PIPJ Trauma
2 Training Program
•FO's clinic experience with the Micro Screw and Nx Nail - how
these offerings provide a new solution to hand trauma.
•Extra articular metacarpal fractures (27 cases per month, $600k
pa).
•Avulsion fractures (24 cases per month, $360k pa).
•Extra articular phalanx fractures (11 cases per month, $264k pa).
•PIPJ and intra-articular phalanx fractures (16 cases per month,
$240k pa).
•Base of thumb (10 cases per month, $180k pa).
• Carpal fractures (5 cases per month, $72k pa). 2
Hand Trauma is Changing
What we now know?
4 Hand Trauma has Changed
• Faster and simpler operations,
• Reduced operative morbidity (faster
return to function with less stiffness),
• Less soft tissue damage, and
• Stronger smaller constructs.
5 Traditional Solutions Are Failing
Newington–
“accurate anatomic reduction of the fracture it-self is not
required, provided a congruous and concentric reduction”.
* now challenged
• Literature suggests little observed difference.
• Data regularly confounded as even minor injuries
can afflict adhesion and misalignment quickly
leads to abnormal wear and stiffness.
• Stiffness is the highest concern.
• Traditional treatments all subject patients to
immobilization.
• Non-operative management has a high total cost
of care and more involved follow-up.
Multi-modal stiffness inducing factors–
Fibrotic inducing inflammation, soft tissue insulting
surgical techniques and prolonged immobilisation.
6 Principals
• Anatomical reduction of the articular surface.
• Maintain length.
• Correct rotation.
• Restore version (angulation).
• Stabilise fragments so union can occur.
• ?Minimise insult to the soft tissues.
Additional:
• Return to activity (decrease morbidity).
• Restoring “normal function”
• Minimising follow up complexity, burden and cost.
The PIPJ
Complex Anatomy and Significant
Stiffness
Significance
8 - Most dislocated joint, over 20% arthritis
>50% - 78.7% M
- 35.9% Sport
- 44.7% Football/ Epicentre of movement (85% gasp
25% Basketball vs 15% DIPJ).
- 16.8% Dark skinned
Positioned 50% along the digital
chain.
Long proximal/distal lever arms
vulnerable.
>20/100K fracture, 4.6-11.11/100K
dislocation.
Often mistaken for being minor,
delaying presentation.
Treatment associated issues
thought to be under appreciated or
reported.
– “every case of delayed or non-healing fracture, there could be
* 2.5 x Base : Condyle at least 100 permanently stiff fingers”
* >50% Base fractures are dislocated
Key Structures
9 - complex hinge
• ROM: 100-110o flexion, 0-10o extension, <5o sagittal
motion, 9o rotation. Greater ROM in ulnar/throughout
flexion.
• Constraints: Volar lip and facet of P2, congruent with
condyles. Proper and accessory collaterals, volar plate and
extensor hood.
• Capsule: No true joint capsule.
• Extensor hood: highly vulnerable to stiffness, however must
be repair (if damaged) to avoid boutonniere deformity .
• Collaterals: Literature stats will regenerate (3 months).
Stiffness – from immobilisation, from hypertrophic
callus or operative inflammation.
10 Dislocation
Subluxation–
requires failure of the bony attachments or volar plate and at
least one collateral ligament.
• Biomechanics: decreased surface area, increased joint
pressure. Most glide and not hinge.
• Basal buttress: essential static stabilisation (and
insertion of volar plate). >40% likely effects all or most
of the collaterals. Size often understated on x-ray.
• Arthritis: 16-27% incidence (13-40% F).
O’Rourke suggested a reduced joint could potentially
remodel however 17% became arthritic.
• Non-op: fragment <25% minimally displaced (<2mm)
11 Stiffness
Time to movement–
time to treatment and restoration of motion is the most
significant variables reduce stiffness.
*>3 weeks will permanently impact the joint.
• Goal: restore anatomy, preserve function and early return
to activities
• Aim: early stability, limit soft tissue damage and enable
early mobilisation.
• Stable: extra articular o(or min incongruity), <10°
angulation, <2mm shortening, reducible and stable with no
rotational deformity.
• Volar: palmar approach lower risk of stiffness.
• Function: functional AROM 36°-86°, patients suggested to
tolerate 15-20° of flexion contracture
* contractures further impact extensor strength.
Stiffness – from immobilisation, from hypertrophic
callus or operative inflammation.
