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Locked Plating for Phalangeal "Pilon" Fractures: Volar, Lateral, Dorsal
Mark Henry, MD
Hand and Wrist Center of Houston, Houston, TX

Introduction: Phalangeal “pilon” fractures have historically been treated with dynamic traction external fixation, yielding suboptimal and unpredictable clinical outcomes characterized by stiffness, malunion, and a higher rate of complications compared to other fracture patterns in the hand. Advances in plate technology and a unique volar surgical approach have allowed the application of small-sized, customizable, locking plates to these difficult fractures.
Materials & Methods: The study is a retrospective consecutive case series of forty patients (29 male, 11 female) with an average age of 39 years treated with locked titanium plates (0.6 mm thickness) and 1.5 mm diameter screws for phalangeal “pilon” complete articular fractures involving 5 index, 9 long, 14 ring, and 12 small fingers. The fracture was approached and the plate applied from the position of greatest comminution and axial collapse: 24 volar, 11 lateral, 5 dorsal. The volar approach uses a hemi-Bruner incision and partially reflects one slip of the FDS tendon to allow application of the longitudinal limb of the plate. Early active motion supervised by a hand therapist was initiated within a week of surgery; assisted motion was added after 3 weeks. Cases were followed until the point of measurable plateau in range of motion, mean 13 weeks. Objective measurements and final DASH scores were statistically compared between the 4 digits and between the 3 approaches using ANOVA, with a p-value of < 0.05.
Results: All fractures healed clinically and radiographically by 6 weeks. There were no cases of hardware failure, infection, tendon rupture, or wound dehiscence. Two patients required subsequent tenolysis. The mean DASH score at final evaluation was 12. Mean active range of motion values at final evaluation were: PIP flexion 93 degrees, PIP extension -5 degrees, DIP flexion 53 degrees, DIP extension -1 degree. The mean articular step-off was 0.1 mm. The mean articular gap was 0.02 mm. Mean coronal mal-alignment of the shaft to the articular surface was 1.2 degrees. There were no statistically significant differences between the 4 fingers or the 3 different approaches.
Conclusion: Locked plating of phalangeal “pilon” fractures produces favorable range of motion results compared to the historical literature using dynamic traction external fixation. Unlike dynamic traction, locked plating demonstrates a high level of consistency in maintaining the fracture reduction, a low average DASH score, and no strategy specific complications.

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