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.