I'm Jeff Lott, and I'm going to speak on ORIF of the proximal and phalangeal joints. So, this is an opportunity to restore articular congruity and concentric reduction of the joint. I'll show you some strategies to deal with these, but realize that this is not for every fracture. We're going to look at fractures involving the base of the middle phalanx, fractures involving the head of the proximal phalanx, which are unicondylar, and those which are bicondylar. I'll start with a case. This is a 24-year-old, right-hand dominant young man who, quote-unquote, jammed his left middle finger. He noted pain, swelling, limited range of motion of the middle finger, and no prior injury. He comes with this X-ray, and he is the prototypical, he makes his living as a ditch digger. So, you look at this X-ray, and you see a subtle sign there on the AP. It's really on the lateral, and this is similar to the X-rays that Steve just showed, where you see a loss of the concentric reduction of the joint with dorsal subluxation. And if you look, you see the subchondral bone. There's his articular surface there, and this is the pilon fracture, as has been described. And again, this jammed finger is more than just a jammed finger. So, what to do? And certainly, one can treat this with closed means external fixation, but again, the opportunity to restore the articular anatomy is what leads you to open reduction internal fixation. Why do we do this? Why do we care? Because this is an unfortunate person of about the same age, 28-year-old, who, quote-unquote, jammed his finger 10 years earlier playing high school football, and before the age of 30, he's got an arthritic, painful, stiff PIP joint. So, Ray Curtis described the PIP joint as the center of the hand, and if all of you sort of take a look at your own hands and then try to immobilize your PIP joint and figure out how easy it is to get your hand flat, get your hand in your pocket, and grab a steering wheel, the PIP joint is a very important joint that we need to pay attention to. Obviously, conservative management of some is appropriate. External fixation, as Steve showed, and I'm going to talk about internal fixation. What do we have at our disposal? Certainly closed reduction pinning, and I'll show you some of that, and then open reduction internal fixation with screw and or plate constructs, as well as a cerclage construct that many of you may not be familiar with that I'll show you. So, ORIF, cartoon-wise, simply, if you have a large fragment, you can put a screw in it and restore the anatomy. As the most interesting man in the world says, I don't often open the PIP joint, but when I do, one of the best approaches to get to the PIP joint is VOLR, and Jen's talk, unfortunately, was going to go through a lot of these approaches, but the approach will take a little bit of time to go through this VOLR approach. Here you see on the index finger a Brunner-type incision. My patients come with their neurovascular bundles dotted, as you can see right there. Flexor sheath, so we're going to go between the A2 and A4 pulleys, leaving the flexor sheath intact, and then retracting. Here you see this rag nail on the flexor tendons, making this incision in the VOLR plate, and as I've outlined here, what I do is I make a longitudinal incision on each limb, and then I figure out where to make my transverse incision, so it's approximately based elevation of the VOLR plate, as you see the VOLR plate coming up here. It's important to leave a tag of tissue here to repair to, and I'll show you the importance of that in a minute. So here, just to orient you, head of the proximal phalanx here, base of the middle phalanx here. You see the flexor tendons. Neurovascular bundles have been dissected so that when you shotgun open or hyperextend the joint, the neurovascular bundles are allowed to drift away and not be tethered. Just to orient you, the joint is somewhat inside out, so the central slip insertion on the base of the middle phalanx is right here, and when you open these up, you're always amazed to see the devastation. So this is a typical appearance, and you see this VOLR cortex, which is intact, and then you sort of see this central depression, and as with a freer and a dental pick, you gently tease this up, open it up, and gently elevate this depressed piece of articular cartilage and tease it up. What are you going to fix it with? Arnold Peter Weiss, about 15 years ago, described this cerclage fixation in an article in Core. He looked at 12 patients, and with two-year follow-up, achieved really impressive range of motion for these devastating injuries. So this is the typical fixation you get. Again, to orient you, the central slip on the base of the middle phalanx would be here, and here you see the cerclage wire is around this, and here you see the knot, or I'm sorry, where the wire is secured. Radiographically, what