Rehabilitation for Proximal Phalangeal Fractures

Transcription

1 Rehabilitation for Proximal Phalangeal Fractures Alan E. Freeland, MD Department of Orthopaedic Surgery and Rehabilitation University of Mississippi Medical Center Jackson, Mississippi Maureen A. Hardy, PT, MS, CHT Hand Management Center St. Dominic Hospital Jackson, Mississippi Shannon Singletary, PT, ATC, CSCS Sports Medicine Service Department of Orthopaedic Surgery and Rehabilitation University of Mississippi Medical Center Jackson, Mississippi ABSTRACT: Proximal phalangeal fracture stability is crucial for the initiation of early and effective exercises designed to recover digital and especially proximal interphalangeal joint motion. Active digital flexion and extension exercises are implemented by synergistic wrist motion. Joint blocking exercises and active tendon gliding exercises in protective blocking splints are instrumental elements of early treatment. Dynamic splinting and serial finger casting are used in recalcitrant, severe, and late presenting cases. Surgical release is a last resort in regaining proximal interphalangeal joint motion. This measure is reserved for a failure of treatment when residual proximal interphalangeal joint contracture is persistent and severe enough to cause serious impairment of digital motion and hand function. J HAND THER. 2003;16: PROBLEM The most common complication after proximal phalangeal fractures is proximal interphalangeal (PIP) joint extensor lag. 1 Phalangeal fractures are among the most challenging injuries that hand surgeons and therapists treat. Although initial injury severity is the most highly correlated determinant of hand fracture outcome, occurrence adjacent to the flexor tendon sheath notoriously accentuates the ultimate risk of stiffness at every level of injury severity, similar to flexor tendon lacerations in the same area. 2 5 In addition to complex wounding, intra-articular fracture involvement, comminution, bone loss, and multiple hand fractures may compound the problem further and increase the risk of digital stiffness. CAUSE OF THE PROBLEM There are two major causes of PIP joint extensor lag: soft tissue adhesions and persistent skeletal deformity. Fracture hematoma permeates the zone of injury. The injury soon incites a proliferative fibroblastic response of the multiple surrounding collagenous structures that is proportionate to injury severity. Scar tissue tends to involve all of the structures within the zone of injury ( one wound one scar ). 6 The resulting Correspondence and reprint requests to: Alan E. Freeland, MD, Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216; <afreeland@orthopedics.umsmed.edu>. scar tends to produce adherence between the bone and the adjacent tendons, joint capsule, and ligaments, especially when the tendons remain dormant during fracture healing (Figure 1). Adhesions formed between the extensor mechanism and the fracture may result in loss of extensor glide. 7 Simple fractures caused by low-energy injuries occasionally may be complicated by some measure of permanent stiffness as a result of this process. When adjacent flexor or extensor tendon injury accompanies a proximal phalangeal fracture, the difficulty of treatment and achieving a favorable outcome may be compounded substantially. Surgical treatment requires a second planned injury, superimposing further soft tissue injury and increasing the risk of soft tissue adhesions. Persistent fracture deformity may contribute to the problem. Fractures of the proximal phalangeal shaft typically exhibit an apex palmar angulation with the fracture gap wider volarly and compressed dorsally. The intrinsic muscles flex the proximal fragment, whereas the distal fragment is extended by the attachment of the central slip to the dorsal lip of the middle phalanx. The axis of rotation of proximal phalangeal fractures lies on the fibro-osseous border of the flexor tendon sheath. The moment arm from the rotational axis of the fracture site to the extensor tendon is greater than that between the axis and the flexor tendons, further contributing to apex palmar angulation. If volar angulation is >15, the dorsal gliding surface of the proximal phalanx (P1) is shortened relative to the length of the extensor mechanism. 8 As palmar angulation incrementally shortens April June

