Abstract
Should we stabilize this metacarpal fracture with percutaneous pins or by open reduction and internal fixation?
Should proximal interphalangeal joint sprains be treated by early mobilization or immobilized for 4–6 weeks?
These are questions that a hand surgeon should consider when faced with acute injuries such as finger fractures which represent about half of all hand trauma. In this editorial, I will comment upon four articles on hand fractures.
Avulsion fractures from the base of the proximal phalanges of the fingers by Shewring and Thomas is a prospective study. It compares surgical fixation of these fractures with conservative treatment and highlights the advantages of the palmar approach over the dorsal one. The results are clear-cut, with 24 of 25 patients treated by primary internal fixation achieving a full range of movement within 10–24 days, and all fractures uniting within 3 months without any post-operative complications. On the contrary, eight patients treated by immobilization for 6 weeks had persistent pain and no signs of bone union. Seven of these eight subsequently had a successful outcome after secondary surgery. Only one patient who had declined surgery had persistent pain and a nonunion at 1 year follow-up.
Zemel (1992) described three degrees of metacarpophalangeal joint ligament sprains, with the third degree being a complete tear with major instability for which surgical repair is indicated. An X-ray may or may not show an avulsed fragment from the base of the proximal phalanx. Zemel preferred a dorsal approach and reattached the ligament using a pull-out technique. Bone fragments, when present, were fixed by K-wires and the metacarpophalangeal joint was pinned in flexion for 3 weeks to prevent loss of finger flexion. Kuhn et al. (2001) used a palmar A1 pulley approach in ten patients with avulsion-fractures of the base of the proximal phalanx, which he stabilized with internal fixation.
I congratulate Shewring and Thomas for achieving union in all cases and restoring full finger mobility and hand strength and wish that I could achieve such good results. I personally hesitate to operate upon such injuries because of the potential for post-operative loss of finger flexion. In my earliest cases, this probably occurred as I used the dorsal approach suggested by Hastings and Carroll (1988). More recently, I have used a palmar approach for my more recent cases and have obtained better functional results.
A prospective randomized controlled study of long oblique and spiral shaft fractures of the proximal phalanx: closed reduction and percutaneous Kirschner wiring versus open reduction and lag screw fixation by Horton et al. compares two different operative techniques for the treatment of fractures of the proximal phalanx. Twenty-eight patients were reviewed at a mean 3.5-year follow-up. Half had undergone Kirschner wire pinning and the other half had been treated with screw fixation.
Subjectively, there was no statistical difference between the two groups. However, though not significant, patients treated by screw fixation returned to work earlier, though there was better mobility, but less strength in the Kirschner wire group. All fractures in both groups united, some with mild degrees of malunion but this was the same in both groups.
Usually, conservative treatment is indicated for undisplaced or minimally displaced reducible and stable fractures, whereas those that are displaced, irreducible, unstable, or open must be reduced and stabilized. Fixation may be achieved by percutaneous Kirschner wires, open wiring, screws, plates or external fixation. Percutaneous interfragmentary Kirschner wires transfix the gliding soft tissues, such as the extensor tendon or joint capsule, as well as the underlying bone, and will hinder movement of the finger and favour adhesion formation and stiffness (Klein and Belsole, 2000; Pointinger et al., 2000).
In my opinion, intramedullary percutaneous wiring of simple transverse or short oblique extra-articular fractures (such as “boxer’s fracture”), as proposed by Foucher et al. (1976), is an elegant and efficient way of stabilizing the fracture and preserving finger mobility. The technique of multiple intramedullary wiring provides good stability to both bending and torsional strains (Hornbach and Cohen, 2001; Liew et al., 2000; Roure et al., 1999). Although I have no personal experience with intramedullary pinning for phalangeal fractures, I routinely treat metacarpal neck fractures by intramedullary pinning with a high success rate (Manueddu and Della Santa, 1996).
Open reduction and internal fixation is indicated if closed reduction and percutaneous fixation is not possible, as with irreducible fractures. Interfragmentary pinning or wiring may be used for fixation of small fragments, but screws and plates give better stability and are preferred when possible. However, it is important to remember that internal fixation of finger fractures may result in complications like joint stiffness or fracture nonunion (Fusetti et al., 2002; O’Sullivan et al., 1999; Page and Stern, 1998; Safoury, 2001). I agree with the authors that minimally or non-displaced finger fractures should be treated conservatively because it is the best way to achieve fracture union and preserve finger function. However if the fracture requires an operation, the surgeon should choose the most effective method to obtain optimal stabilization of the fragments, and that is by screw or plating fixation. Only these techniques allow early mobilization which is essential for recovery of optimal function of the fingers. However, I also agree that the functional result depends upon the patient’s motivation.
