We present a case of malunited fracture of the proximal phalanx with stiffness. Two-stage procedure done to restore hand functions.

1. Reconstruction of
Neglected trauma hand
Dr.Pankaj Jindal
Pune
handsurgeryindia@gmail.com
Web: www.handsurgery.in

2. 7june18Ring : Fixed in hyperextension at PIPJ
Small : Mallet
*42y M.
* Press machine 1½ y old injury.
*C/O Inability to make fist.

3. Bony fusion dorsal edge

4. Past History of a fracture of proximal phalanx as shown.

5. Past history of treatment with Ex. Fix. on Prox. Phalanx.

6. Past history .Patient had the picture on his smart phone.
2nd Sx :
Ex.Fix. extended to MC.

7. Primary Aim at presentation:
Ring finger: Mobilize PIPJ.
Small finger: Correct Mallet.stiff

8. 7june18
*Ring : PIPJ arthrolysis +
PL interposition.
*Small : SORL Reconstruct.
Head P1 : not pristine.

9. 7june18
*Ring: PIPJ arthrolysis.
Head P1 : not pristine.

10. Ring: PIPJ lysis +
Palmaris Longus interposition +
K’ wire in flexion temporarily.
Small finger: Spiral Oblique
Retinacular Ligament Recon + K’ wire

11. Ring finger : PIP in hyper extension
Before surgery
PIP in 400 flexion after surgery
*PIPJ arthrolysis.
*PL interposition in PIPjoint.
*K wire in flexion to prevent re adhesion.

12. Post op

13. Pre
Post
Aim achieved :
Ring : Mobilize PIPJ.
Small : Correct Mallet.

14. Pre
Post
Bony block erased

15. Aim achieved :
Ring : Mobilize PIPJ.
Small : Correct Mallet.
Pre
Post

16. Second problem:
Abducted Ring Finger

17. Normal small finger is in straight line.
Affected ring finger is deviated.

18. The ring finger is angulated
due to
malunited
fracture of the proximal phalanx.

19. Corrective
closing wedge osteotomy
of
proximal phalanx

21. Pre
Post
Second problem solved:
Abducted RF
Angulation corrected

22. Final
Pre
Post
Post
Fixed before surgery
Corrected after surgery
Before
After

23. Discussion : What went wrong?
Reduction is manually
done ,
it was not done.
Easier way was
Reduction +
K’ wire +
Early ROM
Even if ex.- fix. is used,
manual reduction was
not done.
If Ex. Fix. > Reduction +
early ROM

24. Tt : Options
? Can Physio help ?
NO..A bony fusion,
cannot be mobilized
with physiotherapy.

25. Tt : Options
? Shall we Fuse the PIPJ ?
NO ..Pain is not the presenting problem.
And hence all efforts be done to mobilise the PIP joint.

26. Tt : Options
2 stage surgery. Why ?
Stage1: Lysis.
Stage2: Corrective osteotomy.
Why not combine 2 stages ?

27. Tt : Options
2 Surgery .why ?
Stage1: Lysis of PIPJ.
Stage2 : Corrective osteotomy.
Why not combine 2 stages ?
1. ? AVN of distal fragment P1
2. Ease of Mobilization

28. Why single K wire?
*Single pass.
*More lateral entry.
*Short bevel.
*1.5mm.
*Stable physiological load.
*Protect POP.
*More K wires ,
more extensor t’ adhesions.