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Fracture Dislocation of the Finger Joints
Chirag M. Shah, MD, T. G. Sommerkamp, MD

Fracture dislocations of the hand are difficult and often unforgiving injuries. Keys to treatment
include early recognition, stable concentric reduction, and protected early active range of
motion maintaining joint stability. The balance between stability and mobility is difficult to
manage; therefore, surgeons need a wide array of treatments to tailor management to the
specific fracture pattern. With appropriate treatment, residual stiffness and pain can be
minimized. This Current Concepts review aims to provide up-to-date management for
proximal interphalangeal, distal interphalangeal, and metacarpophalangeal joint fracture
dislocations. (J Hand Surg Am. 2014;39(4):792e802. Copyright ! 2014 by the American
Society for Surgery of the Hand. All rights reserved.)
Key words Finger, joint, fracture, dislocation, subluxation.

HE FOLLOWING CURRENT CONCEPTS reviews re- complications are common, including stiffness, pain,
view the fracture dislocations of the proximal and swelling.
interphalangeal (PIP) joint, distal interpha-
langeal (DIP) joint, and metacarpophalangeal (MCP) Assessment
joint. We give an initial brief overview of these in- Initial assessment of dorsal PIP fracture dislocations
juries and then discuss the most up-to-date treatment involves a careful history and clinical examination
options and their respective outcomes. followed by radiographic or fluoroscopic evaluation.
Fracture chronicity and previous treatments must be
PROXIMAL INTERPHALANGEAL JOINT DORSAL clarified, because these have a role in determining
FRACTURE DISLOCATIONS ultimate treatment.
Proximal interphalangeal fracture dislocations are Classification of these injures is based on joint
difficult, unforgiving injuries. Dorsal fracture dislo- stability as well as fracture configuration. Specif-
cations are most common, with an associated volar ically, injured joints are classified as stable versus
fracture of the middle phalangeal base. The etiology unstable, which helps to guide nonsurgical versus
of these injuries is usually an axially directed force to surgical treatment options. Dorsal fracture disloca-
a fully extended digit. The relatively long lever arm tions are inherently more stable in flexion and un-
of energy transmission from the fingertip, and the stable in full extension, which therefore allows the
fixed uniplanar motion of the joint, result in this practitioner to determine stability using fluoroscopy
frequently seen injury pattern. Although many treat- coupled with range of motion examination. Those
ment options exist for these injuries, long-term joints, with concentric reduction with 30! flexion or
less, as well as those with less than 20% articular
involvement of the middle phalanx base, are consid-
From the University of Cincinnati, Department of OrthopedicseHand Surgery Specialists, ered stable. Those with 30% to 50% joint involvement
Cincinnati, OH. or those requiring increased flexion to provide stability
Current Concepts

Received for publication March 25, 2013; accepted in revised form October 6, 2013. are considered tenuous, whereas those with greater
No benefits in any form have been received or will be received related directly or than 50% articular involvement are considered gener-
indirectly to the subject of this article. ally unstable (Fig. 1).
Corresponding author: T. G. Sommerkamp, MD, Hand Surgery Specialists, Inc., 545 Radiographs or fluoroscopy can be used for frac-
Centre View Boulevard, Crestview Hills, KY 41017; e-mail: ture assessment and lateral images are often the most
0363-5023/14/3904-0036$36.00/0 useful. Complete dislocation is usually obvious;
however, subtle joint subluxation can often be missed.

792 r ! 2014 ASSH r Published by Elsevier, Inc. All rights reserved.

FIGURE 1: Anticipated fracture stability according to joint surface involvement as seen on a lateral view of the PIP joint.

