Professional Documents
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8. Ogden J: In Skeletal injury in the child. Philadelphia, II. Smith RJ: Post-traumatic instability of the metacarpo-
1982, Lea & Febiger, p 365 phalangeal joint of the thumb. J Bone Joint Surg [Am]
9. Parikh M, Nahigian S, Froimson A: Gamekeeper's 59:14-21, 1977
thumb. Plast Reconstr Surg 58:24-31, 1976 12. Stener B: Displacement of the ruptured ulnar collateral
10. Smith MA: The mechanism of acute ulnar instability of ligament of the metacarpophalangeal joint at the thumb:
the metacarpophalangeal joint of the thumb. Hand A clinical and anatomical study. J Bone Joint Surg [Br]
12:225-30, 1980 44:869-79, 1962
David M. Black, M.D., Ronald J. Mann, M.D., Ronald M. Constine, M.D., and
A. U. Daniels, Ph.D. Salt Lake City, Utah
Fractures of the proximal phalanx are tion is desired after surgery.I.S Although various internal
common and usually amenable to closed treatment. The fixation methods have been advocated, only a few stud-
basic goals of treatment are union in satisfactory align- ies have dealt with quantitative measurement of the
ment, with special emphasis on avoiding loss of func- relative stability achieved. Previous investigators have
tion. Unstable fracture patterns may lend themselves to used transverse osteotomies, and no data exist on
rigid internal fixation, especially when early joint mo- oblique osteotomies in the hand, which may model
certain types of fractures better than transverse osteoto-
From the Division of Orthopaedics, University of Utah School of mies. 6 l4 Our interest was in studying fixation in the
Medicine, Salt Lake City, Utah. proximal phalanx after oblique osteotomy, which al-
Supported in part by the American Society for Surgery of the Hand lows for the application of interfragmentary lag screws.
seed grant No. 84-3.
In fractures of the proximal phalanx, the displacement
Received for publication Feb. 22, 1985; accepted in revised form
pattern is typically apex palmar angulation, combined
Nov. 5, 1985.
with a variable degree of shortening and rotation (Fig.
Reprint requests: Ronald J. Mann, M.D., Division of Orthopedics,
University of Utah School of Medicine, 50 N. Medical Dr., Salt 1). The proximal fragment is flexed by the bony in-
Lake City, UT 84132. sertion of the interossei muscles into the base of the
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DORSAL DORSAL PLATE
PLATE +INTERfRAG .
LAG SCREW
Fig. 4. Bending rigidity of fixation techniques with mean and Fig. 5. Maximum bending moments of fixation techniques.
range of one standard deviation about the mean depicted. Normal range for control intact proximal phalanges of two
standard deviations is represented by area between hatched
lines .
bending rigidity was EI = UF/48Y where L = span
between supports, F = force measured at the center
point, and Y = bending deflection measured. Both of a dorsal plate alone and a dorsal plate combined with
the techniques that used interfragmentary lag screws an interfragmentary lag screw, two interfragmentary lag
across the oblique osteotomies provided significantly screws, or the tension band technique to be calculated
more rigidity than did dorsal plating alone or crossed (p < 0.01).
Kirschner wires (p < 0.001) . A dorsal plate combined Yield moment, energy absorbed to yield, and fracture
with an interfragmentary lag screw was more rigid than site angulation at yield may also be relevant in com-
were two interfragmentary lag screws (p < 0.01). Dor- paring stability for each technique, but their relative
sal plates alone provided rigidity comparable with importance is difficult to assess (Table I). Yield moment
crossed Kirschner wires while the tension band tech- was calculated in a manner similar to that of maximum
nique resulted in intermediate rigidity. Rigidity of bending moment after determination of the yield point.
the intact proximal phalanges in the controls was sig- Energy absorbed to yield was derived from the area
nificantly greater than all fixation techniques tested under the load-deformation curve to yield, and fracture
(p < 0.001). site angulation at yield was derived trigonometrically
Maximum bending moments were obtained for each assuming that all angulation occurred at the osteotomy
proximal phalanx during testing to failure in an apex site. No statistical differences in moments at yield be-
palmar three-point bend and are shown in Fig. 5. The tween fixation techniques were found. Fracture site an-
equation used was M = FLl4 where F = force mea- gulation allowed at yield was the least with the tech-
sured at the center point and L = the span between niques that used interfragmentary lag screws, resulting
supports. Results for all fixation techniques were sta- in less calculated energy absorbed to yield for these
tistically similar, but strength of the intact proximal techniques.
