Surgical Treatment of a Neglected Thumb Volar Plate Injury in an 11-Year-Old Girl: A Case Report.

BACKGROUND Volar plate injuries are rare and difficult to diagnose and treat. Only a few cases have been described on the thumb, especially in children, that resulted in swan-neck type deformity. Conservative treatment has been suggested as first-line management, but surgical reconstruction utilizing flexor digitorum superficialis tenodesis has been described for refractive cases. Only a few attempted surgical repairs of the volar plate have been reported, since it is a technically demanding procedure. CASE REPORT We present the case of a neglected thumb volar plate injury in an 11-year-old girl after a thumb hyperextension injury. The patient presented 2 months after her injury with functional disability of her thumb. Magnetic resonance imaging had been performed, with no signs of volar plate injury, and she was consequently treated with an extension-blocking splint, with no effect. Clinical examination raised the suspicion of a thumb volar plate injury, which was confirmed during surgical exploration. Therefore, fixation with a bone anchor was performed, and the metacarpophalangeal joint was immobilized in 20° flexion with a percutaneously inserted Kirschner wire. After splinting for 3 weeks, the patient had 10 sessions of physical therapy. At 6-week follow-up, she presented with excellent active and passive range of motion and absence of pain. CONCLUSIONS Magnetic resonance imaging did not have high sensitivity. Six weeks after surgery, full range of motion was achieved, with no stiffness or tenderness at the first metacarpophalangeal joint, suggesting that a thumb volar plate injury had been managed surgically with a suture anchor with excellent results.

Uncommon hand injury to the batsman in 'gully cricket': report of two cases.

Volar plate injuries are typically caused by hyperextension of the proximal interphalangeal joint. These injuries are usually seen in sports where the ball comes in direct contact with the hands. Forceful dorsiflexion of the finger caused by the speeding ball leads to volar plate avulsion. In cricket, such finger injuries predominantly occur in fielders trying to catch or stop the speeding ball with bare hands. We report two unusual cases of volar plate avulsion injury occurring in batsmen that occurred during 'gully cricket' (street-cricket). We propose the possibility of a novel contrecoup-type mechanism causing this type of injury in the two cases. Both were successfully managed with splinting and had excellent recovery without any residual deformity or instability.

Factors Related to Failure of Conservative Treatment in Volar Plate Avulsion Fractures of the Proximal Interphalangeal Joint.

BACKGROUD: Volar plate avulsion fractures of the proximal interphalangeal (PIP) joint are a common hand injury and have been treated conservatively with favorable results. We assumed that conservative treatment of volar plate avulsion fractures of the PIP joint would be unsuccessful if the fracture fragment, even if small, was much displaced or rotated and that delayed excision of the avulsion fractures would result in good outcomes. We report clinical and radiological outcomes of conservative treatment of volar plate avulsion fractures of the PIP joint and risk factors for failure of conservative treatment. METHODS: We retrospectively reviewed the clinical and radiological outcomes of 88 volar plate avulsion fractures (85 patients) treated conservatively at first. In 18 of these fractures, delayed excision of the fracture fragment was required after an average of 75 days of conservative treatment for limited motion or pain of the joint. We compared parameters between failed cases and successful cases after conservative treatment. RESULTS: Compared to the successful cases, the failed cases had a higher prevalence of joint dislocation at the time of injury and greater pain, larger flexion contracture, and less further flexion after conservative treatment. The shape, comminution, and size of the fracture fragments were not related with the need for operation, but the operative cases had greater displacement and rotation of the fracture fragments than the conservative cases. After fragment excision, postoperative protection of the joint was not necessary, pain was reduced, and the mean range of motion increased. CONCLUSIONS: The presence of joint dislocation and greater displacement and rotation of the fragments may be associated with the failure of conservative treatment of volar plate avulsion fractures. Failed cases after conservative treatment could be resolved by delayed fragment excision with favorable results. Therefore, it might be appropriate to consider conservative treatment at first in almost all volar plate avulsion fractures of stable PIP joints.

A Flexor Digitorum Superficialis Tenodesis Technique for Surgical Treatment of Finger PIP Joint Volar Plate Chronic Avulsion.

