The Ishiguro extension block technique for the treatment of mallet finger fracture: indications and clinical results

The results of extension block Kirschner wire fixation for the treatment of mallet fractures of the distal phalanx were retrospectively assessed in 65 consecutive patients. The indications for this technique were the presence of a large bone fragment, and palmar subluxation or the loss of joint congruity of the distal interphalangeal joint. Using the Wehbé and Scheider classification there were 27 type IB, 19 type IIB, 17 type IA, and 2 type IIA fractures. According to the Crawford rating system there were 46% excellent, 32% good, 20% fair and 2% poor results. We believe that this technique, when properly applied, produces satisfactory results.     

Modification of the extension block Kirschner wire technique for mallet fractures

A modification of the extension block Kirschner wire technique that is used for closed reduction of mallet fractures is described. Eighteen mallet avulsion fractures of the distal phalanx treated with this modification were included in this prospective study. The fingers affected were nine small fingers, eight ring fingers, and one long finger. Surgical indications included fractures involving more than 33% of the articular surface and fractures associated with subluxation of the distal phalanx that could not be corrected by closed reduction. The average joint surface involvement was 39.8%. At followup, only one patient had pain, and that was graded as minimal. Objectively, congruous and satisfactory joint surfaces were present in 17 patients. No patient had pseudarthrosis. The average active flexion of the distal interphalangeal joint was 81.1 degrees and the average extensor lag was 1.6 degrees. Neither pin tract infections nor migration of the pins occurred. The average followup was 27.3 months. This modification increased range of motion at the distal interphalangeal joint and showed a trend toward reduced permanent extensor lag when compared with the original method. This technique should be considered when treatment of the mallet fracture is being planned using the extension block Kirschner wire technique.     

Operative treatment of mallet finger due to intra-articular fracture of the distal phalanx

Treatment of a mallet finger due to an intra-articular fracture of the distal phalanx involving one-third or more of the articular surface is controversial. Thirty-three digits with such fractures were treated by open reduction and internal fixation with Kirschner wires. Of these 33 fractures, 13 were associated with subluxation of the distal phalanx. After an average follow-up period of 29 months, the average loss of extension of the distal phalanx was 4 degrees, and the average flexion of the distal interphalangeal joint was 67 degrees. Radiographs of the distal joint in 27 digits appeared normal, while in the remaining 6 digits, slight degenerative changes were noted. In one there was a minor surgical complication. By using the operative technique described, a congruous reduction of the inta-articular fracture and satisfactory function were achieved.     

Pressing fixation of mallet finger fractures with the end of a K-wire (a new fixation technique for mallet fractures)

AimThe aim of this study was to describe and evaluate a surgical technique for the treatment of mallet finger fractures using a K-wire stabilization of the distal interphalangeal (DIP) joint and another K-wire pressing the bone fragment.MethodsBetween June 2007 and March 2014, 41 patients (28 men, 13 women) with isolated closed mallet finger fracture were treated using two K-wires. In the cohort, the mean joint surface involvement was 44.3% (range: 28–62%). With a mean period of 23.6 months, patient follow-up lasted 13–34 months. The fingers were evaluated for loss of extension and flexion of the (DIP) joints. The results were graded using Crawford's criteria.ResultsUnion of all fractures took place at an average of 5.5 weeks after the surgical procedure. Average extension lag was 4°, and active flexion 71°. According to the Crawford rating scale, 35 fingers were excellent, four were good, one was fair, and one was poor.ConclusionsPressing fixation of the bone fragment with the end of a K-wire was a useful technique in the treatment of mallet finger fractures.Type of study/level of evidenceTherapeutic IV.     

