Hand CASE 13

CASE                               13                               

A 56-year-old homemaker fell down the steps of her basement injuring her left ring finger. She was seen at an outside facility with significant deformity of the ring finger. There were no open wounds. There was severe pain and limited motion. Radiographs are shown in Figures 4–11A and B.

 

 

 

Figure 4–11 A–B

 

The most appropriate treatment at this time would be which of the following?

1. Emergent open reduction and internal fixation of the ring finger

2. Emergent closed reduction and splinting

3. Emergent closed reduction and percutaneous pin fixation

4. Application of an external fixator to restore length

 

Discussion

The correct answer is (B). This patient has essentially a closed but significantly

displaced, angulated fracture of the proximal shaft of the ring finger’s proximal phalanx. There is no open wound and the digit is well perfused. Therefore, there is no necessity for emergent surgery. A closed reduction, which can be performed in the emergency room, would be appropriate initial treatment.

The deformity seen in Figure 4–11A and B shows angulation of the digit with apex of the deformity volar.

The causation of the deformity includes which of the following?

1. Deforming force from the fall

2. Attachment of the central extensor mechanism to the base of the middle phalanx

3. Flexion of the base of the proximal phalanx by the attachment of the intrinsics

4. All of the above

 

Discussion

The correct answer is (D). In most instances, these fractures are caused by fall on the outstretched hand. In these, the deforming force is the extension that is applied to the proximal phalanx as the base of the proximal phalanx is held fixed due to the metacarpophalangeal joint, which takes the impact. Typically, after fracturing the shaft of the proximal phalanx, the deformity is apex volar. The central tendon of the extensor, which attaches to the base of the middle phalanx, exerts a deforming force on the distal fragment, and the interossei which attach to the base of the proximal phalanx tend to flex the proximal fragment. Therefore, the apex of this deformity is volar. In situations where the patient has an open wound with this deformity, the wound is usually volar. The attachment of the flexor digitorum superficialis to the base of the middle phalanx is distal to the attachment of the central tendon and therefore is not a deforming force for this particular fracture.

The patient is seen in your office after 4 days. The finger is still swollen and the radiographs, while vastly improved from the radiographs on presentation, continue to demonstrate an apex volar deformity.

The most appropriate treatment at this time would be which of the following?

1. Closed reduction and percutaneous pin fixation

2. Open reduction and plate fixation

3. Application of an external fixator

4. Continued management with closed treatment with buddy taping and hand-based ulnar gutter splint

Discussion

The correct answer is (A). As explained above, this is a significant injury with a large deformity at the time of presentation. The patient does have some residual deformity, and it is very likely that with passage of time and as the fracture heals, the deforming forces described above will not be sufficiently neutralized by a splint. Furthermore, as swelling reduces, the ability of the splint to control deforming forces is likely to be significantly suboptimal. Therefore, this fracture is best treated by closed reduction and percutaneous pin fixation. These pins may be placed across the head of the metacarpal into the base of the proximal phalanx and within the proximal phalangeal medullary cavity. This is the so-called Eaton–Belsky technique. Alternatively, after closed reduction, pins may be placed from the condyles of the proximal phalanx into the medullary canal so as to achieve the same effect without going across the metacarpophalangeal joint. These pins are usually maintained for a period of 3 to 4 weeks before being pulled out, and range of motion is instituted.

The most likely complication after this fracture is likely to be which of the following?

1. Stiffness of the PIP and DIP joints

2. Difficulty with excursion of the FDS and the FDP

3. Reflex sympathetic dystrophy affecting the ring finger

4. Complex regional pain syndrome affecting the ring finger

5. Complex regional pain syndrome

6. Both A and B

 

Discussion

The correct answer is (E). Displaced fractures of the proximal phalanx which have an apex volar deformity and have this degree of displacement are likely to be associated with some degree of deformity due to the surrounding soft tissue trauma to the floor of the flexor sheath which is the proximal phalanx. Patients who have this injury should be cautioned at the time of the initial consultation that the flexor tendons may get adherent to the periosteum of the proximal phalanx in the floor of the flexor sheath at the site of the fracture during the course of immobilization as the fracture is healing. Therefore, a small but definite number of patients who have this degree of displacement and deformity despite adequate rehabilitative exercises are likely to need a localized flexor tenolysis to free up the flexor tendons, which tend to get “spot welded” at the site of the fracture. This localized tenolysis which is best performed through a volar approach after releasing the A1 pulley is uniformly

successful in restoring range of motion. However, cautioning the patient at the time of the initial consultation is critical in the management.

 

Objectives: Did you learn...?

 

 

Treat angulated fractures of the proximal phalanx? Describe complications of this injury?