does this look like? You may worry about that under the flexor tendons, and that's a valid concern. Realizing, though, that the VOLR plate repair is partially covering that and partially elevating the flexor tendons above it, as you see when you do this in real life. And here is motion, even with the stitches still in. So at two weeks, in the right patient, you can get really phenomenal results. Just another case, again, depressed articular fragment, as you see here. One might argue that this joint is concentrically reduced, so maybe doing nothing. This person did have some malrotation, as you can get a suggestion here, as the head of one condyle sat in this fracture unevenly and was causing some rotation. As again, you see here, again, head of the proximal phalanx, central slip insertion here, and here you see that depressed central portion. Here you see it elevated and secured with this cerclage construct. And even though this is a 23, 24, 25-gauge wire wrapped around, in other words, it's a very thin, very malleable wire, it's an incredibly strong construct. And here you see the articular surface restored and the joint reduced, and it's her small finger. And again, in the right patient, you can get very good results. I say in the right patient because patient selection for this technique, I think, is the most important thing. Here's a typical fracture. I don't know how else one might treat this. Steve could probably make an argument for external fixation. After talking with the patient, we discussed the role for ORIF, and despite restoring the joint and achieving a good operative result, the clinical result is poor, meaning he's got a little bit of extensor lag, which I think is common, but he really got poor results. And again, you have to pick the patients appropriately, and this fellow was not tremendously aggressive in therapy. What if you're concerned with the stability of the cerclage construct? This is a case from Paul Binhammer. This is a 32-year-old volleyball injury a week out, and again, this fracture dislocation or fracture subluxation of the PIP joint, in this case with a large fragment. Same approach, Voller approach to the PIP joint, elevating the Voller plate, as you see here, retracting the flexor tendons, shotgunning the joint open with the tendons here, neurovascular bundles dissected on either side. And I stress the importance of that because, as you can imagine, as you hyperextend the joint, if you don't dissect out the neurovascular bundles and allow them to subluxate, you actually make them go up and around and take a longer route than they're used to going, so you can have a significant traction injury. So it's very important to dissect the neurovascular bundles, free Cleland's and Grayson's ligaments to allow the neurovascular bundles to subluxate. And again, you see the central depression. In this case, it was fixed with a mini-frag plate and screws, larger fragment, and again, reasonable results, 20 to 90 for a pretty significant fracture. These injuries come in different flavors. Again, along the theme of base of the middle phalanx fractures, here you see a fracture of the base of the middle phalanx where one of the condyles dug in and caused a rotatory deformity. Here you see a dorsal approach, so this is the dorsal aspect of the finger. The blue is on the central slip insertion onto the middle phalanx. The yellow, or as we call it in Ann Arbor, the maze, is on the collateral ligament, which is left intact. Make a small arthrotomy here where we can look at the articular surface of the base of the middle phalanx, and here you see a mini-fragment screw fracture line right there. And again, now the rotation has been restored with a concentric reduction allowing early motion. Here's what happens when a dad tries to show his kids the safe way to use fireworks, which is oxymoronic. There is no safe way to use fireworks. So this was an open PIP fracture. He had a series of facial injuries as well, but he had this open fracture as you see there, and this is a dorsal approach highlighted here. The middle phalanx is here. The yellow is on the conjoint lateral tendons, and the blue is on the central slip insertion. Small arthrotomy between the central slip and the collateral ligament to evaluate the articular surface. And again, with an inter-fragmentary screw and this neutralization plate allowing early restoration of motion. The requisite for screw fixation, you do need large fragments. And again, early motion with limited traction, meaning no passive extension at the PIP is important. Moving down to condylar fractures. As we know, these are common athletic injuries. These are often misdiagnosed as sprains or jammed fingers. They're classified into stable and unstable unicondylar and bicondylar. Many of these are unstable and require surgical stabilization. Unfortunately, as we all know, many of these