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Internal Fixation of Proximal Phalanx with Synthes® 1.5 mm Compact Hand Plate

    Overview

    Learn the Internal Fixation of Proximal Phalanx with Synthes® 15 mm Compact Hand Plate surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Internal Fixation of Proximal Phalanx with Synthes® 15 mm Compact Hand Plate surgical procedure.
    Proximal phalangeal fractures are fairly common, with their incidence being second only to the metacarpal fractures in the hand. Malunion of these fractures can result in scissoring of the fingers or pseudoclawing – which interfere with the normal function of the hand. Reduction, stabilization and early mobilization are essential for optimal outcomes following this injury.
    This is a step-by-step guide of internal fixation of these injuries using a Synthes® 1.5 mm Compact Hand Set with plates and screws. The technique is very versatile and can be used for most fracture patterns in the proximal phalanx of the finger.


    Indications

    INDICATIONS
    Strickland et al recognized that reduction and stability of the fracture along with length of immobilization are directly related to digital performance. Rigid stabilization with plates and screws allows immediate early mobilisation of the digit. I believe that the indications for internal fixation of proximal phalangeal fractures are:
    Open injuries
    Fracture associated with tendon, ligamentous or neurovascular injuries
    Malrotation or angular deformity of the digit
    Displaced intra-articular fractures
    Comminuted fracture
    SYMPTOMS & EXAMINATION
    Proximal phalangeal fractures occur following an episode of trauma. This may involve a fall on the hand, a blunt impact on the finger or a twisting injury to the finger. It may also be seen in patients involved in significant polytrauma.
    The patient presents with a painful, swollen and often deformed finger. The finger should be examined for any rotational or angular deformity on presentation. Associated injuries to the tendons and neurovascular structures should be identified. Definitive diagnosis is based on radiographic evaluation.
    IMAGING
    Plain radiographs in AP and lateral plane are usually sufficient to identify the fracture pattern and displacement. The basal fractures of the proximal phalanx are typically hyperextended with a volar apex angulation. This is due to the deforming force of the intrinsics – which flex the proximal fragment, and the extrinsic tendons – which extend the distal fragment. Angular and rotational deformities are dependent on the original deforming force of the trauma. Intra-articular extension of the fracture should be identified on the radiographs.
    ALTERNATIVE OPERATIVE TREATMENT
    Manipulation and splintage: This is useful for stable fractures only. However, the reduction needs to be monitored closely with serial weekly radiographs. In addition, the prolonged immobilization required to maintain reduction can be counterproductive for regaining finger function
    Closed reduction and K wiring: This provides better stability and is useful for unstable fractures. Multiple K wire configurations have been described in literature with varying results. Belsky wiring, Single intramedullary wires and crossed K wires have all been shown to have complications of infection, stiffness and metalwork failure. In addition, K wires do not provide rigid stability to allow immediate mobilization. They are also not appropriate for comminuted fractures and for those involving bone loss.
    NON-OPERATIVE MANAGEMENT
    Non-opeartive management should be considered and discussed with the patient. Patient buy-in for the rehabilitation process is extremely crucial for a successful outcome and should be reiterated before planning definitive management for these injuries. Manipulation and splintage is a viable alternative proposed by a number of authors in the literature. The finger needs to be splinted with the MCPJ in flexion and the PIPJ in varying degrees of extension to reliably maintain the fracture reduction. Serial radiographs followed by intensive physiotherapy, to overcome the resultant stiffness, are the mainstay of a nonoperative treatment method.
    CONTRAINDICATIONS
    The only absolute contraindication for definitive fixation is a patient who is not fit for anaesthesia and surgery. However, in my experience, an unsure patient who carries misgivings about any surgical intervention, is a relative contraindication for internal fixation.

    Setup

    Informed consent is an important part of the procedure and the risks and benefits should be clearly explained to the patient. The metalwork lies in close proximity to the articular surface and the extensor tendon. The patient should, therefore, be always counseled regarding the risk of tendon adhesions and stiffness necessitating removal of metalwork after the fracture is healed.
    I prefer regional anaesthesia with axillary block for this procedure. The patient is placed supine with the limb extended on an arm table. Upper arm tourniquet is applied and inflated after exsanguination. A prescrub is performed followed by a sterile prep with Chlorhexidine. A lead hand is used to stabilize the hand. I routinely administer a single dose of antibiotics for this procedure.

    Operation – 1

    A dorsal midline longitudinal incision is planned overlying the proximal phalanx.
    Some surgeons advocate a lateral approach and fixation. The argument for a lateral fixation is the theoretical advantage of reducing tendon adhesions. However, visualisation and reduction of fracture fragments is usually inadequate via a lateral approach. In addition, as the web of the finger lies at the level of midshaft of the proximal phalanx, a lateral incision will result in web scar contracture. Finally, a cadaveric biomechanical study by Ouellette et al (2004) showed equivalent stability with both lateral and dorsal plates.
    On balance, I feel that a dorsal approach is more suitable for fractures at the base of the proximal phalanx.

