Mallet Fracture a Novel Approach

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http://jhs.sagepub.com/Journal of Hand Surgery (European Volume)

http://jhs.sagepub.com/content/32/1/24The online version of this article can be found at:

DOI: 10.1016/j.jhsb.2006.09.007

2007 32: 24J Hand Surg Eur VolL. C. TEOH and J. Y. L. LEE

Mallet Fractures: A Novel Approach to Internal Fixation Using A Hook Plate

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M A L L E T F R A C T U RE S : A N O V E L A P P R O A CH T O I N T E R N A LF I X A T I O N U S I N G A H O O K P L A T E

L. C. TEOH and J. Y. L. LEE

From the Department of Hand Surgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore

A new treatment of mallet fractures of the distal phalanx is presented. Open reduction and internalfixation was performed using a hook plate fabricated from a 1.3 mm AO hand modular systemstraight plate. This technique avoids the need to place implants or wires through the small avulsionfragment while still being able to achieve a stable tension-plate type of fixation construct strongenough to allow protected early active motion of the distal interphalangeal joint. In minimising theneed for prolonged splinting, patient comfort is also improved. In a consecutive series of ninefractures, union was achieved in all cases. At an average follow-up period of 17 months, four hadexcellent and five had good results using the Crawford rating scale. Using the Warren and Norrisscale, all patients had a successful result. The final average active range of flexion of the distalinterphalangeal joint was 641 and there was no extensor lag.Journal of Hand Surgery (European Volume, 2007) 32E: 1: 2430

Keywords: mallet fracture, mallet finger, distal interphalangeal joint fracture, open reduction internal fixation, tension

plate

Although a wide variety of both open and percutaneoussurgical techniques have been described for the treat-ment of mallet fractures, accurate anatomic reductionand stable fixation of mallet fractures remains one of themost challenging operations in hand surgery. Commonproblems with existing pin, wire or screw techniquesinclude loss of reduction, recurrent subluxation, pinmigration, wire cut-out and the common requirementfor prolonged transarticular K-wire splintage andconsequent inability to initiate early motion of the

distal interphalangeal joint.We report a new surgical treatment of mallet fractures

of the distal phalanx. Open reduction and internalfixation was performed using a hook plate fabricatedfrom a 1.3 mm AO hand modular system straight plate.This technique avoids the need to place implants orwires through the small avulsion fragment while stillbeing able to achieve a stable tension-plate type offixation strong enough to allow protected early activemotion of the distal interphalangeal joint.

MATERIALS AND METHODS

Nine mallet avulsion fractures of the distal phalanxtreated by open reduction and internal fixation using ahook plate fabricated from a 1.3 mm AO modularhand system (Mathys, Bettlach, Switzerland) titaniumplate were included in this study. All of the cases wereperformed consecutively without selection by the samesenior hand surgeon.

Our surgical indications included fractures involvingmore than one third of the articular surface, fracturesassociated with palmar subluxation of the distal phalanxthat could not be corrected by closed reduction and

mallet fragments, which had migrated proximally to asignificant degree.

Over a period of 2 years and 6 months, from October2002 to June 2005, nine such displaced mallet fractureswere identified and treated by open reduction andinternal fixation using the described hook plate techni-que (Table 1). There were seven men and two womenwith a mean age of 35 (range 2441) years. The fingersaffected were three little fingers, one ring finger and fivemiddle fingers. Five injuries were due to sport, two were

industrial injuries and two were domestic accidents. Theaverage time from injury to operation was 18 (range630) days.

Pre-operative lateral X-rays of the finger were used todetermine the presence of palmar subluxation of thedistal phalanx, fragment displacement and fragment size(Fig 1). Anteriorposterior radiographs were used toexclude comminution. The average percentage articularsurface involvement was 53% (range 2870%). Six caseshad palmar subluxation of the distal phalanx and threedid not. The fractures were classified by the Wehbe andSchneider (1984) method (Table 2), which is based onanalysis of the lateral X-rays (Table 3). There were three

Type IB, five Type IIB and one Type IIC fractures.Postoperatively, serial lateral and antero-posteriorX-rays were taken immediately after operation, at 3weeks, 6 weeks, 3 months and 6 months, to determinetime to healing and evidence of malunion or non-union.Clinical data collected included range of motion andextensor lag at the DIP joint, tender dorsal prominencesat the attachment of the extensor tendon to the base ofthe distal phalanx and complications.

