Introduction: Dorsally angulated metaphyseal fractures of the proximal phalanges usually occur in the middle aged or elderly and are common. Reduction is difficult to maintain with non-operative treatment, due the action of the intrinsic muscles. Most techniques advocated in the literature suggest a transmetacarpal K-wire fixation.

We present the results of a simple method of stabilisation using intramedullary K-wires without violating the articular surface.

Methods: Over a three-year period, sixty patients with these fractures were treated in this way. A single wire is inserted through the rim of the proximal phalangeal base with MCPJ fully flexed, avoiding transfixion of the collateral ligament. The wire is passed up the medullary canal, across the fracture and up either to subchondral bone or to engage the opposite cortex. The metacar-pophalangeal joints were immobilised with a thermoplastic splint in full flexion and interphalangeal joints mobilised under supervision by the hand therapists. The wire was removed at three weeks.

Results: Most patients achieved a full range of movement at 6 weeks follow-up. There were no pin site infections.

Conclusion: Dorsally angulated metaphyseal fractures of the proximal phalanges fractures are difficult to treat by non-operative means. If the fracture heals in an angulated position the altered line of pull of the intrinsics will result in loss of flexion at the MCPJ and of power grip. This method is straightforward and gives satisfactory results. It avoids damage to the articular surface of the MCPJ, allows mobilisation of the entire digit and reliably controls the fracture.

Aims: Thirty-three patients with condylar fractures of the middle and proximal phalanges were treated with internal fixation using self-tapping titanium lag screws. The results were studied prospectively and prognostic factors identified. Methods: The age range was 14–45 (mean 26 years). Five patients presented at more than five weeks post injury. Four patients had bicondylar fractures. The surgical technique, which utilises a lateral approach, is outlined. All surgery was performed by the senior author (DS), semi-electively, within five days of presentation. Patients were seen in the 4th postoperative day for mobilisation and protective splintage. Results: The results were satisfactory in the majority of cases. 21 patients had achieved a full range of movement when reviewed at six weeks and further eight at 12 weeks. The remainder were left with a flexion contracture of 10–35 degrees (mean 26). All patients achieved full flexion. All fractures healed and there was no loss of fixation. Conclusions: Internal fixation using a single lag screw through a lateral approach restores joint congruity, facilitates union and provides fixation stable enough to allow early mobilisation. Bicondylar and proximal phalangeal fractures had a poorer prognosis. Fractures presenting even at eight weeks can be taken down and reduced. Delay in fixation does not appear to influence the long-term outcome.

Fractures about the radial or ulnar aspects of the base of the proximal phalanx or the metacarpal head represent collateral ligament avulsion injuries. Unlike such injuries in the metacarpophalangeal joint of the thumb these injuries are rare and have received scant attention in the literature.

The results of open reduction and internal fixation, highlighting the surgical approach and technique, of collateral ligament avulsion fractures about the metacar-pophalangeal joints of the fingers are presented.

Over a five year period sixteen patients presented to the hand injury service with the above injury. Thirteen of these fractures occurred at the base of the proximal phalanx. Fourteen were acute injuries and two non-unions. These fractures affected a predominantly young population (average age 24 years) and the majority were sustained during sporting activities. All were treated by ORIF except for one in which the patient declined operative treatment. Metacarpal head fractures are assessed through a standard dorsal approach but as the collateral ligament inserts into the volar - lateral aspect of the proximal phalangeal base access to this fracture is best achieved via a volar approach to the digit. Fractures were stabilized with a single interfragmentary screw.

Surgical fixation gave satisfactory results in fourteen cases. All these patients had a full range of finger movement within 3 weeks. One patient developed symptoms suggestive of RSD. At 3 months review all fractures treated by ORIF had united. The patient who declined surgical treatment developed a symptomatic non-union.

Conservative treatment of these unstable fractures leads to non-union. The surgical anatomy dictates the surgical approach, with fractures at the proximal phalangeal base best accessed via a volar approach. ORIF restores joint surface congruity, establishes union and provides stable fixation to allow early mobilisation and return to normal activities.