may present late at a few weeks out. If there is a concentric reduction of the joint, you can make an argument for observation as opening these does incur a high risk of stiffness. Here you see a case loaned to me, and this is bicondylar fracture fixed with a series of inter-fragmentary screws through a dorsal approach. In looking at these fractures, it's very important to ask yourself, am I going to be able to get rigid fixation so that I can start early motion? Because quite honestly, if you open these up, you cause trauma to the area, and you don't want to do a disservice to the patient, internally fix it in a non-rigid manner, and then have to immobilize them further. And one may think in that situation of doing closed reduction pinning and not opening these and having the extra risk of stiffness. With these unicondylar fractures, again, the importance in terms of blood supply, the collateral and the accessory collateral ligament attach on that fragment, so it's important to respect that. Here's the proper collateral, the accessory collateral with a mini-fragment screw. Series of pictures from Hill Hastings' books with these unicondylar fractures and different screw strategies, again, maintaining the blood supply to this condylar fragment. One can leave the collateral and the accessory collateral intact and place the screw there. Sub-parasitally tease back slightly to allow fixation. Split between the proper collateral and the accessory collateral to fix some of these. Depending on where the fracture fragment lies, you can hyperflex to get beneath the collateral. And then finally, there's a couple different ways to approach these. There's sort of an anti-grade screw fixation where you leave the collateral intact and go on the ipsilateral side and place your screw. Alternatively, you can reduce the fracture, look through a small arthrotomy, leaving the central slip and the collateral ligament intact, inspect the joint, and then bring your screw in a more retrograde fashion to, again, leave that important collateral attachment to the fragment to maintain blood supply. This is the most common way, as you see in this cartoon, with a mini-fragment screw reducing this unicondylar fracture. And here's a clinical example in a college volleyball player. You see this unicondylar fracture with a malalignment clinically and then fixed with two mini-frag screws allowing range of motion after a few days. Again, alternatively, if the fracture fragments are of such small size that you don't believe you can get rigid internal fixation, another alternative is closed reduction pinning. This is a woman, a 58-year-old woman, who was trying to restrain her dog that was running after a squirrel. And you can sort of almost see through these condylar fragments. You just know you're not going to get rigid internal fixation there. So you can see she's obviously multiple fingers were involved in this. But a closed reduction pinning construct, as you see here. Here you see a 15-year-old, nice bone, but again, very, very small fragments and very tough to get rigid internal fixation in his high school auto shop. And again, this was a closed injury. All the bone fragments are there. It's just sort of hard to see. So in this case, I did an open reduction pinning and planned to do a stage capsulectomy. So let this heal. And then at six weeks, took him back. And again, it's good to operate on 15-year-old healthy, non-smoking patients. He healed. And then under local, with a little sedation, did a capsulectomy. And here you see nice flexion. He's extending. And more importantly, I was warned once about watching and looking at pictures shown in the operating room for capsulectomies, be it of the elbow or the PIP joint. And here you see him in the office, again, flexing. And not perfect extension, but pretty good result from a tough fracture to take care of. As we've learned and as things have progressed, Tom Fisher, alone in this case, this is a young guy, meaning a couple years younger than me, 44-year-old, jammed his index finger playing basketball with his kid and has this bicondylar fracture fixed with a conventional plate. And as you look at this with a non-locking plate, you're starting to see a little bit of subsidence here. And this is introducing the topic of dealing with these difficult, comminuted fractures. This is not our problem alone. The big bone doctors share this problem. Metaphyseal and metadiaphyseal fractures with extension near a joint are quite difficult to stabilize, whether you're in the knee or the hip. So we can learn some things from the problems that our big bone colleagues have had. Plating metaphyseal fractures provide stability to one side of the bone. There's a tendency for asymmetrical buttressing or the tendency for the fracture to fall off, as you started to see in that PIP fracture, with tilting or loosening of the screws if