Functional outcomes were determined using theCrawford (1984) criteria and the Warren and Norris(1988) criteria, both of which use loss of extension to

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evaluate outcome (Table 3). The normal range of DIPjoint motion was not clearly stated in either Crawfords(1984), Abouna and Browns (1968) or Warren andNorriss (1988) papers, yet this was used in the definitionof an excellent or successful result. Moiemen and Elliot(2000) found, in their study of all eight fingers in 40normal individuals, that the average range of motion ofthe DIP joint was 691 in men and 791 in the women, withan overall average for both sexes of 741. Theyrecommended that this figure be used as the normal

range of motion of the DIP joint. In our study, 701 ofDIP joint flexion was considered full and an activerange of motion of 601 or more was considerednormal. Presence of persistent pain or residual

stiffness would preclude a good result.

SURGICAL TECHNIQUE

Five cases were performed under general anaesthetic,one under regional (inter-scalene brachial plexus block)anaesthesia and three under local digital block (Table 1).A curvilinear transverse dorsal incision is made and aflap raised (Fig 2a). The extensor tendon overlying thedistal interphalangeal joint is exposed. The fracture siteis exposed and freshened. The fragment is often rotateddue to traction by the attached extensor tendon (Fig 2b)and this should be corrected by anatomic alignment ofthe articular surfaces at reduction (Fig 2c). Thereduction is held in position using the tips of a forcepsuntil the placement of the hook plate.

A two-hole 1.3 mm AO modular hand systemtitanium straight plate is used to fashion the hook plate(Fig 3a). One of the holes is cut to remove a third of itscircumference and the ends of the remaining crescent arebent through approximately 1001 to form two pointedhooks (Fig 3b).

The plate is placed and secured with a 1.3 mm modularscrew (Fig 2d). The hooks plant themselves into thetendon substance and grip the dorsal lip of the fracturefragment. There is only 1 mm between the distal end of the

extensor tendon insertion and the proximal end of thegerminal matrix (Shum et al., 2000). A sub-periostealelevation of the proximal margins of the germinal matrixwill allow the plate to sit directly on the bone without riskof disrupting the germinal matrix. The relationship of theplate and screw construct to the nail matrix elements andfracture site is illustrated in Fig 4. The screw is directedtowards the palmar surface of the base of the distalphalanx to allow the screw head to sit flush with the plate.This affords good purchase. Stability of the fixation istested on table prior to closure by light passive flexion ofthe distal interphalangeal joint. Gapping at the fracture

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Fig 1 Case 2. Lateral radiograph demonstrating a Wehbe and

Schnieder classification Type IIB, displaced large fragment

mallet fracture with subluxation.

Table 1Mechanisms of injury and surgical details

Pt. Age Sex Finger Mechanism of injury Injury to operation interval (days) Anaesthetic/operation time (minutes)

1 31 M Right middle Rugby 28 GA/60

2 38 M Left middle Basketball 17 RA/30

3 37 M Right little Domestic 12 GA/20

4 37 M Right middle Industrial(/electrician) 23 GA/35

5 32 F Left ring Netball 6 LA/40

6 40 M Left middle Football 25 LA/40

7 31 F Right little Boating 30 GA/55

8 24 M Right middle Industrial 7 RA/25

9 41 M Right little Domestic 10 GA/35

LA: local anaesthetic, GA: general anaesthetic, RA: regional anaesthetic (brachial plexus block).

Table 2The Wehbe and Schnieder classification of mallet fractures

Type Wehbe and Schneider classification of Mallet fracture injuries

(1984)

Definition Subtype Articular

surface

I No DIP joint subluxation A o1/3

II DIP joint subluxation B 1/32/3

I II Ep iph yse al and p hys eal in jur ies C 42/3

MALLET FRACTURES: A NOVEL APPROACH TO INTERNAL FIXATION 25



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site or loss of screw purchase would require adjustment ofthe construct, reinsertion of the screw at a different angleor supplementation with a transarticular K-wire. This wasnot required in this series. Postoperative radiographs aretaken to check for fracture reduction, correction of

subluxation, screw placement and length (Fig 5). Atemporary extension splint (tongue depressor or alumi-nium splint) is included in the operative dressings until acustomised removable thermoplastic splint can be fabri-cated on the first postoperative day.

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Table 3Fracture gradings and outcomes

Patient Finger WehbeSchneider classification Outcomes

Subluxation

(yes/no)

% Articular

involvement

Type Follow-up

(months)

DIPj range of

movement (degrees)

Crawford

assessment

Warren Norris

assessment

1 Right middle Yes 57 II B 13 060 Good Success

2 Left middle Yes 57 II B 10 070 Excellent Success

3 Right little No 58 I B 7 070 Excellent Success

4 Right middle No 35 I B 10 070 Excellent Success

5 Left ring Yes 50 II B 37 070 Excellent Success

6 Left middle Yes 70 II C 15 060 Good Success

7 Right little Yes 40 II B 22 060 Good Success

8 Right middle No 57 I B 32 060 Good Success

9 Right little Yes 60 II B 6 060 Good Success

Fig 2 (ad) Clockwise from top left. (a) surgical exposure via a transverse curvilinear incision raising a full thickness flap provides sufficient

exposure for fracture reduction and placement of implants. (b) The fracture fragment is often rotated by the pull of the terminal extensor

tendon. The articular surfaces must be realigned accurately. (c) Reduction is held in place with a forceps. (d) The completed fixation

construct using the modified 1.3 mm modular hand plate and a single screw.