2 FIGURE 1. Extensor tendon adhesions (arrow 1), flexor tendon adhesions (arrow 2), or both may form adjacent to a proximal phalanx fracture. the fractured proximal phalangeal, the extensor mechanism may have 2 to 6 mm of reserve owing to viscoelastic adaptive properties before the sagittal bands tighten to produce a progressive extensor lag at the PIP joint (an average of 12 for every mm of bone tendon discrepancy). 2,9 The redundant extensor mechanism becomes too lax to complete terminal PIP joint extension. Because the extensor mechanism has small excursions, even loose adhesions may have a significant adverse effect on finger function. 10 Phalangeal shortening resulting from bone compression, loss, or comminution may accentuate this problem further. Persistent volar angulation of >25 also progressively limits finger flexion. 11 Oblique fractures may cause digital rotation in addition to the aforementioned deformities. Overlapping or obstruction of the adjacent fingers may occur with flexion. A palmar fracture spike may block adjacent joint flexion. The extensor lag soon develops into a fixed joint contracture, resulting in a worst-case scenario of a joint that has lost extension and flexion A pseudoclaw deformity develops, and further joint contracture may follow. EVALUATION History A thorough account of the circumstances of the injury and a physical examination targeted at the hand are important in establishing the cause and mechanism of the fracture and the likelihood of other injuries. A careful history also clarifies significant personal, social, and demographic data, such as the age, dominant hand, personal responsibilities, recreational preferences, and occupational status of the patient. It is important to establish the patient s dependence on others for activities of daily living or survival. Physical Examination Examination of the hand should identify the area of maximal tenderness; the location, type, and severity of any deformities or wounds; the functional status of all flexor and extensor tendons; and the neurovascular status to the extent that the patient s condition will allow. Angular, rotational, and shortening deformities should be catalogued with regard to direction and extent clinically and radiographically. Digital or wrist block anesthesia may be helpful in the static and dynamic assessment of fracture stability, digital motion, and deformity and in determining whether there is any impingement of the injured digit on another during motion. Imaging Studies Standard x-rays usually are sufficient for evaluation of phalangeal shaft fractures and should include anteroposterior or posteroanterior and lateral views of the involved digit. A true lateral view is especially important in accessing articular fractures and angulation in the sagittal plane. Additional oblique views may be helpful in defining fracture configuration, displacement, deformity, fragment relationships, and intra-articular fracture extension. TREATMENT Successful treatment of proximal phalangeal fractures, the prevention of restrictive adhesions, and a favorable outcome are based on achieving stable anatomic (or near-anatomic) position of the fracture that either is inherently stable or is supported by fixation and an early controlled motion program that focuses on tendon gliding and joint mobility. 10,15 17 Stable fractures do not displace spontaneously or with active range-of-motion (ROM) exercises. 17 Fracture stability is instrumental in pain control and functional recovery. Fixation, when necessary, should be performed with as little additional trauma as possible to avoid unnecessarily compounding the injury. The ideal goal of treatment is a well-aligned, painfree, stable, mobile digit with good sensation and good circulation that participates in unrestricted hand function. The axiom anatomy now, function later is inconsistent with a successful outcome. 2 It makes no sense to fix a fracture and not move it. Loss of tendon gliding of the extensor mechanism over the proximal phalanx is almost always irretrievable. Early digital motion is essential. Despite the difficulty of achieving this goal, the best opportunity lies with a combined effort between the patient, hand surgeon, and hand therapist. The hand surgeon and therapist must communicate with and even inspire the patient. The patient must embrace enthusiastically and comply with the rehabilitation program. Because surgery represents a second and additional injury, operative treatment must be selected prudently. The principle of minimizing operative trauma 130 JOURNAL OF HAND THERAPY

3 when applying internal fixation is essential for successful operative intervention. Nevertheless, phalangeal fractures that require open reduction and fractures that are open owing to injury, especially those with complex wounds, comminution, or bone loss, require secure (and often even mini-plate) fixation for any chance of successful repair or reconstruction and rehabilitation. The surgeon must assess the variables and formulate the treatment plan that he or she believes would suit best a particular fracture (and patient) situation. There may be more than one method that would provide comparable results. In these instances, judgment, the surgeon s training and experience, and available resources may enter into the decision-making process. The method, implant, or implant configuration chosen may be less important than treatment supervision, patient compliance, and adherence to the aforementioned principles of fracture management. The need for biomechanical stability must be balanced with the need to preserve biologic integrity and blood supply, while minimizing the risk of scarring. In each instance, there is no substitute for arming the physician with the facts while allowing him or her to select the methods that correlate best with his or her skills and with the patient s unique circumstances. Hand fracture treatment is a combination of science and the art of its application. CLOSED FRACTURES Nondisplaced Fractures Most closed simple phalangeal shaft fractures are undisplaced or minimally displaced and tend to be stable. 12,18 21 This inherent stability is due to configuration (transverse or short oblique), sufficient periosteal support, or both. Buddy taping or splinting to an adjacent uninvolved finger may be sufficient treatment for stable undisplaced or minimally displaced simple transverse or nearly transverse phalangeal shaft fractures in a compliant patient. 12,18 21 Alternatively a static hand-based or short arm splint may be applied for patients if the physician believes that they may require more protection or support. Patients with undisplaced simple fractures of unstable oblique configuration, such as unicondylar or oblique diaphyseal phalangeal fractures, may be treated more safely with static splinting during the initial 4 weeks of treatment. These fractures may not displace spontaneously in a static splint but may collapse with rigorous motion before the appearance of fracture callus on x-ray. When at rest or immobilized, fingers should be positioned functionally so that the metacarpophalangeal (MCP) joints are supported at 50 to 70 of flexion and the PIP joints are supported at 0 to 15 of flexion to minimize the risk of joint contracture. These positions also allow relaxation of the intrinsic muscles, facilitating balance at the fracture site. Early progressive active ROM exercises are delayed 3 to 4 weeks only in patients treated with static splints; they may be initiated at any time in patients treated with buddy splints. Simple phalangeal fractures treated nonoperatively usually may be presumed sufficiently healed to initiate gentle (not exceeding the patient s pain tolerance) progressive active ROM exercises 4 weeks after injury. The x-ray appearance of fracture callus further verifies this presumption. Normally, fracture callus calcification begins 10 to 21 days after injury. There may be a little delay beyond that time in the x-ray appearance of phalangeal fracture callus, but rehabilitation may proceed rigorously when it is seen. Dynamic functional splinting may be selected for any anatomically positioned simple fracture of stable configuration (transverse or nearly transverse) or of unstable configuration (oblique) that is stable by virtue of spanning fracture callus as visible on x-ray. Functional positioning permits immediate active flexion of the interphalangeal joints and enables the extensor mechanism to act as a tension band over the proximal phalanx. 12,22,23 Active motion simultaneously compresses the fracture and stimulates periosteal callus formation and initiates the recovery of digital motion. The fracture should be monitored serially by x-ray for position, alignment, and healing in each of these treatment methods. Displaced Fractures A minimally displaced fracture has displacement within one or more of these x-ray parameters: <15 of palmar angulation in the sagittal plane, <10 of angulation in the coronal plane, <4 mm of shortening, and <5 of rotation. Although phalangeal fractures have some tolerance for shortening, loss of rotational alignment quickly translates into unacceptable deformity. Additionally, the finger must flex to within 1 cm of the distal palmar crease and have 30 extensor lag, and it must not impinge on or overlap an adjacent finger during digital flexion. These guidelines should be considered as approximate rather than absolute because there are individual exceptions, extenuating circumstances, or individual patient requirements in some cases. A digital block with local anesthesia may help the physician to determine which patients meet these criteria. Patients who meet these criteria and whose fractures are stable either before or after manipulation may be treated by closed methods and without fixation, similar to patients with stable undisplaced fractures, at the discretion of the responsible physician. If a simple proximal phalangeal shaft fracture of stable configuration (transverse or short oblique) has only a palmar angular deformity, there is usually an April June

