effect of the metacarpal head (the metacarpal head is wider anteriorly and the collateral ligaments tighten in flexion) can lead to stiffness of the metacarpophalangeal (MP) joint if it is immobilized in extension, metacarpal fractures are usually immobilized in a splint with the MP joints immobilized at approximately 708 of flexion. The interphalangeal joints are splinted in extension (17 – 19). Multiple modes of fixation are available for unstable transverse metacarpal fractures. Kirschner wire stabilization is particularly useful in patients who would like to avoid the scar associated with internal fixation (Fig. 7). In an unstable fifth metacarpal fracture, two Kirschner wires are placed transversely proximal and two Kirschner wires are placed distal to the fracture line due to the motion at the base of the fourth and fifth metacarpals. The pins are left outside the skin and removed in the office approximately three to four weeks later. Digital range of motion can be initiated while the pins are in place, but the disadvantage of this is a potential increase in the risk of pin track infection. Plate fixation can be useful in contact athletes or in patients that want to return to work as quickly as possible (Fig. 8). For the metacarpals, 2-mm plates are recommended. Four cortices both proximal and distal to the fracture line are required for adequate fracture stability (7,8). Immediate digital range of motion may be started after plate fixation, and strengthening is usually initiated at four weeks postoperatively. Particularly, in the contact sport athlete, the patient may be cleared to return to play in the first several weeks wearing a fracture brace if it is felt adequate fracture stability has been achieved with plate fixation. A number of surgical approaches have been recommended when multiple metacarpal fractures are present (20). The easiest is a vertical incision centered between the two metacarpal bones that are fractured. If fractures exist for the

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Figure 7 (A) A PA radiograph showing a displaced fracture of the fifth metacarpal at the junction of the middle and distal thirds. (B) Under fluoroscopy, the fracture was percutaneously reduced and stabilized. Two Kirschner wires were placed both proximal and distal to the fracture site for stability. The advantage of percutaneous fixation is it is very cosmetic which may be desirable in the female patient.

index through small metacarpals, two longitudinal incisions may be made. One is between the index and long fingers, and the second is between the ring and small fingers. Alternatively, an oblique dorsal incision can be made or a straight transverse incision may be made on the dorsum of the hand to approach multiple metacarpal fractures. The interval between the extensor digitorum communis tendons is utilized. The periosteum is elevated and if plate fixation is utilized, it is important to close the periosteum over the plate to decrease extensor tendon irritation from the plate itself. Unlike fractures of the phalanges, plate fixation of the metacarpals is very well tolerated, as the extensor tendons are not as closely adhered to the bone as compared to the phalanges. Lag screws are the implant of choice for spiral fractures of the metacarpals (Fig. 9). To utilize a lag screw, the fracture line needs at least twice the diameter of the bone (7,8,21 – 24). A minimum of two screws is required. One screw may be placed perpendicular to the shaft, which helps prevent translation of the fracture, and a second screw is placed perpendicular to the fracture to provide compression of the fracture. Alternatively, the two screws may be placed bisecting the angle of the fracture and the shaft (7,8,21 – 24). It is recommended that 2.0 or 1.5 mm screws be used if lag screw fixation is utilized for a spiral metacarpal fracture (7,8,21 – 24).

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Figure 8 (A) Lateral radiograph showing a displaced transverse fracture of the long metacarpal. (B) The fracture was stabilized by plate fixation. The patient was allowed to return to sports in two weeks following suture removal in a playing cast.

Oblique metacarpal fractures have a tendency to shorten along the oblique slope of the fracture line, particularly the index and small metacarpals, due to the lack of support of the transverse metacarpal ligament. With an oblique metacarpal fracture, the fracture line is usually too short for lag screw fixation alone and a single lag screw needs to be neutralized by a plate. It is recommended that 2.0 or 1.5 mm screws and plates be used. Usually, the fracture is compressed by the lag screw and once fracture stability is achieved, a T-plate or L-plate is then placed on the dorsum of the metacarpal. Four cortices, both proximal and distal to the fracture line, are required for adequate stability (7,8,21– 24).

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Figure 9 (A) PA radiographs showing spiral fractures involving the long and ring metacarpals. (B) Clinical radiograph showing the amount of rotation of the involved long and ring digits secondary to rotation of the fracture fragments. (C) A PA radiograph demonstrating lag screw fixation of the spiral fractures involving the long and ring metacarpals. Lag screw fixation is the implant of choice in spiral metacarpal fractures.

When considering when to use a lag screw to stabilize a bone fragment, the fracture fragment should be at least three times the diameter of the screw (7,8). During open reduction, stabilization by a screw is preferable to a Kirschner wire. The advantage of a screw over a wire is that it can compress the fracture to provide added stability. If the fragment is large enough to place a Kirschner wire, then it is usually large enough to compress with a screw. A 0.45 Kirschner wire is equal in diameter to a 1.1 mm drill bit. Therefore, if the surgeon can get a 0.45 Kirschner wire into a bone fragment, this is the same size as the drill bit for the 1.5 mm screw. The Kirschner wire can be removed and fixation can be

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improved by utilizing the screw. Similarly, a 0.065 Kirschner wire is equal in diameter to a 1.5 mm drill bit. The 1.5 mm drill bit is utilized for placement of a 2.0 mm screw. If the fracture fragment is large enough to support a 0.065 Kirschner wire, it is usually large enough for the fixation for improved stabilization with a 2.0 mm screw.

METACARPAL NECK FRACTURES Fractures of the metacarpal neck are very common (Boxer’s fracture). This is usually the result of a direct impact from a clenched fist. It is important to be wary of open injuries either to the fracture site or the joint itself. Excessive palmar tilt to the distal head fragment can occur secondary to the pull of the extrinsic flexor tendon. It is controversial how much angulation to accept to the ring and small metacarpals. Most authors recommend accepting up to 308 to 408 of greater angulation. There should be no rotation or clawing deformity to the finger. Owing to the more rigid carpal – metacarpal joint to the index and long fingers, up to only 108 of angulation may be acceptable for metacarpal head fractures that involve the index and long metacarpals (16,25,26). Several methods of fixation have been recommended for metacarpal neck fractures. These include transverse pinning of the metacarpal head into the adjacent metacarpal and intramedullary pinning. The latter is particularly appealing because it keeps the wires away from the relatively mobile skin near the MP joints thereby limiting the risk of pin track infection and also limits interference with the extensor tendons. For fractures that involve comminution, plate fixation with either a minicondylar plate or a T-plate may be an option as well (Fig. 10).

Figure 10 (A) A PA radiograph demonstrating a comminuted fracture to the metacarpal neck of the fifth metacarpal. (B) The fracture was stabilized by a mini-condylar plate due to the amount of comminution.

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METACARPAL HEAD FRACTURES Intraarticular fractures involving the metacarpal head are uncommon. These fractures have been classified as vertical, horizontal, oblique sagittal, and comminuted. A Brewerton (27) radiographic view is recommended to view the articular detail of the metacarpal head (Fig. 11). This view is obtained by flexing the metacarpal phalangeal joint and placing the dorsum of the

Figure 11 (A) Brewerton radiographic view showing the articular detail of the metacarpal heads. (B) A PA radiograph revealing the displaced intraarticular fracture to the long metacarpal head. (C) The displaced intraarticular fracture was stabilized by lag screw fixation. The fracture was approached by splitting the extensor digitorum communis tendon and exposing the articular surface. Close attention was made to preserve the collateral ligaments, so it would not affect the blood supply to the metacarpal head.

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hand flat on a cassette. This view outlines the articular surface to the metacarpals. The metacarpal head is approached by a dorsal incision. The central slip of the extensor digitorum communis tendon may be split or may be accessed between the sagittal band and the extensor tendon, particularly between the long and ring metacarpals. In fractures involving the index and small metacarpal head, the interval between the extensor digitorum communis and extensor indicis proprius is utilized for the index finger and the interval between the extensor digitorum communis and extensor digiti minimi is utilized for the small finger. It is important to keep the softtissue fragments attached to the bone fragments to prevent avascular necrosis. Kirschner wires, lag screw fixation, or potentially headless cannulated screws or plate fixation have all been recommended for comminuted intraarticular fractures of the metacarpal head (Fig. 11). In very rare instances, metacarpal phalangeal joint arthroplasty may be utilized in elderly patients with extensive comminution (28).

CONCLUSIONS Symptoms resulting from tendon adhesions and joint contracture are the most common complications associated with hand fractures. Stiffness has been directly correlated with the severity of the initial fracture and the presence and severity of initial soft-tissue injuries and excessive immobilization greater than four weeks. If internal fixation is considered, it must be adequately strong enough to support early rehabilitation in order to prevent tendon adhesions and joint contractures from forming. The worst scenario is to consider open reduction internal fixation with poor stability that requires excessive immobilization rather than early range of motion. Following the principles outlined in this chapter may potentially decrease the complication rate from these very difficult fractures.

REFERENCES 1. Kelsey JL, Pastides H, Kreiger N, Harris C, Chernow RA. Upper Extremity Disorders: A Survey of their Frequency and Cost in the United States. St. Louis: Mosby, 1980. 2. Eglseder WA Jr, Juliano PJ, Roure R. Fractures of the fourth metacarpal. J Orthop Trauma 1997; 11:441–445. 3. Barton NJ. Fractures of the hand. J Bone Joint Surg 1984; 66B:159–167. 4. Corley FG Jr, Schenck RC Jr. Fractures of the hand. Clin Plast Surg 1996; 23:447–462. 5. Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000; 8:111 –121.

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6. Stern PJ. Management of fractures of the hand over the last 25 years. J Hand Surg 2000; 25A:817–823. 7. Freeland AE, Geissler WB. Plate fixation of metacarpal shaft fractures. In: Blair WF, Steyers CM, eds. Techniques in Hand Surgery. Baltimore: Williams and Wilkins, 1996:255–264. 8. Freeland AE, Jabaley ME. Open reduction internal fixation: metacarpal fractures. In: Strickland JW, ed. Mater Techniques in Orthopedic Surgery: The Hand. Philadelphia: Lippincott-Raven, 1998:3–33. 9. Strauch RJ, Rosenwasser MP, Lunt JC. Metacarpal shaft fractures: the effect of shortening on the extensor mechanism. J Hand Surg 1998; 23A:519–523. 10. Smith RJ. Balance and kinetics of the fingers under normal and pathologic conditions. Clin Orthop 1974; 104:92– 111. 11. Smith RJ. Intrinsic muscles of the fingers: function, dysfunction, and surgical reconstruction. Instr Course Lect 1975; 24:200–220. 12. Birndorf MS, Daley R, Greenwald DP. Metacarpal fracture angulation decreases mechanical efficiency in human hands. Plast Reconstr Surg 1997; 99:1079– 1085. 13. Royle SG. Rotational deformity following metacarpal fracture. J Hand Surg 1990; 15B:124–125. 14. Freeland AE. Hand Fractures: Repair, Reconstruction, and Rehabilitation. Philadelphia: Churchill-Livingstone, 2000. 15. Lawlis JF III, Gunther SF. Carpometacarpal dislocations. J Bone Joint Surg 1991; 73A:42 –58. 16. Ashkenaze DM, Ruby L. Metacarpal fractures and dislocations. Orthop Clin North Am 1992; 23:19 –33. 17. Burkhalter WE. Hand fractures. In: Green WB, ed. Instructional Course Lectures XXXIX. Park Ridge: American Academics of Orthopaedics Surgeons, 1990. 18. Viegas SF, Tencer A, Woodard P, Williams CR. Functional bracing of fractures of the second through fifth metacarpals. J Hand Surg 1987; 12A:139–143. 19. Konradsen L, Neilson PT, Albrecht-Beste E. Functional treatment of metacarpal fractures: 100 randomized cases with or without fixation. Acta Orthop Scand 1990; 61:531–534. 20. Littler JW. Hand, wrist, and forearm incisions. In: Littler JW, Cramer LM, Smith JW, eds. Symposium on Reconstructive Hand Surgery. St. Louis: Mosby, 1974. 21. Dabezies EJ, Schutte JP. Fixation of metacarpal and phalangeal fractures with miniature plates and screws. J Hand Surg 1986; 11A:283–288. 22. Hastings H. Unstable metacarpal and phalangeal fracture treatment with screws and plates. Clin Orthop 1987; 214:37– 52. 23. Melone CP. Rigid fixation of phalangeal and metacarpal fractures. Orthop Clin North Am 1986; 17:421–435. 24. Diwarker HN, Stothard J. The role of internal fixation in closed fractures of the proximal phalanges and metacarpals in adults. J Hand Surg 1986; 11B:103– 108. 25. Ford DJ, Ali MS, Steel WM. Fractures of the fifth metacarpal neck: is reduction or immobilization necessary? J Hand Surg 1989; 14B:165–167. 26. McKerrell J, Bowen V, Johnston G, Zondervan J. Boxer’s fractures: conservative or operative management? J Trauma 1987; 27:486–490.

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27. Lane CS. Detecting occult fractures of the metacarpal head: the Brewerton view. J Hand Surg 1977; 2A:131 –133. 28. Light TR, Bednar MS. Management of intraarticular fractures of the metacarpophalangeal joint. Hand Clin 1994; 10:303–314.

5 Carpal Dislocations and Fracture Dislocations Santiago A. Lozano-Caldero´n and David C. Ring Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.

INTRODUCTION Dislocations and fracture dislocations of the carpus are uncommon injuries. Fracture dislocations of the radiocarpal joint are considered as a type of distal radius fracture (1). The most common carpal dislocation is the dorsal perilunate dislocation (2 –6), named because the carpus dislocates dorsally around the lunate, with the lunate remaining in its normal relationship with the distal radius in most cases, and occasionally dislocating volarward. Perilunate injuries follow a predictable circular progression of injury from the radial to the ulnar side of the wrist with variations in the injury pattern arising from the fact that at each point failure can occur through either ligament or bone (2,7). Other types of carpal dislocations, including midcarpal, axial, and isolated carpal dislocations and fracture dislocations, are rare (2). Current concepts of carpal dislocations are derived from relatively few retrospective case series, some anatomical observations, and collective experience or wisdom. There is substantial variation in the reported radiological and clinical outcomes (8), and there are many debatable issues in the management of these uncommon injuries. It is clear, however, that even with early, accurate diagnosis and appropriate treatment, substantial permanent wrist dysfunction should be expected in most cases.

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EPIDEMIOLOGY AND MECHANISM OF INJURY Carpal dislocations and fracture dislocations occur in young patients with strong bone that are involved in relatively high-energy injuries such as motor vehicle collisions and high-energy falls (from a height, during sports, downstairs, etc.) (2,9,10). Most patients are relatively young adult males: average 32 years of age, range 16 to 78 years; 94% males (3,10– 15). Perilunate injuries are thought to occur with forceful wrist hyperextension, ulnar deviation, and intercarpal supination. The spectrum of injury observed reflects the injury forces and failure through ligament or bone at each anatomical area. The proposal by Mayfield and colleagues that perilunate instability progresses from radial to ulnar around the lunate in four stages is consistent with observed injury patterns: Stage 1 is injury to the scapholunate interosseous ligament; Stage II adds dorsal dislocation of the capitate with respect to the lunate; Stage III adds injury to the lunotriquetral ligament; and in Stage IV, the hand and wrist return to normal alignment with the radius and the lunate dislocates volarly (Fig. 1) (7,16,17). At each stage, there are alternative bony or ligamentous injuries. Progressing from radial to ulnar around the lunate these include: (i) radial

Figure 1 Mayfield described four stages of perilunate dislocation. The first stage is rupture of the scapholunate interosseous ligament. Next the capitolunate joint dislocates through the space of Poirier. The third stage is rupture of the lunotriquetral ligament. Finally the lunate completely dislocates and the remainder of the wrist returns to normal alignment with the radius. Source: From Ref. 7.

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Figure 2 Each of the areas of injury in a perilunate dislocation can occur either through bone (the so-called greater arc) or through ligaments (the lesser arc). Source: From Ref. 2.

styloid fracture as an alternative to radiocarpal ligament injury; (ii) scaphoid fracture instead of scapholunate interosseous ligament injury; (iii) capitate fracture instead of capitolunate dislocation; and (iv) triquetral fracture instead of lunotriquetral interosseous ligament injury (Fig. 2). The injury mechanisms for rare carpal dislocations and fracture dislocations are incompletely understood (18). The Mayo group has proposed the reverse perilunar dislocation concept, suggesting that some perilunate injuries may progress from ulnar to radial, resulting in relatively more severe ulnar than radial injury. Following the example of Mayfield and colleagues, they demonstrated a progression of reverse perilunar dislocations in cadavers. Three stages were described: Stage 1 adds a tear of the lunotriquetral ligament; Stage 2 adds disruption of the palmar ulnar leash complex as well as the dorsal radiocarpal ligament and the dorsal intercarpal ligament; and Stage 3 adds a tear of the scapholunate ligament with consequent perilunate dislocation (Fig. 3). These injuries are thought to occur in extension of the wrist but with associated hyperpronation at the moment of impact (19). CLASSIFICATION The first classification system for carpal dislocations and fracture dislocations was proposed by Green and O’Brien in 1978 (18,20) in an attempt to help resolve some of the inconsistencies and controversies in the literature. Their most important contribution was a system that recognized perilunate dislocations, lunate dislocations, and fracture dislocations as part of a continuum of injuries with similar mechanisms. They proposed six groups based on the radiographic

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Figure 3 A reverse Mayfield progression has been described progressing from the lunotriquetral ligament through the space of Poirier and then through the scapholunate ligament. Source: Courtesy of Mayo Foundation 2002.

appearance of the injury: (i) dorsal perilunate and volar lunate dislocations; (ii) dorsal transscaphoid perilunate dislocation; (iii) volar perilunate/dorsal lunate dislocations; (iv) variants including four subgroups [transradial styloid perilunate dislocation (subgroup A), naviculo-capitate syndrome (subgroup B), transtriquetral fracture dislocation (subgroup C), and miscellaneous injuries (subgroup D)]; (v) isolated rotatory scaphoid subluxation, which is divided in subgroups A and B, acute scaphoid subluxation, and recurrent scaphoid subluxation, respectively; and (vi) total dislocation of the scaphoid (Table 1). Table 1 Green’s and O’Brien’s Classification for Carpal Dislocations Classification of Carpal Dislocations: (Green and O’Brien, 1978) Dorsal perilunate/volar lunate dislocationa Dorsal transscaphoid perilunate dislocationa Volar perilunate/dorsal lunate dislocation Variants Transradial styloid perilunate dislocationa Naviculocapitate syndrome Transqtriquetral fracture-dislocation Miscellaneous Isolated rotatory scaphoid subluxation Acute subluxation Recurrent subluxation Total dislocation of the scaphoid a

Most common patterns of injury.

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Mayfield and colleagues modified this classification system after several cadaveric studies contributed to an improved understanding of the mechanism of injury. Their system has become the most widely accepted and utilized system for classifying carpal dislocations and fracture dislocations. They classified carpal dislocations and fracture dislocations into four groups: (i) dislocations and fracture dislocations of the lesser arc; (ii) dislocations and fracture dislocations of the greater arc; (iii) variants; and (iv) radiocarpal dislocations and fracture dislocations (16,17). Lesser arc injuries—pure dislocations—include perilunate dislocations and lunate dislocations (2,7,10). Greater arc injuries—perilunate fracture dislocations (21 –23)—include transscaphoid perilunate fracture dislocations (fracture of the scaphoid rather than rupture of the scapholunate interosseous ligament); trans-scapho-capitate fracture dislocations (fractures of the scaphoid and capitate, instead of scapholunate and lunate – capitate ligament ruptures); trans-scapho-capitate-hamate-triquetral fracture dislocations (fractures of the scaphoid, capitate, hamate, and triquetrum instead of ligament rupture between the lunate and these bones); and lastly, the volar transscaphoid perilunate fracture dislocation (Fig. 4). The most prevalent of these injuries is the trans-scaphoperilunate fracture dislocation (6,7,10,11,24 – 27). It has been proposed that greater arc injuries result when greater forces are experienced by the wrist during extension than during ulnar deviation and intercarpal supination (2,16). Among Mayfield and colleagues’ Group 3 or variant injuries are fracture dislocations that involve the radial styloid, the scapho-capitate syndrome (simultaneous fracture of the scaphoid and the capitate without lunate dislocation— most likely just a reduced transscaphoid, transcapitate perilunate dislocation), and the isolated dislocation of any carpal bone. The first subgroup, radial styloid fracture dislocations, is the most common entity in this subset. Watson and Jeffrey (2) proposed a classification with five injury types: (i) perilunate dislocation, (ii) radiocarpal dislocation, (iii) midcarpal dislocation, (iv) axial-carpal dislocation; and (v) isolated carpal injuries (2). The strength of this system is its ability to account for all described carpal dislocations and fracture dislocations according to the anatomic pattern of trauma.

Figure 4 The patterns of greater arc injury. Source: From Ref. 7.