单枚克氏针固定并切开修复肌腱治疗锤状指畸形

目的 探讨应用单枚克氏针贯穿固定远、近侧指间关节治疗锤状指的临床疗效.方法 2005年2月-2007年8月,对18例锤状指行手术治疗.采用单枚1mm克氏针将远侧指间关节(DIP)固定于过伸位,同时贯穿固定近侧指间关节(PIP)于屈曲45°～60°位;修复伸肌腱,如伸肌腱止点处断裂或伴有撕脱骨折者,用微型骨锚或抽出式钢丝法固定.术后3周解除近侧指间关节固定,6周完全拔除克氏针.结果 术后随访2～6个月,远侧指间关节伸屈活动度为O°～70°11例,0°～600°4例,0.～55°2例,0°～35°1例.将患指与健指远侧指间关节的活动度相比较,参照TAM系统评定方法评定:本组优11例.良6例,差1例;优良率为94.4%.结论 应用单枚克氏针固定并切开修复肌腱.操作简单,固定牢靠,是治疗锤状指的有效方法.     

Open reduction and screw fixation of mallet fractures

Twelve patients with mallet fractures treated by open reduction and internal fixation with small screws were reviewed at an average of 31 months after surgery. The indication for surgery was a fracture involving more than one-third of the distal phalanx articular surface or with subluxation of the distal interphalangeal joint. Loss of reduction occurred in one patient and in another one screw loosened slightly without loss of reduction. There were no nail deformities, infections, or secondary procedures. The mean range of motion was from 6 degrees (range, 0-30 degrees ) (extensor lag) to 70 degrees (range, 60-90 degrees ) flexion. Ten patients had no evidence of degenerative changes, one had minor joint space narrowing and one had significant deformity. Open reduction and screw fixation with small screws can lead to satisfactory outcome in appropriate patients.     

Tenodermodesis for chronic mallet finger deformities in children

The treatment of chronic mallet finger deformities in children can be challenging. Previously proposed for the treatment of chronic mallet fingers in adults, tenodermodesis is a reconstructive procedure that may also be applied to the pediatric population. The technique of tenodermodesis for chronic mallet finger injuries in children is presented here, featuring careful repair of the extensor mechanism and temporary transarticular Kirschner wire fixation of the distal interphalangeal joint. Preliminary clinical results with this procedure have been encouraging, with high patient/parent satisfaction and few complications. Most importantly, tenodermodesis allows anatomical reconstruction of the injured extensor mechanism while preserving skeletal growth and distal interphalangeal joint motion in children and adolescents.     

Mallet fractures

In a review of 160 mallet fingers, forty-four were found to have a fracture of the distal phalanx. Of these mallet fractures, twenty-one could be followed for a mean of 3.25 years (range, six months to eight years). Six had been treated surgically and fifteen had simply been splinted. Of these twenty-one mallet fractures, all but one had a good result irrespective of the form of treatment. Bone-remodeling occurred in all digits (including two with fibrous union), with reconstitution of the articular surface and preservation of the joint space as seen on radiographs. There was also a near-normal range of painless motion in all but one finger. Poor patient compliance was an occasional difficulty when conservative treatment was used. Surgical treatment was difficult and unreliable; it offered no advantage over conservative treatment and had a greater rate of morbidity. The major "complication" of both forms of treatment was a bone prominence on the dorsum of the distal interphalangeal joint. These findings suggest that most mallet fractures can be treated conservatively, ignoring joint subluxation and the size and amount of displacement of the bone fragment.     

Mallet骨折内固定方法的改进

目的：探讨Mallet骨折的治疗方法和临床疗效。方法2012年3月—12月，我们采用切开复位应用3枚克氏针内固定治疗Mallet骨折17例，采用Doyle分型，其中ⅣB型12例，ⅣC型5例。结果术后随访6～18个月，切口均一期愈合，17例骨折均愈合，愈合率100%，骨折愈合时间6～10周，平均9周，无并发症发生。采用 Dargan 法评估疗效，优14例，良2例，可1例，优良率94.12%。结论增加一枚加压克氏针内固定技术治疗Mallet 骨折，能稳定有效固定较小的骨折块，改善关节活动范围及降低术后关节疼痛，是治疗Mallet骨折的有效方法之一。     

Modified extension-block K-wire fixation technique for the treatment of bony mallet finger

