Operative Technique in Plastic Surgery – Kevin C.Chung

• Test the proper collateral in 20 to 30 degrees of flexion at the MCP joint: 30
degrees of deviation or more than 15 degrees compared to the contralateral
side is diagnostic for a UCL tear.
• Compare to the contralateral thumb.
• Gross instability with the joint held in MCP extension heralds disruption of
both the accessory and proper collateral ligaments and may obviate the need
for MRI imaging.
IMAGING
■ AP and lateral radiographs of the thumb should be obtained to determine if
there is an avulsion fracture of the UCL and to rule out dislocation and/or
concomitant fractures of the phalanx or metacarpal. Always review radiographs
prior to provocative ligament stress testing to ensure that a nondisplaced
avulsion fracture is not displaced through the examination effort.
■ Stress radiographs of the thumb may be diagnostic for UCL tear.
■ Advanced imaging including ultrasound or MRI may confirm the presence of
a complete rupture of the UCL and/or Stener lesion.
■ Ultrasound has an accuracy of approximately 80% for detecting a complete
tear of the thumb UCL.4
■ MRI has a sensitivity and specificity approaching 100% for complete tears.5
DIFFERENTIAL DIAGNOSIS
■ Metacarpal or proximal phalanx fracture
■ Contusion
■ Ligament strain/sprain
■ MCP dislocation
■ MCP arthritis
NONOPERATIVE MANAGEMENT
■ Indications for nonoperative treatment include incomplete or partial tears as
well as nondisplaced avulsion fractures.
■ Understanding when the injury occurred is important as acute injuries are
better suited for nonoperative management.
■ Nonoperative treatment consists of immobilizing the thumb MCP joint. A
forearm-based thumb spica cast is effective regardless of patient compliance
and is recommended, for a minimum of 6 weeks for an avulsion fracture and 8
weeks for a soft tissue injury.

■ Patients can elect nonoperative treatment for complete tears; however, healing
may be less reliable.
■ Landsman et al. reported that 85% of patients with an acute complete rupture
of the thumb UCL and who were treated in a cast for 3 months reported no
signs of pain or instability.6
SURGICAL MANAGEMENT
■ Indications
■ Instability greater than 30 degrees with the thumb in 20 to 30 degrees of
flexion represents injury to the proper collateral ligament.
■ Instability greater than 30 degrees with the thumb in extension represents
injury to both the proper and the accessory collateral ligament.
■ Instability that is 15 degrees greater than the contralateral side
■ Palpation of a Stener lesion (retracted UCL ligament residing proximal to the
adductor aponeurosis)
■ A bony avulsion with significant displacement that results in laxity to stress
testing
■ Lack of a firm endpoint on examination
Preoperative Planning
■ The surgeon should be prepared and comfortable to both repair or reconstruct
the UCL.
■ Despite an acute tear, a midsubstance rupture may require reconstruction.
■ Some reported acute injuries actually represent a reaggravation of prior
trauma making the UCL untenable for successful reattachment.
■ Suture anchors and a drill should be available.
■ Presence of the palmaris longus tendon should be established.
Positioning
■ The patient is placed in the supine position with the arm on a radiolucent table.
■ The surgeon typically sits in the axilla to allow the best visualization of the
ulnar aspect of the thumb.
Approach
■ The UCL is approached through either a straight or a curvilinear dorsal-ulnar
incision.
■ If a nonstraight incision is chosen, then the distal aspect should follow a gentle

volar path to facilitate access to the insertion of the UCL on the proximal
phalanx.
T E C H N I Q U E S
■ Acute Repair of the Ulnar Collateral Ligament7
Exposure
■ The incision is centered over the MCP joint (TECH FIG 1A).
■ Careful blunt dissection is carried out down to the extensor
mechanism/adductor aponeurosis. The dorsal sensory nerves are identified
and gently retracted (TECH FIG 1B).
■ The adductor aponeurosis may be incised just off of the extensor pollicis
longus or be removed as much as 5 mm. Preserving the distal portion of the
adductor aponeurosis as it merges with the extensor pollicis longus facilitates
later closure. Leaving the confluence of the adductor aponeurosis and the
extensor pollicis longus intact allows for these structures to be closed in a
distal to proximal manner essentially “pulling the zipper” in a retrograde
manner (TECH FIG 1C).
■ The aponeurosis is carefully dissected off of the underlying capsule. In
chronic injuries, this step becomes more challenging but is often made easier
if the adductor aponeurosis is identified in a location slightly more distal than
the joint itself and dissected away from the capsule/UCL ligament complex.
■ The capsule is then incised and the injured UCL identified (TECH FIG 1D).
In most cases, the UCL is ruptured/avulsed from the proximal phalanx.
■ The articular cartilage is inspected for degenerative changes, which, when
present, represent a contraindication to UCL repair/reconstruction (TECH
FIG 1E).
Suture Placement and Closure
■ The proximal phalanx insertion site is debrided to ensure bleeding bone, and
a suture anchor is placed at the center of the insertion site (TECH FIG
2A,B).
■ The stump of the UCL tendon is trimmed back to healthy-appearing tissue

and sutured to the bone using the sutures from the anchor. Additional 3.0
Vicryl sutures are placed between the UCL ligament and the
periosteum/capsule that is just distal to the site of ligament insertion. One or
two of these sutures can augment the biomechanical integrity of the repair
(TECH FIG 2C,D).
■ The adductor aponeurosis is closed using nonabsorbable suture in a
retrograde manner (TECH FIG 2E).
■ The skin is closed using 4-0 nylon sutures.
TECH FIG 1 • A. Planned incision for treatment of
ulnar collateral ligament injuries. The curvilinear
nature allows access to the insertion of the proper
collateral ligament, which is along the volar edge of
the proximal phalanx. B. The skin is incised and blunt
dissection carried out down to the extensor
mechanism. Sensory nerve branches may be crossing
the incision in this location and must be identified and
protected. C. The adductor aponeurosis is incised 5
mm from the extensor pollicis longus, leaving a cuff for
later repair. D. The stump of the ulnar collateral

ligament is identified (arrow). Most tears/avulsions
occur off the proximal phalanx, but the surgeon must
ensure that there is not a midsubstance or proximal
rupture. E. The joint is inspected for signs of
degenerative changes. Degenerative changes are a
contraindication to repair and/or reconstruction.

