Hand Bone

Proximal phalanx and PIP joint fractures

PIP fracture-dislocation, volar plate avulsion injury and proximal phalanx fracture management.

23 questions 3 source pages

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Q1Describe the Eaton classification of PIPJ fracture-dislocation.▸

Type 1: hyperextension
Type 2: dislocation
Type 3: fracture-dislocation, then graded by Hastings: I <30%, II 30-50%, III >50% articular surface
Fracture fragment typically involves ~50% of the joint surface and is likely an avulsion from the volar plate

Q2When does a PIPJ fracture-dislocation require surgery?▸

Eaton III with Hastings II or III
Irreducible dislocation
Aim: stable joint for early mob & prevent stiffness
Also request AP X-ray to check for a rotatory component

Q3How do you perform closed reduction of a PIPJ dislocation?▸

Dorsal: flex wrist and MCPJ, gentle hyperextension of the MP followed by palmar force
Volar: reverse of dorsal
Rotatory: traction with MCPJ and PIPJ at 90deg flexion to relax the lateral band
Check NV status and document collateral and volar plate integrity

Q4How is stability assessed after reduction of a PIPJ fracture-dislocation?▸

Assess PIPJ stability range - unstable if >30deg flexion is needed to remain reduced
Elson test for volar dislocation
Post-reduction XR: articular fragment size, PIPJ Shenton line and V sign

Q5What is the definitive management of PIPJ injuries by direction?▸

Dorsal, stable, no fracture: dorsal block splint allowing active flexion
Dorsal, unstable: operative treatment
Volar: extension splint full time 3 weeks, then 3 weeks nocturnal splint
Lateral: buddy taping

Q6What are the surgical options for PIPJ fracture-dislocation?▸

Dynamic external fixation (Suzuki frame) for comminuted/open - maintains length by ligamentotaxis
ORIF with screw for a sizeable fragment
Extension block pinning for a congruent joint
Hemihamate graft for comminuted/chronic cases; volar plate arthroplasty in chronic cases
Chronic <50% surface: volar plate arthroplasty (K wire 2-3 weeks + dorsal block splint, then dynamic splint 6-8 weeks)
Chronic >50%: ORIF + hemihamate autograft (distal dorsal hamate at 4/5 CMCJ) with K wire fixation

Q7Describe the anatomy of the PIPJ.▸

Hinged joint, congruent with the intercondylar sulcus
3-sided box
Stability from bone and soft tissue (volar plate + collaterals)
2/3 of soft tissue stabilisers must be injured for dislocation to occur

Q8Describe the Eaton classification in terms of ligament disruption.▸

1: partial disruption between the proper and accessory collaterals
2: complete disruption of both collaterals + volar plate
3: fracture - loss of bony stability, collaterals stay with the proximal fragment, unstable++

Q9What history is important in a PIPJ fracture-dislocation?▸

Mechanism of injury
Chronicity
Premorbid status

Q10What examination findings are important in a PIPJ fracture-dislocation?▸

Skin: wounds or dimple
Deformity: chronic dislocation, dorsal pseudoboutonniere
NV status

Q11What are the components of the Suzuki frame for dynamic external fixation?▸

Traction wire, reduction wire and hook wire (1.2mm)
Allows PIPJ movement and maintains length by ligamentotaxis

Q12What are the problems of a chronic PIPJ fracture-dislocation deformity?▸

Resorbed bone fragment
Contracted soft tissue
Scar over the fracture site

Q13What is the function of the volar plate?▸

Reinforces the joint capsule
Enhances joint stability
Limits hyperextension
Loose in flexion, tight in extension

Q14Describe the anatomy of the MCP volar plate.▸

Thickening of the joint capsule volar to the MP joint
Origin: metacarpal head
Insertion: periarticular surface of the proximal phalanx, via checkrein ligaments

Q15Describe the collateral ligament anatomy.▸

Origin from the collateral recess
Proper collateral attached to the metacarpal head (dorsal one)
Accessory collateral attached to the volar plate (volar one)
Tighten in extension

Q16Why do complex dislocations occur at the MCPJ but not the PIPJ?▸

PIPJ: checkrein inserts into the distal PP, stronger, so no complex dorsal dislocation
MCPJ: checkrein inserts into the proximal PP, stronger, so complex dislocation happens in dorsal dislocation

Q17What are the deforming forces in a proximal phalanx fracture?▸

Central slip extends the distal fragment
Interossei flex the proximal fragment

Q18How is malrotation assessed in a phalangeal fracture?▸

Tenodesis check
Scissoring upon making a fist

Q19What are the nonoperative indications for a proximal phalanx fracture?▸

transverse/ short oblique pattern
Stable at >50 degrees ROM
Angulation <20deg
Displacement <2mm
No malrotation

Q20What is the nonoperative regime for a proximal phalanx fracture?▸

Dorsal splint with MCPJ at 90deg flexion
Intrinsic forces act through the extensor mechanism -> tension band effect

Q21What are the operative indications for a proximal phalanx fracture?▸

Long spiral fracture
Displacement, angulation or rotation
Multiple digits

Q22What fixation is used for phalangeal shaft, base and head fractures?▸

Transverse shaft: K wire (antegrade or retrograde), Lister wiring, Bouquet pinning
Spiral/oblique shaft: cross K wires, plate, lag screws
Base: cross K wire or plate
Head: type 1 undisplaced, type 2 unstable displaced unicondylar, type 3 unstable bicondylar/comminuted

Q23Describe the X-ray findings in this proximal phalanx fracture.▸

Short oblique fracture of the proximal 1/3 of the index finger PP
No intra-articular extension
Apex volar with minimal coronal malignment
No rotational deformity

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Proximal phalanx and PIP joint fractures