4 FIGURE 2. A closed displaced unstable transverse midshaft proximal phalanx fracture is treated with closed reduction and transcutaneous retrograde intramedullary Kirschner wires. intact periosteal hinge dorsally opposite the angulation. Manipulative reduction is usually successful. The fracture may be treated similarly to its undisplaced or minimally displaced counterpart. Kirschner wire (K-wire) splinting may be added to ensure a stable reduction during early fracture healing. Surgical Management Indications When phalangeal shaft fractures are intrinsically unstable or require open reduction or when deformity recurs after an initial closed reduction without implants, fixation is indicated. Displaced oblique and comminuted fractures are unstable owing to their configuration and periosteal disruption. Periosteal disruption and the resulting instability often correlate with the amount of fracture displacement. Bone loss also causes instability. Internal fixation may also be preferable to external splinting in patients with polytrauma, patients with systemic impairment, or older patients to avoid a cumbersome splint, cast, or dressing. Reduction should be established and maintained by combining the most reliable and least intrusive techniques appropriate to the situation. Stability need not be rigid and it does not require employment of the strongest of available fixation choices. The fixation method or implant selected need only provide a threshold level of strength that reliably holds the fracture securely until it has healed sufficiently so that it is no longer implant-dependent and would allow simultaneous early rehabilitation. Surgical incision, especially when accompanied by periosteal elevation and particularly in the zone of the flexor tendon sheath, risks additional scar formation and fracture fragment devascularization. The physician must weigh the potential benefit of the increased biomechanical stability of the fracture gained through surgical incision against the additional risk of consequent digital stiffness and delayed healing. This may be especially true of late presenting displaced fractures that are stable and show callus formation on x-ray but are pain-free and functional despite mild and functionally nonobstructive deformity. Operative treatment to achieve an improved or more perfect reduction in these instances risks a double dose of soft tissue damage that may result in digital stiffness and a poorer outcome than that achieved by accepting the initial presentation and the mild deformity and impairment. It is a shallow accomplishment to have an anatomically aligned fracture on x-ray and a stiff finger. Closed Reduction and Internal Fixation Most unstable displaced simple phalangeal shaft fractures may be treated successfully by transcutaneous K-wire insertion. 18,19,24,25 Wires splint but do not compress fractures. K-wires temporarily may transfix the adjacent extensor mechanism to the bone, but permanent problems are rare if the wires are removed within 4 weeks after application. Similarly, pin irritation, infection, and migration seldom cause persistent problems within this short interval. One or more intramedullary wires act as internal reduction splints and reliably support transverse or short oblique fractures. In fractures of the proximal portion of the phalangeal shaft, transcutaneous K- wires may be inserted from proximal to distal for more secure fixation of the smaller proximal fragment to the main body of the phalanx. Conversely, in fractures of the distal portion of the phalangeal shaft, the wires may be inserted from distal to proximal. This latter technique also protects the proximal phalangeal growth plate in children. In the mid portion of the phalanx, either technique may be used (Figure 2). If closed displaced simple oblique fractures can be manipulated into a reduced position, they may be stabilized by percutaneous transfixation pinning (Figure 3). Percutaneous mini-screw fixation is anoth- 132 JOURNAL OF HAND THERAPY

5 er alternative. 26 Mini-screws are simply K-wires that have threads on their core to purchase the distal fracture fragment and a head to buttress the proximal fragment. They compress the fracture and are more secure than K-wire fixation, but they may be technically more difficult to apply. Mini-screws may be exchanged for K-wires in long oblique and intraarticular fractures. Concentric K-wire and mini-screw diameters facilitate this exchange. A inch (1.1- mm) diameter K-wire is the same diameter as the screw core of the 1.5-mm thread diameter mini screw. A inch (1.5-mm) diameter K-wire is the same diameter as the screw core of the 2.0mm thread diameter mini screw. Removal of the K-wire, drilling the proximal cortex to the mini-screw thread diameter, and insertion of the appropriate size self-tapping mini-screw achieve a stable compression mini-lag screw fixation Internal Fixation Incisions and Approaches. Phalangeal shaft fractures traditionally have been approached through a dorsal skin incision. 27 The extensor apparatus may be divided in the midline. O Brien 28 approached the proximal phalanx between the central and lateral bands in an additional effort to preserve the lateral band and its function. A midaxial incision allows implant application to the lateral side of the fractured phalanx. 29,30 This approach decreases the risk of adhesions and irritation under the extensor apparatus and obviates digital impingement between a dorsally applied mini plate and the extensor apparatus that often physically restricts the extremes of finger flexion and extension. The lateral band may be excised to improve exposure, prevent irritation between the implant and the lateral band during motion, and minimize scarring further. 31 Distally a midaxial approach and implant application minimizes the risk of operative injury to the central slip and consequent boutonniere deformity. A distally based flap that divides the central slip proximally to the PIP joint allows access to condylar fractures. 32 Kirschner Wire Fixation. K-wire configurations have been described. Pins may be inserted transcutaneously as previously described after open fracture reduction or crossed retrograde through the intramedullary canal of one fragment preceding reduction. When the latter technique is used, the fracture is reduced and the pins are driven across the fracture to complete the fixation. 33 The wires should cross either proximal or distal to the fracture site to avoid fracture distraction. This technique is particularly effective in the absence of x-ray capabilities. 14 Mini-Screw Fixation. In the clinical setting, miniscrews have been shown to provide stable fracture fixation and little interference with tendon gliding They may be used in unstable or potentially unstable FIGURE 3. A closed oblique proximal phalanx fracture of unstable configuration is treated with closed reduction and transcutaneous transfixation Kirschner wires. This treatment allows earlier and more intensive rehabilitation. oblique fractures of the phalangeal shafts and for intra-articular fractures (Figure 4). Oblique shaft fractures should be twice the adjacent bone diameter so that at least two screws may be inserted. Self-tapping design facilitates mini-screw application. 42 Mini Plates. Mini plates may be used selectively on phalanges. 34,35,38 40,43 44 They may be a good choice in closed transverse or short oblique fractures that require open reduction, open fractures, replantations, and the multiply fractured hand. Mini-plates are especially useful in fractures with comminution or bone loss. Straight mini-plates may be used for middiaphyseal fractures. (Figure 5) Mini-condylar plates are most suitable for periarticular fractures (Figure 6). The laterally applied mini-condylar plate strongly resists the apex volar angulatory forces occurring in proximal phalangeal fractures. 45 Mini External Fixation. Many surgeons advocate the treatment of unstable phalangeal fractures with miniexternal fixation Simple mini-external fixators may be used to stabilize unstable simple closed fractures. Static external fixation offers particular advantages in the treatment of open phalangeal shaft fractures with severe wounds, comminution, and bone April June

