Fractured phalanx in a violinist’s finger: Special considerations in treating musician patients

Abstract

Post-traumatic reconstructive surgery on musician patients is uniquely challenging in that sustained motor deficits imperceptible to the average person can be debilitating for this population.1 Instrument manipulation is extremely physically demanding; even without trauma musicians are at risk of developing a musculoskeletal disorder from mere overuse of the muscles involved in their craft.2 Furthermore, the link between physical and emotional well-being is exaggerated in musicians, as their livelihood revolves around the physical expression of emotion.3 Analyzing medical treatment from a musician's perspective provides a useful demonstration of the increased efficacy in utilizing a whole person approach as opposed to one that is strictly biomedical.4 Heightened sensitivity to motor deficits and the economic and emotional implications thereof are significant factors pertaining to the lifestyle of these patients, and treatment should be tailored accordingly. 5 RESEARCH Case PresentationI n February 2007, a 52-year-old violinist and music teacher opened a steel-framed classroom window, which then fell and crushed her left index finger. Being her string-pressing hand, the impact of this injury was potentially devastating. Unfortunately, she did sustain an oblique fracture of her proximal phalanx, which was near the proximal interphalangeal (PIP) joint but was not interarticular (Figure 1). Additionally, there was a laceration on the volar aspect of the same finger.Three days following her injury, she was brought to the operating room for definitive repair. Previously placed sutures were removed, and the incision was extended by 1 cm on the radial aspect in line with the PIP joint. Careful dissection revealed the tendon sheath and digital nerve on the radial aspect to be intact, though the latter appeared to have sustained some damage. The location of the fracture between opposing flexor and extensor tendons caused displacement of the bone fragments rendering the injury inherently unstable. However, once the fracture planes were exposed, reduction was easily achieved and held using termite forceps. Fixation was then attained using two percutaneous 0.035 inch K-wires. These traversed the fracture from the distal portion of the proximal phalanx into the proximal cortex dorsoventrally. The result, as visualized on a portable x-ray machine (Figure 2), was an excellent reduction, and the wires were trimmed near skin level. The skin edges, which were somewhat macerated, were then debrided and closed using 5-0 Prolene sutures. The final step of the procedure was application of Jelonet, gauze and a volar splint.