TECH FIG 2 • A. The proximal phalanx insertion site is
debrided, and the drill is used to create the hole for
the suture anchor. B. The suture anchor is placed. C.
The sutures are passed through the proper ulnar
collateral ligament and tied to restore the insertion
footprint. D. The ulnar collateral ligament is repaired.
E. Closure of the adductor aponeurosis is performed
using absorbable sutures. Care is taken to not suture
to the extensor pollicis longus, but rather to the cuff of
tissue adjacent to the tendon.

■ Reconstruction of Chronic Tear Using Palmaris
Autograft (Tunnel Technique)
Exposure
■ The same incision is made for a repair or a reconstruction effort (TECH FIG
3A).
■ Careful blunt dissection is carried out down to the extensor
mechanism/adductor aponeurosis. Dorsal sensory nerves are identified and
retracted (TECH FIG 3B).
■ The adductor aponeurosis is incised just as it would be for a repair and
carefully dissected off of the underlying capsule (TECH FIG 3C).
■ The capsule is then incised and the unrepairable remnant of the ulnar
collateral ligament is identified and excised (TECH FIG 3D).
■ The articular cartilage is inspected for the presence of degenerative change.
Significant damage is a contraindication to UCL repair/reconstruction.
TECH FIG 3 • A. Planned curvilinear incision for ulnar
collateral ligament reconstruction. B. Blunt dissection

is carried out down to the level of the extensor
mechanism and adductor aponeurosis. Care is taken
to identify and protect sensory nerves. C. The
adductor aponeurosis is incised and carefully elevated
off the underlying capsule. A 5-mm cuff of tissue
adjacent to the extensor tendons is left for later repair.
D. In the case of a chronic collateral ligament tear,
there is usually very little tendon identified. The origin
(white arrow) and insertion (black arrow) of the proper
ulnar collateral ligament are identified and debrided.
Palmaris Tendon Harvest
■ A 1-cm longitudinal or transverse incision is made over the distal wrist
crease (TECH FIG 4A).
■ The palmaris longus is isolated and a Ragnell retractor placed under the
tendon.
■ Traction is placed on the palmaris longus and its course traced proximally.
■ A longitudinal or transverse incision is made 10 cm proximal to the wrist
crease.
■ The palmaris longus is isolated here and transected. Blunt dissection is used
to free connections between the underlying tissue.
■ The palmaris is pulled through the distal wound and transected distally
(TECH FIG 4B).
TECH FIG 4 • A. The palmaris longus tendon is
palpated and skin incisions planned. B. The palmaris

is identified distally and divided. It is then pulled out of
the wound proximally and divided to obtain maximum
length.
■ The palmaris longus should be trimmed to no smaller than 2 to 3 mm in
width.
Creating Bone Tunnels and Inserting the Tendon Graft
■ A 2.0-mm drill bit is used to make a hole at the insertion of the proper
collateral ligament on the proximal phalanx (TECH FIG 5A).
■ Recognize that the insertion is about 3 mm dorsal from the volar-most edge
of the proximal phalanx and about 3 mm distal from the joint line.
■ Leaving a generous bone bridge, a second hole is made dorsal to the first
hole.
■ Proximally, a single hole is made (using the same 2.0-mm drill bit) at the
isometric point on the metacarpal head (at the origin of the proper collateral
ligament).
■ Two additional holes are made more proximal and dorsal to the hole at the
proper collateral origin.
■ A curette may be used to both gently enlarge and connect the holes to allow
for easier passage of the graft.
■ A 4-0 nylon suture or Hewson suture passer is used to shuttle the palmaris
autograft through the bone tunnels. The 4-0 nylon needle is secured by the
needle driver at its tip and a loop created through which the graft is passed.
The same technique can be used to efficiently pass the graft through all of the
drill holes (TECH FIG 5B).
■ The palmaris is first passed through the tunnels in the proximal phalanx.
■ Both limbs are then passed through the isometric tunnel on the metacarpal
head.
■ One limb is then passed through its respective tunnel on the dorsum of the
metacarpal.
■ The MCP joint is reduced and the tendon limbs tightened. The limbs are
sutured to each other using a nonabsorbable 3-0 suture.
■ The adductor aponeurosis is closed using absorbable suture (TECH FIG
5C).
■ The skin is closed using 4-0 nylon horizontal mattress sutures.

TECH FIG 5 • A. The bone tunnels are planned to
reconstruct the proper collateral ligament. A 2.0-mm
drill bit is used to make a hold at the insertion site of
the proper collateral ligament. The insertion is
approximately 3 mm distal to the articular surface and
3 mm dorsal to the volar edge of the proximal phalanx.
A second hole is placed in line with the first hole but 5
mm dorsal. The same 2.0-mm drill is used to make a
tunnel at the isometric point on the metacarpal head
and then two additional tunnels proximal and dorsal to
allow passage of the autograft. B. The construct after
passage of the graft through the tunnels. The proximal
phalanx is to the left and metacarpal to the right. C.
The aponeurosis is closed using absorbable sutures.
■ Reconstruction of Chronic Tear Using Palmaris
Autograft (Anchor Technique)

■ The aforementioned surgical approach is followed, but instead of using bone
tunnels, two anchors are employed.
■ A K-wire is placed into the center of the UCL origin on the metacarpal head
(TECH FIG 6A).
■ A 3.5-mm cannulated drill hole is placed over the K-wire to enlarge the hole.
■ An Arthrex DX SwiveLock 3.5 mm × 8.5 mm forked tip anchor is used. The
palmaris graft is placed over the fork, and the anchor is then seated into the
bone. An Arthrex FiberTape suture can be incorporated with the repair for
added strength (TECH FIG 6B,C).
■ A K-wire is placed into the center of the UCL insertion on the proximal
phalanx base. The center of the insertion is approximately 4 mm from the
dorsum of the metacarpal and 5 mm proximal to the articular surface (TECH
FIG 6D).
■ A 3.5-mm cannulated drill hole is placed over the K-wire to enlarge the hole.
■ The palmaris autograft is then placed over the forked tip on a second Arthrex
DX SwiveLock anchor (TECH FIG 6E).
■ It is important to leave a little bit of slack as the ligament will tighten as the
anchor is seated into the bone.
■ Prior to tightening the screw anchor, check stability and range of motion of
the MCP joint.
■ Once satisfied with the tension in the graft, range of motion, and stability,
tighten the anchor.
■ The free ends of the autograft are excised (TECH FIG 6F).
■ The adductor aponeurosis is closed using nonabsorbable suture.
■ The skin is closed in the usual manner.

