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TRAUMATOLOGY Table of Contents   
Year : 2005  |  Volume : 39  |  Issue : 3  |  Page : 158-162
Treatment of closed unstable extra articular proximal phalangeal fractures of hand by closed reduction and dorsal extension block cast


Hand surgery unit, Department of Orthopaedics, Sawai Man Singh Medical College and Hospital, Jaipur, India

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   Abstract 

Background: Unstable fractures of proximal phalanges have enormous divergence of opinion regarding the treatment. Treatment options range from fancy over the counter splints to the more exotic forms of internal fixation.
Method: A total of 62 cases with 72 fractures with ages from 10­65 yrs of both sexes were treated. After closed reduction under local anaesthesia the dorsal extension block cast was applied with the metacarpophalangeal joints in full flexion and interphalangeal joints in full extension. This method works on the principle of the intact dorsal soft tissue hinge (extensor apparatus) over the fractured proximal phalanx. The intrinsic plus position keeps the intrinsics lax and prevents them from acting as a displacing force pulling the proximal fragment of the fracture into volar angulation. On an average the cast was used for 3 weeks.
Results: Fifty eight fractures had united by 3 weeks. The results were judged according to modified Buck-Gramcko's point assessment system for finger fractures, which showed 80.64% excellent, 4.83% good, 8.06% satisfactory and 6.45% poor results. The complications were minimal which included only 3 cases with malunion.
Conclusion: Conservative management of unstable proximal phalangeal fractures with dorsal extension block cast has produced excellent results. It maintains mobility of the fingers without compromising the stability of the fracture and prevents future stiffness of hands. It avoids the complications of operative methods and is simple to use.

Keywords: Proximal phalangeal fractures; Dorsal extension block cast.

How to cite this article:
Kar A, Patni P, Dayama R L, Meena D S. Treatment of closed unstable extra articular proximal phalangeal fractures of hand by closed reduction and dorsal extension block cast. Indian J Orthop 2005;39:158-62

How to cite this URL:
Kar A, Patni P, Dayama R L, Meena D S. Treatment of closed unstable extra articular proximal phalangeal fractures of hand by closed reduction and dorsal extension block cast. Indian J Orthop [serial online] 2005 [cited 2020 Jan 21];39:158-62. Available from: http://www.ijoonline.com/text.asp?2005/39/3/158/36705

   Introduction Top


Fractures of hand have always been given step-motherly treatment by Orthopaedicians. Phalangeal fractures present just as great a challenge as fractures of big bones. Sir Reginald Watson Jones [1] had said," a fracture of hand is no less worthy of the skill of an expert than a fracture of a femur".

Most of the fractures require immobilization, but the hand tolerates immobilization poorly, so that the balance between immobilization and movement is a fine line requiring good clinical judgment. It is the unstable fractures of proximal phalanges that have an enormous divergence of opinion between conservative and operative management. Whatever may the methods of treatment be, it is important to remember that one should not make a fracture fit a favourite treatment; rather the method of management should be according to the peculiarities of the given fracture and the needs of the patient.

The types of proximal phalangeal fractures can be classified according to the position (base, mid shaft, neck) or by the shape (transverse, spiral, oblique or comminuted). Over all it has been shown that conservatively managed proximal phalangeal fractures of hand do better than ones operated upon [2],[3],[4] . One such conservative management method is closed reduction and dorsal extension block cast [5],[6],[7] . It definitely has a role in conservative management of unstable extra-articular proximal phalangeal fractures of base and shaft. It works on the principle of the intact dorsal soft tissue hinge (extensor apparatus) overlying the fracture [5] . The fractured proximal phalanx is known to displace and angulate volarwards [Figure - 1]a. The fracture maintains reduction in 90 deg flexion of metacarpophalangeal (MCP) joint and the interphalangeal(IP) joints in full extension(intrinsic plus position) [8] . This position relaxes the pull of the intrinsics. With active finger flexion at proximal interphalangeal (PIP) joint the compressive forces are transmitted to the palmer cortex of the phalanges. The extensor apparatus holds the phalanx like a tight wrap. In addition the dorsal plaster splint holds the fracture in reduction [Figure - 2]. All this holds the fragments in perfect alignment and prevents volar angulation of the fracture. Volar angulation is primarily responsible for the improper gliding of the flexor tendon, which tightens eventually and there is flexion contracture of the finger at PIP and DIP joints [9],[10] . Flexion contracture of the PIP joint is also due to adhesions of the volar plate with the anterior fibres of collateral ligaments [9] . As the fingers move in tandem, there is non-surgical syndactilyzation, which prevents rotatory and angulatory displacements.