THE JOURNAL OF HAND SURGERY VOL. 32E No. 1 FEBRUARY 200726



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Postoperatively, a thermoplastic Stack splint (Stack,1986) is fabricated and applied on the first postoperativeday. This splint is removed for 10 minutes every hour formobilisation. The patient is taught active DIP joint flexionexercises (making a full fist), which are continued for thefirst 2 weeks. At the end of week 2, the patient begins activeDIP joint flexion exercises while holding the PIP jointextended with the opposite hand. No passive stretching is

allowed. The Stack splint is replaced after therapy andworn continuously during daytime activity and whilesleeping. This programme of protected mobilisation iscontinued for a period of 6 weeks (Fig 6). Splints areremoved completely during the day at the end of 6 weeks.

RESULTS

The average follow-up was 17 (range 637) months. Allnine fractures were united by 6 weeks after surgery, withcongruous joint surfaces.

The average final active range of flexion of the distalinterphalangeal joint was 641 (range 601701) andextensor lag was not noted in any of these cases.

All of mallet finger fractures had an excellent or goodresult. Using the Crawford (1984) criteria, four patientswere graded excellent and the remaining five had goodresults. Using the Warren and Norris (1988) classifica-tion, success was achieved in all cases (Table 3).

There were no implant complications, infections ornail deformities. Dorsal soft-tissue swelling over the DIPjoint was, common and was, sometimes, tender. How-ever, this did not cause functional impairment andresolved over time. There was no residual pain by thetime of final assessment.

Although not mandatory, implant removal wasplanned for all cases in accordance with our localpractice and at the time of article submission, this hadbeen performed in all but two cases. The range of flexionwas preserved and there was no deterioration inextensor lag after removal of implants.

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Fig 3 (a) The hook plate is cut from a straight AO 1.3 hand modular system titanium plate in the following manner. (b) The plate is shown in top

and profile views.

Fig 4 Diagram of the relationship between the plate/screw construct, the fracture and the nail matrix elements.




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Long-term results with regard to degenerative arthri-tis are not available from this series.

DISCUSSION

Mallet injuries are avulsions of the terminal extensortendon, from the base of the distal phalanx, with orwithout a bony fragment. The disruption of the terminalextensor mechanism results in a characteristic flexiondeformity of the distal interphalangeal joint. Theseinjuries are commonly encountered in ball-related sportsinjuries from axial loading or a forceful flexion of theextended digit (Mc Cue and Meister, 1993). Inadequatetreatment can result in extensor lag, significant swanneck deformity and early osteoarthritic changes(Garberman et al., 1994; Wehbe and Schneider, 1984).

Surgical treatment is advocated for avulsion fracturesinvolving more than one-third of the articular surface,

for persistent subluxation or fragment displacementwhich cannot be adequately reduced by full extension ofthe distal interphalangeal joint in a splint (Damronet al., 1993; Doyle, 1999). Some authors (Lange andEngber, 1983; Niechajev, 1985) propose that, at least, acongruent articular arc without subluxation should beachieved, while others (Hamas et al., 1978; Stark, 1970)argue that accurate anatomical reduction and internalfixation of displaced fragments is necessary to prevent

joint deformities, post-traumatic arthritis and stiffnessin the three circumstances stated immediately above.Lubahn (1989) compared surgical and non-surgicaltreatment and concluded that surgical treatment

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Fig 5 (ab) Lateral and AP X-rays demonstrating the placement of the

plate/screw construct.

Fig 6 (ac) An early result: the active range of motion of the distal interphalangeal joint at 6 weeks was 01701.




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provided cosmetically and functionally better resultsthan did closed treatment, especially in large displacedfragments with subluxation. Nonetheless, the manage-ment of mallet fractures remains controversial becauseno single treatment modality, whether conservative orsurgical, has achieved consistently excellent results interms of eliminating deformity, stiffness, arthritis andcomplications (Damron et al., 1993).

