While dislocations and ligament injuries are common throughout the hand, they are most common at the proximal interphalangeal (PIP) joint. The spectrum of these injuries ranges from minor stretching (sprains) to complete disruptions of the ligaments.
Dislocations of the PIP joint are classified according to the direction of displacement of the middle phalanx. They can be palmar, dorsal, lateral, or lateral rotatory.
The collateral ligament usually tears at one of two locations: a) at its attachment to the proximal phalanx b) at its attachment to the volar plate and middle phalanx. Often, these injuries are accompanied by a partial lesion of the volar plate.
Lateral subluxation can be accompanied by a condylar fracture, or a plateau fracture (either as an avulsion fracture, or as an impaction fracture).
Avulsion fractures are the result of side-to-side (coronal) forces acting on the finger, putting the collateral ligament under sudden tension. The ligament is usually stronger than the bone, causing the ligament to avulse a fragment of bone at its insertion.
Avulsion fractures result in marked joint instability.
If the fracture is not displaced, nonoperative treatment is usually indicated (buddy taping to the adjacent finger). Displaced fractures, however, must be internally fixed.
Animation of the injury mechanism
Cerclage compression wiring
Cerclage compression wiring of this fracture has been shown to be effective and usually provides good results. The figure-of-eight wire loop acts as a cerclage compression wire when tightened and applied in static mode. The advantage of this technique is its limited disruption. The risk of fragmentation is also minimized. This treatment is contraindicated when the fracture is comminuted.
This form of fixation was referred to as “Tension band wiring”. We now prefer the term “Cerclage compression wiring” because the tension band mechanism cannot be applied consistently to each component of the fracture fixation. An explanation of the limits of the Tension band mechanism/principle can be found here.
In cases of associated dislocation, start by reducing the dislocation. Apply traction to the finger, with the PIP joint in slight flexion, to relax the flexor tendons and the lateral band.
Then, maintaining the traction, deviate the finger laterally...
...and rotate towards the contralateral side.
In the majority of cases, the collateral ligament regains its natural anatomical position after reduction.
Reduction is achieved by pulling the finger laterally, in the direction opposite to the forces that created the fracture, and into MP flexion, as necessary, to approximate the fragment. The avulsed fragment is pushed into place by the surgeon’s thumb.
With tiny fragments, indirect reduction can be achieved by tightening the cerclage wire at the end of the fixation procedure.
In displaced fractures, open reduction is often necessary. A dental pick is used gently to reduce the fracture from palmar to dorsal and from proximal to distal. Application of excessive force can result in fragmentation.
Note Anatomical reduction is important to prevent chronic instability, or posttraumatic degenerative joint disease.
Hold the reduction by inserting a K-wire through the center of the fracture surface. Check reduction using image intensification.
Pearl: use K-wire to reduce fracture
An alternative is to insert the K-wire in the avulsed fragment, and then, using the K-wire as a joystick, simultaneously to reduce the fragment and preliminarily hold it with the wire.
Drill a hole
A hole is drilled in the middle phalanx, from dorsal to palmar. The location of the drill hole should be the same distance from the fracture line as the avulsed fragment’s length. Use a drill guide, for soft-tissue protection, and either a slow-spinning 1.5 mm drill, or a 1 mm K-wire.
Thread a 0.6 mm stainless steel monofilament wire through the drill hole. A fine, curved hemostat can be used to retrieve the wire from the palmar surface, sliding it very closely to the cortical bone in order to avoid damage to the digital nerve and artery. Periosteal elevators can be used for protection.
The wire is passed through the drill hole and then around the fragment and K-wire, through the ligament attachment, in a figure-of-eight mode. This can be achieved by passing a syringe needle of appropriate diameter on the surface of the bone, deep to the ligament attachment, and then inserting one end of the wire into the tip of the needle. The needle and the wire are then carefully drawn through, guiding the wire along the correct track.
Anchoring the K-wire
Check the position of the K-wire using image intensification. If the tip of the wire is in contact with the far cortex, then retract the K-wire by about 2 mm, bend it through 180 degrees, cut the wire to form a small hook, and impact the bent tip into the bone.
Tighten the wire
Once the fragment is reduced, the wire loop is tightened, cut short, and bent along the phalanx, in order to avoid soft-tissue irritation. When tightening the wire, ensure that both ends are twisted around each other rather than twisting one end around the other straight end.
This is achieved by using traction with the pliers to tighten the loop and the twisting, still under tension, to take up the slack.
In more vertical fractures, the K-wire gives the fragment additional stability and prevents secondary axial displacement.
Use image intensification finally to ensure anatomical reduction.
Alternative: anchor screw
An alternative way of anchoring the figure-of-eight wire distally in the phalanx is the use of a screw instead of a drill hole.
Alternative: small fragment
If the avulsed fragment is too small to risk further damage by passing a K-wire, ...
... a simple figure-of-eight cerclage wire is used.
Protect the digit with buddy strapping to the adjacent finger, to neutralize lateral forces on the finger.
While the patient is in bed, use pillows to keep the hand elevated above the level of the heart to reduce swelling.
See the patient 5 days and 10 days after surgery.
The patient can begin active motion (flexion and extension) immediately after surgery.
For ambulant patients, put the arm in a sling and elevate to heart level.
Instruct the patient to lift the hand regularly overhead, in order to mobilize the shoulder and elbow joints.
The implants may need to be removed in cases of soft-tissue irritation.
In case of joint stiffness, or tendon adhesion’s restricting finger movement, tenolysis, or arthrolysis become necessary. In these circumstances, take the opportunity to remove the implants.