Ulnar deviation after volar subluxation of the proximal interphalangeal joint

A rare case of irreducible and progressive ulnar deviation after volar subluxation of the proximal interphalangeal joint is presented. An immobilized proximal interphalangeal joint with remaining volar subluxation after improper reduction showed ulnar deviation at 3 weeks after injury. During surgery, the radial collateral ligament was found to be ruptured at its origin, with formation of concomitant scar tissues. There were no apparent lesions at the central slip, lateral band, and volar plate. Interposition of the ruptured ligament and infiltration of the surrounding scar tissues into the proximal interphalangeal joint were identified. Surgical incision of the capsule along the dorsal margin of the radial collateral ligament readily produced successful reduction. The irreducible and progressive ulnar deviation of the proximal interphalangeal joint seemed to result from gradual infiltration of the scar tissues, subsequent to remaining volar subluxation because of interposition of the ruptured collateral ligament.     

Irreducible Dorsal Dislocation of the Proximal Interphalangeal Joint Caused By An Osteochondral Fragment

We report two cases of irreducible dorsal dislocation of the proximal interphalangeal joint caused by interposition of a small osteochondral fragment that avulsed from the base of the middle phalanx with the volar plate and outstretched collateral ligament.     

Irreducible trans-scaphoid perilunate dislocation

Two cases of irreducible trans-scaphoid perilunate dislocation are described. In each case there was soft tissue interposition between the proximal and distal elements of the fracture-dislocation and this prevented capitolunate and scaphoid reduction. The dorsal capsule was impaled on the distal scaphoid fragment in one case, and a flap of dorsal capsule was entrapped between the capitate and the lunate in the other. In light of these findings, we recommend a dorsal approach for open reduction of trans-scaphoid perilunate dislocation when the capitolunate joint cannot be reduced by closed manipulation.     

Irreducible palmar dislocation of the proximal interphalangeal joint of a finger evaluated by magnetic resonance imaging: a case report.

The irreducible palmar dislocation of the proximal interphalangeal joint (PIPJ) of a finger is rare and central slip rupture with the interposition of the lateral band in the PIPJ is extremely rare. In our present case, magnetic resonance imaging (MRI) enabled a very effective and detailed evaluation of soft tissue damage.     

An irreducible phalangeal epiphyseal fracture-dislocation. A case report

A 20-month-old infant sustained an irreducible epiphyseal fracture-dislocation of a proximal interphalangeal joint. The dorsal dislocation of the joint was associated with a 90 degree rotational displacement (Salter-Harris Type I fracture) of the epiphysis of the middle phalanx. This injury, which seems not to have been described previously, required open reduction through both volar and dorsal incisions because the intact collateral ligaments and extensor central slip did not permit adequate distraction of the joint.     

PIP joint volar rotatory dislocation: An anatomical study to explore extensor system lesions and the Stener effect

Volar rotatory dislocation of the proximal interphalangeal joint results from volar rotation of the condyle around an intact opposite collateral ligament. A cadaveric study was preformed to better understand the mechanisms of this injury. Thirty-two long fingers (II to V) were studied. After partial section of the triangular ligament, the radial collateral ligament was cut (partly or completely, at proximal or distal insertion) and volar rotatory dislocation was induced. We studied the incidence of a fixed dislocation, the distal extension of the triangular ligament lesion, and the Stener lesion of the radial collateral ligament. A buttonhole lesion was produced by a dislocated lateral band in all cases with complete section of the collateral ligament. When the lesion of the triangular ligament extended distally, dislocation became irreducible. A Stener effect (interposition of the lateral band between the condyle and the collateral ligament) was observed after reduction in 21% of cases with proximal lesions of the radial collateral ligament.     