dislocations. The goals of treatment have remained
unchanged over the years. They include a stable,
concentric reduction of the PIP joint to allow smooth
gliding motion as early as possible in the postinjury
period. In addition, edema control has been a main-
stay of treatment regardless of other interventions.
Treatment options include extension block splint-
ing, extension block pinning, external fixation, dy-
namic traction, Kirschner wire joint transfixation, open
reduction internal fixation (ORIF), volar plate arthro-
plasty, and hemihamate arthroplasty. These treatment
modalities have been described in previous reviews;
we will provide a general overview as well as recent
FIGURE 2: Dorsal V sign (arrow) on a lateral radiograph of a PIP
joint fracture subluxation.
Extension block splinting and pinning
The radiographic V sign is a finding on the lateral As noted previously, dorsal fracture dislocations of
radiograph that results from dorsal subluxation of the the PIP joint that are stable, in slight flexion (< 30! )
middle phalanx articular surface, producing a radiolu- can be managed nonsurgically. The mainstay of
cent V sign indicative of the subtle instability (Fig. 2). treatment for these patients is to maintain a concentric
Along with static radiographic examination, fluo- reduction by preventing full extension at the PIP joint.
roscopic evaluation can be invaluable in determining This can be achieved via extension block splinting or
injuries that will be amenable to operative versus extension blocking pinning in the compliant patient.
nonsurgical treatment. Joints that have concentric Splints can be fabricated to allow full flexion and
gliding motion about the rotational axis of the head of limit extension to prevent reaching the point of insta-
the proximal phalanx are likely to be amenable to bility, as noted during the initial assessment of the
nonsurgical treatment. Those that have motion that patient. This can be achieved through dorsal blocking
hinges on the fracture edge are more likely to fail splints and figure-of-eight splints. The amount of
nonsurgical treatment and to result in late post- extension can slowly be increased over a period of 3
Current Concepts

traumatic arthrosis and associated stiffness and pain. weeks, as determined by fracture stability. Serial
A combination of these assessment tools will help weekly radiographs are imperative to detect subsequent
guide the hand surgeon to treat PIP dorsal fracture loss of reduction, which can lead to poor outcomes.
dislocations appropriately with the best possible In a prospective study of 27 patients treated
outcomes. with extension block splinting, Hamer and Quinton2
found that 70% had good results and that poor
Treatment options and outcomes results occurred in those who lost reduction in the
Injury pattern and surgeon preference have key roles splints. They concluded that most of these fractures
in determining treatment options for PIP fracture- could be treated by splinting; however, those authors

J Hand Surg Am. r Vol. 39, April 2014

cautioned about the need for close follow-up to help antibiotics; however, no deep infections were noted.
avoid loss of reduction. All patients returned to their preinjury level of activity,
More recently, extension block pinning, first even though these were active duty military personnel
described by Viegas,3 has been used in techniques with high physical demands.
not only to prevent extension, but also to provide for Both of these techniques require technical exper-
fracture reduction. At a mean 5-year follow-up, Waris tise and not all outcomes are favorable. Agarwal
and Alanen4 retrospectively reviewed 18 PIP fracture et al8 reported on 25 patients with a mean follow-up
dislocations treated with extension block pinning of 13 months. Mean arc of PIP motion was only 67!
combined with intramedullary fracture reduction of and DIP motion was 41! . Three patients had immo-
the volar lip of the middle phalanx using a 1-mm bile DIP joints and 7 (28%) had superficial pin site
prebent Kirschner wire through a cortical window in infections. Loss of motion at both joints was a major
the middle phalanx. They showed that the mean factor in poor outcomes. The authors suggested that a
articular stepoff decreased from 2.1 to 0.5 mm and few technical considerations be kept in mind with this
that PIP motion averaged 83! with a mean flexion treatment modality: (1) The traction pin should be
contracture of 3! . They concluded that this technique centered in the head of the proximal phalanx; (2) the
was useful in the treatment not only of stable fractures, horizontal limb of the traction pin must be perpen-
but also of unstable fractures that were made more dicular to the long axis of the ray; (3) both vertical
stable by indirect fracture reduction and extension limbs on the traction pin should be appropriately
block pinning. distanced from the digit so as to clear the sides of the
digit and not impede adjacent digits; and (4) true
External fixation and dynamic traction concentric glide must be present with PIP joint
Proximal interphalageal fracture dislocations that are flexion so that subluxation does not occur.
unstable or comminuted can be treated in a relatively
minimally invasive way by external fixation as well Open reduction internal fixation
as dynamic traction. Either as an isolated treatment or Open reduction internal fixation of fracture-dislocations
in conjunction with ORIF, many commercially about the PIP joint has a limited but important role.
available digital external fixators are available and Postoperative stiffness and loss of reduction are the
offer both static as well as dynamic options. Disad- main concerns with this method of treatment. Volar,
vantages of these include increased cost compared dorsal, and midlateral approaches have been described
with Kirschner wire dynamic traction, as well as risk for this treatment modality. Large partial articular
of pin track infections and pin loosening. Dynamic fractures with minimal or preferably no comminution
traction systems have many different configurations; are the ideal candidates, whereas extensive comminu-
however, the basic principle remains that the pins tion or chronicity of injury may limit the applicability
counteract the tendency of the middle phalanx to of this treatment. Although technically demanding,
subluxate dorsally while the rubber bands apply con- stable fixation obtained through this approach can
stant longitudinal traction to offload the articular sur- allow early postoperative range of motion protocols to
face and prevent further fracture displacement. Similar provide the best possible outcomes.
to extension block splinting, routine serial radiographs Recent literature has focused more on reconstruc-
are needed to ensure maintenance of joint reduction. tive options for fracture-dislocations about the PIP
Henn et al5 recently reported their surgical tech- joint; however, outcomes have been similar to those
nique for dynamic external fixation using 3 Kirschner previously reported. Hamilton et al9 retrospectively
wires and rubber bands, and reported on 8 patients reviewed 9 patients with unstable dorsal fracture
with an average follow-up of 26 months. Average dislocations treated by ORIF with mini-fragment
PIP motion was from 1! to 89! and grip strength was screw fixation. At an average of 42 months post-
Current Concepts

