PIP Dorsal Fracture Dislocation - Everything You Need To Know - Dr. Nabil Ebraheim скачать в хорошем качестве

PIP Dorsal Fracture Dislocation - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes the PIP dorsal fracture dislocation Proximal interphalangeal (PIP) dorsal fracture dislocation can be challenging in management. With PIP dorsal fracture dislocation, there is involvement of the articular surfaces of the joint. These injuries are the most disabling PIP joint injuries (fellowship level). Reduction of the middle phalanx on the condyles of the proximal phalanx is the primary goal of treatment. The patient frequently presents with a chronic dorsal subluxation due to delay in seeking treatment or from failed treatment. Anatomy: 85% of motion from grasping objects occurs at the PIP joint. The PIP joint has the largest arc of motion (120 degrees ) of the three joints in each digit. Mechanism of injury: three types: 1- Hyperextension: the size of the fragment can range from a small piece of bone up to 30% of the joint surface with minimal communition (usually stable). Treatment: test the stability, apply dorsal blocking splint. Observe the lateral view for any subluxation. 2- Impaction shear: produced by an axial load applied to a slightly extended or flexed PIP joint. The middle phalanx is driven over the head of the proximal phalanx with comminution and impaction of the base of the middle phalanx. Loss of the volar plate tether. Loss of the palmar 50% of the middle phalanx base will make the PIP joint unstable. The extensor tendon and superficialis tendon will aggravate the dorsal subluxation. The splints are inadequate if the injury is not stable. Includes skeletal traction and early range of motion. ORIF if the fragment is large enough. Palmar plate arthroplasty: advance the palmar plate into the defect. Support the palmar plate by filling the defect behind it with fracture chips or bone graft or by superficialis slip. Chronic cases: difficult problem, can do arthrodesis or volar plate arthroplasty. 3- Pylon: a pylon fracture results from axial force that fractures the volar and dorsal articular surfaces with impaction of the central part. A pylon fracture is not a true fracture dislocation will result in a bad outcome. Use dynamic external rotation to help in ligamentotaxis. Allow early range of motion to help remodeling of the joint. Depends on the degree of involvement of the articular surface. Classification (Hastings): depends on the degree of involvement of the articular surface. Type I: stable,30% Type II: tenuous = 30-50% Type III: unstable less than 50% Treatment: dorsal extension blocking splint if the PIP can be reduced in less than 30% of flexion, if 40% joint involved and stable. (Type I or Type II- decrease flexion gradually every week). Type III ORIF, volar plate arthroplasty, hemi-hamat great, if 40% joint involved and unstable. Hemi-hamate graft: the damaged palmar lip of the middle phalanx with a size matched portion of the hamate bone obtained from its distal dorsal articular surface between the 4th and 5th metacarpals. It restores both articular congruity and osseous stability. Extension block pinning: this technique is described and is probably helpful. Treatment must provide stable reduction allowing early mobilization. Stability of the reduction depends on the size of the avulsed fragment and the amount of the ligament remaining attached to the middle phalanx. If less than 40% of the articular segment is avulsed, some of the collateral ligament will be intact. This will keep the reduction stable. If more than 40% of the articular segment has avulsed, only very little or no ligament will remain attached to the base of the middle phalanx, rendering the reduction unstable. Recognizing subluxation: AP and lateral x-rays are necessary for diagnosis. An AP view will help to recognize impaction fractures. Subluxation can be missed on x-rays. Look for the characteristic “V” sign of diverging joint surfaces, which indicates injury and subluxation. Indication for nonoperative treatment: if reduction of the avulsion fracture is achieved with less than a 30-degree bend, nonoperative treatment is a good choice. However, if it takes more than 30 degrees of flexion to reduce the fragment, this may be an indication for surgery. Become a friend on facebook:   / drebraheim   Follow me on twitter: https://twitter.com/#!/DrEbraheim_UTMC Background music provided as a free download from YouTube Audio Library. Song Title: Every Step