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Volar, Dorsal, and Lateral Locking Plate Fixation for Pilon Fractures
Abstract
The more common dorsal fracture subluxations at the base of the middle phalanx have an intact dorsal buttress of articular surface in continuity with the shaft. Capitalizing on this foundation, various fixation methods have met with relatively equivalent success including Kirschner wires, screws only, nonlocking plate and screws, and external fixation. Pilon fractures are complete articular fractures, where the comminuted articular fragments lack any structural connection to the more distal shaft of the middle phalanx, and have largely relied upon external fixation traction systems. The theoretical concept is that axial distraction prevents articular collapse and that the surrounding soft tissue envelope acts to gather the articular fragments; the term "ligamentotaxis" is often applied. Most constructs are founded on a transverse wire through the axis of rotation in the head of the proximal phalanx with the idea that patients will pursue active motion, termed "dynamic fixation." In practice, patients find it difficult to move well while the construct is in place and have rarely achieved much range by the time of removal. These cases are prone to loss of articular reduction leading to posttraumatic arthritis, substantial proximal interphalangeal joint stiffness, and pin-tract infection. Such problems are solved with locking plates that support the articular reduction throughout healing and permit immediate range of motion while avoiding other complications such as pin-tract infection. Outcomes are reported for 40 patients treated with locking plates applied from volar, dorsal, and lateral to treat pilon fractures.
... They are prone to pain, stiffness, and loss of reduction that can lead to permanent hand function impairment [1,2]. Several operative and non-operative techniques and approaches have been devised, including distraction by an external fixator, closed or open internal fixation, and hamate arthroplasty, but there is no universally accepted treatment [3][4][5][6][7][8][9][10][11]. ...
... Closed reduction can be used, but it is difficult to disimpact and stabilize the depressed segments using this technique [5]. Percutaneous reduction technique using K wire frameworks was introduced to overcome this limitation [12,13]. ...
... In cases of complete articular type fractures, the so-called pilon fractures of the middle phalanx, treatment has traditionally relied on a dynamic external fixator [17][18][19][20]. However, a recent report of locking plate fixation for middle phalangeal pilon-type fractures was encouraging and showed excellent finger motion recovery and reduction maintenance [5]. Most fractures in our series were volar split partial articular fractures; there were also a dorsal lip fracture and a complete articular fracture. ...
Purpose
An articular depressed fragment at the base of the middle phalanx can be an obstacle to congruent reduction and stable fixation. This study assessed the outcomes of a transosseous reduction technique combined with locking plate fixation for the treatment of articular depressed middle phalangeal base fracture.
Methods
Between 2015 and 2017, seven patients (eight fingers) with intraarticular comminuted middle phalangeal base fracture were included in this study. Mean follow-up was 19 months (range 12–30 months). All patients showed depression of the articular fragment on sagittal computed tomography (CT) scan and were treated with a transosseous reduction technique and dorsal locking plate fixation. Radiographic evaluation was performed to ensure restoration of a concentric articular surface postoperatively. Total active range of motion (TAM) of the finger, grip strength, and the quick Disabilities of the Arm, Shoulder and Hand (quick DASH) score were evaluated at the last follow-up. Complications were also assessed.
Results
All fractures obtained bony union with a concentric joint. There was no significant loss of reduction during the follow-up period. The mean active proximal interphalangeal (PIP) joint and distal interphalangeal joint motion arcs at follow-up were 89° and 61°, respectively. Mean TAM of the affected finger and mean grip strength were 94% (range 80–100%) and 94% (range 86–100%) of the contralateral side, respectively. Mean quick DASH score was 2.3 (range 0–9.1). All patients returned to work. No surgery-related complications occurred.
Conclusions
This technique provides satisfactory restoration of articular congruence and enables the early joint mobilization of articular depression-type fractures of the base of the middle phalanx.
Type of study/level of evidence
Therapeutic, level IV.
... Um ein zufriedenstellendes Behandlungsergebnis zu erzielen, ist es von zentraler Bedeutung, die imprimierte Gelenkfläche aufzurichten, bestehende Subluxationen zu beheben und eine frühzei-tige Beübung des Gelenks zu gewährleisten. Mehrere Behandlungsmöglichkeiten wurden im Lauf der Jahre vorgestellt und in der Literatur beschrieben [1,4,5,10]. Jedes Verfahren hat spezifische Vor-und Nachteile. ...
... Abb. 5 8 Patientenbeispiel 1: intramedulläre Aufstopfung. Radiologischer Verlauf einer Mittelgliedbasisimpressionsfraktur des rechten Ringfingers. ...