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Table 2 Cooney et al.’s Classification for Carpal Dislocations Dorsal perilunate dislocations or Lesser arc injuries Transcarpal fracture dislocations or Greater arc injuries Transstyloid injuries Transscaphoid injuries Scaphocapitate injuries Transtriquetral Radiocarpal dislocations Longitudinal or axial dislocations Isolated carpal bone dislocations Source: From Ref. 11.

Cooney and colleagues suggested classifying carpal dislocations and fracture dislocations into five groups: (i) dorsal perilunate dislocations or lesser arc injuries; (ii) transcarpal fracture dislocation or greater arc injuries, which includes transstyloid, transscapho, scapho-capitate, and transtriquetral fracture dislocation types; (iii) radiocarpal dislocations and fracture dislocations; (iv) longitudinal or axial dislocations and fracture dislocations; and (v) isolated carpal bone dislocations and fracture dislocations (Table 2). DIAGNOSIS Published case series of perilunate injuries emphasize a substantial percentage of delayed diagnosis, between 25% and 43% (6,10,26,28,29). Factors that may contribute to the potential for delayed diagnosis include: (i) association with severe or life-threatening injuries that require emergent treatment; (ii) alcohol intoxication and alcohol abuse; and (iii) misinterpretation of radiographs. Clinical Diagnosis A thorough secondary survey after primary resuscitation of a critically injured patient with serial repeat examinations as the patient recovers will help to limit the potential for a carpal dislocation or fracture dislocation to be overlooked. During the inspection, the involved limb should be evaluated for open wounds or penetrating trauma. These are uncommon, but in addition to the need for more expedient operative treatment, they are also associated with diminished results (10). Most injuries are associated with obvious deformity, pain, swelling, and ecchymosis. Some patients may have instability or crepitation during palpation. There is a substantial risk of acute carpal tunnel syndrome in association with carpal dislocations and fracture dislocations. Careful evaluation of light touch sensation and intrinsic hand muscle strength are important. Patients should also be warned about the risk of developing acute carpal tunnel syndrome after leaving the emergency room following reduction as this problem can develop hours to days after the injury.

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Radiographic Diagnosis Perilunate injuries and even complete lunate dislocations can be overlooked initially. Wrist anatomy is complex, and careful interpretation of good quality radiographs is helpful in making a timely and accurate diagnosis. At a minimum, good quality posteroanterior (PA) and lateral radiographs should be obtained. Additional oblique views and radiographs made with the wrist in traction may be beneficial. It can be difficult to get good quality radiographs in an injured and uncomfortable patient. The PA view is made with the volar surface of the hand, wrist, and forearm flat on the film, usually with the shoulder abducted 908, the elbow at 908, the wrist in neutral radioulnar deviation, and the forearm supported in neutral rotation. The beam is focused on the midcarpus and is triggered at a distance of 40 inches, perpendicular to the hand. Proper alignment is confirmed as longitudinal alignment of the axes of the middle finger, third metacarpal, and the radius (30 –32) (Fig. 5). The lateral projection is made with the hand, wrist, and forearm placed perpendicular to the cassette. Alignment in neutral wrist flexion is necessary and it is monitored by ensuring that the longitudinal axes of the third metacarpal, capitate, and radius are aligned (Fig. 6). Appropriate rotation can be confirmed in the film by the fact that the distal pole of the scaphoid is located between the palmar surface of the capitate and the palmar surface of the trapezium; the volar margin of the pisiform is between the volar surface of the capitate and the volar tip of the distal pole of the scaphoid (30 – 32); and the inferior pole of the lunate is between the capitate and the inferior pole of the scaphoid.

Figure 5 In a posteroanterior radiograph of a normal wrist, the axes of the long finger metacarpal, capitate, and radius shaft should align.

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Figure 6 The axes of the long finger metacarpal, capitate, and radial shaft should also align on a lateral radiograph with the wrist in neutral flexion.

Interpretation of the radiographs should include careful evaluation of the carpal arcs emphasized by Gilula and Weeks (33). He described two arcs that correspond to the articular surfaces of the radiocarpal joint (proximal arc) and the midcarpal joint (distal arc) in the PA radiograph. The continuous and smooth shape of both arcs is an indirect sign of adequate positioning of the carpal bones. Any alteration in this continuous pattern is an indication of malalignment of one or more carpal bones. The proximal arc is formed by the proximal articular surfaces of the scaphoid, the lunate, and the triquetrum. The distal arc is formed by the articular surface of the head of the capitate, the trapezium’s proximal articular surface, and the proximal articular surface of the hamate (33) (Fig. 7). In perilunate dislocations, the carpal height will be reduced, and an overlap between the proximal and distal rows (lunate and capitate) will obscure the midcarpal space. The carpal ratio (measurement of carpal height) is calculated as the longitudinal length of the carpus (measured from the distal articular radial surface to the capitate-third metacarpal junction), divided by the longitudinal length of the metacarpal longitudinal length (2,7) (Fig. 8). The average value is: 0.54 (range: 0.51 – 0.57) (34). An alternative method for quantifying carpal height was developed to account for the fact that many wrist radiographs do not include the entire third metacarpal. The modified carpal height ratio is calculated as the ratio of the height of the carpus to the height of the long axis of the capitate (Fig. 9). The normal value of this modified ratio is 1.57, ranging from 1.52 to 1.62. A reduction in the intercarpal space and an overlap of the carpal bones were described as the “crowded carpal sign” by Klein and Webb (35). Other things to look for on the PA radiograph include: (i) the lunate having a triangular rather than a trapezoidal shape and overlaps with the capitate in both

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Figure 7 Gilula is credited with describing arcs defined by the proximal and distal articular surfaces of the proximal carpal row and the proximal articular surfaces of the distal carpal row. Abnormal disjunction or overlap of the arcs is suspicious for ligament injury.

perilunate and lunate dislocations; (ii) the so-called “Terry Thomas” sign or widening of the scapholunate space; and (iii) the “Scaphoid Ring” sign caused by volar flexion and rotation of the scaphoid so that the distal pole is viewed along its central axis, and the cortex forms a ring (PA view) (Fig. 10). Finally, associated fractures of the radial styloid, scaphoid, capitate, triquetrum, and/or hamate may be seen.

Figure 8 The carpal height ratio is measured as the quotient of the height of the carpus from the lunate facet of the distal radius to the distal end of the capitate and the length of the long finger metacarpal. It averages 0.54.

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Figure 9 A modified carpal height ratio is useful when the entire third metacarpal is not included on the radiograph. The modified carpal height ratio is the quotient of the height of the carpus over the height of the capitate. Its average value is 1.57.

In the lateral view, the relationships of the radius, lunate, and capitate should be carefully evaluated. In perilunate dislocations and fracture dislocations, the articular relation between the radius and the lunate is maintained, but the capitate is dislocated dorsally from its articulation with the lunate. When the lunate is completely dislocated, the relationship between the capitate and radius is relatively normal, and the

Figure 10 Findings in X rays (antero-posterior projection) characteristic of perilunate dislocations and fracture dislocations. (1) Broken Gilula’s arcs, (2) Terry Thomas sign (scapholunate disruption), (3) crowded carpus sign, (4) triangular shape of the lunate, (5) scaphoid signet ring sign (where the distal pole of the scaphoid looks like a ring because it is seen on end), (6) reduced carpal height, (7) associated fractures. Source: Template courtesy of Taleisnik.

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lunate is dislocated volarly or dorsally according to the type of injury. Complete volar dislocation is sometimes overlooked when the lunate is assumed to be the pisiform. The “empty” or “spilled teacup sign” has been used to emphasize the characteristic appearance of the lunate when it is completely dislocated and rotated on a hinge of intact volar radiocarpal capsule and ligament (Fig. 11B). The normal capitolunate angle is 08 and any value above 158 is considered abnormal. This angle is measured by drawing a line through the longitudinal axis of the capitate and another one perpendicular to the axis of the lunate. The normal scapholunate angle is less than 608 and any value above 808 is considered abnormal. Values between 608 and 808 are considered borderline. This angle is

Figure 11 Complete lunate dislocation can occur in a volar (A, B) or a dorsal direction (C, D), but dorsal is rare. Source: From Ref. 2.

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Figure 12 A patient with a transscaphoid perilunate fracture dislocation was treated with open reduction. (A) The scaphoid was repaired with a screw. (B) The intercarpal and midcarpal articulations were pinned temporarily with percutaneously inserted wires.

obtained by drawing longitudinal lines through the longitudinal axes of the scaphoid and the lunate on a proper lateral radiograph. The radiolunate angle normally is 08 and any value greater than 158 is abnormal. This is measured as the angulation between a line drawn through the longitudinal axis of the radius and a perpendicular line to the longitudinal axis of the lunate (Fig. 12). Radiographs taken while traction is applied to the wrist are useful for the assessment of osseous and articular compromise. In complex injuries, computed tomography may be useful to further characterize the injury, particularly any associated fractures. TREATMENT Proposed treatments have included closed reduction and cast immobilization; closed reduction, percutaneous pin fixation, and cast immobilization; and open reduction and internal fixation. Factors associated with worse results include delayed treatment, injuries associated with an open wound, and nonanatomic reduction (2,10,26). These are uncommon injuries and the best available evidence is from large retrospective case series. There are no prospective clinical trials to guide management of these injuries. Treatment Techniques Closed Manipulative Reduction For acute injuries, a closed, manipulative reduction should be performed soon after the dislocation is identified to limit the risk of acute carpal tunnel syndrome,

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and to allow planning of operative repair at a more convenient time. Delayed diagnosis usually necessitates open reduction. Muscle relaxation facilitates manipulative reduction. In the emergency room, this can be accomplished with a combination of conscious sedation (the administration of short-acting benzodiazepine sedatives and narcotics to an awake patient) with or without local or regional anesthesia (intraarticular anesthesia, Bier block, or peripheral nerve block). The ideal setting for closed manipulative reduction is the operating room where either a brachial plexus block or pharmacological paralysis can be administered. In either setting, muscle relaxation can be facilitated by finger-trap traction. After anesthesia administration, the fingers are placed in the traps and the arm is suspended with the elbow at a 908 angle. Weight of 5 to 15 kg of is suspended from the brachium on a well-padded strap for about 10 minutes. When muscle relaxation is established, the finger traps are removed to allow manipulation. For a perilunate or volar lunate dislocation, with axial traction, the wrist is fully extended and then flexed with the thumb placed over the lunate volarly (36). In this manner, the lunate is held in position with respect to the radius, whereas the capitolunate joint and other carpal articulations are reduced. An image intensifier is useful in order to confirm reduction while the patient is still under optimal anesthesia. It is also much easier to get a good quality lateral radiograph because it can be adjusted under direct radiographic monitoring. If an image intensifier is not available, plain radiographs are obtained as described above. Closed Reduction and Cast Immobilization The traditional recommendation for immobilization after closed manipulative reduction was an above-elbow, thumb spica cast (4,6,11,20,25,28,37,38). It has been recommended that the wrist be placed in as much flexion as it was when reduction was achieved, and the forearm in some pronation to help realign the scaphoid; however, this would increase the potential for acute carpal tunnel syndrome. After four weeks, the long-arm cast is replaced by a cast that immobilizes the wrist and thumb, but not the elbow (a below-elbow, or short arm, thumb spica cast) for an additional four weeks. After eight weeks of cast immobilization, exercises to improve wrist motion and strength are initiated. This protocol can result in reasonable short-term results (11,20). The series of Cooney et al. included nine patients treated with closed reduction within a week of injury and cast immobilization. Using the modified Mayo wrist score (11), the results for patients treated with manipulative reduction and casting had results comparable to patients treated percutaneously or with open operative treatment. This was the most popular method of treatment until approximately the late 1970s when concern regarding residual carpal malalignment led most authors to prefer more invasive treatments (20,22,24,39 – 41). Adkison and Chapman (24) reported that 68% of their patients had inadequate carpal alignment after

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closed treatment. The results of closed treatment of fracture dislocations (greater arc injuries) are particularly poor (2,7). Closed Reduction and Percutaneous Pinning Several case reports and case series advocate percutaneous fixation of the carpal bones in order to improve the alignment of the carpal bones after closed reduction (10,26,42). Raab et al. (42) compared small series of athletes with perilunate dislocations treated with either closed reduction and percutaneous pinning (five patients) or open reduction and internal fixation (five patients). They noted a more rapid return to sport in patients treated percutaneously (five weeks after pinning compared to 10 weeks with open treatment), but it makes no sense why this would be so other than the fact that the surgeon allowed the former group to play sooner. Very little detail was presented regarding the function or radiographic result, and the follow-up was very short. Percutaneous pinning is technically demanding, particularly when fractures are present. This technique should be done only if complete anatomic reduction of the lunate, the capitate, and the scaphoid, including associated fractures, can be achieved by closed reduction. It can be difficult to realign the carpal bones with manipulative reduction alone (7,43). It may prove useful to insert temporarily smooth Kirschner wires (0.062 inch diameter) into the lunate and the scaphoid in order to directly correct rotational and angular malalignment. Next the scaphoid is pinned to the lunate and the capitate with several smooth Kirschner wires (usually 0.045 inch diameter). Kirschner wires between the triquetrum and lunate are also inserted. The pins can be trimmed so that they remain under the skin to be removed at a second operative procedure or they can be bent and trimmed outside the skin for later removal in the office. Traditionally, the wrist is immobilized with a thumb spica, above-elbow cast for six weeks followed by a below-elbow thumb spica cast for four weeks. It may not be necessary to include the elbow, and the thumb in the cast and practice varies. The pins are removed between 8 and 12 weeks after surgery. The authors strongly feel that percutaneous fixation of displaced, unstable scaphoid and capitate fractures cannot be adequately monitored with image intensification alone. Wrist arthroscopy can provide adequate visualization to confirm reduction; however, arthroscopic-assisted, percutaneous treatment of perilunate fracture dislocations should be considered experimentally at this time. Open Reduction and Internal Fixation Open reduction and internal fixation is the only option for patients with delayed diagnosis, inadequate reduction, acute carpal tunnel syndrome, and open wounds. It is currently the treatment of choice for all types of carpal dislocations and fracture dislocations (3,10,13,22,24,44). Open reduction facilitates alignment of the carpus and provides direct assessment and repair of each injury component. It also allows for removal of small osteochondral fragments which are not uncommon in these injuries.

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Various operative approaches have been suggested including volar, dorsal, or combined exposures. Sotereanos et al. (13) reviewed the existing literature, but did not find a clear advantage to one of these approaches. Whatever approach is selected, intraoperative traction can facilitate treatment, particularly with delayed treatment or whenever the wrist remains dislocated. Intraoperative traction can be provided by sterile finger-trap traction, which can be applied horizontally to facilitate the operative exposure. Alternatively, an external fixator can be applied across the wrist and used to apply traction. This external fixator can then be kept in place after the surgery as an alternative to a cast (1). This is particularly useful when treating acute injuries where avoiding constrictive circumferential casts and dressings may help limit swelling and finger stiffness. The volar approach to perilunate injuries has several advantages including: (i) an extended release of the carpal tunnel; (ii) potential access to the stouter, more important volar aspect of the triquetrolunate interosseous ligament; and (iii) repair of volar radiocarpal ligament injury. Disadvantages include: (i) the preference of most surgeons to limit incision of the important volar radiocarpal capsule leading to a more limited view of the carpus through the traumatic rent in the capsule with consequently greater difficulty judging alignment and frequent inability to see or repair the volar triquetrolunate ligament; (ii) no access to the stouter, more important dorsal aspect of the scapholunate interosseous ligament; and (iii) inadequate assessment of carpal fractures and technical difficulties in their reduction and fixation. The dorsal capsule is felt to be less important and is therefore more readily incised in whatever manner the surgeon feels is most useful (transverse, longitudinal, and oblique orientations have been described). The decision on capsular incision is often facilitated by the nature of the traumatic capsular injury. A very broad exposure (sufficient to see a scaphoid fracture and the lunotriquetral joint) is obtained by mobilizing the extensor pollicis longus from the third dorsal compartment transposing it radially into the subcutaneous tissues, followed by elevation of the second and fourth dorsal compartments off of the distal radius. A 0.062-inch Kirschner wire is inserted into the lunate as a “joystick” to realign the bone. The realigned lunate is then stabilized to the distal radius with a 0.045 or 0.062-inch Kirschner wire. The scaphoid is realigned in a similar fashion and then pinned to the capitate. Most surgeons provide definitive stabilization with temporary smooth Kirschner wires between the scaphoid and lunate, the triquetrum and lunate, and the scaphoid and capitate (Fig. 12). Additional wires are often used. Temporary screws can also be used (Figs. 13 and 14). When screws are placed between the scaphoid and lunate, and the lunate and triquetrum, the midcarpal joint can be allowed to move sooner. One disadvantage of Kirschner wires is the risk of infection if they are left out of the skin (or if swelling results in them protruding through the skin). The use of buried Kirschner wires or screws requires a

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Figure 13 (A) A posteroanterior radiograph of a transscaphoid perilunate fracture dislocation. The lunate is triangular in shape. (B) On the lateral capitolunate, dislocation is apparent. (C) Upon dorsal exposure, dislocation of the carpus is apparent. (D) External fixation and open reduction were accomplished. (E) A fracture of the scaphoid was reduced dorsally and secured with a volar percutaneous screw. (F) The triquetrolunate interval was temporarily secured with a screw.

second surgery for implant removal. The wires or screws are left in place for at least two to three months. Wires are protected with a cast, and the wrist is not allowed to move for the entire time. With screws, wrist motion and exercises are usually initiated within a month of surgery.

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Figure 14 A 40-year-old man injured his wrist in a motor cycle accident. (A) A PA radiograph showed a transstyloid perilunate dislocation. (B) Complete dislocation of the lunate was seen on the lateral radiograph. (C) The radial styloid fracture and the triquetrolunate and scapholunate intervals were secured with screws and the corresponding ligaments secured with suture anchors. (D) The short radiolunate ligaments were also repaired with a suture anchor. (E) A PA radiograph after screw removal shows good carpal alignment. (F) The lateral radiograph also shows good alignment. (G) Good function was obtained, (H) although the wrist was quite stiff. Abbreviation: PA, posteroanterior.

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The accessible portions of the interosseous ligaments can be repaired either with small suture anchors or drill holes in the bones. The ligaments usually remain attached to the lunate and need to be reattached to the scaphoid and lunate (2). Some authors recommend repair of the volar portion of the triquetrolunate ligament because it is the stoutest portion of that ligament, but we believe there is insufficient access to do this in most patients. When the carpal bones are realigned and stabilized, the ligaments usually line up into their correct positions, and may heal without direct repair. Although the current preferred treatment is direct open repair, the advantages of this over realignment and stabilization are unproven. Associated Fractures A fracture of the scaphoid can be reduced through a dorsal incision and repaired with a countersunk dorsally inserted screw or a volar, percutaneously inserted screw (Fig. 13). Fracture of the capitate is repaired from dorsal with a countersunk screw. Fractures of the radial styloid and triquetrum can be stabilized with Kirschner wires or screws (Fig. 14). Ulnar styloid fractures are approached through a direct ulnar incision and repaired with a tension band wiring technique (45). In some patients with extreme instability, temporary immobilization of the wrist with a plate can be useful (Fig. 15). Some fractures are so complex that an acute proximal row carpectomy is merited (Fig. 16). PROGNOSIS/RESULTS The data available to guide treatment and prognosis are of limited quality, a fact that is not surprising given the relatively infrequency of these injuries. Most studies are case reports or case series that combined different types of injuries and different treatment options. Other problems are the short follow-up of most of these patients and the various evaluation techniques and instruments used in these studies. Garcia-Elias et al. (26), in their retrospective review of 91 cases, reported a statistically significant impact on clinical outcomes while using a modified Witvoet and Allieu score (46), when treatment was delayed longer than one week, reduction was not maintained appropriately, and the lunate had a significant rotational component (26). Herzberg et al. (10) found a difference in terms of clinical and radiological outcomes if treatment was delayed greater than 45 days or if injury was open. The anatomical pattern of injury had a more limited affect on the outcome. Data that demonstrate an association between open injures and worse prognosis (2,8,10,26) likely reflect greater displacement and more significant soft-tissue damage. Series from Herzberg et al. in 1993 addressed this issue after evaluating clinical outcomes of 166 patients with a modified Green and O’Brien score instrument. They found a statistically significant correlation between poor outcomes and open lesions.

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Figure 15 A 25-year-old man sustained complex injuries to the hand and wrist. (A) This injury oblique radiograph demonstrates a transscaphoid perilunate injury. (B) A lateral radiograph suggests fracture dislocation of the index through small carpometacarpal joints as well. (C) Anteroposterior and lateral radiographs demonstrate screw fixation of the scaphoid and temporary plate fixation of the carpus. (D) Anteroposterior and lateral radiographs after plate removal demonstrate healing and good alignment. (E) Half of his wrist flexion and extension were regained. (F) His function is very good.

