TIPS     AND        TECHNIQUES



  A Novel Hook Plate Fixation Technique for the Treatment
                    of Mallet ...
Annals of Plastic Surgery • Volume 58, Number 1, January 2007                                 Novel Hook Plate Fixation Te...
Theivendran et al                                                     Annals of Plastic Surgery • Volume 58, Number 1, Jan...
Annals of Plastic Surgery • Volume 58, Number 1, January 2007                                                  Novel Hook ...
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Raj Hook Plate

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Raj Hook Plate

  1. 1. TIPS AND TECHNIQUES A Novel Hook Plate Fixation Technique for the Treatment of Mallet Fractures Kanthan Theivendran, BSc, MBBS, Andrew Mahon, MSc, FRCSI(Tr and Orth), and Vaikunthan Rajaratnam, MBBS(Mal), AM(Mal), MBA(USA), FRCS(Ed), FRCS(Glasg), FICS(USA), Dip Hand Surgery(Eur) We describe a new technique for open reduction and Abstract: Bony mallet injuries are generally treated nonoperatively, but when the fragment involves a significant percentage of the internal fixation (ORIF) of mallet fractures using a 1.3-mm articular surface, articular incongruity and instability can occur. A hook plate (Teoh Lam-Chuan, Singapore General Hospital, number of techniques have been described for the fixation of such personal communication, 2005). fractures and each has its own problems. Anatomic reduction and secure fixation of small fragments can be challenging. Our objective TECHNIQUE is to describe a new surgical technique using a 1.3-mm hook plate that provides good reduction and stable fixation of a mallet fracture, Indication for this procedure includes patients with a with early mobilization of the distal interphalangeal joint. clinical mallet deformity, with radiographic evidence of a dorsal intra-articular fracture fragment involving more than Key Words: fracture, hook plate, internal fixation, mallet, 30% of the base of the distal phalanx. open reduction The patient is positioned supine on the operating table, (Ann Plast Surg 2007;58: 112–115) with the hand prepared with standard antiseptic solutions. A digital local anesthetic block is used and a sterile digital tourniquet for the injured finger. A dorsal approach using a Y incision is made over the fracture site to facilitate adequate midline exposure of terminal phalanx. The nailbed is elevated T he management of mallet fractures of the hand represents a unique and problematic challenge. The mechanism of injury usually involves axial loading of the fingertip, with off the periosteum (in a similar manner to performing a vascularized nailbed transfer and avoiding damage to the hyperextension at the distal interphalangeal (DIP) joint, re- germinal matrix) of the distal phalanx. A 1.3-mm 2-hole sulting in a fracture of the dorsal lip of the base of the distal Compact Hand Set (AO, Davos, Switzerland) plate is modi- phalanx. Treatment modalities range from splinting alone,1–3 fied by cutting the proximal hole with plate cutters (Fig. 1A). which has produced satisfactory results, to operative fixation The cut ends spring open and are bent volarly into hooks (Fig. for fragments involving more than 30% of the articular 1B, C). Two very small longitudinal incisions are made in the surface, with or without subluxation of DIP joint.4,5 terminal tendon. The hooks are passed through these slips Nonoperative treatments have resulted in chronic insta- around the dorsal lip at the distal edge of the fracture bility, joint subluxation, osteoarthritic deformity, resulting in fragment. The hooks grab onto the articular surface at the cosmetically unacceptable outcomes.4,6 Healing of the bony dorsal lip in an area which does not articulate with the middle fragment with displacement can lead to extensor lag and a phalanx, so there is no interference with DIP joint function. swan-neck deformity.2 The hooks are then used to control and reduce the fracture Various techniques have been described in the literature fragment. A 1.0-mm K-wire can be used to help reduce and for operative fixation of mallet fractures. These include using hold the fracture fragment temporarily while applying the Kirschner wires (K-wires),6 –10 tension band fixation,4,11 in- plate (Fig. 1D, E). The distal end of the plate with the ternal suture,12 compression pin fixation,13 screw fixation,14 complete hole is held onto the distal phalanx using a 6-mm and volar plate advancement arthroplasty15. screw. The self-tapping 6-mm titanium screw is advanced