Volar Plate Fixation for Extra-Articular Proximal Third Phalangeal Fractures of proximal phalanx: A Comparative Study of Tendon-to-Bone Distances and Functional Outcomes

Volar Plate Fixation for Extra-Articular Proximal Third Phalangeal Fractures of proximal phalanx: A Comparative Study of Tendon-to-Bone Distances and Functional Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Volar Plate Fixation for Extra-Articular Proximal Third Phalangeal Fractures of proximal phalanx: A Comparative Study of Tendon-to-Bone Distances and Functional Outcomes Alvin Kai-Xing Lee, Katie Kai-Yuan Lin, Chen-Wei Yeh, Tsung-Yu Ho, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4767987/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Phalangeal fractures, especially those of the proximal phalanx, account for approximately 25% of hand and wrist fractures. Plating is generally associated with severe tendon-related complications and unsatisfactory hand function. Recently, volar plating has been used to fix intra-articular fractures at the base of the proximal phalanx, and it has been reported to result in excellent finger motion and grip strength. We proposed that volar plating has a lower risk of tendon irritation compared to dorsal plating due to the larger tendon-to-bone distances on the volar side. The purpose of this study was to: 1) present the surgical outcomes of 9 cases of extra-articular fractures in the proximal third of the proximal phalanx treated with volar plating, and 2) compare the tendon-to-bone distances between the volar and dorsal sides of the proximal phalanx. Methods A prospective cohort of nine patients with proximal third fractures of the proximal phalanx was recruited. Each patients underwent an MRI of the healthy middle finger on either hand to evaluate the distances between the flexor and extensor tendons and the proximal phalanx. The distances were measured using our in-built measurement tool. Demographics including age, gender, dominant hand, diabetes, smoking, affected fingers were collated. Complications such as extensor lag, wound infections, delayed wound healing, malunion, non-union, delayed union and tendon rupture were recorded. Total active motion (TAM) was also calculated by addition of ROM at the metacarpophalangeal joint, proximal interphalangeal joint and distal interphalangeal joint. Results Nine patients (6 males, 3 females) with fractures of the proximal third of the proximal phalanx were included in this study. All nine patients achieved good bone healing and recovery of functional range of motion (235 ± 24 degrees) after 1 year of follow-up. No major complications were reported, except for one patient with delayed wound healing. The measurements of the distances between the bone and the flexor and extensor tendons were reported as follows. There were significant differences in the average distance from the tendons to the bone cortex for the middle (volar: 1.07 cm, dorsal: 0.21 cm) and distal (volar: 2.96 cm, dorsal: 0.64 cm) third of the proximal phalanx (p = < 0.001). Conclusions The increased tendon-to-bone distance on the volar side may be an important factor contributing to the excellent hand function observed with volar plating in the treatment of proximal phalangeal extra-articular fractures Volar plating tendon irritation extensor lag proximal phalanx fractures Figures Figure 1 Introduction Phalangeal fractures, especially the proximal phalanx, accounts for approximately 25% of hand and wrist fractures [ 1 ], [ 2 ]. Despite this, there is still no common consensus on the optimal treatment strategy for proximal phalanx fractures [ 3 ]. Closed reduction with splinting, buddy taping, or functional bracing had been reported to be suitable for selected patients with non- to minimally displaced, stable, or transverse fractures [ 2 ], [ 4 ]. The criteria for conservative management depend on the degree of displacement, extra-articular involvement, age, compliance, and activity level of patients. In patients requiring surgical interventions, various surgical techniques have been extensively discussed over the past decade, including open reduction and internal fixation (ORIF) with plates, screws or wires, percutaneous pinning, and intramedullary fixation with headless screws [ 2 ]. ORIF with a metallic plate provides good stability for early postoperative rehabilitation, thereby reducing the risk of joint stiffness and promoting faster functional recovery [ 5 ]. However, several complications have been reported with plate fixation of proximal phalanx fracture, including fixed flexion contractures of the proximal interphalangeal joint, extensor tendon irritation or injury, extensor lag, and tendon adhesions [ 1 ]. Secondary surgeries to remove implants are often needed to relieve symptoms and aid functional recovery [ 6 ]. Currently, various surgical approaches for plate fixation of proximal phalanx fractures exist, including volar, lateral and dorsal methods. The dorsal plating method provides direct visualization and access to the fracture site, but it is often associated with high risks of extensor tendon irritation, adhesions, extensor lag, and joint stiffness due to tendon involvement [ 5 ], [ 7 ]. Furthermore, Cheah et al. reported that disruption of the dorsal veins might lead to increased postoperative swelling and a poor range of motion (ROM) [ 8 ]. Conversely, lateral plating has lower risks of tendon irritations but is reported to be more suitable for fractures in the distal and middle thirds of the proximal phalanx. Nonetheless, it has limited space for plate placement, which carries the potential for neurovascular injuries [ 7 ]. Volar plating was first introduced in treating intra-articular fractures of the base of the proximal phalanx by Hattorri et al. [ 9 ]. Excellent functional outcomes, including recovery of up to 98% grip strength and full active range of motion, were reported in their study. However, there were only four cases in their case series. The excellent outcomes were hypothesized to be due to no interferences with the extensor apparatus. [ 9 ]. To our knowledge, there were no other publications reporting on volar plating for extra-articular proximal phalangeal fractures. Furthermore, discussions regarding the relationships between flexor and extensor tendons, as well as dorsal and volar approaches, had not been addressed. We proposed that volar plating had lower risks of tendon irritation compared to dorsal plating due to larger tendon-to-bone distances on the volar side. Therefore, the purpose of this study was to: 1) present the surgical outcomes of 9 cases of extra-articular fractures in the proximal third of the proximal phalanx treated with volar plating, and 2) compare the tendon-to-bone distances between the volar and dorsal sides of the proximal phalanx. Materials and methods Patient cohort This study was approved by the ethics committee of China Medical University Hospital, Taichung, Taiwan and conducted in accordance with the Helsinki Declaration (IRB approval number CMUH110-REC1-66). Written informed consent was obtained from all participants. From January 2022 to December 2022, nine patients with extra-articular proximal third of proximal phalanx fracture treated with volar plate fixation were prospectively recruited. Indications for volar plate fixation in our study fractures of the proximal third of the proximal phalanx in a single digit without any other associated injuries. Contraindications for this procedure include open fractures, concomitant ligament tears, tendon ruptures, neurovascular injuries, multiple fractures, existing associated injuries in other organs, and patients with comorbidities such as cardiovascular diseases or immune-compromised conditions that could affect wound healing. All patients completed at least 6 months of postoperative follow-ups at our department. Surgical procedures: Volar plating with Bruner’s incision done under local anesthesia All nine patients received local anesthesia and was placed under supine position. Skin incision was made using a volar Bruner’s incision. The A1 pulley was partially incised, followed by a complete incision of the A2 pulley, and the neurovascular bundles were identified and well protected. The flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) were then retracted to the radial or ulnar side of the metacarpophalangeal joint to expose the proximal third of the proximal phalanx. Temporary fixation was achieved using traction, and a 1.7mm locking miniplate (Stryker, Germany) was then applied to the volar cortex of the proximal phalanx. The plate position was confirmed using a C-arm image intensifier prior to screws insertion. Intraoperatively, the patient was asked to mobilize the finger immediately after completing the volar plate fixation to check for fixation stability, malalignment or mechanical block. The remnants of the A1 and A2 pulley flaps were placed under the flexor tendons and reapproximated with 4 − 0 nonabsorbable sutures to cover the plate. The wound was closed in layers after final confirmation using intraoperative fluoroscopy. Post-operative care Active finger ROM was allowed