Chronic fracture dislocations of the proximal interphalangeal joint. Treatment by the "S" Quattro

Management of intraarticular proximal interphalangeal joint fracture-dislocations and pilon fractures with the Ligamentotaxor® device

INTRODUCTION

Fracture-dislocation and pilon injuries of the proximal interphalangeal joints (PIPJ) continue to pose significant management challenges. Stable fracture configurations can be treated with extension block splinting or pinning. Unstable fractures usually require open or closed reduction and fixation either directly/internally onto the fracture using Kirschner wires, cerclage wires, screws or miniplates or indirectly/externally by ligamentotaxis using external fixators which can be dynamic or static. Dynamic external fixators, such as Suzuki's pins and rubber traction system, S-Quattro and Hynes/Giddins frame, appear intuitive as they provide axial distraction, which reduces the fracture whilst obviating the need to open the fracture. They also allow immediate active movement whilst maintaining reduction. The Ligamentotaxor® (Arex, Pallaiseau Cedex, France) is a commercially-available dynamic external fixator which has been used at our institution since 2013.

MATERIALS AND METHODS

This retrospective study assessed the outcomes (interphalangeal joint active range of movement (AROM), QuickDASH score and complications) in 19 patients [mean age of 48.6 (SD 16.2)] whose proximal interphalangeal joint (PIPJ) fracture-dislocations and/or pilon fractures were treated with the Ligamentotaxor®. Injuries were classified according to Seno i.e. (1) volar lip fracture ± dorsal dislocation (2) dorsal lip fracture ± volar dislocation (3) pilon fracture.

RESULTS

There were fifteen (79%) pilon/Seno 3, three (16%) Seno 1 and one (5%) Seno 2 fractures. The mean PIPJ AROM was 70.6° (SD 4.48°) for all Seno classes and 70° (SD 5.6°) for the pilon subgroup. The QuickDASH score averaged to 2.65 (SD 0.88). There were two pin-site infections, three pin-site inflammations, one osteomyelitis and two complex regional pain syndrome diagnoses. One patient required arthroplasty after missing several appointments.

CONCLUSIONS

These results, considering the predominance of pilon fractures, compare favourably the published Ligamentotaxor® and other dynamic external fixator systems.

The S-Quattro in the Management of Acute Intraarticular Phalangeal Fractures of the Hand

Intraarticular phalangeal fractures of the hand are difficult and challenging to manage. Dynamic external fixation devices offer the advantages of allowing distraction of the impacted fracture and early joint mobilization. We present our study of 100 patients with a variety of fractures who were treated with the S-Quattro technique over a 6-year period, with an average follow-up of 10.5 months. The mean active range of motion regained was 92° for proximal interphalangeal joints (81 fractures), 82° for distal interphalangeal joints (10 fractures), 91° for metacarpophalangeal joints (6 fractures) and 80° for interphalangeal joints of the thumb (3 fractures). Only nine patients complained of mild or moderate pain. Postoperative radiographic appearances were satisfactory in all but five out of the 100 patients. This device is a simple and effective technique for the management of these difficult fractures. It offers advantages in terms of versatility, ease of application, good tolerance by patients, few complications and good outcome.

Staged external fixation for chronic fracture-dislocation of the proximal interphalangeal joint: outcomes of patients with a minimum 2-year follow-up

PURPOSE

To introduce a new surgical strategy for chronic fracture-dislocations of the proximal interphalangeal (PIP) joint with 2-staged external fixation. We also assessed the results of this method in all of our patients with at least 2 years of follow-up.

METHODS

We used the procedure in 6 cases. For the first step, we applied mini external fixators for 1 week before surgery to apply traction to the PIP joint with sufficient force to stretch the dislocated joint components. The second procedure was surgical release of the PIP joint and an attempt at percutaneous reduction and fixation. This was not possible in 4 cases, and we performed an open reduction and corrective osteotomy. Postoperative early rehabilitation was achieved under controlled movement using an external fixator that allowed PIP joint flexion and extension.