    The skin is incised with a No.15 blade.

    The subcutaneous tissue is incised with sharp dissection and the skin flaps retracted. Dorsal subcutaneous veins are cauterized along the way. The extensor tendons to the finger are exposed immediately beneath the subcutaneous tissues.

    The proximal phalangeal bone can be approached through the interval between lateral bands and the central slip. However, for basal fractures, I prefer to incise the tendon in the midline – as shown.

    A self retaining retractor is used to elevate the skin flaps.
    Incision is made with the blade right onto the bone, dividing the periosteum. I do not routinely elevate the tendon and periosteum as separate flaps.

    A periosteal elevator is used to elevate the periosteum off the bone. Care should be taken to prevent devitalizing the small, comminuted fragments. I always attempt to retain the soft tissue attachments to these fragments.

    The periosteum at the base of the phalanx is elevated with sharp dissection using a knife. For basal fractures, I incise the capsule of the metacarpophalangeal joint, so as to better visualize the reduction of the articular surface.

    The fracture is usually hyperextended and can be reduced with simple longitudinal traction applied to the finger (as shown in the image).

    The distal fragment is simultaneously elevated to correct the hyperextension at the fracture site. (Note the surgeon’s middle finger under the fracture, elevating it, thereby correcting the deformity; while the surgeon’s index finger and thumb grasp the patient’s finger applying simultaneous longitudinal traction)
    Special care is taken to correct the rotational malalignment.

    Once aligned, flexing the finger and supporting it in the lead hand can maintain this reduction. This will also prevent malrotation of the finger in the subsequent steps of fixation.

    The small basal fragments can now be reduced with bone reduction clamps. Articular congruity can be confirmed through the incision in the capsule.

    The Synthes® 1.5 mm Compact Hand System, used in this instance, contains a variety of plate designs. (A new addition to the Synthes® system is the LCP set with provision of locking plates.)
    The T-plate is chosen in this instance. The plate is cut into the appropriate size and contoured to the shape of the bone. The horizontal limb will align with the base of the proximal phalanx allowing insertion of screws in the transverse plane. The vertical limb should allow for atleast 2 screws in the distal fragment.
    The contoured plate is placed on the realigned phalanx, bridging any comminuted segment if present. The proximal edge of the plate lies adjacent to the articular margin at the base of the phalanx. The horizontal limb encloses the lateral basal fragments, buttressing them. The vertical limb should lie in the midline of the distal fragment.

    The first screw may be inserted into the proximal or distal fragment; whichever is most convenient while maintaining the position of the plate on the reduced fragments. In this instance, the distal screw is being inserted first.
    A 1.1 mm drill bit is used to drill a pilot hole. A drill sleeve may be used if required.
    Note the assistant stabilising the plate onto the bone with a pair of forceps, while the surgeon drills the pilot hole.

    The screw length is measured with the depth gauge provided.
    It is crucial to get the appropriate screw length. Volar protrusion of the screw tip has been shown to cause flexor tendon irritation – resulting in flexor adhesions and a loss of movement. On the other hand, a shorter screw may not engage the volar cortex – thereby reducing the biomechanical stability of the construct.

    The appropriately sized 1.5 mm screw is inserted into the previously drilled hole. The screws are self tapping.
    I do not tighten this screw completely at this stage as this allows me the freedom to rotate the plate into its final optimal position on the bone.
    Note that the plate is being stabilised proximally and distally to maintain its alignment on the bone.

    The reduction is checked. The position of the plate on the bone is confirmed. A proximal pilot hole is now drilled through the plate with a 1.1 mm drill bit

    The screw size is measured and a cortical screw inserted and tightened. This will allow the plate to firmly appose the bone.
    Note: a cross-headed screwdriver is used for these screws.
    The previously inserted distal screw is now fully tightened.

    The lateral screws in the proximal fragment are now inserted on either side. The drill sleeve acts as a useful tissue protector and aids in guiding the direction of the drill hole.
    Note: the base of the proximal phalanx has a convex surface. Proximal screws can, therefore, sometimes breach the articular margin and have to be positioned carefully to avoid this.

    The fracture reduction and the plate position is confirmed visually.
    If required, a lag screw can be inserted to better appose the lateral fragments. However, consideration should be given to increased surgical time and the potential disruption to the critical extensor apparatus in trying to achieve radiographic perfection. In this particular instance, I was satisfied with the overall fracture alignment, and chose not to proceed with this step.

    The rotational alignment is checked to confirm that there is no scissoring of the finger. Note that all the fingers point towards the scaphoid tubercle on passive tenodesis manoeuvre.
    Check X-rays can be taken at this stage to confirm the fracture reduction and the plate position.

