Surgical Management

The arm was prepped with antiseptic soap, draped with a sterile field, exsanguinated, and the tourniquet elevated to 250 mm Hg for less than 2 hours. Disposable, sterile plastic finger traps with a traction tower provided distraction of the MP joint.

We used the minifluoroscopy unit to locate the exact location of the joint to minimize the chance of cartilage injury while establishing joint portals (Fig. 43—1). Using minifluoroscopic assistance, we marked the proposed dorsal-ulnar and dorsal-radial portals on the skin and used a free 19-gauge needle to locate the entry portals. We longitudinally incised the skin at the sites identified by the free 19-gauge needles. We were careful to incise only the skin and not the underlying tissue, as dorsal sensory nerves can cross through the area of the portals. We then performed blunt dissection with a small hemostat to the level of the joint

Fracture The Base Proximal Phalanx
Figure 43—1. Minifluoro-scopic view of index finger base of proximal phalanx fracture. Fracture involves 50% of articular surface.

capsule and used the hemostat to carefully spread the joint capsule and enter the joint.

The direct visualization of arthroscopy and the direct removal of tissues blocking reduction aid in reduction of intraarticular fractures. We established standard dorsal portals with the arthroscope in one portal and a shaver initially placed in the second (Fig. 43—2). We improved visualization by performing a partial synovectomy with a 2.5-mm shaver. We debrided the fracture surfaces with minicurettes, occasionally reducing traction to allow for easier fracture fragment debridement and reduction. After fracture alignment under arthroscopic vision (Fig. 43-3), the fracture surfaces were temporarily stabilized with a 0.045-inch Kirschner wire (K wire) (Fig. 43-4). This guidewire can also serve as a joystick to assist in fracture reduction. We used arthroscopy to confirm intraarticular reduction and minifluoroscopy to visualize the architectural alignment of the metaphyseal and diaphyseal fragments. We used interfragmentary-cannulated screws to stabilize the fracture fragments (Fig. 43-5). Other forms of fixation include K wires and/or a condylar buttress plate placed percutaneously. After fracture sta-

Figure 43—4. Minifluoroscopy (A) and photograph (B) showing hemostat-assisted temporary Kirschner wire fixation of fracture.

bilization, we removed longitudinal traction and performed a fluoroscopic exam of the digit through a full arc of motion to confirm stable fracture fixation and unimpeded motion. We closed the portals with a single stitch of 4—0 nylon suture and dressed them with a compressive dressing.

Figure 43—5. (A) Minifluoroscopy of reduced fracture with cannulated screw in place. (B) Arthroscopic intraarticular view of reduced fracture.

Arthroscopy is the perfect tool to apply these principles to intraarticular fractures around the MP joints. Recently we presented our work on the effectiveness of arthroscopic assisted fracture reduction for the MCP joint. This study documented fewer complications and improved final range of motion when compared with fractures treated with standard open reduction. Fractures of both the base of the proximal phalanx and the head of the metacarpal can be accurately reduced and repaired through small incisions. In pediatric cases, Salter type III physeal fractures have been reduced and secured without further injury to the growth plate.

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