Clinical Example: Hemicondylar Hamate Replacement Arthroplasty for Proximal Interphalangeal Joint Fracture Dislocation

20 year old on the track to pro baseball, with a story that he jammed his non dominant left ring finger in training 6 weeks ago. Still playing, but it hurts when hit on the end or when hyperextended.

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PIP is swollen and a bit tender. E/F 20/80, probably a few degrees of radial angulation.

Range of motion not terrible, but...

Xrays show an apparently healed PIP fracture dislocation with dorsal subluxation - but concentric tracking of the abnormal palmar articulation.

First impression was that the palmar fragment was probably big enough to take down and reinsert. However, comparison of films shortly after the fracture (above) and at two months (below) confirms the injury as a healed comminuted central impaction fracture with splay and hinging of the volar cortex.

Operative approach, similar to the exposure for a volar plate arthroplasty:

Shotgun view of the pathology: the dorsal half of the base of the middle phalanx appears preserved, the palmar half recessed and covered with scar:

Dorsal hamate "gull-wing" graft donor site, where the three dimensional contour matches that of the missing surface of the base of the middle phalanx:

The old fracture surface has been excised, and the graft (far right) is ready for insertion:

Intraoperative fixation and motion: Initial attempts of micro screw fixation were not successful, and wire cerclage was used:

This is a technically demanding procedure. Although the apparent bone defect seems triangular, it is better to start with a rectangular graft as in

this case

to avoid problems illustrated below:

Because of questionable stability of the fixation, a Dynamic Traction Splint for Proximal Interphalangeal Joint Fracture Dislocations was used:

Results six months after surgery: