|Year : 2016 | Volume
| Issue : 6 | Page : 708-713
A prospective study of dynamic treatment of fracture phalanx and metacarpals of the hand with Kirschner-wire fixation/external fixator and finger splint: Daycare management (30 cases)
Rahul Madhukar Salunkhe, Hitesh Joshi, Tushar Krishna Pisal, Samar Kumar Biswas, Jay Janakbhai Patel, Ashutosh Singh
Department of Orthopedics, Dr. D.Y. Patil Medical College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||16-Nov-2016|
Rahul Madhukar Salunkhe
Department of Orthopaedics, Dr. D.Y. Patil Medical College and Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Fractures of the phalanx and metacarpals are some of the most frequently encountered orthopedics injuries and constitute between 14-28% of all visits to emergency department which comprises 46% of the hand fracture and out of that mostly involved are the proximal phalanx and metacarpal neck fracture are most common and then the middle and distal phalanx and the base of metacarpal. The commonest complication with surgical treatment were stiff painful joints due to prolonged immobilization at fracture sites. This prospective study was undertaken to evaluate the functional outcome after surgical stabilization of metacarpal and phalanx fracture on day care basis. Materials And Methods: In our study we treated 30 patients who came to our hospital by fixation either with K wire or external fixation or hybrid fixation under local anaesthesia depending on the type of fracture between 2013 to 2014 with the average age 28 years with the youngest being 18 years and the oldest being 41 years with transverse, spiral, oblique closed fracture, grade 1 compound fracture, intraarticular, extraarticular, comminuted and non comminuted fracture of phalanx and metacarpals.These were day care treatment. Patient was allowed to begin his daily routine work from post operative day l. During this course the operated site was protected with splinting. Results: Clinical Outcomes were assessed as Excellent, Good, Satisfactory and Poor. Radiological assessment was done by taking x-ray to check radiological union.There were 24 cases had excellent outcome, 5 cases had good outcome and only 1 case had satisfactory outcome which occurred due to mal-union. There were 3 cases of pin-tract infection which subsided with oral antibiotics, and 3 cases of malunion. Conclusion: This was a day care procedure, patient were admitted, treated and discharged on the same day & encouraged to begin mobilization of the joints of hands from day 1.
Keywords: External fixation, fracture metacarpal and phalanx, hybrid fixation, Kirschner-wire fixation
|How to cite this article:|
Salunkhe RM, Joshi H, Pisal TK, Biswas SK, Patel JJ, Singh A. A prospective study of dynamic treatment of fracture phalanx and metacarpals of the hand with Kirschner-wire fixation/external fixator and finger splint: Daycare management (30 cases). Med J DY Patil Univ 2016;9:708-13
|How to cite this URL:|
Salunkhe RM, Joshi H, Pisal TK, Biswas SK, Patel JJ, Singh A. A prospective study of dynamic treatment of fracture phalanx and metacarpals of the hand with Kirschner-wire fixation/external fixator and finger splint: Daycare management (30 cases). Med J DY Patil Univ [serial online] 2016 [cited 2019 Sep 20];9:708-13. Available from: http://www.mjdrdypu.org/text.asp?2016/9/6/708/194187
| Introduction|| |
Fractures of the phalanx and metacarpals are some of the most frequently encountered orthopedics injuries and constitute between 14% and 28% of all visits to the emergency department. Metacarpal and phalanx fractures comprise 46% of the hand fracture and out of that mostly involved are the proximal phalanx and metacarpal neck fracture are most common and then the middle and distal phalanx and the base of metacarpal. Surgical treatment of phalanx and metacarpal fracture is necessary when the fracture is displaced, and reduction is not possible.  Conventionally, buddy strapping and splinting treated these fractures. For metacarpal fractures, currently modalities of treatment are dorsal locking plate and Kirschner-wire (K-wire) fixation.  The most common complication with these modes of treatment were stiff painful joints due to prolonged immobilization at fracture sites. This prospective study was undertaken to evaluate the functional outcome after surgical stabilization of metacarpal and phalanx fracture on day care basis.
| Materials and Methods|| |
In this study, we treated thirty patients who came to our hospital by fixation either with K-wire or external fixation or hybrid fixation depending on the type of fracture between 2013 and 2014 with the average age 28 years with the youngest being 18 years and the oldest being 41 years in which 21 patients were male and 9 patients were female.
