The above radiograph is from a 45-year-old man who has had pain, swelling, and ecchymoses over the ulnar aspect of the thumb metacarpophalangeal joint since falling on his outstretched hand three days ago. On examination, a tender mass can be palpated.

Which of the following is the most appropriate management?

(A) Application of a thumb spica splint
(B) Application of a thumb spica cast
(C) Closed reduction
(D) Open reduction

The correct response is Option D.

Open reduction is the most appropriate management of this patient's deformity. These findings are consistent with a classic Stener lesion, in which the ulnar collateral ligament (UCL) avulses and retracts proximally. The interposed adductor aponeurosis precludes primary healing; the UCL will not heal properly without contact at the site of avulsion. Avulsion of the UCL can occur with or without a bony fragment. A mass can be palpated. Laxity of the ulnar capsule will occur and will not improve with immobilization of the fracture, resulting in chronic pain and instability. Open reduction and internal fixation should be performed to effectively restore contact between the fracture fragments and allow the fracture to heal.
In patients who have partial tears of the UCL, operative repair is indicated if collateral ligament instability is greater than 30 degrees during stress in both full extension and semi-flexion. Conservative management is recommended instead for incomplete ligament tears not associated with instability.

Appropriate surgical repair of this injury includes debridement of the fracture fragment, division of the adductor aponeurosis, and anchoring of the residual UCL to the small area of decorticated proximal phalanx using sutures. The adductor aponeurosis is repaired after the UCL is attached. The repaired ligament can be protected with a transarticular Kirschner wire and a cast for four weeks. After the cast is removed, a thumb spica splint should be worn for four weeks.

As mentioned above, splint immobilization or closed reduction would be ineffective in restoring contact between the fracture fragments in this patient.

References
1. Durham JW. Thumb metacarpophalangeal ulnar collateral ligament repair with local tissues. In: Blair WF, ed. Techniques in Hand Surgery. Baltimore, Md: Williams & Wilkins; 1996:533-537.
2. Glickel SZ, Barron OA, Eaton RG, et al. Dislocations and ligament injuries in the digits. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:788-793.

A 17-year-old girl sustains an open pilon fracture of the middle finger of the dominant right hand during a basketball game. Open reduction and internal fixation with autologous bone grafting are performed; on examination three months later, there is a flexion contracture of the proximal interphalangeal (PIP) joint. Active range of motion is 90 degrees to 95 degrees. Radiographs show a stable, healed fracture with a smooth surface and congruency of the PIP joint. Hand therapy has not resulted in any improvement in hand function.

Which of the following is the most appropriate operative management?

(A) Bone grafting
(B) Capsulectomy
(C) Arthroplasty
(D) Arthrodesis
(E) Amputation

The correct response is Option B.

This 17-year-old girl sustained an open pilon fracture of the middle finger; fractures such as this one involving the proximal interphalangeal (PIP) joint are often extremely difficult to manage. The articular surfaces should be re-established surgically; autologous bone grafts can be applied to maintain reduction. Ligamentotaxis will aid in realignment of the joint. Early controlled motion is associated with the best functional outcome.

In patients who develop flexion contractures following PIP joint injury, early management will result in optimal return of function. Serial casting is recommended for patients who have PIP joint contractures of greater than 30 degrees; dynamic splinting is used subsequently. Controlled application of 100 g to 250 g of torque will stretch the soft tissues
Because treatment of this patient's severe posttraumatic flexion contracture has been delayed, the most appropriate management at this time involves release of the scarred soft tissues. The collateral ligaments, volar plate, capsule, and check rein ligaments of the PIP joint should be evaluated and then released sequentially. Capsulectomy is recommended to improve active motion of the finger.

Bone grafting is best when performed at the time of initial repair to maintain reduction following re-establishment of the articular surfaces; grafting at this time is not warranted. Arthroplasty is appropriate for posttraumatic degeneration of the PIP joint in a radial digit, while arthrodesis is recommended for the same condition in an ulnar digit. Amputation should only be performed if the patient has severe, uncontrolled neuropathic pain and loss of function of the digit.

References
1. Diao E, Eaton RG. Total collateral ligament excision for contractures of the proximal interphalangeal joint. J Hand Surg. 1993;18A:395.
2. Kasabian A, McCarthy J, Karp N. Use of a multiplanar distracter for the correction of a proximal interphalangeal joint contracture. Ann Plast Surg. 1998;40:378-381.
3. Prosser R. Splinting in the management of proximal interphalangeal joint flexion contracture. J Hand Ther. 1996;9:378-386.

PHOTO

The above radiograph is from a 53-year-old woman who sustained a closed, rotatory volar dislocation of the proximal interphalangeal joint of the nondominant left ring finger when it accidently became caught in a spin dryer. Closed reduction cannot be maintained. Which of the following is the most appropriate management?

(A) Extension block splinting
(B) Extension block pin fixation
(C) Dynamic skeletal traction
(D) Repair of the lateral band
(E) Volar plate arthroplasty

PHOTO

The correct response is Option D.

This patient has a volar rotary dislocation of the proximal interphalangeal (PIP) joint, an injury that is often described as irreducible. This type of dislocation occurs following partial rupture of the volar plate, collateral ligament, and accessory collateral ligament; the flared ipsilateral condyle of the proximal phalanx often becomes entrapped between the central slip and lateral band in a "buttonhole" manner. The fragmented fibers of the lateral band become trapped beneath the flare of the condyle and redirected through the PIP joint. The usual maneuver for obtaining closed reduction, which involves traction and extension of the middle phalanx, actually tightens the encirclement around the condyle and ultimately leads to loss of the reduction. In some patients, closed reduction may be maintained by flexing the metacarpophalangeal and PIP joints, which relaxes the volarly displaced lateral band; a rotary motion can be used to re-establish congruity between the proximal and middle phalanges. However, in the majority of patients who have this type of injury, open repair should be considered. During this procedure, the fragmented lateral band should be repaired and properly aligned, and the central slip should also be repaired. Intraoperative photographs of this technique are shown above.

Extension block splinting and pin fixation can be used for treatment of dorsal fracture-dislocations. Skeletal traction is also an option for patients who have dorsal fracture-dislocations, especially pilon fractures. Volar plate arthroplasty is the preferred management of unstable dorsal dislocations of the PIP joint.

References
1. Deitch MA, Kiefhaber TR, Comisar BR, et al. Dorsal fracture dislocations of the proximal interphalangeal joint: surgical complications and long-term results. J Hand Surg. 1999;24A:914-923.
2. Glickel SZ, Barron OA, Eaton RG, et al. Dislocations and ligament injuries in the digits. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;1:772-808.
3. Schenck RR. Dynamic traction and early passive movement for fractures of the proximal interphalangeal joint. J Hand Surg. 1986;11A:850-858.
4. Wang KC, Hsu KY, Shih CH. Irreducible volar rotatory dislocation of the proximal interphalangeal joint. Orthop Rev. 1994;23:886-888.