Background
Depressed fractures of the base of the middle phalanges are problematic because of frequent subluxations and centrally depressed fragments. There are two minimally invasive procedures available: 1) the less known intramedullary padding technique according to Hintringer and 2) the widely used distraction fixator of Suzuki. This article describes the technique and outcome of these two procedures.MethodologyThe follow-up collective included 42 patients after treatment of a depressed fracture of the base of the middle phalanx. An intramedullary padding with percutaneous Kirschner wire retention was performed 28 times (group A) and treatment with a Suzuki fixator 14 times (group B). The study examined the hand function, the radiological results and the subjective pain level.ResultsAccording to the American Society for Surgery of the Hand (ASSH) classification 81% of the patients in group A achieved a good result but in group B the same result was achieved by only 50% of the patients. The median range of movement in the proximal interphalangeal joint was 82.5° after intramedullary padding and 47.5° after Suzuki fixator. In median, the impression was reduced from 2.35 mm to 0.5 mm in group A, but only from 1.6 mm to 1.15 mm in group B. Pain was a limiting factor in 2 out of 28 patients in group A and 1 out of 14 patients in group B.Conclusion
The intramedullary padding technique according to Hintringer enables good treatment of depressed fractures of the base of the middle phalanx of the finger. Repositioning of dorsal subluxations can be performed and centrally impressed fragments can be reduced better than by using the Suzuki dynamic fixator. In addition, the radiological course assessments can be assessed better than with the distraction fixator.
... Many different external fixator frame designs have been described in literature without clear superiority of one over the other. [5][6][7] The rigid-hinged external fixators are also referred to as dynamic fixators as they allow joint motion. It is important for the distraction to be dynamic as well to match the elasticity of the soft tissues (ligaments, joint capsule, etc.), as with the original Schenk fixator 8 and others. ...
Background: Fracture dislocations of the proximal interphalangeal joint (PIPJ) are challenging injuries and a dynamic external fixator frame is often used. We devised a dynamic external fixator device called the Gexfinger ® that allows greater control of the degree of traction. The aim of this study is to report the mid-term outcomes of this device.
Methods: This is a retrospective study of patients with fracture dislocation of the PIPJ who were treated with the Gexfinger ® over a 3-year period. Clinical data with regard to the patient, the injury, treatment and period of follow-up were recorded. The outcome measures included time to return to work, arc of motion at the interphalangeal joints, grip strength, visual analogue score (VAS) for pain, patient satisfaction and complications.
Results: We studied 26 patients (17 men and 9 women) with an average age of 38 years. The average articular surface involvement was 56%. The mean period between injury and surgery was 6 days and the frames were maintained for 5.5 weeks on average. The mean follow-up period was 8.5 weeks. All patients returned to work at an average of 7 weeks. The mean arc of motion at the PIPJ and distal interphalangeal joint (DIPJ) were 82° and 65°, respectively and the mean grip strength was 83% of the contralateral side. 22 patients reported no pain at the final follow-up. Fifteen patients were very satisfied, 8 satisfied and 3 unsatisfied. Two patients had stiffness of the PIPJ.
Conclusions: The mid-term outcomes of the Gexfinger ® are similar to other methods of dynamic traction described in literature. It is modular, easy to assemble and allows a greater control of the degree of traction. In combination with additional screws and/or K-wires, it has allowed us to treat a wide spectrum of PIPJ fracture dislocations with good outcomes.
Level of Evidence: Level IV (Therapeutic)
The proximal interphalangeal joint (PIPJ) is a complex anatomical structure. In managing fracture dislocations about the PIPJ, the aim is to restore a congruent joint that allows for smooth gliding motion. Detailed knowledge of the anatomy and biomechanics of the PIPJ is necessary in managing these injuries with predictable success. The breadth of techniques previously described in the treatment of such injuries is testament to the difficulties faced in achieving optimal clinical and radiological outcomes. In this article we detail the anatomy and biomechanics of the PIPJ and summarize current literature and principles for the treatment of dorsal fracture dislocations.
Pilon fractures of the proximal interphalangeal (PIP) joint are challenging injuries that can lead to arthritis, limited motion, and pain. Internal fixation is often difficult owing to comminution and inadequate bony support. External fixation requires a compliant patient and may result in pin-track infection, stiffness, and malunion. In this report, I describe a simple surgical technique of immediate bridge plating of the PIP joint with bone grafting followed by plate removal and joint release. This approach maintains the alignment, restores the articular congruity without the risk of pin-track infection, and allows immediate return to activities of daily living until fracture healing is completed.
