Comminuted fractures are rarely isolated injuries, as they usually result from high-energy trauma (crushing). Soft-tissue lesions are frequently associated with the potential risk of edema, fibrotic reactions and eventual stiffness.
For these reasons, these injuries are usually treated by ORIF, in order to provide sufficient stability for immediate mobilization, reducing the risk of joint stiffness and tendon adhesions.
Depending on the forces acting on the bone, two kinds of comminuted fractures are common: small fragment comminution, or wedge fractures.
Small fragment comminution
Even in the hand, which is well vascularized, small fragment comminution means poor soft-tissue attachment to the fragments and, thereby, compromised vascularity.
The degree and type of comminution depends on the forces and energy acting on the finger. In some cases, a large wedge fragment may result from the injury. In such cases, vascularity has not usually been significantly compromised.
For this procedure the following approaches may be used:
Length can be gained by traction applied either manually by the surgeon, by a finger trap, or with pointed reduction forceps.
Manipulate the fragments with pointed reduction forceps in order to reduce rotation and restore correct angulation.
At this stage, after provisional fixation, it is advisable to check the alignment and rotational correction by moving the finger through a range of motion.
Rotational alignment can only be judged with the fingers in a degree of flexion, and never in full extension. Malrotation may manifest itself by overlap of the flexed finger over its neighbor. Subtle rotational malalignments can often be judged by tilting of the leading edge of the fingernail, when the fingers are viewed end-on.
If the patient is conscious and the regional anesthesia still allows active movement, the patient can be asked to extend and flex the finger.
Any malrotation is corrected by direct manipulation and later fixed.
Under general anesthesia, the tenodesis effect is used, the surgeon fully flexing the wrist to produce extension of the fingers, and fully extending the wrist to cause flexion of the fingers.
Alternatively, the surgeon can exert pressure against the muscle bellies of the proximal forearm to cause passive flexion of the fingers.
Select a straight plate that is long enough to have at least 2 holes on each side of the wedge fragment. Apply the plate laterally and center it on the shaft axis of the phalanx in the lateral projection.
Using a drill guide and 1.1 mm drill bit, carefully drill a neutral first screw hole through a plate hole directly adjacent to the wedge fragment.
Use a depth gauge to determine screw length.
Insert the first screw in a neutral position. Do not yet completely tighten it, to avoid displacement.
Drill for a neutral second screw through the plate hole adjacent to the opposite end of the wedge fragment. Measure for screw length, and insert the screw.
Now tighten both screws alternately.
Fill the remaining screw holes on each side of the wedge fragment in a similar fashion. The most proximal and most distal screws should be inserted at a divergent angle, thereby increasing stability.
In some cases it may be desirable to approximate the wedge fragment to the plate in order to strengthen the construct. Insert a short neutral monocortical screw, and carefully tighten it.
While the patient is in bed, use pillows to keep the hand elevated above the level of the heart to reduce swelling.
For ambulating patients, put the arm in a sling and elevate to above the heart.
As pain and swelling recede, early, active, controlled digital range of motion exercises (six-pack exercises) gently progress.
The importance of mobilization must be emphasized to the patient and rehabilitation should be supervised by a physical therapist.
See patient after 5 days for changing of the dressing. After 10 days remove the sutures and confirm with x-rays that no secondary displacement has occurred.