Phalangeal neck fractures of the proximal phalanx of the fingers in adults

Introduction

The outcome of adult phalangeal neck fractures of the proximal phalanx of the fingers has not been previously investigated.Purpose To report the outcome of adult phalangeal neck fractures of the proximal phalanx of the fingers following a specific management protocol.

Methods

A total of 10 phalangeal neck fractures of the proximal phalanx of the fingers in nine adult male patients are presented. Three patients presented with type I (undisplaced) fractures and these were treated with splinting for 3 weeks. There were a total of five type II (displaced but with bone-to-bone contact) fractures: two were stable after closed reduction and were treated with splinting alone and the other three were unstable requiring Kirschner (K)-wire fixation. The last patient had a type III (displaced with no bone-to-bone contact) fracture, which was treated with open reduction and K-wire fixation. We emphasised that K-wires should not immobilise any of the finger joints to allow immediate active motion after surgery.

Results

All fractures healed clinically and radiologically without complications. The outcome in our series, following our management protocol, was excellent in one patient and good in the remaining eight patients.

Conclusion

Phalangeal neck fractures of the proximal phalanx in adults are rare and there are not many available options for fixing unstable type II/III fractures. Our protocol of management and the technique of K-wire fixation (leaving both the proximal interphalangeal and metacarpophalangeal joints free) followed by early active mobilisation gives consistent satisfactory results.     

Malunion of fractures of the proximal phalangeal neck in children

Abstract

We report three cases of malunion after fractures of the proximal phalangeal neck in children. A 12-year-old boy and a 7-year-old girl had malunited fractures with dorsal and ulnar deviation of their fingers. Several years later remodeling had been achieved well for dorsal deviation but little for the ulnar deviation in each case. A 10-year-old boy had a similar malunited fracture with dorsal and ulnar deviation of his finger. The proximal bony spike, which protruded to the volar side, collided with the middle phalanx during flexion of the proximal interphalangeal (PIP) joint, so we shaved it. One year after operation, flexion of the PIP joint had improved. In cases of these malunited fractures in children, remodeling is considered possible for dorsal deviation but difficult for ulnar deviation. Surgical shaving of the protruding bone should be considered.     

Outcome of closed proximal phalangeal fractures of the hand

Background:

The proximal phalanx (PP) of the fingers is fractured more frequently than the middle or even distal phalanges. The problems of malunion, stiffness and sometimes loss of skin or other soft tissues associated with PP fracture increases the disability. The optimum treatment depends on fracture location, fracture geometry and fracture stability. The objective of the study was to analyse the treatment outcome in a series of closed proximal phalangeal fractures of the hand.

Materials and Methods:

Eighty-four proximal phalangeal fractures in 68 patients were enrolled from 2007 to 2009. The treatment modalities were broadly categorised into two groups, Group A consisted of conservative treatment, and Group B consisted of surgical treatment. Group A included 47 digits treated with closed reduction (CR) with immobilization (n=43), extension block cast and dynamic traction (n=4), while 37 digits were treated in Group B, which included closed or open reduction (OR) and internal fixation (IF) with K-wires (n=31), OR and IF with stainless-steel wiring (n=2), and mini external-fixator (n=4). Belsky''s criteria and Gingrass’ criteria were used for assessment of finger injuries and to assess the efficacy of conservative and surgical modalities for closed proximal phalangeal fractures of the hand.

Results:

Average period of follow-up was 1 year (range 10-14 months). The excellent to good results seen in Groups A and B were 89% and 92%, respectively. Six complications were seen in Group A, which included four cases with malunion and two cases with digital stiffness. Three complications were seen in Group B, which included one each of malunion, digital stiffness and extensor lag. Overall, maximum poor results (n=4) were seen with CR and buddy strapping.

Conclusion:

Conservative treatment is an inexpensive method, particularly suitable for stable fractures, and in patients who are poor candidates for surgery, Surgical modalities have distinct advantage of stable fixation, but with added risk of digital stiffness. Percutaneous pinning is a reliable, most commonly used surgical modality and technically easier. Both conservative and surgical modalities have good efficacy when used judiciously     

Treatment of triplane fractures of the head of the proximal phalanx

We report the morphology and treatment of 2 cases of a triplane intra-articular bicondylar fracture of the head of the proximal phalanx. Fracture lines in the coronal, sagittal, and transverse planes characterize this fracture, making it highly unstable. Open reduction and internal fixation using two 1.5-mm interfragmentary screws oriented in a dorsal to volar direction resulted in anatomic restoration of the articular surfaces and satisfactory functional results. In 1 case, autogenous cancellous bone graft was harvested from the ipsilateral radial styloid to support the articular fragments.     