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Figure 16 A 38-year-old man had a complex, widely displaced transscaphoid, transtriquetral perilunate fracture dislocation. (A) Fracture fragments extend well proximal in the forearm. (B) The lunate is widely dislocated and fractured. (C) An acute proximal row carpectomy was elected. The distal radioulnar joint was unstable. (D) The radial styloid was secured with Kirschner wires and the wrist immobilized with an external fixator. (E) The final radiographic result was good. (F) Reasonable function was restored given the complexity of the injury.

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Russell (6) reviewed 59 patients with wrist dislocations and fracture dislocations and found an association between nonanatomical reduction and diminished wrist function. In Pai’s series of 20 patients, diminished results were observed in patients that did not have initial anatomic reduction or presented with malunion or secondary degenerative arthritis. Herzberg et al. (10) reported better outcomes in patients that achieved anatomic reduction and adequately maintained it independent of the fixation method. Altissimi et al. (25), in their analysis of 19 cases, found worse results in patients that did not have initial adequate and stable reduction. In general, they progressed to chronic stability and secondary degenerative arthritis. Lastly, one of the largest series confirming this association of good outcomes and initial adequate reduction is the series of Garcia-Elias (91 patients) where good outcomes were statistically significantly related to the carpal alignment (26). This concern of anatomic reduction is particularly true in fracture dislocations, where nonunion and avascular necrosis are also associated with nonanatomic reduction, as reported in series and case reports (5,6,10,25,26). The influence of surgical technique is less well established. As a general rule, it seems that techniques that achieve and maintain anatomical reduction are correlated with better results (3,10,22,24,44,47). Older series suggested worse outcomes in patients with fracture dislocations (6,13,25,38,48); however, more recent and larger series have not born this out (10,13,49). Herzberg et al.’s review of 166 patients and Garcia-Elias’ review of 91 patients found no correlation between clinical outcomes and type of lesion. COMPLICATIONS Median Neuropathy Rates of incidence for median neuropathy in association with carpal dislocations and fracture dislocations range from 11% to 45% in various series (20,24,26,28,44,48). Median nerve symptoms resolved in most patients even when the carpal tunnel was not released; however, we believe that carpal tunnel release is merited in the presence of any median nerve symptoms or dysfunction and should be strongly considered for all high-energy injuries with substantial swelling even when median nerve dysfunction is not present. Avascular Necrosis It is quite impressive that avascular necrosis is extremely uncommon after these injuries in spite of the dislocation, soft-tissue injury, and inherently limited blood supply to the carpal bones. When this rare complication presents, it seems to depend on the initial degree of displacement and the injury to the capsular flap where the lunate usually attaches (10,11,13,26,27,48). Avascular necrosis seems most frequent in perilunate fracture dislocations treated closed

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leading to scaphoid nonunion and avascular necrosis of the proximal pole (11,26,50).

Late Complications/Salvage Procedures The most common late complication is arthrosis. Salvage options include total or partial wrist arthrodesis and proximal row carpectomy. Patients must be willing to sacrifice motion and be exposed to the risks of surgery for the goal of pain relief (51 – 54).

REFERENCES 1. Fernandez DL, Mader K. The treatment of complex carpal dislocations by external fixation. Injury 2000; 31(suppl 1):92– 101. 2. Watson KHW, Jeffrey. The wrist. In: Watson KHW, Jeffrey, eds. Fracture Dislocations of the Carpus. Philadelphia: Lippincott Williams and Wilkins, 2001:203–229. 3. Minami A, Kaneda K. Repair and/or reconstruction of scapholunate interosseous ligament in lunate and perilunate dislocations. J Hand Surg [Am] 1993; 18(6):1099– 1106. 4. Dunn AW. Fractures and dislocations of the carpus. Surg Clin North Am 1972; 52(6):1513– 1538. 5. Pai CH, Wei DC, Hu ST. Carpal bone dislocations: an analysis of twenty cases with relative emphasis on the role of crushing mechanisms. J Trauma 1993; 35(1):28–35. 6. Russell TB. Inter-carpal dislocations and fracture-dislocations: a review of 59 cases. J Bone Joint Surg Am 1949; 31B(4):524–531 [illustrations]. 7. Taleisnik J. Dislocation and fracture dislocation of the carpus. In: Tracy TM, ed. The Wrist. New York: Churchill Livingstone, 1985:195–228. 8. Herzberg G. The treatment of perilunate dislocations. In: Buchler U, ed. Wrist Instability. London: Federation of European Societies for Surgery of the Hand, 1996:101–107. 9. Linscheid RL, Dobyns JH, Beabout JW, Bryan RS. Traumatic instability of the wrist: diagnosis, classification, and pathomechanics. J Bone Joint Surg Am 1972; 54(8):1612– 1632. 10. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg [Am] 1993; 18(5):768–779. 11. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures: perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res 1987; (214):136–147. 12. Siegert JJ, Frassica FJ, Amadio PC. Treatment of chronic perilunate dislocations. J Hand Surg [Am] 1988; 13(2):206–212. 13. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, Tomaino MM, Herndon JH. Perilunate dislocation and fracture dislocation: a critical analysis of the volar-dorsal approach. J Hand Surg [Am] 1997; 22(1):49–56. 14. Hildebrand KA, Ross DC, Patterson SD, Roth JH, MacDermid JC, King GJ. Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation. J Hand Surg [Am] 2000; 25(6):1069– 1079.

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15. Trumble T, Verheyden J. Treatment of isolated perilunate and lunate dislocations with combined dorsal and volar approach and intraosseous cerclage wire. J Hand Surg [Am] 2004; 29(3):412–417. 16. Mayfield JK. Mechanism of carpal injuries. Clin Orthop Relat Res 1980; Jun(149):45 –54. 17. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg [Am] 1980; 5(3):226– 241. 18. Green DP, O’Brien ET. Classification and management of carpal dislocations. Clin Orthop Relat Res 1980; Jun(149):55–72. 19. Shin AY, Battaglia MJ, Bishop AT. Lunotriquetral instability: diagnosis and treatment. J Am Acad Orthop Surg 2000; 8(3):170–179. 20. Green DP, O’Brien ET. Open reduction of carpal dislocations: indications and operative techniques. J Hand Surg [Am] 1978; 3(3):250–265. 21. Johnson RP. The acutely injured wrist and its residuals. Clin Orthop Relat Res 1980; Jun(149):33 –44. 22. Moneim MS. Management of greater arc carpal fractures. Hand Clin 1988; 4(3): 457 –467. 23. Kohut GS, Smith A, Giudici M, Buchler U. Greater arc injuries of the wrist treated by internal and external fixation: six cases with midterm follow up. Hand Surg 1996; 1(2):159–166. 24. Adkison JW, Chapman MW. Treatment of acute lunate and perilunate dislocations. Clin Orthop Relat Res 1982; Apr(164):199–207. 25. Altissimi M, Mancini GB, Azzara A. Perilunate dislocations of the carpus: a long-term review. Ital J Orthop Traumatol 1987; 13(4):491–500. 26. Garcia-Elias M, Irisarri C, Henriquez A, et al. Perilunar dislocation of the carpus: a diagnosis still often missed. Ann Chir Main 1986; 5(4):281– 287. 27. Morawa LG, Ross PM, Schock CC. Fractures and dislocations involving the navicular-lunate axis. Clin Orthop Relat Res 1976; Jul– Aug(118):48–53. 28. Campbell RD Jr, Lance EM, Yeoh CB. Lunate and perilunar dislocations. J Bone Joint Surg Br 1964; 46:55 –72. 29. Rawlings ID. The management of dislocations of the carpal lunate. Injury 1981; 12(4):319–330. 30. Poznanski A. The Hand in Radiologic Diagnosis. Philadelphia: W.B. Saunders Company, 1974. 31. Clark KC. Positioning in Radiography. 8th ed. New York: Intercontinental Medical Book Corp., 1967. 32. Meschan I. An Atlas or Normal Radiographic Anatomy. 2nd ed. Philadelphia: W.B. Saunders Company, 1959. 33. Gilula LA, Weeks PM. Post-traumatic ligamentous instabilities of the wrist. Radiology 1978; 129(3):641–651. 34. McMurtry RY, Youm Y, Flatt AE, Gillespie TE. Kinematics of the wrist. II. Clinical applications. J Bone Joint Surg Am 1978; 60(7):955– 961. 35. Klein A, Webb LX. The crowded carpal sign in volar perilunar dislocation. J Trauma 1987; 27(1):82–84. 36. Watson-Jones R. Carpal semilunar dislocations of the carpal bones and dislocations of the lunate bone. Proc R Soc Med 1929; 22:1071.

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37. Hill NA. Fractures and dislocations of the carpus. Orthop Clin North Am 1970; 1(2):275–284. 38. Wagner C. Fracture dislocations of the wrist. Clin Orthop 1959; 15:181–196. 39. Engel AF, Keeman JN. Transscaphoid perilunate fracture dislocation and pseudoarthrosis of the scaphoid. Neth J Surg 1990; 42(5):128–130. 40. Hawkins L, Torkelson R. Transnavicular perilunar fracture-dislocations of the wrist. J Bone Joint Surg [Am] 1974; 56-A:108. 41. Howard FM, Dell PC. The unreduced carpal dislocation: a method of treatment. Clin Orthop Relat Res 1986; Jan(202):112–116. 42. Raab DJ, Fischer DA, Quick DC. Lunate and perilunate dislocations in professional football players: a five-year retrospective analysis. Am J Sports Med 1994; 22(6):841–845. 43. Green DP. Carpal dislocations and instabilities. In: Green DP, ed. Operative Hand Surgery. New York: Churchill Livingstone. 1993:861–928. 44. Moneim MS, Hofammann KE III, Omer GE. Transscaphoid perilunate fracturedislocation: result of open reduction and pin fixation. Clin Orthop Relat Res 1984; Nov(190):227–235. 45. Jupiter JB, Ring D. Perilunate and lunate dislocations and fracture dislocations. In: Jupiter JR, ed. AO Manual of Fracture Management, Hand and Wrist. New York: Thieme, 2005:145– 188. 46. Witvoet J, Allieu Y. Le´sions traumatiques fraiches du semi-lunaire. Rev Chir Orthop 1973; 59(suppl 2):98 –125. 47. Panting AL, Lamb DW, Noble J, Haw CS. Dislocations of the lunate with and without fracture of the scaphoid. J Bone Joint Surg Br 1984; 66(3):391–395. 48. MacAusland W. Perilunar dislocations of the carpal bones and dislocation of the lunate bone. Surg Gynecol Obstet 1944; 79:256–266. 49. Mamon JF, Tan A, Pyati P, Hecht A. Unusual volar dislocation of the lunate into the distal forearm: case report. J Trauma 1991; 31(9):1316–1318. 50. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg [Am] 1984; 9(3):358– 365. 51. Ashmead DT, Watson HK, Damon C, Herber S, Paly W. Scapholunate advanced collapse wrist salvage. J Hand Surg [Am] 1994; 19(5):741–750. 52. Wyrick JD, Stern PJ, Kiefhaber TR. Motion-preserving procedures in the treatment of scapholunate advanced collapse wrist: proximal row carpectomy versus four-corner arthrodesis. J Hand Surg [Am] 1995; 20(6):965–970. 53. Krakauer JD, Bishop AT, Cooney WP. Surgical treatment of scapholunate advanced collapse. J Hand Surg [Am] 1994; 19(5):751–759. 54. Gelberman RC, Szabo WP. Instructional course: carpal instability. J Bone Joint Surg Am 2000; 82A(4):578–592.

6 Fractures of the Scaphoid Satoshi Toh Department of Orthopedic Surgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan

INTRODUCTION Scaphoid fractures are prevalent in young, active people. There is often a strong desire to return to sports or work. Delayed diagnosis and nonunion of the scaphoid are fairly common as well, probably as a result of several factors, including the difficulty of radiographic diagnosis of nondisplaced fractures and underestimation of the injury by the patient. The goal of treatment is solid union in good alignment. Malalignment [either malunion (1) or nonunion with malalignment] contributes to a dorsal intercalated segmental instability (DISI) deformity (2 – 4) that may be followed by carpal collapse and eventual osteoarthrosis (5– 7)—the so-called scapholunate advanced collapse (SLAC) (8) or scaphoid nonunion advanced collapse (SNAC) wrist (9). The development of countersunk, variable pitched screws (such as the Herbert screw) improved fixation of scaphoid fractures (10). Percutaneous screw insertion—which we and others developed with the standard Herbert screw—has been greatly facilitated by the development of cannulated screws. Percutaneous screw fixation has become an accepted alternative to cast immobilization for the treatment of nondisplaced fractures of the scaphoid and allows patients to avoid prolonged cast immobilization (11–18). Arthroscopic-assisted percutaneous fixation of displaced scaphoid fractures is also increasingly common.

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MECHANISM AND EPIDEMIOLOGY Fracture of the scaphoid is usually the result of a fall onto the outstretched hand resulting in hyperextension and ulnar deviation of the wrist (19). Injuries that cause forceful wrist extension (e.g., sports activities and car accidents) may also cause scaphoid fractures. In Japan, from the late 1980s, we have seen an increase in wrist flexion scaphoid fractures due to the increasing popularity of punching game machines (20,21). In these punching games, as in Karate or fighting, the wrist is in slight palmar flexion and slight radial deviation. With radial deviation and flexion, the waist of the scaphoid is impacted between the distal and volar edge of the radius and the trapezium and trapezoid over the radioscaphocapitate ligament (21). Fracture of the scaphoid is the most frequent carpal fracture and occurs most commonly in young active individuals. The average age of occurrence in athletes has been reported as being approximately 17 years of age (22). This is similar to our observations in Japan of a peak during high school age, between 15 and 18 years, with an increasing overall prevalence that may be related to the growing popularity of sports and punching game machines (20,21).

DIAGNOSIS There is some tendency for the diagnosis of fracture of the scaphoid to be delayed because of misdiagnosis or because patients do not see a doctor immediately after injury. The latter seems particularly common in children, some of whom may be reluctant to tell their parents about their use of a punching machine or fighting. A delayed presentation is also common among athletes because members of sports clubs or teams do not want to lose their position. In addition, the clinical symptoms are not usually severe, and may resemble a wrist sprain—something an athlete may have experienced numerous times and may not be particularly concerned about. Many patients with delayed presentations are found to have nonunion (23). When examining a patient with wrist pain, detecting the tender spot is the most important finding on examination. Tenderness with palpation of the scaphoid radially in the so-called anatomical snuffbox (between the extensor pollicis longus dorsally and the abductor pollicis longus and extensor pollicis longus volarly), volarly at the distal pole of the scaphoid, and with axial compression of the thumb are all useful palpatory examination maneuvers for scaphoid fracture. Provocative maneuvers of the wrist, such as the scaphoid shift test reported by Watson et al. (24), which originally was initially described to check for scapholunate dissociation or rotatory instability of the scaphoid, are also helpful to diagnose this fracture. The radiographic examination should consist of posteroanterior (PA), lateral, and semipronated and semisupinated oblique views. A view of the

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scaphoid with the wrist in ulnar deviation is useful because it extends the scaphoid, making its longitudinal axis more perpendicular to the X-ray beam. Nondisplaced fractures can be very subtle and difficult to see on plain radiographs. When a fracture is suspected based upon the injury mechanism and examination, but the radiographs are interpreted as normal, a suspected or occult scaphoid fracture is diagnosed. The management of suspected scaphoid fractures has traditionally consisted of two weeks of cast or splint immobilization followed by repeat radiographical and clinical examination. In the vast majority of patients, the repeat examination will resolve the issue. When suspicion for fracture persists after repeat evaluation, the use of a bone scan has largely been replaced by the use of magnetic resonance imaging (MRI), depending on its availability and relative cost. It is not yet clear whether attempts to triage suspected scaphoid fractures in the acute setting with more sophisticated diagnostic tests are worthwhile. It takes a few days after a fracture before a bone scan will be useful. MRI is not usually immediately available, but it can be obtained within a few days in many centers. Worldwide, an MRI is generally difficult to obtain in any circumstance, let alone in a timely fashion. Computed tomography (CT) is more readily available in some centers, but may not be best for suspected fractures because nondisplaced fractures can be very subtle on CT, can have a similar appearance to vascular channels, and may be distorted by volume averaging. Given that most suspected scaphoids are not true scaphoid fractures, any costs of advanced radiological interventions will have to be balanced by the potential costs due to lost work, although even a wrist sprain usually requires a few weeks of rest. Diagnosis of displacement is very important. Fracture displacement (or instability) is strongly associated with nonunion. The lines of Gilula should be checked for irregularity (25) and in the lateral view, the rotation of the lunate with respect to the radius are evaluated. The diagnosis of fracture displacement or instability is usually made as follows (Fig. 1): 1. 2.

3. 4.

One millimeter or greater gap or translation at the fracture site. Radiolunate angle greater than 108 to 158 on a true lateral radiograph (third metacarpal in line with the radial shaft; lower margin of the pisiform between the lower margins of the capitate and the distal pole of the scaphoid). Carpal height ratio (CHR) of the affected side is less than the opposite side and the discrepancy is 0.03 or greater (26). Scaphoid length is shorter on the affected side and the discrepancy is 1 mm or greater (27).

CT and MRI provide very detailed depictions of the scaphoid and may be more useful for diagnosing displacement. CT is cheaper, more

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Figure 1 Diagnosis of scaphoid fracture displacement. The following radiographic factors indicate fracture instability. (A) One millimeter or greater translation or gap at the fracture site on any view. (B) Greater than 158 dorsal angulation of the lunate with respect to the radius. (C) When the carpal height ratio (CHR) of the affected side is less than the opposite side by at least 0.03. The CHR is defined as L2 divided by L1. (D) If the scaphoid length is greater than 1 mm and shorter than the affected side. Abbreviation: CHR, carpal height ratio.

readily available, and perhaps superior for bone imaging, at least as far as displacement and other fracture detail are concerned (28,29). The best scan plane for evaluating the scaphoid fracture is along the long axis of the scaphoid. Scans in line with the longitudinal axis plane can be obtained by placing the patient in the prone position with the arm overhead, fully pronated, and flat on the table, and the forearm passing through the gantry at a 458 angle (30). A “coronal plane” scan in this axis is obtained by supinating the forearm 908 (Fig. 2). Alternatively, a high-resolution scan can be obtained and reformatted in selected planes using image manipulation software. Any gapping or angular or translational displacement suggests instability of the fracture. CLASSIFICATION Herbert’s classification is widely recognized and useful (10). The modification of this system, described by Filan and Herbert in 1996, omitted Type B5 (comminuted fractures) and Type C (delayed union) because they did not form natural groups. All fractures diagnosed more than six weeks after the initial injury were classified as Type D (nonunion) in the newer system, reflecting concerns about delayed diagnosis (Fig. 3).

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Figure 2 CT of the scaphoid. (A) The patient lies prone and the wrist crosses the gantry at a 458 angle. (B) This sagittal image depicts a displaced fracture of the scaphoid waist in a 36-year-old man who presented three months after the initial injury with nonunion. (C) This coronal image depicts a proximal pole nonunion in a 20-year-old man who presented 11 months after the initial injury. (D) Percutaneous screw fixation using dorsal approach at 11 months after the initial injury. (E) PA radiograph four months after the operation revealed solid bony fusion. Abbreviations: CT, computed tomography; PA, posteroanterior.

TREATMENT CONSIDERATIONS Acute unstable fractures (Type B) and delayed and nonunion fractures (Type D) are indications for operative intervention. Scaphoid fractures that are part of a more complex injury pattern (perilunate fracture dislocation, or combined distal radius and scaphoid fracture) are also best treated operatively. For acute

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Figure 3 Classification of scaphoid fractures according to Herbert. (A) The original Herbert classification. Type A fractures are stable acute fractures including: A1, fracture of scaphoid tubercle; A2, incomplete or nondisplaced fracture through the scaphoid waist. Type B fractures are acute and unstable including: B1, distal oblique fracture; B2, complete fracture of the waist; B3, proximal pole fracture; B4, trans-scaphoid-perilunate fracture dislocation; and Type B5 comminuted fractures. Type C comprised delayed unions and Type D established nonunions either stable/fibrous (D1) or unstable pseudoarthrosis (D2). (B) The modified Herbert classification of Filan and Herbert omitted Type B5 fractures and Type C fractures, which were now included as a type of D1 fracture. Type A fractures are defined as presenting within six weeks of the initial injury. Additional subtypes of nonunion were added.

stable fractures (Type A), conservative treatment achieves a high union rate and excellent wrist function, but requires prolonged cast immobilization. According to Leslie’s paper, six to eight weeks were required for fractures of the distal pole, 8 to 12 weeks for fractures of the waist, and 12 to 20 weeks for fractures proximal pole (31). However, in practice, there is substantial variation in these times and even in the type of cast used. Dias et al. (32) have shown that radiographs cannot reliably determine union, so the time of immobilization will be determined mostly by the surgeon’s preference, radiographic appearance, and clinical findings. An alternative to immobilization is to insert a screw into the scaphoid percutaneously, and forego cast immobilization. Percutaneous fixation can be used with displaced fractures if wrist arthroscopy is used to monitor and ensure adequate reduction. Percutaneous fixation may also be appropriate for some patients with Type D1 fractures (fibrous union) when good alignment is present, and a bone graft is felt to be unnecessary (Fig. 4). This may be more reliable in relatively recent fractures. For long-standing nonunions, it remains

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Figure 4 Percutaneous fixation of a delayed union of the scaphoid. (A) PA radiograph of a waist fracture in a 53-year-old man. The fracture line was not clear. (B) PA view one month after the initial injury. The fracture line was more clearly identifiable. (C) PA view three months after the initial injury shows an established nonunion. (D and E) Oblique and lateral radiographs eight months after operative treatment with percutaneous screw fixation through a dorsal approach shows union. Abbreviation: PA, posteroanterior.

somewhat unclear how to define a fracture as a stable or fibrous union. It has also not been demonstrated that percutaneous treatment is effective for all stable nonunions, regardless of age. Although the concept is worthy of further study, caution is warranted. For Type D1 nonunions which require curettage and type D2 nonunions which require bone grafting to correct the length and deformity such as DISI, open reduction from a volar approach and screw fixation is recommended (Fig. 5). In the more advanced types of nonunions—in particular, multiply operated patients or nonunions associated with avascular necrosis of the proximal pole—vascularized bone grafting from the distal radius or other salvage operations such as partial carpal fusion or proximal row carpectomy are indicated depending on the case (Fig. 6) (33 – 36).