6 FIGURE 4. A closed, slightly displaced unstable intra-articular fracture at the base of the proximal phalanx is treated with closed reduction and percutaneous mini-screw fixation. FIGURE 5. A closed displaced unstable transverse midshaft proximal phalanx fracture could not be reduced satisfactorily by closed manipulation. It was treated by open reduction through a dorsal incision and dorsal mini-plate fixation. loss. 53,54 Static mini-external fixators have been especially helpful in the initial and provisional fixation of severe open hand fractures with significant bone and soft tissue destruction. They may be maintained for definitive fracture management or replaced by internal fixation, usually mini-plates, at the time of bone grafting and wound closure or coverage. The refinement of mini external fixators allows stabilization of phalangeal fractures, while permitting a relatively uninhibited ROM of adjacent digits. The pins are inserted dorsolaterally between the extensor tendon and lateral band whenever possible, and the extensor mechanism may be incised longitudinally for a short distance on either side of each pin to avoid tenodesis of the extensor mechanism to the adjacent phalanx. Ideally, there should be a minimum of two pins on either side of the fracture. Each pin should engage two cortices whenever possible. Adjunctive independent supplementary K-wire insertion may be used (Figure 7). The advantages of the mini-external fixator in finger fractures include minimal or no surgical exposure of the fracture site, adequate stability, and the ability to manipulate an inadequately reduced or secondarily displaced fracture. Because transfixion of part of the extensor mechanism is often unavoidable in the proximal phalanx, functional results of external fixation at the phalangeal level are less reliable than when mini-external fixators are used at the metacarpal level. OPEN FRACTURES Open fractures present dual problems: the fracture and the wound. 3,15 17,55 58 Fractures must be stabilized using the principles outlined earlier. The wound must be cleaned, and then closed or covered. Wound cleanliness is the critical determinant of treatment. Simple wounds usually may be rendered surgically clean, and simple fractures may be fixed definitively at the time of initial surgery. Wound closure may be carried out simultaneously. Complex wounds may require a second look to ensure cleanliness at 48 to 72 hours after initial surgery before proceeding with reconstruction. Open fractures may require extension of the wound by incision to apply adequate fixation. Bone defects may be filled with bone graft or bone graft substitute. When open fracture reduction and secure internal fixation are required, repaired digits are capable of and require more accelerated and intense mobilization to optimize functional recovery. Secure fixation and early motion may help to reduce the risk of joint contractures and tendon adhesions in these severe injuries. Low-energy gunshot injuries to the hand often result in significant comminution or bone loss. Soft tissue damage is generally limited, however, especially when compared with severe crush or highenergy bullet injuries. Primary closure of the surgi- 134 JOURNAL OF HAND THERAPY