92% of the contralateral side. Two patients had operatively, the mean PIP arc of motion was 70! ,
radiographic evidence of early arthritis and 3 had an with better motion noted for the 2 patients with only 1
articular stepoff of 1 mm or greater.6 fracture fragment (85! ) versus those with multiple
Ruland et al7 retrospectively reviewed 26 PIP fragments (65! ). Eight of 9 joints had a residual
fracture dislocations and 8 pilon-type fractures treated flexion contracture with a mean flexion contracture
with dynamic distraction external fixation at a mean of 14! . The authors concluded that this was a viable
follow-up of 16 months. Average PIP arc of motion treatment option, but it should be approached
was 88! and the DIP arc was 60! . Eight patients (24%) cautiously in the setting of comminution with a known
had superficial pin site infections treated with oral universal risk of PIP flexion contracture. Similarly, Lee

J Hand Surg Am. r Vol. 39, April 2014

FIGURE 3: A Lateral view of hyperextended PIP joint with hemihamate autograft recreating the volar buttress (arrow). B Lateral and
posteroanterior radiographs of healed hemihamate autograft.

and Teoh10 reported their results using a dorsal with angular deformities, recurrent subluxation, hy-
approach and similar treatment. Twelve patients were perextension, pin and wire track infections, and re-
reviewed and average PIP arc of motion achieved was sidual pain and stiffness.11
85! . Seven of the 12 digits had flexion contractures at
final follow-up. Although ORIF is a viable option for Hemihamate arthroplasty
simple noncomminuted fracture patterns, reconstruc- Most of the recent literature on the treatment of dorsal
tion via volar plate arthroplasty or hemihamate PIP fracture dislocations has addressed hemihamate
arthroplasty may be a better option for more complex arthroplasty. This treatment option aims to recon-
injury patterns. struct the volar buttress of the middle phalanx with an
autologous osteochondral graft from the dorsal distal
Volar plate arthroplasty hamate in fractures that involve 50% or more of the
Volar plate arthroplasty is a time-tested procedure articular surface (Fig. 3). Looking at the suitability of
that has been used to reconstruct PIP fracture dislo- this graft, Capo et al12 studied fresh-frozen cadavers
cations involving less than 50% to 60% of the artic- to assess biomechanics and radiographic features of
ular base of the middle phalanx. As initially the PIP as well as carpometacarpal (CMC) joints
described, the procedure reconstructs a volar soft before and after hemihamate arthroplasty. They
tissue buttress to a dorsally unstable articulation. To showed that there was no tendency for the CMC joint
our knowledge, there have been no recent reports to subluxate, the hamate’s central ridge and bicon-
Current Concepts

regarding this surgical procedure, and previous re- dylar facets were similar to those of the middle
ports looking at combined outcomes show better phalanx base, and harvesting of the graft led to no
results when surgery was performed within 6 weeks clinical instability of the CMC joint.
of injury (95! vs 78! PIP motion), with worse out- A recently described modification to the surgical
comes when more than 50% of the articular base is technique brings to light the slight difference in
involved.1 Because of the need for considerable PIP articular contour between the hamate and the base of
flexion postoperatively for larger defects, complica- the middle phalanx. Yang et al13 retrospectively
tions for this procedure have been noted to include reviewed 11 patients who had undergone a modified
persistent flexion contractures of the PIP joint along hemihamate arthroplasty. The authors’ modifications

J Hand Surg Am. r Vol. 39, April 2014

FIGURE 4: A Lateral radiograph of volar PIP joint fracture dislocation. B Lateral radiograph demonstrating fracture reduction after
relocation of the PIP joint.

