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Dynamic external fixation for fracture dislocations of the proximal interphalangeal joint
DYNAMIC EXTERNAL FIXATION FOR FRACTURE DISLOCATIONS OF THE PROXIMAL INTERPHALANGEAL JOINT RANDALL W. CULE MD
The complications of proximal interphalangeal joint fracture dislocations include stiffness, instability, and degenerative arthritis. Hinged external dynamic fixators permit protected proximal interphalangeal joint mobilization while maintaining the joint in the reduced position. It appears that the fixator can play a role in reducing complications and providing for improved outcome for this challenging problem. KEY WORDS: internal fixation, proximal interphalangeal joint, fracture-dislocations
Fig 1. The Compass PIP Hinge device: The gear in the upper right corner is turned to allow passive motion. It may be disengaged to allow active motion as well.
Fig 2. Axis pin insertion through PIP center of rotation.
INDICATIONS Fracture-dislocations of the proximal interphalangeal joint are among the most difficult problems in hand surgery. Although it is clear that most can be treated by simple closed metods, others require more advanced forms of treatment. This would include open reduction, ~ extension block s p l i n t i n g y dynamic force coupling, 4 volar plate arthroplasty, 5 and silicone spacers. 6 The treatment of comminuted fracture-dislocations presents the greatest dilemma because of the inherent difficulties with surgical treatment. Open reduction and internal fixation, although highly effective in restoring anatomN is technically demanding and can be associated with a significant complication rate. Enough stability to allow for early motion is often precluded. It is in this group of severe fracture-dislocations that external fixation may play a role in providing stability to allow for early active motion. 7-12
From The Philadelphia Hand Center, Philadelphia, PA. Address reprint requests to Randall W. Cuip, MD, The Philadelphia Hand Center, 901 Walnut St, Philadelphia, PA 19107. Copyright © 1997 by W.B. Saunders Company 1048-6666/97/0702-0006505.00/0
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The indications for which dynamic external fixation may be used includeS,9: (1) acute volar and dorsal fracturedislocations; (2) chronic volar and dorsal fracture dislocations; (3) pilon fractures13; (4) in combination with volar plate arthroplasty; (5) augmentation of limited internal fixation; and (6) contractures.
Fig 3. Sequence and location of pin insertion. Operative Techniques in Orthopaedics, Vol 7, No 2 (April), 1997: pp 116-119
Fig 4. (A) Preoperative lateral radiograph of a patient with a comminuted, intra-articular fracture of ring finger middle phalanx. (B) Oblique radiograph of same patient. (C) Lateral fluoroscopic image of axis pin insertion. (D) A-P fluoroscopic image of pin placement. (E) Lateral fluoroscopic image in full extension. (F) Lateral fluoroscopic image in full flexion. (G) Clinical view of Compass hinge from top. Note distance from skin to device to allow for postoperative swelling. (H) Side view of device in position. (I) Lateral radiograph after removal of device demonstrating healed fracture. (J) A-P radiograph of healed fracture. (K) Clinical view 12 weeks postoperative demonstrating extension. (L) Clinical view demonstrating flexion. (Fig 4 continues on next page)
SURGICAL TECHNIQUE My current preferred technique uses a dynamic external design by Dr Robert Hotchkiss. Termed the Compass Proximal Interphalangeal Hinge (Smith & Nephew, Richards), it centers the mechanical axis of the external hinge at the instant center rotate of the joint. It is radiolucent, which can allow for more accurate alignment of this axis. The device has the ability to allow for passive and active motion as well as distraction (Fig 1). The equipment provided in the Compass kit includes a EXTERNAL FIXATION PIP JOINT
hinge, pin block, 0.045-inch K-wires, and a hex driver. Image intensifier and K-wire driver is required. Center of Rotation Pin Insertion
The procedure begins with a pin insertion. The axis pin is placed first using a 0.045 or 0.035 K-wire. The center of rotation is located between the most proximal fibers of the dorsal and volar bundles of the collateral ligaments if the joint is open. If the pin is being placed percutaneously, the axis is located equidistant from the dorsal, distal, and volar
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Fig 4. (Cont'd.)
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RANDALL W. CULP
apices of curvature presented b y the proximal interphalangeal head (Fig 2). This initial pin must be accurately placed for the hinge to function properly. Fluoroscopy verifies its position in both the lateral and anteroposterior (AP) planes.
flexion and extension. Active motion is b e g u n with place and hold techniques. The device allows for active motion b y disengaging the w a r m gear device. The hinge is left on for approximately 6 weeks.