immediately after surgery, and sutures were removed at two weeks postoperatively. Subsequently, patients were permitted to return to their full activity level without further restrictions after 6 weeks postoperatively. MRI Evaluation Prior to surgery, the patients underwent an MRI of the healthy middle finger on either hand to evaluate distances between the flexor and extensor tendons and the proximal phalanx. The distances were measured using our in-built measurement tool and as shown in Fig. 1. Demographics including age, gender, dominant hand, diabetes, smoking, affected fingers were collated and presented in Table 1 . Complications and revision surgeries were also compiled and presented in Table 1 . Complications including extensor lag, wound infections, delayed wound healing, malunion, non-union, delayed union and tendon rupture were recorded. Total active motion (TAM) was also calculated by addition of ROM at the metacarpophalangeal joint, proximal interphalangeal joint and distal interphalangeal joint. An intraoperative video recording of the patient performing an active full range of motion of the phalanx was recorded and as shown in Supplementary Video 1. Statistical analyses SPSS software (Version 20) was used for statistical analyses, with a p-value of less than 0.05 considered statistically significant. Student's t-test was used to compare distances between dorsal and volar cortex to extensor and flexor tendons respectively. . Results Nine patients (6 males, 3 females) with proximal phalanx fractures were recruited in this study from January 2022 to December 2022. All fractures were treated using a 1.7mm locking miniplate (Stryker, Germany) with volar plating technique. The mean age was 32 ± 15 years old, the duration from injury to surgical intervention was 4 ± 2 days and the mean follow-ups duration was 12 months. The most common finger involved was the little finger (n = 5), followed by the index finger (n = 2) and the ring finger (n = 2). All patients had proximal third, extra-articular fracture of the proximal phalanx. A video recording of the patient performing an active full range of motion of the phalanx at postoperative 2 months was also as shown in Supplementary Video 2. All nine patients achieved uneventful bone healing and satisfactory recovery of range of motion (235 ± 24 degrees) after one year of follow-up. No major complications were reported, except for one patient with delayed wound healing. The patient had diabetes and with dedicated wound care, the surgical site healed well one month postoperatively. The measurement of distance from extensor and flexor tendons to dorsal and volar cortex of middle finger proximal phalanx were as shown in Table 2a and 2b respectively. As seen from Table 2c, the average distance of flexor tendons to the proximal third, middle third, and distal third of proximal phalanx were 0.95 cm, 1.07 cm, and 2.96 cm respectively, with an average of 1.67 cm. The average distance of extensor tendons to the proximal third, middle third, and distal third of proximal phalanx were 0.67 cm, 0.21 cm, and 0.64 cm respectively, with an average of 0.51 cm. As seen from Table 2c, there were significant differences between the average distance of tendons to bone cortex for the middle (volar: 1.07 cm, dorsal: 0.21 cm) and distal (volar: 2.96 cm, dorsal: 0.64 cm) third of the proximal phalanx (p = < 0.001). Discussions There is currently no consensus regarding the optimal plate fixation strategy for proximal phalanx fractures. In some cases, such as for patients who are glove-wearing workers or janitors, the K-wire fixation technique is an unacceptable treatment option. Plate fixation may be a preferred method due to its fixation strength, allowing for early range of motion rehabilitation [ 5 ], [ 10 ], [ 11 ]. Brei-Thoma et al. reported that, among 32 patients with dorsal plate fixation, 2 required secondary surgery for rotational malunion, 8 had total active motion of less than 180°, and more than half of the patients had extensor lags [ 12 ]. To find an alternative to the dorsal approach, Dabezies et al. were among the pioneers of lateral plating, and their results showed satisfactory functional outcomes in 22 patients, with a mean postoperative total active motion of 243 degrees [ 13 ]. Nevertheless, subsequent studies were unable to reproduce similar results. Instead, several publications have shown that lateral approach has the highest neurovascular injuries amongst all approaches [ 7 ]. The lateral approach only provides limited exposure due to the lateral band of the extensor tendon obstructing the surgical view and fixation of the fracture site may require extensive soft tissue dissection. A recent retrospective study by Robinson et al. showed that the lateral and dorsal plate fixation had similar mediocre functional outcomes [ 7 ]. However, Omokawa et al. conducted a prospective study and demonstrated that lateral plating fared significantly better than dorsal plating in terms of total active mobility [ 14 ]. It was also reported to have lower rates of tendons-related complications as compared to dorsal plate [ 5 ], [ 7 ]. From an anatomical perspective, this is only true when the fracture occurs in the middle and distal thirds of the proximal phalanx as the lateral band of the extensor tendon lies on the lateral side of the proximal third of the proximal phalanx. For reducing an intra-articular fracture of proximal phalanx, Hattori et al. performed ORIF on the base of proximal phalanx fracture via a volar approach in 4 patients and reported excellent functional outcomes with no cases of tendon-related complications [ 9 ]. Their results suggested that volar approach might be an alternative approach to avoid extensor tendons complications when treating proximal phalangeal fracture. According to our knowledge, our study is currently the largest series reporting on volar plating for proximal third of the phalangeal fracture. Instead of longitudinal splitting of the extensor tendon via the dorsal approach, volar approach uses pulleys venting technique and retraction of FDP and FDS for fracture site visualization and plate placement [ 8 ]. Even though volar plating preserves the integrity of extensor mechanisms, several key surgical considerations must be noted during the procedure. Firstly, iatrogenic injuries to the neurovascular bundles should be avoided through meticulous dissection. Secondly, the plates should be positioned to avoid impingement, especially during deep flexion of metacarpophalangeal joint. Lastly, bowstringing effects of the flexor tendon can be prevented by making a controlled incision to the pulley system. The function of the pulley systems is to ensure stabilization of flexor tendons to volar aspect of the phalanx, thereby enabling the tendons to glide smoothly during range of motion in flexion-extension arc. Even though the integrity of the pulley was reported to affect finger kinematics and ROM, it had been shown that preservation of ideal finger ROM was still allowed even after 50% of the A2 or A4 pulleys had been sacrificed [ 15 ]. A recent study by Cox et al. pointed out that in selective venting of one of the two pulleys, finger ROM was not affected if the rest of synovial sheath and cruciate pulleys were intact [ 16 ], [17]. In this case series, partial excision of distal A1 pulley and complete excision of the A2 pulley were performed. After plate fixation, the excised A1 and A2 pulley flaps were placed under the flexor tendons and reapproximated with 4 − 0 nonabsorbable sutures to cover the plate. This ensured that the tendon remained protected from plate, and the distance between tendon and bone can be further increased after pully venting without causing a bowstring effect. The main concern with plate fixation for phalangeal fracture is the space-occupying effect of the plate and the area of contact between tendon and plate, which adversely affects tendon gliding. In our study, it is worth mentioning that all patients achieved satisfactory active ROM even with implant retention. In contrast, dorsal plating has been reported to have higher rates of complications such as fixed flexion contractures of the proximal interphalangeal joint, extensor tendon irritation or injury, extensor lags, and tendon adhesions [ 9 ], [ 11 ]. The plates used in our study were approximately 10 mm in thickness. Our MRI results confirmed that the average tendon-to-bone distances on the volar side was greater than 10 mm and that the volar side had higher tendon-to-bone distances as compared to the dorsal side. This result showed that there is more room for volar plate fixation to avoid tendon attrition or adhesion as compared to dorsal plate fixation. The average distance for the dorsal side was 0.67 cm, 0.21 cm and 0.64 cm for the proximal, middle and distal proximal phalanx. Therefore, there are high concerns for tendon irritation and extensor lags as there are insufficient space for placement of the plate for dorsal plate fixation. Furthermore, the extensor tendons are flatter, thinner, broader and are more superficial as compared to the flexor tendons. According to a study conducted by Xiao