This article describes the treatment of a bony mallet finger deformity using 2 extension-block Kirschner wires (K-wires) with a transarticular K-wire fixation technique for precise alignment of the terminal extensor tendon-bone relationship and effective immobilization of the distal interphalangeal joint. Twenty-nine patients (33 fingers) with a bony mallet finger deformity and fracture fragment involving more than one-third of the articular surface were treated surgically. The fracture fragment was fixed and the mallet finger deformity was corrected in all patients using modified extension-block K-wires (2 dorsal extension-block pins) with a transarticular K-wire (volar side pin) fixation technique. Active motion of the proximal interphalangeal and metacarpophalangeal joints was not restricted. The wires are removed in the clinic 6 weeks postoperatively when the bridging trabeculae were observed in the radiographs, and immobilization in a stock splint was continued for an additional 2 weeks. According to Crawford's evaluation criteria, there were 24 (73%) excellent, 7 (21%) good, and 2 (6%) fair results. Three patients showed radiological signs of mild degenerative changes, which did not limit their daily activities. Nail ridging occurred in 3 cases (9%), which disappeared after an average of 6 months with normal growth, and mild scarring at the dorsal pin site occurred in 2 cases (6%). Modified extension-block K-wires with a transarticular K-wire fixation technique is an acceptable alternative treatment modality for the management of bony mallet finger deformities with or without subluxation of the distal phalanx.     

Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation

PURPOSE: The purpose of this study was to compare the outcomes of 2 treatments for unstable distal radius fractures: open reduction internal fixation (ORIF) through a volar approach with a fixed-angle implant and a standard external fixation (EF) method. METHODS: This study included patients with comminuted unstable intra-articular and extra-articular distal radius fractures treated by a single surgeon. Data were gathered retrospectively on 11 patients treated with EF who had been followed up for an average of 47 months (range, 12-84 mo). Prospective data were gathered on 21 patients who were treated with ORIF through a volar approach with a fixed-angle implant. Follow-up evaluation for this group averaged 17 months (range, 12-24 mo). The 2 groups were compared for range of motion (ROM), strength, and functional outcome as measured by the Patient Rated Wrist Evaluation (PRWE) and the Disability of the Arm, Shoulder, and Hand Questionnaire (DASH). Fracture reduction was evaluated from radiographs taken at the last follow-up visit and compared between groups. RESULTS: The mean passive wrist ROM at the final follow-up evaluation in EF patients was 59 degrees extension and 57 degrees flexion, compared with 63 degrees extension and 64 degrees flexion in patients treated with ORIF. Passive pronation/supination arc of motion was similar for the 2 groups, as were the DASH and PRWE scores. Grip strength as a percentage of the opposite wrist was significantly greater in the external fixation group, a possible consequence of longer follow-up evaluation. Final radiographic measurements for the EF group averaged 5 degrees volar tilt and 25 degrees radial inclination, with 2.2-mm ulnar-positive variance. The ORIF with volar plating group averaged 10 degrees volar tilt and 22 degrees radial inclination, with .5-mm ulnar-negative variance. Radial length and volar tilt were significantly greater for the ORIF group. The average final intra-articular step-off was significantly different, with 1.4-mm step-off in the EF group and .4 mm in the ORIF group. CONCLUSIONS: The use of ORIF with a volar fixed-angle implant resulted in stable fixation of the distal articular fragments, allowing early postsurgical wrist motion. The PRWE and DASH scores for the groups were equivalent, whereas intra-articular step-off, volar tilt, and radial length were better in the ORIF group. There were few complications, implant removal was not necessary, and early postsurgical wrist ROM was initiated without loss of reduction.     

经甲下克氏针压迫复位技术治疗Mallet骨折

目的 介绍一种治疗Mallet骨折的新方法. 方法 自2003年3月至2007年7月,采用远侧指间(DIP)关节背侧切口,将1枚克氏针从甲床与指骨间顺行自指尖穿出,骨块复位后,过伸DIP关节将克氏针逆行打入中节指骨,然后屈曲DIP关节,弯曲的克氏针压迫骨折块,使之维持复位状态.共治疗Mallet骨折17例. 结果 17例骨折均于术后4周临床愈合,9例得到随访,随访时间4～54个月(平均16个月),采用Crawford法进行疗效评定:优2例,良4例,可3例,差0例.结论 该方法 不损伤关节软骨,避免了骨块碎裂,简单易行、疗效可靠,是治疗Mallet骨折的较好方法.     

