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A New Fixation Technique For Phalangeal Neck Fracture

in Adults: Report of 2 cases
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Ayhan Kilic, MD* and Gazi Huri, MDw

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affected hand revealed a severe dorsally displaced type 3 neck fracture

Summary: Several open and closed surgical techniques have been of the proximal phalanx of the thumb (Fig. 1).
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reported in the treatment of displaced phalangeal neck fractures. The
most common fixation is provided by a Kirschner wire, which is placed
in a retrograde manner through the interphalangeal joint in extension.
Although it provides a stable fixation, it may lead to joint stiffness and
cartilage damage. The purpose of this report is to describe a new
fixation technique for phalangeal neck fractures in 2 cases, which may
provide stable fixation and prevent cartilage damage and joint stiffness.
Key Words: phalangeal neck—fracture—antegrade—percutaneous
fixation.
(Tech Orthop 2013;28: 333–337)
Closed reduction under sedation was performed applying longi-
tudinal traction, followed by immobilization using a forearm cast in a
functional position. However, upon detection of the reduction loss in
plain radiographs at first week follow-up control, the patient underwent
surgical treatment.
Case 2
A 28-year-old female patient presented to the emergency service
with pain and flexion disturbance in the right fifth finger following a
low-energy trauma (Fig. 2). Initial examination revealed slight swel-
ling and tenderness on the dorsal side of the interphalangeal joint of the
right fifth finger. Slight rotational deformity was also observed on
initial examination. The active range of motion was 0-degree extension

P halangeal neck fractures are frequently seen in children,

whereas rarely seen in adults.1 Management of these
fractures is difficult and thus can lead to joint stiffness, delay
union, and malunions. Although type I neck fractures can be
treated adequately with splinting for 3 to 4 weeks, displaced
fractures are usually unstable and require reduction and fix-
ation.1–3 Intact collateral ligaments cause rotation of the distal
fragment in the type 2 and 3 phalangeal neck fractures, which
makes it difficult to maintain adequate reduction without
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internal fixation.3,4 The most common fixation for phalangeal

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neck fractures is provided by a Kirschner wire (K-wire), which

is placed in a retrograde manner through the interphalangeal
joint in extension. Although retrograde K-wire fixation that
crosses the joint provides a stable fixation, it may cause joint
stiffness and articular damage.
In this paper, a new fixation technique for type 3 pha-
langeal neck fractures in 2 cases, which may provide stable
fixation and prevent cartilage damage and joint stiffness, is
described.

CASE REPORTS

Case 1
A 21-year-old male patient presented to the emergency room
with a deformity, swelling, and painfully restricted motion at the level
of interphalangeal joint of the thumb. Rotational deformity associated
with hyperextension was observed during physical examination and
neurovascular structures were intact. The plain radiographs of the

From the *Department of Orthopaedic and Traumatology Surgery,

İstanbul Taksim Research and Training Hospital, Istanbul; and wDepart-
ment of Orthopaedic and Traumatology Surgery, Cukurova University,
Adana, Turkey.
The authors declare that they have nothing to disclose.
Address correspondence and reprint request to Ayhan Kılıc¸, MD,
Department of Orthopaedic and Traumatology Surgery, İstanbul Taksim
Research and Training Hospital, Taksim Egitim ve Arastirma Hastanesi,
Siraselviler cad. No: 112, 34433, Beyoglu, Istanbu, Turkey.
E mail: kilicayhan@yahoo.com.
Copyright r 2013 by Lippincott Williams & Wilkins FIGURE 1. Type 3 neck fracture of the proximal phalanx of the
ISSN: 0148-703/13/2804-0333 thumb.