TECH FIG 6 • A. The guide wire is placed at the
isometric point on the metacarpal head. B. The anchor
is used to secure the graft and additional suture into
the metacarpal head. C. After the graft and suture has
been secured. D. The guide wire is placed into the
insertion site on the proximal phalanx. E. The suture

anchor is again used to secure the graft and suture
down into the proximal phalanx. F. The construct after
the extra tendon and suture has been removed.
PEARLS AND PITFALLS
Dorsal sensory
nerve
■ Carefully dissect and gently retract the dorsal sensory nerves.
Graft tension
■ When repairing or reconstructing the UCL with bone tunnels,
ligament tension may be maximized without overtightening the
MCP joint as time-dependent soft tissue properties allow for
dissipation of undue graft tension. Thumb stiffness is avoided as
long as the MCP joint is flexed 30 degrees while being
immobilized in the postoperative setting.
Adductor
aponeurosis
■ Leave the distal confluence of adductor aponeurosis with
extensor pollicis longus tendon intact so that precise closure
may be accomplished. Careful “teasing away” of aponeurosis
from UCL/scar/capsule is important to ensure that the adductor
aponeurosis maintains its biomechanical integrity when securely
reattached to the extensor pollicis longus tendon.
Degenerative
changes
■ Degenerative changes are a contraindication to UCL repair
and/or reconstruction. A fusion should be performed.
Placement of
anchors/tunnels
on proximal
phalanx
■ Remember that the insertion of the proper UCL is volar, only 3
mm dorsal to the volar edge of the proximal phalanx.
Restoration of both proper and accessory collateral ligaments is
ensured when bone tunnels are placed.
Postoperative Care
■ A well-molded plaster thumb spica cast is placed. Care is taken to avoid any
valgus force imparted to the MCP joint.
■ The MCP joint is best held in 30 degrees of flexion status post repair or
reconstruction effort. Due to “cam” appearance of metacarpal head, the
ligament is tighter in flexion and may become unable to stretch out in patients

who are immobilized and then heal in full extension.
■ At the 2-week visit, the wound is inspected and patient placed in either a
removable thermoplast splint or a short-arm thumb spica cast for an additional
4 weeks.
■ Thumb IP joint and finger motion is encouraged.
OUTCOMES
■ Operative treatment results in good to excellent results in over 90% of
patients.
■ Glickel et al. reported on 26 patients who underwent thumb UCL
reconstruction using free tendon graft at an average of 3.9 years’ follow-up.
■ The authors reported excellent results in 20 patients, good results in 4
patients, and fair results in 2 patients.
■ The operative thumb averaged a 10% increase in laxity compared to the
nonoperative thumb and yet retained 80% of its arc of motion.
■ Mild or intermittent pain with heavy use was reported in 8/26 thumbs; the
remainder reported no pain.
COMPLICATIONS
■ Thumb stiffness particularly when the MCP joint was immobilized in full
extension.
■ Persistent instability, which is more likely in a repair rather than a
reconstruction effort.
■ Injury to the radial sensory nerve during exposure and/or retraction.
■ Fracture of the metacarpal and/or proximal phalanx when creating bone
tunnels or during anchor placement.
■ Degenerative changes of the MCP joint over time.
REFERENCES
1. Carlson MG, Warner KK, Meyers KN, et al. Anatomy of the thumb
metacarpophalangeal ulnar and radial collateral ligaments. J Hand Surg [Am].
2012;37(10):2021-2026.
2. Tsiouri C, Hayton MJ, Baratz M. Injury to the ulnar collateral ligament of the
thumb. Hand (N Y). 2009;4(1):12-18.
3. Tang P. Collateral ligament injuries of the thumb metacarpophalangeal joint. J
Am Acad Orthop Surg. 2011;19(5):287-296.
4. Papandrea RF, Fowler T. Injury at the thumb UCL: is there a Stener lesion? J

Hand Surg [Am]. 2008;33(10):1882-1884.
5. Hergan K, Mittler C, Oser W. Ulnar collateral ligament: differentiation of
displaced and nondisplaced tears with US and MR imaging. Radiology.
1995;194(1):65-71.
6. Landsman JC, Seitz WH Jr, Froimson AI, et al. Splint immobilization of
gamekeeper’s thumb. Orthopedics. 1995;18(12):1161-1165.
7. Weiland AJ, Berner SH, Hotchkiss RN, et al. Repair of acute ulnar collateral
ligament injuries of the thumb metacarpophalangeal joint with an intraosseous
suture anchor. J Hand Surg [Am]. 1997;22(4):585-591.

10
CHAPTER
Closed Reduction and
Fixation of Bennett and
Rolando Fractures
John R. Fowler and Thomas B. Hughes
DEFINITION
■ A Bennett fracture (FIG 1A) is defined as an intra-articular base of the thumb
metacarpal fracture consisting of a volar-ulnar fragment that is attached to the
anterior oblique ligament.1
■ A Rolando fracture (FIG 1B) is defined as a comminuted intra-articular
metacarpal base fracture.1 The fracture is often a T- or Y-type pattern.
ANATOMY
■ The base of the thumb metacarpal has a saddlelike shape to accommodate its
articulation with the trapezium. The articular surface is convex when viewed
posterior to anterior and concave when viewed from lateral to medial.2
■ The abductor pollicis longus inserts along the lateral edge of the metacarpal
base.
■ The anterior oblique ligament originates from the volar beak of the thumb
metacarpal and inserts onto the trapezium (FIG 2).2
■ The dorsal ligament complex is the strongest and thickest ligament complex
around the thumb CMC joint. It consists of the dorsal radial and posterior
oblique subligaments. If the dorsal ligament complex is disrupted, the joint is
unstable even if the anterior oblique ligament is intact.2
■ The intermetacarpal ligament runs transversely from the index metacarpal to
the thumb metacarpal.
PATHOGENESIS
■ Bennett fractures are caused by an axial load on the partially flexed thumb

metacarpal.
■ The anterior oblique ligament is attached to the volar-ulnar fragment and the
trapezium (FIG 3). This holds the volar-ulnar fragment in place while the
metacarpal base subluxates.
■ The metacarpal base is displaced in a dorsal, radial, and proximal direction.
■ Bennett fractures are classified using the Gedda classification (FIG 4).
■ Rolando fractures are the result of an axial load on the thumb metacarpal that
has a pilon effect on the articular surface.
NATURAL HISTORY
■ As with other intra-articular fractures, articular congruity results in
symptomatic arthritis at long-term follow-up.3
■ Fractures that are not reduced result in chronic instability, pain, and decreased
function.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ History should document the acuity of the injury, as chronic injuries may be
less amenable to closed reduction.
■ Patients typically describe a fall onto the thumb with axial loading.
Alternatively, athletes may report a jamming-type injury from either a ball or
contact with another player or the ground.
FIG 1 • PA radiographs demonstrating a Bennett
fracture (A) vs a Rolando fracture (B).