included a forceful volar subluxation of the 4th and 40% and 90%, except for extremely rare, large, non-
5th CMC joints with distal to proximal osteotomy of comminuted volar fragments that are amenable to
the hamate performed in a volar oblique fashion so ORIF. Our postoperative rehabilitation protocol in-
that the graft would sit obliquely into the recipient site cludes the following: early active range of motion
and better reproduce the volar buttress of the middle (AROM) by postoperative day (POD) 1 to 3 with
phalangeal base. They reported average PIP joint extension block splinting at 5! to 10! flexion with a
motion of 85.4! at a mean follow-up of 38 months. protective volar position splint between exercises;
In a longer follow-up of 8 patients, Afendras progressing to differential interphalangeal blocking by
et al14 reported their outcomes with a mean follow-up POD 7 to 10, and reduction of extension block splint-
of 5 years. They noted a mean arc of motion of 67! ing to 0! by POD 17; dynamic extension splinting by
and grip strength of 91% of the contralateral side. week 4; and strengthening by week 6.
Upon radiographic examination, 2 patients had severe
arthritis of the PIP joint and 2 had mild arthritis, but PROXIMAL INTERPHALANGEAL JOINT PALMAR
only 1 was symptomatic with troublesome pain. FRACTURE DISLOCATION
Similarly, Calfee et al15 reported on 22 patients Although rare, PIP palmar fracture dislocations occur
with a mean follow-up of 4.5 years after hemihamate as a result of axial load combined with a palmar-
arthroplasty. Fourteen acute injuries (< 6 wk) and 8 directed force over the middle phalanx base. This
chronic injuries (mean, 30 wk) were included. Mean injury usually includes a dorsal fracture at the base of
PIP joint arc of motion was 70! (acute, 71! ; chronic, the middle phalanx (Fig. 4). There has not been much
69! ) and grip strength was 95% of the contralateral recent change in the treatment of these injuries, and
Current Concepts

side. One dissatisfied patient underwent revision the largest series reported is by Rosenstadt et al,16
surgery; chronic injures were noted to have an who reported on 13 patients, 9 acute and 4 chronic,
increased visual analog scale pain rating (2.5 vs 1.6) with a mean follow-up of 55 months. Treatment
compared with those with acute treatment. included closed reduction and percutaneous pin fix-
ation for 7 of 9 acute injuries, ORIF for the remaining
Preferred treatment algorithm and postoperative protocol: 2 patients with acute injuries, and open reduction and
dorsal PIP fracture dislocation soft tissue reconstruction for the 4 chronic injuries.
Our preferred approach is hemihamate replacement Postoperative PIP joint arc of motion averaged 91!
arthroplasty for articular surface involvement between for the acute group and 70! for the chronic group. A