et al., the extensor tendons are weaker and tend to be overstretched during active movement [ 5 ]. Together with decreased tendon-to-bone distances, plate placement on the dorsal side might affect sliding capacity of the tendon and subsequently lead to functional diminishment due to pain, thereby further increasing chances of adhesion. Our low complication rates and excellent functional results echo the finding of Hattori et al., suggesting that volar plating is not only a solution for intra-articular fractures of the proximal phalangeal base but can also be applied to metaphyseal and proximal phalangeal shaft fracture. A limitation of our study was the small sample size involved which would lead to Type II errors. Therefore, future prospective studies would involve comparative studies between the various approaches with a larger sample size. In addition, future studies would involve validating for distances between bone and tendon of proximal third of proximal phalanx after pulley release and inclusion of dorsal plating for comparative evaluation. Conclusions There is currently no consensus regarding the optimal plate fixation strategy for proximal phalanx fractures. The increased tendon-to-bone distance on the volar side may be an important factor contributing to the excellent hand function observed with volar plating in the treatment of proximal phalangeal extra-articular fractures. Declarations Consent for publication Not applicable Conflict of interest statement Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. Authors’ contributions Kai-Xing, Alvin Lee and Katie Kai-Yuan Lin conceptualized the study design and drafted the article. Chen-Wei Yeh, Tsung-Yu Ho and Wei-Chih Wang compiled data and conducted results analysis. Yung-Cheng Chiu was the attending surgeon in charge. Cheng-En Hsu and Yi-Hsun Huang revised the manuscript. The authors read and approved the final manuscript. Availability of data and materials All data generated in this study are included in this article. Human ethics and Consent to participate This study was approved by the ethics committee of China Medical University Hospital, Taichung, Taiwan and conducted in accordance with the Helsinki Declaration (IRB approval number CMUH110-REC1-66). All patients were briefed and provided a signed informed consent regarding participation in this study. Funding The authors declare that they received no funding for this study. Competing interests The authors declare that they have no competing interests in this study. References J. J. Heifner and F. Rubio, “Fractures of the phalanges,” The Journal of Hand Surgery: European Volume , vol. 48, no. 2_suppl. SAGE Publications Ltd, pp. 18S-26S, Sep. 01, 2023. doi: 10.1177/17531934231185219. T. T. Lögters, H. H. Lee, S. Gehrmann, J. Windolf, and R. A. Kaufmann, “Proximal Phalanx Fracture Management,” Hand , vol. 13, no. 4. SAGE Publications Inc., pp. 376–383, Jul. 01, 2018. doi: 10.1177/1558944717735947. S. Carpenter and R. S. Rohde, “Treatment of phalangeal fractures,” Hand Clinics , vol. 29, no. 4. pp. 519–534, Nov. 2013. doi: 10.1016/j.hcl.2013.08.006. S. Takigawa, S. Meletiou, M. Sauerbier, and W. P. Cooney, “Long-term assessment of swanson implant arthroplasty in the proximal interphalangeal joint of the hand,” Journal of Hand Surgery , vol. 29, no. 5, pp. 785–795, 2004, doi: 10.1016/j.jhsa.2004.03.008. G. Xiao, J. Wang, N. Zhang, and J. Hao, “Factors predicting the adhesion and prolonged lost days of work in patients with extensor tendon adhesion of the hand,” Front Surg , vol. 11, May 2024, doi: 10.3389/fsurg.2024.1304202. A. D. Widgerow, M. Edinburg, and S. L. Biddulph, “An analysis of proximal phalangeal fractures,” J Hand Surg Am , vol. 12, no. 1, pp. 134–139, 1987, doi: 10.1016/S0363-5023(87)80178-8. L. P. Robinson et al. , “Dorsal versus lateral plate fixation of finger proximal phalangeal fractures: a retrospective study,” Arch Orthop Trauma Surg , vol. 137, no. 4, pp. 567–572, Apr. 2017, doi: 10.1007/s00402-017-2650-x. A. E. J. Cheah and J. Yao, “Surgical Approaches to the Proximal Interphalangeal Joint,” Journal of Hand Surgery , vol. 41, no. 2. W.B. Saunders, pp. 294–305, Feb. 01, 2016. doi: 10.1016/j.jhsa.2015.11.013. Y. Hattori, K. Doi, S. Sakamoto, H. Yamasaki, A. Wahegaonkar, and A. Addosooki, “Volar Plating for Intra-Articular Fracture of the Base of the Proximal Phalanx,” J Hand Surg Am , vol. 32A, no. 8, pp. 1299–1303, 2007. K. Silins, T. Turkmen, E. Vögelin, and L. C. P. Haug, “Comparing treatment of proximal phalangeal fractures with intramedullary screws versus plating,” Arch Orthop Trauma Surg , vol. 143, no. 3, pp. 1699–1706, Mar. 2023, doi: 10.1007/s00402-022-04516-z. C. J. Nessralla, K. Ranganath, K. A. Benavent, D. Zhang, B. E. Earp, and P. Blazar, “Risks of Reoperation in Surgically Treated Fractures of the Proximal Phalanx,” J Hand Surg Glob Online , vol. 6, no. 2, pp. 169–172, Mar. 2024, doi: 10.1016/j.jhsg.2023.11.004. P. Brei-Thoma, E. Vögelin, and T. Franz, “Plate fixation of extra-articular fractures of the proximal phalanx: do new implants cause less problems?,” Arch Orthop Trauma Surg , vol. 135, no. 3, pp. 439–445, Mar. 2015, doi: 10.1007/s00402-015-2155-4. E. J. Dabezies and J. P. Schutte, “Fixation of metacarpal and phalangeal fractures with miniature plates and screws,” J Hand Surg Am , vol. 11, no. 2, pp. 283–288, 1986, doi: 10.1016/S0363-5023(86)80072-7. S. Omokawa, R. Fujitani, Y. Dohi, T. Okawa, and H. Yajima, “Prospective Outcomes of Comminuted Periarticular Metacarpal and Phalangeal Fractures Treated Using a Titanium Plate System,” J Hand Surg Am , vol. 33, no. 6, pp. 857–863, Jul. 2008, doi: 10.1016/j.jhsa.2008.01.040. J. W. Vahey, L. Vegas, and D. A. Wegner, “Effect of Proximal Phalangeal Fracture Deformity on Extensor Tendon Function,” J Hand Surg Am , vol. 23A, no. 4, pp. 673–681, 1998. H. G. Cox, J. B. Hill, A. F. Colon, P. Abbasi, A. M. Giladi, and R. D. Katz, “The Impact of Dividing the Flexor Tendon Pulleys on Tendon Excursion and Work of Flexion in a Cadaveric Model,” J Hand Surg Am , vol. 46, no. 12, pp. 1064–1070, Dec. 2021, doi: 10.1016/j.jhsa.2021.05.013. Tables Table 1. Demographics and baseline characteristics Number of patients (n = 9) % Age (years old) 32 ± 15 - Gender Male 6 66.67 Female 3 33.33 Injury to surgery interval (days) 4 ± 2 Operated hand Left 5 55.56 Right 4 44.44 Dominant hand Yes 7 77.78 No 2 22.22 Comminuted Yes 3 33.33 No 6 66.67 Diabetic Yes 1 11.11 No 8 88.89 Smoker Yes 6 66.67 No 3 33.33 Complications 1 (poor wound healing) 11.11 Secondary surgery (including removal of implant) 4 (removal of implant) - Follow up durations (months) 14 ± 2 - Mean total active motion (degrees) 235 ± 24 Table 2a. The distance between flexor tendon to distal third, middle third, proximal third of volar bone cortex of proximal phalanx in middle phalanx Proximal (cm) Middle (cm) Distal (cm) Average of volar side (cm) Patient 1 0.77 0.72 1.74 1.08 Patient 2 0.64 1.45 2.91 1.67 Patient 3 0.84 1.07 2.7 1.54 Patient 4 1.28 1.15 3.1 1.84 Patient 5 0.53 1.29 2.92 1.58 Patient 6 1.14 1.01 3.32 1.82 Patient 7 0.93 0.93 3.55 1.8 Patient 8 1.43 1.26 3.25 1.98 Patient 9 1.26 0.75 3.13 1.71 Average 0.95 1.07 2.96 1.67 SD 0.31 0.25 0.52 0.26 Table 2b. The distance between extensor tendon to distal third, middle third, proximal third of dorsal bone cortex of proximal phalanx in middle phalanx Proximal (cm) Middle (cm) Distal (cm) Average of dorsal side (cm) Patient 1 0.52 0.35 0.35 0.4 Patient 2 0.11 0.11 0.23 0.15 Patient 3 0.88 0.21 0.73 0.61 Patient 4 0.25 0.13 0.57 0.32 Patient 5 1.29 0.19 0.53 0.67 Patient 6 0.56 0.28 0.68 0.51 Patient 7 1.01 0.23 1.07 0.77 Patient 8 0.39 0.27 0.74 0.47 Patient 9 0.99 0.14 0.86 0.66 Average 0.67 0.21 0.64 0.51 SD 0.40 0.08 0.26 0.20 Table 2c. The average distance between the volar and dorsal cortex of the proximal phalanx in the middle phalanx. Average distance of volar side (cm) Average distance of dorsal side (cm) p value Proximal third 0.95 0.67 0.1164 Middle third 1.07 0.21 <0.001 Distal third 2.96 0.64 <0.001 Additional Declarations No competing interests reported. Supplementary Files Supplementary1.VideorecordingofintraoperativeROM.mp4 Supplementary2.Videorecordingofpostoperative2months.mp4 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4767987","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":331408974,"identity":"2c73c0cc-8634-45dd-8b99-5494319178a7","order_by":0,"name":"Alvin Kai-Xing Lee","email":"","orcid":"","institution":"China Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Alvin","middleName":"Kai-Xing","lastName":"Lee","suffix":""},{"id":331408975,"identity":"a4d5e24a-691e-44f0-93f2-ffc0cdd1b44d","order_by":1,"name":"Katie Kai-Yuan Lin","email":"","orcid":"","institution":"China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Katie","middleName":"Kai-Yuan","lastName":"Lin","suffix":""},{"id":331408976,"identity":"f0b6dc08-bf72-487c-bfe6-ddc3633ec262","order_by":2,"name":"Chen-Wei Yeh","email":"","orcid":"","institution":"China Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chen-Wei","middleName":"","lastName":"Yeh","suffix":""},{"id":331408977,"identity":"321a89e5-b901-472d-8125-4d726df81322","order_by":3,"name":"Tsung-Yu