FRACTURE
OF THE
PROXIMAL
PHALANX
An unusual complication of pulley reconstruction in a child W. B. CONOLLY and A. W. LEICESTER
Sydney Hospital Hand Unit, Sydney, Australia We report a case of a fracture occurring in the proximal phalanx of a child following pulley reconstruction. The operative technique and the difficulties of pulley reconstruction in the immature skeleton are discussed.
Journal of Hand Surgery (British Volume, 1992) 17B: 420-421 A seven-year-old boy was referred for treatment of flexion contracture of the right index and middle fingers at the PIP joints following surgical division of the entire flexor sheaths on the proximal phalanges for triggering in early childhood. The flexion contractures were released and pulleys reconstructed over the A2 and A4 areas of the index and middle fingers. The FDS tendon of the index finger was sectioned at the M P joint level. The radial slip was used to reconstruct the A2 pulley and the ulnar slip used to reconstruct the A4 pulley. The distal attachments were still intact. The other end of each was attached to the fibro-osseous rim on the other side. A free graft of FDS was used to reconstruct the A2 pulley in the middle finger. The slip of tendon was passed around the finger deep to the extensor apparatus and sutured to the fibro-osseous rim on the ulnar side with fine wire (Fig. 1). FDS of the middle finger had been excised previously. A flexor tenolysis was carried out in both fingers. K wires were placed across the PIP joints holding them
in extension and were removed three weeks later. Meanwhile the child was encouraged to flex the DIP joints. He regained satisfactory extension and overall function in the finger and hand. At the age of nine years he caught the right middle finger in a fence and fractured the proximal phalanx (Fig. 2). There was an unsuccessful attempt at closed
Fig. 1 X-Ray 16 months after pulley reconstruction showing diaphyseal narrowing at the level of the reconstruction.
Fig. 2 X-Ray 19 months after pulley reconstruction showing fracture at the level of the reconstruction. 420
F R A C T U R E D P R O X I M A L P H A L A N X A F T E R PULLEY R E C O N S T R U C T I O N
421
reduction, and open reduction was carried out after two weeks. The reconstructed A2 pulley had become caught between the fracture fragments. Following removal of this and debridement of the fracture area, the reduction was held by a K wire placed across the phalanx (Fig. 3). The fracture is now united and the child has regained useful finger and hand function.
Discussion Pulley reconstruction is a difficult surgical procedure. Schneider and Hunter (1988) recommend that the repair should be strong. This case illustrates a complication of tight pulley reconstruction in a skeletally immature hand. As the finger grew the reconstructed pulley weakened the diaphysis of the proximal phalanx and the subsequent fracture required open reduction. The ability of tendon grafts in children to grow has not been proven (Hage and Dupuis, 1965; Koch, 1933). It might therefore be inadvisable to construct a tight pulley in a child.
j
References
/ 8'
Fig. 3
9
X - R a y following o p e n reduction o f the fracture, r e m o v a l o f the t e n d o n pulley f r o m the fracture site, a n d K w i r e fixation.
S C H N E I D E R , R. L. H. and H U N T E R , J. M. Flexor tendon, late reconstruction. In: Green, D. P. (Ed.) 2nd Edn. Operative Hand Surgery, New York, Edinburgh, London, Melbourne, Churchill Livingstone, 1988: vol 3: 2 0 2 ~ 2021. HAGE, J. and DUPUIS, C. C. (1965). Tiae intriguing fate of tendon grafts in small children's hands and their results. British Journal of Plastic Surgery, 18: 341-349. K O C H , S. L. (1933). Complicated contractures of the hand; their treatment by freeing fibrosed tendons and replacing destroyed tendons with grafts. Annals of Surgery, 98 : 546-580.
