Can proximal phalanx fractures be treated with intramedullary compression screws?

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Phalanx fractures are extremely frequent, with those of the proximal phalanx being more common than the middle or distal. There is a debate about the best way to surgically approach these fractures, since open reduction and rigid internal fixation would allow greater early mobility and less rigidity, however, in these cases there is greater dissection and surgical aggression, which can lead to adhesions.

Although fixation with Kirschner wires is widely used, there is low compression and less stability, requiring a longer period of immobilization. Recently, the use of intramedullary compression screws has been performed more frequently, especially for metacarpal fractures, providing good stability and minimal aggression. However, evidence on the use of such a technique in proximal phalanx fractures is limited.

proximal phalanx

The study

It was published that month in the magazine hand a systematic review with the objective of identifying and evaluating the results of the use of intramedullary compression screws in fractures of the proximal phalanx. A search was performed in November 2019 in the Pubmed, Medline, Embase and Central databases and English-language studies were selected where at least one measure of postoperative function was evaluated.

Four studies were eligible for inclusion (82 fractures with 77% of these treated anterogradely), with a further 3 studies evaluating the proximal and middle phalanges analyzed separately. The mean follow-up time was 70.5 weeks, ranging from 20 to 216. Total active movement was greater than 240° in all studies of the proximal phalanges and the mean postoperative DASH was 3.62.

The complications observed ranged from 3.6 to 6% of the cases, including infection, long screws, unrecognized intra-articular trace, early deviation requiring revision and malunion.

Read too: What is the epidemiology of distal radius fractures in children?

In practice

In the same way as in metacarpal fractures, the intramedullary screw can be used in phalanx fractures with mainly transverse features. Patients operated on using this technique can start rehabilitation very early due to the stability of the fixation and little aggression to the soft tissues. However, there is still a portion of surgeons who question a difficult resolution in case of complications due to the fact that the implant is located intramedullary.

Randomized clinical trials evaluating functional outcomes and even the resolution of complications will be necessary in order to define whether one technique is superior over the others.

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# Sivakumar BS, An VVG, Graham DJ, ledgard J, Lawson RD, furniss D. intramedullary compression Screw fixation of proximal Phalangeal fractures: A systematic literature review. Hand (NY). 2022 Jul;17(4):595-601. It hurts: 10.1177/1558944720928503. epub 2020 sep 28. PMID: 32988227.