   Material and methods Top


Sixty five cases attending the accident and emergency wing and the hand surgery out patient unit of the hospital were selected. Closed unstable extra articular fractures of the base or shaft of the proximal phalanx with ability to maintain reduction in the cast during active mobilization, were included in study. Fractures of the neck of proximal phalanges, intra articular fractures of the base or head of proximal phalanges and open fractures were excluded from study. Abrasions of the skin were not a contraindication. In three cases the treatment was abandoned in favour of open reduction and internal fixation, as there was persistent displacement in the cast.

Radiographs of the involved hand with particular focus to the fingers were taken (an antero-posterior view with the fingers laying flat against the cassette and an oblique view with the hand at an angle of 60 0 to the cassette).

Reduction of fracture and cast application

The fractures, which were displaced or angulated, were reduced under digital block with 1% lignocain. After giving longitudinal traction and using the thumb of the surgeon as a fulcrum the fracture was reduced [11] [Figure - 1]b. Angulation and rotation were checked with reference to the curvature of the fingernails. The patient was asked to maintain the position of the hand with the MCP joints in 90 deg flexion[8] , IP joints in full extension and the wrist in 30 deg dorsiflexion.

An 8 layered dorsal plaster of Paris (POP) slab was applied and moulded over the dorsum of hand starting from the PIP joints of all fingers till the upper dorsum of forearm. The moulding was also carried over the mid lateral borders of the index and little fingers in such a way that there is no side-to­side movement of the fingers. POP rolls were now applied over the slab maintaining the position of reduction. The cast trimming was done in such a manner as to free the thumb and the volar aspect of the fingers till the proximal palmer crease [5] . Check radiographs were taken as described above. The patients were immediately asked to mobilize the fingers and carry out activities within the limits of comfort.

Follow up

At weekly follow up patients were assessed clinically for rotation, angulation or shortening of fingers signifying loss of reduction [Figure - 3]. This should be confirmed with a radiograph. A second attempt at reduction may be attempted but a persistent loss of reduction calls for abandoning the treatment in cast in favour of open reduction and internal fixation (three cases).

Casts were removed at 3 weeks and check radiographs were taken. Patients were assessed for pain, tenderness, total active motion (TAM), combined lack of extension at MCP, PIP and DIP joints and the finger palm distance (the distance of the pulp of finger from the distal palmer crease (The last three are part of the Buck's Gramcko's point assessment system)[3] . Fifty eight fractures had united at 3 weeks and the radiological union at 3 weeks did not correlate with clinical union or functional performance [12] .

Patients with stiffness and less than satisfactory motion were put on active and passive physiotherapy and followed up for 6 months. The final results were tabulated in accordance with the modified Buck Gramcko's point assessment system for finger fractures [3] .


   Results Top


Seventy two fractures in 62 cases were studied. There were ten cases with multiple finger fracture. Forty-six cases were male. Patients were from the age range of 10-65 years. The commonest mode of injury was road traffic accident (25), followed by fall (12); industrial accidents (11); direct impact (8) and assault (6). The dominant hand was involved in 50 cases. Only 22 cases reported immediately after the injury. The rest has a time delay ranging from1-15 days before the cast application.

The commonest site for fracture was the base (48 fingers) and the shaft was involved in 24 fingers. Fifty fractures were of transverse type followed by nine oblique; eight spiral and five comminuted fractures. The little finger was involved in 50 and the ring, middle and index finger in 16, 4 and 2 cases respectively. The duration in cast varied, with 51 patients needing 3 weeks of cast treatment, six cases needed less than 3 weeks of cast and five cases needed more than 3 weeks of cast (maximum upto 5 weeks). Fifty four patients could return to work within 3 weeks.

The complications in the series were malunion (3), tight cast (2) and persistent finger swelling (6). Fifty-three patients were pain free at cast removal.


   Discussion Top


The incapacitation that a fracture of the proximal phalanx can inflict to a person, underscores against the permanent handicap that a malunited and wrongly treated proximal fracture can cause.

