Clinical Example: Hamate osteochondral graft for PIP fracture dislocation

Dorsal fracture dislocations of the proximal interphalangeal joint are a common and difficult injury. The seriousness of the problem is often underestimated by the patient, leading to delay in treatment. Even when treated early, these fractures are difficult because the joint surface is crushed into small pieces. Many treatment options exist, none perfect. A new approach for these fractures involves replacing the destroyed section of the joint with an osteochondral graft taken from the dorsal hamate, where the shape of the joint surface matches that of the base of the middle phalanx. This is an example of this technique.

Click on each image for a larger picture

This gentleman injured his ring finger almost two weeks ago playing football, and has continued playing with the finger buddy taped. The distal interphalangeal joint has not bent for years following a different prior injury.

Xrays show a comminuted dorsal fracture dislocation of the proximal interphalangeal joint with dorsal subluxation.

The joint moves, but through an unnatural hinging on the edge of the fracture.

In the operating room, the crushed bone is removed and provisional fixation of the volar graft is obtained with Kirschner wires.

These wires are then replace, one at a time with micro screws.

The joint is approached through a volar "shotgun" hyperextension approach, as for a volar plate arthroplasty. In this case, the end of the profundus tendon is on the right, evidence of an old profundus avulsion injury.

Here, the graft is in place and the joint has been reduced. The proximal two screws were then backed out slightly, and the volar plate was secured with sutures looped around the proximal two screws, which were then tightened back (not shown).

Final reconstruction.