Percutaneous pinning of middle phalangeal neck fractures: surgical technique

Extra-articular middle phalangeal neck fractures are uncommon fractures of the hand that are often difficult to treat. Surgery is indicated when closed reduction fails; 1 option is closed reduction and percutaneous pinning. Maintaining closed reduction while inserting K-wires is challenging. We present a new technique for percutaneous pinning of these fractures that was developed to address these issues. Our technique uses flexion of the interphalangeal joints during K-wire insertion to maintain fracture reduction and improve fixation.     

尺骨近端截骨矫形术治疗儿童陈旧性孟氏骨折的疗效分析

目的观察尺骨近端截骨矫形术治疗儿童陈旧性孟氏骨折的临床疗效。方法回顾性分析自2008-01—2017-12采用尺骨近端截骨矫形术治疗的41例儿童陈旧性孟氏骨折,分析不同年龄段患儿的术后疗效。将年龄<12岁的患儿分为低龄组,年龄≥12岁的患儿分为大龄组,比较2组病程、手术时间、术中出血量、术后影像学Nakamura分级、末次随访时肘关节功能Kim评分。结果 41例均获得随访,低龄组随访时间平均8(6~24)个月,大龄组随访时间平均12(6~36)个月。低龄组术后1例出现感染,未出现神经损伤症状及再手术患者;大龄组术后出现2例感染,2例神经损伤症状,1例再手术。与大龄组比较,低龄组病程更短,术后影像学Nakamura分级优,手术时间更短,术中出血量更少,末次随访时肘关节功能Kim评分更优,差异有统计学意义(P <0.05)。结论尺骨近端截骨矫形术治疗儿童陈旧性孟氏骨折可获得满意的疗效,可有效恢复肘关节屈伸及旋转功能,而且低龄患儿术后的效果优于高龄患儿。     

Valgus toe deformity of fourth proximal phalanx due to osteochondroma treated with closing wedge osteotomy

Osteochondroma is the most common benign tumor of all benign and primary bone tumors. It rarely occurs in the proximal phalanx of the lesser toe. The treatment of osteochondroma usually consists of simple resection. However, if other deformities remain, added procedures may be considered. We report a case of a valgus toe deformity of the fourth proximal phalanx due to osteochondroma. The patient was a 21-year-old man who noticed a valgus deformity of his fourth toe over 10 years earlier. He began to experience pain in his fifth toe because of crossover of the fourth toe when wearing formal shoes. Although resection of osteochondroma was performed, the valgus deformity was not sufficiently corrected. Therefore, closing wedge osteotomy of the proximal phalanx was performed at the same time. A good outcome was achieved for this patient.     

Treatment of type III middle phalangeal neck fractures through a palmar approach: a case report

Phalangeal neck fractures occur almost exclusively in children. We present the case of a 49 years old man with a dislocated fracture of the neck of the middle phalanx with the distal fragment rotated at 180°, due to a traumatic circular saw injury to the left index, which was solved by anatomical reduction and bone fixation with two 1.5 mm Synthes screws and a temporary transarticular Kwire at the distal interphalangeal joint. Zone Iflexor digitorum profundus repair was performed using a modification of the Kessler 4-strands core suture and a full-thickness skin graft from the hypothenar eminence was taken to cover the skin gap. At 6-month follow-up the patient was pain-free and with a total active movement equivalent to 190°. No radiological signs of avascular necrosis of the head of the middle phalanx or nonunion of the distal fragment was detectable with recovery to the previous manual work. Owing to the position of the phalangeal head maintained in position by the collateral ligaments an anatomic reduction from dorsal approach is difficult to be performed and a longitudinal traction can render the reduction harder too. The volar approach permits an easier reduction of the fracture through a derotation of the distal fragment facing palmar.     

Open reduction of fractures of the neck of the proximal phalanx in children.

Fractures through phalangeal necks of proximal phalanges in children, which are angled so as to produce a dislocation or subluxation at the next distal joint, require open reduction. The technique includes a zigzag incision, a splitting of the extensor tendon, and the use of crossed Kirschner wires of .035 mm. Infections have not occurred from allowing the wires to protrude through the skin. The end results are better than those reported from conservative management of this fracture. The earlier the surgery the better the end results.     

Volar plating for intra-articular fracture of the base of the proximal phalanx

Comminuted fractures involving the articular surface of the base of the proximal phalanx are relatively rare and pose a challenging problem for hand surgeons because of the difficulty in achieving an accurate reduction and secure fixation of the articular surface. These fractures usually comprise a volar base fracture associated with a central depression of the articular surface. We describe a technique for open reduction and plate fixation of intra-articular fractures of the base of the proximal phalanx through a volar A1 pulley approach. Compared with the dorsal approach, this technique offers the advantages of direct visualization of the volar base fragment and the depressed central fragment, allowing for a more accurate reduction and rigid internal fixation using a volar buttress plate. In addition, there is no interference with extensor apparatus. Although our experience is limited to 4 patients, we have had a positive experience with this technique. The technique is useful for internal fixation of intra-articular fractures of the base of the proximal phalanx.     