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Figure 5 Nonunion with pseudoarthrosis (Type D2). (A and B) Oblique and lateral radiographs of a waist fracture in a 15-year-old boy immediately after the initial injury. The fracture was treated in a cast. (C and D) Radiographs two months later revealed bony absorption and widening of the fracture site, shortening of length of the scaphoid, and dorsal rotation of the lunate.

OPERATIVE TECHNIQUES Percutaneous Screw Fixation Using Image Intensifier Anesthesia Alternatives for anesthesia include general or regional anesthesia. The latter can be administered as an intravenous regional anesthesia (Bier block) or as a brachial plexus block. Type A

Patients w/ special background

Type B

*

Good reduction

Type D1

Poor reduction Type B4

Type D2-4

***

** Cast

Percutaneous screw fixation w/o open reduction

ORIF

ORIF w/ BG Vascularized BG Other salvage op.

Figure 6 Algorithm of treatment options depending on Filan and Herbert classification.  Patient who does not want long-term immobilization, or who wants to return to sports activities as soon as possible or whose fracture is combined with another fracture such as distal end of the radius.  Cases of delayed fibrous union when good alignment can be achieved and a bone graft is unnecessary.  Comminuted fracture open reduction and internal fixation with screw. Abbreviations: BG, bone grafting; ORIF, open reduction and internal fixation.

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Approaches There are two approaches for percutaneous screw insertion: volar and dorsal. In the volar approach, the trapezium hinders insertion of the screw in the proper location of the scaphoid. Some authors recommend removal of the foot process of the trapezium to gain access to the entry location to target the axis of the scaphoid. It is easier to place the screw in the central axis of the scaphoid using a dorsal approach (37 – 39). The dorsal approach is particularly useful for small fractures of the proximal pole (10). Volar approach: A 1-cm transverse or longitudinal skin incision is often made over the scaphotrapezium joint (Fig. 7). The joint is identified, and its capsule is incised transversely. The beak of the trapezium is resected if this proves helpful for screw placement. Wrist arthroscopy can be used to confirm displacement and to monitor reduction. The fracture cannot be seen through the radiocarpal portals, but is well visualized via midcarpal portals. If the fracture is displaced or unstable, a reduction

Figure 7 A 1-cm transverse skin incision over the scaphotrapezium joint is used for volar percutaneous screw fixation.

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is performed either by manipulating the wrist into extension and radial deviation, or using Kirschner wires inserted into each fragment as “joysticks” to manipulate the fracture. Alternatively, a single wire can be placed in the distal pole of the scaphoid, used to manipulate the fracture, then driven across the fracture site for provisional stabilization. The reduction may be evaluated using wrist arthroscopy. When using a noncannulated screw, the fracture is first stabilized temporarily by a Kirschner wire inserted ulnarward and parallel to the intended line of the screw. Then the wire is pulled volarward to rotate the scaphoid, and a second wire is inserted along the intended line of the screw (Fig. 8). Using the second

Figure 8 Percutaneous screw fixation. Volar approach. (A) The fracture is stabilized with a temporary Kirschner wire. The wire is pulled volarward to rotate the scaphoid. (B) A guide pin for the cannulated screw is then inserted along the intended line of the screw. (C) Image intensifier views from the operation. The arrow indicates a guide pin. (D) Using the second wire as a guide pin, a cannulated screw is inserted. With the original Herbert screw, after removal of the second wire, the screw is inserted free-hand. (E and F) Radiographs after screw insertion.

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wire as a guide pin, a cannulated screw is inserted (Fig. 8D). With the original Herbert screw, after removal of the second wire, the screw is inserted freehand. If there is no problem with stability of the fracture site, the first Kirschner wire is removed (Fig. 8E and F). When using a cannulated screw, a second wire is only needed to secure a displaced fracture. For nondisplaced fractures, an incision of more than a few millimeters is not necessary, although it might be used to excise part of the trapezium to facilitate screw passage. In most cases, the wire is placed across the fracture and the screw is placed over it. It can be difficult to pass the screw pass the trapezium and obtain good positioning. A more radial starting point and partial excision of the trapezium may help. Alternatives include drilling the wire for the screw through the trapezium and either passing a countersink over the wire as a way of resecting part of the edge of the trapezium or even passing the screw through the trapezium. Dorsal approach: This is an elegant technique that results in the wire being automatically inserted along the central axis of the scaphoid. It was originally reported by Slade who performed this technique keeping the hand vertically (16,40). The author performs it in a horizontal position (Fig. 9). After flexion and ulnar deviation followed by forearm pronation, the image intensifier is used to obtain a good perpendicular view of the long axis of the scaphoid. The scaphoid is visualized as two rings: distal and proximal (Fig. 10). The guide wire is then inserted perpendicularly through the centers of the two rings. After inserting only the tip of the wire and confirming its position proper (Fig. 11), the guide wire is advanced to the volar side (Fig. 12). Then the screw is inserted (Fig. 13). If instability exists at the fracture site, reduction is obtained as described above and a Kirschner wire is used for stabilization of the fracture site before inserting the guide wire.

Figure 9 Percutaneous screw fixation. Dorsal approach. Position of the hand and wrist. Slade performed this technique keeping the hand in a vertical position (A) and the author used a horizontal position (B).

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Figure 10 Percutaneous screw fixation. Dorsal approach. Views of the insertion point of the guide wire. After ulnar deviation (A) and flexion followed by forearm pronation, the image intensifier is used to obtain a good perpendicular view of the long axis of the scaphoid. The scaphoid is visualized as two rings: distal and proximal (B).

Implants Many cannulated screws are available and each has advantages and disadvantages for osteosynthesis of scaphoid fractures. The screw which we prefer to use now is a double-thread screw developed by Dr. Tanaka of Japan. The characteristic of this screw system is that the diameter of the guide wire is 1.2 mm thicker than that of the other cannulated screws, and the screw is self-drilling and self-tapping (Fig. 14). This is essentially a cannulated self-tapping doubleheaded, countersunk, variable pitched screw (like a Herbert screw), and other screws of this type are available.

Figure 11 Percutaneous screw fixation. Dorsal approach. The guide wire is then inserted perpendicularly through the centers of the two rings (A). After inserting only the tip of the wire (B), its proper positioning is confirmed (C).

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Figure 12 Percutaneous screw fixation. Dorsal approach. PA (A) and lateral (B) image intensifier views reveal that the wire is inserted along the central axis of the scaphoid. Abbreviation: PA, posteroanterior.

Postoperative Management Patients are immobilized for comfort for two to three weeks (Figs. 2 and 15). After removal of the cast or splint, wrist range of motion exercises is initiated. Once bony union is established and the patient had regained at least 80% of wrist motion and grip power compared to the opposite, uninjured wrist, resumption of sports activity is permitted, usually around three months after the operation (Fig. 16).

Figure 13 Percutaneous screw fixation. Dorsal approach. Then the screw is inserted free-hand. PA (A) and lateral (B) radiographs reveal good screw position. The hole of the cannulated screw is seen in the position of the wrist which is the same as for insertion of the guide wire (C). Abbreviation: PA, posteroanterior.

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Figure 14 Author’s preferred screw. The double-thread screw was developed by Dr. Tanaka of Japan. Its characteristics are that the diameter of the guide wire (A) is 1.2 mm thicker than that of the other cannulated screws and it is, therefore, stronger, and the screw is self-drilling and self-tapping (B).

Figure 15 Case with Type A2. This is an 18-year-old male with a scaphoid waist fracture. Posteroanterior (A) and lateral (B) radiographs at 26 months after the surgery revealed good bony fusion. Good functional results were also achieved (C and D).

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Figure 16 Patient with Type D1 nonunion. (A and B) A waist fracture in a 19-year-old man was treated by percutaneous screw fixation using dorsal approach at 30 days after the initial injury. PA radiograph (A) and CT scan (B). (C– E: ) Three months later, good bony fusion was revealed in PA (C) and lateral radiographs and CT scan (E). (F and G) Due to achievement of about 80% of ROM and grip power of the opposite healthy side, resumption of sports activity was permitted. Abbreviations: CT, computed tomography; PA, posteroanterior; ROM, range of motion.

Results From 1988 to date, 103 patients (91 men and 12 women), all with follow-up times over six months, had percutaneous fixation of a fractured scaphoid in our center. The average age was 29 years (range 11 to 73 years). Thirty-two patients had

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Figure 17 Patient with Type D1 nonunion. In this 14-year-old boy, the duration between injury and to operation was 107 days. Oblique (A) and lateral (B) radiographs revealed Type D1 nonunion. (C and D) Percutaneous screw (Herbert –Whipple) fixation was performed. PA (A) and lateral (B) radiographs revealed good bony fusion. Abbreviation: PA, posteroanterior.

acute stable fractures, 47 had acute unstable fractures, and 24 had delayed fibrous union according to the modified Herbert’s classification. The duration from injury to operative treatment in the fibrous union group averaged 104 days (range 42 to 316 days) (Fig. 17). We used standard Herbert screws in 49 patients and cannulated screws of various types in 54 patients. One of the 103 cases achieved bony fusion but revealed symptomatic malunion. One patient with delayed union used sonic accelerated fracture healing system (SAFHS) (low-intensity pulsed ultrasound) and achieved union without a second operation. In three patients, union was not achieved—one nonunion healed after a subsequent open surgery with bone grafting (Fig. 18). In the remaining 98 cases, union and good wrist function were documented.

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Figure 18 Nonunion after percutaneous screw fixation. In this 19-year-old male, the initial operation was performed two months after the injury. Unfortunately, the fracture was not reduced perfectly before fixation was performed (A), resulting in nonunion (B). Four months later, a second operation was performed following the Russe method (C). PA (D) and lateral (E) radiographs five months later revealed good bony fusion. The range of motion of the wrist (89%) and grip power (90%) were almost acceptable. Abbreviation: PA, posteroanterior.

The four persistent nonunions, delayed unions, and malunions seemed to be related to technical problems in the initial operations. For example, one patient (Fig. 18) operated two months after the injury had inadequate reduction, resulting in nonunion. Four months later, a second operation was performed using the Russe method (41). The graft harvested from the iliac crest was remodeled to match the shape of the inside of the scaphoid because of severe bone absorption

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(Fig. 18). Six months after the second operation, the wrist motion and grip strength were satisfactory. Open Reduction and Internal Fixation with Bone Grafting For cases that require curettage and bone grafting to correct length and angular deformity, we use open reduction, structural bone grafting, and internal fixation from a volar approach. As reported by Fernandez (27), for nonunion with malalignment, we use a wedge-shaped graft to correct the scaphoid length and malalignment including DISI deformity. Alternatively, one can fill the opening wedge defect anteriorly with pure cancellous graft, using the screw for primary structural support. This simplifies the technical aspects of the procedure. Preoperative Planning Using PA radiographs of both the injured and uninjured wrists in maximum ulnar deviation, the length of the scaphoids are calculated (Fig. 19). From this, the size and shape of the grafted bone is planned preoperatively. Operative Procedure A zigzag skin incision is performed on the volar side of the wrist. The flexor carpi radialis (FCR) sheath is used to gain deeper exposure. The wrist capsule is incised. The fracture site is opened, and the nonunion site with the fibrous tissue is resected until the previously sclerotic fracture surfaces are fresh and able to bleed. Using two Kirschner wires as joysticks, the gap of the nonunion site is opened and resected. In a case with DISI deformity, the rotation of the

Figure 19 Preoperative planning for cases with established nonunion. Using the PA radiographs of both the opposite uninjured wrist (A) and the injured wrist in maximum ulnar deviation (B), the length of the scaphoids were calculated. PA radiograph seven months after the open reduction and bone grafting revealed good bony fusion (C). Abbreviation: PA, posteroanterior.

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Figure 20 Open reduction and volar wedged bone graft technique. (A) Volar approach for nonunion of the scaphoid. Using two Kirschner wires as joysticks, the gap of the nonunion site is opened and resected. (B) In a case with DISI deformity, the rotation of the lunate is corrected using a spring made by inserting a Kirschner wire in the lunate. The position is maintained during the bone grafting. (C) A silicon block is used as a trial spacer, and tricortical corticocancellous bone graft is obtained in the same size and shape as this silicon block. Abbreviation: DISI, dorsal intercalated segmental instability.

lunate is corrected using a spring made by inserting a Kirschner wire in the lunate (42). Alternatively, the lunate can be temporarily pinned to the radius in proper alignment. The position is maintained during the bone grafting. A silicone block is used as a trial spacer, and a tricortical corticocancellous bone graft is obtained in the same size and shape as this silicone block (Fig. 20). After grafting the bone, a Kirschner wire is inserted to stabilize both the proximal and distal fragments and grafted bone. Then a guide wire is inserted in the same manner as the percutaneous methods from volar or dorsal side. We prefer to use a volar graft and dorsal percutaneous screw insertion. Postoperative Management The wrist is usually immobilized in a cast for four weeks. After removal of the cast, wrist range of motion exercises is initiated. If a Kirschner wire has been inserted to stabilize the alignment of the lunate, it is removed six weeks after the operation. Resumption of sports activity is managed as for percutaneous treatment. Results From 1984 to 2003, we performed open reduction and screw fixation with bone grafting for 109 patients with Type D nonunions. Ages ranged from 12 to 64 years (average 26 years). The duration from injury averaged 29 months (range six weeks to 487 months). In five of the 109 cases, union was not achieved. The reasons for failure were inadequate screw length, incorrect screw position, and improper size of grafted bone. In two of these five failed cases, an additional

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bone graft was performed, and good bony union was achieved. In the remaining three cases, patients did not desire further operation. In the remaining 104 cases, union and good wrist function were achieved. Pitfalls and Pearls Poor results seem to be related to inadequate reduction, screw position, or screw length. Trumble et al. (43) reported that the time to union was significantly shorter when the screw had been placed in the central third of the proximal pole of the scaphoid. The insertion techniques for the original Herbert screw were somewhat difficult for less-experienced surgeons. However, cannulated screws have been developed to resolve this problem. In the volar approach, the trapezium hinders insertion of the screw in the proper location of the scaphoid. Direct visualization of the fracture site using arthroscopy may make open exposures unnecessary for displaced fractures and stable nonunions (44 – 46).

REFERENCES 1. Fisk GR. Carpal instability and the fractured scaphoid. Ann R Coll Surg Engl 1970; 46(2):63–76. 2. Smith DK, et al. The effects of simulated unstable scaphoid fractures on carpal motion. J Hand Surg [Am] 1989; 14(2 Pt 1):283 –291. 3. Linscheid RL, Dobyns JH, Beabout JW, et al. Traumatic instability of the wrist: diagnosis, classification, and pathomechanics. J Bone Joint Surg Am 1972; 54(8):1612– 1632. 4. Jupiter JB, Shin AY, Trumble TE, et al. Traumatic and reconstructive problems of the scaphoid. Instr Course Lect 2001; 50:105–122. 5. Mack GR, Bosse MJ, Gelberman RH, et al. The natural history of scaphoid non-union. J Bone Joint Surg Am 1984; 66(4):504–509. 6. Ruby LK, Stinson J, Belsky MR. The natural history of scaphoid non-union: a review of fifty-five cases. J Bone Joint Surg Am 1985; 67(3):428– 432. 7. Vender MI, Watson HK, Wiener BD, et al. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg [Am] 1987; 12(4):514–519. 8. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg [Am] 1984; 9(3):358– 365. 9. Watson HK, Weinzweig J, Zeppieri J. The natural progression of scaphoid instability. Hand Clin 1997; 13(1):39– 49. 10. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br 1984; 66(1):114–123. 11. Wozasek GE, Moser KD. Percutaneous screw fixation for fractures of the scaphoid. J Bone Joint Surg Br 1991; 73(1):138–142. 12. Toh SH, Inoue S, Tsubo K, Nakamura R, Nakahara K. The treatment of scaphoid fractures using free-hand insertion of a Herbert screw. In: Linscheid RLM, Nakamura R, eds. Wrist Disorders. Tokyo: Springer, 1992:177–181. 13. Haddad FS, Goddard NJ. Acute percutaneous scaphoid fixation: a pilot study. J Bone Joint Surg Br 1998; 80(1):95–99.

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14. Inoue G, Shionoya K. Herbert screw fixation by limited access for acute fractures of the scaphoid. J Bone Joint Surg Br 1997; 79(3):418–421. 15. Adolfsson L, Lindau T, Arner M. Acutrak screw fixation versus cast immobilisation for undisplaced scaphoid waist fractures. J Hand Surg [Br] 2001; 26(3):192– 195. 16. Slade JF III, Jaskwhich D. Percutaneous fixation of scaphoid fractures. Hand Clin 2001; 17(4):553–574. 17. Bond CD, Shin AY, McBride MT, et al. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am 2001; 83A(4):483–488. 18. Yip HS, Wu WC, Chang RY, et al. Percutaneous cannulated screw fixation of acute scaphoid waist fracture. J Hand Surg [Br] 2002; 27(1):42–46. 19. Weber ER, Chao EY. An experimental approach to the mechanism of scaphoid waist fractures. J Hand Surg [Am] 1978; 3(2):142– 148. 20. Horii E, Nakamura R, Watanabe K, et al. Scaphoid fracture as a “puncher’s fracture.” J Orthop Trauma 1994; 8(2):107– 110. 21. Tsubo K, Toh S, Inoue S. Scaphoid fractures caused by punch actions. J Jpn Soc Surg Hand 1992; 9:713 –716. 22. Rettig AW, Weidenbener EJ, Gloyeske R. Gloyeske R. Alternative management of midthird scaphoid fractures in the athlete. Am J Sports Med 1994; 22:711–714. 23. Toh S, Miura H, Arai K, et al. Scaphoid fractures in children: problems and treatment. J Pediatr Orthop 2003; 23(2):216–221. 24. Watson HK, Ashmead DT, Makhlouf MV. Examination of the scaphoid. J Hand Surg [Am] 1988; 13(5):657–660. 25. Peh WC, Gilula LA. Normal disruption of carpal arcs. J Hand Surg [Am] 1996; 21(4):561–566. 26. Youm Y, McMurthy RY, Flatt AE, et al. Kinematics of the wrist. I. An experimental study of radial-ulnar deviation and flexion-extension. J Bone Joint Surg Am 1978; 60(4):423–431. 27. Fernandez DL. A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg [Am] 1984; 9(5):733–737. 28. Sanders WE. Evaluation of the humpback scaphoid by computed tomography in the longitudinal axial plane of the scaphoid. J Hand Surg [Am] 1988; 13(2):182–187. 29. Bain GI, et al. Longitudinal computed tomography of the scaphoid: a new technique. Skeletal Radiol 1995; 24(4):271–273. 30. Ayabe KI, Ugai K, Nishiura Y, Iwabu S, Sato K. Coronal and sagittal section CT in the hand and wrist. Seikeigeka 1998; 49(10):1296–1299. 31. Leslie IJ, Dickson RA. The fractured carpal scaphoid: natural history and factors influencing outcome. J Bone Joint Surg Br 1981; 63B(2):225– 230. 32. Dias JJ, Brenkel IJ, Finlay DB. Patterns of union in fractures of the waist of the scaphoid. J Bone Joint Surg Br 1989; 71(2):307–310. 33. Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg [Am] 1991; 16(3):474–478. 34. Shin AY, Bishop AT. Pedicled vascularized bone grafts for disorders of the carpus: scaphoid nonunion and Kienbock’s disease. J Am Acad Orthop Surg 2002; 10(3):210–216. 35. Viegas SF. Limited arthrodesis for scaphoid nonunion. J Hand Surg [Am] 1994; 19(1):127–133. 36. Tomaino MM, Miller RJ, Cole I, et al. Scapholunate advanced collapse wrist: proximal row carpectomy or limited wrist arthrodesis with scaphoid excision? J Hand Surg [Am] 1994; 19(1):134–142.