RESULTS

At long-term follow-up (mean, 3.5 y), the range of movement of PIP joints had increased by 76°, and that of distal interphalangeal joints by 35°. Osteochondral remodeling likely occurred not only while the joint was protected with the dynamic external fixator during a 12-week period (range, 8-14 wk), but also after removal.

CONCLUSIONS

Preoperative traction softens the PIP joint, facilitating both surgery and rehabilitation. Postoperative early exercise with controlled movement, while maintaining concentric reduction with the external fixator, may accelerate osteochondral repair of the injured PIP joint.

"S" Quattro external fixation for complex intra-articular thumb fractures

PURPOSE

To report outcomes in 10 patients who underwent dynamic "S" Quattro external fixation for complex fractures of the base of the thumb.

METHODS

Nine men and one woman aged 18 to 69 (mean, 31) years underwent "S" Quattro external fixation for complex fractures of the base of the thumb. The dominant hand was involved in 8 patients. Three patients had Bennett fractures, 5 had Rolando fractures, one had an open multi-fragmented fracture, and one had a fracture-subluxation. Four of them had had prior (failed) treatment with splints and/or Kirschner wires. The "S" Quattro external fixator was applied for a mean of 4.9 weeks. Patients were followed up in an out-patient setting for a mean of 10.7 months until bone union and removal of the external fixator. Finger flexor function was assessed based on total active movement (TAM). Functional outcomes were assessed using the Disability of Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

No pin-site infection, malunion, or non-union was encountered. Mean loss of TAM was 7.5 degrees. Five patients lost 10 degrees or more, 2 of whom lost 20 degrees (one with an open comminuted fracture and one was elderly). Four patients regained full TAM and 6 attained more than 75% TAM compared to the contralateral thumb. At the 3-year follow-up, the mean DASH score was 3.4. Four patients reported no functional disability. Poorer outcomes were reported in the 2 patients who once had lost 20 degrees of TAM.

CONCLUSION

The "S" Quattro external fixator is recommended as a primary and definitive treatment modality for complex intra-articular thumb fractures when conservative and other surgical interventions have failed.

Single-stage distraction correction for neglected dorsal fracture dislocations of the proximal interphalangeal joint: a report of eight cases

We present the outcome of treatment of eight chronic neglected dorsal fracture dislocations of the proximal interphalangeal joint treated with a single-stage ligamentous distraction using the Penning mini-external fixator and a closed reduction. The distraction correction and 2 to 3 mm over distraction was performed acutely at the time of operation in all eight cases at an average injury-to-surgery time of 6 weeks. Satisfactory results with an average range of motion of 79 degrees were obtained at an average follow-up of 20 months. This technique is simple, effective and offers the advantage of being minimally invasive. We recommend this single-stage distraction correction technique for the treatment of chronic neglected dorsal dislocations of the proximal interphalangeal joint, which are no more than 10 weeks-old.

Treatment of proximal interphalangeal dorsal fracture-dislocation injuries with dynamic external fixation: a pins and rubber band system

PURPOSE

Unstable, dorsal, intra-articular, fracture-dislocations of the proximal interphalangeal (PIP) joint can be difficult to treat and often lead to long-term pain, stiffness, and functional deficit. We present the outcomes of patients sustaining such injuries that were treated by a novel dynamic external fixator. This fixator uses a system of K-wires and rubber bands that maintains a concentrically reduced PIP joint while allowing for early motion.

METHODS

Fourteen patients with unstable, dorsal fracture-dislocation injuries of the PIP joint were treated between September 2001 and January 2006. Eight were available for follow-up evaluation at an average of 26 months. We measured PIP range of motion and grip strength, and assessed pain on a visual analog scale. Demographic information about the original injury was recorded. New radiographs were obtained to assess joint congruency and the presence of arthritis or articular step-off deformity.

RESULTS

In the 8 patients available for follow-up evaluation, the average motion of the affected PIP joint was from 1 degrees (range 0 degrees to 5 degrees) to 89 degrees (range 75 degrees to 110 degrees). Grip strength was 92% (range 71% to 110%) of the unaffected hand. The average score on the visual analog pain scale was 0.6 (range 0-1.5). There were few complications. Radiographs at follow-up evaluation showed a concentric reduction in all joints, but with evidence of a small step-off deformity or arthritis in 5 patients.