7 FIGURE 6. A closed displaced unstable transverse fracture of the distal diaphysis of the proximal phalanx could not be reduced by closed manipulation. It was treated by open reduction through a midaxial incision and lateral application of a mini-condylar plate. FIGURE 7. A closed displaced unstable oblique fracture of the diaphysis of the proximal phalanx required open reduction. It was treated with a mini-external fixator and an ancillary Kirschner wire. The mini-external fixator does not cross the proximal interphalangeal joint or limit its motion. cally clean wounds, internal fixation, and autogenous bone grafting do not appreciably increase the incidence of infection. 55,59 Stable fixation allows the initiation of early active digital motion. Bone Grafting Cancellous bone may be used for incomplete bone defects and for complete bone defects of approximately 1.5 cm. The ipsilateral distal radius is an excellent donor source. Cancellous bone may be compacted in a small syringe with a plunger, then tapped out with a long spinal needle. Compressing cancellous bone increases its structural integrity, may provide more potentially viable bone-generating cells per unit volume, and may help to ensure timely bone healing. Intercalated corticocancellous bone grafts are used for larger defects. Bone carpentry techniques, such as dowels and sockets and mortising, are used to enhance stability and healing at the fracture-bone graft interfaces. 55,60 REHABILITATION The purpose of phalangeal fracture treatment is to achieve stable anatomic (or near-anatomic) position that controls pain and allows early progressive rehabilitation to proceed commensurate with the patient s tolerance (Figure 8). Protective functional positional splinting is maintained at rest, and blocking and tendon gliding exercises and synergistic wrist and digital exercises are an integral part of the recovery program. Dynamic splinting and serial casting may be used in instances when active exercises are insufficient in recovering digital motion. The recovery of digital motion may be the most important determinant of final functional outcome in all hand fractures. Theoretically, because there are no fibroblasts in a closed injury or wound for 48 hours and no fibrin of any strength for 4 to 5 days, this inflammatory period should be respected with immobilization and edema control measures. Edema draws tissues into predictable patterns of deformity. Distended joint nociceptors, through selective facilitation or inhibition of muscles, causes the joint to rest in its most comfortable position, one that accommodates the most volume of effusion. 61 At the PIP joint, this is achieved at 30 to 40 of flexion. Unless edema and joint positioning are controlled, this posture of joint comfort becomes fixed and contracted (Figure 9). April June

8 KIRSCHNER OR OTHER WIRE TREATMENT STATIC PROTECTIVE SPLINTING FUNCTIONAL POSITIONAL SPLINTING FIGURE 8. All methods of proximal phalangeal fracture treatment are designed to provide reliable fracture stability so that early rehabilitation may be initiated safely. The more stable the fracture, the more quickly and intensely the rehabilitation may proceed within the patient s individual tolerance. Functional Positional Splinting Positioning of the hand after injury may be used to assist in biasing tension from strong to weak soft tissues. Casts or removable splints have the goal of fracture protection yet allow the controlled motion necessary for tendon gliding. Radial or ulnar gutter splints that totally immobilize the digit and encase the PIP joint are indicated only for displaced fractures that remain unstable after closed reduction (Figure 10). 64 Functional splinting has been recommended for stable fracture reduction with or without internal fixation to prevent joint contractures and ensure compliance with the postoperative exercise regimen. 8,23,65,66 Positional training splints are worn continuously for 3 weeks for stable undisplaced or minimally displaced fractures and thereafter as a removable exercise splint (Figure 11). Inclusion of adjacent noninjured fingers in the cast or splint, buddy taped to the fractured finger, may help to protect the injured finger and control angulation and rotation. Functional positional splinting with the wrist placed in slight flexion increases tension in the extensor mechanism and simultaneously relaxes flexor tendon tension. 12,22,67 Ashort arm splint is used initially (Figure 12), which can be reduced serially to a hand based splint (Figure 13). Positioning the MCP joint in flexion with a dorsal block has several advantages: The extensor hood moves distally with MPJ flexion providing circumferential compression to the proximal phalangeal fracture. Hyperextension at the MPJ with proximal extensor tendon glide is prevented. Extensor tendon tension is focused at the PIP joint. In MCP jointflexion, the flexor tendons rest farther away from the proximal phalangeal fracture site. 68,69 FIGURE 9. Extension lag after open treatment of a phalangeal fracture. FIGURE 10. A splint immobilizing the proximal interphalangeal joint should be used only for unstable proximal phalangeal fractures that are reduced, unstable, and not internally fixed. 136 JOURNAL OF HAND THERAPY

9 FIGURE 11. A short arm protective splint with functional wrist extension and a dorsal metacarpophalangeal joint block. If the patient has difficulty recovering or maintaining full passive PIP joint extension after the initial 3 weeks of functional positioning splinting, specific PIP joint extension splints can be applied to achieve full joint mobility (Figures 14 and 15). Dial-out extension splints (Figure 16) or serial casting (Figure 17) is indicated for severe or established joint contractures. Alternatively, if the patient has difficulty achieving full PIP joint flexion, static splints that block MCP joint flexion allow the full force of digital flexion to be transmitted to recover PIP joint flexion (Figure 18). FIGURE 12. A and B, A short arm protective splint with the wrist placed in slight flexion and a metacarpophalangeal joint block to maximize proximal interphalangeal joint active extension. C, A volar component may be added at rest or at night to maintain interphalangeal joint extension. Tendon Gliding Tendon gliding exercises are performed to glide the tendons differentially, reestablish joint motion, and prevent restrictive adhesions overlying the fracture (Figure 19). Digital flexor and extensor excursion of 5 mm, or PIP joint motion of 0 to 40, achieved during the initial 4 weeks after injury or operation minimizes the risk of serious tendon adhesions and is a favorable prognostic sign. 70,71 These gliding exercises are initiated at the first therapy session within the positional splint and later are reinforced and continued when splinting is discontinued. Extensor Tendon Gliding Exercises The central slip and lateral bands work in concert to extend the PIP joint. Micks and Reswick 72 reported FIGURE 13. A hand-based protective splint with a metacarpophalangeal joint block. April June

10 FIGURE 14. A finger-based dynamic proximal interphalangeal joint extension splint. FIGURE 16. A dial-out dynamic extension splint. FIGURE 15. A dynamic extension assist splint that may be used for initial or early proximal phalangeal fracture rehabilitation and is especially useful for early proximal interphalangeal joint flexion contractures. a differential action between the two. They found that the central tendon initiates extension with the PIP joint fully flexed, whereas the lateral bands contribute more as the PIP joint approaches full extension. The lateral bands are responsible for terminal PIP joint extension. The normal finger extensor mechanism requires 20 mm of glide for full digital motion 69 ; 14 mm occurs at the MCP joint and 6 mm at the PIP joint. In theory, the distal interphalangeal joint requires an additional 4 FIGURE 17. Serial casting for proximal interphalangeal joint flexion contractures. mm of excursion; however, the normal volar movement of the lateral bands during finger flexion obviates this requirement. Adhesions formed between the extensor mechanism and the fracture result in loss of extensor glide. 7 Because the extensor mechanism 138 JOURNAL OF HAND THERAPY