Abstract A fracture of the proximal interphalangeal (PIP) joint at the base of the middle phalanx is rare, but is a challenge to treat. Posttraumatic osteoarthritis is a known complication causing impaired hand function and disability. The aim of the present retrospective study was to evaluate characteristics and outcome of complex PIP joint fractures treated by the pins and rubbers traction system (PRTS). Medical records of 42 patients with fractures treated with a PRTS in 1999-2010 were reviewed, and followed-up by questionnaires (QuickDASH, CISS, self-composed questionnaire). Eighteen of the 42 were clinically examined. The fractures were divided into three types of fractures: volar lip, dorsal lip, and pilon fractures. The volar lip fracture was most frequent (26/42; dorsal lip 3/42; pilon 13/42). Most fractures were sport-related (19/42; 45%) and males predominated (M:F ratio = 1.8). All fractures united. Infection occurred in 17/41 (41%) cases. Radiological signs of posttraumatic osteoarthritis were found in 25/41 (61%) patients. In 18/42 patients, where a clinical evaluation was performed, 66% of contralateral total active range of motion (TAM), 93% grip strength, and 100% pinch strength were achieved. The volar lip fracture had the best outcome according to the self-reported QuickDASH and CISS score and regained 77% of contralateral TAM. Fractures of the PIP joint in the middle phalanx can be treated with the PRTS, but reduced mobility, grip strength, infection, and osteoarthritis are seen. The device is well tolerated by the patients, easy to apply, and with ready accessible materials for the surgeon.
Basal fractures of the middle phalanx are uncommon, but difficult to treat. We have reviewed our first 20 patients using the Suzuki pins and rubber traction who were treated during an 8.5 year period (June 1998-December 2006) and 18 who were reviewed after 49 (range 17-116) months. All injuries were closed fractures of the base of the middle phalanx. Ten patients had a fracture of the volar lip and dorsal subluxation of the phalanx, one had a fracture of the dorsal lip, and seven had comminuted pilon fractures. Median operating time was 33 (18-255) minutes. Thick "vessel loops" were often used for traction, and active movement before the traction was removed after 38 (8-46) days was disappointing. There were two superficial infections and one deep. One proximal interphalangeal (PIP) joint had been treated by arthrodesis and another amputated before review. On a visual analogue scale (VAS) from 0 (best) to 10 (worst), patients at review reported discomfort when wearing the traction as 5.5 (0-10), pain as 0 (0-6), and finger function as 3 (0-6). The median Quick-DASH score (100 = worst) was 2 (0-48) and grip strength 97 (75-118) % of the other hand. Median extension, flexion, and total range of movement of the PIP joint in 16 fingers were -9°, 83°, and 72°, respectively. Our results are no more than adequate. They might have been better if the force of traction had been less by using rubber bands instead of vessel loops, if postoperative follow-up had been more frequent allowing for correction of traction when necessary, and if traction had been discontinued earlier.
Unstable, dorsal, intra-articular, fracture-dislocations of the proximal interphalangeal (PIP) joint can be difficult to treat and often lead to long-term pain, stiffness, and functional deficit. We present the outcomes of patients sustaining such injuries that were treated by a novel dynamic external fixator. This fixator uses a system of K-wires and rubber bands that maintains a concentrically reduced PIP joint while allowing for early motion.
Fourteen patients with unstable, dorsal fracture-dislocation injuries of the PIP joint were treated between September 2001 and January 2006. Eight were available for follow-up evaluation at an average of 26 months. We measured PIP range of motion and grip strength, and assessed pain on a visual analog scale. Demographic information about the original injury was recorded. New radiographs were obtained to assess joint congruency and the presence of arthritis or articular step-off deformity.
In the 8 patients available for follow-up evaluation, the average motion of the affected PIP joint was from 1 degrees (range 0 degrees to 5 degrees) to 89 degrees (range 75 degrees to 110 degrees). Grip strength was 92% (range 71% to 110%) of the unaffected hand. The average score on the visual analog pain scale was 0.6 (range 0-1.5). There were few complications. Radiographs at follow-up evaluation showed a concentric reduction in all joints, but with evidence of a small step-off deformity or arthritis in 5 patients.
The dynamic external fixator studied is an effective method of treating unstable, dorsal fracture-dislocation injuries. Outcomes compared favorably with those of other similar devices studied in the literature.