Our study tries to establish the fact that there is a place for conservative management of unstable proximal phalangeal fractures to achieve bone union and recovery of motion simultaneously not consecutively [5],[6],[7] . It has been demonstrated that duration of immobilization definitely influences the function after phalangeal fractures. Whatever the kind of injury sustained immobilization more than 3 weeks is correlated with significantly poor results [13] . The method of extension block splinting and immediate or early mobilization of unstable phalangeal fractures has been used previously with encouraging results [5],[6],[7] . The other forms of conservative management are POP anterior-posterior splints, gutter splints, circular casts and aluminum splints [14] . They have the disadvantage of not allowing immediate range of movements. The forms of operative treatment are closed reduction and K­wire fixation [15] , open reduction with plates and screws [16] , tension band wiring [17] , intramedullary rods [18] and external fixators [19]. Apart from closed reduction and K-wire fixation, which has been shown, to have good results [15] , the other forms of open reduction and internal fixation treatment have been shown to be associated with less comparable results [2] and high complication rates [4] . Even the most ardent advocates of operative fixation have cautioned that the methods have limited indications [16] and should be used only in selected fracture patterns and severe open injuries. Osteosynthesis may be harmful to the delicate soft tissues of hand and may itself contribute to stiffness either by pinning soft tissues to bone when per cutaneous K-wires are used or through surgical scarring in open reduction and internal fixation of whatever type. Most of the patients have to undergo secondary procedures for hardware removal. Above all, most of the operative interventions if done by an inexperienced surgeon can do more harm than good.

Dorsal extension block casting is unique in conservative management that it maintains stability of fracture as well as mobility of the joints of the hand. It can be applied to all age groups except very young children because of their uncooperative nature.

Due to various reasons there was a delay in application of the cast ranging from 1- 14 days. This delay didn't have any bearing on the end result although the time taken for the patients to retain full range of movement was slightly delayed. Judging by the excellent results in 5 patients whose cast was removed between 15-19 days period, not all patients require the mandatory 3 weeks of cast. Reyes and Latta[5] used it for 3 weeks where as Thomine7 et al used it for an average of 5 weeks. Similarly it may be required to extend the period in cast beyond 3 weeks in select cases who don't show clinical signs of union at 3 weeks, though the number will be fairly less. The patients who have excellent results at 3 weeks time don't require a prolonged follow up, as they don't regress to poor category[5] . They can be followed up for another 3 weeks, as there is a very miniscule chance of secondary displacement at 3rd and 4th week [7],[20] . We didn't experience any case of secondary displacement in our series. On the contrary some patients who didn't show good result at three weeks showed improvement upto 6 months with physiotherapy.

The most important high point of this method is that all patients could carry out their activities of daily living with special reference to two of our patients; one a fine arts student who could draw with the hand in cast and another an auto­rickshaw driver who could drive with the cast applied. Most people were able to return to active duty much before 3 weeks. Radiographs with AP and oblique views as mentioned is sufficient to check the reduction unlike tomograms that were used by Reyes and Latta [5] . Weekly follow up is mandatory as there is a chance of loss of reduction which if occurs can be timely dealt with. Majority of the patients had good movements and minimal pain during the cast treatment.

The complications in our series were minimal, with malunion(5%), tight cast and persistent pain in a few of them. There was no case of non-union. Reyes and Latta [5] in their series had 2% malunion and Thomine et al [7] in their series had 8% malunion.It has to be remembered that the cast can be applied in fresh fractures without compromising the circulatory status of the fingers, as there is ample space on the volar aspect. Radiographs at 3 weeks showed little evidence of union, as it is a known fact that there is very little callus formation in phalanges [11] . Hence routine follow up radiographs at 3 week onwards is not required, but may be required if there is a suspicion of secondary loss of reduction or delayed healing. Fractures with multiple digits involvement and comminuted fractures were similarly treated with the same precautions [5] .

Final results in our series according to the modified Buck­Gramcko's [3] point assessment system for finger fractures showed a combined acceptable result of 85.45% (80.64% excellent plus 4.83% good results). Reyes and Latta [5] used full active flexion and lack of extension as the criteria for assessing results and found combined acceptable results of 87%(70% excellent plus 17% good result), Thomine et al [7] used motion at the PIP joint to classify results and found 55% good results. Their series also included open fractures, which could be responsible for the less number of good results. Operative interventions for unstable proximal phalangeal fractures have yielded low results. Pun et al [4] used AO mini screws and plates and found only 35.7% good results. They used the total active motion as their criteria for results. Till date there is no uniform system for evaluating the clinical, radiological and functional outcome of digital fractures including proximal phalangeal fractures

Difficulties were encountered while treating fractures with long spiral, long oblique and grossly comminuted fracture patterns. Such fractures may be initially treated with a trial reduction and mobilization in cast, but at the first instance of finding any loss of reduction there should be no hesitation in abandoning the treatment in favour of operative intervention [5] . Whatever is the treatment protocol, it is important to again remember that appropriate methods based on sound principles of biomechanics and biology of healing will delineate the options available. Perhaps the most difficult thing is to anticipate and recognize failure of a treatment mode early and then to act promptly.