Irreducible volar dislocation of the proximal interphalangeal finger joint

Volar dislocation of the proximal interphalangeal finger joint is rare. The trauma that causes this injury consists in a rotation mechanism in almost all cases. It may be initially missed and diagnosed at a late sequel stage. Closed reduction should always be attempted first but this procedure may result in failure, necessitating a surgical intervention. In irreducible cases, the surgical investigation shows a longitudinal split which separates one of the lateral bands (ulnar or radial) from the central slip of the terminal extensor tendon. In addition, the lateral band is displaced to the volar aspect of the head of the first phalanx, and partially entrapped into the proximal interphalangeal joint, the head of the first phalanx being trapped between the central slip and the displaced lateral band. Surgical relocation of the displaced lateral band gives an immediate reduction of the dislocated joint. We present a case of irreducible dislocation of the proximal interphalangeal joint of the right index finger in a 42-year-old female patient who required a surgical treatment. We present the diagnostic, anatomic and therapeutic aspects of this rare injury, together with a review of the literature.     

Complex dislocations of the distal radioulnar joint. Recognition and management.

Contrary to most reported series, it has been the authors' experience that dislocations of the distal radioulnar joint (DRUJ) associated with fractures of the forearm are frequently irreducible. This report reviews the authors' experience with these injuries, focusing on the recognition and management of what the authors call "complex" DRUJ dislocations: dislocations characterized by obvious irreducibility, recurrent subluxation, or "mushy" reduction caused by soft tissue or bone interposition. From 1984 until 1989, at the authors' institution, 11 patients were treated for fractures of the radius associated with dislocations of the DRUJ. Eight of these patients had a classic Galeazzi fracture dislocation. Two patients had severe open radius and ulnar fractures. One had an unstable comminuted intraarticular fracture of the distal radius. Of these 11 patients, four had "complex" dislocations of the DRUJ. In two cases, the extensor carpi ulnaris was displaced volar to the distal ulna, necessitating open reduction. A third case involved delayed recognition of multiple wrist and forearm joint dislocations associated with a severe open fracture of both bones of the forearm and required late exploration, reduction, and temporary internal fixation. A fourth case involved recurrent dorsal subluxation of the distal ulna after open reduction and internal fixation of a comminuted intraarticular distal radius fracture. It is clear that complex dislocations of the DRUJ occur more frequently than previously noted. Careful attention to these injuries during initial reduction attempts will reveal "mushy" or unobtainable reductions, an important indication for exploration for entrapped tendon, bone, or soft tissue.     

PLASTER OF PARIS SPLINTAGE FOR THE HAND: VOLAR OR DORSAL?

The effectiveness of a volar or a dorsal plaster of Paris slab for splinting a hand in the ‘safe’ position was studied prospectively. Seventy-two splints, comprising 36 dorsal and 36 volar, were applied. Measurements of the metarcarpophalangeal joint angle and the proximal interphalangeal joint angle on the lateral radiograph revealed the volar splint to be significantly more consistent in securing the proximal interphalangeal joint angle at less than 15°. There was no significant difference between volar or dorsal splints for the metarcarpophalangeal joint angle. As the volar splint was also subjectively more comfortable, its use is recommended.     

Irreducible dislocation of the thumb interphalangeal joint due to displaced flexor pollicis longus tendon: case report and new reduction technique

Dislocation of the thumb interphalangeal (IP) joint is uncommon because of the inherent stability of the joint. Cases in which reduction was blocked by the volar plate, the flexor pollicis longus (FPL) tendon, the sesamoid bone, and an osteochondral fragment have been described in the literature. This article reports a case of closed thumb IP joint dislocation caused by the displacement of the FPL tendon. A new percutaneous reduction technique for this injury will also be presented. A 63-year-old woman presented to the emergency room with an obvious thumb deformity. Radiographs confirmed dorsal dislocation of the thumb IP joint without associated fracture. Closed reduction was not successful. Percutaneous reduction was performed under locoregional anesthesia, because the dislocation was due to an FPL tendon that had displaced dorsally and radially to the proximal phalanx. After reduction, Kirschner wire fixation was not needed, but IP joint immobilization with a splint was required for 3 weeks. Postoperatively, there were no complications in soft tissues and the operative scar was almost unrecognizable. This technique enables a mini-invasive reduction by operating percutaneously on the FPL. In addition, unlike with a volar zigzag approach, it is possible to suppress the occurrence of postoperative adhesion of the flexor tendon. This new minimally invasive reduction technique is useful for irreducible dislocation of the thumb IP joint due to a displaced FPL tendon.     