11 FIGURE 18. A, Reverse angle showing proximal interphalangeal joint stiffness. B and C, A static metacarpophalangeal joint blocking splint allows all of the forces of digital flexion to be transmitted to the proximal interphalangeal joints. over the proximal phalanx has such a small excursion, even loose adhesions have a significant effect on finger function. 10 Evans and Thompson 71 reported on the sequence of events causing extensor tendon adhesions over the proximal phalanx after central slip injuries, which can be extrapolated to describe the same problem after proximal phalangeal fracture. The entire 20 mm of extensor glide occurs at the MCP joint alone, resulting in a gradual MCP joint hyperextension. A pseudo-claw deformity of the finger occurs when the PIP joint extensor lag accompanies MCP joint hyperextension (Figure 20).Therapeutic attempts to stretch the PIP joint into flexion only serve to attenuate the central slip distal to the site of its adherence to the bone. Although flexion may improve with central slip attenuation, the extensor lag remains. The functional positioning splint prevents MCP joint hyperextension and directs extensor tension distally to the PIP joint. While in the splint, the distal PIP joint extension strap is released for gliding exercises, and the patient relaxes the PIP joint into flexion. The emphasis initially is on full 0 active extension with progressive PIP flexion as the starting point. Evans and Thompson 71 state that achieving 4 mm of early extensor tendon glide prevents adherence and extensor lag. The patient must be monitored to prevent substitution for extensor glide by instead actively FIGURE 19. The three key blocking exercises. flexing the PIP joint and allowing it to relax back into semiextension. Later when out of the cast, active digital flexion and extension exercises are implemented by synergistic wrist motion, and the patient is instructed to block manually the MCP joint from full extension and slightly flex the wrist while performing PIP joint extension exercises (Figure 21). Functional electrical stimulation, using dual stimulation of extensor digitorum communis and the intrinsics, can be used to facilitate correct muscle action for full PIP joint extension. Flexor Tendon Gliding Exercises Both flexor tendons, the flexor digitorum profundus proximally where it lies along the proximal phalanx and the flexor digitorum superficialis distally as it divides into two insertions that wrap around the profundus, can become adherent to the fracture callus. 8 Within the functional positioning splint, blocking exercises can be performed to activate flexor digitorum profundus and flexor digitorum superficialis and FDS gliding across the fracture site. Composite fisted flexion is gained as PIP joint mobility improves. When splints are removed, synergistic wrist and finger exercises can be initiated. Patients are instructed simultaneously to extend the wrist while flexing the fingers then flex the wrist while extending the fingers (see Figure 20). The full range of each repetitive active exercise cycle consists of first extending the April June

12 FIGURE 20. A pseudoclaw finger. wrist and making a fist, then flexing the wrist to create a digital tenodesis effect while forcefully straightening the fingers. This technique has been shown to apply low load with high excursion for tendons When fingers move synchronously together toward full flexion or extension, the tethering quadriga effect of the common profundus muscle to the middle, ring and small finger profundus tendons is eliminated, and the digits may move to gain greater force and power. 76 Strengthening and conditioning exercises are phased gently and progressively into the rehabilitation program beginning at 6 weeks after fracture, depending on the adequacy of healing as judged by clinical and x-ray evaluation. Bone remodeling in response to stress is not predicated on the method of fixation. Fractures treated by either closed or rigid methods of fixation must be protected from excessive stresses initially during the inflammatory and repair stages. Although rigid fixation methods allow for earlier, unprotected motion, they do not accelerate the fracture repair process. During the remodeling phase, progressive loading of the fracture assists in callus conversion to bone and strength development in primary bone healing. CONCLUSION Most phalangeal shaft fractures are closed, either undisplaced or minimally displaced, and stable. They may be treated nonoperatively and with supportive and symptomatic treatment. When necessary, phalangeal shaft fracture fixation needs only to be strong enough to immobilize the fracture until the strength of the healing callus surpasses that of the fixation. Generally, this takes about 4 to 6 weeks for uncomplicated simple hand fractures and longer for comminuted fractures and fractures with complex wounds, including those in which there is bone loss that requires bone grafting. The selected implant also should be able to withstand the rigors of early digital motion. The decision of whether or not to open and FIGURE 21. A, Synergistic synchronous wrist extension and finger flexion. B, Synergistic synchronous wrist flexion and finger extension. C, Manual metacarpophalangeal joint blocking exercises maximizing extrinsic extension at the proximal interphalangeal joints. consequently to devascularize the fracture and potentially expose the adjacent moving and gliding structures to restrictive scarring is of equal or more importance than that of implant selection and configuration. The additional stability provided by the implant must offset the risks of operative dissection. Early postfracture controlled motion programs focus on hand positioning and tendon gliding as the best measures in preventing the pseudo-claw deformity common to proximal phalangeal fractures. Functional positional splint techniques are used to provide soft tissue tension compression to the fracture site, protect the healing fracture from excessive stresses, direct contractile forces to distal joints, and prevent joint deformities. Specific differential tendon gliding exercises are performed for the extensors (central slip and lateral bands) and for the flexors (flexor digitorum superficialis and flexor digitorum profundus). Synergistic wrist motion may be used to bias tension in the desired direction of digital motion. This therapy regimen seeks to balance the requirements for preservation of fracture stability, while achieving soft tissue mobility through a program of progressive and controlled digital motion. 140 JOURNAL OF HAND THERAPY