Background: Chronic, post-traumatic, avulsion of the proximal interphalangeal (PIP) joint volar plate represents a disabling lesion. The purpose of this report is to describe a flexor digitorum superficialis (FDS) tenodesis using a mini-bone anchor inserted into the proximal phalanx, and its clinical outcome. Methods: 15 patients with chronic post-traumatic hyperextension instability of the PIP joint were treated surgically. From the first post-operative day patients were invited to start an early gradual joint active motion, wearing an extension block splint. Forty days after surgery, clinical evaluations were carried out, including: joint stability, pain and range of motion (ROM). The use of a circumferential splint was recommended for two further months, avoiding strenuous manual activities. The range of motion, time lost at work and the functional results were recorded six months after surgery. Results: At last follow up, 7 of the 13 reviewed patients presented an excellent functional recovery, with complete resolution of pain and stability with attainment of ROM comparable to the contralateral finger. The others 6 patients obtained good results, with remission of the functional impairment and pain, with either residual hyperextension or flexion contracture. There was one case of recurrence consecutively to a premature traumatic work-related activity. Conclusions: The FDS tenodesis via a bone anchor, combined with early active PIP joint protected motion, was shown in this study to be effective and reliable.

Dorsal Block Splinting of Volar Plate Injuries at Neutral Position.

PURPOSE: Volar plate injuries of the proximal interphalangeal joint (PIPJ) of a finger are common, often occurring in sporting or workplace incidents. Treatment of a stable dorsal dislocation entails a conservative approach, directed at preventing hyperextension and allowing the ligament to heal in position that does not negatively impact on healing. Current treatment regimens include dorsal block splinting (DBS) in 30° of flexion, which maintains the PIPJ in flexion in order to prevent any strain on the healing tissue while attempting to restore anatomical position. Recognized complications of DBS are flexion deformities of the joint and hyperextensibility. We propose that DBS in neutral position, rather than 30° flexion, reduces hyperextensibility as well as preventing flexion deformities of the PIPJ, allowing sooner return of function and participation in daily activities. METHODS: A retrospective review of patients sustaining volar plate injuries was undertaken. Inclusion criteria involved patients splinted at either 30° or neutral position, both those having undergone surgical or conservative regimens and the joint assessed as stable. Data were collected focusing on the number of hand therapy sessions, the time from injury to discharge, active angles of flexion and extension of the PIPJ, and pain. RESULTS: Over 2 years, 125 patients were treated for volar plate injuries: 20 with DBS at neutral position and 105 DBS at 30°. There were no significant differences in patient demographics. There were fewer hand therapy appointments required for those splinted in neutral position and weeks of hand therapy predischarge. There were no flexion deformities for patients undergoing DBS at neutral position, but no difference in PIPJ extension. There were no differences in hyperextensibility or pain. CONCLUSIONS: Dorsal block splinting at neutral position results in fewer flexion deformities following volar plate injuries of the PIPJ, without resultant hyperextensibility. There are fewer demands on hand therapy. Dorsal block splinting at neutral position may result in better function for patients suffering this injury, with decreased complications and quicker return to daily activities.

Accuracy and Reliability of Radiographic Estimation of Volar Lip Fragment Size in PIP Dorsal Fracture-Dislocations.

Background: A cadaveric study was performed to evaluate the accuracy and reliability of radiographic estimation of the volar lip fragment size in proximal interphalangeal joint fracture-dislocations. Methods: Middle phalangeal base volar lip fractures of varying size and morphology were simulated in 18 digits. Radiographs and digital photographs of the middle phalangeal joint surface were obtained pre- and postinjury. Ten orthopedic surgeons of varying levels of training estimated the fracture size based on radiographs. The estimated joint involvement on radiograph was compared with the digitally measured joint involvement. Results: Radiographic estimation underestimated the volar lip fragment size by 9.02%. Estimations possessed high intraobserver (0.76-0.98) and interobserver (0.88-0.97) reliabilities. No differences were detected between levels of surgeon training. Conclusions: The significant underestimation of the volar lip fragment size demonstrates the lack of radiographic estimation accuracy and suggests that surgeons should be mindful of these results when making treatment plans.

Swan neck deformity due to chronic radial collateral ligament injury of the little finger proximal interphalangeal joint.

We present seven cases of a relatively rare swan neck deformity resulting from chronic radial collateral ligament (RCL) injury of the proximal interphalangeal (PIP) joint in the little finger. All patients were middle-aged women (mean 51 years old, range 42-55), and the duration between the initial injury and surgery was 20 years (range 5-40). The chief complaint was painful snapping of the PIP joint. All patients had hyperextension and ulnar deviation of the PIP joint with mobile swan neck deformities that had not improved with conservative treatment. Radiographs revealed osteoarthritis and ulnar deviation of the PIP joints in all cases. We describe a method for reconstruction of both the palmar plate and the RCL of the affected PIP joint using a distally-based ulnar slip of flexor superficialis tendon. The prevention of PIP joint hyperextension was critical for successful resolution of symptoms; the aim of RCL augmentation was to prevent the recurrence of the deformity. LEVEL OF EVIDENCE: IV.