J Hand Surg Am. r Vol. 39, April 2014

brief 3- to 4-week period of immobilization with mallet fractures of the dorsal articular surface. Sta-
simple PIP static extension splinting at 0! after closed bility of the DIP joint has been evaluated in the past
reduction, as long as the PIP joint is reasonably and is noted to be proportional to the amount of
congruent and concentrically reduced, is certainly articular surface involvement. Husain et al20 studied
preferable over more aggressive approaches. 29 cadaver digits with mallet fractures of differing
size to compare the rate of DIP subluxation. The DIP
PROXIMAL INTERPHALANGEAL JOINT RADIAL/ joint remained concentrically reduced when less than
ULNAR FRACTURE DISLOCATION 43% of the joint surface was involved, whereas sub-
Proximal interphalangeal fracture dislocations can luxation consistently occurred when more than 52% of
also occur in the coronal plane. Unlike the dorsal or the articular surface was involved. This can be used by
palmar counterparts, these injuries usually involve a practitioners to construct a treatment algorithm.
unicondylar fracture pattern at the head of the prox- Treatment options and outcomes
imal phalanx and an associated coronal instability.
Although these are rare injuries, recent literature has Treatment of DIP fracture dislocations varies from
looked at different treatment options with severely nonsurgical to surgical; to date, personal preference
comminuted unicondylar fractures. Similar to the has a large role in treatment decisions. Aside from
concave hemihamate osteochondral graft, a convex conservative management, surgical treatment has
autologous osteochondral graft for the proximal been recommended for fractures involving more than
phalanx condyle would be an ideal solution. one third of the articular surface and those with volar
In a morphometric analysis of potential osteochon- subluxation of the DIP joint. Options have included
dral autografts, in 2010, Hernandez and Sommer- extension block pinning and ORIF with screws,
kamp17 studied 40 cadaver proximal phalanges and 20 wires, and hook plate constructs.
metacarpals (4th and 5th) to assess whether the base of Kalainov et al21 reviewed 22 closed mallet frac-
the metacarpals could be used as a donor site for tures involving more than one third of the articular
autologous transfer. They found that in relation to surface at mean follow-up of 24.5 months after
radius of curvature as well as radioulnar and dorsal- treatment with continuous extension splinting for a
volar dimensions, the ulnar aspect of the small finger mean of 5.5 weeks. Nine cases had a reduced joint at
metacarpal base would provide the best match for presentation and 13 had joint subluxation. Across
resurfacing of distal condylar defects of the proximal outcome measures for pain, function, and satisfac-
phalanges. In a similar manner, Cavadas et al18 used tion, patients had resolution of pain and improvement
osteochondral grafts from the ulnar base of the 5th of function; however, they were only marginally
metacarpal to reconstruct a condylar defect in the satisfied with finger appearance. Although not sta-
proximal phalanx in 16 patients. They reported an tistically significant, joints with residual subluxation
average active arc of PIP joint motion of 49! with no were more likely to have degenerative arthrosis,
donor-site morbidity at midterm follow-up. swan-neck deformity, and dorsal prominence, which
Recently, Zhang et al19 reported on outcomes of a led to suboptimal patient satisfaction.
novel treatment for articular defects of the head of the Much has been reported on extension block
proximal phalanx. Fifteen patients were treated with an pinning of palmer DIP fracture dislocations; the most
osteoarticular pedicle flap from the capitate to the head recent review was by Lee et al.22 Those authors
of the proximal phalanx. At an average of 52 months, treated 32 digits with a 2eextension block Kirschner
mean active arc of motion at the PIP joint was 50! , with wire technique. Mean articular involvement was
pinch and grip strength that was similar to the contra- 38.4% and 18 of 32 had joint subluxation. At mean
lateral side. Although this is an innovative treatment, follow-up of 49 months, all fractures united with
congruent reduction of the joint surfaces. Average
Current Concepts

further research into the effectiveness and compara-
bility with other treatment modalities is needed. DIP flexion was 83.1! and mean extension loss was
about 1! . No digit had a prominent dorsal bump or
recurrent mallet deformity.
DISTAL INTERPHALANGEAL JOINT VOLAR Open reduction internal fixation using screws,
FRACTURE DISLOCATION: MALLET FRACTURE Kirschner wires, and hook plates has been described
DISLOCATION as a treatment modality. Kronlage and Faust23 re-
Introduction ported on 12 patients treated with ORIF with screw
Unlike PIP joint injuries, DIP joint fracture disloca- fixation at an average of 31 months postoperatively.
tions usually involve palmar dislocations with boney Mean DIP joint range of motion was 6! to 70! . Loss

J Hand Surg Am. r Vol. 39, April 2014

FIGURE 5: A Lateral radiograph of volar mallet fracture subluxation at the DIP joint. B Intraoperative photograph of modified cerclage
technique with 26-gauge wire being passed though the terminal extensor tendon and already passed through the distal phalanx. C Post-
operative lateral radiographs showing DIP joint transfixation and cerclage. D Final radiographs showing reduced healed mallet fracture

of reduction occurred in 1 patient and arthrosis was Preferred treatment algorithm and postoperative protocol:
noted in 2 (1 mild and 1 severe). Teoh and Lee24 volar-mallet fracture subluxation
reported on 9 patients treated with a hook plate Our preferred approach is to treat all mallet fractures
fabricated from a 1.3-mm AO hand modular system conservatively regardless of the percentage of artic-
straight plate. The benefit of this fixation was the ular surface involvement, unless the DIP joint sub-
avoidance of fixation directly into small avulsion luxes volarly, either initially or during the course
fragments, which still allowed a stable tension-plate of treatment. For mallet fracture subluxations, we
construct that allowed early active motion. At mean prefer a modified cerclage wire technique originally
follow-up of 17 months, active DIP flexion averaged described by Melone (personal communication) with
64! with no extensor lag. Finally, Phadnis et al25 a 26-gauge wire inserted through the terminal extensor
Current Concepts

recently reported on ORIF with buried Kirschner wire tendon fibers, then passed through a drill hole in the
fixation including both fracture fixation and DIP joint base of distal phalanx made by a 20-gauge Tuohy
transfixation. Twenty patients with average follow-up needle after reducing the DIP joint and stabilizing
of 12.7 months were reviewed. Seventeen patients with a 0.9-mm (0.035-in) Kirschner wire (Fig. 5).
had full extension and no deformity, whereas 3 had Postoperative rehabilitation protocols include mallet
an extension lag of less than 10! . Eighteen patients splint with volar position splint and early AROM of
had full flexion; 2 patients lost 10! and 15! , respec- the MCP/PIP joint at POD 5 to 7, followed by DIP
tively. The best results were seen in patients treated AROM at week 4 after the transarticular pin is
within 2 weeks of the injury. pulled.