Open proximal phalangeal shaft fractures of the hand treated by theta fixation

Background:Many implants and techniques are used for the treatment of open phalangeal fractures with varying grades of stability. The ubiquitous and simple Kirschner (K) wiring does not provide adequate stability to allow early mobilization of fingers. Lister described a combination of coronal interosseous wire and oblique K-wire technique for phalangeal fracture fixation with a stable construct that allowed early mobilization. Due to the fancied resemblance of this construct to the Greek alphabet θ (theta), we have referred to this as the theta fixation.Results:90% patients were graded excellent and 10% good, with none having fair or poor results. All fractures allowed the mobilization at a mean of 2.9 days and all healed at an average of 6.1 weeks. No loss of stability was seen on followup X-rays. All patients returned to their old profession.Conclusion:The theta fixation technique is a safe, simple and effective method for open transverse phalangeal fractures with results comparable to other techniques. This method gives superior fracture stability to allow early mobilization of joints and thus early return of function. It is also a cost effective way of management for the developing world.     

Classification of proximal tibial fractures in children

Purpose  To develop a classification system for all proximal tibial fractures in children that accounts for force of injury and fracture patterns. Methods  At our institution, 135 pediatric proximal tibia fractures were treated from 1997 to 2005. Fractures were classified into four groups according to the direction of force of injury: valgus, varus, extension, and flexion–avulsion. Each group was subdivided into metaphyseal and physeal type by fracture location and Salter–Harris classification. Also included were tibial tuberosity and tibial spine fractures. Results  Of the 135 fractures, 30 (22.2%) were classified as flexion group, 60 (44.4%) extension group, 28 (20.8%) valgus group, and 17 (12.6%) varus group. The most common type was extension-epiphyseal-intra-articular-tibial spine in 52 fractures (38.5%). This study shows that proximal tibial fractures are age-dependent in relation to: mechanism, location, and Salter–Harris type. In prepubescent children (ages 4–9 years), varus and valgus forces were the predominate mechanism of fracture creation. During the years nearing adolescence (around ages 10–12 years), a fracture mechanism involving extension forces predominated. With pubescence (after age 13 years), the flexion–avulsion pattern is most commonly seen. Furthermore, metaphyseal fractures predominated in the youngest population (ages 3–6 years), with tibial spine fractures occurring at age 10, Salter–Harris type I and II fractures at age 12, and Salter–Harris type III and IV physeal injuries occurring around age 14 years. Conclusion  We propose a new classification scheme that reflects both the direction of force and fracture pattern that appears to be age-dependent. A better understanding of injury patterns based on the age of the child, in conjunction with appropriate pre-operative imaging studies, such as computer-aided tomography, will facilitate the operative treatment of these often complex fractures.     

微型锁定钢板外置治疗近节指骨粉碎性骨折

目的 ：探讨采用微型锁定钢板外置联合小切口复位治疗近节指骨粉碎性骨折的临床疗效。方法 ：自2018年1月至2019年12月,采用微型锁定钢板配合小切口切开复位治疗17例近节指骨粉碎性骨折患者,其中男13例,女4例;年龄16～64(37.2±20.1)岁;2例伴有软组织挤压开放伤,Ⅰ期急诊清创后固定治疗。术后6个月随访时根据美国手外科协会手指总主动屈曲量表（total active flexion scale,TAFS）评价疗效,观察骨折愈合,钉道情况,局部软组织愈合及并发症情况。结果：17例患者均获随访,时间6～12(9.3±3.6)个月。2例出现骨折延迟愈合,1例出现局部皮肤坏死,Ⅱ期植皮修复创面,无外置断钉及感染,皮肤软组织愈合良好,均达到骨性愈合,骨折愈合时间12～24(15.7±2.1)周。术后6个月根据TAFS标准评定：优9例,良5例,差3例。结论：微型锁定钢板外置联合小切口复位治疗近节指骨粉碎性骨折,皮肤软组织情况良好,操作简便,有利于早期功能锻炼,指间关节活动度好,恢复期功能评分优良率高。     

(iii) Post-traumatic reconstruction for sequelae of fractures of the proximal humerus

In spite of the development of new techniques and implants, undesirable early and late sequelae may occur after both nonoperative and operative treatment of fractures of the proximal humerus. In this review, we aim to give some clear directions on how to manage these often complex post-traumatic conditions, in an area where there is a little consensus on treatment in the literature.     

