Composite wiring of metacarpal and phalangeal fractures

Surgical Treatment of Lateral Malleolar Fractures Using the Compression Cerclage System

Background Lateral malleolar fractures (Weber type B or OTA 44-B) account for 60% of all ankle fractures. To achieve anatomic restoration, surgical stabilization provides better results than conservative treatment. Various fixation methods are available to treat these fractures; however, the best method is still unknown. Our objectives were to present a new, useful, and efficient surgical technique for stabilizing lateral malleolar fractures and to analyze the outcomes of patients treated with the compression cerclage system. Methods The surgical technique consists of a Kirschner wire that is passed percutaneously and perpendicular to the fracture line, and a cerclage wire that is passed in a semi-circular fashion over the ends of the Kirschner wire on the lateral side of the bone, leaving loops on each side to allow bilateral compression while twisting both wires. We retrospectively evaluated patients treated with this technique, with or without additional fractures. Follow-up of <24 months and bilateral ankle fractures were the exclusion criteria. Fractures were examined clinically and radiologically in comparison to the uninjured side and were rated according to the criteria reported by McLennon and Ungersma. Olerud and Molander ankle score was used to evaluate functional outcome. Results At the final follow-up, 15 out of 21 patients (9 women and 6 men; mean age, 48.2 years [range, 19-78 years]) were evaluated. The mean follow-up was 5.16 years (28-129 months). Five patients had an isolated lateral malleolar fracture; eight had lateral and medial malleolar fractures; and two had trimalleolar fractures. At the final follow-up, 11 patients were rated good functionally and four were fair, and all patients were rated good radiographically according to the criteria by McLennon and Ungersma. Mean Olerud and Molander ankle score was 93.3 (range, 80-100). Conclusions The compression cerclage system provides good functional and radiological outcomes in patients with lateral malleolus fractures. This method is useful, safe, and efficient with minimum hardware. It can be applied through limited soft-tissue stripping, which is especially important in patients with a high risk for wound complications.

Metacarpal Shaft Fractures of the Fingers: Treatment with Interosseous Loop Wire Fixation and Immediate Postoperative Finger Mobilisation in a Wrist Splint

It is widely believed that interosseous loop wire fixation of metacarpal shaft fractures alone is not rigid enough to allow immediate postoperative mobilisation. In this report, the author reviews the results in 36 cases of metacarpal shaft fractures of the fingers treated by interosseous loop wire fixation and immediate postoperative mobilisation of all finger joints. The study included 30 males and six females, with a mean age of 31 (range 12–52) years. The fracture pattern was transverse in 26 and oblique, or spiral, in the remaining 10 patients. Following loop wire fixation, the wrist was immobilised using a volar plaster splint for 3 weeks but all finger joints were mobilised immediately after surgery. After a mean follow-up of 8 weeks, all patients, except two, had regained full range of motion of the fingers and no complications were noted. It was concluded that interosseous loop wire fixation of metacarpal shaft fractures is rigid enough to allow immediate postoperative finger mobilisation in a wrist splint and achieve good functional results.

Comparison of Clinical Outcomes of Phalangeal Fracture Treated with Dorsolateral Approach or Post-middle Approach Using AO Mini Titanium Plate

The aim of this study is to investigate the clinical outcomes of various fixation methods for proximal phalangeal fractures with Arbeitsgemeinschaft für Osteosynthesefragen (AO) mini titanium plate by dorsolateral approach or post-middle approach. Clinical results of 62 fingers of 53 patients with proximal phalangeal fracture were evaluated. For dorsolateral approach, the lateral bundle of the extensor tendon was drawn away to expose the fracture part of the bone. After reduction, the plate was located at the dorsolateral side of the bone. For post-middle approach, the extensor tendon was split to expose the fracture part of the bone. After reduction, the plate was fixed to the proximal phalangeal side of the bone, and the extensor tendon was repaired with 3-0 nonabsorbable silk sutures. We found low overall complication rates in both groups. The mean total active motion (TAM) for the dorsolateral group and post-middle group was 234.60° ± 22.63° and 221.08° ± 25.69°, respectively. There was a statistical significance between the two groups (P = 0.037 < 0.05), indicating that TAM was notably affected by various fixation methods. With AO mini titanium plate, movement in dorsolateral approach group was significantly higher than in post-middle approach group. Dorsolateral approach is an acceptable technique of incision for proximal phalangeal fractures.

Open proximal phalangeal shaft fractures of the hand treated by theta fixation

BACKGROUND

Many implants and techniques are used for the treatment of open phalangeal fractures with varying grades of stability. The ubiquitous and simple Kirschner (K) wiring does not provide adequate stability to allow early mobilization of fingers. Lister described a combination of coronal interosseous wire and oblique K-wire technique for phalangeal fracture fixation with a stable construct that allowed early mobilization. Due to the fancied resemblance of this construct to the Greek alphabet θ (theta), we have referred to this as the theta fixation.

MATERIALS AND METHODS

Ten patients with open proximal phalangeal shaft (transverse) fractures were treated with theta fixation between January and June 2010. Outcome was analysed in terms of stability, early mobilization, fracture healing and function of hand. They were graded according to the Belsky score.

