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Proximal Phalanx Frx: Percutaneous Intramedullary K Wire

- See: proximal phalangeal fractures:

- Disscusion
    - indicated for unstable frx of base, shaft, and neck;
    - K wire characteristics:
          - use 0.035 or 0.045 inch wires, depending on the size of the phalanx
          - holding power of the wires:
                  - increased penetrating ability and holding power with trocar tips, when compared to diamond tips;
                  - increased holding power w/ lower drilling speeds;

- Technique:
    - reduction:
             - note that the proximal phalanx has a natural dorsal apex curve and that any K wire IM technique will have a tendency to straighten out
                     the phalanx (which tends to give a volar apex deformity);
             - apply longitudinal traction across the PIP joint as the MP joint is flexed to 60 deg and the PIP joint is flexed to 45 deg;
             - ensure that that clinically there is no rotational deformity, and then confirm frx reduction w/ flouroscopy;
    - fixation:
             - trans-MP joint fixation:
                     - most indicated for fractures proximal to the midline;
                     - allows early PIP joint motion (which is the joint that tends to remain most stiff post op);
                     - MP joint is flexed to 60 deg, and insert a percutaneous K wire longitudinally across metacarpal head to pass down the meduallary canal of the proximal phalanx to
                              end just shy of the subchondral surface of the condyle;
                              - ensure that the wire is inserted along one side of the extensor tendon, through the metacarpal head (to pass across the MP joint);
                     - becuase this technique is technique is difficult, consider initial retrograde K wire insertion thru the distal phalangeal condyle (requires maximal PIP
                              joint flexion during insertion), which is then driven across the flexed MP joint;
                              - the K wire is then pulled proximally until its end clears the distal condyle;
             - in the reprot by Hornbach, et al, the authors report the results of 12 unstable extraarticular fractures of the proximal
                     phalanx treated with transarticular intramedullary Kirschner wires;
                     - early proximal IP joint motion was allowed and all patients achieved uneventful union, with an average total active motion of 265°;
                     - excellent results were observed in ten of the 12 patients;
                     - ref: Closed Reduction and Percutaneous Pinning of Fractures of the Proximal Phalanx.
               - w/ distal neck frx, consider insertion of 2-3 0.028 inch intramedullary K wires;
             - wires may be best inserted down the medullary canal by hand w/ use of T handle device;


- Post Op:
    - well padded dressing is then applied to protect the pin sites, but it is important that there remains some PIP motion;
           - PIP motion will help to impact frx fragments;
    - generally, cast is left on for 3 weeks

 Closed Reduction and Internal Fixation of Proximal Phalangeal Fractures.

Percutaneous screw treatment of spiral oblique finger proximal phalangeal fractures.