Patient-Reported Outcomes and Complications After Surgical Fixation of 143 Proximal Phalanx Fractures

Early Postoperative Outcomes of Surgical Fixation of Proximal Phalanx Fractures With Intramedullary Nails Versus Kirschner Wires

BACKGROUND

Kirschner wire (K-wire) and intramedullary (IM) screw fixation are accepted techniques for treatment of unstable proximal phalanx fractures, but comparative reports are lacking. This study aimed to evaluate early clinical outcomes following treatment with K-wire or IM fixation.

METHODS

A retrospective review of all proximal phalanx fractures treated surgically at a single center by multiple surgeons was performed from May 1, 2019 to March 1, 2024. Inclusion criteria consisted of patients above 18 years of age with transverse or short-oblique proximal phalanx fractures, without associated soft-tissue injury or involvement of multiple digits, who were treated with IM screw or K-wire fixation. Outcomes were available for 49 patients (27 K-wire, 22 IM nail). Chart review was performed to assess range of motion (ROM) and Quick Disabilities of the Arm, Shoulder, and Hand outcomes 6 and 12 weeks postoperatively.

RESULTS

A significant difference was found in total active motion (TAM) (207.4° vs 150.8°, P = .03) and proximal interphalangeal (PIP) joint motion (71.8° vs 54.5°, P = .04) between the IM and K-wire cohorts 12 weeks after surgery. Proximal interphalangeal motion was also significantly different (57.6° vs 34.3°, P = .03) 6 weeks after surgery with no significant difference in TAM (176.6° vs 122.1°, P = .13) at that time point. Quick Disabilities of the Arm, Shoulder, and Hand scores 12 weeks after surgery were not significantly different between the IM (M: 15.8) and K-wire (M: 28.15) groups (P = .13).

CONCLUSIONS

Total active motion and PIP joint motion were found to be significantly higher 12 weeks postoperatively following IM fixation compared to K-wire fixation for extra-articular proximal phalanx fractures.

Closed Reduction Percutaneous Pinning Versus Open Reduction With Plate and Screw Fixation in Management of Unstable Proximal Phalangeal Fractures: A Systematic Review and Meta-analysis

BACKGROUND

Proximal phalanx fractures are common, with surgical fixation indicated for unstable fractures. Traditionally, closed reduction percutaneous pinning (CRPP) resulted in decreased stiffness and tendon irritation compared to open reduction internal fixation (ORIF). We hypothesized that more recent studies would have more similar outcomes to CRPP. The purpose of this study was to compare CRPP and ORIF in terms of range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and complications.

METHODS

Four electronic databases were queried from 2010 to present. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two independent reviewers performed a two-step review process to identify relevant articles. Patient demographics, total active motion (TAM), DASH, and complications were extracted. The methodological quality of each study included was assessed independently. Meta-analysis was performed for comparative trials.

RESULTS

Fourteen studies met inclusion criteria including four comparative studies: Thirteen studies included TAM. The weighted average TAM was 228 ± 34° for CRPP and 223 ± 32° for ORIF (P = .07 with 95% confidence interval (CI), -0.5 to 10.5). Seven studies evaluated DASH scores; weighted average was 8.2 ± 8.9 for CRPP and 11.7 ± 6.5 for ORIF (P < .01 with 95% CI, 1.8-5.2). Two studies directly compared CRPP to ORIF, favoring ORIF for both TAM with d = 1.07 and DASH with d = 0.23. Rates of tenolysis or hardware removal were higher for ORIF (P < .01).

CONCLUSIONS

New literature suggests more equipoise with regard to treatment of proximal phalanx fracture with CRPP versus ORIF.

TYPE OF STUDY/LEVEL OF EVIDENCE

Meta-analysis, Level II.

Phalangeal fractures: A retrospective comparison of open reduction and internal fixation vs. closed reduction and percutaneous pinning

The treatment of phalangeal fractures is guided by fracture characteristics, patient factors and surgeon judgment. This study retrospectively compares characteristics of phalangeal fractures treated with closed reduction percutaneous pinning (CRPP) with those of fractures treated with open reduction internal fixation (ORIF) to identify risk factors associated with reoperation. A total of 901 phalangeal fractures were included and treated operatively by either CRPP (748 fractures, 83 ​%) or ORIF (153 fractures, 17 ​%). Demographics, surgical management, and complication data were collected. Statistical analyses were performed to stratify risk associations and identify potential predictors of reoperation. With multivariate analysis and bootstrapped LASSO regression, fractures addressed by means of ORIF (vs. CRPP), work-related fractures, and open fractures were found to be independently associated with reoperation. These findings can be used to guide patient selection, surgical planning and timing of fracture repair.