RESULTS

90% patients were graded excellent and 10% good, with none having fair or poor results. All fractures allowed the mobilization at a mean of 2.9 days and all healed at an average of 6.1 weeks. No loss of stability was seen on followup X-rays. All patients returned to their old profession.

CONCLUSION

The theta fixation technique is a safe, simple and effective method for open transverse phalangeal fractures with results comparable to other techniques. This method gives superior fracture stability to allow early mobilization of joints and thus early return of function. It is also a cost effective way of management for the developing world.

Internal fixation of distal metacarpal fractures: new uses for an old plate

Certain metacarpal fracture patterns require operative fixation to restore anatomy and optimize results. Compared with dorsal plating, the width of the minicondylar blade plate buttresses the deforming volar pull of the intrinsics and provides a stronger construct. The implant provides firm fixation in the juxta-articular fragment with minimal space requirements. Therefore, the purpose of this study was to examine the outcomes following the use of a minicondylar blade plate for the treatment of distal metacarpal fractures. Twenty-two distal metacarpal fractures in 20 patients treated with a minicondylar blade plate were retrospectively reviewed. Outcome measures collected included postoperative grip strength, range of motion, return to work, and radiographic evidence of osseous union. Average range of motion of the metacarpophalangeal joint was 62° postoperatively. Eighty-two percent (18/22) of fractures were able to flex their digits to their distal palmar crease. Seventy-one percent (12/17) of patients had at least 75% return to grip strength compared with the contralateral side. Seventeen patients returned to full activity at a mean of 2.5 months (range, 1-3 months) postoperatively; 1 patient was on disability, and data were not available for the final 2 patients. No major complications occurred. The minicondylar blade plate is a safe and effective technique for stabilizing unstable periarticular metacarpal fractures. Stable fixation allows for early range of motion, rapid return to strength, and a relatively quick return to full work duty.

Outcome of closed proximal phalangeal fractures of the hand

BACKGROUND

The proximal phalanx (PP) of the fingers is fractured more frequently than the middle or even distal phalanges. The problems of malunion, stiffness and sometimes loss of skin or other soft tissues associated with PP fracture increases the disability. The optimum treatment depends on fracture location, fracture geometry and fracture stability. The objective of the study was to analyse the treatment outcome in a series of closed proximal phalangeal fractures of the hand.

MATERIALS AND METHODS

Eighty-four proximal phalangeal fractures in 68 patients were enrolled from 2007 to 2009. The treatment modalities were broadly categorised into two groups, Group A consisted of conservative treatment, and Group B consisted of surgical treatment. Group A included 47 digits treated with closed reduction (CR) with immobilization (n=43), extension block cast and dynamic traction (n=4), while 37 digits were treated in Group B, which included closed or open reduction (OR) and internal fixation (IF) with K-wires (n=31), OR and IF with stainless-steel wiring (n=2), and mini external-fixator (n=4). Belsky's criteria and Gingrass' criteria were used for assessment of finger injuries and to assess the efficacy of conservative and surgical modalities for closed proximal phalangeal fractures of the hand.

RESULTS

Average period of follow-up was 1 year (range 10-14 months). The excellent to good results seen in Groups A and B were 89% and 92%, respectively. Six complications were seen in Group A, which included four cases with malunion and two cases with digital stiffness. Three complications were seen in Group B, which included one each of malunion, digital stiffness and extensor lag. Overall, maximum poor results (n=4) were seen with CR and buddy strapping.

CONCLUSION

Conservative treatment is an inexpensive method, particularly suitable for stable fractures, and in patients who are poor candidates for surgery, Surgical modalities have distinct advantage of stable fixation, but with added risk of digital stiffness. Percutaneous pinning is a reliable, most commonly used surgical modality and technically easier. Both conservative and surgical modalities have good efficacy when used judiciously.

The use of a combination of cerclage and unicortical interosseous loop dental wires for long oblique/spiral metacarpal shaft fractures

A literature review of metacarpal fracture fixation techniques revealed that the use of a combination of interosseous and cerclage dental loop wires has not been previously described. In this report, we review the results of 24 patients with long oblique/spiral metacarpal shaft fractures of the fingers treated by this combined technique of internal fixation, followed by immediate postoperative finger mobilisation in a wrist splint. The study included 20 men and four women with a mean age of 32 (range 20-48) years. After a mean follow-up of 10 weeks, 23 patients had regained full range of motion of the fingers. Complications included one case of CRPS Type 1 resulting in mild stiffness and all four women complained of the hyperpigmentation of the dorsal hand scars. The advantages of dental wire fixation were discussed and compared to those of lag screws.