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37. Ring D, Jupiter JB, Herndon JH. Acute fractures of the scaphoid. J Am Acad Orthop Surg 2000; 8(4):225–231. 38. Menapace KA, Larabee L, Arnoczky SP, et al. Anatomic placement of the Herbert– Whipple screw in scaphoid fractures: a cadaver study. J Hand Surg [Am] 2001; 26(5):883–892. 39. Wu WC. Percutaneous cannulated screw fixation of acute scaphoid fractures. Hand Surg 2002; 7(2):271–278. 40. Slade JF III, Gutow AP, Geissler WB. Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach. J Bone Joint Surg Am 2002; 84A(suppl 2):21 –36. 41. Russe O. Fracture of the carpal navicular: diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg Am 1960; 42A:759–768. 42. Nakamura R, Hori M, Horii E, et al. Reduction of the scaphoid fracture with DISI alignment. J Hand Surg [Am] 1987; 12(6):1000–1005. 43. Trumble TE, Clarke T, Kreder HJ. Non-union of the scaphoid: treatment with cannulated screws compared with treatment with Herbert screws. J Bone Joint Surg Am 1996; 78(12):1829–1837. 44. Slade JF III, Grauer JN, Mahoney JD. Arthroscopic reduction and percutaneous fixation of scaphoid fractures with a novel dorsal technique. Orthop Clin North Am 2001; 32(2):247–261. 45. Toh S, Nagao A, Harata S. Severely displaced scaphoid fracture treated by arthroscopic assisted reduction and osteosynthesis. J Orthop Trauma 2000; 14(4): 299 –302. 46. Whipple TL. Stabilization of the fractured scaphoid under arthroscopic control. Orthop Clin North Am 1995; 26(4):749–754.

7 Distal Radius Fractures Karl-Josef Prommersberger and Thomas Pillukat Klinik fu¨r Handchirurgie, Bad Neustadt, Germany

INTRODUCTION Fractures of the distal radius are extremely common injuries, which are steadily becoming a public health issue. Although it was once believed that all patients with distal radius fractures did relatively well, regardless of the treatment, it is now well-recognized that undertreated distal radius fractures may be often associated with poor results. The primary goals of treatment should be restoration of pain-free hand and wrist function and prevention of long-term disability. EPIDEMIOLOGY In the 1970s and 1980s, fractures of the distal radius were estimated to account for upwards of one-sixth of all fractures seen in the emergency room (1,2). Some have suggested that they may account for approximately 25% of all long-bone fractures (3). Fractures of the distal radius are associated with osteoporosis. They are more common in women than in men with an incidence increasing rapidly after menopause and reaching a maximum between 60 and 69 years (4 – 10). The most common injury mechanism is a fall from a standing height (11,12). Hegeman et al. (13) assessed the bone mineral density (BMD) of the lumbar spine and hip in 94 women (mean age, 69 years) with a distal radius fracture. A low BMD was found in 85% of the patients, and osteoporosis was diagnosed in 51%. Ring and Jupiter (14) suspected that fracture of the distal radius is typically a fracture of relative fit osteoporotic individuals. Looking at the survival 137

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among elderly patients after fractures of the distal radius, Rozental et al. (15) found at seven years after the fracture that survival rates after distal radius fractures were notably lower than those expected for individuals of the same age and gender in standard populations. Men were twice as likely to die as women and did so almost twice as quickly. In addition, in older males, a recent study found that a fracture of the distal radius was associated with a risk of hip fractures statistically significantly greater than in women (16). As the population ages, fractures of the distal radius may become a significant challenge to the orthopedic surgeon and the health care system. CLASSIFICATION Despite the fact that the observations of Colles, Barton, Smith, and Pouteau were made solely from postmortem specimens, their descriptions of fracture morphology have served as guidelines for treating surgeons over 150 years and may still provide a comfortable base for communication among clinicians (17). Classification systems for fractures of the distal radius have focused on the direction of fracture displacement, the radiographic appearance, the mechanism of injury, the articular joint surface involvement, and the degree of comminution (5,18–26). We have found the classification system of Fernandez (26) extremely helpful in decision-making in our clinical practice and the arbeitsgemeinschaft fu¨r osteosynthesefragen/association for the study of internal fixation (AO/ASIF) Comprehensive Classification of Fractures (23) useful in preparing scientific papers. The Comprehensive Classification of Fractures (AO/ASIF Classification) The Comprehensive Classification of Fractures (or AO classification) divided fractures of the distal radius into three types: extraarticular fractures (type A), partial articular fractures (type B), and complete articular fractures (type C). Further divisions into groups and subgroups are based upon patterns and severity of articular and metaphyseal comminution. Observer reliability and reproducibility is adequate for the three basic types of the classification but was less reliable when analyzing the groups and subgroups (27 –31). Fernandez’ Classification Fernandez divided distal radius fractures into five major types (Fig. 1). Type I fractures are bending fractures of the metaphysis in which one cortex fails to tension stress and the opposite cortex shows a certain degree of comminution. Type II fractures are shearing fractures of the joint surface. Type III fractures are compression fractures of the joint surface with impaction of the subchondral and metaphyseal cancellous bone. Type IV fractures are avulsion fractures of ligament attachments, including ulnar and radial styloid fractures associated with radiocarpal fracture dislocations. Type V fractures result from high-energy

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Figure 1 Fernandez’ classification for fractures of the distal radius.

injuries and involve combinations of bending, compression, shearing, and avulsion mechanism and often bone loss.

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Distal Radioulnar Joint In 1996, Fernandez and Jupiter (32) established a prognosis- and treatmentoriented classification of distal radioulnar joint injuries associated with fractures of the lower end of the radius. Depending on the residual stability of the distal radioulnar joint (DRUJ) after reduction and stabilization of the radius, three basic types of DRUJ lesions were differentiated. Type I are stable DRUJ lesions, which means that the joint is clinically stable and the radiographs show articular congruity. Type II are unstable DRUJ lesions with clinical and radiographic evidence of subluxation or dislocation of the ulnar head. Type III are potentially unstable lesions due to extension of distal radius fracture in the sigmoid notch or due to a fracture of the ulnar head.

FUNCTIONAL AND RADIOGRAPHIC ANATOMY The distal radius articulates with both the proximal carpal row and the head of the ulna. The radiocarpal articular surface is divided into the scaphoid and lunate fossae. These two concave articular surfaces are separated from each other by a bony dorsal-volar ridge, the crista radii (33). The articular surface of the distal radius inclines volarward in the sagittal plane an average of 108 to 128 (34 –41) and inclines ulnarward in the frontal plane an average of 228 (42 – 45). The sigmoid notch is a concave structure that articulates with the ulnar head (46). The shape and the orientation of the sigmoid notch of the radius vary in relation to the ulnar variance (47). With rotation of the radius about the ulna, the ulnar head translates volarly in supination and dorsally in pronation (48 – 50). The ulnar side of the wrist is supported by the triangular fibrocartilage complex (TFCC), which articulates with both the lunate and the triquetrum. The TFCC and radioulnar ligaments were attached to the ulnar edge of the distal radius and may be injured in lunate fossa fractures, and disruptions of distal radioulnar joint (51 – 53). The radial border of the TFCC is attached along the entire margin of the lunate fossa of the distal radius and onto its border with the sigmoid notch. The TFCC originates from the base of the ulnar styloid. Although the volar metaphyseal surface of the distal radius is relatively flat, the dorsal aspect of the distal end of the radius is convex with specific areas for anchoring the extensor retinaculum. The first dorsal extensor compartment tendons run through a groove on the radial styloid. The extensor pollicis longus (EPL) is routed around Lister’s tubercle, which functions as a fulcrum. Ligamentotaxis for reduction of fractures of the distal radius is possible because of dorsal and volar radiocarpal ligaments (54). The volar ligaments transmit more force to fracture fragments around the distal radius than do the dorsal ligaments when traction is applied across the wrist joint. Several investigators, such as Medoff and Kopylov (55), Pechlaner (56), and Rikli and Regazzoni (57), have realized that the distal metaphyseal and

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articular regions of the radius and the ulna represent structural units or “columns.” Rikli and Regazzoni described an ulnar column comprising the distal ulna, TFCC, and distal radioulnar joint; an intermediate column made up of the lunate fossa and sigmoid notch of the radius; and a lateral column including the scaphoid fossa and radial styloid process. Medoff and Pechlaner divided fractures of distal radius into five fracture components: the radial column, which is comprised three orthogonally oriented cortical surfaces; the dorsal and the volar rim, and the intra-articular and ulnar split. These concepts have added substantially to our understanding of methods for achieving operative stability of complex fractures and have lead to the development of implants designed specifically for the anatomy of the various columns. The radiographic anatomy of the distal radius and its relationship to the distal end of the ulna can be evaluated using four measurements: the volar tilt, the ulnar inclination, the radial length, and the ulnar variance (Fig. 2). To provide reliable data, a standardized radiographic technique is essential. Because the elbow and shoulder positions affect the relationship between the distal radius and the ulna, the standard posterior – anterior view of the wrist should be obtained with the elbow flexed 908 and the shoulder abducted 908 with the forearm and wrist in a neutral position. The hand is placed palm flat on the cassette without any flexion, extension, or deviation. A correct position of the examination shows the edge or the entire groove of the extensor carpi ulnaris tendon is at or radial to the fovea at the base of the ulnar styloid. The lateral view of the wrist is taken with the elbow flexed 908 and adducted against the trunk with the forearm and wrist in neutral position whilst a vertical X-ray beam enters radially and exits ulnarly at the level of the distal pole of the scaphoid (58). A correct position of the examination shows the volar surface of the pisiform located at the midpoint between the volar surface of the distal pole of the scaphoid and volar surface of the capitate head. For both, the posteroanterior (PA) view and the lateral of the wrist at least 5 cm of the distal radius have to be included to allow for accurate assessment of the long axis of the radius. Radial length, also called radial height or length of the radial styloid, is defined as the distance between two lines perpendicular to the long axis of the radius, one passing through the distal tip of the radial styloid and the other passing through the most distal aspect of the ulnar articular surface of the radius. The average is 11 to 12 mm (34,40). This distance is less useful in assessing relative radial shortening, because it reflects loss of ulnar inclination of the articular surface of the distal radius and not the position of the distal articular surface of the radius relative to the articular surface of the distal ulna. The ulnar variance describes the relative positions of the distal articular surfaces of the radius and the ulna. All methods used to measure ulnar variance have shown to be highly reliable with respect to intra- and interobserver variations (59,60). Therefore, clinicians may use whichever technique he or she prefers when measuring ulnar variance. According to Gelberman et al. (61), the measurement can be obtained as the difference along the line of the longitudinal axis of

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Figure 2 Radiographic anatomy of the distal radius. (A) The volar tilt is determined by a line (Z) perpendicular to the long axis (X) of the radius, as determined by a line through the center of its medullary space at 2 cm (B) and 5 cm (A)proximal to the radiocarpal joint and a line (Y) joining the most distal parts of the dorsal and the volar rims of the radial articular surface. (B) Radial length is defined as the distance (D –E) between two lines perpendicular to the long axis of the radius, one passing through the distal tip of the radial styloid and the other passing through the most distal aspect of the ulnar articular surface of the radius (C). The degree of ulnar inclination is derived by an intersection of a line formed between the radial styloid and the sigmoid notch (Y) and one perpendicular to the long axis of the radius (Z). (C) According to Gelberman et al. (61), the ulnar variance is determined as the difference along the line of the longitudinal axis of the forearm between a perpendicular line at the ulnar edge of the lunate facet of the distal radius articular surface and another perpendicular at the distal articular surface of the ulnar head.

the forearm between a perpendicular line at the ulnar edge of the lunate facet of the distal radius articular surface and another perpendicular at the distal articular surface of the ulnar head. A difference of 2 mm in length between the radius and the ulna is considered normal (62). A positive ulnar variance occurs when the articular surface of the ulna is distal to the distal articular surface of the radius. Post-traumatic positive ulnar variance due to radial shortening can cause ulnar impaction with degenerative tears of the TFCC and the luno-triquetral ligament (51 –53,63).

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The volar tilt, also known as dorsal tilt, dorsal angle, volar tilt, and volar slope, is determined by a line joining the most distal parts of the dorsal and the volar rims of the radial articular surface. The degree of the volar tilt is derived by an intersection of the line of volar tilt and one perpendicular to the long axis of the radius, as determined by a line through the center of its medullary space at 2 and 5 cm proximal to the radiocarpal joint (41). The ulnar inclination, also called radial inclination or radial tilt, describes the angulation of the distal radial articular surface in relationship with the long axis of the radius in the frontal view. It is determined by a line perpendicular to the long axis of the radius and a line formed between the radial styloid and the distal sigmoid notch (64). When evaluating the extent of deformity caused by an extraarticular fracture of the distal radius, comparing the radiologic criteria outlined above to those of the opposite uninjured side will clarify the extent of displacement (65). For intra-articular fractures, several investigators have shown that computed tomography (CT) scans improve the sensitivity of measurement of articular surface gapping, improved the accuracy of detection of comminution, and altered proposed treatment plans within observers (66 – 70). In addition, CT appears to be a superior diagnostic modality for detecting and quantifying sigmoid notch fracture step-off and articular gapping as well as subluxation and dislocation of the distal radioulnar joint (71 – 73). In most distal radius fractures, standard radiographs of the wrist in two plains will be adequate to control the reduction and to measure the final radiological result at the time of fracture union. In a study of Chern et al. (74), sonographically guided monitoring compared well with conventional radiographic techniques during closed reduction of extraarticular distal radial fractures. However, after open reduction and internal fixation of the distal radius screw position relative to the articular surface may be difficult to determine on standard PA and lateral radiographs taken perpendicular to the long axis of the forearm in both the frontal and the sagittal planes, in part because of the failure of standard radiographic views to compensate for the normal inclination and tilt of the distal radius articular surface. In addition, the dorsal plate often obscures the articular surface itself on both PA and lateral views. Boyer et al. (75) have shown the so-called anatomic tilt PA and lateral radiographs of the distal radius to be an accurate and clinically useful tool for the evaluation of both the presence and location of screw penetration of the articular surface after dorsal plating. Distinctive to volar fixed-angle plating of the distal radius, the optimal position of the distal fixed-angle support is in the subchondral bone immediately proximal to the articular surface. Standard radiographic imaging of the distal radius during placement of a volar fixed-angle plate does not provide adequate visualization of the subchondral bone –distal support interface. To address this specific issue of whether volar hardware placed at the immediate subchondral bone level has effectively avoided the radiocarpal joint, Smith and Henry (76) described a 458 pronated oblique view of the distal radius. If there are concerns in regard to

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screw penetration in the articular surface of the distal radius, CT scanning may be helpful (77) (Fig. 3). BIOMECHANICS Normal wrist biomechanics depend upon maintenance of the anatomical position of the distal end of the radius with respect to the carpus and the distal end of the ulna. Normal wrist motion consists of greater than 1208 of wrist flexion and extension, 508 of wrist radial and ulnar deviation, and 1508 of forearm rotation at the DRUJ (78). The distal radius carries 80% of the axial load through the wrist, and the distal ulna carries 20% (79). In clinical and laboratory studies, multidirectional deformity of the distal radius caused alterations of the radiocarpal joint, the midcarpal joint, and the distal radioulnar joint (80). The osseous deformity affects the normal mechanics of the radiocarpal joint producing a limitation of the extension-flexion arc of motion. In addition, the malalignment affects the normal load transmission through the radiocarpal joint, but also across the whole wrist joint. Dorsal tilting of radial surface shifts axial loading through the wrist dorsally and ulnarly and decreases the joint contact area. The pressure distribution on the radial articular surfaces becomes more concentrated (81 – 84) and may represent a prearthritic condition of the wrist joint (85). Furthermore, shortening of the radius and dorsal tilting of the articular surface increase the force borne by the ulna. The load through the ulna increases from 21% to 67% of the total load as the angulation of the distal radius fragment increases from 108 of volar tilt to 458 of dorsal tilt (86). Lengthening of the ulna by 2.5 mm increases the force borne by the ulna from 18.4% to 41.9% of the total axial load (79). Malalignment of the surface of the distal radius in both the sagittal and coronal planes may result in a decreased mechanical advantage of the flexor tendons as they pass through the carpal tunnel (87), diminishing grip strength. In addition, median nerve compression neuropathy can also be encountered as a result of the deformity of the distal radius (88 – 94). At the midcarpal level, dorsal tilt of the distal radius may lead to a compensatory flexion deformity as an adaptive response to the dorsally rotated proximal carpal row (95), an extrinsic midcarpal dynamic instability (96), and a fixed carpal malalignment in dorsiflexion (97). Angular and shortening deformity of the distal radius may cause incongruity of the distal radioulnar joint and reduction of radioulnar contact area (98). Radial shortening in relation to the distal part of the ulna can increase the strain in the TFCC (99) and result in a disruption of the deep portion of the dorsal radioulnar ligament (100). These factors may limit the arc of forearm rotation (101,102). Fellmann et al. (103) found that an anatomical reduction of acute distal radial fracture correlated with a significantly better range of motion, whereas

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Figure 3 (Continued on next page) Open reduction and internal fixation of a dorsally angulated, comminuted distal radius fracture with 908 to 908 plates position. (A) An intraarticular fracture of the distal radius was stabilized with an external fixator. (B and C) Preoperative CT demonstrated substantial intraarticular and metaphyseal comminution. (D and E) The postoperative radiographs demonstrate the situation after open reduction and internal fixation with a 908 to 908 plating with one plate applied lateral to the radial styloid and use of a volar fixed-angle plate without bone grafting. On the anteroposterior view, the articular surface of the radius seems to be well restored. However, there may be some concerns whether the distal pegs have effectively avoided the radiocarpal joint. In addition, the distal pegs and screws obscure the articular surface on the lateral view. (F and G) Postoperative CT demonstrates that screw penetration in the articular surface of the distal radius was avoided. To diminish side effects from the hardware, the software program for CT has to be modified. Abbreviation: CT, computed tomography.