A novel closed reduction with extension block and flexion block using Kirschner wires and microscrew fixation for mallet fractures

Background

Some patients with mallet fractures who undergo extension block pinning complain of exposed wires, which delay their return to sports and causes inconvenience while performing tasks that require the use of hands during the early postoperative period. The purpose of this retrospective study was to present and evaluate a novel surgical procedure for mallet fractures.

Methods

We treated 20 patients (14 males and six females; mean age, 38.4 years; range 17–68 years) with displaced mallet fractures involving >30 % of the articular surface using the closed reduction and microscrew fixation between January 2009 and January 2012. The distal interphalangeal joint (DIP) joint was immobilized with a splint for 1–3 weeks on an individual case basis. According to Wehbe and Schneider’s classification, there were 12 type IB, six type IIB, and two type IA fractures. The mean follow-up duration was 12.6 months (range 6–31 months).

Results

Bone union was achieved in all patients within a mean period of 6.8 weeks, with no incidence of infection, skin necrosis, permanent nail deformity, or secondary osteoarthritis. Only two complications—temporary nail ridging in one patient and a dorsal bump caused by the screw in one patient—were observed. Minimum postoperative displacement was observed in one patient, for whom immobilization with a splint was continued for 4 weeks. Articular incongruity was <1.0 mm in four patients and 1.0–2.0 mm in two patients. Mean DIP joint extension loss was 6.5° and mean flexion was 67.8°. The surgical outcomes were excellent in seven patients, good in nine, and fair in four according to Crawford’s evaluation criteria.

Conclusion

Our novel surgical procedure combining closed reduction with extension block and flexion block using Kirschner wires and microscrew fixation produces good clinical results with relatively few complications.     

Treatment of mallet fractures using compression fixation pins.

Fifteen patients who underwent percutaneous fixation of mallet fractures of the distal phalanx using compression fixation pins were assessed. Anatomical reduction was achieved in all patients. There were no nonunions. The mean active range of motion of the distal interphalangeal joint was 1 degrees of hyperextension to 69 degrees of flexion. The fixation was stable enough to allow early active motion exercise of the distal interphalangeal joint. This technique results in a good range of motion in a shorter period of time than other treatments.     

Osteosynthesis in digital replantation using bioabsorbable rods

There are several fixation techniques for osteosynthesis in digital replantation. Kirschner wire fixation is used commonly but the wires protrude and disturb mobilization. Moreover, it requires removal. Since February 1995, the authors have been using a bioabsorbable rod made of poly-L-lactide as an intramedullary nail for osteosynthesis in digital replantation. The advantages of this technique include the absence of protruding hardware that would require removal and technical simplicity. This method has been applied for 15 arthrodeses (12 distal interphalangeal joints, 1 proximal interphalangeal joint, and 2 interphalangeal joints of the thumb) and for 11 diaphysis fractures (5 proximal, 5 middle, and 1 distal phalanx). All patients were observed until there was clinical and radiographic evidence of fusion (average interval to fusion, 8.4 wk). Bone resorption occurred in one patient. There were no cases of nonunion or infection. Poly-L-lactide rod fixation is a simple and effective technique.     

Extension block pinning for large mallet fractures

PURPOSE: The purpose of this report is to review the results of displaced mallet fractures treated with an extension block pin and transarticular fixation of the distal interphalangeal joint. METHODS: We retrospectively reviewed 23 patients with 24 fractures to determine the results of treatment, time to union, range of motion, and associated complications. RESULTS: The average patient age was 24 years and the average fracture size was 40% of the joint surface. Ten patients were treated acutely (less than 10 days), 10 subacutely (10-30 days), and 3 chronically (greater than 30 days). Average time to fracture union was 35 days. At 1-year or greater follow-up evaluation the average extension loss was 4 degrees and the average flexion was 77 degrees. There were no major complications and there were 5 minor complications. Using the established outcome criteria for mallet injuries, 92% had excellent or good results. CONCLUSIONS: The results of this study showed that this surgical technique resulted in rapid fracture union with only minor complications and has excellent functional outcome based on established criteria.     