obliquely using a handheld screwdriver, thereby levering on the distal hole to reduce the fracture (Fig. 1E). The screw is Received April 9, 2006, and accepted for publication, after revision, June 6, 2006. then advanced perpendicular to the distal phalanx, thereby From the Birmingham Hand Centre, University Hospital Birmingham, Selly anchoring the fragment in position (Fig. 1F), and the wound Oak Hospital, Birmingham, UK. is closed. This provides compression of the fracture fragment No financial support was received for this article. at the fracture site using the “tension band” principle. In most Reprints: K. Theivendran, BSc, MBBS, 81 Pennine Way, Ashby-de-la- cases, a modified 2-hole plate can be used; however, for a Zouch, Leicestershire, LE65 1EZ, UK. E-mail: kanthan@hotmail.co.uk. Copyright © 2006 by Lippincott Williams & Wilkins larger unstable dorsal fragment, a modified 3-hole plate with ISSN: 0148-7043/07/5801-0112 2 hooks and 2 holes may be required. The longer plate allows DOI: 10.1097/01.sap.0000232858.80450.27 the titanium screw to be placed in the distal fragment to 112 Annals of Plastic Surgery • Volume 58, Number 1, January 2007
  2. 2. Annals of Plastic Surgery • Volume 58, Number 1, January 2007 Novel Hook Plate Fixation Technique FIGURE 1. Operative technique for the application of the titanium hook plate and screw. provide secure fixation. A radiographic image intensifier is used to assess reduction. Postoperatively, the injured finger is placed in a mallet splint for 2 weeks and then protected by immobilization with a splint for a further 3 weeks. Radio- graphic images are obtained after the procedure to assess bony union. CASE REPORT A 53-year-old right-hand-dominant writer had injured his left ring finger after falling on a dry ski slope. He was seen in the emergency department 6 days after the injury. He had complained of pain, swelling, and deformity over the DIP joint. On clinical examination, there was dorsal tenderness and swelling, with extensor lag at the DIP joint. Radiographs depicted a dorsal avulsion fracture of the base of the terminal FIGURE 2. Lateral (A) and anterior-posterior (B) radiographs of a mallet fracture with 50% involvement of articular sur- FIGURE 3. Extension (A) and flexion (B) of the DIP joint face. showing excellent range of motion of the ring finger. © 2006 Lippincott Williams & Wilkins 113
  3. 3. Theivendran et al Annals of Plastic Surgery • Volume 58, Number 1, January 2007 phalanx (Fig. 2A, B). The patient was referred to the hand surgeon and underwent an ORIF 2 days later. There was mild volar subluxation noted under a digital anesthetic block. Through a dorsal Y incision, the nailbed was elevated off the periosteum from the proximal part of the distal phalanx. The exposed fracture fragment was reduced and held temporarily with a single 1.0-mm K-wire. The 1.3-mm hook plate was then applied by the usual method described previously. The DIP joint was immobilized for 2 weeks, with protected mobilization for a further 3 weeks. Six months after the procedure, the patient had 8° to 70° FIGURE 5. Dorsal view showing a healed scar with no nail- of pain-free range of motion at the DIP joint (Fig. 3). The patient bed deformity. had returned to normal activities at 5 weeks and had no disabil- ity, with a DASH (disabilities of the arm, shoulder and hand)16,17 score of 0 at 6 months. The fracture had united at 7 anatomic reduction, with stable fixation of a large dorsal bony weeks, with no articular step (Fig. 4). There were no complica- fragment. The patient treated by this method had good, tions, and the patient was satisfied with the treatment. pain-free range of motion at the DIP joint, with bony union at 7 weeks. The use of the low-profile plate did not cause any skin irritation or nailbed deformity (Fig. 5), and there was no DISCUSSION radiographic evidence of plate loosening. It is generally There have been conflicting reports in the literature indicated that fractures involving less than 30% of the artic- regarding the management of mallet fractures. Nonoperative ular surface should be treated conservatively with a mallet treatment has been proposed by Wehbe and Schneider,2 splint. However, for a larger displaced fragment, a minimally including those with fracture subluxation of the distal pha- invasive technique of extension-block percutaneous K-wire lanx. Many authors have advocated operative fixation with pinning is easy to perform and is an effective, safe alternative larger dorsal fragments with palmar subluxation.5,6,18 Oper- to the