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Figure 3 (Continued from previous page)

McQueen and Caspers (104) found that motion was significantly worse in wrists with dorsal angulation of more than 128. Jenkins and Mintowt-Czyz (105) and Cooney et al. (106) reported that decreased grip strength had a close relationship with the severity of residual fracture deformity. Aro and Koivunen (107) found that the functional end result was unsatisfactory in only 4% of the patients with an acceptable anatomic result, compared with 25% of the patients with minor shortening and 31% of the patients with gross shortening of the radius. TREATMENT General Considerations In spite of the anatomic and biomechanic rationale supporting attempts to restore the alignment of the fractured distal radius, the need for anatomic reduction

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remains controversial, and several studies have championed one side or the other. Furthermore, in spite of the explosion of new implants designed specifically for internal fixation of distal radius fractures, the role of traditional treatment methods such as closed reduction and casting, percutaneous K-wire pinning, and/or external fixation must also be considered (108). In a prospective study, Anzarut et al. (109) looked at the radiological and patient-reported functional outcomes in 74 patients who were at least 50 years of age with conservatively treated distal radius fractures. The average dorsal/ volar tilt measured by a radiologist was 3.48 dorsal; overall 47 patients (64%) were considered to have an acceptable radiographic reduction (dorsal tilt ,108 or volar tilt ,208). Acceptable radiographic reduction was not associated with better generic physical or mental health status, lesser degrees of upper-extremity disability, or greater satisfaction with outcomes than was unacceptable reduction. The average score on the DASH (disabilities of the arm, shoulder, and hand) was 24 (SD 17). Forty-four (60%) of the 74 patients were satisfied with their functional status six months after injury. The DASH score averaged 27 (SD 19) in patients judged to have unacceptable dorsal/volar tilt and 22 (SD 16) in patients with an acceptable radiographic result. In a prospective, randomized study of 57 patients older than 60 years of age with unstable, extraarticular fractures of the distal radius, Azzopardi et al. (110) looked at the outcome of immobilization in a cast alone compared with that using supplementary, percutaneous pinning. At one year, the mean volar/dorsal tilt, radial length, and ulnar inclination were significantly better in patients treated using percutaneous wire fixation than in patients by immobilization in a cast alone, but ulnar variance was not. Nonetheless, there was no significant difference in functional outcome in terms of pain, range of movement, grip strength, activities of daily living, and the SF-36 score except for an improvement of the range of motion in ulnar deviation in the percutaneous wire group. The authors concluded that percutaneous pinning of unstable, extraarticular fractures of the distal radius provides an improvement in the radiological parameters compared with immobilization in cast alone, but this does not correlate with an improved functional outcome in the investigated population of elderly people. Harley et al. (111) evaluated augmented external fixation versus percutaneous pinning and casting for unstable fractures of the distal radius in a prospective fashion with a one-year radiographic and clinical follow-up period. Their hypothesis was that external fixation with augmentation would provide superior results compared with percutaneous pinning and casting. Fifty patients younger than 65 years of age were randomized into these treatment groups. Over 80% of the fractures were classified as AO/ASIF C2 or C3 and there was a similar distribution of fracture types in each group. The use of augmented external fixation did not improve the mean radiographic outcome with respect to radial length, ulnar inclination, and volar tilt. Improved articular surface reduction was noted with the use of an external fixator but overall only three patients were recognized to have steps or gaps greater than 2 mm. No significant differences in mean

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DASH scores, total range of motion, and grip strength were found between the groups. However, all three patients diagnosed with a chronic regional pain syndrome had external fixation. Kreder et al. (112) conducted a prospective, randomized study comparing open reduction and internal fixation with indirect reduction and percutaneous fixation for treatment of displaced intra-articular fractures of the distal radius. Internal fixation, usually involving an arthrotomy, was performed either through an extended carpal tunnel approach on the volar side or between the third and fourth compartments on the dorsum of the wrist. If necessary, fixation by small- or mini-fragment plates and screws was supplemented with K-wires or an external fixator. Percutaneous fixation was limited to percutaneous K-wires, cannulated or regular small- or mini-fragment screws, and/or external skeletal fixation. An arthrotomy was not performed. A total of 179 adult patients were followed for two years with careful patient-related and physician-related outcome assessments. There were no statistically significant differences in the radiological restoration of anatomical features or the range of movement between the two groups. However, during the study period, patients treated with indirect reduction and external fixation had a more rapid return of function and a better functional outcome as those who underwent open reduction and internal fixation, provided that the intraarticular step and gap deformity were minimized. The Cochrane Musculoskeletal Injuries Trial Registry reviewed 44 “eligible” trials, such as those mentioned above, over a 13-year period comprising a total of 3193 patients with 3197 fractures. They concluded that there is neither enough evidence to tell whether surgery gives a better result nor which type of surgery is best for most types of fractures. In other words, there is neither “one way” nor “one implant” to treat fractures of the distal radius and often different ways of treatment lead to similar results. The relationship between anatomy and function of the distal radius may be more notable in active, healthy patients and after high-energy injury. Substantial malalignment will lead to carpal malalignment and distal radioulnar joint dysfunction. Associated problems such as carpal fractures or ligament injuries, acute carpal tunnel syndrome, and hand swelling and stiffness are important sources of dysfunction after distal radius fractures. Furthermore, many of our treatments can lead to problems. To achieve the goal of restoring the distal radius as a base for optimal hand and wrist function, we consider three questions: (i) Who is the patient? Infirm or healthy? High-demand or low-demand? Good bone/high-energy versus poor bone/low energy? (ii) What is the extent and pattern of articular involvement? (iii) What is the integrity of metaphyseal support? The first question highlights the role of the patient interview and examination. The history and physical examination should include age, occupation, daily activity level, and general medical condition. The population of healthy older people is expanding rapidly. Many of these patients remain active well into their eighth decade, some of them pursuing activities such as skiing, golf,

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or tennis. On the other hand, most of the older persons have at least one chronic medical condition and many have multiple medical conditions. Keeping in mind that in the elderly the bone of the distal radius is weaker and thus not only more likely to fracture but also more likely to collapse with plaster immobilization, the aggressiveness with which we treat the fracture must be tempered by the patient’s functional limits and general medical condition rather than by the patient’s age. Therefore, we have found it helpful for treatment purposes to divide adult patients with fracture of the distal radius into two groups: the physiological young and/or active and the physiological old and/or inactive. In addition to age and activity, the physical examination should define the urgency of treatment by inspecting the wrist for wounds, tendon, and nerve function, with special attention to the function of the median nerve. The second question addresses the extent of fractures involving the articulations between the radius and the proximal carpal row, and the radius with the ulnar head. As shown by Kreder et al. (112), the final outcome on distal radius fractures following fracture union depends primarily on residual joint stability and the presence or absence of post-traumatic arthritis of the DRUJ. For the radiocarpal joint surface of the distal radius, it is generally accepted that a greater than 2 mm step-offs or gaps seen on plain radiographs is likely to lead to an unacceptable outcome. In a retrospective study, Knirk and Jupiter (113) investigated the effect of residual radiocarpal incongruity after intra-articular fractures of the distal end of the radius in young adults. At a mean follow-up of 6.7 years, there was radiographic evidence of post-traumatic arthritis in 28 (65%) of the fractures. Accurate articular restoration was the most critical factor in achieving a successful result. Of the 24 fractures that healed with residual incongruity of the radiocarpal joint, arthritis was noted in 91%, whereas of the 19 fractures that healed with a congruous joint, arthritis developed in only 11%. In addition, radial styloid fractures with the fracture line ending at the scapholunate gap should be suspected of the concurrence of the distal radial fracture with a scapholunate dissociation (114). The third question directs the surgeon to determine the metaphyseal support. If the volar metaphysis is involved, the fracture may be reducible but will never maintain reduction. Those dorsal fractures with involvement of greater then one-third of the sagittal diameter of the radius metaphysis may redisplace despite excellent close reduction, because those fractures are inherently unstable. Extensive metaphyseal comminution with involvement of both the dorsal and volar metaphysis makes it more difficult to restore the alignment of the distal fragments and leaves them with little or no bone-to-bone contact to help prevent loss of alignment despite external fixation with or without ancillary K-wires or internal fixation with a single dorsal or volar plate. Treatment options for fractures of the distal radius can be divided into nonoperative or operative treatment. The surgical options of treatment of distal radial fractures can be categorized into three main tools that may be used individually or in combination to obtain optimal stability: percutaneous pinning, external

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fixation, and internal fixation. Whether patients have a nondisplaced fracture requiring a minimal degree of immobilization or a markedly displaced fracture requiring open reduction and internal fixation, all patients need to be instructed and encouraged to perform hand and finger exercises, such as the “six pack” of exercises described by Dobyns and Linscheid (115). Most patients can perform these on their own, but some may benefit from supervised hand therapy. Shoulder and elbow motion should also be encouraged and maintained during healing, especially in the elderly. Nondisplaced Distal Radius Fractures Nondisplaced and minimally displaced distal radius fractures can be treated with a removable prefabricated splint of the wrist, leaving the elbow, fingers, and thumb free to avoid stiffness. O’Connor et al. (116) conducted a study in which 66 adult patients with minimally displaced distal radial fractures were randomly assigned to treatment with either a plaster cast or a lightweight removable splint. Outcome assessment by clinical and radiological evaluation, and an independent physiotherapy assessment showed greater satisfaction, few treatmentrelated problems, and a superior functional assessment score at six weeks for the removable splint compared to the cast. A prefabricated, functional brace can also recommended for those patients with displaced fractures which need closed manipulation as reported in a prospective, randomized study by Tumia et al. (117). A total of 339 patients were placed into two groups, those with minimally displaced fractures not requiring manipulation and those with displaced fractures which needed manipulation. Treatment was by either a conventional Colles’ plaster cast or with a prefabricated functional brace. Similar results were obtained in both groups with regard to the reduction and to pain scores but the brace provided better grip strength in the early stage of treatment. This was statistically significant after five weeks for both manipulated and nonmanipulated fractures. There was no significant difference in the functional outcome between the two treatment groups. However, younger patients and those with less initial displacement had better functional results. Displaced Distal Radius Fractures On the basis of the large body of clinical and experimental evidence, we believe that an attempt at anatomic reduction of most distal radius fractures is warranted. However, if substantial displacement is present—defined as intra-articular displacement greater than 2 mm, metaphyseal angulation greater than 208, or metaphyseal shortening from a collapse greater than 3 mm—there is a high risk for secondary displacement during the immobilization period (118). In a prospective study, Nesbitt et al. (119) evaluated the radiographic outcome of unstable distal radius fractures in 50 patients with three or more instability factors as described by Lafontaine et al. (120) treated by closed reduction and sugar tong splinting.

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At four weeks after reduction, only 46% of these unstable distal radius fractures maintained an adequate reduction. Of the 54% of fractures that failed to maintain an adequate reduction, age was the only statistically significant predictor of secondary displacement. In our experience, secondary displacement is associated with a suboptimal outcome and sequelae in active or “physiologically young” patients. Again, when developing a treatment program the treating physician must always bear in mind the patient’s functional demands and general (medical) condition. Closed Reduction A good long-term prognosis after closed reduction and casting can be expected when there is limited displacement. There are essentially two different techniques for obtaining closed reduction, direct manipulation of the distal radius fragment, and longitudinal traction through the hand, wrist, and fracture site. It has been suggested that longitudinal traction results in a better reduction, is less painful, and has a lower rate of redisplacement than direct manipulation. Earnshaw et al. (121) compared these two methods in a prospective, randomized controlled trial. Two hundred and twenty-five patients that displaced Colles’ fractures were randomized to treatment with closed reduction with either finger-trap traction or manual manipulation. All underwent cast immobilization. The fractures were assessed radiographically by measurement of the ulnar inclination, volar tilt, and radial shortening before reduction, immediately after reduction, and at one and five weeks after reduction. No significant differences were found between the alignment of the fractures in the two treatment groups at any time. However, the percentages of fractures in an acceptable alignment (,108 dorsal tilt and radial shortening ,5 mm) were only 27% and 32% at five weeks after finger-trap traction and manual manipulation, respectively. The greatest challenge of closed treatment of dorsally displaced fractures of the distal radius is maintaining the position obtained by reduction of the fracture. The Cotton-Loder position with extreme volar flexion and ulnar deviation of the wrist might be mechanically effective in restoring volar tilt; however, this position can be dangerous, causing excessive median nerve compression and may also contribute to hand stiffness because it is difficult to close the fist with the wrist in this position. Our recommended position of immobilization for a dorsally tilted metaphyseal fracture is that of a neutral position with respect to extension/ flexion, and a slight ulnar deviation of the wrist. Although an argument can be made for immobilization of Colles’ fractures in a sugar tong splint or a longarm cast, we favor immobilization in a below-elbow cast or a prefabricated, functional brace because we feel that stability of the fracture determines maintenance of reduction far more than the method of immobilization. If displacement of the fracture would influence the patient and surgeon to consider operative care, radiographs should be used to monitor the fracture prior to the establishment of early healing that would make manipulative reduction more difficult (i.e., within two weeks). The patient should be warned that loss of reduction may occur.

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If redisplacement during the immobilization period occurs, remanipulation has been shown to have little value (122)—again most likely a reflection of the inherent instability of the fracture—and operative treatment should be considered. Jupiter et al. (123) achieved excellent and good results with open reduction and internal fixation in 18 of 20 patients aged 60 years and older who presented to their institution with a radius fracture made complex by virtue of displacement after closed reduction and cast or external fixation immobilization. Closed Reduction and Percutaneous K-Wire Fixation Percutaneous pinning alone is contraindicated in extraarticular fractures with marked metaphyseal comminution, in soft osteoporotic bone, and in fractures with severe shortening. It can be recommended for reducible extraarticular or simple intraarticular fractures without metaphyseal comminution and with good bone stock (Fig. 4). A variety of different techniques have been described in the literature. These include pins placed through the radial styloid, crossing pins from the radial and ulnar sides of the distal fragment into the distal shaft, intrafocal pinning as advocated by Kapandji (124), and transulnar pinning with or without transfixation of the DRUJ. In a prospective study on 96 patients with extraarticular or intra-articular dorsally displaced fractures of the distal radius, Lenoble et al. (125) compared the radiological and clinical outcome after transstyloid fixation and immobilization with Kapandji fixation and early mobilization. Pain and reflex dystrophy were more frequent after Kapandji fixation and early mobilization, but the range of movement was better although this became statistically significant after six weeks. The radiological reduction was better soon after Kapandji fixation, but there was some loss of reduction and increased radial shortening during the first three postoperative months. The clinical result at two years follow-up was similar in both groups. Percutaneous fixation techniques may be more reliable when supplemented with additional stabilization from bone grafts, bone graft substitutes, calcium phosphate bone cement, or external fixation (126). To avoid injury to the sensory branch of the radial nerve, it has been suggested that the K-wires be inserted through a small skin incision after blunt dissection with a small hemostat down to the bone. Alternatively, an oscillating wire driver can be used. The wires can be either cut beneath the skin or cut to lie outside the skin. To minimize the risk of pin infection, we prefer to cut off the wires just below the skin and then bent it back to the bone. However, this requires an operative procedure to remove the wires six to eight weeks later. In the rare situation of a deep infection after percutaneous pinning, operative treatment including removal of the pins is necessary. However, pin track infections are usually superficial and can be treated with wound care and antibiotics. Ruschel and Albertoni (127) observed six complications in 29 unstable extraarticular distal radius fractures treated by intrafocal Kapandji pinning. Four patients

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Figure 4 (A –C) K-wire fixation of a distal radius fracture.

developed reflex sympathetic dystrophy (RSD), one patient had a superficial K-wire infection, and another patient had radial nerve superficial branch paresthesia. External Fixation External fixation remains a valuable option in the management of fractures of the distal radius (Fig. 5). Depending on the specific mechanical features inherent in

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Figure 5 (A –D) External fixation for an unstable fracture of the distal end of the radius.

the fracture pattern, external fixation may act as a joint distractor, neutralization frame, buttress, or even for compression. In acute fractures, an external fixator is mainly used with joint distraction to obtain an indirect reduction of comminuted fractures by applying tension on the capsuloligamentous structures attached to the distal radius and after the device is statically locked to maintain fracture fragment alignment. Attention is important not only in the recognition of indications, functions, and limitations of the external fixation, but also on the application of a specific external fixator. It has been recognized that excessive distraction is harmful to the hand and median nerve and can created stiffness and develop

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sympathetic reflex dystrophy. In addition, distraction alone does not provide anatomical reduction in every case, especially in those fractures with intra-articular fragments and severe comminution. Finally, distraction alone often cannot prevent a secondary collapse. Therefore, several authors have advocated limited open reduction, supplementary pin fixation, or bone grafting in addition to external fixation (128 – 132). Others have tried to create dynamic fixators that maintain length and alignment but allow for wrist flexion and extension (133 – 135). By avoiding wrist traction, investigators hoped to avoid wrist stiffness, finger stiffness, or nonunion, all secondary to overdistraction. Overdistraction of the wrist can be avoided by applying a “nonbridging” fixator which does not span the wrist joint. The distal pins of a nonbridging external fixator are placed in the distal fracture fragments directly, permitting at least a limited arc of wrist motion (136). In a prospective comparison of spanning and nonspanning external fixators, McQueen (137) has found improved radiological results, grip, and wrist flexion in the nonspanning group at all stages of review. However, the results by Krishnan et al. (138), also comparing static bridging and dynamic nonbridging external fixation in a prospective randomized study, did not demonstrate a statistically significant difference in the radiological and clinical outcomes achieved with these two treatments. External fixation can also be used for temporary fixation in severe open fractures until the soft-tissue situation allow an open reduction and internal fixation and as a neutralization frame to unload and protect a fracture that has more tenuous internal fixation due to fracture complexity or osteoporosis. Limited Open Reduction and Internal Fixation The choice of surgical approach is dependent on the type of fracture, direction of displacement, associated injuries (if any) and now, where volar locking plates for the fixation of dorsally displaced distal radius fractures are available, in many fractures on the preference of the treating surgeon. Pneumatic tourniquet control is strictly recommended for all open procedures. Dorsal approach: A lazy-S or a straight longitudinal dorsal midline incision is made from the midcarpus proximally centered over the radius, extending between 8 and 10 cm (139). The third extensor compartment is opened, with the EPL tendon mobilized proximally and distally so that it can be transposed. The fourth and the second dorsal compartments are elevated with sharp subperiosteal dissection. Some surgeons prefer to resect the terminal branch of the posterior interosseous nerve. The fourth compartment extensor tendons are then retracted ulnarward, and the second and third compartments radialward. Using a T-plate for fixation of the radius fracture, Lister’s tubercle is ronguered flush with the shaft, while it is preserved when using a Pi-plate or two small plates. With extraarticular fractures or shearing dorsal fracture dislocation, the dorsal wrist capsule can be preserved because the accuracy of the reduction can easily be confirmed by the interdigitation of the fracture lines and by

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fluoroscopic control. To reduce the fragments under direct vision for complex intra-articular fractures with impacted articular fragments as well as for fractures associated with carpal bone or ligament injuries, the dorsal wrist capsule is opened by an incision along the dorsal rim of the distal radius, exploring the underlying proximal carpal row and the articular surface of the distal radius. After reduction and fixation of the fracture, the capsulotomy—if performed—is closed with side-to-side sutures and the extensor retinaculum is reapproximated, leaving the EPL tendon subcutaneous. Volar approaches: The most commonly used volar exposure of the distal radius is the distal part of the Henry (140) approach between the flexor carpi radialis and the radial artery. A longitudinal incision from the wrist flexion crease proximally, extending 5 to 8 cm is used. The flexor carpi radialis tendon and the flexor tendons are retracted ulnarly, thus protecting the median nerve, while the radial artery is retracted radially. The pronator quadratus is identified and with an L-shaped incision at its most radial and distal attachment elevated off of the radius with sharp dissection and retracted ulnarly. The volar carpal ligaments should not be incised. If a carpal tunnel release is necessary, a separate incision on the ulnar side of the palm should be made so that the volar cutaneous branch of the median nerve is not transected by connecting the incisions. After reduction and fixation of the fracture, the implant is covered by suturing the pronator quadratus to the edge of the brachioradialis. An extension of this approach can provide access to the articular surface and to the dorsal aspect of the radius (141). The first extensor compartment is opened and the brachioradialis tendon is released from its attachment at the distal radius to enable reduction of the radial styloid. To visualize the intraarticular fragments and the dorsal die-punch, the proximal shaft fragment must be pronated “out of the way” with a bone clamp. This gives free—intrafocal— access to the articular fragments through the fracture plane. After indirect reduction of these fragments against the proximal carpal row, the shaft fragment is supinated back in place. With more complex volarly displaced fractures, particularly with involvement of the volar die-punch fragment, and to avoid two incisions—if a carpal tunnel release is planned—in volar shearing fractures, a different approach is chosen. An incision is outlined to extend from the midpalm obliquely crossing the wrist flexor crease and extending proximally for 6 to 10 cm. The flexor retinaculum is opened at its ulnar border. The space between the ulnar vascular structures and the flexor tendons is dissected. The ulnar neurovascular bundle together with the flexor carpi ulnaris tendon are retracted ulnarly, whereas the flexor tendons, median nerve, and radial artery are retracted radially, exposing the pronator quadratus. After elevating the muscle from the radius, an excellent exposure of the medial side of the radius is given. Approach to the radial styloid: In some circumstances, a specific approach to the radial styloid may be useful. This can be done with a longitudinal

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incision between the first and second extensor compartments. Throughout the whole procedure, care must be taken to protect the branches of the superficial radial nerve and lateral antebrachial cutaneous nerves. The exposure includes subperiosteal elevation of the extensor compartments, which are then retracted away from the fracture site. If the exposure is extended distally to the tip of the radial styloid, then the dorsal branch of the radial artery is at risk. Limited open reduction and internal fixation: The concept of limited open reduction is defined as a selective surgical exposure of fracture fragments in association with closed reduction and in conjunction with arthroscopic treatment of distal radius fractures. Articular and metaphyseal fragments which remain displaced after closed reduction are approached through limited incisions in an effort to achieve anatomic reduction with minimal soft-tissue disruption devascularization of the fragments. The choice of surgical approach depends on the location of the displaced fragment. The limited incision allows only the use of small implants such as wires, tension bands, and small buttress plates. The following fractures cannot be managed by limited open reduction: irreducible metaphyseal fractures, shearing marginal fractures of the joint surfaces, irreducible intra-articular fractures, radiocarpal fracture dislocations, redisplaced fractures after closed reduction, fractures associated with carpal or DRUJ injuries which need to be addressed operatively, and fractures associated with soft-tissue lesions. The choice of surgical approach depends on the location and direction of displacement of the fracture fragments, but also on the implant that the surgeon prefers to use for stabilization of the fracture. In addition, soft-tissue problems as well as associated carpal and DRUJ injuries may influence the choice of the surgical approach. Volarly displaced fractures have to be approached through volar exposures. But dorsally angulated fractures can be approached dorsally or volarly using a volar fixed-angle plate fixation (Fig. 6). Volar incisions are also appropriate for primary repair of a torn wrist capsule in radiocarpal fracture dislocations and whenever median nerve decompression is indicated. Combined dorsal and volar exposure and fixation: Complex articular and metaphyseal fractures of the distal radius may merit a combined dorsal and volar exposure and plate fixation (142,143). A single dorsal or volar plate may not provide adequate stability, and the distal fragments may displace in the direction opposite to the plate. The combined dorsal and volar plate can cradle the articular fragments, compressing them together and providing improved support at the metaphyseal level (Fig. 7). Distraction plating: As an alternative for double plating, internal distraction plating can also be used for the treatment of highly comminuted distal radius fractures especially in the elderly patient (144). The technique involves the use of 3.5 or 2.7 dynamic compression plates. The instrumentation is applied in distraction dorsally from the radial diaphysis, bypassing the

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Figure 6 Fixation of a dorsally displaced distal radius fracture with a volar fixed-angle device. (A and B) Radiographs of a 40-year-old man showing an extraarticular dorsally displaced distal radius fracture. (C and D) Postoperative radiographs demonstrating anatomic reconstruction of the distal radius using a volar fixed-angle plate and screws.

comminuted segment, and fixed to the long metacarpal (Fig. 8). A disadvantage of this technique is the need for a second operation to remove the plate. Implants for Internal Fixation An innumerable and ever-increasing variety of implants for internal fixation of fractures of the distal radius continue to appear, largely as a result of the attempts by many different companies to corner a part of this market. This together with a

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Figure 7 (Continued on next page) Combined dorsal and volar plate fixation of a complex fracture of the distal radius. (A) Radiograph of a type V complex distal radius fracture according to Fernandez in an elderly woman. (B and C) Preoperative CT scans reveal the severity of both intraarticular and metaphyseal comminution with involvement of the radial column, the central articular surface, the dorsal and the volar rim, and a split of the ulnar facet. In addition, CT scans demonstrate degenerative changes at the tip of the radial styloid. (D and E) Postoperative radiographs showing an acceptable reduction and restoration of radial length after open reduction, bone grafting, and volar and dorsal plate fixation. However, the dorsal plate obscures the articular surface on the frontal view. (F –H) Postoperative computed tomography scans confirm an acceptable realignment of the severely comminuted articular surface. Abbreviation: CT, computed tomography.

