12/4/2023 0 Comments Comminuted fracture hand10, 11Ī cadaver study showed that K-wires placed away from the extensor tendon create less of a tether to the PIP joint than those placed through or adjacent to it. The transarticular technique crosses the MCP joint, 3 whereas the periarticular technique places the pins from radial and ulnar starting points on the base of the proximal phalanx. (b) Periarticular technique where the pins start radial and ulnar from the base of the proximal phalanx and cross the fracture site. (a) Transarticular technique where the K-wire crosses the metacarpophalangeal joint prior to crossing the fracture site. Kirschner wire (K-wire) fixation methods for proximal phalanx fracture. 11 The 2 primary techniques for K-wire insertion in this area are transarticular and periarticular ( Figure 1). K-wires are particularly valuable in the management of proximal third fractures, where the extensor tendon cloaks this region and where permanent plates may cause adhesions. Compression loading is best resisted by K-wires placed in line with the shaft. In oblique fractures, bending, torsion, and distraction forces are best neutralized by wires placed perpendicular to the fracture. 4, 22 Four crossed K-wires obtain the highest rigidity in a transverse fracture pattern. 22 Understanding various methods of pin placement is important as adequate stability may require multiple K-wires be placed in different orientations. 31, 32 A diameter of at least 0.9 mm is recommended for the proximal phalanx. 3 Relative stability encourages abundant callus formation. The goal of K-wire fixation is to create a biomechanical environment that is stable enough to allow early postoperative mobilization. Wrist motion was significantly greater for the wrist free group at 6 weeks, but this difference disappeared at 12 weeks. 14 No significant differences were noted in fracture angulation, finger motion, or PIP extensor lag. 29 Seventy-two percent attained near normal total active motion (TAM), and only 2 (6%) had fair to poor results.Ī prospective randomized multicenter study was carried out to compare outcome differences with the wrist immobilized or left free. Nonoperative treatment using a hand-based (wrist free) thermoplastic splint demonstrated no tendon adhesion, contracture, infection, nonunion, or malunion. Ninety-one percent maintained an acceptable position with an average shortening of 1.1 mm that resulted in a mild extensor lag. The injured finger was buddy-taped to the adjacent digit to control for rotation. 17 All fractures were reduced and maintained in a dorsal MCP flexed splint. 8 A method of qualifying this is lack of discomfort when direct manual pressure is applied to the injured bone.Ī prospective cohort study treated both stable (39%) and unstable (61%) extra-articular proximal phalanx fractures nonoperatively. 12 Proximal phalanx fractures will often be clinically healed 4 weeks status post injury, at which time it is unlikely that the fracture will displace. Many stable phalanx fractures can be treated nonoperatively through close monitoring until clinical healing is noted. 8, 14, 17, 22, 29 Allowing active proximal interphalangeal (PIP) joint flexion further compresses the fracture and may be considered for particularly stable fractures. Immobilization in an “intrinsic-plus” position through metacarpophalangeal (MCP) joint flexion reduces the displacing force of the interossei and also shifts the extensor tendon distally so that two-thirds of the proximal phalanx is embraced by the extensor mechanism, adding to the overall fracture stabilization. Nonoperative treatment is recommended for stable proximal phalanx fractures.
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