Level of evidence

Level III, Therapeutic.

Evaluating Kirschner wire fixation versus titanium plating and screws for unstable phalangeal fractures: A systematic review and meta-analysis of postoperative outcomes

Background

Unstable phalangeal fractures represent a clinical challenge in hand surgery. The choice of fixation method, whether Kirschner wire (K-wire) fixation or titanium plating with screws, often depends on surgeon preference due to the lack of comprehensive comparative data. This article aimed to compare the postoperative outcomes of K-wire fixation versus titanium plating and screws in the treatment of unstable phalangeal fractures.

Methods

This review was conducted according to the PRISMA guidelines for reporting systematic reviews and meta-analyses. A systematic review and meta-analysis of the existing literature was done encompassing PUBMED, EMBASE, Google Scholar, and Cochrane library using the keywords: "K wire/ Kirschner wire", "titanium plate/ screws", "Miniplate/ screws", and "Unstable phalan∗ fracture/ hand fracture".

Results

After screening 2374 articles, 6 final studies with a total of 414 patients were included. Operative time was significantly shorter with K-wire fixation compared to plating, by a mean difference of -27.03 ​min [95% CI -43.80, -10.26] (p ​= ​0.02). Time to radiographic union averaged 7.43 weeks with K-wires versus 8.21 weeks with titanium plates. No statistically significant differences emerged between groups for overall complications (p ​= ​0.69), infection (p ​= ​0.47), malunion (p ​= ​0.36), stiffness (p ​= ​0.11), or need for reoperation (p ​= ​0.10).

Conclusion

K-wire fixation demonstrated shorter mean operating time and faster radiographic union versus plating for unstable phalangeal fractures. These findings can guide surgical decisions and emphasize the need for individualized treatment based on fracture type and patient factors.

Early Return of Motion in Patients With Intramedullary Screw Placement for Metacarpal and Phalangeal Fracture Fixation

INTRODUCTION

Hand fractures are associated with significant morbidity. Current management standards often result in prolonged immobilization, stiffness, and delayed return to functional use. Intramedullary (IM) compression screws offer minimal soft tissue disruption and early postoperative active motion. In this study, we describe our outcomes after intraosseous fracture fixation using IM cannulated headless screws for a multitude of fracture patterns.

METHODS

This study is a retrospective review of patients who underwent IM screw placement for fixation of metacarpal and phalangeal fractures by a single surgeon from 2017 to 2022. Data were collected to include patient demographics, fracture details, postoperative complications, and follow-up. Time to range of motion and return to unrestricted motion was recorded.

RESULTS

There were 69 patients with 92 fractures (n = 54 metacarpal, n = 38 phalanx). The median patient age was 45 years (range, 18-89 years) with 75.4% males. Majority presented with a single fracture (n = 50, 72.5%), and 38 patients (55.1%) had open fractures. Small finger was the most affected digit (n = 35, 37.6%). The median time to allow range of motion from surgery was 8.7 days (interquartile range, 0-32) with 32 days (interquartile range, 10-62) for unrestricted use of the hand. Thirty-five patients (50.7%) were allowed controlled motion from the first postoperative day. One patient had loss of reduction requiring reintervention for hardware removal, and 1 patient had superficial skin infection managed with oral antibiotics.

CONCLUSIONS

Our findings indicate that the IM screw provides reliable fixation for a wide variety of fracture patterns with a low complication rate and offers early return to functional use.

Phalangeal Fractures Requiring Vascular Reconstruction: Epidemiology and Factors Predictive of Reoperation

BACKGROUND

Demographic information related to phalangeal fractures that undergo simultaneous vascular repair, as well as their complication and reoperation profiles, remain incompletely understood. This study aimed to examine the patient and fracture characteristics influencing the outcomes after these injuries in a large Unites States adult patient cohort and to identify risk factors associated with unplanned reoperation of these fractures.

METHODS

A retrospective study was performed, identifying 54 phalangeal fractures in 48 patients; all fractures were also associated with vascular injuries requiring repair. Patients with digital amputations were excluded. A manual chart review was performed to collect epidemiologic, radiographic, and surgical outcome information.

