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Volar hook plate fixation(Synthes compact hand) and bone grafting for a PIP joint fracture dislocation

    Overview

    Learn the Volar hook plate fixation(Synthes compact hand) and bone grafting for a PIP joint fracture dislocation surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Volar hook plate fixation(Synthes compact hand) and bone grafting for a PIP joint fracture dislocation surgical procedure.
    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.


    Indications

    INDICATIONS:
    Dorsal fracture dislocations of the PIPJ including those with central joint comminution and fragment depression.
    SYMPTOMS & EXAMINATION:
    Following a hyperextension and axial loading injury to the PIPJ there is typically swelling of the effected digit with limitation of flexion. There is pain and tenderness at the PIPJ.
    IMAGING:
    Radiographs should be taken of the digit including AP and true lateral views of the PIPJ. There is dorsal subluxation of the P2 base on the P1 head with loss of the joint congruency. The subluxed joint has a dorsal joint space has a “sourcil” (eyebrow) sign due to the curved “V” shape of the dorsal joint space visible on the radiograph. Minor subluxation may be missed if the radiograph is not a true lateral.
    ALTERNATIVE OPERATIVE TREATMENT:
    There are a number of alternative treatment strategies for management of the PIPJ fracture-subluxation. Minor instability can be corrected with flexion of the PIPJ and prevention of the terminal 30 degrees of joint extension using a dorsal blocking splint.
    When splinting is challenging due to swelling, a dorsal blocking wire can be placed through the central slip into the P1 head so that it abuts the dorsal aspect of the P2 and prevents PIPJ extension. In severe instability a joint transfixing Kirschner (K) wire can be place for 4 weeks to allow soft tissue healing.
    External fixation can be used to distract and reduce the subluxation, however the impacted central joint fragments will frequently remain unreduced and there is a consequent persistent loss of volar and central joint congruency.
    In cases with extensive comminution involving the dorsal rim of the P2 base, a bridge plate may be used across the PIPJ without opening the joint or fracture. The plate is placed between the central slip and lateral band over the P1 and after distraction and reduction of the joint the distal plate is fixed to the P2 between the lateral bands with some PIPJ flexion or around 30 degrees. The plate is removed after 6 weeks when soft callus has formed and there is some fracture stability.
    Arthrodesis is used for persistently painful and stiff PIPJs after treatment for fracture dislocation. On occasion it may be indicated acutely, for example for severe, non-reconstructable articular comminution, or where there was pre-existing joint disease. The position of fusion must be discussed with the patient.
    NON-OPERATIVE MANAGEMENT:
    Reduction of the subluxation with distraction and flexion may be followed by application of a dorsal blocking splint at the PIPJ to prevent extension and recurrent subluxation. The splint may be applied static for 2 weeks to allow swelling to settle and then active mobilisation with prevention of extension beyond 30 degrees until 4 weeks. Serial radiographs are required in the splint at 1 week and 2 weeks to ensure that there is no recurrence of the subluxation. The splint may need adjusting as the swelling reduces.The FDP and FDS should be mobilised to allow differential gliding. At 4 weeks the digit can be mobilised to extension with any residual fixed flexion deformity (FFD) treated with volar serial night extension splinting from 6 weeks until extension is achieved. Typically there is some persistent FFD of 15 degrees after these injuries and as long as the range of flexion is functional to around 90-100 degrees without pain, the hand function is not significantly impacted.
    CONTRAINDICATIONS:
    When the fracture involves the complete AP diameter of the P2 base and the dorsal P2 cortex is fractured, the buttress plating technique described here in this technical note cannot be completed. The buttress plating depends on the intact dorsal cortex to prevent secondary displacement of the volar plate fragment on loading in flexion at the PIPJ.