J Hand Surg Am. r Vol. 39, April 2014

FIGURE 6: A Preoperative lateral radiograph of dorsal fracture subluxation at the DIP joint. B Postoperative radiograph showing
fixation via 1.5-mm AO screws.

Distal interphalangeal joint dorsal fracture dislocation: skin can be seen over the palmer surface of the MCP
Leddy and Packer type III flexor digitorum profundus joint, which is pathognomonic of the injury (Fig. 7).
avulsion fracture dislocation Afifi et al27 studied complex MCP dislocation in 6
Dorsal fracture dislocations of the DIP joint are rare cadavers to determine methods for operative reduc-
and there is no consensus on treatment of these in- tion of the joint. They noted that the flexor tendons
juries. Rettig et al26 reviewed 10 patients with chronic went ulnar to the metacarpal head in every case, the
dorsal fracture-dislocations treated with volar plate radial digital nerve was superficial and radial to the
arthroplasty. At mean follow-up of 25 months, the metacarpal head (5 of 6 cases), and the lumbrical was
mean DIP arc of motion was 42! and mean flexion radial to the metacarpal head (5 of 6 cases). Division
contracture was 12! . Other treatment options for of the superficial transverse metacarpal ligament,
these injuries include ORIF using screw versus suture natatory ligament, flexor tendons, lumbrical muscles,
fixation. We are unaware of any recent literature or deep transverse metacarpal ligament did not
reviewing outcomes from these procedures specif- help with reduction, whereas division of the volar
ically; however, zone I flexor tendon repairs are plate was needed for all 6 reductions. The authors
presumed to have similar outcomes. concluded that careful dissection is needed to prevent
iatrogenic injury to the various structures involved in
Preferred treatment algorithm and postoperative protocol: this injury pattern.
dorsal DIP (Leddy and Packer type III) flexor digitorum Closed reduction of the dorsally dislocated MCP
profundus avulsion fracture dislocation joint is attempted with hyperextension to recreate the
Our preferred approach is to reduce the DIP joint by injury deformity followed by sliding the proximal
stabilizing the avulsed volar articular fragment phalanx around the metacarpal head. Longitudinal
attached to the flexor digitorum profundus tendon traction is usually avoided because of the possibility
with 2 1.5-mm AO screws, taking great care to avoid of creating a complex dislocation by allowing the
any distal angulation where a prominent screw tip volar plate (which ruptures proximally) to interpose
might irritate the overlying germinal matrix (Fig. 6). between the articular surfaces. In addition, the meta-
Our postoperative rehabilitation protocol follows carpal head, which is between the lumbrical muscle
Current Concepts

typical zone I flexor tendon protocols. radially and flexor tendons ulnarly, is further incar-
cerated by longitudinal traction. Surgical reduction, on
MCP JOINT DORSAL DISLOCATION the other hand, can procede either via a volar or dorsal
Metacarpophalangeal joint dislocation most often approach.
occurs dorsally; the index finger is the most Durakbasa and Guneri28 followed 7 cases of com-
commonly involved. These injuries are categorized as plex MCP joint dorsal dislocations treated with an open
complex when they are irreducible by closed means. volar approach for reduction. At mean follow-up of
They often present with MCP joint extension with 91 months, range of motion, grip power, stability, and
flexion at the PIP and DIP joints. Puckering of the sensation were normal. At the time of surgery, the volar

J Hand Surg Am. r Vol. 39, April 2014

FIGURE 7: A Lateral clinical picture showing index finger dorsal MCP fracture dislocation. B Clinical picture showing pathognomonic
skin puckering over the palmer surface of the MCP joint.
Current Concepts

FIGURE 8: A Posteroanterior radiograph of MCP dorsal fracture dislocation. B Lateral radiograph of MCP dorsal fracture dislocation.
C Postoperative posteroanterior radiograph status post ORIF. D Postoperative lateral radiograph status post ORIF.

