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Report on Use of Hook Plate Fixation for Avulsion Finger Fractures
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Posted on: 06/27/2012
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Fractures of the fingers can be a complex surgical challenge -- especially if it's an avulsion fracture. Avulsion means the bone has broken off with a piece of soft tissue still attached. There could be a slip of tendon, ligament, or volar plate still connected to the bone fragment.
Reattaching the tiny bone fragment requires special surgical tools and techniques. As you can imagine they don't even make screws tiny enough for some of the smaller pieces of bone that avulse. And the force of putting a screw through the bone fragment can be enough to cause another fracture (or even break the bone fragment into a number of smaller pieces).
To avoid such complications, a special hook plate has been designed. The hook plate is made of titanium. It is used when the avulsion fracture fragment is unstable and displaced (separated from the main bone). Joint instability and loss of finger function cannot be treated without this type of fixation.
In this report, hand surgeons from the Singapore General Hospital describe their use of the hook plate in 13 patients with finger avulsion fractures. Conventional fixation devices such as regular-sized bone screws, wires, plates or tension bands can't be used to secure a stable fixation in these small avulsion fractures.
This technique with the plate hook applies tension to the fracture site as well as acts as a buttress. The head of the screw is flush with the bone, so there's nothing sticking outside the skin. Inside the finger, the tiny hooks on the plate bite into the soft tissue where it inserts into the bone. The effect is to draw the pieces of bone back together.
The patient can move the finger right after surgery. In fact, hand therapy is started on the second day after the operation. In this group of patients there was a wide range of causes for the fractures (e.g., sports injuries, assault, industrial accidents). Any of the fingers can be affected by avulsion fractures. In this group of patients, six little fingers, three long fingers, two index fingers, and two ring fingers were fractured.
The authors include a detailed description of the surgical techniques used to implant the hook plates.
Drawings and X-rays provided show the placement of the plate with fracture reduction. Instructions are given to help other surgeons avoid creating a hinge as the fracture site and to prevent infections.
All patients were followed for at least three months and some for as long as 52 months (four years and four months). X-rays were taken at regular intervals to observe and record the formation of bone to bridge the gap made by the fracture. Pain, finger range-of-motion, and function were also used as measures of success.
In all 13 fingers, there was bone healing (referred to as union) and no complications. Good-to-excellent motion was reported without joint stiffness or contractures (inability to move the joint through full motion). In three of the patients, there was an extension lag reported (unable to fully straighten the finger).
Adhesions and scarring were avoided with early movement and hand therapy. Patients wore a splint holding the affected finger as straight as possible. The splint was taken off once every hour during the day to move the finger.
The authors summarize their study by saying this hook plate technique works well for finger avulsion fractures when there is a dislocated bone fragment and unstable finger joint. This fixation technique can also be used with a wide range of different types of avulsion injuries because the plates can be placed side-by-side or even in a T-pattern.
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References:
Gavin Chun-Wui Kang, MBBS, MRCSEd, MMed(Surg), MEng, et al. The Hook Plate Technique for Fixation of Phalangeal Avulsion Fractures. In The Journal of Bone and Joint Surgery. June 2012. Vol. 94A. No. 11. Pp. e72(1-6).
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