FIG 2 • Anatomy of the thumb carpometacarpal joint
with special focus on the anterior oblique ligament and
dorsal ligament complex.
■ There is often significant soft tissue swelling and ecchymosis around the
thumb CMC joint.
■ Evaluate the thumb MP collateral ligaments, the EPL, EPB, and FPL.
■ Active and passive thumb motion is painful. There may be crepitus of the

CMC joint.
FIG 3 • The deforming forces in thumb metacarpal base
fractures result in the characteristic radial displacement
of the metacarpal shaft.

FIG 4 • The Gedda classification for Bennett fractures.
Type I: large volar-ulnar fragment with subluxation of
the thumb metacarpal. Type II: impaction of the articular
surface without subluxation of the thumb metacarpal.
Type III: avulsion of volar-ulnar metacarpal with
dislocation of thumb metacarpal.
IMAGING
■ One must obtain at true AP (Robert’s view) and true lateral radiograph (Bett’s
view) to assess the amount of articular incongruity.1
■ A true AP is obtained by maximally pronating the forearm and placing the
dorsum of the thumb on the cassette.
■ A true lateral is obtained by pronating the forearm 20 degrees and placing the
lateral border of the thumb on the cassette. The x-ray beam is angled 10
degrees distally.
■ Computed tomography is not routinely needed for thumb metacarpal base
fractures.
NONOPERATIVE MANAGEMENT
■ Closed reduction and thumb spica casting is indicated for articular step-off of
less than 1 mm.

■ Because of comminution and articular incongruity, Rolando fracture is
typically not treated nonoperatively.
SURGICAL MANAGEMENT
■ Indications for surgery:
■ Articular step-off more than 1 mm4
■ Inability to reduce joint subluxation by closed reduction
Preoperative Planning
■ The surgeon should be prepared to perform both closed reduction and open
reduction as indicated by operative findings.
■ Have mini-fragment plating system and K-wires available.
Positioning
■ The patient is placed in the supine position with an upper arm tourniquet.
■ The surgeon should sit at the axilla and assistant opposite.
■ This allows the surgeon the ability to drill K-wires into the index metacarpal
or trapeziometacarpal joint.
Approach
■ Fractures that require open reduction and internal fixation are typically
approached using the Wagner approach to gain access to the joint and fracture
fragments.
T E C H N I Q U E S
■ Closed Reduction and Pinning of Bennett and
Rolando Fractures
■ Longitudinal traction is placed on the thumb (TECH FIG 1A).
■ The thumb is then abducted and pronated to reduce the fracture.
■ Reduction is confirmed using fluoroscopy.
■ A 0.045-in. K-wire is then drilled either into the trapezium or into the index
metacarpal (TECH FIG 1B–D).
■ A second K-wire is used if reduction to the index metacarpal is performed.

■ Rolando fractures can also be treated with traction and pinning if alignment
can be restored with traction. Pinning of individual fragments is typically not
successful because there is often significant comminution.

TECH FIG 1 • A. Illustration demonstrating the

reduction maneuver for Bennett fractures. Longitudinal
traction and abduction is performed. The surgeon’s
thumb places direct ulnar pressure on the base of the
metacarpal, and the thumb is then pronated. B. PA
radiograph demonstrating typical Bennett fracture. C.
PA radiograph after pinning. D. Oblique radiograph after
pinning.
■ Open Reduction and Internal Fixation of Bennett
Fractures
■ The Wagner approach is used.
■ The incision is made along the radial border of the thumb between the
glabrous and nonglabrous skin.
■ Blunt dissection is performed down to the fascia overlying the thenar
musculature. Branches of the palmar cutaneous branch of median nerve and
branches of the dorsal radial sensory nerve are identified and carefully
retracted.
■ The thenar muscles are elevated off of the metacarpal.
■ A longitudinal incision is made in the thumb CMC joint capsule.
■ Do not strip the individual fragments of their soft tissue attachments.
■ The fracture is reduced under direct visualization using ligamentotaxis and/or
a fracture clamp and stabilized using K-wires or mini-fragment screws. We
prefer to use 1.7-mm mini-fragment screws using a lag technique (TECH FIG
2).
■ A K-wire can be placed between the thumb metacarpal and index metacarpal
to relieve compression stresses on the fracture site.
■ Anatomic reduction of the joint surface is confirmed with direct visual
inspection.
■ The capsule is closed using nonabsorbable sutures and the skin is typically
closed using interrupted nylon horizontal mattress sutures.

TECH FIG 2 • A,B. Preoperative PA and lateral
radiographs demonstrating Bennett fracture. C,D. PA
and lateral radiographs after open reduction and
internal fixation with lag screws.

■ Open Reduction and Internal Fixation of Rolando
Fractures
■ The Wagner approach is used.
■ The exposure is similar to the approach above for Bennett fracture.
■ A longitudinal incision is made in the thumb CMC joint capsule.
■ Do not strip the individual fragments of their soft tissue attachments.
■ The fracture is reduced under direct visualization using ligamentotaxis and/or
a fracture clamp. A 1.7- or 2.3-mm mini-fragment plate can be contoured and
used to stabilize the fracture fragments (TECH FIG 3).
■ A K-wire can be placed between the thumb metacarpal and index metacarpal
to relieve compression stresses on the fracture site.
■ One or more additional K-wires may be necessary to capture additional
fracture fragments or to pin the joint in distraction for stability.
TECH FIG 3 • A,B. PA and lateral radiographs
demonstrating a Rolando fracture. C. Illustration
showing placement of a 2.3-mm mini-fragment T-plate