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Figure 7 (Continued from previous page)

steady stream of case series (level 4 evidence) claiming excellent results in the treatment of distal radial fractures using one special plate or another may be tiresome (145 – 156). Nonetheless, we believe that there have been some important developments. One was the inauguration of fixed-angle plate fixation and the other the development of the fragment specific fixation. Walz et al. (157) compared the loss of reduction after internal fixation of distal radius fractures in elderly patients following plate fixation with a conventional T-plate with that following fixed-angle plate fixation. The two groups were comparable with respect to age and fracture type, but there were more women in the group with the fixedangle plate fixation. A loss of reduction was found in 12 of the 30 patients treated with a conventional T-plate (40%), whereas a loss of reduction was observed only in two out of 44 patients (4.5%), which were treated with a fixed-angle device. In a biomechanical study, Dodds et al. (158) compared the fragment-specific fixation with low-profile modular implants and the augmented external fixation for intraarticular distal radius fractures. In the four-part fracture pattern,

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Figure 8 (Continued on next page) Internal distraction plating of distal radius fracture. (A) Radiograph of a 25-year-old, right-handed patient, who was injured in a motorcycle accident, with a fracture of the distal third of the ulna, and an open highly comminuted intraarticular distal radius fracture type V according to Fernandez. (B) Notice the fracture fragments in the wound. (C) These radiographs demonstrate the open reduction and internal fixation of the distal ulna fracture combined with repair of the laceration of the FDP V tendon, and the external fixation of the distal radius fracture. After the external fixation of the distal radius fracture, the distal radioulnar joint was still grossly unstable and was temporarily stabilized with an outlier of the external fixator. Notice the persisting gross deformity of the distal radius. (D) A postoperative PA radiograph demonstrates bridge plate fixation with ancillary Kirschner wires. (E) Five months postoperatively, the patient presented with a broken plate which was then removed. (F and G) Final clinical and radiographical examination 13 months after the injury showed an arc of motion of wrist extension/flexion of 45/508, wrist ulnar/radial deviation of 20/108, and a forearm supination/pronation of 70/808.

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Figure 8 (Continued from previous page)

fragment-specific fixation was shown to be significantly more stable when compared with static augmented external fixation. Meanwhile, it has been shown in several clinical and laboratory studies that these ultrathin modular implants that can be shaped to customize fixation for different fragment configurations

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provide an extremely high degree of stability allowing active, unresisted motion exercises within a week of surgery even in unstable intraarticular fractures of the distal radius. Again, we believe that there is not one best method or one superior implant to treat fractures of the distal radius and that often different ways of treatment result in a similar outcome. The treating physician must always bear in mind that the primary goal in the treatment of distal radius fractures is to restore hand and wrist function and to prevent long-term disability. On the other hand, recognizing that distal radius fractures are associated with a high rate of complications and frequently poor results should lead us to be more aggressive in the original case of these fractures. ASSOCIATED INJURIES As a result of the original trauma, distal radius fractures can be associated with several soft-tissue and bony injuries. Injuries associated with fractures of the distal radius are open fractures, nerve injuries, lesions of the distal radioulnar joint with or without fractures of the distal ulnar, and injuries to the carpal ligaments and bones. Associated injuries often lead to more problems than the distal radius fracture itself and might have a negative effect on the final outcome, particularly if they are missed initially. Associated injuries can influence decisionmaking on whether to operate on a distal radius fracture or not as well as how to fix the fracture. Open Fractures Open fractures of the distal radius are unusual. However, all open fractures— whether there is a massive skin injury or a pinpoint—are indications for emergency operative treatment of the injury. Preoperative cultures are advised as the first step of the treatment plan followed by broad-spectrum antibiotic therapy, debridement, and irrigation of the wound with saline solution. Decision-making how to deal with the fracture itself depends on the wound situation on the one hand—result of a low- or high-energy trauma, suitable cleaned or not, open for less or more than eight hours—and the fracture stability. If there is any doubt about the wound situation, the wound is left open and closed secondarily, and the fracture is fixed with use of an external fixator. If the wound could be suitably cleaned and the fracture is unstable, we are not afraid to stabilize the fracture with an internal fixation or a combined internal and external fixations. Nerve Injuries Although ulnar nerve dysfunction is less frequent, symptoms of median nerve dysfunction is the most common problem associated with acute distal radius fractures (90,159 – 164). However, in general, they were resolved, if a satisfactory reduction of the fracture is obtained. Therefore, we recommend immediate

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reduction for all distal radius fractures with neurologic symptoms, but do not routinely release the carpal tunnel, even in patients with fractures, which require operative treatment unless there is previous history of carpal tunnel syndrome or a massive swelling, so that compartment syndrome must be considered. Carpal Injuries Resulting from a similar injury mechanism, intraarticular and extraarticular fractures of the distal radius are often accompanied by soft-tissue and bony injuries within the carpus. Initially, these injuries are often missed because the attention is drawn to the obvious deformity of the distal radius, but may in part be responsible for continued discomfort even after a seemingly well-healed fracture (165). Therefore, our treatment plan for the setting of distal radius fracture suspected to be associated with a carpal ligament disruption calls for diagnostics of the carpal ligaments (166). Special attention is mandatory in the evaluation of the carpal architecture after reduction of the distal radius fracture, particularly in intra-articular fracture with the fracture line entering the ridge between the scaphoid and lunate fossa (114). Traction radiograms may be helpful to detect complete scapholunate ligament tears because the scaphoid translates distally under traction, if the ligament is completely disrupted (167). If there are further concerns, a CT with intraarticular injection of gadolinium or an MRI with intravenous gadolinium should be recommended in distal radius fractures which do not require operative treatment and arthroscopy or direct visualization of the carpal ligaments in distal radius fractures requiring surgical treatment. Treatment plans for distal radius fractures associated with carpal bone or ligament injuries must take into account the stability of the distal radius fracture and the severity of the carpal injury. Nondisplaced carpal fractures usually require no additional treatment because the methods used for immobilization of the radius are sufficient. Because it takes a long time to heal the scaphoid even in a nondisplaced fracture, internal fixation of the scaphoid may be recommended in the setting of distal radius fracture combined with a nondisplaced scaphoid fracture to allow mobilization of the wrist joint after healing of the distal radius fracture (168) (Fig. 9). Although partial nondissociative carpal ligament lesions may heal uneventfully during the immobilization time required for healing of the distal radius fracture, dissociative lesions require aggressive treatment. This includes reduction of the carpal malalignment, ligament repair, and temporary K-wire stabilization (Fig. 10). Associated DRUJ Lesions The stability of the DRUJ depends on the congruity of the sigmoid notch and the ulnar head, the integrity of the TFCC and the capsular, as well as on the stability of the ulnar styloid. Therefore, assessment of the DRUJ requires that the radius is adequately restored with respect to length and shape and that the anatomic

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Figure 9 Radius fracture associated with fracture of the scaphoid. (A) An oblique radiograph of a diaphyseal radius fracture with extension in the radiocarpal joint associated with a transverse fracture of the scaphoid. (B) Postoperative radiograph showing reconstruction of the metaphyseal radius fracture with three transverse lag screws, additional lag screw fixation of the radial styloid fragment, and neutralization plating of the diaphyseal radius fracture as well as Herbert screw fixation of the scaphoid fracture through an extended volar approach.

relationship of the sigmoid notch and the ulnar head is re-established. According to Fernandez and Jupiter (32), associated lesions of the DRUJ are categorized as stable, unstable, and potentially unstable. Type I lesions with the DRUJ clinically stable and radiographically congruent allow early forearm rotation and do not require special external support. Type II lesions with the joint clinical and radiographic evidence of subluxation or even dislocation require operative treatment. Tension band or interosseous wire is recommended to fix the ulnar styloid fragment when its avulsion at the base is causing DRUJ instability. If the instability of the DRUJ is caused by a massive tear of TFCC, the TFCC lesions may be treated with arthroscopic or open repair. Immobilization with the forearm in neutral position for six weeks is indispensable. For those type III DRUJ lesions, in which the fracture of the ulnar head could be rigidly fixed with plate and screws (169) (Fig. 11), functional aftercare with early active forearm rotation is possible. Type III lesions with instability of the DRUJ due to dorsally displaced dorsoulnar fragment of the distal radius require exact anatomic reduction of the sigmoid notch to gain DRUJ stability (170).

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Figure 10 Fracture of the distal radius associated with a complete scapholunate ligament rupture. (A and B) Radiographs, after closed reduction and immobilization in a cast, showing partial insufficient reduction and a step-off between the scaphoid and the lunate fossae suspicious for scapholunate ligament tear. (C and D) Radiographs, after open reduction and internal fixation with a 908 to 908 plating using fixed-angle devices and stabilization of the scapholunate injury with two additional K-wires.

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Figure 11 Distal radius fracture associated with fracture of the ulna head. (A and B) Dorsally displaced intraarticular fracture of the distal radius associated with a fracture of the ulna head and a fracture at the base of the ulnar styloid in an elderly woman. (C and D) After open reduction and volar fixed-angle plate fixation, the distal radioulnar joint (DRUJ) was grossly unstable. The ulna head fracture was treated with blade plate fixation. Because of persisting instability of the DRUJ, stabilization of the ulnar styloid fracture was provided with K-wire and tension band wiring.

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COMPLICATIONS Although it was once widely believed that patients with fracture of the distal radius generally do very well regardless of the radiological result, it is now appreciated that fractures of the distal radius fractures are susceptible to several complications, many of which will lead to poor clinical results. In a study of 565 Colles’ fractures, Cooney et al. (106) found a complication rate of 31%. The main complications were median neuropathy, finger stiffness, RSD, degenerative changes at the radiocarpal and distal radioulnar joints, malunion, nonunuion, and tendon ruptures. Reflex Sympathetic Dystrophy RSD (complex regional pain syndrome type I) is a complex of symptoms characterized by diffuse pain, usually with associated swelling, vasomotor instability, and severe functional impairment of the extremity. RSD presents with very varied symptoms and signs occurring in different combinations and intensity. The incidence of RSD after fractures of the distal radius has been variably reported at between 0.02% and 32% (171 – 175). The higher estimates of the prevalence of RSD most likely reflect a broader definition of the problem, including patients with stiffness and swelling that are more related to anxiety, fear, and other psychological difficulties associated with treatment and recovery from injury. With a more strict definition—one that requires objective evidence of a role of sympathetic nerves in the pain via measurement of the response to a stellate ganglion block—the prevalence of true RSD is very low. If RSD is suspected, prompt intervention is recommended to prevent many of the problems of this serious complication. RSD may be present in the patient who has increasing finger stiffness associated with an inordinate amount of pain, or paresthesias, and swelling during fracture healing. These might be caused by tight dressings, casts, or splints. Removal of a dressing or cast to relieve pressure, elevation of the swollen hand, and intensive physiotherapy are mostly adequate to prevent the development of full RSD. However, in the severe condition, more aggressive intervention with sympathetic blocks, appropriate medication, and physiotherapy is necessary. Recognition and treatment of acute carpal tunnel syndrome may also abort the development of RSD. Nonunion Although nonunions of fractures of the ulnar styloid process associated with distal radius fractures are quite common and mostly do not cause symptoms, nonunions of distal radius fractures are an extremely rare occurrence and are usually symptomatic (176 – 181). In a study of more than 2000 fractures of the distal end of the radius, Bacorn and Kurtzke (182) reported a nonunion rate of 0.2%. Watson-Jones (183) reported one case of distal radius nonunion of 3199 fractures. In 1998, Segalman and Clark (184) presented a series of 12 distal radius

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nonunions in 11 patients treated during a 24-year period. Recently, we reported on our experience with 23 nonunions of the distal radius (185). Some investigators have speculated that delay and arrest in healing of a fracture of the distal radius may have become more common since surgical treatment of distal radius fractures has become more popular (186). Indeed, factors associated with fracture treatment may contribute to the failure of fractures of the distal radius to unite, including inadequate immobilization, inadequate fixation during open reduction, and excessive distraction during application of an external fixator. In addition, some medical conditions and some drugs may disturb the bone metabolism and, therefore, may delay or even prevent fracture healing. Segalman and Clark (184) reported 15 comorbid medical condition in their 11 patients with 12 distal radius nonunions including diabetes mellitus, peripheral vascular disease, peripheral neuropathy, and psychiatric disorders, alcoholism, hypothyroidism, morbid obesity, and scleroderma. The most striking association of the five patients treated for radial fracture nonunion by Smith and Wright (187) was that all patients were heavy smokers. Tobacco previously has been implicated in an increase in the nonunion rate in patients having spinal fusion and limited intercarpal arthrodesis. In addition, three of the five patients reported by Smith and Wright were heavy alcohol abusers. Alcoholism may negatively affect compliance of the patients during fracture treatment. A distal radial fracture nonunion should be suspected clinically if there is continuing pain after remobilization of the wrist associated with an advancing deformity. The pain is related to the use of the hand and shows no sign of improving. The diagnosis may be confirmed by showing movement at the fracture site on lateral radiographs with the wrist in flexion and extension. If there is any doubt regarding the radiographic signs of fracture union, a CT scan should be recommended (188). Because of the rarity of nonunion after fracture of the distal end of the radius, it is not surprising that there is no consensus on the optimum mode of operative treatment. A small, osteoporotic distal fragment, associated soft-tissue contracture with radial deviation of the carpus and hand, and atrophic status at the site of the nonunion are features that can make surgical correction of a distal radial nonunion difficult and has led some authors to recommend total wrist fusion (180,184,189). Several series describe surgical attempts to gain union (179,186,190,191). Segalman and Clark (184) used the extent of the metaphyseal subchondral bone supporting the articular surface distal to the site of the nonunion as a criterion to determine the appropriate treatment. They suggested that surgical attempts to gain bony union are worthwhile when at least 5 mm of subchondral bone beneath the lunate facet of the distal radius is available for application of implants. For nonunions with less than 5 mm of subchondral bone supporting the articular surface distal to the nonunion site, they recommend total wrist arthrodeses. We compared the results of reconstruction of distal radial fracture nonunions in 10 patients in whom the distal fragment had less than 5 mm of subchondral bone

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supporting the articular surface distal to the site of the nonunion with those of reconstruction of nonunions of the distal radius in 13 patients with a larger distal fragment (185). The overall functional and radiographic outcomes were similar, but more postoperative complications were observed in the patients with small fragments than in the patients with large fragments. On the basis of this experience, and because the radiocarpal and midcarpal articulations are often uninvolved, we think that an attempt to maintain functional mobility of the wrist by obtaining anatomic realignment of the distal fragment and union of the fracture seems warranted. Total wrist arthrodeses should be reserved as a final resort. Malunion In spite of advances in the treatment of fractures of the distal radius, malunion is still a common complication. Malunion of the distal radius usually occurs following conservative treatment; however, now that internal fixation of fractures of the distal radius has become more commonplace, we are seeing an increasing number of radial malunions after operative treatment. Malunion of the distal end of the radius may be extraarticular with a metaphyseal angulation, loss of length relative to the ulna, and rotational deformity of the distal fragment (192). In addition, the distal fragment may be translated in either the sagittal or the frontal plane (193). Distal radial malunion may be intra-articular with a step-off or a gap at the radiocarpal and/or the distal radioulnar joint or both, intra-articular and extraarticular. It may be true that not all nonanatomically aligned fractures of the distal radius result in a poor functioning outcome. However, in our experience many patients with malunited fractures of the distal end of the radius complain of decreased range of wrist motion and forearm rotation, weakness and pain, especially on the ulnar side of the wrist, where an ulnocarpal impaction as a result of radial shortening often exists. Many patients, both men and women, complain of the cosmetic deformity. In a small number of patients, there may be a carpal tunnel syndrome caused by the deformity of the wrist. All these complaints are related to the disorder of the wrist joint caused by the deformity at the radiocarpal level, the distal radioulnar joint, and the midcarpal level. Treatment options for symptomatic malunion of the distal radius must take into account the patient’s motivation, the functional demands of the patient, and the anatomy of the deformity. Newer fixation devices allowing more stable fixation of osteoporotic bone have made consideration of the bone quality less important. Intervention to correct symptomatic malunions may be categorized into four broad areas: procedures aimed at restoring anatomic relationships, procedures aimed solely at gaining a functional improvement, procedures aimed at eliminating pain, and procedures that combined two or more of the above approaches. Procedures aimed at eliminating pain are wrist denervation and arthrodesis. Arthrodesis may involve the total wrist joint or only radius, scaphoid, and lunate

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(194 – 196). From the different procedures aimed solely at gaining a functional improvement on forearm rotation, we have had very satisfactory results with Bowers hemiresection interpositional arthroplasty (197,198). Procedures aimed at restoring anatomic relationships between the distal end of the radius and the carpus as well as the distal end of the ulna are primarily osteotomies of the distal radius and the ulna. The aim of a radial corrective osteotomy is to improve wrist function and diminish pain by restoring the anatomic position of the distal end of the radius in relation to the carpus and to the distal end of the ulna. Therefore, corrective osteotomy is considered whenever there is a radiological malunion, but undertaken only when there is a substantial likelihood that improved radiological alignment will lead to improvement in symptoms and function. It is important to distinguish symptomatic and asymptomatic malunions. There are no fixed radiological parameters to determine the indication for corrective osteotomy. Poor general health and marked degenerative changes of the radiocarpal joint are contraindications for radial osteotomy. Additional contraindications include fixed carpal malalignment, evidence of a sympathetic reflex dystrophy, limited function of the fingers, as well as severe osteoporosis. A slight instability of the distal radioulnar joint is not a contraindication for radial osteotomy, because the corrective osteotomy reestablishes, in general, its stability. Also a marked instability of the distal radioulnar joint is no contraindication for radial osteotomy, but requires a simultaneous procedure on the ulnar side of the wrist (198 – 201). There is no upper age limit for osteotomy of the distal radius provided that there is adequate bone quality and impaired wrist function. Regarding distal radial malunion in children, due to the remodeling capacity of the distal radial metaphysis, osteotomy is rarely necessary. Ideally, radial corrective osteotomy should be performed as soon after the fracture as it is decided that the patient meets the criteria and the swelling is subsided. Jupiter and Ring (202) evaluated the time of intervention comparing two groups of patients who had had a corrective osteotomy of the distal radius. One group had had the surgery an average of eight weeks after the initial injury, and a comparable group had had the osteotomy an average of 40 weeks after the fracture. The overall functional and radiographic outcomes were similar, but earlier intervention reduced the total duration of disability and the time until the patient returned back to work was significantly shorter in patients out of the early-intervention group. Preoperative work-up includes an exact evaluation of the clinical situation and the radiological findings. The indication for corrective osteotomy is usually based on plain radiographs of the injured wrist. Comparison of the opposite side is helpful to determine ulnar variance and the inclination in the frontal and sagittal planes. A CT may be helpful to detect degenerative changes and malalignment of the distal radioulnar joint as well as rotational deformity of the distal radius (192). An arthroscopy of the wrist may be indicated to assess the articular cartilage and the ligaments. Preoperative drawing of the planned surgical intervention