A variety of surgical techniques have been describedincluding open reduction and K-wire fixation (Hamas,1978; Stark, 1970; Takami et al., 2000), tension bandwire (Bischoff et al., 1994; Damron and Engber, 1994;Jupiter and Sheppard, 1987), tenodermodesis (Iselinet al., 1977), pull-out steel wires (Damron and Engber,1994) and screw fixation (Kronlage and Faust, 2004;Sakaue et al., 1986). Percutaneous pin fixation (Fritzet al., 2005; Tetik and Gudemez, 2002; Yamanaka andSasaki, 1999), percutaneous extension block pinning(Hofmeister et al., 2003; Inoue, 1992; Ishiguro, 1988)

and percutaneous compression fixation pins (Penniget al., 1994; Yamanaka and Sasaki, 1999) have also beenused to try to minimise surgical complications whileimproving fragment reduction.

Some deficiencies in existing techniques were high-lighted in a biomechanical study by Damron et al.(1993) comparing four common techniques of malletfracture fixation, using K-wire (Wehbe and Schneider,1984), figure-of-eight wire (Hamas, 1978), tension bandwire and tension band suture. This study demonstratedsignificantly higher energy absorbed to failure and atrend towards greater peak loads to failure for bothfigure-of-eight wire and tension band suture techniques.Irreversible loss of reduction during testing occurred inall K-wire fixed fractures, in 60% of tension band wirefixations and in 50% of figure-of-eight wire-fixedfractures (Damron et al., 1993). Rigidity adequate toallow early motion was not achieved by any techniquetested and all four techniques are applied with transar-ticular K-wire splintage. Migration of the K-wire splint,leaving the primary mode of internal fixation unpro-tected, was not uncommon (Damron et al., 1993). Thesefindings suggest that a tension band type of fixation,which was strong enough not to require transarticularsplintage, would be ideal.

Reported postoperative complication rates of malletfractures ranged from 3% to 53% (Auchingloss, 1982;

Kang et al., 2001; Nakamura and Nanjyo, 1994; Sternand Kastrup, 1988) and included marginal skin necrosis,loss of surgical reduction, recurrent extension lag, naildeformities, joint incongruities, pin track infection andosteomyelitis, implant failure and joint deviation. Sternand Kastrup (1988) have suggested, however, thatcomplication rates differ significantly between differentoperative techniques: with composite K-wiring andtransarticular pinning being associated with the highestsurgical complication rate, while pullout wires withtransarticular pin fixation yielded the lowest complica-tion rate in their series.

In our own practice of pin, wire and screw-onlytechniques for mallet fractures, we have encounteredsimilar problems of K-wire migration, wire cut-out orslippage of bone on the smooth pins, leading to a loss ofreduction, and fragmentation of the dorsal fracturefragment following implant placement. In addition, themajority of techniques require percutaneous transarti-cular pin splintage, which does not allow early jointmobilisation and requires meticulous pin care withregular dressings.

To address these concerns, we devised a hooked plate,which can be easily adapted from existing implants. Theplate is fabricated from an AO 1.3 mm two-holetitanium modular plate using the method describedabove, to form two hooks at one end. This technique (1)allows anatomical reduction of the fracture, (2) avoidsthe need to place implants through the small dorsalfragment, risking fragmentation, (3) utilises a biome-chanically superior tension plate/band principle, (3)

affords stable fixation, obviating the need for trans-articular pinning and allowing early mobilisation and (4)improves patient comfort, acceptability and compliance.

This limited study was designed to document theresults of a new technique of open reduction andinternal fixation of mallet fractures in situations wherethis was indicated. During this period, other methods ofinternal fixation were not routinely used and, thus, nocomparisons between techniques can be made. This wasintended as a small series reporting our early results andhas a short average follow-up of 17 months. At 46months, fracture union may be ascertained and thepresence of any recurrent subluxation excluded. Rangeof motion and symptoms have usually stabilised or willcontinue to improve. However, a longer follow-upwould be required to assess the incidence of osteoar-thritis.

Not all authors agree as to the significance ofachieving anatomical reduction in mallet injuries assubstantial remodelling can occur and the DIP jointcontributes less to the full arc of movement of the fingerthan the proximal joints. Open reduction and internalfixation using the hook plate, allows early motion andcan provide acceptable functional results in suitablecases. However, it is technically demanding. While therewere no complications from the use of the hook platein this series, our numbers are small and it is acknowl-

edged that the potential for fixation failure and collapse,as well as development of postoperative adhesions,leading to stiffness, could lead to poor outcomes andsignificant disability.

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Received: 3 January 2006Accepted after revision: 5 September 2006

Dr Lam-Chuan Teoh, Senior Consultant Surgeon and Clinical Associate Professor,

Department of Hand Surgery, Singapore General Hospital, Outram Road, Singapore

169608, Singapore. Tel.: +656321 4588; fax: +65 63213573.

E-mail: [email protected]

r 2006 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights

reserved.

doi:10.1016/j.jhsb.2006.09.007 available online at http://www.sciencedirect.com

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