Dorsal Dislocation of the Distal Interphalangeal Joint and Volar Dislocation of the Metacarpophalangeal Joint in the Same Finger: A Case Report

Double dislocations of the finger interphalangeal and/or metacarpophalangeal joints are a rare entity. Sixty-four cases of distal and proximal interphalangeal joint double dislocations have been previously reported. Five cases of metacarpophalangeal and interphalangeal double dislocations of the thumb have also been reported. Only one case has been reported in the English literature regarding simultaneous dislocations of the distal interphalangeal and metacarpophalangeal joints in the nonthumb digit. The directions of the dislocation were the same; both were dorsal. We report, to our knowledge, the first ever case of a double dislocation a non-thumb digit in opposing directions—volar at the metacarpophalangeal joint and dorsal at the distal interphalangeal joint.     

Dorsal fracture dislocations of the proximal interphalangeal joint: surgical complications and long-term results.

This retrospective study assessed the short-term complications and long-term subjective and objective results of operative treatment of acute unstable dorsal proximal interphalangeal joint dislocations treated by 2 methods: open reduction internal fixation and volar plate arthroplasty. Fifty-six patients were included in this study. Twenty-three (41%) were treated by volar plate arthroplasty and 33 (59%) were treated by open reduction internal fixation. Postoperative complications occurred in 10 patients (18%). The most frequent complication was redislocation, which occurred in 6 patients (volar plate arthroplasty, 3 patients; open reduction internal fixation, 3 patients) and necessitated salvage surgery in 4 of these 6 cases. In all 6 cases, the fracture of the base of the middle phalanx involved more than 50% of the articular surface. Twenty-four patients (43%) returned for long-term evaluation at an average follow-up period of 46 months (range, 13-125 months). Twenty of these 24 patients (83%) reported little or no pain despite a high incidence (96%) of posttraumatic degenerative changes. Eighteen (75%) reported no difficulty with work activities; 92% continued leisure activities with little or no modification. Proximal interphalangeal joint flexion contractures and extension lag at the distal interphalangeal joint were common. These data indicate that if reduction is maintained, patients may expect few functional deficits despite radiographic degenerative changes and loss of mobility.     

Isolated complex dislocation of the metacarpophalangeal joint of the third finger

Two unusual cases of isolated closed complex dislocation of the metacarpophalangeal joint of the third finger are presented. The single most important element preventing reduction was interposition of the volar plate between the proximal end of the phalanx and the head of the metacarpal, but the deep transverse ligament was also intimately involved in the entrapment mechanism. Such dislocations require open reduction as in the two cases presented, and we found the dorsal approach to be simple and effective.     

Tendon transfers for restoring hand intrinsic muscle function: a biomechanical study.

Four fresh-frozen arms were biomechanically tested to determine the effect of the route of tendon transfer (dorsal vs volar) and the site of digital tendon insertion (A1 pulley, A2 pulley, proximal phalanx, or lateral band/extensor mechanism) on restoring metacarpophalangeal joint flexion and interphalangeal joint extension. A volar carpal canal route of tendon transfer appears to be more mechanically efficient than a dorsal intermetacarpal route. A lateral band insertion provides a small but significant increase in proximal interphalangeal and distal interphalangeal joint extension.     

Soft tissue distraction using pentagonal frame for long-standing traumatic flexion deformity of interphalangeal joints

Objective:Interphalangeal joint contracture is a challenging complication of hand trauma,which reduces the functional capacity of the entire hand.In this study we evaluated the results of soft tissue d...     