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showing the level of osteotomy, the angle of correction, and the change in ulnar variance is important. Nowadays, the preoperative planning of the surgical intervention is often done on a computer (193,203 –205). Most surgeons feel that the approach to expose the distal part of the radius depends on the direction of the deformity using a classic volar Henry approach for volarly tilted malunions and a dorsal incision between the third and fourth dorsal compartments for dorsally angulated malunions as outlined by Fernandez (206 – 208). Because of formation of callus and remodeling at the site of the fracture localized upon the dorsal aspect of the radius in dorsal malunions, visual alignment of cortical surfaces may be difficult and inaccurate by using a dorsal approach. In addition, the morbidity of dorsal plates such as extensor tendon complications has been well documented (209– 212). In 1937, Campbell (213 – 215) published a technique in which the radius is osteotomized through a radial approach. Now that newer plates designed specifically for the volar fixation of dorsally unstable distal radius fractures by incorporating buttress pins and screws that lock to the plate are available, the idea to correct dorsally tilted malunion through a volar or a radial approach has become more popular (216– 220). However, there are many facts which may influence the approach to the distal radius for corrective osteotomy. For corrective osteotomy of a dorsal malunion of the distal radius following volar plate fixation, the radius can easily be approached using the prior incision. If the distal fragment of the radius following dorsal plating is displaced in the direction opposite to the plate or if the fracture is overcorrected a second approach on the volar aspect of the radius may be needed. In the rare situation where an additional procedure on the carpal ligaments or on the ulnar side of the wrist is required simultaneously with the radial corrective osteotomy, the radius should be approached dorsally. Corrective osteotomy should include correction of malrotation of the radius along with correction of angular deformities and radial shortening. Correct rotational alignment of the distal radius with respect to the radial diaphysis can easily be achieved by application of a buttress plate on the volar aspect of the radius. In patients with a soft-tissue problem associated with distal radius malunion, such as extensor pollicis longus or flexor pollicis longus rupture, the soft-tissue problem may influence the choice of the approach to the radius (Fig. 12). The osteotomy can be performed either at the prior fracture site or at a different site. In many cases, it is technically easier to perform the osteotomy proximal to the original fracture site. However, this can result in a severe humpback deformity of the distal radius and/or a dislocation of the DRUJ. The humpback deformity with the long axis of the carpus volar to the long axis of the radius may disturb force transmission and can lead to a refracture after hardware removal. Such problems can be avoided by locating the osteotomy as close to the original fracture site as possible and by exact preoperative planning of the center of rotation. The center of rotation can lie in, on, or outside the margins of the radial cortex (221). When a limited lengthening is needed, the center of rotation lies on the bone margins, and an incomplete opening-wedge osteotomy

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Figure 12 (Continued on next page) Dorsally tilted malunion of the distal radius following volar plating associated with rupture of the flexor pollicis longus tendon. (A and B) Dorsal malunion of the distal radius following volar plating of a dorsally displaced fracture with a nonlocking device. (C and D) Intraoperative views showing the rupture of the flexor pollicis longus tendon and the loose distal screws. (E) Intraoperative view showing the reconstruction of the flexor pollicis longus tendon and the reconstruction of the distal radius with osteotomy, bone grafting, and volar fixed-angle plate fixation. (F and G) Radiographs, after corrective osteotomy. Notice the large cortical iliac bone graft. (H and I) Radiological appearance of the wrist four months after corrective surgery showing the radius healed with an acceptable reduction and restoration of the length.

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Figure 12 (Continued from previous page)

is enough. This situation is encountered in many volar malunions. When the radius needs to be largely lengthened, the center of rotation is away from the bone and a complete osteotomy is required. This situation is rarely given in volarly angulated malunion but in most dorsal malunion. It is important to restore the anatomic relationship between the distal radius and the distal ulna. Radial shortening up to 12 mm can be corrected with a radial osteotomy alone. If radial lengthening is complicated by soft-tissue contracture, complete tenotomy or z-lengthening of the brachioradialis tendon may be helpful (222). Although callotaxis is an useful technique to achieve satisfactory radial length for young patients with growth arrest, combined radius – ulna osteotomy can be recommended for elderly people (223,224).

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Mostly, the defect created by the open-wedge osteotomy is filled with corticocancellous or with cancellous bone graft harvested from the iliac crest. Some investigators have reported about the use of bone substitute (225,226). Hemicallotaxis is also described for correction of the radial deformity (227). In most volarly angulated malunions in the sagittal plane, the graft will form a triangular shape with its apex placed dorsally. For dorsally tilted malunions, a double trapezoidal-shaped graft is needed to fill the gap. In 1988, Watson and Castle (228) picked by a technique described by Durman in 1935 (229) cutting the graft longitudinally from the distal end of the proximal fragment of the radius. Campbell (213) harvested the graft from the distal ulna. Whatever is used to fill the osteotomy gap, the large cancellous bone surface of the osteotomy of the distal radius guarantees a fast integration of the bone graft, respectively, the bone substitution and a fast consolidation (230). Every technique used for fixation of the distal radius in acute radius fractures, such as pinning and plating, can also be used to stabilize the distal radius in corrective osteotomy. However, decision-making how to fix the radius should take into account the quality of the bone graft and the interval between the injury and the corrective osteotomy. To avoid implant failure, the used plate should be strong, especially in a longstanding malunion and if the bone graft is very tiny. Another option for stabilization of the site of the corrective osteotomy is an external fixator with pins placed in the distal fragment (227). This allows postoperative adjustment should the restoration of length or alignment prove to be inadequate. More than 100 papers on radial corrective osteotomy were published over the last three decades. All of them show that corrective osteotomy improves wrist and forearm motion as well as grip strength and diminishes pain. In a study published in 2002, we were able to show that patients with no or only a minor residual deformity after corrective osteotomy had significantly better results than those with a gross residual deformity (231). Recently, we published a study on corrective osteotomy for intra-articular malunion of the distal part of the radius (232). We found that intra-articular osteotomy can be performed with acceptable safety and efficacy. The results of intra-articular corrective osteotomy are comparable with those of osteotomy for the treatment of extraarticular malunion. However, the indication is limited by both chronology and the type of injury. It is preferable to reserve such a procedure for those malunited fractures that have a relative simple intraarticular component. CT scans are absolutely necessary to plan the surgical procedure. Tendon Injury Tendon injury associated with fractures of the distal radius is uncommon. However, an unique complication that can occur in extraarticular distal radius fractures is spontaneous rupture of the EPL tendon. This more commonly occurs within four to eight weeks of the fracture (233 –235).

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Index

Carpal crowded sign, 98 height ratio, 99, 100 Carpal dislocations, 91 –114 avascular necrosis, 111–112 classification, 93– 96 clinical diagnosis, 96 closed reduction and cast immobilization, 103–104 manipulation, 102– 103 and percutaneous pinning, 104 complications, 111–112 Cooney’s classification, 96 diagnosis, 96–102 epidemiology, 92–93 Green and O’Brien’s classification, 94 open reduction and internal fixation, 104–107 prognosis, 108–110 radiographic diagnosis, 97– 98 treatment, 102–105 Carpal injuries distal radius fractures, 164 Carpal-metacarpal fracture dislocations, 78– 80 Cast immobilization carpal dislocations, 103–104 Circular saw injury, 15

Amputation index fingertip, 14 thumb, 17 AO Classification. See Comprehensive Classification of Fractures (AO/ASIF Classification) Arcs, 99 Articular injuries, 10, 12 ASIF Classification. See Comprehensive Classification of Fractures (AO/ASIF Classification) Avascular necrosis carpal dislocations, 111 –112 Avulsion fractures, 49–51 open reduction, 52 radial collateral small finger, 53 Avulsion injuries digitorum tendon, 5–6 flexor digitorum profundus tendon, 4–5 terminal extensor tendon distal and fingertip injuries, 5– 6 Bone grafting internal fixation scaphoid fractures, 132 –135 Bony mallet percutaneous fixation, 11

189

190 Classification AO/ASIF, 138 Cooney’s, 96 Fernandez, 138 –139 Green and O’Brien’s, 94 Herbert’s scaphoid fractures, 118, 120 Closed reduction carpal dislocations, 102 –103, 103–104, 104 distal radius fractures, 151 –152 internal fixation, 26 metacarpophalangeal joint, 43 –44 and percutaneous K-wire fixation distal radius fractures, 152 –153 Comminuted and displaced proximal phalanx fractures middle finger, 31 Comminuted depressed fractures phalangeal base of ring finger, 54 Comminuted fractures fifth metacarpal, 80 index metacarpal head, 51 Comprehensive Classification of Fractures (AO/ASIF Classification), 138 Compression fractures, 52– 54 Condylar fractures PIP joint, 56–57 Cooney’s classification carpal dislocations, 96 Cross-finger flaps, 14–16 Crowded carpal sign, 98 Crush injury multiple proximal phalanx fractures, 35–36 Cuticle, 3 Diaphyseal middle phalanx fractures ring finger, 29 Digitorum tendon avulsion, 5–6 DIP. See Distal interphalangeal (DIP) joint Discriminatory sensation, 3 Dislocations. See also Carpal dislocations carpal-metacarpal fracture, 78 –80 lunate complete, 101

Index [Dislocations] metacarpophalangeal joint, 42 MP joints, 41 –74 multiple carpal-metacarpal, 78 PIP joint, 41– 74, 58–59 Displaced and unstable diaphyseal fractures middle finger, 35 Displaced fractures distal radius, 150–163 fifth metacarpal, 82 long metacarpal, 83 middle finger, 31, 38 proximal phalanx shaft, 22 Distal and fingertip injuries, 1–20 anatomy, 2 –3 distal phalanx fractures base, 4– 5 incidence, 1 terminal extensor tendon avulsion (mallet) injuries, 5–6 Distal interphalangeal (DIP) joint, 4, 5, 6, 9, 10, 11, 13 Distal phalanx fractures, 4–5 distal and fingertip injuries base, 4– 5 tuft and shaft fractures, 4–5 unstable, 5 Distal radioulnar joint fractures, 140 Distal radius fractures, 137 associated injuries, 163–167 biomechanics, 144– 146 classification, 138–140 closed reduction, 151–152 and percutaneous K-wire fixation, 152–153 combined dorsal and volar exposure and fixation, 157 complications, 168–175 displaced, 150–163 distraction plating, 157–158 DRUJ injuries, 164–167 epidemiology, 137– 138 external fixation, 153–158 dorsal approach, 155–156 radial styloid approach, 156–157 volar approach, 156

Index [Distal radius fractures] functional and radiographic anatomy, 140–144 implants for internal fixation, 158–163 malunion, 170 –175 nondisplaced treatment, 150 nonunion, 168 –170 open reduction and internal fixation, 145–146, 157 tendon injuries, 175 treatment, 146– 150 Distraction plating distal radius fractures, 157 –158 Extensor pollicis longus (EPL), 140 Extensor tendons, 3 External fixation distal radius fractures, 153 –158 dorsal approach, 155 –156 radial styloid approach, 156 –157 volar approach, 156 FDP. See Flexor digitorum profundus (FDP) tendon Fernandez classification, 138 –139 Fifth metacarpal comminuted fractures, 80 displaced fractures, 82 Fight-bite injuries, 46 Finger index metacarpal fractures, 46 long metacarpal, 98 metacarpal head fractures, 47 middle comminuted and displaced proximal phalanx fracture, 31 displaced and unstable diaphyseal fractures, 35 displaced proximal phalanx shaft fractures, 22 displaced transverse fractures, 38 proximal phalanx base fracture, 26 –28

191 [Finger] ring displaced proximal phalanx shaft fractures, 22 phalangeal base comminuted depressed fracture, 54 small oblique displaced proximal phalanx fractures, 33– 34 radial collateral avulsion fractures, 53 Fingertip. See also Distal and fingertip injuries sensation, 3 Fixation. See also External fixation internal closed reduction, 26 distal radius fractures, 158–163 open reduction, 104– 107, 145–146, 157 percutaneous bony mallet, 11 percutaneous K-wire closed reduction, 152–153 Flaps cross-finger, 14 –16 homodigital island, 13, 16 moberg, 16–17 thenar, 13 –14 Flexor digitorum profundus (FDP) tendon, 7, 9 avulsion injuries, 4–5 Flexor tendons, 3 Fracture dislocations, 91 –114 transscaphoid perilunate, 102, 106, 107, 109, 110 two-part carpal-metacarpal, 79 Fractures. See also Fractures under distal radius; metacarpal; phalanx; scaphoid avulsion, 49–51 comminuted fifth metacarpal, 80 index metacarpal head, 51 comminuted and displaced proximal phalanx middle finger, 31

192 [Fractures] comminuted depressed phalangeal base of ring finger, 54 compression, 52 –54 condylar PIP joint, 56 –57 diaphyseal middle finger, 35 diaphyseal middle phalanx ring finger, 29 displaced middle and ring fingers proximal phalanx shaft, 22 displaced transverse long metacarpal, 83 middle finger, 38 distal phalanx, 4 –5 distal and fingertip injuries, 4– 5 distal radioulnar joint, 140 mallet, 9 –10 metacarpal, 45 –50 index finger, 46 operative management, 75–90, 76–77, 77 –78 extraarticular base, 76 –77 intra-articular base, 77–78 metacarpal head, 86 –87 metacarpal neck, 85 metacarpal shaft, 81–85 MP joints, 41–74 nondisplaced distal radius treatment, 150 oblique displaced proximal phalanx small finger, 33 –34 osteochondral transverse metacarpal head of long finger, 47 PIP joint, 41–74 proximal phalanx, 37 displacement pattern, 23 radial collateral avulsion small finger, 53 screws, 32 spiral metacarpals, 84 tuft and shaft distal phalanx fractures, 4–5 vertical metacarpal head, 48

Index [Fractures] volar coronal, 51 metacarpal head, 49 wounds, 10 –11 Free toe pulp transfer, 17–18 Greater arc injury patterns, 95 Green and O’Brien’s classification carpal dislocations, 94 Hand-based functional splints proximal phalanx fractures, 24 Hematoma subungual, 4 Herbert’s classification scaphoid fractures, 118, 120 Homodigital island flaps, 13, 16 Implants internal fixation distal radius fractures, 158–163 Index finger metacarpal fractures, 46 Index fingertip amputation, 14 Index metacarpal head comminuted fracture, 51 Internal fixation bone grafting scaphoid fractures, 132–135 closed reduction, 26 implants distal radius fractures, 158–163 open reduction carpal dislocations, 104–107 distal radius fractures, 145–146, 157 Lag screws metacarpal head oblique fracture, 46 vertical fracture, 48 Lister’s tubercle, 142 Long finger metacarpal, 47, 98 Long metacarpal displaced transverse fractures, 83

Index Lunate dislocations complete, 101 Lunula, 2–3 Mallet fractures, 9–10 Mallet injuries distal and fingertip injuries, 5 –6 Malunion distal radius fractures, 170 –175 Median neuropathy carpal dislocations, 111 Meissner’s corpuscles, 3 Metacarpal fractures, 45 –50, 85, 86–87 comminuted, 80 index, 51 displaced, 82 displaced transverse, 83 index finger, 46 long finger, 47 operative management, 75–90 extra-articular base, 76– 77 intra-articular base, 77–78 shaft, 81 –85 vertical, 48 long finger, 98 Metacarpophalangeal (MP) joints, 13 articular incongruity, 55 closed reduction, 43– 44 dislocations, 41–74, 42 dorsal approach, 44 fractures, 41 –74 hyperextension, 42 imaging, 43 pathoanatomy, 42–43 postoperative management, 44 surgical anatomy, 41–42 surgical management, 44 volar approach, 44 Middle finger comminuted and displaced proximal phalanx fracture, 31 displaced and unstable diaphyseal fractures, 35 displaced proximal phalanx shaft fractures, 22 displaced transverse fractures, 38

193 [Middle finger] proximal phalanx base fracture, 27 proximal phalanx fracture with comminution, 26 Middle phalanx basal fractures, 57 –58 volar fractures, 69 Moberg flap, 16– 17 MP. See Metacarpophalangeal (MP) joints Multiple carpal-metacarpal dislocations, 78 Nail distal groove, 2 folds, 2 plate, 2 Nerve injuries distal radius fractures, 163–164 Nondisplaced distal radius fractures treatment, 150 Oblique displaced proximal phalanx fractures small finger, 33– 34 Oblique fractures metacarpal head of index finger, 46 Open fractures distal radius fractures, 163 Open reduction avulsion fractures, 52 and internal fixation carpal dislocations, 104–107 distal radius fractures, 145–146, 157 internal fixation with bone grafting scaphoid fractures, 132–133, 132–135 Osteochondral transverse fractures metacarpal head of long finger, 47 Percutaneous fixation bony mallet, 11 Percutaneous K-wire fixation closed reduction distal radius fractures, 152–153 Percutaneous pinning carpal dislocations, 104

194 Percutaneous screw fixation using image intensifier scaphoid fractures, 122 –124 dorsal approach, 125 –126 implants, 126 –127 postoperative, 127 –132 Phalanx. See also Proximal phalanx middle basal fractures, 57–58 fractures, 29 volar fractures, 69 ring finger comminuted depressed fracture, 54 shaft fractures, 21– 40 evaluation, 21 –22 irreducible, 30– 31 vs. metacarpal injuries, 23 proximal, 22 reducible and stable injuries, 24 reducible and unstable injuries, 25–26 Pinning percutaneous carpal dislocations, 104 Proximal interphalangeal (PIP) joint, 5 clinical assessment, 61 condylar fractures, 56–57 classification, 56 –57 conservative treatment, 62 open reduction, 63 –65 percutaneous techniques, 62– 63 dislocations, 58–59 conservative treatment, 66 and fractures, 41 –74 management, 65–66 open reduction and fixation, 67–70 percutaneous techniques, 66– 67 dorsal dislocations, 58 –59 dorsal fracture dislocation, 70 fracture dislocation distractor-external fixator, 68 imaging, 61–62 lateral dislocations, 59– 60 salvage, 70 –71

Index [Proximal interphalangeal (PIP) joint] surgical anatomy, 55– 56 volar dislocation, 60–61 Proximal phalanx basal fractures, 49 –50 cross-section, 23 displaced shaft fractures middle and ring fingers, 22 fractures, 37 oblique fracture, 28 shaft fractures displacement pattern, 23 volar approach, 53 Pseudoarthrosis nonunion, 122 Radial collateral avulsion fractures small finger, 53 Radius. See Distal radius fractures Reduction. See also Closed reduction; open reduction closed manipulation carpal dislocations, 102–103 Reflex sympathetic dystrophy (RSD) distal radius fractures, 168 Rete arteriosum, 3 Reverse Mayfield progression, 94 Ring finger displaced proximal phalanx shaft fractures, 22 phalangeal base comminuted depressed fracture, 54 Ring sign scaphoid, 99 signet, 101 Roller/crush injury multiple proximal phalanx fractures, 35– 36 RSD. See Reflex sympathetic dystrophy (RSD) Scaphoid fractures, 115–136 diagnosis, 116– 118 Herbert’s classification, 118, 120 mechanism and epidemiology, 116

Index [Scaphoid fractures] open reduction and internal fixation with bone grafting, 132 –135 operative, 132 –133 pitfalls, 134 postoperative, 133 preoperative, 132 percutaneous screw fixation using image intensifier, 122–124 dorsal approach, 125 –126 implants, 126 –127 postoperative, 127 –132 screws, 128 volar approach, 122 –125 treatment, 119– 122 Scaphoid ring sign, 99 Screws, 128 fractures, 32 lag, 46, 48 Sensation discriminatory, 3 Sidewinder method, 30 Sigmoid notch, 142 Sign crowded carpal, 98 scaphoid ring, 99 signet ring, 101 spilled teacup, 101 Terry Thomas, 99 Signet ring sign, 101 Small finger oblique displaced proximal phalanx fractures, 33–34 radial collateral avulsion fractures, 53 Soft-tissue coverage, 13 –15 Spilled teacup sign, 101 Spiral fractures metacarpals, 84 Splints hand-based functional proximal phalanx fractures, 24

195 Tendons digitorum, 5–6 extensor, 3 flexor, 3 flexor digitorum profundus, 4–5 injuries, 175 terminal extensor, 5– 6 Terminal extensor tendon avulsion (mallet) injuries distal and fingertip injuries, 5–6 Terry Thomas sign, 99 TFCC. See Triangular fibrocartilage complex (TFCC) Thenar flaps, 13– 14 Thumb partial amputation, 17 Transosseous wiring, 30 Transscaphoid perilunate fracture dislocations, 102, 106, 107, 109, 110 Transverse arcus venosus, 3 Triangular fibrocartilage complex (TFCC), 142 Tuft and shaft fractures distal phalanx fractures, 4– 5 Two-part carpal-metacarpal fracture dislocations, 79 Two-point testing, 3 Unstable middle finger proximal phalanx fracture with comminution, 26 Vertical fractures metacarpal head lag screws, 48 Volar coronal fractures, 51 metacarpal head, 49 Volar zigzag approach volar coronal fractures, 49 Wounds fractures, 10–11 Wrist long finger metacarpal, 98