Transverse, spiral, oblique closed fracture, grade 1 compound fracture, intra-articular, extraarticular, comminuted, and noncomminuted fracture patients were included in the study and patients with infection, immunodeficiency, uncontrolled diabetes, open fractures (except grade 1) and metacarpal or phalanx fracture along with other long or small bone fracture which requires prolonged hospitalization were the limitations of the study. We did not have any control group.
There were 16 patients with extraarticular fractures, 7 patients with intra-articular fracture, 6 patients with combined (intra-articular + extraarticular), and 1 patient with MP joint fracture.
We used K-wire in the simple extraarticular fracture, K-wire with an external fixator (hybrid fixation) for intra-articular fracture and external fixator for comminuted and grade 1 compound fractures.
The mode of the treatment in this study was fixation either with K-wire or external fixation or by hybrid fixation. This was a day care treatment, i.e., the patient was admitted, treated, and discharged on the same day. All the patients were taught to do betadine soaked gauze dressing for pin care at home.
All the cases were done in local anesthesia, i.e., ring block in fingers and wrist block in metacarpal fractures. For that 2% xylocaine without adrenaline was used as regional anesthesia. Under image intensifier reduction was achieved after giving appropriate traction and fracture was stabilized with cross K-wires or intramedullary K-wire or external fixator depending on the type of fracture, whether intra-articular or extraarticular or combined or with subluxation or dislocation [Figure 1] [Figure 2] [Figure 3].
|Figure 1: Case 1: Extraarticular proximal phalanx fracture and Kirschner-wire fixation|
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|Figure 2: Case 2: Intra-articular proximal phalanx fracture and hybrid fixation|
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|Figure 3: Case 3: Comminuted intra-articular fracture and hybrid fixation|
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Patients were encouraged to begin mobilization of the joints of hands from day 1. All patients were allowed to begin activities of daily living but not allowed to do heavy weight lifting. We started the movement of one joint above and one joint below in case where distraction of joint was done and after removal of implant we started the movement of the joint involved in distraction. During this course, the operated site was protected with splinting (frog splint/cock-up splint). We did not take photographs when splint was applied to the patient. This is the method photograph as per manufacturer.
Clinical outcomes were assessed as excellent, good, satisfactory, and poor. Methods of assessment are given in the [Table 1]. Radiological assessment was done by taking X-ray to check radiological union.
- Cock up splint: Plastic coated malleable aluminum which keeps the wrist in extension. Velcro straps for easy application and removal [Figure 4]
- Frog splint: Provides perfect alignment of the interphalangeal joints by maintaining them in optimal functional position. No tapes required [Figure 5]
- Finger cot: Patient were called for follow-up weekly. After 4 weeks, implants were removed and proper physiotherapy was started in the form of an active range of motion [Figure 6].
During follow-up, we checked for mobility at the fracture site, radiological evaluation for fracture union and complications such as pin tract infection, malunion, and finger stiffness.
| Results|| |
The average age of the patients was 28 years, with the youngest being 18 years and the oldest 41 years of age. There were 21 males and 9 females. Most of the patients were involved in industrial trauma and road traffic accident. We did not find any association between involvement of the right or left side.
There were 16 cases with extraarticular fracture, 7 cases with articular involvement, and 7 were combined injuries. Cross K-wire fixation was done in 7 cases, Joshi's External Stabilization System in 5 cases, hybrid fixation in 12 cases and 6 cases were treated with intramedullary K-wire fixation.
There were 3 cases of pin-tract infection which subsided with oral antibiotics, and 3 cases had malunion, but 2 patients had good functional result and rest 1 patient had a satisfactory functional outcome. Overall, 24 cases had an excellent outcome, 5 cases had good outcome, and only 1 case had a satisfactory outcome which occurred due to malunion.