    Setup

    The patient must be consented for the surgery and alternative treatment options discussed together with the expected outcome and the risks and impact of complications.
    The typical procedure is completed under a regional anaesthetic axillary block or general anaesthesia. `It is technically possible to perform under “Wide Awake Local Anaesthetic with No Tourniquet” (WALANT), however the tissue swelling from the local anaesthetic infiltration and the lack of paralysis of the digital flexors can impede the surgical approach.
    Antibiotics are administered prior to tourniquet inflation. Typically a single dose of flucloxacillin 1g is sufficient cover for common skin organisms unless there is a history of prior atypical culture. In cases of penicillin allergy our hospital antibiotic policy recommends clindamycin as a single dose.
    A padded pneumatic tourniquet is placed around the upper arm. A forearm tourniquet may be used, however the flexor tendons must be retracted during the procedure and a tourniquet in the forearm can limit their mobilisation. The arm is exsanguinated prior to tourniquet inflation to approximately 250mmHg. The tourniquet timer is activated.
    The operated arm is positioned in supination on a side arm table with the patient supine on the operating table.
    Skin preparation is completed from the fingertips to the elbow with an alcohol-based chlorexidine solution.
    The arm is draped and positioned in a “lead hand” immobiliser to facilitate positioning for the surgery.
    Basic hand instruments are required including skin hooks and a tendon hook. The instrumentation for fracture reduction and stabilisation should include a dental pick, 1.3mm compact hand plates, screws and instrumentation. An air drive or battery operated driver is used with AO drill and wiring heads. K-wiring equipment including wire cutters and 1.25 ad 1.6mm wires should be available in case temporary wire stabilisation of the joint is needed to facilitate the internal fixation.
    A mini C-arm fluroscope is required to confirm congruent reduction, screw length and final joint position.

    Operation – 1

    This lateral view illustrates the intact dorsal rim, the centrally depressed fragment with comminution as well as the seperate volar lip fragment.
    The dorsal subluxation of the joint is clear here but can be subtle. The loss of congruity is best seen on a true lateral view, where the V shape of the dorsal joint space may be seen.

    The PA view of the injury demonstrated the central depressed fragment and subluxation of the joint.

    Loss of the normal digital cascade with ring finger swelling
    The hand is positioned on the arm table.
    A lead hand will be used to aid positioning of the fingers.
    This technique utilises a volar approach to the proximal interphalangeal joint (PIPJ) and base of middle phalanx.

    V shaped incision is made on the volar PIPJ between the A2 and A4 flexor sheath pulleysA Brunners incision is marked with the point placed in the mid-axial line at the PIPJ joint crease.
    This minimises the risk of scar contracture across the joint and allows a great deal of access to the volar plate and base of middle phalanx.

    Full thickness skin flaps are raisedThis ensures that the tip of the flap is not devascularised.
    Great care is required to avoid damage to the neuro-vascular bundles during the approach.
    Here my hand is used to apply some traction to the skin to ensure the dermis is incised under vision. A skin hook or forceps may be useful to achieve this.

    Skin hooks aid lifting of a full thickness flap
    Lifting the skin flap leaves a layer of fat surrounding the digital nerve and vessels to either side of the flexor sheath.
    The neurovascular bundle lies in a layer of fat to either side of the flexor sheath, slightly volar to the midaxial line.

    Bipolar diathermy is used to cauterise any vessels crossing the approach.
    An attempt is made to preserve some volar veins wherever possible.

    This diagram shows the arrangement of the pulleys of the flexor sheath.
    The A2 and A4 pulleys are preserved during this approach but the sheath over the PIPJ in between these two pulleys will be raised as a rectangular, laterally based flap. This is demonstrated in the next slide.

    The flexor sheath is opened between the A2 and A4 pulleysA blade is used to lift a broad flap of the sheath as a window to allow access to the tendons.
    This flap is retracted to the same side as the volar skin flap. The proximal and distal edges of the flap are defined by the proximal margin of the A4 pulley and the distal margin of the A2 pulley respectively.

    The skin flap is retracted and held in position with a stay-sutureAccess is very limited through this approach.The skin flap is reliably held retracted with a stay suture and a clip.
    The flexor tendons, devoid of their covering are now seen.
    The A4 pulley(1) can be seen distally.