We recommend this technique of closed reduction and dorsal extension block cast for closed extra articular proximal phalangeal fractures of hand because of its simplicity, speedy rehabilitation and union of fracture permitting early return to occupation with minimal complications. Patients can carry out not only their activities of daily living in the cast but can also perform fine task with dexterity.

 
   References Top

1.Watson-Jones R. Fractures and joint injuries. Vol II. 3rd Ed. Edinburg London: E&S Livingstone.1983.  Back to cited text no. 1    
2.Widgegrow A, Edinburg M, Biddulp SS. An analysis of proximal phalangeal fractures. J Hand Surg(Br).1987;12:134  Back to cited text no. 2    
3.Ip WY, Ng KH, Chow SP. A prospective study of 924 digital fractures of hand. Injury.1996; 27:279  Back to cited text no. 3    
4.Pun WK, Chow SP, So YC, Luk KD, Ngai WK, Ip FK, Peng WH, Ng C, Crosby C. Unstable phalangeal fractures: treatment by A.O. screw and plate fixation. J Hand Surg (Am). 1991; 16(1):113-7.  Back to cited text no. 4    
5.Reyes FA, Latta LL. Conservative management of difficult fractures of proximal phalanx. Clin Orthop.1987; 24:214.  Back to cited text no. 5    
6.Burkhalter WE. Closed treatment of hand fractures. J Hand Surg (Am). 1989;14: 390.  Back to cited text no. 6    
7.Thomine JM, Gibon Y, Bendjeddou MS, Biga N. Functional brace in the treatment of diaphyseal fractures of the proximal phalanges of the last four fingers.Ann Chir Main. 1983; 2(4): 298-306.  Back to cited text no. 7    
8.Mansoor IA. Fractures of proximal phalanges of fingers. A method of reduction. J Bone Joint Surg (Am). 1969; 51: 196  Back to cited text no. 8    
9.Kuczynski K. The proximal interphalangeal joint. Anatomy and cause of stiffness in fingers. J Bone Joint Surg (Br). 1968; 50: 656.  Back to cited text no. 9    
10.Agee J. Treatment principles for proximal and middle phalangeal frac­tures. Orthop Clin North Am. 1992 Jan; 23(1): 35-40.  Back to cited text no. 10    
11.Charnley JC. The closed treatment of common fractures. 3rd ed. Edinburg: Churchill-Livingstone. 1961:150  Back to cited text no. 11    
12.Smith FL, Rider DL. A study of healing of 100 consecutive phalangeal fractures. J Bone Joint Surg. 1935; 17:91  Back to cited text no. 12    
13.Wright TA. Early mobilization in fractures of the metacarpals and phalanges. Can J Surg.1968 Oct: 11(4): 491-8.  Back to cited text no. 13    
14.Maitra A, Burdett-Smith P. The conservative management of proximal phalangeal fractures of the hand in an accident and emergency depart­ment. J Hand Surg (Br). 1992; 17(3): 332-6.  Back to cited text no. 14    
15.Belsky MR, Eaton RG, Lane LB. Closed reduction and internal fixation of proximal phalangeal fractures. J Hand Surg (Am). 1984; 9(5): 725-9.  Back to cited text no. 15    
16.Hastings H. Unstable metacarpal and phalangeal fracture treatment with screws and Plates. Clin Orthop. 1987;(214): 37-52.  Back to cited text no. 16    
17.Safoury Y. Treatment of phalangeal fractures by tension band wiring. J Hand Surg (Br). 2001 Feb; 26(1):50-2.  Back to cited text no. 17    
18.Gonzalez MH, Igram CM, Hall RF. Intramedullary nailing of proximal phalangeal fractures. J Hand Surg (Am). 1995 Sep; 20(5): 808-12.  Back to cited text no. 18    
19.Parsons SW, Fitzgerald JA, Shearer JR. External fixation of unstable metacarpal and phalangeal fractures. J Hand Surg (Br). 1992 Apr;17(2):151-5.  Back to cited text no. 19    
20.Barton NJ. Fractures of hand. J Bone Joint Surg (Br). 1984 Mar;66(2):159­67.  Back to cited text no. 20    

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Correspondence Address:
Abheek Kar
House no 22; 2nd main, 2nd cross, MM Layout, Kaval Byra, Sandra, Bangalore-560032
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.36705

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]
 
 
    Tables

  [Table - 1], [Table - 2]

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