[Early active motion management of volar plate disruption of the proximal interphalangeal joint after finger hyperextension injury: extension block splinting versus buddy taping]. / Frühfunktionelles Management bei Hyperextensionstraumata des proximalen Interphalangealgelenkes mit Läsion der palmaren Platte: Extensionsblock versus Achterschlaufe.

Background Volar plate disruption of the proximal interphalangeal joint (PIP) is a common hand injury following finger hyperextension. At our institution, patients presenting with disruptions of the palmar plate (Eaton and Littler types I and II) before 2011 were treated with extension block splinting (group A). Since 2011, all patients with Eaton and Littler types I and II have received buddy taping (group B). The aim of this retrospective study was to compare the respective treatment outcomes. Patients and Methods In this retrospective study, we analysed the data of 44 patients visiting our department with volar plate disruption (Eaton and Littler types I and II) from 2009 to 2012. In group A, 23 patients were treated with custom-made extension block splinting in 10 ° flexion, compared with 21 patients treated with buddy taping in group B. Both groups received dorsal night splinting in 10 ° flexion. Results No statistically significant differences between the two groups were found in regard to treatment duration (p = 0,981), amount of required treatment sessions (p = 0,271), total active motion (TAM) (p = 0,693) and extension deficit (p = 0,404) in the PIP joint at the end of treatment, time until hand therapy was started (p = 0,285) or the Eaton und Littler diagnosis (p = 0,241). In the extension block group (group A), 10 out of 23 (44 %) patients after a median of 9 (4-10) weeks of treatment had an excellent result, 11 (48 %) had a good result, and 2 (8 %) patients had a poor result with a median 90 ° (85-100 °) TAM in the PIP joint and no extension deficit. In group A, all patients received a median of 4 (3-6) treatment sessions. Of those treated with buddy taping (group B), 14 out of 21 (66 %) patients at a median of 6 (4-13) weeks had an excellent result, 6 (29 %) had a good result, and 1 (5 %) patient had a poor result with a median TAM of 95 ° (82,5-100 °) and no extension deficit. In this group, patients received a total of 4 (3-5) treatment sessions. The type of treatment had no significant influence on the Benke and Stableforth outcome (χ2 = 2,385, df = 3, p = 0,304). No patient developed palmar joint instability. Conclusion No treatment option proved to be superior. We consider buddy taping to be faster, easier and more flexible to use.

The Central Slip Fracture: Results of Operative Treatment of Volar Fracture Subluxations/Dislocations of the Proximal Interphalangeal Joint.

PURPOSE: Fractures of the base of the middle phalanx are particularly challenging. Dorsal fracture-subluxations/dislocations of the proximal interphalangeal (PIP) joint are relatively common, but the volar fracture-subluxation/dislocation, the so-called "central slip fracture," is quite rare. The current study presents our experience with surgically treated patients with central slip fracture subluxation/dislocation with a minimum of 1 year follow-up. We hypothesized that the majority of patients with a central slip fracture-subluxation/dislocation have poor outcomes. METHODS: Thirteen patients with central slip fracture-subluxations/dislocation were identified from departmental billing records between 2003 and 2013. Nine patients completed the study follow-up examination and 8 were included in the final analysis. Clinical data assessed included age at injury, sex, mechanism of injury, injured digit, type of treatment, additional intervention(s), complications, length of follow-up, and range of motion follow-up. Fluoroscopic images and Quick Disabilities of the Arm, Shoulder, and Hand surveys were obtained at study follow-up. RESULTS: All patients underwent at least 1 surgery and 7 of 8 underwent open reduction. The average age at the time of injury was 41 years (range, 25-60 years). All injuries were closed. The average follow-up was 43 months (range, 17-67 months). Average passive and active range of motion of the PIP joint at follow-up were 62° and 54°, respectively. Six of 8 patients developed radiographic evidence of arthritic change and 4 experienced an outcome that required additional interventions. CONCLUSIONS: Patients should be counseled about the outcomes following surgical treatment of this uncommon, difficult injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Volar dislocation of the metacarpophalangeal joint of the thumb: A case report.

We present an 18 year-old patient with a volar dislocation of the metacarpophalangeal joint of the thumb. Open reduction was performed through a dorsal incision. Because of the soft tissue interposition such as dorsal capsule, volar plate, dislocated extensor pollicis longus and brevis tendons, ruptured ulnar collateral ligament; open reduction, soft tissue and ligament repair are recommended for this type of thumb dislocations.

Results of conservative treatment of volar plate sprains of the proximal interphalangeal joint with and without avulsion fracture.