Proximal Phalangeal Fixation
COMPLICATIONS
The hinge is n o w slid over the pin to provide fixation to the proximal phalanx. If it is being placed b e t w e e n digits, the small block should be used to prevent abutment to surr o u n d i n g digits. A 0°035 or 0.045 K-wire is placed in the most proximal aspect of the block. It should be parallel to the axis pin. The pin block can be temporarily tightened to the hinge. A second 0.035 or 0.045 K-wire is n o w inserted in the distal portion of the block, still into the proximal phalanx. T h r e a d e d bolts of the pin holding the clamps are tightened. Each side needs to be progressively tightened. Once tightened to the pins, the block is tightened to the frame. Ensuring the block is not too close to the skin, wires are cut flush to the hinge.
Distal Phalangeal Fixation The pins in the m i d d l e phalanx are often difficult to place. If the fixation is being used for a fracture-dislocation, reducing the middle phalanx before K-wire placement is beneficial. If reduction is p e r f o r m e d with the joint in flexion, the hinge needs to be flexed to the same degree with the w a r m gear on top. W h e n the pin block is parallel to the hinge and middle phalanx, the pins are placed identically as that of the proximal phalanx. Ensure pin placement with fluoroscopy (Fig 3).
Joint Reduction If the joint is reduced, the hinge can be tightened on the digital block. If incongruency still exists, the joint is manually reduced and the block secured to the hinge.
Distraction To a p p l y distraction, the distal phalanx block is left unsecured to the hinge. Distraction is p r o d u c e d b y using the threaded screw in the distal portion of the distal block. The axis pin is n o w r e m o v e d as the final part of the procedure (Fig 4).
POSTOPERATIVE PROTOCOL Motion is b e g u n in controlled fashion, d e p e n d i n g on the particular injury being treated. Usually, the initial postoperative w e e k is spent in maximal extension until swelling subsides. Next, the passive gear drive is used to maximize
EXTERNAL FIXATION PIP JOINT
1. Loss of reduction 2. Pin tract infection 3. Pin loosening
CONCLUSIONS Complex, unstable fracture-dislocations of the proximal interphalangeal joint frequently pose a dilemma. The goal of treatment is to restore joint a n a t o m y and allow early motion and to decrease joint stiffness and posttraumatic arthritis. 14 Dynamic external fixation is safe and appears to give results that are clinically and radiographically comparable if not superior to more difficult open techniques. 7-1°
REFERENCES 1. Wilson J, Rowland S: Fracture-dislocations of the proximal interphalangeal joint of the finger.J BoneJoint Surg [Am] 54:1705-1710,1972 2. McElfresh E, Dobyns J, O'Brien E: Management of fracturedislocation of the proximal interphalangeal joints by extensor-block splinting. J BoneJoint Surg Am 54:1705-1711,1972 3. Schenck R: Dynamic traction and early passive movement for fractures of the proximal interphalangeal joint. J Hand Surg [Am] 11:850-858,1986 4. AgeeJ: Unstable fracture dislocations of the proximal interphalangeal joint of the fingers: A preliminary report of a new technique. J Hand Surg 3:386-389,1978 5. Eaton R, Malerich M: Volar plate arthroplasty of the proximal interphalangeal joint: A review of ten years' experience. J Hand Surg 5:260-268, 1980 6. Swanson A, Maupin B, Gajjar R, et al: Flexibleimplant arthroplasty in the proximal interphalangeal joint of the hand. J Hand Surg [Am] 10:796-805,1985 7. Fahmy N, Harvey R: The "S" quattro in the management of fractures in the hand. J Hand Surg [Br] 17:321-331,1992 8. Hastings H, Carroll C: Treatment of closed articular fractures of the MCP and PIP joints. Hand Clin 4:503-527,1988 9. Hastings H, Ernst J: Dynamic external fixation for fractures of the proximal interphalangeal joint. Hand Clin 9:659-674,1993 10. Inanami I, Ninomiya S, Okutsu I, et al: Dynamic external finger fixator for fracture dislocation of the proximal interphalangeal joint. J Hand Surg [Am] 18:160-164,1993 11. Patel M, Joshi B: Distraction method for chronic dorsal fracture dislocation of the proximal interphalangeal joint. Hand Clin 10:327337,1994 12. Stark R: Treatment of difficult PIP joint fractures with a mini-external fixation device. Orthop Rev 23:609-615,1993 13. Stern P, Roman R, Kiefhaber T, et al: Pilon fractures of the proximal interphalangeal joint. J Hand Surg [Am] 16:844-850,1991 14. Frank C, Akeson W, Woo S, et al: Physiology and therapeutic value of passive joint motion. Clin Orthop 185:113-123,1984
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The complications of proximal interphalangeal joint fracture dislocations include stiffness, instability, and degenerative arthritis. Hinged external dynamic fixators permit protected proximal interphalangeal joint mobilization while maintaining the joint in the reduced position. It appears that the fixator can play a role in reducing complications and providing for improved outcome for this challenging problem. KEY WORDS: internal fixation, proximal interphalangeal joint, fracture-dislocations
Fig 1. The Compass PIP Hinge device: The gear in the upper right corner is turned to allow passive motion. It may be disengaged to allow active motion as well.