    The flexor tendons are retracted to expose the volar plate and fractureThe flexor digitorum profundus (FDP) is retracted and reveals the insertion zone of the flexor digitorum superficialis (FDS).
    The two slips converge at the insertion point and lie superficial to the volar plate.
    The FDS tendon insertion is split in the midline for 3-4 mm.
    This allows one to retract the FDS slips to either side and expose the volar plate and fracture.
    The tendons are retracted using sloops, or as here with a pair of Ragnell retractors.

    The volar plate and volar rim fragment are mobilisedThe volar plate has been detached distally by virtue of its attachment to the volar lip fragments.
    Proximally the volar plate remains attached to the proximal phalanx, an important attachment for restoring stability.
    The only way to mobilise the volar plate and the lip fragments together is to divide the accessory collateral ligaments.
    These are carefully divided at their insertion onto the volar plate at its radial and ulnar margins.

    The fracture is entered, mobilised and its morphology assessedThe distal part of the volar plate will contain the volar lip fragment of the middle phalanx.
    This must be carefully mobilised to enter the fracture. The attachment of the volar plate to the fragment must be carefully preserved as the final reduction of the joint will be dependant upon its integrity.
    Here the forceps are grasping the volar lip fragment and volar plate and gently lifting it in a volar direction. Through the fracture one can see the central comminution and the proximal interphalangeal joint articular surfaces.
    At this point the joint is reduced and a decision made about how to maintain reduction during fixation. Reduction may be held with a temporary K-wire passed as a dorsal blocking wire through the central slip and into the head of the proximal phalanx. Here, however the joint was easily reducible with some gentle traction and flexion of the PIPJ and this was achievable without a dorsal blocking wire.

    Here the entire volar lip fragment can be seen. The fragment is rotated to reveal its anterior surface and articular cartilage. Just beyond one can make out the articular surface of the head of the proximal phalanx.
    Care is required not to fragment this critical fragment or to detach it from the volar plate. Its integrity is critical to the technique described here.
    After assessing the centrally depressed fragment, it becomes clear that the main central articular fragment will remain depressed in the absence of good subchondral support.
    Cancellous bone graft will be required to fill the subchondral void and allow the depressed articular fragment to return to its correct height and restore articular congruency.

    The interval between extensor pollicis longus (third compartment) and the extensor carpi radialis brevis (second compartment) is developed to harvest cancellous bone graft.An incision is made just radial to Listers tubercle.

    A 5 mm osteotome is used to make an opening in the cortex of the dorsal radius.With the tendons retracted to either side.
    The periosteum is lifted and a 5mm osteotome used to lift a cap of cortex in the metaphysis.
    This is raised as a square of cortical bone with three sides cut through the cortex and one side left attached as a hinge.

    Once access to the underlying cancellous bone is achieved, a small curette is used to scrape out a some cancellous bone.1-2 ml of bone are enough for the typical defect in this fracture pattern.
    Once enough bone is harvested the cortical cap can be closed on its hinge and pushed back into its original position to cover the defect.

    Bone graft is used to pack the subchondral cavity with the volar rim and volar plate are carefully lifted whilst graft is placed into the subchondral area.The depressed articular fragment is positioned into the correct orientation. This is aided by the convexity of the distal articular surface of the proximal phalanx against which the concavity of the fractured articular fragment can be reduced.
    Depending upon the degree of comminution, some tiny articular fragments may be removed to reduce the risk of leaving loose fragments in the joint.
    Note the assistant is holding the joint reduced during the next few steps, until plate fixation.

    After grafting the depressed articular fragment is positioned into the correct orientation and position of the central fragments is checked and the joint is then washed out.If the cavity has been packed adequately the depression should be corrected, and the central fragment or fragments are well supported. This is directly visualised using this approach.
    The joint is now washed out to remove loose joint debris prior to closing the defect with the volar rim fragment.

    A 1.3mm Synthes LCP compact hand plate is fashioned cut and contoured to use the proximal hole as a hook to capture the volar rim fragment.This is shown in the next slide.
    The distal part of the plate is curved to sit as a buttress plate against the rest of the volar cortex.
    In this case a straight plate was cut to include three screw holes beyond the hook to allow at least one good distal bicortical screw that would allow the plate to act as both hook and buttress.

