This case demonstrates the use of the gull-wing shaped hamate articular graft for replacement of loss of the palmar half of the distal phalanx articular surface from a DIP dorsal fracture-dislocation. This is analogous to the
HHRA reconstruction described for PIP fracture dislocation
(
Case 1,
Case 2,
Case 3,
Article
)
, but because of differences in anatomy, has been performed through a bayonette exposure rather than the traditional PIP shotgun exposure. One goal of this exposure is to allow immediate postoperative motion by avoiding the need to perform a tenotomy to expose the joint.
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The injury:dorsal DIP fracture dislocation of the ring finger of a 16 year old male sports hopeful.
Unstable even in a well molded splint.
Custom articular osteotome designed to create an intraarticular osteotomy through the distal hamate surface, a bit easier to control than a Freer elevator.
Intraoperative fluoros: The injury, reconstruction through a bayonette exposure, stable reduction.
Procedure Summary in 90 seconds
Skin Incision
Collateral ligaments take down
Dorsal dislocation "Bayonette" exposure
Fracture debridement
Measure defect
Graft harvest from ring-small juncture of hamate
Provisional fixation with Kwires through extensor tendon
Replace Kwires with screws
Closure
Technical note regarding
closure: the eponychial wound has two skin layers: superficial and
deep. If they are not closed separately, the closure will heal with
prolonged inflammation. This can usually be prevented with a
layered closure using a deep pullout suture, as shown here:
Three months postop, following a program of immediate protected motion supervised in therapy. No pain, full flexion, 20 degree extensor lag, ready for sports.