My only complaint with this article is the use of a midlateral approach for a shaft fracture. I prefer a dorsal lazy “S” approach which spares the dorsal branches of the digital nerves. It avoids scar tenderness and even cold intolerance, which was reported in five out of the 13 fractures treated with screw fixation. Finger function may be improved after internal fixation by the application of Adcon® gel. This is a mucopolysaccharide of porcine origin which is supposed to act as an adhesion barrier. It has already been tested with some success on peripheral nerves and flexor tendons (Merle et al., 1977).
The Ishiguro extension block technique for the mallet finger fracture: indications and clinical results by L. Pegoli et al. concerns the surgical treatment of mallet finger. Sixty-five patients who were treated for a mallet fracture by the Ishiguro technique were assessed at a mean follow-up of 5.5 years. The indications for surgery were the presence of a large bone fragment, palmar subluxation of the distal interphalangeal joint with loss of articular congruity, and an extension lag of greater than 30° of the distal interphalangeal joint. According to the classification of Wehbe and Schneider (1984), there were 27 type I B, 19 type II B, 17 type I A and two type II A fractures.
The technique involves retrograde insertion of a Kirschner wire into the medullary canal of the middle phalanx while flexing the distal interphalangeal joint. The K-wire is placed dorsal to the avulsed fragment. The distal interphalangeal joint is then reduced to 30–40° flexion and pinned axially in a retrograde manner. The wires are removed after 4–6 weeks, depending on radiographic evidence of healing. A palmar splint is then used for an average of 4 weeks in one-third of the patients because of flexion contracture.
According to Crawford’s criteria, there were 30 excellent, 21 good, 13 fair and one poor result. The authors explain that the fair results were due to incorrect initial reduction of the fracture and that the poor result was due to a fixed flexion deformity and a nail deformity. I agree with the authors that surgery is indicated when the distal interphalangeal joint is subluxed. However, in my experience, excellent results may be obtained in other cases with simple distal interphalangeal joint extension splints which are worn for 4 weeks or more as necessary (Lester et al., 2000; Wilson and Khoo, 2001). Moreover, the choice of surgical technique is debatable. The distal interphalangeal joint is small and delicate and must be treated very carefully. Takami et al. (2000) reported on 33 mallet fractures treated with a Kirschner wiring technique and observed an 18% incidence of degenerative changes on follow-up radiographs. The principle of the Ishiguro technique is quite interesting as it maintains both the reduction of the dorsal fragment on the distal phalanx and the articular congruity of the distal interphalangeal joint. However this small joint is pinned with two Kirschner wires and is locked in at least 30° of flexion for 4–6 weeks. Pegoli et al. acknowledge that a disadvantage of their technique is the potential for articular damage and thus the subsequent risk of osteoarthritis, but do not report whether they observed instances of these problems in their series. I also feel that the authors should consider flexion contracture as a major problem following this injury. Although they corrected this deformity with a splint after Kirschner wire removal, this extended the treatment for 2 months or more. In my opinion, the only indication for surgical treatment of an acute closed mallet finger is palmar subluxation with articular incongruency of the distal interphalangeal joint. When the fracture fragment is large, open reduction and internal fixation with a small screw is indicated. If there is subluxation and a small bone fragment, stabilization of the distal phalanx after reduction can be achieved with a 0.9 mm Kirschner wire which holds the distal interphalangeal joint in extension (0°) for 4 weeks.
Irreducible tuft fractures of the distal phalanx by Al Qattan is a report of two displaced tuft fractures which could not be reduced or closed. In one case, open reduction and stabilization of the fragment with axial intramedullary retrograde Kirschner wires was performed.
Al Qattan states that the majority of tuft fractures require no treatment or, at most, protection in a splint for 2–4 weeks while the pain subsides. He also states that this type of fracture often fails to unite, but stabilizes with fibrous union. The point of this paper is that displaced fractures of the distal phalanx may be irreducible because the fragments are trapped by the fibrous septa of the finger pulp. These cases must be treated surgically as, if left unreduced, they fail to unite and may cause chronic pain. This article concerns distal phalanx tuft fractures which represent about half of all finger fractures (Alnot and Leroy, 1979) and usually heal without any treatment or long-term sequelae. Al Qattan’s report reminds us that some of these fractures require operative treatment and I agree that large tuft fragments must be reduced and pinned to the proximal fragment, not only to achieve bony union, but also to preserve the length of the phalanx so as to prevent nail deformity (DaCruz et al., 1988; Read, 1982).
These four articles confirm that after more than 50 years of hand surgery, fractures of the fingers are better understood, the indications for surgical treatment are more clearly defined, and that operative techniques and implants for osteosynthesis are continuing to evolve and improve. However, the results of treatment will continue to vary according to the type of fracture, the surgeon’s experience and patient compliance.