CONCLUSIONS

The dynamic external fixator studied is an effective method of treating unstable, dorsal fracture-dislocation injuries. Outcomes compared favorably with those of other similar devices studied in the literature.

[Dynamic external traction system for management of distal displaced fractures of the head of the proximal phalanx]

INTRODUCTION

Phalangeal fractures are generally underestimated injuries, but result in pain, stiffness, instability, degenerative arthritis and loss of finger function. Treatment varies from open reduction with internal fixation giving perfect anatomical reduction but a risk of side effects, to orthopaedic treatment with variable results. Unstable fractures must be fixed rigidly to minimize joint immobilization. It is this concept of solid fixation and early mobilization, which directed us in the choice of dynamic external distraction in the management of these fractures.

MATERIAL AND METHOD

The authors present a prospective study of twelve patients treated for unstable fractures of the proximal interphalangeal joint by closed reduction and dynamic external distractor, we describe this simple device created with pins and rubber bands and examine the functional clinical results.

RESULTS

The average follow-up period was 7.5 months. We only noted one pin-track infection. Three patients complained of pain at postoperative follow up. In this series, the total active motion varied from 70 degrees to 120 degrees (average 94.16 degrees), the mean lack of extension was 5.6 degrees (from 0 to 15 degrees). Ten patients had good mobility and were satisfied.

DISCUSSION

Different traction devices for the management of displaced intraarticular phalangeal fractures have been reported. Most of them are complex to construct and expensive. The traction system is simple to assemble, economical and it allows early active motion of the affected digits. We consider that it is an effective mode of treatment for the management of complex intraarticular phalangeal fractures.

A technique for the repair of chronic volar plate avulsion of the proximal interphalangeal joint: a review of 54 cases

BACKGROUND

The authors delineate a subgroup of proximal interphalangeal joint injuries with chronic pain and limitation of movement, despite a stable joint, and describe and evaluate a surgical procedure.

METHODS

Through a volar approach, the volar plate is freed from scar but remains connected on either the ulnar or radial border. A new connection to the middle phalanx is established by creating a bony groove, and the volar plate is loosely attached distally. Fifty-four joints with chronic volar plate avulsion injuries of the proximal interphalangeal joint were evaluated. All patients had chronic pain and limitation of motion and function in a stable and congruent joint. Patients were examined at 6 weeks, 3 months, and 1 year after surgery. Range of motion, grip strength, and pain were evaluated. The average time to surgery was 10.5 +/- 11.8 months (range, 2 to 65.4 months). The mean postoperative follow-up period was 10.0 +/- 12.8 months (range, 3 to 73.5 months).

RESULTS

All patients had an improved range of motion following surgery. The difference from the preoperative range of motion was statistically significant (p < 0.0001). None of the patients reported pain on rest after surgery, and five patients reported activity pain. The mean grip strength was 32.4 +/- 13.4 kg for hand that had been operated on and 41.0 +/- 14 kg for the hand that had not been operated on.

CONCLUSIONS

This technique for repair of chronic volar plate avulsion injuries allows early motion and results in significant improvement in range of motion, pain, and overall function in this subgroup of patients.

Results of osteotomy, open reduction, and internal fixation for late-presenting malunited intra-articular fractures of the base of the middle phalanx

PURPOSE

To present our results in the treatment of late-presenting impaction fractures of the base of the middle phalanx treated by osteotomy with full exposure of the articular surface to restore the normal anatomy.

METHODS

Eleven patients with a malunited (impacted) fracture of the base of the middle phalanx were treated by osteotomy more than 5 weeks after the injury. All fractures had varying degrees of impaction, comminution, and dorsal subluxation. The malunited joint surface was visualized by dislocating the joint by hyperextension (shotgun approach). The restoration of the cup-shape contour of the middle phalangeal base was accomplished by osteotomy and mobilization of small osteochondral fragments. Rigid fixation was performed by cerclage wire, screws, or a combination of these. A distal radius bone graft was placed beneath disimpacted fragments in 9 of the 11 procedures.