conservative treatment of displaced mallet frac- ative techniques using K-wires,7 tension band wires,4,8 pull- tures.20 –22 We would advocate this treatment for the most out sutures,19 miniscrews,14 and volar plate arthroplasty15 part; however, stiffness and swelling may persist as the DIP have been reported. joint is rigidly immobilized for up to 6 weeks as compared The operative goals for the treatment of mallet fractures with 2 weeks with the hook plate. are to provide anatomic reduction with rigid fixation while We recommend the use of the hook plate as it offers allowing early joint motion to prevent contractures at the DIP anatomic reduction, rigid internal fixation with early joint joint. Many of the operative procedures described can be mobilization. This technique provides an alternative and demanding and may obstruct early joint motion. The hook acceptable treatment modality, especially in large dorsal plate technique is relatively simple to perform and provides fragment mallet fractures, with or without subluxation of the terminal phalanx. REFERENCES 1. Okafor B, Mbubaegbu C, Munshi I, et al. Mallet deformity of the finger: five-year follow-up of conservative treatment. J Bone Joint Surg Br. 1997;79:544 –547. 2. Wehbe MA, Schneider LH. Mallet fractures. J Bone Joint Surg Am. 1984;66:658 – 669. 3. Schneider LH. Fractures of the distal interphalangeal joint. Hand Clin. 1994;10:277–285. 4. Jupiter JB, Sheppard JE. Tension wire fixation of avulsion fractures in the hand. Clin Orthop Relat Res. 1987;214:113–120. 5. Stark HH, Gainor BJ, Ashworth CR, et al. Operative treatment of intra-articular fractures of the dorsal aspect of the distal phalanx of digits. J Bone Joint Surg Am. 1987;69:892– 896. 6. Hamas RS, Horrell ED, Pierret GP. Treatment of mallet finger due to intra-articular fracture of the distal phalanx. J Hand Surg Am . 1978; 3:361–363. 7. Fritz D, Lutz M, Arora R, et al. Delayed single Kirschner wire com- pression technique for mallet fracture. J Hand Surg Br . 2005;30:180 – 184. 8. Damron TA, Engber WD. Surgical treatment of mallet finger fractures by tension band technique. Clin Orthop Relat Res. 1994;300:133–140. 9. Darder-Prats A, Fernandez-Garcia E, Fernandez-Gabarda R, et al. Treatment of mallet finger fractures by the extension-block K-wire technique. J Hand Surg Br . 1998;23:802– 805. 10. Takami H, Takahashi S, Ando M. Operative treatment of mallet finger FIGURE 4. Lateral (A) and anterior-posterior (B) radiographs due to intra-articular fracture of the distal phalanx. Arch Orthop Trauma at 7 weeks postsurgery showing fracture union. Surg. 2000;120:9 –13. 114 © 2006 Lippincott Williams & Wilkins
  4. 4. Annals of Plastic Surgery • Volume 58, Number 1, January 2007 Novel Hook Plate Fixation Technique 11. Bischoff R, Buechler U, De Roche R, et al. Clinical results of tension 17. SooHoo NF, McDonald AP, Seiler JG 3rd, et al. Evaluation of the band fixation of avulsion fractures of the hand. J Hand Surg Am . construct validity of the DASH questionnaire by correlation to the 1994;19:1019 –1026. SF-36. J Hand Surg Am . 2002;27:537–541. 12. Bauze A, Bain GI. Internal suture for mallet finger fracture. J Hand Surg 18. Green DP. Fractures and Dislocations in the Hand. 3rd ed. Philadelphia: Br . 1999;24:688 – 692. JB Lippincott; 1991:448 – 453. 13. Yamanaka K, Sasaki T. Treatment of mallet fractures using compression 19. Doyle JR. Extensor Tendons: Acute Injuries. 4th ed. New York: fixation pins. J Hand Surg Br . 1999;24:358 –360. Churchill Livingstone; 1999:1950 –1987. 14. Kronlage SC, Faust D. Open reduction and screw fixation of mallet 20. Mazurek MT, Hofmeister EP, Shin AY, et al. Extension-block pinning fractures. J Hand Surg Br . 2004;29:135–138. for treatment of displaced mallet fractures. Am J Orthop. 2002;31:652– 15. Rettig ME, Dassa G, Raskin KB. Volar plate arthroplasty of the distal 654. interphalangeal joint. J Hand Surg Am . 2001;26:940 –944. 21. Inoue G. Closed reduction of mallet fractures using extension-block 16. Hudak PL, Amadio PC, Bombardier C. Development of an upper Kirschner wire. J Orthop Trauma. 1992;6:413– 415. extremity outcome measure: the DASH (disabilities of the arm, shoulder 22. Pegoli L, Toh S, Arai K, et al. The Ishiguro extension block technique and hand) corrected : the Upper Extremity Collaborative Group for the treatment of mallet finger fracture: indications and clinical (UECG). Am J Ind Med. 1996;29:602– 608. results. J Hand Surg Br . 2003;28:15–17. © 2006 Lippincott Williams & Wilkins 115

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