    If the reduction on the radiographs is satisfactory, inserting the remaining screws distally completes the fixation.

    Final X-rays confirm the reduction. The screw lengths are checked and the screws changed if required. Note that the hyperextension deformity is corrected.
    One should always ensure that the image obtained is a true lateral, which is confirmed by the perfect overlap of the two condyles in the distal part of the proximal phalanx.

    Note that the condyles of the proximal phalanx are well aligned to the base confirming no malrotation.

    After a thorough lavage, the periosteum is closed over the plate with interrupted monofilament absorbable sutures. I believe this creates a layer underneath the tendon, minimizing the risk of adhesions. It is not always possible to obtain a watertight closure because the periosteum is usually ragged over the comminuted segment. In addition, the presence of the plate stretches the periosteum, making its closure difficult.

    The split in the extensor tendon is approximated with monofilament absorbable sutures.

    Operation – 2

    Skin is closed with interrupted monofilament nylon sutures.

    A non-adherent soft dressing is applied. The fixation is stable and rigid and therefore does not require protection in a plaster splint.

    The dressing encloses two adjacent fingers to minimise risk of compression to the digital neurovascular bundles. The dressing leaves the palm free, thereby allowing better use of the hand while recovering from the procedure.

    Post Operative

    The dressings are reduced in the clinic in 48-72 hours. Active mobilization exercises are commenced at this stage along with gentle passive exercises. Special emphasis is needed to mobilise the MCP and PIP joints. A splint is usually not required.
    Sutures are removed in 2 weeks. Gentle routine activities of daily living can be started as soon as comfortable. Rigorous and heavy activity is avoided.
    Radiographs are repeated at 6 weeks. Once the fracture healing is confirmed, aggressive passive exercises can be instituted. Activities of daily living can be increased at this stage. I advise patients against heavy activities for atleast 3 months until the fracture is consolidated.
    Tendon adhesions and stiffness remain the main complication of the procedure. Stern et al (1987 and 1988) confirmed that stiffness was the most common complication of this procedure. An extensor lag at the PIPJ, which is correctible passively, signifies extensor tendon adhesions. Reduced range of active flexion as compared to passive flexion signifies flexor tendon adhesions – and may be due to incorrect screw lengths protruding out of the volar cortex. Tendon adhesions may require tenolysis, which is best delayed for 3 months so as to allow the fracture to fully consolidate.
    We presented our review of 39 consecutive proximal phalangeal fractures treated with plates and screws at the British Hand Society Meeting in May 2014 (Gupta, Mikalef: Do plates have a role in phalanges). Only 5/39 patients required tenolysis due to stiffness and extensor lag in our series. All fractures healed with 0% incidence of infection.

    Recommended Reading

    The results reported in the literature of phalangeal fractures treated with plates and screws are scarce and contradictory. However, the following may help the reader start on the journey of exploring the efficiency of internal fixation in phalangeal fractures:
    Strickland JW, Steichen JB, Kleinman WB, et al: Phalangeal fractures: factors influencing digital performance, Orthop Rev 11:39-50, 1982. One of the early reports on predictive factors of outcome following this injury.
    Shimizu T, Omokawa S, Akahane M, Murata K, Nakano K, Kawamura K, Tanaka Y. Predictors of the postoperative range of finger motion for comminuted periarticular metacarpal and phalangeal fractures treated with a titanium plate. Injury. 2012 Jun 1;43(6):940-5. A recent report on predictors of outcome. The authors concluded that increasing age and soft tissue injury were significant predictors of stiffness following internal fixation with plates and screws. The same center, in an earlier publication (2008), concluded that plating of phalangeal fractures was highly efficient in maintain reduction and resulted in reasonable outcomes with few complications.
    Miller LG, Ada L, Crosbie J, Wajon A. Time to commencement of active exercise predicts total active range of motion 6 weeks after proximal phalanx fracture fixation: A retrospective review. Hand Therapy. 2017 Jun;22(2):73-8. A retrospective review of 49 fractures showed that the time to commencement of active exercises was the single independent predictor of total range of movement at 6 weeks. The authors concluded that K wire fixation delayed the exercises by atleast 2 weeks, resulting in poorer outcomes than those treated with open reduction and internal fixation.
    Lundin M, Woo E, Hardaway J, Pratt CK, Clarkson JH. The cost of quality: Open reduction and internal fixation techniques versus percutaneous K-wire fixation in the management of extra-articular hand fractures. Journal of Orthopedic Surgery and Rehabilitation. 2017;1(1). The authors concluded that that open reduction and internal fixation had better outcomes and fewer complications as compared to percutaneous K wire fixation. However, the numbers of proximal phalangeal fractures included in the study were very small – (8 K wire fixations and 4 internal fixations)

    Reference

    • orthoracle.com

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