Technique Spotlight: Phalanx Fractures—Pins vs. Screws vs. Plates—When and How

Closed Reduction Percutaneous Pinning

The majority of proximal phalanx fractures displace with apex volar angulation. Therefore closed reduction involves traction with simultaneous flexion at the metacarpophalangeal (MP) joint to 70–90 degrees and extension at the proximal interphalangeal (PIP) joint. This maneuver relaxes the intrinsic muscles, which flex the proximal fragment, and permits the extensor hood to aid the reduction by serving as a tension band dorsally. Several percutaneous fixation constructs have been described. Our preference is to perform a closed reduction and place pins perpendicular to the plane of the fracture. The senior author uses one to two fracture-reduction clamps applied percutaneously to anatomically reduce and maintain the reduction while the pins are inserted. Using intraoperative fluoroscopy, a single 0.035- or 0.045-inch K-wire can be inserted into the near cortex perpendicular to the fracture site. We prefer multiple pins, at least three, to increase the stiffness of the construct. The pins can then be cut and bent above the skin or cut short and buried beneath the skin to be removed in the operative theater at 3–4 weeks.

In the setting of significant comminution, very proximal extra-articular base fractures, or if placing a perpendicular pin could tether the flexor or extensor tendons from a volar or dorsal starting point, we prefer the Belsky technique of anterograde transarticular pinning through the metacarpal head. Following closed reduction as described above, a single 0.045-inch K-wire is drilled anterograde through the metacarpal head across the MP joint and into the medullary canal of the proximal phalanx, stopping short of the articular surface of the condyles. It should be noted that the exact angle of insertion is determined under fluoroscopy. An additional wire can be added for increased stability; however, we feel a single wire is adequate for most fracture patterns ( Fig. 79.1 ).

Fractures of the middle phalanx can present with variable angulation depending on where they occur with respect to the insertion of the flexor digitorum superficialis (FDS). The method of closed reduction is variable based on the location of the fracture in relation to the insertion of the FDS; fractures proximal to the insertion require flexion proximally and extension of the distal fragment. Conversely, those fractures distal to the insertion require extension of the proximal fragment and flexion of the distal fragment. Percutaneous fixation with K-wires can be achieved via a variety of techniques; however, the senior author’s preferred method is placing multiple 0.035- or 0.045-inch K-wires perpendicular to the plane of the fracture, similar to that described for the proximal phalanx ( Fig. 79.2 ).

Postoperatively, the digit should be immobilized in an intrinsic plus position, with the distal interphalangeal (DIP) joint left free to permit active range of motion and promote flexor digitorum profundus (FDP) tendon gliding. It is critical that the patient be instructed to work on active DIP joint flexion. This helps eliminate FDP tendon adhesions within the zone of injury. Also, the PIP and/or MP joints should be immobilized for no more than 4 weeks, at which point the pins should be removed and active range of motion should be initiated.