plate was found to impede reduction in all cases. The approach to free the volar plate from within the joint,
longitudinal split made in the volar plate to aid in which prevents the need for the longitudinal split
reduction could be repaired from the volar approach, altogether.
and the authors cited no complications as a result Dorsally, the MCP joint can be accessed with
of iatrogenic injury to other anatomic structures. minimal risk to anatomic structures. The volar plate
Along with this, an elevator can be used from the volar can be visualized and divided longitudinally to allow

J Hand Surg Am. r Vol. 39, April 2014

FIGURE 9: A Lateral radiograph of MCP volar fracture dislocation. B Postoperative posteroanterior radiograph status post ORIF via
dorsal approach.

for joint reduction. Advocates of this approach cite the dorsal counterparts, there are usually no inter-
the ease of exposure and relatively little risk to the posed anatomic structures with these injuries and
radial neurovascular bundle, unlike the volar closed reduction is usually successful. We are un-
approach. That being said, personal preference usu- aware of any recent literature looking at outcomes of
ally has a role in determining surgical approach. these closed reductions.

Preferred treatment algorithm and postoperative protocol: Preferred treatment algorithm and postoperative protocol:
dorsal MCP dislocation volar MCP dislocation
Our preferred approach is dorsal with longitudinal Our preferred approach is to perform a closed
division of the volar plate, because most associated reduction in the vast majority of these rare injuries
condylar fractures of the metacarpal are more easily because the proximally detached dorsal capsule, or
addressed through this approach (Fig. 8). The asso- more remotely, the distally disrupted volar plate,
ciated metacarpal condylar fractures are usually sta- seldom blocks reduction. In the rare exception where
bilized with small Herbert screws, or the articular closed reduction is unsuccessful or there is a signif-
corner fractures of the proximal phalanx are stabilized icant associated fracture, a dorsal approach for ORIF
with 1.5- to 2.0-mm AO screws or Kirchner wires. is preferred (Fig. 9). Postoperatively, the MCP joint is
Current Concepts

Our postoperative rehabilitation protocol includes splinted only briefly in extension at neutral, serially
dorsal block splinting of the MCP joint in 30! flexion flexing the MCP joint down by 20! to 30! weekly to
with early AROM of IP and MCP joints by POD 5 to prevent an MCP extension contracture.
7, depending on fracture construct stability.
MCP JOINT VOLAR DISLOCATIONS 1. Calfee RP, Sommerkamp TG. Fracture-dislocation about the finger
Similar to DIP dorsal fracture dislocations, MCP volar joints. J Hand Surg Am. 2009;34(6):1140e1147.
2. Hamer DW, Quinton DN. Dorsal fracture subluxation of the proximal
dislocations are rare injuries and there is no con- interphalangeal joints treated by extension block splintage. J Hand
sensus regarding treatment of these injuries. Unlike Surg Br. 1992;17(5):586e590.