    The plate bender is then used to twist each half of the cut hole by 90 degrees forming two prongs, or hooks that sit on the volar plate, over the volar lip fragment.The hook, fashioned out of the proximal hole, can be seen here. A single cut at the midline is made using the plate cutter. This splits the hole into two equal halves to make the hooks.

    The reduction and plate contour are checked using image intensifier.Intra-operative imaging is now used to check the reduction (notice the joint still held flexed with some traction) as well as the position and conformity of the plate.
    This is the final image prior to plate fixation. One must therefore confirm:
    1. Reduction of the PIPJ
    2. Correction of the central articular depression
    3. Capture of the volar lip by the hooks without interference with deep flexion of the joint
    4. Conformity of the plate to the volar surface of the middle phalanx
    5. A distal screw hole that allows bicortical fixation distal to the fracture.

    A 1.0 drill bit is used to drill the distal hole on the plate and depth gauge is used to measure the screw length.The reduction must be held with PIPJ flexion during these steps.
    The plate is also held in position against the volar lip fragment.

    The depth gauge is used to measure the screw length.

    As the 1.3mm bicortical screw is tightened, the plate should sit firmly against the bone, conforming to its curvature.
    The joint should now be held in reduction without the need for flexion or a dorsal wire.
    A second screw is occasionally needed in a more proximal hole to augment fixation.

    Operation – 2

    The position of the fixed plate and the reduction are checked through a full range of joint motion and with Image intensifier,

    The mini C-arm is used to check reduction

    Both lateral and PA views confirm a well reduced joint and correction of the articular depression during full range of motion.

    PA view of the joint
    The wound is washed out and haemostasis confirmed.
    The flexor sheath is replaced over the flexor tendons.

    Closure of the wound with interrupted 5/0 nylon suture

    The dorsal wound is closed with deep dermal sutures followed by an dissolving continuous suture

    Non-adherent dressings are applied to the wounds.
    This is followed by some gauze and a resting volar backslab that holds the PIPJ in extension. This is left in position for 1 week to allow for pain and swelling before allowing mobilisation.

    Post Operative

    Day of surgery: A resting volar backslab that holds the PIPJ in extension is left in position for 1 week to allow for pain and swelling before allowing mobilisation. The patient is allowed to return home the same day if well.
    Week 1: An outpatient clinic review is performed to reduce the dressing and check the wound.
    A resting thermoplastic splint with the PIPJ in extension is fashioned by the hand therapist at week 1. Full active flexion and extension are encouraged
    Week 2: Suture removal
    Week 4: Passive motion is added to the regime.
    Week 6: Outpatient review with radiographs to check for fracture union.

    Recommended Reading

    Fractures of the proximal interphalangeal joints of the fingers.
    Ng CY, Oliver CW. J Bone Joint Surg Br. 2009 Jun;91(6):705-12. doi: 10.1302/0301-620X.91B6.21953. Review.
    An excellent overview of fractures in this challenging area.
    Unstable Dorsal Fracture-Dislocations of the Proximal Interphalangeal Joint: Volar Plate Fixation with or without Bone Graft.
    Milner C, Samson D, Tan S. J Hand Surg Asian Pac Vol. 2019 Mar;24(1):50-54. doi: 10.1142/S2424835519500097.
    PubMed PMID: 30760155.
    A series of 14 cases treated using the techniques described here. There was a mean 12.9 degrees loss of extension and a mean 81 degree arc of motion restored without the need for extension block splinting. The hardware removal rate was 36%
    The Versatile Hook Plate in Avulsion Fractures of the Hand. Thirumalai A, Mikalef P, Jose RM.
    Ann Plast Surg. 2017 Sep;79(3):270-274. doi: 10.1097/SAP.0000000000001119.
    PMID: 28604550
    An overview of the use of hook plates in hand fracture management. A series of perarticular injuries and avulsion fractures demonstrates the versatility of this technique.

    Reference

    • orthoracle.com

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