to stabilize the intra-articular fragments.
PEARLS AND PITFALLS
Indications
■ Open reduction and internal fixation is indicated if there is more than
1 mm of articular step off after closed reduction.
Proper
imaging
■ Obtain true AP and lateral radiographs to accurately assess articular
step-off.
Hardware
■ Ensure that there are no intra-articular screws after ORIF.
Treatment
■ Perform the necessary procedure to restore articular congruity and
reduce metacarpal subluxation.
Approach
■ Perform the Wagner approach to visualize the joint surface and
directly visualize articular congruity.
POSTOPERATIVE CARE
■ Patients are immobilized in a nonremovable thumb spica splint for 2 weeks.
■ If closed reduction and pinning is performed, the patient is placed into a short-
arm thumb spica cast for 2 weeks.
■ The pin sites are examined at 4 weeks from surgery. If there is no erythema,
the pins are left for another 2 weeks.
■ If there is pin site irritation, the pins are removed and patient placed into
thumb spica cast for another 2 weeks.
■ If open reduction internal fixation was performed, the patient is placed in a
thumb spica cast at the 2-week visit for 4 weeks.
■ Hand therapy is started at 6 weeks to regain motion and strength.
OUTCOMES
■ Middleton et al.5 reported long-term outcomes of 62 patients who underwent
closed reduction and pinning of Bennett fractures at mean follow-up of 11
years. Mean DASH was 3, and 94% of patients were satisfied with their
outcome and none had undergone further surgery.
■ Griffiths6 followed 21 patients with Bennett fractures treated with closed

reduction and casting and evaluated at mean 6.8 years after treatment. More
than half of patients had lost reduction, but there was little correlation between
lost reduction and functional disability or symptoms.
■ Livesley3 reported on 17 patients at a mean follow-up of 26 years and noted
that all 17 had decreased motion and grip strength with radiographic evidence
of arthritis and subluxation.
COMPLICATIONS
■ Pin tract infections can occur if closed reduction and percutaneous pinning is
performed.
■ Post-traumatic arthritis with decreased motion and strength may develop
despite treatment.
■ Superficial sensory nerve injury may occur during open or percutaneous
treatment.
REFERENCES
1. Carlsen BT, Moran SL. Thumb trauma: Bennett fractures, Rolando fractures,
and ulnar collateral ligament injuries. J Hand Surg [Am]. 2009;34(5):945-952.
2. Edmunds JO. Current concepts of the anatomy of the thumb
trapeziometacarpal joint. J Hand Surg [Am]. 2011;36(1):170-182.
3. Livesley PJ. The conservative management of Bennett’s fracture-dislocation:
a 26-year follow-up. J Hand Surg Br. 1990;15(3):291-294.
4. Liverneaux PA, Ichihara S, Hendriks S, et al. Fractures and dislocation of the
base of the thumb metacarpal. J Hand Surg Eur Vol. 2015;40(1):42-50.
5. Middleton SD, McNiven N, Griffin EJ, et al. Long-term patient-reported
outcomes following Bennett’s fractures. Bone Joint J. 2015;97-B(7):1004-
1006.
6. Griffiths JC. Bennett’s fracture in childhood. Br J Clin Pract. 1966;
20(11):582-583.

11
CHAPTER
Section III: Joints
Volar Plate Arthroplasty of
the Proximal
Interphalangeal Joint
James T. W. Saunders and Amy M. Moore
DEFINITION
■ Volar plate arthroplasty (VPA) of the proximal interphalangeal joint (PIP)
involves the elevation and advancement of the volar plate in an attempt to
resurface the fractured articular region of the middle phalanx and reduce dorsal
subluxation of the PIP joint.
ANATOMY
■ A combination of bony constraints, the volar plate and the collateral ligaments
provide stability of the PIP joint (FIG 1).
■ The concave articular surface of the middle phalanx articulates with the
convex condyles of the proximal phalanx, allowing the joint to function as a
hinge.
■ The volar plate is a fibrocartilaginous structure that originates from the
proximal phalanx via two strong checkrein ligaments. It inserts distally to the
volar base of the middle phalanx. The volar plate resists PIP joint
hyperextension.
■ The proper and accessory collateral ligaments are the primary restraints to
radial- and ulnar-directed forces. The accessory collateral ligaments, situated
volarly, attach to the lateral margin of the volar plate as it crosses the joint.

FIG 1 • Anatomy of proximal interphalangeal (PIP) joint.
In this view of volar aspect of the joint, note the
relationship between the volar plate and collateral
ligaments. These structures create stability of the joint
and are often injured with PIP joint dislocations.
PATHOGENESIS
■ The strong volar plate is frequently injured in dorsal PIP dislocations and/or
hyperextension injuries of the PIP joint.
■ The most common injury is avulsion of the volar plate from the base of the
middle phalanx due to the strength of checkrein ligaments and attachments to
the accessory collateral ligaments.
■ The distal attachment often avulses a fragment of the base of the middle
phalanx (FIG 2).
■ Disruption of 40% to 50% of the volar articular surface of the base of the
middle phalanx can lead to joint instability (ie, dorsal subluxation of the
middle phalanx) requiring correction (FIG 3).1

FIG 2 • A. Illustration of volar plate avulsion with dorsal
PIP dislocation. B. The middle phalanx subluxes
dorsally, creating a V deformity of the dorsal joint. C. A
volar bone fragment is commonly avulsed with the volar
plate (arrow).

FIG 3 • Fracture stability. Fractures with 50% articular
involvement are inherently unstable. Fractures with
30% to 50% involvement are tenuous and need to be
evaluated closely for instability. Fractures of less than
30% tend to be stable.
NATURAL HISTORY
■ Disruption of the volar plate with or without an associated base of middle
phalanx fracture can lead to2:
■ Pain
■ Premature degenerative arthritis
■ Stiffness and loss of PIP joint motion
■ Persistent dorsal subluxation of the joint
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The most common cause of acute injury is an axial or dorsal load to the finger
leading to a dorsal dislocation. The patients will often report that their finger
was “jammed” or “dislocated.”
■ Patients most often reduce the joint themselves prior to presentation.
■ On physical examination:
■ Patients have ecchymosis, edema, decreased range of motion, and tenderness
located to the PIP joint.
■ Repeated dorsal dislocation on flexion of the PIP joint is characteristic of a
volar plate disruption.
■ Minimal resistance to hyperextension at the PIP joint is also suggestive of
volar plate injury.
• This is best tested under anesthetic block.

