Open Reduction Internal Fixation With Transverse Volar Plating for Unstable Proximal Interphalangeal Fracture-Dislocation: The Seatbelt Procedure

Abstract

Background: Unstable intra-articular proximal interphalangeal (PIP) joint fracture-dislocations present a difficult problem that requires congruous joint reduction and stable internal fixation or distraction. Though fractures with limited articular involvement may be treated successfully with less invasive procedures, fracture-dislocations with a volar shear component may benefit from joint reduction with subchondral support for maintenance of stability. The purpose of this article is to describe a volar transverse plate and screw technique and report the short-term postoperative results. Methods: Seventeen patients with volar shear PIP dorsal fracture-dislocations were treated with transverse plate and screw constructs at an average of 21 days (range, 2-52) after injury. Information on postoperative stability, range of motion at PIP and distal interphalangeal (DIP) joints, and radiographic outcomes and complications were retrospectively collected. Results: At a mean of 7.3 months post-operation (range, 1.5-24), there were no recurrent dislocations and an average PIP arc of 77.4° and DIP arc of 61.5°. Sixteen of 17 patients had radiographically concentric joints, with 1 patient showing slight radiographic dorsal subluxation not apparent clinically. Two of 17 patients (11.8%) had revision surgery for tenolysis and removal of hardware to improve range of motion at 4 and 9 months post-operation. Conclusions: In the setting of PIP dorsal fracture-dislocations with volar shear component >40% of the articular surface, the Seatbelt procedure allows for concentric joint and articular surface reduction with subchondral support for maintenance of stability. This volar transverse plating technique allows for highly functional range of motion without PIP dorsal subluxation clinically in the setting of comminution and delayed presentation.