they're not locked. This can lead to angular deformity. So again, what can we learn with a non-locked construct? And for those of my colleagues in plastic surgery, this is the femur, this is the knee, lateral is here. So this is tilting into varus, or the tendency for the knee to collapse inward and be bow-legged. Again, with the insufficient ability to buttress this side of the fracture, the fracture tends to collapse. So what can we do? In the bigger bones, we have this concept of a locked, angled blade plate. So again, with a similar kind of fracture, with still no fixation here, this is a rigid construct. It has great resistance to bending and torsion. And it is excellent control of this distal most fragment. So, in the 80s, this concept of the blade plate was miniaturized and turned into the condylar buttress plate. So this can be used in the PIP. It's a fixed-angle device, meaning that this is a rigid angle here that can be altered. Specifically designed implant for treating these fractures near a joint surface. And again, in the late 80s is when this came out. There's some unique concepts of this. The blade, or the fixed-angle device. The plate has some things that allow you to contour it in three dimensions, as you see here. And then finally, the adjacent holes. So this is the blade. This is an adjacent screw. And then this angled screw here. And again, you can see that multiple different fracture configurations near the condyles of the small bones of the hand are able to be treated very well with this plate. So the goals of putting a pararticular fracture together, you restore anatomic articular congruity, stabilize that fragment with the blade and the pararticular screw, and then bring the diaphysis to the plate. This allows you to restore length, rotation, and angulation and get the articular surface to the metathesis to the diaphysis. This allows fixation of the fracture components with a device that's most importantly rigid enough to allow for early motion. And again, just to go over the surgical technique, provisional fixation, fixation of an anatomic reduction of the articular surface, as you see here and here, and then bringing the plate in. When I use devices like this, I think of putting my K-wire in a place that I'm going to reserve for this screw so I actually bring the plate down on top of that K-wire so you get fixation with that screw and the blade, and then you get rigid fixation down to the diaphysis here. And again, you see these pictures courtesy of Tom Fisher. Articular surface anatomically reduced. Held with a tenaculum. K-wire stabilizing that, bringing the blade plate in. There you see it provisionally fixed to the diaphysis. So these come in rights and lefts. And here you see a case done by the master. This is a very hard device to use. I don't know if any of you have tried this device. It's a great device for this tough fracture in that it provides rigid stabilization, allows early motion, but it has had some challenges. Even according to Tom, insertion is technically demanding and placement must be controlled in three planes simultaneously. While it controls rotation in the coronal, sagittal, and transverse planes, that means you have to be dead on when you place it. What's come along more recently, the implant has been modified to make it more friendly in that it's not a blade but a threaded pin that at least makes it a little bit easier to insert. Locking plates aren't necessarily magic. They do help in some of these, and just to give you a concept of what they can and can't do, if you think of this distal radius fracture that you're going to treat with an external fixator, what a locking plate does is it brings the external fixator inside. It does not make up for a poor reduction or unstable reduction, but it's a way to bring the fixation from outside to inside to provide this rigid internal fixation of this comminuted pararticular fracture. And again, we now have such devices of various configurations for use in the hand. The modification more recently that's come about is a variable angle fixation, so it takes these rigid constructs and makes them even more convertible. Outcomes of this, I'd like to say that X technique works to such and such a degree. We don't actually have prospective comparative studies of any of these. I think what you can tell your patients is a flexion deformity or an extensor lag is common. Full range of motion is rare. ORIF certainly has the most complications, but I think in the right patient has the most to be gained. In certain patients, skeletal traction may be safest. Be wary of those who present in a delayed fashion. With recurrent subluxation, those are not gonna do well. And overall, a reduced joint is more important than a perfect X-ray and articular congruity. So thank you.

ORIF

fractures

articular congruity

surgical techniques

hand function

locking plates