Ho","email":"","orcid":"","institution":"China Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tsung-Yu","middleName":"","lastName":"Ho","suffix":""},{"id":331408978,"identity":"27f95c2d-eafa-4b0a-82ed-da963831dd18","order_by":4,"name":"Wei-Chih Wang","email":"","orcid":"","institution":"China Medical University Hsinchu Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wei-Chih","middleName":"","lastName":"Wang","suffix":""},{"id":331408979,"identity":"9ceeb7da-9e41-4f11-a917-f3bfa529c081","order_by":5,"name":"Yi-Hsun Huang","email":"","orcid":"","institution":"China Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yi-Hsun","middleName":"","lastName":"Huang","suffix":""},{"id":331408980,"identity":"07174d33-edca-49b0-b4b6-b111e6f344a6","order_by":6,"name":"Cheng-En Hsu","email":"","orcid":"","institution":"Taichung Veterans General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Cheng-En","middleName":"","lastName":"Hsu","suffix":""},{"id":331408981,"identity":"d36aab3f-f89f-4469-9163-a1ef1cacf4b4","order_by":7,"name":"Yung-Cheng Chiu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYBACAyCWYGyQYOBnZmA8wMDATIIWyWYGBpK0ABkHiNVizn724I2fOywSNx9nfnDgY5s1A397dwJeLZY9ecmWvWckErcdZjM4OLMtnUHizNkN+B12IMdMmrENpIWH4TBv22EGA4lcAlrOv4Fo2dxMtJYbUFs2MBOv5Y2xZW+bhPEMkF9mnEvnIeyX8zmGN3621cn29x9++OBDmbUcf3svfi0YgIc05aNgFIyCUTAKsAIA6A1IcJvCyAgAAAAASUVORK5CYII=","orcid":"","institution":"China Medical University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yung-Cheng","middleName":"","lastName":"Chiu","suffix":""}],"badges":[],"createdAt":"2024-07-19 13:06:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4767987/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4767987/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62733180,"identity":"fcf0bbb5-aaae-49d5-8cf9-b3912557914f","added_by":"auto","created_at":"2024-08-18 23:54:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":552245,"visible":true,"origin":"","legend":"\u003cp\u003eMRI images of (A) left middle finger of a 35 years old male and (B) right middle finger of a 40 years old male and the respective distances between the flexor and extensor tendons and the proximal phalanx. The distances were measured using our in-built measuring tool and measured at the proximal, middle and distal portion as indicated.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4767987/v1/bfeebc731cd9f9a427b3aa37.png"},{"id":105904960,"identity":"338148fc-fe4c-4735-b79e-82737b933f4d","added_by":"auto","created_at":"2026-04-01 10:11:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1264324,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4767987/v1/9f5c2107-0e02-431a-9e43-0da169cf07ff.pdf"},{"id":62733179,"identity":"4bde0b0a-31a7-47d4-b81f-e42ac699ac0b","added_by":"auto","created_at":"2024-08-18 23:54:14","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":33563789,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary1.VideorecordingofintraoperativeROM.mp4","url":"https://assets-eu.researchsquare.com/files/rs-4767987/v1/0387d9385d4041f264c4a0bf.mp4"},{"id":62733178,"identity":"47e6ba18-f0a8-4650-9651-4b8a7ad8a352","added_by":"auto","created_at":"2024-08-18 23:54:13","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":37758669,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary2.Videorecordingofpostoperative2months.mp4","url":"https://assets-eu.researchsquare.com/files/rs-4767987/v1/46c376ab52e719d1479ff3a2.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Volar Plate Fixation for Extra-Articular Proximal Third Phalangeal Fractures of proximal phalanx: A Comparative Study of Tendon-to-Bone Distances and Functional Outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePhalangeal fractures, especially the proximal phalanx, accounts for approximately 25% of hand and wrist fractures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite this, there is still no common consensus on the optimal treatment strategy for proximal phalanx fractures [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Closed reduction with splinting, buddy taping, or functional bracing had been reported to be suitable for selected patients with non- to minimally displaced, stable, or transverse fractures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The criteria for conservative management depend on the degree of displacement, extra-articular involvement, age, compliance, and activity level of patients. In patients requiring surgical interventions, various surgical techniques have been extensively discussed over the past decade, including open reduction and internal fixation (ORIF) with plates, screws or wires, percutaneous pinning, and intramedullary fixation with headless screws [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eORIF with a metallic plate provides good stability for early postoperative rehabilitation, thereby reducing the risk of joint stiffness and promoting faster functional recovery [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, several complications have been reported with plate fixation of proximal phalanx fracture, including fixed flexion contractures of the proximal interphalangeal joint, extensor tendon irritation or injury, extensor lag, and tendon adhesions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Secondary surgeries to remove implants are often needed to relieve symptoms and aid functional recovery [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Currently, various surgical approaches for plate fixation of proximal phalanx fractures exist, including volar, lateral and dorsal methods. The dorsal plating method provides direct visualization and access to the fracture site, but it is often associated with high risks of extensor tendon irritation, adhesions, extensor lag, and joint stiffness due to tendon involvement [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Furthermore, Cheah et al. reported that disruption of the dorsal veins might lead to increased postoperative swelling and a poor range of motion (ROM) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Conversely, lateral plating has lower risks of tendon irritations but is reported to be more suitable for fractures in the distal and middle thirds of the proximal phalanx. Nonetheless, it has limited space for plate placement, which carries the potential for neurovascular injuries [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVolar plating was first introduced in treating intra-articular fractures of the base of the proximal phalanx by Hattorri et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Excellent functional outcomes, including recovery of up to 98% grip strength and full active range of motion, were reported in their study. However, there were only four cases in their case series. The excellent outcomes were hypothesized to be due to no interferences with the extensor apparatus. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. To our knowledge, there were no other publications reporting on volar plating for extra-articular proximal phalangeal fractures. Furthermore, discussions regarding the relationships between flexor and extensor tendons, as well as dorsal and volar approaches, had not been addressed. We proposed that volar plating had lower risks of tendon irritation compared to dorsal plating due to larger tendon-to-bone distances on the volar side. Therefore, the purpose of this study was to: 1) present the surgical outcomes of 9 cases of extra-articular fractures in the proximal third of the proximal phalanx treated with volar plating, and 2) compare the tendon-to-bone distances between the volar and dorsal sides of the proximal phalanx.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003ePatient cohort\u003c/h2\u003e\n \u003cp\u003eThis study was approved by the ethics committee of China Medical University Hospital, Taichung, Taiwan and conducted in accordance with the Helsinki Declaration (IRB approval number CMUH110-REC1-66). Written informed consent was obtained from all participants. From January 2022 to December 2022, nine patients with extra-articular proximal third of proximal phalanx fracture treated with volar plate fixation were prospectively recruited. Indications for volar plate fixation in our study fractures of the proximal third of the proximal phalanx in a single digit without any other associated injuries. Contraindications for this procedure include open fractures, concomitant ligament tears, tendon ruptures, neurovascular injuries, multiple fractures, existing associated injuries in other organs, and patients with comorbidities such as cardiovascular diseases or immune-compromised conditions that could affect wound healing. All patients completed at least 6 months of postoperative follow-ups at our department.