Surgical Management

Closed reduction under intravenous sedation was attempted in the emergency department by flexing the wrist and applying pressure to the dorsal base of the index proximal phalanx. No change in alignment was achieved. The patient was taken to the operating room for open reduction on the same day.

Open reduction was performed under general anesthesia through a dorsal approach. Surgical exposure was gained through an ulnarly based triangular flap over the dorsal aspect of the index MP joint. The ulnar sagittal band was incised and the extensor tendon retracted radially. The dorsal joint capsule was incised longitudinally to expose the joint. There was a 5 X 6 mm chondral fragment attached by soft tissues to the dorsal aspect of the metacarpal neck (Fig. 49—3). The fragment was reflected proximally, revealing the base of the proximal phalanx with the volar plate attached and interposed over the metacarpal head. The proximal portion of the volar plate was incised longitudinally in the midline. The proximal phalanx was then easily reduced with pressure over the dorsal aspect of the base. The MP joint remained reduced from 0 to 90 degrees of flexion and there was no laxity of the collateral ligaments with the joint flexed.

The chondral fragment was reduced and stabilized by closing the dorsal joint capsule. The ulnar sagittal band was repaired. The skin was closed in layers with buried subcuticular sutures. The hand was immobilized in a volar splint with the MP joints in 60 degrees of flexion and the interphalangeal joints extended.

Chondral Fracture
Figure 49—3. Dorsal view of the index metacarpophalangeal joint, showing the chondral fracture fragment.
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