• Always compare to noninjured digits.
■ Acute or chronic development of a swan-neck deformity can suggest a volar
plate injury.
IMAGING
■ Appropriate preoperative radiographic imaging of the affected finger is
important to assess bony injury. These include AP and lateral radiographs (FIG
4A–C).
■ Radiographs in both flexion and extension allow the stability of the joint to be
assessed when volar base of middle phalanx fractures exist.
■ Preoperative live fluoroscopy is also useful to further assess stability of the
joint in real time.
■ Complex fractures can be evaluated with a high-resolution CT to evaluate
bony fragment size and location (FIG 4D).
■ In cases of acute or chronic instability without an underlying fracture, signs of
arthritic damage or malalignment should be evaluated.
NONOPERATIVE MANAGEMENT
■ Nonoperative management for PIP joint dislocations may be considered in
those patients with stable injury patterns (less than 30% articular surface
involvement).
■ Stability may be confirmed with a lateral radiograph of the PIP joint.
■ If mild subluxation of the PIP joint exists, the digit should be examined for
adequate reduction with the joint blocked in 15 to 20 degrees of flexion using a
dorsal blocking splint. If a dorsal blocking splint offers an adequate reduction,
conservative treatment can be pursued with close follow-up. If more than 60
degrees of flexion is needed to maintain reduction, surgical intervention should
be considered.

FIG 4 • A–C. Radiographs of the left ring finger
demonstrate a fracture-dislocation of the PIP joint with
dorsal subluxation. There is also a displaced intra-
articular fracture of the distal phalanx. D. A CT scan of
the affected digit can be obtained to evaluate the size
and number of bony fragments involving the middle
phalanx.
■ Treatment options for stable PIP joints include dorsal blocking splint, buddy
taping to a neighboring digit, and early motion. A figure-eight splint or silver
ring splint may also be used.
SURGICAL MANAGEMENT
■ For most PIP fracture-dislocations, joint reconstruction with a hemihamate
arthroplasty (HHA) has largely replaced the use of VPA because of the HHA’s
ability to restore near-anatomic alignment of the joint. However, the HHA is
technically demanding and has a steep learning curve. For inexperienced
surgeons, the VPA is a reasonable conservative option.
■ Indications:
■ Acute dorsal dislocation injury with gross instability
■ Acute fracture dislocation involving over 30% of the articular surface with
subluxation of the middle phalanx.
■ Chronic dorsal subluxation with failed conservative management

■ Osteoarthritis of PIP joint3
Preoperative Planning
■ Appropriate preoperative imaging is necessary to assess bony joint
quality/deformity.
■ The dorsal cortex must be intact to perform VPA.
■ Articular surface of the proximal phalanx must also be intact.
■ General, regional, or local anesthesia can be used.
FIG 5 • Skin markings to access the volar aspect of the
finger. A traditional Bruner incision is also acceptable.
Positioning
■ Patient is placed in the supine position with the affected limb abducted on a
radiolucent hand table.
■ Tourniquet is placed on upper arm or forearm.
■ A malleable lead/aluminum hand may be used to help retract the nonoperative
digits.
Approach
■ A volar approach through either a Chevron-shaped or Bruner-style incision is
based over the PIP joint (FIG 5).

T E C H N I Q U E S
■ Volar Plate Advancement for Base of Middle
Phalanx Fractures
Exposure
■ Exposure is planned from the A2 pulley to A4 pulley (TECH FIG 1A).
■ A2 and A4 pulleys are preserved, but the flexor tendon sheath between them
is incised and reflected.
■ A Penrose drain can then be looped around the exposed flexor tendons to
retract them, allowing visualization of the underlying volar plate (TECH FIG
1B).
■ With the volar plate exposed, the fracture can be visualized by
hyperextending the PIP joint.
■ Incise and free the lateral margins of the volar plate from the accessory
collateral ligaments with a Beaver or no. 15c blade.
TECH FIG 1 • A. The distal margin of A2 and the
proximal margin of A4 pulleys are identified (purple
dotted lines), and the flexor tendon sheath is reflected
laterally. The pulleys are maintained. B. The flexor
tendons are reflected laterally and secured with a
Penrose drain. The volar plate (VP) is incised and

reflected proximally to expose the joint.
■ The distal margin of the volar plate often maintains its attachments to the
fracture fragment, which can be sharply excised if necessary.
■ If not completely free, the volar plate is then divided transversely as distally
as possible to maximize the length of the now proximally based flap.
■ This can be done by first placing a Freer elevator under the volar plate to
identify the distal margin and then sliding a no. 15 blade under the volar
plate to divide it.
■ It is important to obtain a volar plate flap as long and broad as possible.
■ To further hyperextend or shotgun the joint (in cases of joint reconstruction),
the collateral ligaments must be released from the middle phalanx at this
point.
Preparation of the Middle Phalanx
■ The middle phalanx is then prepared with a rongeur to make smooth the
volar articular surface with careful maintenance of the dorsal articular surface
and cortex (TECH FIG 2A).
■ Two straight Keith needles are drilled through the middle phalanx base from
volar to dorsal angling them slightly distally (TECH FIG 2B).
■ Each needle is started laterally at the volar margin of the cartilaginous
surface and aimed toward the midline dorsally (toward the triangular
ligament) to avoid injuring the lateral bands or central slip on the dorsal
surface.
• Flexing the DIP joint as the K-wires are driven will help prevent the DIP
joint from being locked in extension if the extensor mechanism is caught
with the pull-through suture.
■ In the situation of a middle phalanx fracture, the needles are started at the
lateral margin of the remaining intact cartilaginous surface.
Passing and Setting the Suture
■ A Prolene or stainless steel suture is passed in a grasping fashion around the
fibrocartilaginous portion of the volar plate ending at the distal margin
(TECH FIG 3A).
■ After the needle is removed, the suture ends are fed through the holes in the
Keith needles.
■ The Keith needles are then manually pulled through the dorsal aspect of the

finger using a needle driver.
■ If both needles can be brought out through the same hole in the triangular
ligament, you can minimize the chance of injuring or entrapping the
extensor mechanism.
■ The suture is passed through a folded wad of petroleum-impregnated gauze
for skin protection before being passed through a button.
■ The suture tension is set temporarily over the button with the PIP joint
extended to 0 degrees (TECH FIG 3B,C).
■ Fluoroscopic images are taken to ensure an adequate reduction (TECH FIG
3D,E).
■ It is important to observe congruent joint surfaces through a full range of
motion on fluoroscopy.
■ If hinging (gapping over the dorsal cortex) is still present, consider further
advancement of the volar plate or releasing the dorsal joint capsule.
■ Once satisfied with positioning, the sutures can be permanently secured over
the button (TECH FIG 3F).
■ The lateral margins of the volar plate are then sutured to the adjacent
collateral ligament margins to restore three-dimensional stability.
■ In the case of a base of middle phalanx fracture, an oblique Kirschner wire is
placed to maintain 20 to 30 degrees of flexion and joint congruity.
TECH FIG 2 • A. Preparation of the middle phalanx
surface. The volar plate is reflected, and the dorsal

cortex and articular surface are maintained. B. The
dotted lines show the paths of the Keith needles for
the pull-through technique. The needles are angled in
a volar to dorsal direction toward the midline of the
finger. They are also angled slightly in a proximal to
distal direction to avoid injury to the central slip
dorsally.