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eSurgical procedures: Volar plating with Bruner\u0026rsquo;s incision done under local anesthesia\u003c/h2\u003e\n \u003cp\u003eAll nine patients received local anesthesia and was placed under supine position. Skin incision was made using a volar Bruner\u0026rsquo;s incision. The A1 pulley was partially incised, followed by a complete incision of the A2 pulley, and the neurovascular bundles were identified and well protected. The flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) were then retracted to the radial or ulnar side of the metacarpophalangeal joint to expose the proximal third of the proximal phalanx. Temporary fixation was achieved using traction, and a 1.7mm locking miniplate (Stryker, Germany) was then applied to the volar cortex of the proximal phalanx. The plate position was confirmed using a C-arm image intensifier prior to screws insertion. Intraoperatively, the patient was asked to mobilize the finger immediately after completing the volar plate fixation to check for fixation stability, malalignment or mechanical block. The remnants of the A1 and A2 pulley flaps were placed under the flexor tendons and reapproximated with 4\u0026thinsp;\u0026minus;\u0026thinsp;0 nonabsorbable sutures to cover the plate. The wound was closed in layers after final confirmation using intraoperative fluoroscopy.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003ePost-operative care\u003c/h2\u003e\n \u003cp\u003eActive finger ROM was allowed immediately after surgery, and sutures were removed at two weeks postoperatively. Subsequently, patients were permitted to return to their full activity level without further restrictions after 6 weeks postoperatively.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eMRI Evaluation\u003c/h2\u003e\n \u003cp\u003ePrior to surgery, the patients underwent an MRI of the healthy middle finger on either hand to evaluate distances between the flexor and extensor tendons and the proximal phalanx. The distances were measured using our in-built measurement tool and as shown in Fig. 1. Demographics including age, gender, dominant hand, diabetes, smoking, affected fingers were collated and presented in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Complications and revision surgeries were also compiled and presented in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Complications including extensor lag, wound infections, delayed wound healing, malunion, non-union, delayed union and tendon rupture were recorded. Total active motion (TAM) was also calculated by addition of ROM at the metacarpophalangeal joint, proximal interphalangeal joint and distal interphalangeal joint. An intraoperative video recording of the patient performing an active full range of motion of the phalanx was recorded and as shown in Supplementary Video 1.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical analyses\u003c/h2\u003e\n \u003cp\u003eSPSS software (Version 20) was used for statistical analyses, with a p-value of less than 0.05 considered statistically significant. Student\u0026apos;s t-test was used to compare distances between dorsal and volar cortex to extensor and flexor tendons respectively. .\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eNine patients (6 males, 3 females) with proximal phalanx fractures were recruited in this study from January 2022 to December 2022. All fractures were treated using a 1.7mm locking miniplate (Stryker, Germany) with volar plating technique. The mean age was 32 \u0026plusmn; 15 years old, the duration from injury to surgical intervention was 4 \u0026plusmn; 2 days and the mean follow-ups duration was 12 months. The most common finger involved was the little finger (n = 5), followed by the index finger (n = 2) and the ring finger (n = 2). All patients had proximal third, extra-articular fracture of the proximal phalanx. A video recording of the patient performing an active full range of motion of the phalanx at postoperative 2 months was also as shown in Supplementary Video 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll nine patients achieved uneventful bone healing and satisfactory recovery of range of motion (235 \u0026plusmn; 24 degrees) after one year of follow-up. No major complications were reported, except for one patient with delayed wound healing. The patient had diabetes and with dedicated wound care, the surgical site healed well one month postoperatively. The measurement of distance from extensor and flexor tendons to dorsal and volar cortex of middle finger proximal phalanx were as shown in Table 2a and 2b respectively. As seen from Table 2c, the average distance of flexor tendons to the proximal third, middle third, and distal third of proximal phalanx were 0.95 cm, 1.07 cm, and 2.96 cm respectively, with an average of 1.67 cm. The average distance of extensor tendons to the proximal third, middle third, and distal third of proximal phalanx were 0.67 cm, 0.21 cm, and 0.64 cm respectively, with an average of 0.51 cm. As seen from Table 2c, there were significant differences between the average distance of tendons to bone cortex for the middle (volar: 1.07 cm, dorsal: 0.21 cm) and distal (volar: 2.96 cm, dorsal: 0.64 cm) third of the proximal phalanx (p = \u0026lt; 0.001).\u003c/p\u003e"},{"header":"Discussions","content":"\u003cp\u003eThere is currently no consensus regarding the optimal plate fixation strategy for proximal phalanx fractures. In some cases, such as for patients who are glove-wearing workers or janitors, the K-wire fixation technique is an unacceptable treatment option. Plate fixation may be a preferred method due to its fixation strength, allowing for early range of motion rehabilitation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Brei-Thoma et al. reported that, among 32 patients with dorsal plate fixation, 2 required secondary surgery for rotational malunion, 8 had total active motion of less than 180\u0026deg;, and more than half of the patients had extensor lags [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. To find an alternative to the dorsal approach, Dabezies et al. were among the pioneers of lateral plating, and their results showed satisfactory functional outcomes in 22 patients, with a mean postoperative total active motion of 243 degrees [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Nevertheless, subsequent studies were unable to reproduce similar results. Instead, several publications have shown that lateral approach has the highest neurovascular injuries amongst all approaches [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The lateral approach only provides limited exposure due to the lateral band of the extensor tendon obstructing the surgical view and fixation of the fracture site may require extensive soft tissue dissection. A recent retrospective study by Robinson et al. showed that the lateral and dorsal plate fixation had similar mediocre functional outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, Omokawa et al. conducted a prospective study and demonstrated that lateral plating fared significantly better than dorsal plating in terms of total active mobility [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. It was also reported to have lower rates of tendons-related complications as compared to dorsal plate [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. From an anatomical perspective, this is only true when the fracture occurs in the middle and distal thirds of the proximal phalanx as the lateral band of the extensor tendon lies on the lateral side of the proximal third of the proximal phalanx. For reducing an intra-articular fracture of proximal phalanx, Hattori et al. performed ORIF on the base of proximal phalanx fracture via a volar approach in 4 patients and reported excellent functional outcomes with no cases of tendon-related complications [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Their results suggested that volar approach might be an alternative approach to avoid extensor tendons complications when treating proximal phalangeal fracture. According to our knowledge, our study is currently the largest series reporting on volar plating for proximal third of the phalangeal fracture.\u003c/p\u003e \u003cp\u003eInstead of longitudinal splitting of the extensor tendon via the dorsal approach, volar approach uses pulleys venting technique and retraction of FDP and FDS for fracture site visualization and plate placement [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Even though volar plating preserves the integrity of extensor mechanisms, several key surgical considerations must be noted during the procedure. Firstly, iatrogenic injuries to the neurovascular bundles should be avoided through meticulous dissection. Secondly, the plates should be positioned to avoid impingement, especially during deep flexion of metacarpophalangeal joint. Lastly, bowstringing effects of the flexor tendon can be prevented by making a controlled incision to the pulley system. The function of the pulley systems is to ensure stabilization of flexor tendons to volar aspect of the phalanx, thereby enabling the tendons to glide smoothly during range of motion in flexion-extension arc. Even though the integrity of the pulley was reported to affect finger kinematics and ROM, it had been shown that preservation of ideal finger ROM was still allowed even after 50% of the A2 or A4 pulleys had been sacrificed [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A recent study by Cox et al. pointed out that in selective venting of one of the two pulleys, finger ROM was not affected if the rest of synovial sheath and cruciate pulleys were intact [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], [17]. In this case series, partial excision of distal A1 pulley and complete excision of the A2 pulley were performed. After plate fixation, the excised A1 and A2 pulley flaps were placed under the flexor tendons and reapproximated with 4\u0026thinsp;\u0026minus;\u0026thinsp;0 nonabsorbable sutures to cover the plate. This ensured that the tendon remained protected from plate, and the distance between tendon and bone can be further increased after pully venting without causing a bowstring effect.