Ligamentotaxis is now a well-established treatment method for proximal interphalangeal (PIP) joint fractures. Despite satisfactory results, the technique is considered complex and the devices cumbersome. The aim of this study was to evaluate a miniaturized dynamic external fixator (Ligamentotaxor(®)) for the management of these fractures. Eighty-six patients with 88 fractures of the PIP joint were treated at 10 European hand surgery centers. The device was applied within eight days of the injury and was removed 40-45 days after the injury. Treatment complications included superficial infection (4 cases), osteoarthritis (1 case), and localized but resolving complex regional pain syndrome (4 cases). The fracture healed in all cases. At final follow-up (mean: 15.2 months), average range of motion was 70° (range: 0-110°). Functional results were comparable between the 10 participating centers. Pain occurred upon exertion in 47% of the patients, 40% were sensitive to weather changes and 26% experienced constant pain. The mean QuickDASH score was 15.7 (range: 11-37) and 83.7% of the patients had no limitations during their daily activities. The results of this series are similar to those reported in other studies of PIP fracture treatment with external fixators. This technique is reliable and reproducible. The device is easy to handle by surgeons and well tolerated by patients. We think that this simple, reliable technique could be relevant for the management of PIP joint fractures.
To clarify the factors affecting functional results of fracture-dislocations of the proximal interphalangeal (PIP) joint treated by open reduction and internal fixation (ORIF), 60 patients, including 38 patients with a dorsal fracture-dislocation and 22 with a pilon fracture, were analysed. The mean ratio of articular surface involvement was 48.5% and a depressed central fragment existed in 75.3% of the cases. ORIF was performed in 47 patients through a lateral approach using Kirschner wires and in 13 through a palmar approach using a plate or screws. The mean flexion, extension and range of motion (ROM) of the PIP joint was 89.5°, 11.5° and 78.0°, respectively. Stepwise regression analysis revealed that a delayed start of active motion exercise after surgery, elderly age and ulnar ray digit were factors affecting functional outcomes. Although ORIF allows accurate restoration of the articular surfaces, an early start of motion exercise is essential for good results.
To report our results of open reduction internal fixation with volar mini plate and screw fixation for unstable dorsal fracture dislocations (DFDs) of the proximal interphalangeal (PIP) joint.
We performed a retrospective review of 13 consecutive DFDs of the PIP joint treated with volar mini plate and screw fixation, measuring both clinical and radiological outcomes.
The age range of our patients was 15 to 56 years (average, 33 y). Six injuries were related to work, 5 to sports, and 2 to motor vehicle accidents. Of the 13 DFDs, 6 were comminuted. Articular involvement ranged from 30% to 70% (average, 44%). The average time to surgery was 7 days (range, 0-23 d). Patients had follow-up of 12 to 60 months (average, 25 mo). Four patients had a postoperative course complicated by plate and screw removal at an average of 4 months later, either as part of a secondary procedure to improve range of motion or owing to patient request. All patients returned to their original occupation. Of the 13 patients, 11 were satisfied with the result, and 12 of 13 had either no or mild pain. All 13 DFDs united in good alignment but 3 showed degenerative changes. Average grip strength was 85% of the unaffected side, and average active PIP joint and distal interphalangeal joint motion arcs were 75° and 65°, respectively. Average Quick Disabilities of Arm, Shoulder, and Hand score was 4 (range, 0-9). All patients had non-tender swelling of the proximal interphalangeal joints but no signs of flexor tenosynovitis or infection.
Fixation of unstable PIP joint DFDs via a volar approach is technically feasible with mini plates and screws. This treatment allows early active range of motion and provides good objective and subjective outcomes; however, noteworthy complications occurred in 39% of patients.
Therapeutic IV.
The management of proximal interphalangeal joint fractures of the fingers is difficult. Dynamic traction splinting systems are cumbersome and the Suzuki fixator does not prevent secondary fracture displacement. Fifteen cases were treated with a new dynamic external fixator with distraction, the Ligamentotaxor. In two cases, additional fixation was required with a screw. After 10 months, grip strength scored 85.7% compared with the contralateral hand, flexion achieved 76.3 degrees and the extension deficit was 19.6 degrees . The visual analogical scale pain level (VAS) was 1.9 and the Quick DASH score totalled 16.9. Revision treatment was needed for sepsis for one patient. A case of secondary fracture displacement was corrected in the outpatient clinic. Consolidation was achieved in all cases. In conclusion, despite imperfect outcomes for these complex fractures, we believe that the Ligamentotaxor technique is useful.
Eight consecutive pilon fractures of the finger proximal interphalangeal joint and one of the interphalangeal joint of the thumb were treated by closed reduction and application of a new dynamic external fixator. The average range of movement achieved was 12 degrees -88 degrees and there were no serious complications. The technique described offers an effective and simple solution for treatment of pilon fractures of the interphalangeal joint.
We describe a very cheap, simple and effective dynamic external fixator for treatment of pilon fractures of the proximal interphalangeal joint. At final follow-up, nine such fractures had regained an average range of motion of 79 degrees (range, 65-90 degrees ). There was high patient satisfaction and there were no serious complications.
