Ab

Figure 41-8 A, Radiograph of a proximal phalanx fracture. B, Radiograph after reduction.

thus creating "ice cream on the tip of a cone" effect. Intraarticular fractures that are nondisplaced (<1mm) or minimally displaced dorsal or volar chip avulsions may be treated with splinting and early ROM. Radiographs must be checked frequently to ensure that there has been no change in the fracture position.28 Surgical indications include displacement of the joint surface of greater than 3 mm, fractures involving greater than 40% of the articular surface, or comminuted fractures with large fragments. Occasionally pins are placed across the PIP joint. Rotational alignment is crucial, especially in children. If the fracture fragment is large, then screw fixation can be entertained, but the surgeon must be careful not to devascularize the condyle during the operative approach. Return to sports can be expected at 4 to 6 weeks.

Middle Phalanx Fractures

The middle phalanx (MP) is usually protected from a fracture by its hard cortical nature. Also, the distal and PIP joints help to absorb the blow. When fractures do occur, they usually are from a direct blow and create an oblique or transverse fracture. There are forces acting on the MP, which are dependent on where the fracture occurs, that will cause angulation of the phalanx. If the fracture occurs distal to the flexor digitorum profundus insertion, this will cause a volar apex angulation of the fracture due to the pull of the flexor tendon on the proximal fragment. If the fracture occurs proximal to this location, angu-lation will be dorsal secondary to the pull of the central slip on the proximal portion of the MP and the flexor tendon distally29 (Fig. 41-9).

For nondisplaced fractures, early return to sports with buddy taping is permitted. Three weeks of continuous splinting is usually necessary.30,31 If volar angulation is greater than 30 degrees, this must be corrected in order to avoid an extensor lag or a swan neck deformity. Also, angulation should be less than 10 degrees in the anterior/posterior plane, shortening less than 2 mm, and bone apposition greater than 50% if nonoperative interphalangeal joint motion is begun, and K wires are removed at 3 weeks and protection for another 3 weeks in a splint is recommended.

Midshaft Proximal Phalanx Fractures

With midshaft proximal phalanx fractures, there is minimal soft-tissue disruption; thus, the fractures are usually stable. Rotational stability is conveyed by the fibro-osseous tendon sheath, specifically the A-2 pulley. Nondisplaced fractures are treated with buddy taping the injured finger to the adjacent digit and early ROM. Displaced fractures are reduced by traction and digital flexion, causing a tension band effect through the dorsal mechanism. ROM is initiated by 3 weeks with progression to full motion by 4 to 6 weeks. For unstable fractures, closed reduction and internal fixation, open reduction with screws and/or plate and screws, or external fixation can be used for sta-bilization27 (Fig. 41-8). Return to sports can be anticipated at 2 to 4 weeks.

Condylar Fractures of the Proximal Phalanx

Fractures involving the condyles (unicondylar or bicondylar) often require surgery to restore the articular surface. These fractures frequently rotate and are difficult to hold in a reduced position due to the phalanx narrowing in the subcondylar area,

Middle phalanx

Figure 41-9 A, Fracture proximal to flexor digitorum superficialis insertion, dorsal angulation. B, Fracture distal to flexor digitorum superficialis insertion, volar angulation. (From Hastings, Rettig, Strickland: Management of Extra-articular Fractures of the Phalanges and Metacarpals. Philadelphia, Elsevier, 1992.)

Middle phalanx

Figure 41-9 A, Fracture proximal to flexor digitorum superficialis insertion, dorsal angulation. B, Fracture distal to flexor digitorum superficialis insertion, volar angulation. (From Hastings, Rettig, Strickland: Management of Extra-articular Fractures of the Phalanges and Metacarpals. Philadelphia, Elsevier, 1992.)

treatment is employed. Closed reduction and percutaneous pinning, screws, or plate and screws may be chosen when operative intervention is necessary.32,33

Distal Phalanx Fractures

More than half of all fractures of the hand occur at the distal phalanx.34 The distal phalanx of the long finger is most commonly involved, followed by the thumb.35 Unique to the distal phalanx is the tuft. The tuft anchors specialized skin and the complex nail matrix and plate. Fibrous septae radiate from the bone to the skin to form a dense meshwork that stabilizes the fracture and prevents displacement. Most injuries occur as a result of a direct blow or a crushing injury.

With a nondisplaced fracture, it is important to protect only the distal phalanx (e.g., a tip protector or splint) and to allow PIP motion. A tip protector should extend distal to the tip to protect this area from external trauma. Occasionally displaced fractures require closed reduction and pinning (Fig. 41-10). Usually a wire is placed across the distal interphalangeal joint for approximately 3 weeks.

Displaced fractures or fractures beneath the nail plate suggest that there has been damage to the nail fold. In this instance, some recommend that even if the nail plate is intact, it should be removed and the nail bed repaired. If a subungal hematoma is present, it is not only beneficial to relieve this pressure, and, in the case of hematomas involving greater then 50% of the nail plate, some recommend removal of the nail plate and repair of the nail bed.

These fractures can have significant morbidity with as many as 31% of the fractures still nonunited and 70% of patients with residual tenderness at 6 months. Most injuries that involve the distal phalanx will allow the athlete to return to sports rapidly with splinting.

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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