Treatment is aimed at restoring or stabilising the cup-shaped geometry of the base of the middle phalanx by reconstructing its palmar deficiency, which is responsible for the instability of these fractures. Unstable palmar lip fractures involve greater than 50% of the palmar articular surface of the middle phalanx base and those involving 30–50% require more than 30° of flexion to maintain concentric reduction of the PIP joint. Descriptions of type of classification used in the treatment section are represented in schematic diagram.
We used the classification devised by Joseph J. Multiple systems of categorising this injury exist. The management of intra-articular fractures of the PIP joint is a therapeutic problem. There was no functional deficit in the 4 th and 5 th CMC joint following the procedure.įracture dislocation of the PIP joint of the hand, although relatively uncommon, is a potentially disabling injury which leads to persistent pain and stiffness. There were no complications at the donor site. All the grafts united with normal maintenance of joint space without evidence of resorption or degenerative changes. Average size of the graft used for reconstruction was about 1–1.5 cm in length and 0.5–0.75 cm in breadth. Except for the immediate postoperative pain, no patients had complaints of pain during mobilisation or movement of fingers after surgery. All patients including the chronic cases presented with pain during movement preoperatively. At final evaluation, no instability of the joints was observed. Proper reduction and congruency of the joint was noted on final anteroposterior and lateral radiographs. The average range of motion of the PIP joint at final follow-up was 0°–96° (0°–100°). All patients presented with posterior subluxation of PIP joint, with the range of movement from 5°–15° associated with pain and loss of grip involving the adjacent fingers. There was a mean delay of 32 days (14–90 days) between the injury and surgery. The mean period of follow-up was 22 months (7–32 months). Passive flexion is done after wound closure to confirm the position of the graft. Tendon sheath is repaired and wound closed in layers. After positioning the graft, volar plate is repaired on the lateral side. Graft is placed and fixed in position with screws. Fascia and capsule over the CMC joint are closed. Measurement and marking of the donor graft is done. Schematic diagram shows bifaceted nature of the hamate and graft location. Fourth and fifth CMC joints are exposed between the extensor digitorum communis of the ring finger and the extensor digiti quinti tendons. Longitudinal incision is made over the fourth and fifth carpometacarpal (CMC) joints with mobilisation of dorsal sensory branches of the ulnar nerve. A 4-mm oscillation saw is used to resect the comminuted articular fragments and create a box-like recipient defect. Schematic representation of the area of comminuted articular base to be resected is shown in Figure 4. Joint involvement is estimated from direct intraoperative measurement. Comminution and depression of the volar middle phalangeal articular base is identified. At this point, with the volar plate and collateral ligaments released, the joint can be shotgun opened to expose the particular surfaces. The collateral ligaments are then mobilised from the proximal phalanx but are reinserted again at the end of the procedure. The volar plate will be repaired at closure. Care is taken to maintain the volar plate's distal attachment on the middle phalanx. The proximal aspect of the volar plate is reflected from the proximal phalanx. A Penrose drain is then placed under the flexor tendons so that they can be retracted either radially or ulnarly to allow for greater visibility of the joint. As the sheath is entered, it is protected so that it can be repaired at the end of the procedure. The flexor tendon sheath is then entered between the A2 and A4 pulleys.
#Pilon fracture orif cpt skin#
The skin flap is elevated, and care is taken to protect the radial and ulnar digital neurovascular bundles. The first step in the volar approach is a Bruner incision centred over the flexion crease of the PIP joint. The arm is prepared up to the tourniquet level. Patient is placed in supine position with the involved extremity supported by a hand table. A general or regional block anaesthetic is administered.
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