Open Reduction Internal Fixation With Transverse Volar Plating For Unstable Proximal Interphalangeal Fracture Dislocation: The Seatbelt Procedure
Andrew Federer, MD; Evan Guerrero, MD; Travis J Dekker, MD; Suhail Mithani, MD; David Ruch, MD; Marc Richard, MD
Duke University, Durham, NC
Unstable proximal interphalangeal (PIP) joint fracture dislocation treatment remains problematic for hand surgeons. Recent cadaveric models studying the biomechanical stability of these injuries demonstrated when there was loss of 40% of the volar base of the middle phalanx, there was consistent subluxation of the PIP joint. Surgical techniques must balance anatomic reduction with minimal soft tissue disruption and prevention of re-dislocation in an anatomic location that is prone to both stiffness and instability. In this case series we describe a technique that allows for fracture reduction, articular congruity, minimization of irritation from prominent hardware and prevention of dorsal dislocation in the setting of repairable base of the middle phalanx fracture dislocations.
Methods: A retrospective chart review was performed on patients who had undergone open reduction internal fixation (ORIF) with volar, transverse plating for unstable PIP fracture dislocations at a single institution over a 7-year period. Indications includedpatients with a volar shear fracture with involvement of 45% of the PIP articular surface in combination with persistent dorsal subluxation on lateral radiograph. After a volar approach to the PIP joint, a curved transverse plate with 3 screws was used for fracture fixation, with the volar plate placed over for soft tissue coverage, preventing flexor tendon irritation. PatientsŐ percentage of PIP joint articular involvement, complications, range of motion (ROM), clinical and radiographic subluxation and level of functioning data was collected at each clinic and occupational therapy appointment.
Results: In this study we reviewed 10 patients with an average of 29 years of age who underwent surgery at 24 (range, 2-52) days since their injury. There was an average of 56% of PIP articular involvement encountered at time of surgery. At 3.5 months post-operatively, patients rated their operative hand level of functioning at 70% their contralateral hand. There was an average clinic follow up of 7.3 months with 10/10 patients having no signs of clinical subluxation and an average PIP arc of motion of 76o, with 9/10 patient having an arc greater that 70o.
Unstable intra-articular PIP fracture dislocations present a difficult problem that requires reduction of the articular congruity and stable internal fixation. This volar transverse plating technique will allow for highly functional range of motion without PIP dorsal subluxation clinically.
Figure 1: Unstable PIP joint fracture dislocation with volar shear component of middle phalanx.
Figure 2: Volar transverse plating with 3 screws resulting in stable fixation of middle phalanx. ADDIN EN.REFLIST
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