\u003c/p\u003e \u003cp\u003eThe main concern with plate fixation for phalangeal fracture is the space-occupying effect of the plate and the area of contact between tendon and plate, which adversely affects tendon gliding. In our study, it is worth mentioning that all patients achieved satisfactory active ROM even with implant retention. In contrast, dorsal plating has been reported to have higher rates of complications such as fixed flexion contractures of the proximal interphalangeal joint, extensor tendon irritation or injury, extensor lags, and tendon adhesions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The plates used in our study were approximately 10 mm in thickness. Our MRI results confirmed that the average tendon-to-bone distances on the volar side was greater than 10 mm and that the volar side had higher tendon-to-bone distances as compared to the dorsal side. This result showed that there is more room for volar plate fixation to avoid tendon attrition or adhesion as compared to dorsal plate fixation. The average distance for the dorsal side was 0.67 cm, 0.21 cm and 0.64 cm for the proximal, middle and distal proximal phalanx. Therefore, there are high concerns for tendon irritation and extensor lags as there are insufficient space for placement of the plate for dorsal plate fixation. Furthermore, the extensor tendons are flatter, thinner, broader and are more superficial as compared to the flexor tendons. According to a study conducted by Xiao et al., the extensor tendons are weaker and tend to be overstretched during active movement [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Together with decreased tendon-to-bone distances, plate placement on the dorsal side might affect sliding capacity of the tendon and subsequently lead to functional diminishment due to pain, thereby further increasing chances of adhesion. Our low complication rates and excellent functional results echo the finding of Hattori et al., suggesting that volar plating is not only a solution for intra-articular fractures of the proximal phalangeal base but can also be applied to metaphyseal and proximal phalangeal shaft fracture.\u003c/p\u003e \u003cp\u003eA limitation of our study was the small sample size involved which would lead to Type II errors. Therefore, future prospective studies would involve comparative studies between the various approaches with a larger sample size. In addition, future studies would involve validating for distances between bone and tendon of proximal third of proximal phalanx after pulley release and inclusion of dorsal plating for comparative evaluation.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThere is currently no consensus regarding the optimal plate fixation strategy for proximal phalanx fractures. The increased tendon-to-bone distance on the volar side may be an important factor contributing to the excellent hand function observed with volar plating in the treatment of proximal phalangeal extra-articular fractures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKai-Xing, Alvin Lee and Katie Kai-Yuan Lin conceptualized the study design and drafted the article. Chen-Wei Yeh, Tsung-Yu Ho and Wei-Chih Wang compiled data and conducted results analysis. Yung-Cheng Chiu was the attending surgeon in charge. Cheng-En Hsu and\u0026nbsp;Yi-Hsun Huang\u0026nbsp;revised the manuscript. The authors read and approved the final manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated in this study are included in this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman ethics and Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics committee of China Medical University Hospital, Taichung, Taiwan and conducted in accordance with the Helsinki Declaration (IRB approval number CMUH110-REC1-66). All patients were briefed and provided a signed informed consent regarding participation in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they received no funding for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJ. J. Heifner and F. Rubio, \u0026ldquo;Fractures of the phalanges,\u0026rdquo; \u003cem\u003eThe Journal of Hand Surgery: European Volume\u003c/em\u003e, vol. 48, no. 2_suppl. SAGE Publications Ltd, pp. 18S-26S, Sep. 01, 2023. doi: 10.1177/17531934231185219.\u003c/li\u003e\n\u003cli\u003eT. T. L\u0026ouml;gters, H. H. Lee, S. Gehrmann, J. Windolf, and R. A. Kaufmann, \u0026ldquo;Proximal Phalanx Fracture Management,\u0026rdquo; \u003cem\u003eHand\u003c/em\u003e, vol. 13, no. 4. SAGE Publications Inc., pp. 376\u0026ndash;383, Jul. 01, 2018. doi: 10.1177/1558944717735947.\u003c/li\u003e\n\u003cli\u003eS. Carpenter and R. S. Rohde, \u0026ldquo;Treatment of phalangeal fractures,\u0026rdquo; \u003cem\u003eHand Clinics\u003c/em\u003e, vol. 29, no. 4. pp. 519\u0026ndash;534, Nov. 2013. doi: 10.1016/j.hcl.2013.08.006.\u003c/li\u003e\n\u003cli\u003eS. Takigawa, S. Meletiou, M. Sauerbier, and W. P. Cooney, \u0026ldquo;Long-term assessment of swanson implant arthroplasty in the proximal interphalangeal joint of the hand,\u0026rdquo; \u003cem\u003eJournal of Hand Surgery\u003c/em\u003e, vol. 29, no. 5, pp. 785\u0026ndash;795, 2004, doi: 10.1016/j.jhsa.2004.03.008.\u003c/li\u003e\n\u003cli\u003eG. Xiao, J. Wang, N. Zhang, and J. Hao, \u0026ldquo;Factors predicting the adhesion and prolonged lost days of work in patients with extensor tendon adhesion of the hand,\u0026rdquo; \u003cem\u003eFront Surg\u003c/em\u003e, vol. 11, May 2024, doi: 10.3389/fsurg.2024.1304202.\u003c/li\u003e\n\u003cli\u003eA. D. Widgerow, M. Edinburg, and S. L. Biddulph, \u0026ldquo;An analysis of proximal phalangeal fractures,\u0026rdquo; \u003cem\u003eJ Hand Surg Am\u003c/em\u003e, vol. 12, no. 1, pp. 134\u0026ndash;139, 1987, doi: 10.1016/S0363-5023(87)80178-8.\u003c/li\u003e\n\u003cli\u003eL. P. Robinson \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Dorsal versus lateral plate fixation of finger proximal phalangeal fractures: a retrospective study,\u0026rdquo; \u003cem\u003eArch Orthop Trauma Surg\u003c/em\u003e, vol. 137, no. 4, pp. 567\u0026ndash;572, Apr. 2017, doi: 10.1007/s00402-017-2650-x.\u003c/li\u003e\n\u003cli\u003eA. E. J. Cheah and J. Yao, \u0026ldquo;Surgical Approaches to the Proximal Interphalangeal Joint,\u0026rdquo; \u003cem\u003eJournal of Hand Surgery\u003c/em\u003e, vol. 41, no. 2. W.B. Saunders, pp. 294\u0026ndash;305, Feb. 01, 2016. doi: 10.1016/j.jhsa.2015.11.013.\u003c/li\u003e\n\u003cli\u003eY. Hattori, K. Doi, S. Sakamoto, H. Yamasaki, A. Wahegaonkar, and A. Addosooki, \u0026ldquo;Volar Plating for Intra-Articular Fracture of the Base of the Proximal Phalanx,\u0026rdquo; \u003cem\u003eJ Hand Surg Am\u003c/em\u003e, vol. 32A, no. 8, pp. 1299\u0026ndash;1303, 2007.\u003c/li\u003e\n\u003cli\u003eK. Silins, T. Turkmen, E. V\u0026ouml;gelin, and L. C. P. Haug, \u0026ldquo;Comparing treatment of proximal phalangeal fractures with intramedullary screws versus plating,\u0026rdquo; \u003cem\u003eArch Orthop Trauma Surg\u003c/em\u003e, vol. 143, no. 3, pp. 1699\u0026ndash;1706, Mar. 2023, doi: 10.1007/s00402-022-04516-z.\u003c/li\u003e\n\u003cli\u003eC. J. Nessralla, K. Ranganath, K. A. Benavent, D. Zhang, B. E. Earp, and P. Blazar, \u0026ldquo;Risks of Reoperation in Surgically Treated Fractures of the Proximal Phalanx,\u0026rdquo; \u003cem\u003eJ Hand Surg Glob Online\u003c/em\u003e, vol. 6, no. 2, pp. 169\u0026ndash;172, Mar. 2024, doi: 10.1016/j.jhsg.2023.11.004.\u003c/li\u003e\n\u003cli\u003eP. Brei-Thoma, E. V\u0026ouml;gelin, and T. Franz, \u0026ldquo;Plate fixation of extra-articular fractures of the proximal phalanx: do new implants cause less problems?,\u0026rdquo; \u003cem\u003eArch Orthop Trauma Surg\u003c/em\u003e, vol. 135, no. 3, pp. 439\u0026ndash;445, Mar. 2015, doi: 10.1007/s00402-015-2155-4.\u003c/li\u003e\n\u003cli\u003eE. J. Dabezies and J. P. Schutte, \u0026ldquo;Fixation of metacarpal and phalangeal fractures with miniature plates and screws,\u0026rdquo; \u003cem\u003eJ Hand Surg Am\u003c/em\u003e, vol. 11, no. 2, pp. 283\u0026ndash;288, 1986, doi: 10.1016/S0363-5023(86)80072-7.\u003c/li\u003e\n\u003cli\u003eS. Omokawa, R. Fujitani, Y. Dohi, T. Okawa, and H. Yajima, \u0026ldquo;Prospective Outcomes of Comminuted Periarticular Metacarpal and Phalangeal Fractures Treated Using a Titanium Plate System,\u0026rdquo; \u003cem\u003eJ Hand Surg Am\u003c/em\u003e, vol. 33, no. 6, pp. 857\u0026ndash;863, Jul. 2008, doi: 10.1016/j.jhsa.2008.01.040.