TECH FIG 3 • A. Lateral aspect of the joint
demonstrating the Keith needle placement and locking
suture placement of volar plate. B. The sutures are
pulled through the middle phalanx and secured over a
button. C. The volar plate is tensioned symmetrically
(white arrow) to obtain joint congruity. D. Lateral
radiograph demonstrates dorsal subluxation following
a volar base of middle phalanx fracture. The middle
phalanx is subluxed dorsally creating a dorsal V sign
with overexaggeration of the dorsal joint space.

Approximately 30% of the articular surface is involved
in the fracture. E. Postreduction radiographs
demonstrate restoration of joint congruity using a
stainless steel wire with the volar plate arthroplasty. F.
A petroleum-impregnated gauze strip is used to avoid
injury to the underlying skin.
■ Correction of PIP Joint Instability Without a
Middle Phalanx Fracture
■ The procedure is similar to the volar plate arthroplasty for volar base of
middle phalanx fractures with the following differences:
■ A postreduction K-wire can be replaced with a dorsal blocking splint if the
reduction is maintained through a full arc of motion allowing for immediate
mobilization of the PIP joint.
■ Although the volar plate should still be separated from the collateral
ligaments, the collateral ligaments do not need to be divided as the joint is
not shotgunned open.
PEARLS AND PITFALLS
Fracture
characterization
■ Patients with volar base of middle phalanx fractures need
radiographs to assess the stability of the joint.
■ The dorsal cortex and articular surface must be intact.
■ The fracture pattern should be evaluated in flexion and
extension preoperatively.
■ Volar plate arthroplasty is appropriate for volar base of middle
phalanx fractures with greater than 40% of the articular surface
involved.
Timing
■ Operative management within the acute time period avoids
working against scar tissue.
Pull-through
wire placement
■ Volar placement of the wire and angled distal to central slip is
key to an adequate reduction.
■ Centralized dorsal placement of the wire will prevent
entrapment of the extensor mechanism.

■ Symmetric tension setting of the volar plate will ensure
adequate reduction.
Intraoperative
fluoroscopy
■ Joint congruity throughout a full range of motion
intraoperatively must be obtained and maintained.
Postoperative
care
■ Initiate early guarded range of motion to prevent flexion
contracture.
POSTOPERATIVE CARE
■ VPA for unstable volar base of middle phalanx fractures:
■ K-wire immobilization of the joint is maintained for 3 weeks.
■ DIP joint ROM is started immediately to promote tendon glide.
■ Active range of motion of the PIP joint is initiated 4 weeks following surgery.
■ Dynamic extension splinting is initiated if full extension has not been reached
by 5 to 6 weeks following surgery.
■ The button and suture are removed 5 to 6 weeks following surgery.
■ Buddy taping is initiated once the dorsal blocking splint is discontinued at 6
weeks.
■ Return to sporting activities is permitted at 8 weeks as long as buddy taping
is maintained.
■ VPA for nonfractured joints with restored congruency:
■ DIP and PIP range of motion is initiated the day after surgery with a dorsal
blocking splint in place under the guidance of a hand therapist.
■ The button and suture are removed 5 to 6 weeks after surgery.
■ Buddy taping is initiated once the dorsal blocking splint is discontinued at 6
weeks.
■ Dynamic extension splinting is initiated if full extension has not been reached
within 5 to 6 weeks after surgery.
■ Return to sporting activities is permitted at 8 weeks as long as buddy taping
is maintained.
OUTCOMES
■ Reported outcomes vary greatly, but two long-term follow-up papers
demonstrate maintenance of motion and stability of the reconstruction.
■ Eaton and Malerich in 1980 reviewed 24 patients over a 100-year period and
noted the following2:
■ An average of 95 degrees of motion and a 6-degree flexion contracture if

treated within 6 weeks from a fracture
■ An average of 78 degrees of motion and a 12-degree flexion contracture if
treated after 6 weeks from the date of fracture
■ Dionysian and Eaton reported their VPA results of 17 patients with an average
of 11.5 years’ follow-up and found4:
■ Patients with VPA within 4 weeks of injury maintained total active ROM of
85 degrees.
■ Patients with VPA after 4 weeks of injury averaged 61 degrees of active
ROM.
COMPLICATIONS
■ Complications are relatively uncommon with reports of patient satisfaction
rates as high as 94%.5
■ Complications can include the following:
■ Redisplacement: Due to failure to achieve a stable reduction or suture failure
■ PIP joint angulation: Commonly due to a failure to recognize or manage an
asymmetric fracture pattern
■ DIP joint stiffness: Failure to initiate early DIP motion or capturing the
extensor mechanism in the pull-through suture can lead to stubborn DIP
stiffness.
■ Flexion contracture: This is the most common complication and is due to
splinting or stabilization in excessive PIP flexion or failure to initiate
aggressive/hand therapist–supervised hand therapy at an appropriate interval.
REFERENCES
1. Calfee RP, Sommerkamp TG. Fracture-dislocation about the finger joints. J
Hand Surg [Am]. 2009;34(6):1140-1147.
2. Eaton RG, Malerich MM. Volar plate arthroplasty of the proximal
interphalangeal joint: a review of ten years’ experience. J Hand Surg [Am].
1980;5(3):260-268.
3. Burton RI, Campolattaro RM, Ronchetti PJ. Volar plate arthroplasty for
osteoarthritis of the proximal interphalangeal joint: a preliminary report. J
Hand Surg [Am]. 2002;27(6):1065-1072. doi: 10.1053/jhsu.2002.35871.
4. Dionysian E, Eaton RG. The long-term outcome of volar plate arthroplasty of
the proximal interphalangeal joint. J Hand Surg [Am]. 2000;25(3):429-437.
5. Durham-Smith G, McCarten GM. Volar plate arthroplasty for closed proximal
interphalangeal joint injuries. J Hand Surg Br. 1992;17(4):422-428.