The average duration of surgery was 45 min. Average blood loss was 5 ml. The average stay in the hospital was 1 day. The outcomes of each case has been shown in Appendix 1.
| Discussion|| |
The treatment of metacarpal and phalanx fractures has been extensively discussed, and several guidelines are available. ,, Guidelines are designed to help clinical decision-making and are based on the best available evidence. Proposed surgical indications for a metacarpal fracture include significant palmar angulation, shortening >2 mm, any rotational deformity, >1 mm of articular surface step-off, and involvement of >25% of the articular surface. ,, With respect to how much palmar angulation can be tolerated, recommendations vary in the literature from 20° to 70° in the ulnar two digits and 5-10° in the index and middle digit. , Other variables that influence management are the anatomical location of the fracture within the metacarpal, the type of fracture, surgeon experience, and patient characteristics.
Many factors, such as prevention of infection and early and appropriate physiotherapy other than accurate reduction and fixation affect recovery of good mobility. 
Closed reduction with K-wire fixation was done for stabilization of 13 fractures using two different techniques. (a) Intramedullary K-wire without transfixing the joint (n = 6) is technically more difficult than retrograde K-wire fixation. No stiffness was observed in any of the cases treated by this method. (b) Cross K-wire fixation (n = 7) using two K-wires was done for stabilization of seven fractures. No stiffness was observed in any of the cases treated by this method.
However, Ikuta and Tsuge  reportedly observed distraction with crossed K-wire fixation using two wires, thereby holding it responsible for delayed union and nonunion. However, 3 cases of malunion were observed by us following cross wire fixation with two K-wires. It is desirable that while using cross K-wire fixation crossing point of the wires should not be located at the fracture site so as to avoid distraction.
The recent evidence-based review by Friedrich and Vedder  suggested that IM fixation is an attractive option for metacarpal fracture treatment. IM fixation of metacarpal fractures was first introduced in 1957, and its efficacy has been demonstrated in multiple case series and observational studies. ,,,,,,,,,, Foucher et al. , introduced the bouquet osteosynthesis technique in 1976. The technique is relatively quick and reproducible while allowing for early mobilization. Rhee et al.  recently published a large prospective series of their modified IM fixation technique for metacarpal neck and shaft fractures with excellent functional and cosmetic results. The potential benefits of IM fixation include less total operative time, fewer days of missed work for patients, and therefore, a hypothesized favorable cost/benefit ratio; however, this was not addressed in this review and should be further studied.
A major drawback of IM fixation is that it does not truly provide rigid fixation.  Therefore, a longer period of immobilization is necessary than with PS fixation. Since patient compliance can be suboptimal in this population, there is a theoretical risk of delayed union or malunion in the patient noncompliant of immobilization protocols. However, none of the studies included in this review assessed rates of compliance. Although no regimen has been determined to be optimal,  some period of immobilization will be necessary postoperatively after IM fixation, which requires the cooperation of the patient.
External fixator can provide distraction across the joint, which takes load off the articular fragments, thereby allowing them to heal without a deforming force. Second, traction across the joint and soft tissue can reduce fracture fragments through ligamentotaxis. Third, early active and passive range of movements allowed by this fixator prevent contractures or adhesions of the collateral ligaments, volar plate, and tendons. The continuous passive motion itself has been shown to help cartilage healing by supplying nutrition to and removing waste products from the joints. Literature review suggests that an external fixator is a good option for treatment of these fractures. ,,, Our findings were consistent with the above studies. We believe these complex fractures can be successfully treated with distraction dynamic external fixator, and its results are reproducible. We believe these complex fractures can be successfully treated with JESS fixator and Hybrid fixation, and its results are reproducible. We used the construct in reverse to the original description by Hynes and Giddins  and we feel this may reduce the risk of infection by avoiding movement at wire-bone interface in the proximal phalanx. In the original study, there were 2 pin-site infections in 8 cases, while in our series we had 2 pin-site infections in 17 cases done with JESS and Hybrid fixation.
| Conclusion|| |
Being a day care procedure, with encouraged mobilization of the joints of hands from day 1 protected with splinting with quick return to activities of daily life.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]