Discussion

          In some cases of malunion, the patient may be left with a disability (Delforge, 2002). For these reasons, malunion should be avoided whenever possible and treated so that angular or rotational deformity does not exceed five degrees (Court-Brown, 2006). Prior to transferring from his junior college, the patient did not seek treatment for slight finger malalignment and function. This injury progressed into gross deformity and loss of function. Compliance with rehabilitation and physician visits is unknown, but there is a high likelihood that multiple complications from the patient’s initial finger injury would not have occurred if he had been totally compliant.

        Surgery is not always necessary; however, it may be proper for a disfigurement, and obligatory when disabling (Binnie, 1913). Although the fingers have an outstanding ability for functional adaptation and tolerance of great deformities from fractures, surgery was still required (Freeland, 2006). This further demonstrates the severity and rarity of this athlete’s injury.

        Nonunion and malunion surgery in the hand and fingers must be based on a detailed analysis of risks and benefits. The probability of achieving a functional outcome with surgery should be heavily weighed (Ring, 2005). Discretion and full consideration of risks and benefits should be given prior to selection of a corrective procedure. The team physicians weighed the individual patient risks and ultimately chose operation even though possibility of massive improvement was diminished due to the length of time since the initial injury. Nevertheless, any amount of straightening and movement would produce more functionality, and make the finger more aesthetically pleasing.  

        Malunions requiring operation are infrequent; however, an angulation of 15 degrees inward in the proximal or middle finger should have surgery (Freeland, 2006). This fact is consistent with this case. Even if the fracture heals, it is unlikely the joint will be returned to useful motion, which was one result of this case. Surgeons have debated the site preference for malunion correction, either at the site of injury or a separate site (Ring, 2005). More recent literature states that surgery must be done at the site of the malunion when accompanied by a significant angular deformity or adhesion, which this case involved (Freeland, 2006). A closing wedge osteotomy is easier than an opening osteotomy and avoids the need for a bone graft. Kirschner wire fixation is more easily adjustable than plate fixation (Ring, 2005). A closing wedge osteotomy was used along with the suggested Kirschner wire fixation; however, a bone graft was needed later on. Such bone grafting is extremely rare because it is not mentioned in the literature. While it cannot be assumed that the need for bone grafting is completely unheard of, its infrequency relegates it to an issue of small importance.

       Surgery of a malunion fracture should be performed within ten weeks due to the possibility of recreating the original fracture line by mobilizing the callus (Ring, 2005). Early operation may allow removal of an immature callus and thus promote more optimal reduction of the original fracture. Risk of tendon or joint adhesion increases with a longer lasting deformity (Freeland, 2006). If enough malunion is present to cause a functional loss, correction should not be delayed (Ring, 2005). The patient in this case waited more than two years for correction, more than eleven times the recommendation. A delay in healing is also unusual. Buchler et al. (1996) reviewed the results of 59 osteotomies for malunion correction. Union was obtained in 100% of patients, with satisfactory correction in 76%. 89% achieved net gains in motion (Buchler, 1996). This patient did not achieve union or any gain in motion, nor did he achieve successful union. Contrasting research states that corrective osteotomies almost always heal with improved finger motion, but still have remaining stiffness (Freeland, 2006). Looking at either study, this patient’s finger did not heal as it should have and a radial bone graft was ultimately necessary.
 
       While malunion fractures are somewhat common in the phalanges, the need for operative correction is minimal. Tubiana showed that of 10,000 hand injuries, only 30 malunion fractures (.003%) required operative intervention (Tubiana, 1985). It is noteworthy that much of the early research had somewhat small patient populations, which demonstrated a surgeon’s unwillingness to operate on a finger malunion. More recent studies are beginning to show a change in treatment, with osteotomies being largely, if not entirely, successful (Freeland, 2006).

        It is extremely unusual to achieve nonunion in the metacarpals and phalanges. Occurrence is only present when accompanied by some complex scenario or complication, such as tendon adhesion, contracture, or joint stiffness (Ring, 2005). Such a complication was part of this case. Various studies show between 0-25% of malunion correction surgeries result in nonunion. While rare for malunion correction to result in nonunion healing, the factors of this case actually made it more likely to occur due to the aggravating circumstances.

         A detailed radiographic study by Smith and Rider (1935) observed that delays in union occur as long as fourteen months. Evidence of complete healing is usually present around five months. Based on this lengthy healing time, bony union should not be completely suspected until at least one year has passed (Smith, 1935). Surgery is performed when nonunion is present clinically and radiographically (Ring, 2005). Treatment of nonunion fractures requires absolute immobilization (Scudder, 1915). Only a single bone juncture must heal with a closing wedge osteotomy; therefore, a bone graft is usually unnecessary (Freeland, 2006). Outcomes of the case presented here are inconsistent with the above statements.

        Elderly people are immediately at risk for posttraumatic osteoarthritis due to the presence of generalized osteoarthritis. Younger individuals are less likely to develop posttraumatic osteoarthritis, the exception being involvement at the end of a bone or residual angular deformity (Wright, 1990). Posttraumatic osteoarthritis progresses over years eventually leaving bone-on-bone touching, causing severe pain, loss of mobility, and deformity (Buckwalter, 2003). Even when degeneration begins immediately after injury, these complications take two to five years in the most severe cases, such as joint line fractures and dislocations. Other cases will take ten years (Wright, 1990). The time of diagnosis for the patient’s posttraumatic osteoarthritis was 1.5 years after the original injury, indicating the aggressiveness and severity of the condition.

       Accelerated damage can come from partial dislocation of a joint or malalignment by disrupting the normal force distribution of contact stresses within a joint. Peak stresses are increased in some regions, allowing normal physical activities to produce damaging levels of this focal stress. These increased levels of focal stress will lead to cartilage damage and joint degeneration.  Sport participation further accelerates these changes. Predisposition is given to those with a previous significant joint injury, abnormal anatomy, or alignment. Disruption of normal joint function from malalignment accelerates degenerative changes with participation sports (Buckwalter, 2003).

Conclusion