Closed reduction and percutaneous K-wires versus open reduction and interosseous loop wires for displaced unstable transverse fractures of the shaft of the proximal phalanx of the fingers in industrial workers

Seventy-eight male industrial workers with displaced unstable transverse fractures of the shaft of the proximal phalanx of the fingers were divided into two groups: Group 1 (n = 40 men, mean age = 34 years, range = 22-46 years) was treated with closed reduction and percutaneous K-wires, and Group 2 (n = 38 men, mean age = 33 years, range = 20-48 years) was treated with open reduction and interosseous loop wire fixation. At final follow-up, the total active motion (TAM) score of the injured finger was graded as excellent, good, fair or poor if it was greater than 240 degrees , 220 degrees , 180 degrees or less than 180 degrees , respectively. Group 2 had significantly better overall TAM scores than Group 1 (P = 0.03). The complication rate was higher in Group 1 than Group 2 (28% versus 11%) but the difference did not reach statistical significance (P = 0.084). The results were compared with those reported by other authors and other techniques of fixation of these fractures.

Open reduction and cerclage wire fixation for long oblique/spiral fractures of the proximal phalanx of the fingers

Fifteen cases of long oblique/spiral fractures of the shaft of the proximal phalanx of the fingers treated by open reduction, cerclage wire fixation and immediate postoperative mobilisation were studied prospectively. Twelve patients presented early (within 24 hour of injury) and the remaining three cases were treated initially elsewhere by closed reduction and percutaneous oblique K-wire fixation with failure of the fixation. The latter three patients presented to our clinic late (10-14 days after injury). Following internal fixation with cerclage wires, no cases of infection, complex regional pain syndrome (CRPS) Type 1, fracture re-displacement, wire migration or extrusion were noted. One patient complained of a palpable wire which was removed 4 months after surgery. All fractures united and all patients returned to work at a mean of 8 (range 7-11) weeks after surgery. Twelve patients obtained a full range of motion (total active motion-TAM = 260 degrees ) and the remaining three patients had a mild (5-15 degrees ) flexion contracture of the proximal interphalangeal joint. Cerclage wire fixation is an acceptable technique of fixation for these fractures.

Fixation choices for closed simple unstable oblique phalangeal and metacarpal fractures

Percutaneous K-wire fixation is still a useful technique for closed oblique phalangeal and meta-carpal fractures when an adequate closed reduction can be achieved. Lag screw fixation may be the best choice for open fixation of long oblique phalangeal and metacarpal fractures. For short oblique fractures, plating or tension band wiring is recommended. Plating provide rigid fixation to allow early mobilization; however, one may encounter frequent complications such as extensor lag, stiffness, or joint contracture when plating technique is used in phalangeal fractures. Tension band wiring technique at the phalangeal location may reduce such complications. Overall, successful outcomes of treating phalangeal and metacarpal fractures require a clear appreciation of fracture anatomy and pattern. It is mandatory for the treating surgeon to be familiar with all the treatment techniques discussed in order to tailor a specific technique for a particular injury and patient type.

External fixation of closed metacarpal and phalangeal fractures of digits. A prospective study of one hundred consecutive patients

Stable and undisplaced phalangeal and metacarpal fractures treated with strapping or functional splinting and controlled active exercises offer from about 70 to 80% of good results. The goal of treatment of closed unstable and displaced fractures should be to achieve similar or better outcome. External fixation combines the simplicity of time-honoured fixation with K-wires and an external frame to increase rigidity. This combination was used in a prospective study of 100 consecutive patients with closed fractures of the proximal and middle phalanges and the distal three-quarters of the metacarpal bones. Good clinical results (TAM > or = 230 degrees) were obtained in 76% of isolated phalangeal fractures, in all metacarpal fractures and in 89% of multiple fractures.

The Bone Tie. A new device for interfragmentary fixation

A new method of bone fixation is described, using a small stainless steel device to provide compression between fragments with a single drill hole. The Bone Tie uses an old architectural principle to hold bone fragments together with minimal surgical dissection for access. The technique has been used in 14 cases, and the results are presented. In ten cases the outcome was good. Complications were encountered in four, mostly through technical error, although the final outcomes were acceptable.

Modification of tension band wiring of displaced intra-articular phalangeal fractures

Numerous techniques have been described for internal fixation of displaced intra-articular fractures of the phalanges, including percutaneous pinning, microplating, interosseous wiring and tension banding techniques. One method, described by Rayhack and Bottke, is a modified tension banding method using a K-wire and a stainless steel wire. Although this technique has been found to be very useful, certain complications have led to the development of a modification of this technique.

Comparative fatigue strengths and stabilities of metacarpal internal fixation techniques

To study quantitative differences in the fatigue strength and stability obtained with 5 types of internal fixation of metacarpal fractures, 105 preserved human metacarpals were cyclically tested in bending, torsion, and axial loading after oblique osteotomies of the metacarpal and internal fixation. The dorsal plate with lag screw was superior in all modes, followed by the two dorsal lag screws, crossed Kirschner wire tension banding, and intramedullary Kirschner wire fixation. The five intramedullary and the paired intramedullary Kirschner wire fixations were not statistically different. The fatigue life of the plate fixation was significantly larger in bending (1.5 times), torsion (1.6 times), and axial loading (2.5 times) than the second strongest fixation, two dorsal lag screws. Its initial rigidity was significantly higher in axial loading (1.5 times) but was not statistically different in bending and torsion.