Fig 2. Axis pin insertion through PIP center of rotation.
INDICATIONS Fracture-dislocations of the proximal interphalangeal joint are among the most difficult problems in hand surgery. Although it is clear that most can be treated by simple closed metods, others require more advanced forms of treatment. This would include open reduction, ~ extension block s p l i n t i n g y dynamic force coupling, 4 volar plate arthroplasty, 5 and silicone spacers. 6 The treatment of comminuted fracture-dislocations presents the greatest dilemma because of the inherent difficulties with surgical treatment. Open reduction and internal fixation, although highly effective in restoring anatomN is technically demanding and can be associated with a significant complication rate. Enough stability to allow for early motion is often precluded. It is in this group of severe fracture-dislocations that external fixation may play a role in providing stability to allow for early active motion. 7-12
From The Philadelphia Hand Center, Philadelphia, PA. Address reprint requests to Randall W. Cuip, MD, The Philadelphia Hand Center, 901 Walnut St, Philadelphia, PA 19107. Copyright © 1997 by W.B. Saunders Company 1048-6666/97/0702-0006505.00/0
116
The indications for which dynamic external fixation may be used includeS,9: (1) acute volar and dorsal fracturedislocations; (2) chronic volar and dorsal fracture dislocations; (3) pilon fractures13; (4) in combination with volar plate arthroplasty; (5) augmentation of limited internal fixation; and (6) contractures.
Fig 3. Sequence and location of pin insertion. Operative Techniques in Orthopaedics, Vol 7, No 2 (April), 1997: pp 116-119
Fig 4. (A) Preoperative lateral radiograph of a patient with a comminuted, intra-articular fracture of ring finger middle phalanx. (B) Oblique radiograph of same patient. (C) Lateral fluoroscopic image of axis pin insertion. (D) A-P fluoroscopic image of pin placement. (E) Lateral fluoroscopic image in full extension. (F) Lateral fluoroscopic image in full flexion. (G) Clinical view of Compass hinge from top. Note distance from skin to device to allow for postoperative swelling. (H) Side view of device in position. (I) Lateral radiograph after removal of device demonstrating healed fracture. (J) A-P radiograph of healed fracture. (K) Clinical view 12 weeks postoperative demonstrating extension. (L) Clinical view demonstrating flexion. (Fig 4 continues on next page)
SURGICAL TECHNIQUE My current preferred technique uses a dynamic external design by Dr Robert Hotchkiss. Termed the Compass Proximal Interphalangeal Hinge (Smith & Nephew, Richards), it centers the mechanical axis of the external hinge at the instant center rotate of the joint. It is radiolucent, which can allow for more accurate alignment of this axis. The device has the ability to allow for passive and active motion as well as distraction (Fig 1). The equipment provided in the Compass kit includes a EXTERNAL FIXATION PIP JOINT
hinge, pin block, 0.045-inch K-wires, and a hex driver. Image intensifier and K-wire driver is required. Center of Rotation Pin Insertion
The procedure begins with a pin insertion. The axis pin is placed first using a 0.045 or 0.035 K-wire. The center of rotation is located between the most proximal fibers of the dorsal and volar bundles of the collateral ligaments if the joint is open. If the pin is being placed percutaneously, the axis is located equidistant from the dorsal, distal, and volar
117
Fig 4. (Cont'd.)
118
RANDALL W. CULP
apices of curvature presented b y the proximal interphalangeal head (Fig 2). This initial pin must be accurately placed for the hinge to function properly. Fluoroscopy verifies its position in both the lateral and anteroposterior (AP) planes.
flexion and extension. Active motion is b e g u n with place and hold techniques. The device allows for active motion b y disengaging the w a r m gear device. The hinge is left on for approximately 6 weeks.