\u003c/li\u003e\n\u003cli\u003eJ. W. Vahey, L. Vegas, and D. A. Wegner, \u0026ldquo;Effect of Proximal Phalangeal Fracture Deformity on Extensor Tendon Function,\u0026rdquo; \u003cem\u003eJ Hand Surg Am\u003c/em\u003e, vol. 23A, no. 4, pp. 673\u0026ndash;681, 1998.\u003c/li\u003e\n\u003cli\u003eH. G. Cox, J. B. Hill, A. F. Colon, P. Abbasi, A. M. Giladi, and R. D. Katz, \u0026ldquo;The Impact of Dividing the Flexor Tendon Pulleys on Tendon Excursion and Work of Flexion in a Cadaveric Model,\u0026rdquo; \u003cem\u003eJ Hand Surg Am\u003c/em\u003e, vol. 46, no. 12, pp. 1064\u0026ndash;1070, Dec. 2021, doi: 10.1016/j.jhsa.2021.05.013.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Demographics and baseline characteristics\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"631\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of patients (n = 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years old)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e32 \u0026plusmn; 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e33.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInjury to surgery interval (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e4 \u0026plusmn; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperated hand\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e55.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e44.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDominant hand\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e77.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e22.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComminuted\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e33.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e88.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoker\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e33.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e1 (poor wound healing)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary surgery (including removal of implant)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e4 (removal of implant)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow up durations (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e14 \u0026plusmn; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.10618066561014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean total active motion (degrees)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.608557844690964%\" valign=\"top\"\u003e\n \u003cp\u003e235 \u0026plusmn; 24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28526148969889%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2a. The distance between flexor tendon to distal third, middle third, proximal third of\u0026nbsp;volar\u0026nbsp;bone cortex of proximal phalanx in middle phalanx\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"501\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.330677290836654%\" valign=\"top\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.326693227091635%\" valign=\"top\"\u003e\n \u003cp\u003eProximal (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003eMiddle (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003eDistal (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.274900398406373%\" valign=\"top\"\u003e\n \u003cp\u003eAverage of volar side (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.330677290836654%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.326693227091635%\" valign=\"top\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e1.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.274900398406373%\" valign=\"top\"\u003e\n \u003cp\u003e1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.330677290836654%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.326693227091635%\" valign=\"top\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e1.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e2.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.274900398406373%\" valign=\"top\"\u003e\n \u003cp\u003e1.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.330677290836654%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.326693227091635%\" valign=\"top\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.274900398406373%\" valign=\"top\"\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.330677290836654%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.326693227091635%\" valign=\"top\"\u003e\n \u003cp\u003e1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.274900398406373%\" valign=\"top\"\u003e\n \u003cp\u003e1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.330677290836654%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.326693227091635%\" valign=\"top\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e2.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.274900398406373%\" valign=\"top\"\u003e\n \u003cp\u003e1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.330677290836654%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.326693227091635%\" valign=\"top\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e3.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.274900398406373%\" valign=\"top\"\u003e\n \u003cp\u003e1.82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.330677290836654%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.326693227091635%\" valign=\"top\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e3.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.274900398406373%\" valign=\"top\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.330677290836654%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.326693227091635%\" valign=\"top\"\u003e\n \u003cp\u003e1.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e3.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.274900398406373%\" valign=\"top\"\u003e\n \u003cp\u003e1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.330677290836654%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.326693227091635%\" valign=\"top\"\u003e\n \u003cp\u003e1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e3.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.274900398406373%\" valign=\"top\"\u003e\n \u003cp\u003e1.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.330677290836654%\" valign=\"top\"\u003e\n \u003cp\u003eAverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.326693227091635%\" valign=\"top\"\u003e\n \u003cp\u003e0.95\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e1.07\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e2.96\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.274900398406373%\" valign=\"top\"\u003e\n \u003cp\u003e1.67\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.330677290836654%\" valign=\"top\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.326693227091635%\" valign=\"top\"\u003e\n \u003cp\u003e0.31\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e0.25\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.53386454183267%\" valign=\"top\"\u003e\n \u003cp\u003e0.52\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.274900398406373%\" valign=\"top\"\u003e\n \u003cp\u003e0.26\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2b. The distance between extensor tendon to distal third, middle third, proximal third of dorsal bone cortex of proximal phalanx in middle phalanx\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"453\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.162995594713657%\" valign=\"top\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.29955947136564%\" valign=\"top\"\u003e\n \u003cp\u003eProximal (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.537444933920705%\" valign=\"top\"\u003e\n \u003cp\u003eMiddle\u003c/p\u003e\n \u003cp\u003e(cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.555066079295154%\" valign=\"top\"\u003e\n \u003cp\u003eDistal (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.44493392070485%\" valign=\"top\"\u003e\n \u003cp\u003eAverage of dorsal side (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.162995594713657%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.29955947136564%\" valign=\"top\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.537444933920705%\" valign=\"top\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.555066079295154%\" valign=\"top\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.44493392070485%\" valign=\"top\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.162995594713657%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.29955947136564%\" valign=\"top\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.537444933920705%\" valign=\"top\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.555066079295154%\" valign=\"top\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.44493392070485%\" valign=\"top\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.162995594713657%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.29955947136564%\" valign=\"top\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.537444933920705%\" valign=\"top\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.555066079295154%\" valign=\"top\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.44493392070485%\" valign=\"top\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.162995594713657%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.29955947136564%\" valign=\"top\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.537444933920705%\" valign=\"top\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.555066079295154%\" valign=\"top\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.44493392070485%\" valign=\"top\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.162995594713657%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.29955947136564%\" valign=\"top\"\u003e\n \u003cp\u003e1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.537444933920705%\" valign=\"top\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.555066079295154%\" valign=\"top\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.44493392070485%\" valign=\"top\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.162995594713657%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.29955947136564%\" valign=\"top\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.537444933920705%\" valign=\"top\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.555066079295154%\" valign=\"top\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.44493392070485%\" valign=\"top\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.162995594713657%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.29955947136564%\" valign=\"top\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.537444933920705%\" valign=\"top\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.555066079295154%\" valign=\"top\"\u003e\n \u003cp\u003e1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.44493392070485%\" valign=\"top\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.162995594713657%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.29955947136564%\" valign=\"top\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.537444933920705%\" valign=\"top\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.555066079295154%\" valign=\"top\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.44493392070485%\" valign=\"top\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.162995594713657%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.29955947136564%\" valign=\"top\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.537444933920705%\" valign=\"top\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.555066079295154%\" valign=\"top\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.44493392070485%\" valign=\"top\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.162995594713657%\" valign=\"top\"\u003e\n \u003cp\u003eAverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.29955947136564%\" valign=\"top\"\u003e\n \u003cp\u003e0.67\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.537444933920705%\" valign=\"top\"\u003e\n \u003cp\u003e0.21\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.555066079295154%\" valign=\"top\"\u003e\n \u003cp\u003e0.64\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.44493392070485%\" valign=\"top\"\u003e\n \u003cp\u003e0.51\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.162995594713657%\" valign=\"top\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.29955947136564%\" valign=\"top\"\u003e\n \u003cp\u003e0.40\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.537444933920705%\" valign=\"top\"\u003e\n \u003cp\u003e0.08\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.555066079295154%\" valign=\"top\"\u003e\n \u003cp\u003e0.26\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.44493392070485%\" valign=\"top\"\u003e\n \u003cp\u003e0.20\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2c. The average distance between the volar and dorsal cortex of the proximal phalanx in the middle phalanx.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"538\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.964749536178108%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.34508348794063%\" valign=\"top\"\u003e\n \u003cp\u003eAverage distance of volar side (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.34508348794063%\" valign=\"top\"\u003e\n \u003cp\u003eAverage distance of dorsal side (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.34508348794063%\" valign=\"top\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.964749536178108%\" valign=\"top\"\u003e\n \u003cp\u003eProximal third\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.34508348794063%\" valign=\"top\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.34508348794063%\" valign=\"top\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.34508348794063%\" valign=\"top\"\u003e\n \u003cp\u003e0.1164\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.964749536178108%\" valign=\"top\"\u003e\n \u003cp\u003eMiddle third\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.34508348794063%\" valign=\"top\"\u003e\n \u003cp\u003e1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.34508348794063%\" valign=\"top\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.34508348794063%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.964749536178108%\" valign=\"top\"\u003e\n \u003cp\u003eDistal third\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.34508348794063%\" valign=\"top\"\u003e\n \u003cp\u003e2.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.34508348794063%\" valign=\"top\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.34508348794063%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Volar plating, tendon irritation, extensor lag, proximal phalanx fractures","lastPublishedDoi":"10.21203/rs.3.rs-4767987/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4767987/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePhalangeal fractures, especially those of the proximal phalanx, account for approximately 25% of hand and wrist fractures. Plating is generally associated with severe tendon-related complications and unsatisfactory hand function. Recently, volar plating has been used to fix intra-articular fractures at the base of the proximal phalanx, and it has been reported to result in excellent finger motion and grip strength. We proposed that volar plating has a lower risk of tendon irritation compared to dorsal plating due to the larger tendon-to-bone distances on the volar side. The purpose of this study was to: 1) present the surgical outcomes of 9 cases of extra-articular fractures in the proximal third of the proximal phalanx treated with volar plating, and 2) compare the tendon-to-bone distances between the volar and dorsal sides of the proximal phalanx.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA prospective cohort of nine patients with proximal third fractures of the proximal phalanx was recruited. Each patients underwent an MRI of the healthy middle finger on either hand to evaluate the distances between the flexor and extensor tendons and the proximal phalanx. The distances were measured using our in-built measurement tool. Demographics including age, gender, dominant hand, diabetes, smoking, affected fingers were collated. Complications such as extensor lag, wound infections, delayed wound healing, malunion, non-union, delayed union and tendon rupture were recorded. Total active motion (TAM) was also calculated by addition of ROM at the metacarpophalangeal joint, proximal interphalangeal joint and distal interphalangeal joint.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNine patients (6 males, 3 females) with fractures of the proximal third of the proximal phalanx were included in this study. All nine patients achieved good bone healing and recovery of functional range of motion (235\u0026thinsp;\u0026plusmn;\u0026thinsp;24 degrees) after 1 year of follow-up. No major complications were reported, except for one patient with delayed wound healing. The measurements of the distances between the bone and the flexor and extensor tendons were reported as follows. There were significant differences in the average distance from the tendons to the bone cortex for the middle (volar: 1.07 cm, dorsal: 0.21 cm) and distal (volar: 2.96 cm, dorsal: 0.64 cm) third of the proximal phalanx (p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe increased tendon-to-bone distance on the volar side may be an important factor contributing to the excellent hand function observed with volar plating in the treatment of proximal phalangeal extra-articular fractures\u003c/p\u003e","manuscriptTitle":"Volar Plate Fixation for Extra-Articular Proximal Third Phalangeal Fractures of proximal phalanx: A Comparative Study of Tendon-to-Bone Distances and Functional Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-18 23:54:07","doi":"10.21203/rs.3.rs-4767987/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"da2a7b7f-ad68-4911-84ce-7ed2d6c16846","owner":[],"postedDate":"August 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-31T15:41:56+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-18 23:54:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4767987","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4767987","identity":"rs-4767987","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}