RESULTS

The incidence of phalangeal fractures undergoing vascular repair was higher in the non-dominant hand, middle finger, proximal phalanx, and phalangeal shaft. Most (52.9%) fractures were due to occupational injury, with the most common mechanism being sharp injuries. More than half of the fractures had a nerve injury, and 13% required a vein graft for vascular repair. More than half of the fractures required at least one reoperation, most commonly due to "stiffness/tendon adhesion" (50%) and "nonunion or delayed union" (21.4%). In multivariable analysis, thumb (odds ratio [OR]: 35.1, P = .043) and index (OR: 14.0, P = .048) fingers' fractures were found to be independently associated with unplanned reoperation.

CONCLUSIONS

Phalangeal fractures requiring vascular repair occurred most often in the occupational setting and more than 50% required at least one unplanned reoperation. Injuries sustained in the thumb and index finger were more likely to undergo unplanned reoperation, which may guide initial treatment decision-making and postoperative follow-up.

Risks of Reoperation in Surgically Treated Fractures of the Proximal Phalanx

Purpose

The objective of this study was to determine the risk factors and the rate of reoperation after closed reduction percutaneous pinning (CRPP) of isolated closed single-digit proximal phalanx fractures.

Methods

A retrospective cohort study was conducted for patients who underwent CRPP of non-thumb closed proximal phalanx fractures between 2010 and 2020 at two level-I trauma centers and two community teaching hospitals. Demographics, fracture, and treatment characteristics were collected. The primary outcome measure was reoperation. Secondary outcome measures were complication and reoperation specifically for digital stiffness.

Results

Of the 115 patients who underwent surgical treatment, 46 patients (40.0%) had a complication and 13 patients (11.3%) underwent reoperation at a mean of 6.7 months-most of which (84.6%) were for digital stiffness.

Conclusions

Surgeons and patients may be aware that CRPP of closed extra-articular proximal phalanx fractures carries considerable rates of complication and reoperation.

Type of study/level of evidence

Therapeutic III.

Novel Tools to Approach and Measure Outcomes in Patients with Fractures

Upper extremity fractures are prevalent and pose a great burden to patients and society. In the US alone, the annual incidence of upper extremity fractures is 67.6 fractures per 10,000 persons. While the majority of patients with upper extremity fractures demonstrate satisfactory outcomes when treated appropriately (the details of which are discussed in prior articles), the importance of follow-up and outcome measurement cannot be understated. Outcome measurement allows for accountability and improvement in clinical outcomes and research. The purpose of this article is to describe recent advances in methods and tools for assessing clinical and research outcomes in hand and upper extremity care. Three specific advances that are broadly changing the landscape of follow-up care of our patients include: 1) telemedicine, 2) patient-reported outcome measurement, and 3) wearables/remote patient monitoring.

Outcome of functional treatment with a Lucerne Cast in patients with hand fractures: a retrospective case series

PURPOSE

The purpose of this study was to determine the clinical outcome of patients treated with a functional Lucerne Cast (LuCa) for different types of hand fractures. Static casting has traditionally been the preferred treatment for hand fractures. However, functional casting may lead to good functional outcomes, less stiffness, and earlier return to work.

METHODS

A retrospective case series of all consecutive patients with a metacarpal or proximal phalangeal fracture treated with a LuCa between 2018 and 2019 was conducted. A total of 90 patients were included. Clinical data were collected directly from the patient's medical records. Functional outcome was assessed with the Michigan Hand Outcomes Questionnaire (MHQ).

RESULTS

The median MHQ score was 95 (IQR 83-100) with a median follow-up of 23 months. Complications occurred in 7 of 90 patients (8%). Functional impairment occurred in two (2%) patients. Functional impairment was defined as stiffness, persisting rotational deformity, a boutonnière or swanneck deformity. Persisting pain or CRPS occurred in six (7%) patients.

CONCLUSION

The LuCa shows to be effective in the functional treatment of both metacarpal and proximal phalangeal fractures with excellent patient-reported outcomes but at a relatively high rate of persisting pain.

Intramedullary Crossed K-wire Fixation for the Hand Fractures is a Useful Treatment Modality: A Prospective Observational Study

BACKGROUND

Various modalities of treatment have been used for the management of metacarpal and phalangeal fractures which include K-wire fixation, mini plates, lag screws fixation, intramedullary screw fixation and external fixator application. The aim of this study was to analyse complications and patient-related functional outcomes after antegrade or retrograde crossed intramedullary K-wire fixation of metacarpal and proximal phalangeal fractures.

METHODS

Thirty-one patients (36-fractures, 16-metacarpals, 20-proximal phalanx) meeting the study criteria were included in this prospective study. Fixation of the fractures was done by use of crossed intramedullary K-wire using the principles of 3-point fixation.

