Surgical Management

In the unlikely event that the joint cannot be reduced, as in the case presented here, surgery is necessary to remove the structure blocking reduction. This is most often due to the interposed volar plate, which is still attached to the distal phalanx. Other reported causes include entrapment of the FDP tendon, buttonholing the volar plate, and osteochondral fractures.

The surgery can be performed under metacarpal block as described above. A dorsal H or Y incision is centered over the DIP joint (Fig. 48-2). The extensor tendon is retracted and the volar plate can be teased back over the head of the middle phalanx with a Freer elevator.

Joint stability is then tested as described above, and because the patient is awake and under a digital block, he can demonstrate active and passive motion. Radiographs are likewise obtained.

In the case presented, the joint was explored as described and the volar plate was blocking the reduction. Once the joint was reduced, however, it still had a tendency to sublux. Therefore, a 0.035-inch Kirschner wire (K wire) was placed across the joint with the joint in extension (Fig. 48-3).

Figure 48—3. Lateral radiograph after open reduction and pinning of DIP joint.

Postoperatively, the K wire was removed at 3 weeks and active and passive motion was started. It is important to have the patient moving the metacarpophalangeal (MP) and PIP joints during the time the DIP joint is immobilized.

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