Accepted: 18 March 1992 Mr W, B. Conolly, Hand Unit, Sydney Hospital, Maequarie Street, Sydney 2000, Australia. 9 1992The British Society for Surgeryof the Hand
OF THE
PROXIMAL
PHALANX
An unusual complication of pulley reconstruction in a child W. B. CONOLLY and A. W. LEICESTER
Sydney Hospital Hand Unit, Sydney, Australia We report a case of a fracture occurring in the proximal phalanx of a child following pulley reconstruction. The operative technique and the difficulties of pulley reconstruction in the immature skeleton are discussed.
Journal of Hand Surgery (British Volume, 1992) 17B: 420-421 A seven-year-old boy was referred for treatment of flexion contracture of the right index and middle fingers at the PIP joints following surgical division of the entire flexor sheaths on the proximal phalanges for triggering in early childhood. The flexion contractures were released and pulleys reconstructed over the A2 and A4 areas of the index and middle fingers. The FDS tendon of the index finger was sectioned at the M P joint level. The radial slip was used to reconstruct the A2 pulley and the ulnar slip used to reconstruct the A4 pulley. The distal attachments were still intact. The other end of each was attached to the fibro-osseous rim on the other side. A free graft of FDS was used to reconstruct the A2 pulley in the middle finger. The slip of tendon was passed around the finger deep to the extensor apparatus and sutured to the fibro-osseous rim on the ulnar side with fine wire (Fig. 1). FDS of the middle finger had been excised previously. A flexor tenolysis was carried out in both fingers. K wires were placed across the PIP joints holding them
in extension and were removed three weeks later. Meanwhile the child was encouraged to flex the DIP joints. He regained satisfactory extension and overall function in the finger and hand. At the age of nine years he caught the right middle finger in a fence and fractured the proximal phalanx (Fig. 2). There was an unsuccessful attempt at closed
Fig. 1 X-Ray 16 months after pulley reconstruction showing diaphyseal narrowing at the level of the reconstruction.
Fig. 2 X-Ray 19 months after pulley reconstruction showing fracture at the level of the reconstruction. 420
F R A C T U R E D P R O X I M A L P H A L A N X A F T E R PULLEY R E C O N S T R U C T I O N
421
reduction, and open reduction was carried out after two weeks. The reconstructed A2 pulley had become caught between the fracture fragments. Following removal of this and debridement of the fracture area, the reduction was held by a K wire placed across the phalanx (Fig. 3). The fracture is now united and the child has regained useful finger and hand function.
Discussion Pulley reconstruction is a difficult surgical procedure. Schneider and Hunter (1988) recommend that the repair should be strong. This case illustrates a complication of tight pulley reconstruction in a skeletally immature hand. As the finger grew the reconstructed pulley weakened the diaphysis of the proximal phalanx and the subsequent fracture required open reduction. The ability of tendon grafts in children to grow has not been proven (Hage and Dupuis, 1965; Koch, 1933). It might therefore be inadvisable to construct a tight pulley in a child.
j
References
/ 8'
Fig. 3
9
X - R a y following o p e n reduction o f the fracture, r e m o v a l o f the t e n d o n pulley f r o m the fracture site, a n d K w i r e fixation.
S C H N E I D E R , R. L. H. and H U N T E R , J. M. Flexor tendon, late reconstruction. In: Green, D. P. (Ed.) 2nd Edn. Operative Hand Surgery, New York, Edinburgh, London, Melbourne, Churchill Livingstone, 1988: vol 3: 2 0 2 ~ 2021. HAGE, J. and DUPUIS, C. C. (1965). Tiae intriguing fate of tendon grafts in small children's hands and their results. British Journal of Plastic Surgery, 18: 341-349. K O C H , S. L. (1933). Complicated contractures of the hand; their treatment by freeing fibrosed tendons and replacing destroyed tendons with grafts. Annals of Surgery, 98 : 546-580.
Accepted: 18 March 1992 Mr W, B. Conolly, Hand Unit, Sydney Hospital, Maequarie Street, Sydney 2000, Australia. 9 1992The British Society for Surgeryof the Hand