Reduction
Application of anatomical knowledge
13 Reduction
• An application of applied anatomy. Deforming forces
are opposed through manual techniques that respect
the anatomical structures.
• Key manoeuvres include:
• Applying traction and joint flexion will reduce to the volar lip.
• Blocking wires can be placed dorsally to pin P2, and
• Whilst the volar fragment can be pinned percutaneously or fixed
directly.
• Definitive fixation is as per the surgeons preference,
with modern options commonly involving lag screws.
*Depending on the fracture pattern fixation can occur via a mini
open, respecting the flexor tendons and directed by x-ray.
14 Surgical approach
• Volar approach: Strong evidence suggesting best outcomes seen in a
volar approach. Caution required of the vincular arteries.
• Less stiffness: On average 10-15° less contracture.
• Shotgun approach: complete and direct visualisation of the joint
surface possible.
*no observed evidence suggesting increased risk of stiffness.
* The surgical approach will initiate an inflammatory cascade that promotes additional fibroses
and adhesion. Consideration and care is needed to maximise results.
Construct Choices
The quest to cure without stiffness
16 Treatment Options
17 Implant performance Pinning Plates Lag
Screws
Ex-fix
Dissection Minimal Extensive Variable Minimal
Operation time Approx 30 >60 30-50 Approx 30
Immobilization 3 weeks 3 week 3 week* 3 week
Short term 15% 15% * 15%
Complications
2nd Operation 100% >60% 4% 100%
Step defect 27% 20-30% <5% Most
Arthritis 16-27% 30% * 60%
ROM 83o 8-87o 83-105o 79o
Return to work >8 weeks >8 weeks * >8 weeks
18 Pinning
• Proposed as an alternative to splinting to
decrease reliance on patient compliance.
• High morbidity and extensive follow up
required. Pinning through the extensor
complex has been associated with increase
stiffness.
• 15% pin tract infections, ROM 83o.
• Time off work >2months, 27% step defects.
• Once preference in small fragments however
wires 1.2-1.4mm which is larger the the pilot
holes for modern cannulated screws.
Morbidity –
“psychological impact of pin fixation often cited as a concern.”
Total cost of care is not significantly different to other
treatment methods.
19 Ex-Fix
• High cost of all treatment options. Noted
implant cost, extensive hand therapy
• Limited applications. Unable to maintain
reduction in full extension (restrict to 20o)
• Suzuki frame, gained popularity due to
reduced cost and sparring of extensor
apparatus.
• Complications. short term similar to pinning;
long term 60% arthritis.
• Time off work >2months, ROM 79o.
Selection Bias–
Often used for most serve (communited) cases, hence hard to
compare reported data.
20 Platting
• High cost of all treatment options. Noted
implant cost, extensive hand therapy
• Function. Volar buttress (dorsal platting
should be avoided).
• Mechanics, strength lacking (0.6-1.0mm
plates fixed with 1-3 non-locking screws).
- plate bending 20-50N.
- screw failure 50-100N.
- construct strength 20-100N.
* needs 30o blocking splint to augment.
• Complications. Most/all get stiff (PIPJ + DIPJ).
40-60% implant removal, 20-30% arthrolysis,
30% progress to arthritis.
• Time off work >2months, ROM 8-87o.
21 Lag Screws
• Modern volar screw use has best outcome
data. ROM 83-105o
• Modern screws are designed for
percutaneous use and fragment fixation. The
availability of 1.5/2.0mm cannulated lag
screws addresses past problems (distraction
and operative efficiency).
• Early usage highly confounded.
• Mechanics, strength lacking (0.6-1.0mm
plates fixed with 1-3 non-locking screws).
- pull out 100N.
- bending 1.5x pull out. Native Bones Fracture approximately 482.8N +/- 104.8N
- Increase performance with screw placement.
*dorsal > 2 x volar
• Recommended in factures without
comminution.
22 Clinical Examples
- Control and options
ORIF ORIF/Hemi-hamate
A small and strong repair suitable for fragments 4mm Volar approach provides the option for direct ORIF or conversion to hemi
diameter or more. Buttressing the volar lip with >100N hamate. Same approach and fixation configuration with the buttressing force
construct strength with great visualisation. The 0.6mm wire provided via strong thread engagement, in contrast to a thin extra-cortical
simplifies the management of lip fragments. plate.
Thank You
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24
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Micro Screw
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