13 REFERENCES 1. Page S, Stern P. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg Am. 1998;23: Buchler U, Hastings H. Combined Injuries. In: Green DP (ed). Operative Hand Surgery, 4th ed. New York, NY: Churchill Livingstone, 1999: Duncan RW, Freeland AE, Jabaley ME, Meydrich E. Open hand fractures: an analysis of the recovery of active motion and of complications. J Hand Surg Am. 1993;18: Ip WY, Ng KH, Chow SP. A prospective study of 924 digital fractures of the hand. Injury. 1996;27: Strickland JW, Steichen JB, Kleinman WB, Hastings H. Phalangeal fractures: factors influencing digital performance. Orthop Rev. 1982;11: Peacock EE, Van Winkle W. Surgery and Biology of Wound Repair, 3rd ed. Philadelphia, Pa.: WB Saunders, Schneider L. Tenolysis and capsulectomy after hand fractures. Clin Orthop. 1996;327: Agee J. Treatment principles for proximal and middle phalangeal fractures. Orthop Clin North Am. 1992;23: Vahey JW, Wegner DA, Hastings H. Effect of proximal phalangeal fracture deformity on extensor tendon function of the hand. J Hand Surg Am. 1998;23: Lanz U, Hahn P. Tendon adhesions. In: Bruser P, Gilbert A (eds). Finger, Bone, and Joint Injuries. London: Martin Dunitz, 1999: Coonrad RW, Puhlman MH. Impacted fractures in the proximal portion of the proximal phalanx of the finger. J Bone Joint Surg Am. 1969;51: Burkhalter WB. Closed treatment of hand fractures. J Hand Surg. 1989;14: Burrows W, Hartwig R, Kleinman W, Strickland J. The role of tenolysis after phalangeal fractures. In: Strickland J, Steichen J (eds). Difficult Problems in Hand Surgery. St. Louis, Mo.: CV Mosby, 1982: Widgerow AD, Edinburg M, Biddulph SL. An analysis of proximal phalangeal fractures. J Hand Surg Br. 1987;12: Freeland AE, Sennett BJ. Phalangeal fractures. In: Peimer CA (ed). Surgery of the Hand and Upper Extremity. New York, NY: McGraw-Hill, 1996: Freeland AE. Hand Fractures: Repair, Reconstruction, and Rehabilitation. Philadelphia, Pa: Churchill Livingstone, Freeland AE, Geissler WB, Weiss APC. Operative treatment of common displaced and unstable fractures of the hand. J Bone Joint Surg Am. 2001;83: Barton NJ. Fractures of the shafts of the phalanges of the hand. Hand. 1979;2: Barton NJ. Fractures of the hand. J Bone Joint Surg Br. 1984;66: Stern PJ. Management of fractures of the hand over the last 25 years. J Hand Surg Am. 2000; 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: Burkhalter WE. Hand fractures. Course Lect. 1990;39: Reyes FA, Latta LL. Conservative management of difficult phalangeal fractures. Clin Orthop. 1987;214: Green DP, Anderson JR. Closed reduction and percutaneous pin fixation of proximal phalanges. J Bone Joint Surg Am. 1973: 55: Belsky MR, Eaton RG, Lane LB. Closed reduction and internal fixation of proximal phalangeal fractures. J Hand Surg Am. 1984;9: Freeland AE, Roberts TS. Percutaneous screw treatment of spiral oblique finger proximal phalangeal fractures. Orthopedics. 1991;14: Pratt DR. Exposing fractures of the proximal phalanx of the finger longitudinally through the dorsal apparatus of the finger. Clin Orthop. 1959;15: O Brien ET. Fractures of the metacarpals and phalanges. In: Green DP (ed). Hand Surgery, 2nd ed. New York, NY: Churchill Livingstone, 1988: Littler JW. Hand, wrist, and forearm incisions. In: Littler JW, Cramer LM, Smith JW (eds). Symposium on Reconstructive Hand Surgery. St. Louis, Mo: CV Mosby, 1974: Field LD, Freeland AE, Jabaley ME. Mid-axial approach to the proximal phalanx for fracture fixation. Contemp Orthop. 1992; 25: Freeland AE, Sud V, Lindley SG. Unilateral intrinsic resection of the lateral band and oblique fibers of the metacarpophalangeal joint for proximal phalanx fractures. Tech Hand Upper Extrem Surg. 2001;5: Chamay A: A distally based dorsal and triangular tendon flap for direct access to the proximal interphalangeal joint. Ann Chir Main. 1988;7: Edwards GS Jr, O Brien ET, Heckman MM. Retrograde crosspinning of transverse metacarpal and phalangeal fractures. Hand. 1982;14: Dabezies EJ, Schutte JP. Fixation of metacarpal and phalangeal fractures with miniplates and screws. J Hand Surg Am. 1986; 11: Diwaker HN, Stothard J. The role of internal fixation in closed fractures of the proximal phalanges and metacarpals in adults. J Hand Surg Br. 1986;11: Ford DJ, El-Haddidi S, Lunn PG. Fractures of the phalanges: results of internal fixation using 1.5 mm and 2 mm AO screws. J Hand Surg Br. 1987;12: Freeland AE, Jabaley ME. Screw fixation of the diaphysis for phalangeal fractures. In: Blair WF (ed). Techniques in Hand Surgery. Baltimore, Md: Williams & Wilkins, 1996: Hastings H. Unstable metacarpal and phalangeal fracture treatment with screws and plates. Clin Orthop. 1987;214: Bosscha K, Snellen JP: Internal fixation of metacarpal and phalangeal fractures with AO minifragment screws and plates: a prospective study. Injury. 1993;24: Baratz ME, Divelbiss B. Fixation of phalangeal fractures. Hand Clin. 1997;13: Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Assoc Orthop Surg. 2000;8: Bickley MB, Hanel DP. Self-tapping versus standard tapped titanium screw fixation in the upper extremity. J Hand Surg Am. 1998;23: Buchler U, Fischer T. Use of a minicondylar plate for metacarpal and phalangeal periarticular injuries. Clin Orthop. 1987;214: Ouellette EA, Freeland AE. Use of the minicondylar plate in metacarpal and phalangeal fractures. Clin Orthop. 1996;327: Nunley JA, Kloen P. Biomechanical and functional testing of plate fixation devices for proximal phalangeal fractures. J Hand Surg Am. 1991;16: Shehadi SI. External fixation of metacarpal and phalangeal fractures. J Hand Surg Am. 1991;16: Parsons SW, Fitzgerald JA, Shearer JR. External fixation of unstable metacarpal and phalangeal fractures. J Hand Surg Am. 1992;17; Ashmead D 4th, Rothkoph DM, Walton RL, Jupiter JB. Treatment of hand injuries by external fixation. J Hand Surg Am. 1992;17: Nagy L. Static external fixation of finger fractures. Hand Clin. 1993;9: Schuind F, Cooney WP, Burney F, An KN. Small external fixation devices for the hand and wrist. Clin Orthop.1993;293: Fricker R, Thomann Y, Troeger H. AO external mini-fixateur for the hand bones: surgical technique and initial experiences. Chirurg. 1996;67: April June

