Case Report

           This case report was generated following all accepted protocols related to the Health Insurance Portability and Accountability Act (HIPAA), consent, and patient privacy laws. Any specific information related to the patient’s identity has been changed to protect their privacy.

          This athlete was a 28 year old male and NCAA Division 1 basketball player. The subject stood 6’ 11’’, weighed 225 lbs., was a student and former member of the U.S. Marine Corps. The athlete suffered a fracture to the proximal (closest) bone of his left index finger and a second joint dislocation while playing at a junior college in February 2005. (The second joint is anatomically known as proximal interphalangeal joint [PIP].) The cause of injury was a force applied directly to the tip of the athlete’s finger from a basketball. Surgical repair with screws was performed in March 2005. The athlete reported no change in alignment post surgically.

          The athlete transferred from his junior college in May 2006, a little more than a year after the initial injury and repair. His finger was noticed at his pre-participation examination. Questioning revealed persistent pain at the left PIP joint of his index finger that increased with activity. Despite stating that the joint remained chronically stiff and had never really improved since surgery, the athlete maintained that he was able to compete effectively. The resting position of the PIP was in 60 degrees of flexion. The finger segment distal (away from) to the injury site had a lateral angular deformity of 30 degrees. Active range of motion (AROM) showed slight second joint extension, but no active or passive flexion. The screw head from the previous surgery was visible under the skin along with breakdown of the tissue at the site. Stability and ROM were unaffected in the other fingers and wrist.

          An initial differential diagnosis of a boutonniere deformity or pseudo-boutonniere deformity was ruled out due to the length of time of the injury and angulation of the joint. Referral for diagnostic imaging revealed a single screw across the proximal bone of the left index finger, a marked angular deformity, a hyperextension deformity, and arthritis within the joint (Figure 1). The final diagnosis was a malunion fracture to the PIP joint of the left index finger, post traumatic arthritis, and PIP joint contracture.

Figure 1. X-ray of the affected finger at initial evaluation.

           Despite expressing desire for operative correction, the athlete initially chose to attempt to play through the basketball season since he was able to function during the previous one. The athlete later injured the first joint of the finger (anatomically known as the metacarpalphalangeal joint [MCP]) of the same finger and was diagnosed with a radial collateral ligament sprain. Findings were instability, pain with full flexion, and AROM limited to 60 degrees out of a normal range of 90-100 degrees. Conservative care was given. The athlete performed rehabilitation in the athletic training room accompanied by buddy taping—taping two fingers together—until fully healed. Improvements were achieved.

          The athlete returned again mid season complaining of a substantial increase in pain and stiffness at both the PIP and MCP joints. The team physician decided to perform a two-stage corrective reconstructive surgery after the season ended. A closing wedge osteotomy and screw removal was performed first to straighten the finger. A piece of bone was cut out on the inner side, and the segment was realigned. Pins were inserted on both sides of the finger to better maintain alignment (Figure 2). Kirshner wires were also used. A splint was applied and instructions were given to wear it at all times. Follow-up x-rays exhibited a still open fragment, but good evidence of a healing callus. Pins were removed and the second stage was planned.

Figure 2. X-ray of the affected finger post closing wedge osteotomy.

        A joint contracture release to restore motion was performed ten weeks later on the PIP and MCP joints. The MCP release was uneventful. The PIP release revealed no cartilage whatsoever on either joint side and difficulty finding any joint space. The extensive osteoarthritis completely destroyed the joint. Resulting lack of cartilage required the finger to be fixated with pins and Kirshner wires in MCP and PIP flexion. These procedures were performed to provide a better functional position and less pain. The PIP joint was further pinned in a position to attempt fusion (Figure 3). Protective splinting was applied three weeks post surgery with accompanying pin removal. Aggressive rehabilitation increased MCP flexion to 80 degrees; however, patient noncompliance reversed these effects.

Figure 3. X-ray of the affected finger post MCP and PIP joint contracture release.

       Further postoperative evaluation showed no further healing at the osteotomy site. The athlete was diagnosed with a stable nonunion fracture. A crossroad was reached, in which the athlete could have attempted further intervention or leave the finger as it was. Operation was eventually chosen due to the faster return to competition provided. A PIP joint fusion using a bone graft from his wrist was performed. Surgeons would attempt to have the bones join together. Hardware was again inserted to maintain alignment (Figure 4). Follow-up showed progressive signs of healing, but the final outcome is still undetermined. Athlete was allowed to return to competition, as this would not affect healing. He continues reevaluation as scheduled.

Figure 4. X-ray of the affected finger post PIP fusion using a bone graft from the radius