12
CHAPTER
Hemihamate Arthroplasty
for the Proximal
Interphalangeal Joint
Fracture Dislocation
David Wei, Mark A. Vitale, and Amy M. Moore
DEFINITION
■ Fracture dislocations of the proximal interphalangeal (PIP) joint are injuries in
which the volar lip of the middle phalanx is fractured with accompanying
instability of the middle phalanx on the proximal phalangeal head.
■ The majority of PIP joint fracture dislocations are dorsal dislocations.
■ PIP joint fracture dislocations are classified by their mechanical stability as
well as the percentage of joint surface fractured and other radiographic
parameters.1
■ The most important radiographic determinant of stability is the percentage of
the middle phalangeal articular surface that has been fractured:
■ Disruption of 30% or less of the articular surface is likely to be stable.
■ Thirty to thirty-five percent of articular surface involvement may be tenuous.
■ More than 50% of articular surface involvement is considered unstable.1
■ Other radiographic signs of instability include the dorsal V sign and loss of
continuity of the dorsal cortices of the proximal and middle phalanges.2,3
■ Evaluation of mechanical stability is also important and can be tested by
evaluating range of motion of the PIP joint using live fluoroscopic imaging or
with radiographs in both full extension and full flexion (usually under a digital
block). Injuries in which the PIP joint subluxates as the joint approaches
extension are deemed unstable.
■ Hemihamate arthroplasty, originally introduced by Hastings in 1999, is a
method of reconstructing the damaged volar base of the middle phalanx by

using the natural contour of the size-matched portion of the distal dorsal
articular surface of the hamate.4
ANATOMY
■ The bony anatomy of the PIP joint allows it to function as a hinge, permitting
flexion and extension in the sagittal plane.
■ The normal range of motion of the PIP joint is 0 to 120 degrees.
■ Stability of the joint is conferred by a combination of bony constraints, the
volar plate and the collateral ligaments (FIG 1).
■ The concave articular surface of the middle phalanx articulates with the
convex condyles of the proximal phalanx. There is slight asymmetry between
the proximal phalangeal condyles, which causes mild supination of the middle
phalanx with flexion.5
■ The volar plate is a fibrocartilaginous structure that is firmly attached distally
to the volar base of the middle phalanx and which originates proximally from
the proximal phalanx via two checkrein ligaments. The volar plate resists PIP
joint hyperextension.
■ The collateral ligaments are the primary restraints to radial- and ulnar-
directed forces. They are composed of the proper and accessory collateral
ligaments.
■ Hemihamate arthroplasty takes advantage of the anatomy of the hamate (FIG
2A), which can replicate the volar proximal portion of the middle phalanx
(FIG 2B), and cadaveric studies have demonstrated ideal suitability as an
autologous graft.6
■ The distal surface of the hamate, which articulates with the base of the fourth
and fifth metacarpals, contains a bicondylar facet that is separated by a central
ridge.
■ The ridge closely replicates the bicondylar facet and central ridge of the
proximal portion of the middle phalanx.
■ Though the contour of the hamate is more shallow than the contour of the
middle phalanx (with the phalangeal radius of curvature ranging from 45% to
61% of the hamate) with proper orientation and tilting of the graft, a stable,
congruent joint is achievable.6
PATHOGENESIS
■ Two mechanisms of injury to the PIP joint have been described: avulsion and
impaction shear.7

■ Avulsion injuries occur when the PIP joint is hyperextended. The volar plate
remains attached to the proximal phalanx, and the distal attachment avulses a
fragment of the middle phalangeal volar lip (FIG 3A).
FIG 1 • Anatomy of the proximal interphalangeal (PIP)
joint, including the proper (P) and accessory (A)
collateral ligaments and the bony anatomy consisting of
the convex condylar articular surface of the proximal
phalanx (P1), which articulates with a concave articular
surface of the middle phalanx (P2).

FIG 2 • The distal portion of the hamate bone of the
carpometacarpal joint—which consists of a central ridge
and bicondylar facet and articular cartilage distally,
where it articulates with the articular cartilage of the
fourth and fifth metacarpal bases (A)—is an ideal match
in size, morphology, and dimensions to the volar
proximal surface of the PIP joint of the digits (B).
■ Although avulsion fractures vary in size, there is typically no comminution.
■ In impaction injuries, an axial load applied to the digit can drive the middle
phalanx into the head of the proximal phalanx, creating a shear force through
the middle phalangeal base. This creates a shear fracture of the volar lip.
■ In this mechanism because the fractured base is impacted into the head of the
proximal phalanx, the metaphyseal bone of the middle phalanx is often
comminuted (FIG 3B). When the volar fragment is sufficiently large, the
buttressing effect of the volar margin of the middle phalanx and the restraint of
the volar plate and collateral ligaments is lost, allowing the middle phalanx to
displace dorsally.

NATURAL HISTORY
■ The natural history of untreated dorsal PIP joint fracture dislocations is loss of
motion, pain, and degenerative joint disease.2
■ Even with adequate treatment, injury can result in chronic pain, stiffness, and
swelling, as PIP joint injuries are relatively unforgiving owing to the
combination of bony injury, cartilage damage, soft tissue disruption, and
scarring.2,8
■ Traditional surgical options for unstable fracture dislocations of the PIP joint
include external fixation, volar plate arthroplasty, and fracture fixation via
percutaneous methods or open reduction and internal fixation.
■ When more than 50% of the volar aspect of the middle phalanx is injured,
these traditional techniques lead to recurrent instability.9
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A patient’s history will typically reveal a specific trauma in which the digit
was “jammed” or “sprained”; the patient complaints of swelling, pain, and
decreased range of motion.
■ Physical examination should include a thorough examination of the skin. If
surgery is needed and there is a compromised soft tissue envelope,
percutaneous pinning or external fixation may be preferred to hemihamate
arthroplasty.

FIG 3 • A. Lateral radiograph of a middle finger
demonstrating a small volar plate avulsion fracture
without any evidence of PIP joint subluxation. B. Lateral
radiograph of a ring finger demonstrating an impaction
injury to the middle phalanx in which the base of the
middle phalanx is driven into the head of the proximal
phalanx resulting in comminution of the metaphyseal
bone of the middle phalanx. This fracture was unstable
and required closed reduction with a dorsal blocking
splint and ultimately required surgical fixation.