Delayed single Kirschner wire compression technique for mallet fracture

Twenty-four mallet fractures which involved at least one third% of the articular surface of the distal interphalangeal joint were treated by open reduction and internal fixation using a single double-ended Kirschner wire at a mean of 9 days after injury (range 4-15). At a mean follow-up of 43 (range 12-18) months the active range of motion, pain and the Warren and Norris criteria were evaluated. The mean active range of motion was from - 2 degrees extension (range 0-10 degrees ) to 72 degrees flexion (range 50-90 degrees ). Nineteen patients were pain free and five suffered from mild pain during strenuous work. The Warren and Norris results were successful in 22 and improved in two cases. Radiographs showed, that all the fractures united in a near-anatomic position but with joint narrowing in six digits.     

Percutaneous fixation of mallet fractures by the "umbrella handle" technique

Over a period of 8 years, 48 fingers with mallet fractures of Wehbé and Schneider Types 1 and 2, subtypes B and C, were treated in 31 men and 17 women of mean age 42 (range 17-61) years. The fractures included 5 Type 1 subtype B, 2 Type 1 subtype C, 23 Type 2 subtype B and 18 Type 2 subtype C fractures. The technique used consisted in passing a K-wire percutaneously from dorsal to volar and pinning the fracture fragment while leaving the distal interphalangeal joint free to allow immediate postoperative mobilisation. Fracture splintage was removed at 6 weeks. The results at 8 weeks, which remained unchanged at 12 months in 46 fingers, were assessed as excellent in 11, good in 35 and fair in two cases by the Crawford rating system. One case of pin track infection required early removal of the pin.     

A novel hook plate fixation technique for the treatment of mallet fractures

Bony mallet injuries are generally treated nonoperatively, but when the fragment involves a significant percentage of the articular surface, articular incongruity and instability can occur. A number of techniques have been described for the fixation of such fractures and each has its own problems. Anatomic reduction and secure fixation of small fragments can be challenging. Our objective is to describe a new surgical technique using a 1.3-mm hook plate that provides good reduction and stable fixation of a mallet fracture, with early mobilization of the distal interphalangeal joint.     

儿童肱骨外髁骨折骨不连的治疗

目的 探讨儿童肱骨外髁骨折骨不连的治疗方法.方法 对13例肱骨外髁骨折骨不连进行诊治.患几年龄平均10.5岁(6～14岁),受伤至就诊时间平均6.7年(0.9～10年).其中Milch Ⅰ型3例(X线片表现为肱骨外髁骨块较小、桡骨小头呈圆形、肱骨小头凹陷),Milch Ⅱ型10例(X线片表现为肱骨外髁骨块较大、肱桡关节结构近似正常).13例中行单纯骨折切开复位内固定术1例,游离髂骨植骨内固定术3例,游离髂骨植骨内固定+尺神经松解前置术1例,游离髂骨植骨内固定+肱骨髁上楔形截骨术5例,游离髂骨植骨内固定+肱骨髁上楔形截骨+尺神经松解前置术3例.结果 术后随访时间平均为5.6年(2.2～12年).除2例患者骨延迟愈合外,其余患者均达到骨愈合.术前疼痛症状及肘关节不稳消失.患手握力恢复至健侧的87%(84%～100%).3例肘关节屈伸活动度得到明显改善.平均改善47.7°(30°～58°);2例肘关节屈伸活动度无明显改善;8例肘关节屈伸活动度与术前相比有所下降,平均下降16°(8°～30°).13例中除2例肘外翻角度增加和2例继发肘内翻外,其余9例提携角平均下降14.2°.按Broberg肘关节功能评分系统评定:优7例,良6例;优良率为100%.结论 儿童肱骨外髁骨折骨不连可行外科手术治疗,骨折切开复位、植骨内固定术是确实且有效的治疗方法.