phalanges in the control group was significantly greater Failure modes for each configuration were observed
(p < 0.00 I). A dorsal plate alone was similar to a plate visually and documented photographically during test-
bending test and the standard deviation was small, al- ing to failure in apex palmar three-point bending. Prox-
lowing for a statistical difference in strength between imal phalanges fixed with a dorsal plate alone failed by
The Journal of
676 Black et al. HAND SURGERY
Table I. Calculated moment at yield, energy absorbed to yield, and fracture site angulation at yield of fixation
techniques
Moment at yield Energy absorbed to yield Fracture site angulation
(Nn'S) (joules) at yield (degrees)
simple bending of the plate with no contribution from nized that the fracture configuration often dictates the
the bone. Dorsal plates combined with an interfrag- technique used and that the optimum rigidity and
mentary lag screw failed in the cortical purchase of the strength for fracture healing are unknown. 2 -5 . 10 Bio-
lag screw, which then allowed bending of the plate. mechanical analysis also does not assess factors such
Metaphyseal or epiphyseal fractures did not occur in as the extent of soft tissue dissection required or the
any of the plated specimens. Fixation with two inter- need for subsequent hardware removal.
fragmentary lag screws failed in the cortical purchase Our results showed that both techniques that used
of one screw, allowing rotation about the other screw. interfragmentary lag screws across the oblique osteo-
Techniques that used interfragmentary lag screws al- tomies provided significantly more rigidity than did dor-
lowed minimal angulation at the fracture site at failure. sal plating alone or the wired configurations. Results
The tension band technique failed by sliding of the from the strength tests including maximum bending
Kirschner wires in their bony channels with the flexible moment and moment at yield were not statistically dif-
figure of eight wire at a mechanical disadvantage on ferent among the fixation techniques tested. Dorsal
the compression surface. No untwisting of the flexible plates alone were at a mechanical disadvantage on the
wires occurred. Crossed Kirschner wires failed by slid- compression surface in our apex palmar bend test and
ing and twisting of the stiff wires in their bony channels. therefore only provided rigidity and strength compa-
Failure occurred through sliding and not bending of the rable with the wired techniques. The tension band tech-
Kirschner wires. nique in our phalangeal model and testing mode rep-
resented a combination of stiff and flexible intraosseous
Discussion wires, and tension band principles were not strictly
We compared the stability provided by five com- applied. The use of the tension band technique resulted
monly used fixation techniques in proximal phalanges in intermediate rigidity and strength. Similar results
after oblique osteotomy. Standard mechanical tests might be expected with other techniques not tested that
were performed to determine apex palmar bending ri- involve multiple wires or combinations of stiff and flex-
gidity, yield and maximum bending moment, and en- ible intraosseous wires. 9 . 11-13.16 Rigidity and strength in
ergy absorbed and angulation at yield. No standard an equal number of intact proximal phalanges in the
formula exists for weighing each of these factors in control group were significantly greater than that found
arriving at an overall stability; thus it is best to judge in all fixation techniques tested. Fracture site angulation
each separately. Values for intact proximal phalanges allowed at yield was the least with the techniques that
were also studied to establish a normal range. If early used an interfragmentary lag screw, resulting in less
joint motion is desired, restoration of stability com- calculated energy absorbed to yield for these tech-
parable with intact bones would seem desirable. Our niques. Failure modes were also observed and docu-
study used an oblique osteotomy that allowed for ap- mented for all techniques tested and differed signifi-
plication of interfragmentary lag screws, whereas all cantly.
previously published studies on internal fixation in the Fyfe and Mason's8 work on fixation in proximal pha-
hand have used a transverse osteotomy. Significant dif- langes has been widely quoted in the field of hand
ferences in the stability provided by the various fixation surgery. Their choice of an apex palmar cantilever bend
techniques evaluated were found. It should be recog- test is appealing, but rigid and reproducible fixation of
Vol. IIA, No.5
September 1986 Stability of internal fixation in proximal phalanx 677