This 47 year old male surgeon had this injury while skiing. He works as an eye surgeon.
This is his dominant hand. What are your treatment options and discuss how you would make your choice
This is a high demand patient with an intra articular fracturfe and therefore needs early mobilisation and active movements.
Only way to provide this is by an Internal Fixation. The principle of treating these fractures are:-
- anatomical reduction
- stable fixation
- ealry mobilisation
Note it is communited fracture
This can be difficult to fix
Using a T platewith recution of the articular fragments held with the plate. Note use of unicortical screws to hold the bone out to length using ligamnetotaxis for reduction . This prevents driling onto the volar surfacce and damage the FPL producing adhesion. Mechanically this is sound.
The communition in the front is left to heal without attempts at bone grafting which can be troouibleosme and induce scarring.
http://emedicine.medscape.com/article/1287814-overview
Clin Biomech (Bristol, Avon). 2008 Nov;23(9):1136-40. Epub 2008 Jul 22.
Biomechanical comparison of pull-out force of unicortical versus bicortical screws in proximal phalanges of the hand: a human cadaveric study.
Khalid M, Theivendran K, Cheema M, Rajaratnam V, Deshmukh SC.
Birmingham Hand Centre, University Hospital Birmingham, Selly Oak Hospital, Birmingham, UK.
Abstract
BACKGROUND: Bicortical fixation of proximal phalangeal fractures may damage underlying flexor tendons secondary to drilling and screw protrusion in the dorsal-ventral direction. The aim of this study was to measure and compare the pull-out force of unicortical screws compared to bicortical screws in human cadaveric proximal phalanges to identify optimal configuration for internal fixation. METHODS: Forty proximal phalanges were harvested. Bicortical and unicortical self tapping 1.7mm screws were inserted into paired phalanges at the distal and proximal metaphysis and at the mid-diaphysis placed in the dorso-ventral direction. Pull-out force of unicortical and bicortical screws were measured and compared. FINDINGS: Bicortical screw pull-out force is significantly higher than that of unicortical screws in the dorsal-ventral direction. Pull-out strength of unicortical screws at the mid-diaphysis was significantly higher than the pull-out strength of bicortical screws at the proximal metaphysis (181.8N versus 31.5N, P<0.0001). INTERPRETATION: Diaphyseal fixation is stronger than metaphyseal for both unicortical and bicortical configurations. Unicortical mid-diaphyseal is stronger than bicortical proximal metaphyseal screw pull-out strength. This study provides biomechanical data that may be helpful for individualizing fracture fixation techniques at the proximal phalanx.
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