Surgical Management

Closed reduction under general anesthesia was attempted in the operating room on the day of injury but was unsuccessful. Open reduction was performed through a volar zigzag incision over the ring finger metacarpal extending up to the PIP flexion crease. The digital neurovascular bundles were identified and retracted. The base of the proximal phalanx was found to be displaced volar and radial to the flexor tendons. There was an articular fragment missing from the radial base of the proximal phalanx (Fig. 50—3). The volar plate and collateral ligaments were no longer attached to the proximal phalanx, but were found dorsal to the proximal phalanx. The base of the proximal phalanx was trapped between the flexor tendons on the ulnar side, the lumbrical on the radial side, and the volar plate on the dorsal side.

The A1 pulley was incised and the flexor tendons returned to their normal position volar to the proximal phalanx. The base of the phalanx was then easily reduced. An interosseous wire was placed through drill holes to secure the fracture fragment to the base of the phalanx, restoring anatomic alignment (Fig. 50—4). The volar plate was reattached to the proximal phalanx with 4—0 Prolene passed through the periosteum and flexor tendon sheath at the lateral edges of the A2 pulley. After reduction and repair, the MP joint was stable through a passive range of motion between 0 and 90 degrees of flexion.

After skin closure, a short arm cast was applied with the wrist in slight extension, the MP joints in flexion and the PIP joints fully extended.

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