The prognosis of isolated volar plate sprains of the proximal interphalangeal (PIP) joint is related to the extension deficit. Some consider an associated avulsion fracture as a sign of severity. The goal of this study was to find out whether the outcomes of conservative treatment in PIP volar plate injury was impacted by the presence of an avulsion fracture. Our series included 75 patients, 27 years old on average, of which 58 were men. All sprains were stable. The X-rays were normal in 52 cases (group 1); an avulsion fracture was found in 23 cases (group 2). The patients were treated by buddy taping during the day and a straight finger splint at night for 3 weeks. At the last follow-up, no significant difference was found between the two groups regarding pain, extension/flexion range of motion or edema. The results of this study show that the prognosis of conservative treatment of PIP volar plate injuries does not depend on the presence of an avulsion fracture.

The Use of a Simple Dynamic External Fixator for the Treatment of Volar Fracture Subluxation of Proximal Interphalangeal Joints of the Fingers.

Volar fracture dislocation is very uncommon, with few series reported in the literature. Patients with such injuries were treated by modified dynamic external fixators. The mean follow-up was 18 months (range, 6 to 92 mo). The mean range of interphalangeal (proximal interphalangeal) joints and distal interphalangeal joints were 90 and 74 degrees, respectively. The total active range of motion (TAM) was excellent (256 degrees). The mean quick disabilities of the arm, shoulder and hand score was 1.2. The advantages of our external fixators are that they are simple, cheap, adjustable, and allow immediate range of motion.

A Review of Published Radiographic Indicators of Carpometacarpal Dislocation Including Their Application to Volar Dislocations Through a Case Study.

BACKGROUND: Carpometacarpal joint dislocation is an uncommon injury that is at risk of being overlooked on initial presentation. Dislocation in a volar direction is rare, with a number of case reports published in the literature. CASE REPORT: We report a case of volar dislocation at our institution, and review the application of two reported radiographic signs of carpometacarpal dislocation to volar dislocation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Radiographic signs provide an aid to the emergency physician in the busy department. These are particularly helpful to rule out rare injuries. Carpometacarpal dislocations in a volar direction risk being missed by one radiographic sign reported in the literature, as this article highlights.

Irreducible volar subluxation of the proximal interphalangeal joint due to radial collateral ligament interposition: case report and review of literature.

Irreducible volar subluxation should be considered when assessing a patient with flexion deformity of the proximal interphalangeal finger joint (PIPJ). Primary assessment requires careful examination of the collateral ligaments and extensor tendon. Preoperative imaging such as ultrasound and MRI can help identify the interposed structures and plan the subsequent operation. Although rare, irreducible volar subluxation due to radial collateral ligament interposition is an important entity to be aware of. Prompt and appropriate management can prevent joint stiffness and loss of function.

A rare combination: locked volar distal radio-ulnar joint dislocation with isolated volar capsule rupture.

Distal Radioulnar Joint (DRUJ) dislocation is a commonly missed injury. A high clinical suspicion is required as the dislocation may not be obvious in the conventional views of radiographs. Volar DRUJ dislocations are far less common than the dorsal ones. Since triangular fibrocartilage complex (TFCC) is the major stabilizer of DRUJ, it is common that the irreducible DRUJ dislocation is associated with TFCC tear. We report a patient who had irreducible volar DRUJ dislocation blocked by the volar lip of sigmoid notch, with only isolated volar capsule rupture.

The role of post-operative radiographs in predicting risk of flexor pollicis longus tendon rupture after volar plate fixation of distal radius fractures - a case control study.

BACKGROUND AND AIM: Volar plating of distal radius fractures is one of the common procedures performed in trauma surgery. Flexor pollicis longus (FPL) rupture has been described as complication following volar plating of distal radius fractures. The aim of our study was to investigate the possible relation between parameters measured on post-operative radiographs and the occurrence of FPL ruptures. MATERIALS AND METHODS: This was a case control study. The post-operative radiographs of 11 FPL rupture, and 22 non-FPL rupture patients were reviewed with respect to fracture reduction and plate position and the various parameters were calculated by five independent people. Logistic regression was used to examine the importance of the variables. RESULTS: We identified two significant factors to predict FPL rupture after volar plating of distal radial fractures. These were radial tilt and plate distance from the joint line. The odds ratio of ruptures was 0.74 (95% CI 0.57-0.95) for every degree of radial tilt <25° and 0.50 (95% CI 0.28-0.88) for every millimetre that the distal end of the plate was away from the volar lip of the distal radius at the wrist joint. CONCLUSION: Post-operative radiographs could help us predict FPL rupture after distal radius volar plating. The findings also highlight the need for good fracture reduction and thoughtful placement of the volar plate intraoperatively to minimise the risk of FPL tendon rupture.