This study evaluates the use of limited internal fixation and dynamic traction for the treatment of severely displaced digital and thumb pilon fractures.
Six patients were evaluated both clinically and radiographically at an average of 29 months after surgery (range, 18-36 months) for pain, range of motion, and radiographic signs of joint space narrowing and congruence. Surgery involved the placement of a pin for dynamic traction and an assessment of the adequacy of the articular alignment. A limited incision and supplemental K-wires were often used to improve the position of severely displaced fragments or for the repair of the central tendon.
Three patients were pain free, 2 patients experienced pain with prolonged activity, and 1 patient had pain associated with activities of daily living. Average digital arc of motion of the proximal interphalangeal joint was 94 degrees (range, 90 degrees-100 degrees) and thumb interphalangeal motion was 62.5 degrees (range, 60 degrees-65 degrees). The average duration of digital traction was 3.5 weeks. Four patients had greater than 1 mm incongruity of the articular surface immediately after surgery. At final evaluation, all patients had good joint congruency and 2 patients had joint space narrowing but were asymptomatic. There was 1 minor pin tract infection.
Dynamic traction combined with limited internal fixation can be an effective treatment for displaced intra-articular pilon fractures. This technique may allow for earlier removal of traction and simultaneous repair of soft tissue injuries.
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.
Surgical intervention may be necessary to treat unstable dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint of the hand. One method of stabilization is open reduction and internal fixation (ORIF). The purpose of this study was to assess the outcomes of ORIF for unstable dorsal fracture-dislocations of the PIP joint using mini-screws via a volar approach.
A retrospective chart review with clinical follow-up evaluation was performed on 9 patients who had ORIF for unstable dorsal fracture-dislocations of the PIP joint. The fracture fragment(s) from the middle phalangeal base were reduced and secured using mini-screws.
A clinical evaluation was performed at an average of 42 months after surgery. The average arc of motion for the involved PIP joint was 70 degrees (range, 55 degrees -90 degrees ). The average PIP joint motion in the 2 patients with 1 fracture fragment was 85 degrees , and the average PIP joint motion for the remaining 7 patients was 65 degrees . One joint was subluxated with an intra-articular screw. Nine patients had an average flexion contracture of 14 degrees . Seven patients had no pain, and 2 had pain only with heavy activity.
Open reduction and internal fixation of unstable dorsal PIP joint fracture-dislocations using mini-screws can be considered if the fracture fragment(s) can accommodate the screws. The procedure attempts to restore the concave contour of the middle phalangeal base and permits early protected range of motion. The procedure should be approached cautiously, especially in the presence of comminution. Proximal interphalangeal joint range of motion is usually compromised; 8 of our 9 joints had a residual flexion contracture.
Therapeutic IV.
Unstable fracture-dislocations of the proximal interphalangeal (PIP) joint remain a difficult management problem, often leading to residual pain, stiffness, and recurrent instability. In a military setting, an easily applied, simple to operate, and inexpensive device becomes an attractive option. The purpose of this clinical investigation was to retrospectively review use of dynamic distraction external fixation (DDEF) for unstable fracture-dislocations and pilon injuries of the PIP joint in an active-duty population.
The fixator is assembled under a local anesthetic from three 1.4-mm (0.045-inch) K-wires and rubber bands. It uses the principles of a lever and ligamentotaxis to assist and maintain reduction. Thirty-four members of the Armed Services, 27 men and 7 women (average age, 30 y), had DDEF for pilon fractures and unstable fracture-dislocations of the PIP joint. A retrospective review of these individuals was conducted. Final range of motion was determined from the clinical records at the final visit.
There were 26 PIP fracture-dislocations (3 chronic, average 6 weeks) and 8 PIP pilon injuries. The average follow-up period was 16 months (range, 6-84 months). The final arc of motion at the PIP joint averaged 88 degrees , and the average distal interphalangeal joint arc of motion was 60 degrees . Eight patients experienced superficial pin-track infections that were easily controlled with oral antibiotics. There were no cases of septic arthritis or osteomyelitis requiring intravenous antibiotics or premature fixator removal. Loss of reduction did not occur. All patients returned to their prior level of activity and duties.
Our results are comparable with other techniques used in the management of unstable PIP joint fracture-dislocations. Easily applied and simple to operate, DDEF is a valuable addition to the hand surgeon's armamentarium. We recommend its use for both primary and adjunctive treatment of acute and chronic unstable PIP joint fracture-dislocations and for primary treatment of PIP pilon injuries.
Therapeutic IV.