The epidemiology of fractures in children

A retrospective study of all paediatric fractures presenting to hospital in Edinburgh, Scotland in 2000 was undertaken. It showed that the incidence of fractures was 20.2/1000/year and that 61% of children's fractures occurred in males. Analysis of paediatric fractures shows that there are six basic fracture distribution curves with six fractures showing a bimodal distribution but most having a unimodal distribution affecting younger or older children. The incidence of fractures increases with age with falls from below bed height (<1m) being the commonest cause of fracture. The majority of fractures in children involve the upper limb. Lower limb fractures are mainly caused by twisting injuries and road traffic accidents. The incidence of fractures in cyclists and pedestrians remains relatively high whereas the incidence in vehicle occupants is low suggesting that road safety programs have been successful. Similar programs should be instituted for young cyclists. The importance of accident prevention programmes in the home is also highlighted.     

Treatment of phalangeal neck fractures in children: technical suggestion

INTRODUCTION: Phalangeal neck fractures in children are not very frequent lesions. The purpose of this study is to bring out results of treatment of these fractures and provide an adequate procedure. PATIENTS AND METHODS: Twenty-three patients with 24 phalangeal neck fractures were reviewed. Seventeen boys and six girls with a mean age of 7 years and 6 months. Open wound fractures were noted in 13 cases. A direct trauma was noted in 17 cases and an indirect trauma in seven cases. Treatment consisted of a closed reduction and cast immobilization in four cases. A closed reduction and percutaneous pinning in seven cases. Open reduction and osteosynthesis in 13 cases. RESULTS: All patients were reviewed with a mean follow-up of 16 months and functional results were evaluated by measuring the Total Active Motion. Fractures treated orthopedically (4) gave Good results; percutaneous pinning (seven cases) gave one Poor, one Fair and five Good results; open reduction and osteosynthesis gave zero Good, six Fair and seven Poor results. Phalangeal head osteonecrosis was noted in four cases treated by open reduction. DISCUSSION: Closed reduction and percutaneous treatment of these fractures give the best functional results. This study demonstrates that open surgical reduction of these fractures leads to phalangeal head osteonecrosis and poor functional result. We propose here a technical improvement of percutaneous reduction with intrafocal pining and osteosynthesis. CONCLUSION: This technical improvement of percutaneous reduction and pinning allow to combine the advantages of a closed reduction and to avoid distal epiphyseal necrosis.     

Nonunion following subcapital (neck) fractures of the proximal phalanx of the thumb in children

Six cases of nonunion of subcapital (neck) fractures of the proximal phalanx of the thumb in children were seen over a period of 5 years. Ages at the time of injury ranged between 2 and 3 years. Entrapment of the thumb in a closing door was the mechanism of injury in all cases. All fractures were closed and were significantly displaced. Immediate management was by closed reduction and splinting in four cases, closed reduction and K-wire fixation in one case and no treatment in one case, which was later treated by delayed open reduction and K-wire fixation. Only two of the six ununited fractures were eventually treated with bone grafts and both fractures united resulting in a stable thumb but with a limited range of flexion of the interphalangeal joint. Factors that may increase the risk of nonunion of these fractures in children are discussed.     

The influence of local bone quality on fracture pattern in proximal humerus fractures

IntroductionBone mineral density and fracture morphology are widely discussed and relevant factors when considering the different treatment options for proximal humerus fractures. It was the aim of this study to investigate the influence of local bone quality on fracture patterns of the Neer classification as well as on fracture impaction angle in these injuries.Materials and methodsAll acute, isolated and non-pathological proximal humerus fractures admitted to our emergency department were included. The fractures were classified according to Neer and the humeral head impaction angle was measured. Local bone quality was assessed using the Deltoid Tuberosity Index (DTI). The distribution between DTI and fracture pattern was analysed.Results191 proximal humerus fractures were included (61 men, mean age 59 years; 130 women, mean age 69.5). 77 fractures (40%) were classified as one-part, 72 (38%) were two-part, 24 (13%) were three- and four-part and 18 (9%) were fracture dislocations. 30 fractures (16%) were varus impacted, whereas 45 fractures (24%) were classified as valgus impacted. The mean DTI was 1.48. Valgus impaction significantly correlated with good bone quality (DTI ≥ 1.4; p = 0.047) whereas no such statistical significance was found for the Neer fracture types.DiscussionWe found that valgus impaction significantly depended on good bone quality. However, neither varus impaction nor any of the Neer fracture types correlated with bone quality. We conclude that the better bone quality of valgus impacted fractures may be a reason for their historically benign amenability to ORIF. On the other hand, good local bone quality does not prevent fracture comminution.