RESULTS

Ten of 11 patients were followed-up for more than than 1 year. One patient with a volar lateral impaction fracture was lost to follow-up study 4 weeks after the surgery and was excluded from the results. All patients except 1 achieved a functional range of motion of the proximal interphalangeal joint. Moderate limitations of the distal interphalangeal joint motion were common. Grip and thumb-affected finger tip pinch strengths were 95% and 90%, respectively, of the healthy side. The average pain level (as rated on a visual analog scale of 0-10) improved from a preoperative score of 9.1 to a postoperative score of 0.8. One patient was somewhat dissatisfied; all other patients were satisfied or very satisfied. All returned to their previous work at an average of 13 weeks after surgery.

CONCLUSIONS

Favorable results have been achieved in this challenging scenario in the short- and middle-term in 9 of 10 patients. Previous surgery and moderate to severe wearing of the cartilage of the proximal phalanx head negatively affected the results.

Dynamic intradigital external fixation for proximal interphalangeal joint fracture dislocations

PURPOSE

Many skeletal traction devices have been described to treat fracture dislocations of the proximal interphalangeal (PIP) joint. Most of these techniques are technically challenging or involve cumbersome frames. We present a design modification that enhances the stability of a simple dynamic fixation system described previously and report our results with this technique.

METHODS

A previously described simple dynamic fixator with no rubber bands was applied to 6 patients who sustained fracture dislocations of the PIP joint. The middle finger was involved in 3 patients, the ring finger in 1 patient, and the small finger in 2 patients. The average age of the patients was 27 years (range, 21-42 y). The average involvement of the base of the middle phalanx was 48% (range, 35% to 60%). The average time from the injury to the surgery was 6 days (range, 1-14 d). The average follow-up period was 24 months (range, 7-43 mo). Immediate active flexion extension was allowed and the fixator was removed after 3 to 4 weeks.

RESULTS

The average range of motion of the PIP joint at the final follow-up evaluation was 5 degrees to 89 degrees (range, 0 degrees to 100 degrees ). Two patients developed pin track infection that resolved with oral antibiotics. Only one patient complained of mild pain with extreme flexion. Proper reduction and congruency of the joint was noted on final anteroposterior and lateral radiographs.

CONCLUSIONS

A simple dynamic fixator for the treatment of unstable PIP joint fracture dislocations was used successfully in 6 digits to maintain reduction and restore digital range of motion. The addition of modifications to the original technique not only improves the solidity of the construct but also provides satisfactory functional results. Based on our experience we recommend this easy technique to treat fracture dislocations of the PIP joint.

Treatment of fracture-dislocation of the proximal interphalangeal joint using the Suzuki external fixator

We describe a simple technique for fracture-dislocations of the proximal interphalangeal joint. Eight fingers with a fracture-dislocation were treated with a self-manufactured dynamic external fixator, allowing early mobilization. The fixator consists of pins and rubbers. The clinical and radiographic outcome was evaluated and recorded. A near-normal function was obtained in four patients. The average total active motion was 82 degrees. Radiographic reduction was maintained. This external fixator is an inexpensive and simple technique for these difficult fracture-dislocations. Early intervention (before two weeks post-trauma) is recommended.

Operative repair of a chronic, ulnar proximal interphalangeal dislocation of the little finger with an excellent functional result

Chronic dislocations of the proximal interphalangeal joint are not common. The instability and physical impairment, however, can render the digit or hand quite dysfunctional. A case report of the reconstruction of a nine-year chronic proximal interphalangeal joint dislocation of the left little finger is presented. The functional recovery is described. A literature review of the treatment of chronic dislocations of the proximal interphalangeal joint is also discussed.

The "S" Quattro Turbo in the management of neglected dorsal interphalangeal dislocations

We have used the "S" Quattro Turbo to treat four neglected dorsal interphalangeal joint dislocations. At an average follow up period of 45 months, there was a mean increase in the range of movement of the PIP joints by 74 degrees and of the IP joint of the thumb or DIP joints by 45 degrees. We recommend this technique for treating dorsal dislocations of the interphalangeal joints of more than 3 weeks duration.