RESULTS

The mean preoperative angulation of the fractures noted in this study was 35.8° which was significantly reduced at final follow-up. Union was noted at a mean period of 4.2 ± 6.8 weeks. The mean range of motion at the metacarpophalangeal and proximal interphalangeal joint was 96.4% and 86.3%, respectively as compared to the opposite hand. Stiffness (n = 3, 14.2%) and persistent pain (n = 2, 9.5%) at the joints were the most common complications noted in this study.

CONCLUSION

Crossed percutaneous intramedullary fixation of small bone fractures of the hand is a versatile method with advantages such as cost-effectiveness and lesser operative time when compared to other modalities of fixation. Earlier range of motion (ROM) exercises can be started due to preservation of gliding planes, no surgical wound along with good fracture stability and minimal hardware impingement.

HOW TO CITE THIS ARTICLE

Ahmad S, Gupta T, Ansari S, et al. Intramedullary Crossed K-wire Fixation for the Hand Fractures is a Useful Treatment Modality: A Prospective Observational Study. Strategies Trauma Limb Reconstr 2022;17(2):74-80.

[Percutaneous, antegrade Pinning of proximal phalangeal Fractures: Comparison of Early Active Motion vs. Immobilization by Splinting]

PURPOSE

This retrospective study compares the functional outcome after early active postoperative motion with the outcome after 6 weeks of immobilization by splinting in patients with proximal phalangeal fractures treated by percutaneous, antegrade pinning.

PATIENTS AND METHODS

46 out of 90 patients treated by closed reduction and percutaneous antegrade pinning of isolated fractures of the proximal phalanges were re-evaluated on average after 18.5 months. There were 17 women and 29 men with a mean age of 42.8 years. 28 patients underwent early active postoperative motion and 18 patients were immobilized by splinting for 6 weeks postoperatively. The two groups were statistically comparable with respect to age, gender, fracture localisation and morphology, mechanism of injury and operative time. Follow-up examination included measurement of active and passive range of motion (TAM; TPM) of the injured finger and the uninjured finger of the opposite side as well as grip strength of both hands. In addition, postoperative complications, the DASH-score and time interval between surgery and return to work were registered.

RESULTS

There were no significant differences between the two groups regarding rate of complication, number or required revisions, finger motion and grip strenght. Patients with early active motion returned earlier back to work than patients treated by postoperative splinting (2.5 vs. 9.0 weeks; p = 0.035). With 1.7 the DASH-score in the group with early active motion was better than in the splinting group with 2.5 (p = .269).

CONCLUSION

Patients with early active postoperative motion returned earlier back to work. There was no significant difference between both groups respecting global finger function.Compliant patients with a fracture of the proximal phalanx treated by closed reduction and percutaneous pinning can be treated with early active motion postoperatively.

Minimally Invasive Intramedullary Screw Versus Plate Fixation for Proximal Phalanx Fractures: A Biomechanical Study

PURPOSE

To compare the maximum interfragmentary displacement of short oblique proximal phalanx (P1) fractures fixed with an intramedullary headless compression screw (IMHCS) versus a plate-and-screws construct in a cadaveric model that generates finger motion via the flexor and extensor tendons of the fingers.

METHODS

We created a 30° oblique cut in 24 P1s of the index, middle, ring, and little fingers for 3 matched pairs of cadaveric hands. Twelve fractures were stabilized with an IMHCS using an antegrade, dorsal articular margin technique at the P1 base. The 12 matched-pair P1 fractures were stabilized with a radially placed 2.0-mm plate with 2 bicortical nonlocking screws on each side of the fracture. Hands were mounted to a frame allowing a computer-controlled, motor-driven, linear actuator powered movement of fingers via the flexor and extensor tendons. All fingers underwent 2,000 full-flexion and extension cycles. Maximum interfragmentary displacement was continuously measured using a differential variable reluctance transducer.

RESULTS

The observed mean displacement differences between IMHCS and plate-and-screws fixation was not statistically significant throughout all time points during the 2,000 cycles. A 2 one-sided test procedure for paired samples confirmed statistical equivalence in fracture displacement between fixation methods at the final 2,000-cycle time point.

CONCLUSIONS

The IMHCS provided biomechanical stability equivalent to plate-and-screws for short oblique P1 fractures at the 2,000-cycle mark in this cadaveric model.

CLINICAL RELEVANCE

Short oblique P1 fracture fixation with an IMHCS may provide adequate stability to withstand immediate postoperative active range of motion therapy.