J Hand Surg Am. r Vol. 39, April 2014

3. Viegas SF. Extension block pinning for proximal interphalangeal 15. Calfee RP, Kiefhaber TR, Sommerkamp TG, Stern PJ. Hemi-hamate
joint fracture dislocations: preliminary report of a new technique. arthroplasty provides functional reconstruction of acute and chronic
J Hand Surg Br. 1992;17(5):896e901. proximal interphalangeal fracture-dislocations. J Hand Surg Am.
4. Waris E, Alanen V. Percutaneous, intramedullary fracture reduction 2009;34(7):1232e1241.
and extension block pinning for dorsal proximal interphalangeal 16. Rosenstadt BE, Glickel SZ, Lane LB, Kaplan SJ. Palmar fracture
fracture-dislocations. J Hand Surg Am. 2010;35(12):2046e2052. dislocation of the proximal interphalangeal joint. J Hand Surg Am.
5. Henn CM, Lee SK, Wolfe SW. Dynamic external fixation for 1998;23(5):811e820.
proximal interphalangeal fracture-dislocations. Oper Techn Orthop. 17. Hernandez JD, Sommerkamp TG. Morphometric analysis of poten-
2012;22(3):142e150. tial osteochondral autografts for resurfacing unicondylar defects of
6. Ellis SJ, Cheng R, Prokopis P, et al. Treatment of proximal interpha- the proximal phalanx in PIP joint injuries. J Hand Surg Am.
langeal dorsal fracture-dislocation injuries with dynamic external 2010;35(4):604e610.
fixation: a pins and rubber band system. J Hand Surg Am. 2007;32(8): 18. Cavadas PC, Landin L, Thione A. Reconstruction of the condyles
1242e1250. of the proximal phalanx with osteochondral grafts from the ulnar base
7. Ruland RT, Hogan CJ, Cannon DL, Slade JF. Use of dynamic of the little finger metacarpal. J Hand Surg Am. 2010;35(8):
distraction external fixation for unstable fracture-dislocations of 1275e1281.
the proximal interphalangeal joint. J Hand Surg Am. 2008;33(1): 19. Zhang X, Fang X, Shao X, Wen S, Zhu H, Ren C. Osteoarticular
19e25. pedicle flap from the capitate to reconstruct traumatic defects in
8. Agarwal AK, Karri V, Pickford MA. Avoiding pitfalls of the pins and the head of the proximal phalanx. J Hand Surg Am. 2012;37(9):
rubbers traction technique for fractures of the proximal interphalan- 1780e1790.
geal joint. Ann Plast Surg. 2007;58(5):489e495. 20. Husain SN, Dietz JF, Kalainov DM, Lautenschlager EP.
9. Hamilton SC, Stern PJ, Fassler PR, Kiefhaber TR. Mini-screw fixa- A biomechanical study of distal interphalangeal joint subluxation
tion for the treatment of proximal interphalangeal joint dorsal after mallet fracture injury. J Hand Surg Am. 2008;33(1):26e30.
fracture-dislocations. J Hand Surg Br. 2006;31(8):1349e1354. 21. Kalainov DM, Hoepfner PE, Hartigan BJ, Carroll C, Genuario J.
10. Lee JYL, Teoh LC. Dorsal fracture dislocations of the proximal Nonsurgical treatment of closed mallet finger fractures. J Hand Surg
interphalangeal joint treated by open reduction and interfragmentary Am. 2005;30(3):580e586.
screw fixation: indications, approaches and results. J Hand Surg Br. 22. Lee YH, Kim JY, Chung MS, Baek GH, Gong HS, Lee SK. Two
2006;31(2):138e146. extension block Kirschner wire technique for mallet finger fractures.
11. Blazar PE, Robbe R, Lawton JN. Treatment of dorsal fracture/dis- J Bone Joint Surg Br. 2009;91(11):1478e1481.
locations of the proximal interphalangeal joint by volar plate 23. Kronlage S, Faust D. Open reduction and screw fixation of mallet
arthroplasty. Tech Hand Up Extrem Surg. 2001;5(3):148. fractures. J Hand Surg Br. 2004;29(2):135e138.
12. Capo JT, Hastings H, Choung E, Kinchelow T, Rossy W, Steinberg 24. Teoh LC, Lee J. Mallet fractures: a novel approach to internal fixa-
B. Hemicondylar hamate replacement arthroplasty for proximal tion using a hook plate. J Hand Surg Br. 2007;32(1):24e30.
interphalangeal joint fracture dislocations: an assessment of graft 25. Phadnis J, Yousaf S, Little N, Chidambaram R, Mok D. Open
suitability. J Hand Surg Am. Elsevier; 2008;33(5):733e739. reduction internal fixation of the unstable mallet fracture. Tech Hand
13. Yang DS, Lee SK, Kim KJ, Choy WS. Modified hemihamate Up Extrem Surg. 2010;14(3):155e159.
arthroplasty technique for treatment of acute proximal interphalan- 26. Rettig ME, Dassa G, Raskin KB. Volar plate arthroplasty of the distal
geal joint fracture-dislocations. Ann Plast Surg. 2012 Dec 13. [Epub interphalangeal joint. J Hand Surg. 2001;26(5):940e944.
ahead of print]. 27. Afifi AM, Medoro A, Salas C, Taha MR, Cheema T. A cadaver
14. Afendras G, Abramo A, Mrkonjic A, Geijer M, Kopylov P, Tägil M. model that investigates irreducible metacarpophalangeal joint dislo-
Hemi-hamate osteochondral transplantation in proximal interpha- cation. J Hand Surg Am. 2009;34(8):1506e1511.
langeal dorsal fracture dislocations: a minimum 4 year follow-up in 28. Durakbasa O, Guneri B. The volar surgical approach in complex dorsal
eight patients. J Hand Surg Eur Vol. 2010;35(8):627e631. metacarpophalangeal dislocations. Injury. 2009;40(6):657e659.
Current Concepts

J Hand Surg Am. r Vol. 39, April 2014