Kilic and Huri
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FIGURE 2. Type 3 phalangeal neck fracture of the fifth finger. (A) AP view; (B) lateral view.
and complete inability of flexion, as well as 0-degree extension and 45-
degree flexion at the dorsal side of the interphalangeal and proximal
interphalangeal joints, respectively; thus, the range was evidently
limited. The plain radiographs revealed displaced type 3 neck fracture
of the middle phalanx of the fifth finger. Closed reduction was per-
formed as in the previous case. Because of inadequate reduction, the
patient underwent surgery with the technique, which is described
below.
TECHNIQUE
Closed reduction of the fracture was performed with
gradual longitudinal traction under fluoroscopy control and the
dorsally displaced head was pushed gently in the palmar
direction (Fig. 3). After maintaining the alignment, a stab
incision was made along the radial border of the phalanx
metaphysis, 5 mm proximal to the metacarpophalangeal joint.
Through the stab incision made, the near cortex was penetrated
in a 45-degree angle relative to the shaft axis to create the entry
point (Fig. 3A). The prebent K-wire of size 035 to 0.045 inch
with its 3-mm end bent even sharper was introduced from the
entry point and driven along the intramedullary canal to the
fracture line (Fig. 3B). Particular attention was paid to avoid
multiple attempts of K-wire passage, which may cause sig-
nificant damage to the articular cartilage. At this stage, the wire
was advanced gently into subchondral bone of the distal seg-
ment, leaving the metacarpal head free (Fig. 3C). The residual
displacement of the fracture was reduced by turning the K-wire
around its long axis through an angle of 180 degrees to produce
the shift of the distal fragment and reduce it (Fig. 3D).
Thereafter a second cross pin (0.035 to 0.045 inch) was
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Techniques in Orthopaedics$  Volume 28, Number 4, 2013
introduced antegradely from the ulnar side and advanced into
the distal fragment (Fig. 3E). Final fluoroscopic views are
taken in anteroposterior, lateral, and 45-degree oblique planes
and position of the K-wires was checked to confirm the
absence of penetration of articular cartilage, which may lead to
joint stiffness (Figs. 4, 5). The lower metaphyseal end of the
pin is then cut and the skin dressed (Fig. 6). A volar splint was
applied and passive range of motion exercises was begun
immediately. After 2 weeks, the cast was removed and patients
were allowed for active motion. In both patients the wires were
removed in the fourth week, after union was achieved (Fig. 7).
At final follow-up, active range of motion of the meta-
carpophalangeal and interphalangeal joints was recorded, and
the percentage normal total active motion of all finger joints
was documented by comparison with the contralateral normal
finger (Fig. 8).
DISCUSSION
Neck fracture of the proximal phalanx is a relatively
uncommon injury and occurs almost exclusively in children.
Closed reduction and percutaneous K-wire fixation are still the
recommended treatment options for unstable fractures.5
Although K-wire fixation is considered simple and less inva-
sive compared with most other techniques, the methods of
reduction and K-wire fixation of these fractures are technically
demanding and require special attention to avoid several
technical pitfalls. Probability of significant damage to articular
cartilage and iatrogenic intra-articular fracture due to multiple
penetrations of metacarpal head and irritation of the extensor
tendons, which may lead to joint stiffness, delay union, and
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Techniques in Orthopaedics$  Volume 28, Number 4, 2013 New Fixation Technique For Phalangeal Neck Fracture
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FIGURE 3. Antergrade fixation technique for displaced phalangeal neck fracture. A, Penetration of the near cortex in a 45-degree angle
relative to the shaft axis to create the entry point. B, Advancement of the prebent Kirschner wire (K-wire) along the intramedullary canal.
C, Advancement of the prebent K-wire into subchondral bone of the distal segment. Particular attention should be paid not to penetrate
the cartilage. D, Turning the prebent K-wire around its long axis through 180 degrees to produce the shift of the distal fragment and
maintain the reduction. E, Final position of the K-wire.
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malunions, are the main restrictions of these fixations. In this
paper, a new antegrade fixation technique for unstable prox-
imal phalangeal neck fracture, which may prevent cartilage
damage, joint stiffness, and provide a stable fixation, is
reported.
Many closed techniques have been previously described
in pediatric population; however, there are few reports about
adults.1,3–10 Al-Qattan1 reported poor outcomes of type II
fractures treated with closed reduction and splinting in pedia-
tric patients. Therefore, displaced unstable (type II/III)

FIGURE 5. Confirmation of the reduction and positions of the

FIGURE 4. Confirmation of the reduction and positions of the Kirschner wires under image intensifier in an anteroposterior
Kirschner wires under image intensifier in a lateral view. view.

Kilic and Huri
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FIGURE 6. Early postoperative x-ray. (A) AP view; (B) lateral view.
FIGURE 7. Complete bone union on plain radiograph.
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Techniques in Orthopaedics$  Volume 28, Number 4, 2013
pediatric phalangeal neck fractures of the proximal phalanx are
usually treated with K-wire fixation, which crosses and
immobilizes the proximal interphalangeal joint.1,2 Some
authors described good outcomes about using longitudinal
K-wires inserted through the articular cartilage, without com-
plication.11 Londner et al7 reported 11 excellent and 2 good
results among the 13 phalangeal neck fractures treated with an
intrafocal pinning technique in children.
Unlike pediatric patients, transarticular fixation is not
well tolerated in adults and thus results in joint stiffness.10
Previous studies also revealed that closed reduction and per-
cutaneous K-wires driven across the flexed metacarpo-
phalangeal joint noted significant stiffness at all finger joints
because of the irritation of the extensor tendon in zone 5.12,13
Gonzalez et al14 described a joint-free fixation technique
(intramedullary fixation) for phalangeal shaft fractures, which
provides excellent results with a low complication rate.
As mentioned above, several fixation techniques were
described for phalangeal neck fractures; however, joint stiff-
ness seems to be the main problem especially in adults even if
it is treated with open or closed procedures. To our knowledge,
there is only 1 technique described by Al-Qattan5 for pha-
langeal neck fracture in adults that may avoid joint stiffness.
Although placing the K-wire in antegrade manner avoids the
surrounding joints and allows early active mobilization of all
finger joints, only 1 K-wire may be inadequate for providing
rotational stability and maintaining the reduction.5 In our
technique, 2 K-wires consisting of 1 straight and 1 prebent
were placed antegradely. To our opinion, 2 K-wires may
provide both more rotational stability and rigid fixation com-
pared with 1 wire, and it is crucial for postoperative early
rehabilitation.
In conclusion, phalangeal neck fractures of the proximal
phalanx in adults are rare and there is a lack of information
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FIGURE 8. Full recovery after treatment. (A) Thumb in extension; (B) thumb in flexion.
about the optimal technique for fixing unstable type II/III
fractures. Our technique for unstable fractures emphasizes that
antegrade advancement of the K-wires keeping the articular
cartilage intact may provide a stable reduction and fixation and
allows a reliable postoperative rehabilitation protocol includ-
ing early active mobilization of all finger joints to obtain a
satisfactory outcome.
REFERENCES
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2. Campbell RM Jr. Operative treatment of fractures and dislocations of
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New Fixation Technique For Phalangeal Neck Fracture
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