Volar hook plate fixation(Synthes compact hand) and bone grafting for a PIP joint fracture dislocation
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Fractures of the proximal interphalangeal joint frequently involve a volar lip fracture at the base of the middle phalanx in association with dorsal instability of the joint. The injury often includes a centrally depressed articular fragment. These injuries are typically sustained during an axial load in hyperextension and are challenging to treat.
The volar lip component is usually an avulsion injury which includes the volar plate attachment. If the fragment involves more than 1/3 of the antero-posterior width of the base of the proximal phalanx then the collateral ligaments become incompetent and the joint subluxes. PIPJ instability into extension is particularly a problem.
High energy injuries are associated with greater comminution and the central fragments are often completely detached from the adjacent bone and become depressed due to impaction. Though closed reduction techniques are often used to address the subluxation and volar detachment they cannot address the centrally placed intra-articular depression.
The technique described here addresses the articular component of the injury by utilising a volar approach through the flexor sheath.
The fracture is accessed by partially retracting the volar plate, so entering the joint and then visualising the central articular fragments. Once reduced these fragments often require subchondral support with bone graft. The volar fragment and volar plate are then replaced and the construct buttressed using a hook plate that is fashioned using a standard 1.3mm LCP plate and screws.
This technique however cannot be used if the dorsal cortex of the proximal phalanx is not intact, since it relies upon a buttressing effect.
The technique requires a meticulous surgical approach, dissecting out often tiny and fragile fragments of bone with their soft tissue attachments intact. However if successfully done it allows early range of motion and addresses all the key components of this challenging injury.
Author: Tahseen Chaudhry, Consultant hand and peripheral nerve surgeon
Institution: Queen Elizabeth Hospital, Birmingham, UK.
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