Proximal interphalangeal joint dislocations without fractures

Injuries to the proximal interphalangeal joint are extremely common. An understanding of the complex anatomy of this joint is essential for diagnosis and treatment of proximal interphalangeal joint sprains and dislocations. Lateral injuries are among the commonest injuries in the hand. These are often stable after reduction, requiring only closed treatment. Occasionally, however, the collateral ligament can be trapped in the joint and require open reduction. Dorsal dislocations represent the most common dislocation in the hand. These, too, are usually stable after reduction and can be treated by closed methods. On occasion, however, these dislocations will be open or irreducible by closed means, requiring surgical intervention and repair of damaged structures. Complex rotary dislocations are exactly that: complex. An exact understanding of the damaged structures and causes of irreducibility frequently makes this an injury often requiring open reduction and selective repair of damaged soft tissue structures. Fortunately, prompt diagnosis, reduction, and institution of appropriate treatment can usually afford the patient good function after these injuries. It must be noted that stiffness is more common than instability, and active range-of-motion exercises instituted at the proper time are essential. These joints will often remain permanently thicker after injury in spite of optimal care, and tenderness and soreness with use may persist for 6 to 12 months.     

手背U-Ⅰ型血管蒂岛状皮瓣的临床应用

目的 介绍应用手背U-Ⅰ型血管蒂岛状皮瓣修复示、中指近侧指间关节以远皮肤软组织缺损的手术方法。方法 以第一掌背动脉为皮瓣血管轴，部分桡动脉、腕背动脉弓及第二掌背动脉为血管蒂，第二掌背动脉远端为旋转点的手背U-Ⅰ型血管蒂岛状皮瓣转移修复示、中指软组织缺损11例。结果 10例皮瓣全部存活，1例因伤口感染导致皮瓣坏死。结论 该皮瓣血管蒂长，转移范围大，是治疗示、中指近侧指间关节以远掌、背侧软组织缺损的较好方法。     

Irreducible palmar dislocation of the proximal interphalangeal joint caused by a fracture fragment: a case report

We present a case of irreducible palmar dislocation of the proximal interphalangeal joint of the little finger caused by entrapment of a fracture fragment attached to the collateral ligament. The bony fragment was trapped between the radial condyle of the proximal phalanx and the volar plate. Reduction was easily accomplished by hooking out the fragment.     

Simultaneous dislocation of the metacarpophalangeal and interphalangeal joints of the thumb.

Combined dislocation of the metacarpophalangeal and interphalangeal joints of the thumb is uncommon. We know of only four previously reported cases. We report a new case characterised by dorsal dislocation of both joints. Because of entrapment of the volar plate, open reduction at the interphalangeal joint was necessary. The metacarpophalangeal dislocation was treated by closed reduction. After three weeks of immobilisation, physiotherapy resulted in a satisfactory outcome. Even if the diagnosis of dislocation of the interphalangeal joint is obvious it would be easy to overlook a simultaneous dislocation of the metacarpophalangeal joint with serious consequences. Whole hand examination remains an essential rule.     

Dorsal fracture-dislocation of the proximal interphalangeal joint: a comparative study of percutaneous Kirschner wire fixation versus open reduction and internal fixation

Nineteen patients with a dorsal fracture-dislocation of the proximal interphalangeal joint of a finger were treated with either closed reduction and transarticular Kirschner wire fixation (eight cases) or open reduction and internal fixation, using either one or two lag screws (six cases) or a cerclage wire (five cases). At a mean follow-up of 7 (range 6-9) years, most patients reported satisfactory finger function, even though some of the injuries healed with proximal interphalangeal joint incongruency (seven cases) or subluxation (four cases). Those treated by open reduction complained of more "loss of feeling" in the affected finger and those specifically treated by cerclage wire fixation reported more cold intolerance and had a significantly larger fixed flexion deformity (median, 30 degrees : range 18-38 degrees ) and a smaller arc of motion (median, 48 degrees : range 45-60 degrees ) at the proximal interphalangeal joint, despite having the best radiological outcomes. Closed reduction and transarticular Kirschner wire fixation produced satisfactory results, with none of the eight patients experiencing significant persistent symptoms despite a reduced arc of proximal interphalangeal joint flexion (median=75 degrees ; range 60-108 degrees ). The results of this relatively simple treatment appear at least as satisfactory as those obtained by the two techniques of open reduction and internal fixation, both of which were technically demanding.