14 52. Drenth DJ, Klasen HJ. External fixation for phalangeal and metacarpal fractures. J Bone Joint Surg Br. 1998;80: Freeland AE. External fixation for the skeletal stabilization of severe open fractures of the hand. Clin Orthop. 1987;214: Seitz WH, Gomez W, Putnam MD, Rosenwasser MP. Management of severe hand trauma with a mini external fixateur. Orthopedics. 1987;10: Freeland AE, Jabaley ME, Burkhalter WE, Chaves ACV. Delayed primary bone grafting in the hand and wrist after traumatic bone loss. J Hand Surg Am. 1984;9: Freeland AE, Jabaley ME: Stabilization of fractures of the hand and wrist with traumatic soft tissue and bone loss. Hand Clin. 1988;4: Chen SH, Wei FC, Chen HC, et al. Miniature plates and screws in acute complex hand injury. J Trauma. 1994;37: Levin LS, Condit DP. Combined injuries-soft tissue management. Clin Orthop. 1996;327: Gonzalez MH, Hall M, Hall RF Jr. Low-velocity gunshot wounds of the proximal phalanx: treatment by early stable fixation. J Hand Surg Am, 1998;23: Littler JW. Metacarpal reconstruction. J Bone Joint Surg. 1947; 29: Young A, Stokes M, Iles J. Effects of joint pathology on muscle. Clin Orthop. 1987;219: Crosby CA, Wahbe MA. Early motion protocols in hand and wrist rehabilitation. Hand Clin. 1996;12: Margoles SW. Early motion in the treatment of fractures. Hand Clin. 1996;12: Pun WK, Chow SP, So YC, et al. A prospective study on 284 digital fractures of the hand. J Hand Surg Am. 1989;12: Jupiter JB, Belsky M. Fractures and dislocations of the hand. In: Browner B (ed). Skeletal Trauma. Philadelphia, Pa: WB Saunders, 1997: Ebinger T, Erhard N, Kinzl L, Mentzel M. Dynamic treatment of displaced proximal phalangeal fractures. J Hand Surg Am. 1999;24: Savage R. The influence of wrist motion on the minimum force required for active movement of the interphalangeal joints. J Hand Surg Br. 1988;13: Zancolli EA, Cozzi EP. The extensor apparatus of the fingers. In: Zancolli E Cozzi EP (eds). Atlas of Surgical Anatomy of the Hand. New York, NY: Churchill Livingstone, 1992: Brand PW, Thompson DE, Micks JE. The biomechanics of the interphalangeal joints. In: Bowers WH (ed). The Interphalangeal Joints. New York, NY: Churchill Livingstone, 1987: Duran RS, Houser RG. Controlled passive motion following flexor tendon repair in zones two and three. In: AAOS Symposium on Flexor Tendon Surgery in the Hand. St. Louis, Mo: CV Mosby, 1975: Evans R, Thompson D. An analysis of factors that support early active short arc motion of the repaired central slip. J Hand Ther. 1992;5: Micks J, Reswick J. Confirmation of differential loading of lateral and central fibers of the extensor tendon. J Hand Surg Am. 1981;6: Lieber RL, Silva MJ, Amiel D, Gelberman RH. Wrist and digital motion produce unique flexor tendon force and excursion in the canine forelimb. J Biomech. 1999;32: Silva MJ, Brodt MD, Boyer MI, et al. Effects of increased in vivo excursion on digital range of motion and tendon strength following flexor tendon repair. J Orthop Res. 1999;17: Zhao C, Amadio PC, Momose T, et al. Effect of synergistic wrist motion on adhesion formation after repair of partial flexor digitorum profundus tendon lacerations in a canine model in vivo. J Bone Joint Surg. 2002;84: Verdan C. Syndrome of the quadriga. Surg Clin North Am. 1960;40: JOURNAL OF HAND THERAPY