Proximal Phalangeal Fixation
COMPLICATIONS
The hinge is n o w slid over the pin to provide fixation to the proximal phalanx. If it is being placed b e t w e e n digits, the small block should be used to prevent abutment to surr o u n d i n g digits. A 0°035 or 0.045 K-wire is placed in the most proximal aspect of the block. It should be parallel to the axis pin. The pin block can be temporarily tightened to the hinge. A second 0.035 or 0.045 K-wire is n o w inserted in the distal portion of the block, still into the proximal phalanx. T h r e a d e d bolts of the pin holding the clamps are tightened. Each side needs to be progressively tightened. Once tightened to the pins, the block is tightened to the frame. Ensuring the block is not too close to the skin, wires are cut flush to the hinge.
Distal Phalangeal Fixation The pins in the m i d d l e phalanx are often difficult to place. If the fixation is being used for a fracture-dislocation, reducing the middle phalanx before K-wire placement is beneficial. If reduction is p e r f o r m e d with the joint in flexion, the hinge needs to be flexed to the same degree with the w a r m gear on top. W h e n the pin block is parallel to the hinge and middle phalanx, the pins are placed identically as that of the proximal phalanx. Ensure pin placement with fluoroscopy (Fig 3).
Joint Reduction If the joint is reduced, the hinge can be tightened on the digital block. If incongruency still exists, the joint is manually reduced and the block secured to the hinge.
Distraction To a p p l y distraction, the distal phalanx block is left unsecured to the hinge. Distraction is p r o d u c e d b y using the threaded screw in the distal portion of the distal block. The axis pin is n o w r e m o v e d as the final part of the procedure (Fig 4).
POSTOPERATIVE PROTOCOL Motion is b e g u n in controlled fashion, d e p e n d i n g on the particular injury being treated. Usually, the initial postoperative w e e k is spent in maximal extension until swelling subsides. Next, the passive gear drive is used to maximize
EXTERNAL FIXATION PIP JOINT
1. Loss of reduction 2. Pin tract infection 3. Pin loosening
CONCLUSIONS Complex, unstable fracture-dislocations of the proximal interphalangeal joint frequently pose a dilemma. The goal of treatment is to restore joint a n a t o m y and allow early motion and to decrease joint stiffness and posttraumatic arthritis. 14 Dynamic external fixation is safe and appears to give results that are clinically and radiographically comparable if not superior to more difficult open techniques. 7-1°
REFERENCES 1. Wilson J, Rowland S: Fracture-dislocations of the proximal interphalangeal joint of the finger.J BoneJoint Surg [Am] 54:1705-1710,1972 2. McElfresh E, Dobyns J, O'Brien E: Management of fracturedislocation of the proximal interphalangeal joints by extensor-block splinting. J BoneJoint Surg Am 54:1705-1711,1972 3. Schenck R: Dynamic traction and early passive movement for fractures of the proximal interphalangeal joint. J Hand Surg [Am] 11:850-858,1986 4. AgeeJ: Unstable fracture dislocations of the proximal interphalangeal joint of the fingers: A preliminary report of a new technique. J Hand Surg 3:386-389,1978 5. Eaton R, Malerich M: Volar plate arthroplasty of the proximal interphalangeal joint: A review of ten years' experience. J Hand Surg 5:260-268, 1980 6. Swanson A, Maupin B, Gajjar R, et al: Flexibleimplant arthroplasty in the proximal interphalangeal joint of the hand. J Hand Surg [Am] 10:796-805,1985 7. Fahmy N, Harvey R: The "S" quattro in the management of fractures in the hand. J Hand Surg [Br] 17:321-331,1992 8. Hastings H, Carroll C: Treatment of closed articular fractures of the MCP and PIP joints. Hand Clin 4:503-527,1988 9. Hastings H, Ernst J: Dynamic external fixation for fractures of the proximal interphalangeal joint. Hand Clin 9:659-674,1993 10. Inanami I, Ninomiya S, Okutsu I, et al: Dynamic external finger fixator for fracture dislocation of the proximal interphalangeal joint. J Hand Surg [Am] 18:160-164,1993 11. Patel M, Joshi B: Distraction method for chronic dorsal fracture dislocation of the proximal interphalangeal joint. Hand Clin 10:327337,1994 12. Stark R: Treatment of difficult PIP joint fractures with a mini-external fixation device. Orthop Rev 23:609-615,1993 13. Stern P, Roman R, Kiefhaber T, et al: Pilon fractures of the proximal interphalangeal joint. J Hand Surg [Am] 16:844-850,1991 14. Frank C, Akeson W, Woo S, et al: Physiology and therapeutic value of passive joint motion. Clin Orthop 185:113-123,1984
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