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Dynamic Intradigital External Fixation for Proximal Interphalangeal Joint Fracture Dislocations
LITERATURE ABSTRACTS
Abstracts from the Literature editor is Greg Hritzo, MPT, CHT [email protected] Dynamic Intradigital External Fixation for Proximal Interphalangeal Joint Fracture Dislocations. Badia A et al. J Hand Surg [Am]. 2005;30A:154–60. The authors present modifications to a previously described skeletal traction device used to treat fracture dislocations of the proximal interphalangeal (PIP) joint. Their design improves the stability of the fixation and provides satisfactory functional results. Their report is based on a sample of six patients with fracture dislocations of the PIP joint. Fracture dislocations of the PIP joint are common injuries. Without proper treatment, pain, stiffness, and posttraumatic arthritis often occur. Dorsal dislocations are more common than volar dislocations and are often seen in ball-handling athletes. Treatment for these fracture dislocations is either nonsurgical or surgical, depending on the severity of the comminution and the stability of the PIP joint. Surgical treatment is required when the fracture is unstable and/or when there is significant fragment displacement. There are many surgical treatment techniques described: closed reduction and percutaneous pinning, dorsal extension block pinning, open reduction and internal fixation, and traction fixation. Early mobilization of the PIP joint along with traction and stable fixation offers the most favorable functional outcomes. Gaul and Rosenberg devised a simple frame that provided traction without rubber bands or complicated connecting pieces. The authors introduce their own modification to the frame created by Gaul and Rosenberg and describe its use in six patients with fracture dislocation of the PIP joint. Methods. The authors treated six patients (four male, two female) who sustained fracture dislocations of the PIP joint with a dynamic external fixator. Fracture dislocation was caused by crush injury in all patients, and the fractures were all closed. The
456
JOURNAL OF HAND THERAPY
average age of the patients was 27 years (range 21–42 yr). The middle finger was involved in three patients, the little finger in two patients, and the ring finger in one patient. The average follow-up period was 24 months (7–43 mo). Surgical Technique. Digital block anesthesia is administered, and a 1.4-mm K wire (K1) is placed transversely through the center of the head of the proximal phalanx under fluoroscopy. Another K wire (K2) is driven through the head of the middle phalanx. The K1 wire actually protrudes out on each side of the PIP joint and is bent at a 90° angle there so that the ends lay parallel and 1 cm away from the middle phalanx. The original description by Gaul and Rosenberg outlined a volar direction and longer lever arm of this K1 wire. The modifications by the author ensure a traction force parallel to the middle phalanx that will not lead to a loss of distraction force over time. The K1 wire is bent to 90° again at the level of the base of the distal phalanx where it loops into and hooks around the K2 wire. This is how the traction force is applied and maintained. The amount of distraction of the joint space is then evaluated and confirmed by x-ray. Open reduction is only necessary when articular fragments remain displaced. Fluroscopy is used to monitor flexion and extension of the PIP joint with the external fixator in place. Soft, minimally bulky dressings are applied for the first postoperative day. But immediate active PIP joint motion, supervised by a hand therapist, is initiated on the following day. The fixator provides traction and maintains joint space while allowing for active motion. It remains in place for three to four weeks. Results. The average range of motion of the PIP joint at the follow-up evaluation was 5–89° (range 0–100°). The average range of motion of the distal interphalangeal joint (DIP) was 2–80° (range 0–90°). At final evaluation, no instability of the PIP joint was noted.
Case Report. The authors include the case report of a 21-year-old male who sustained an intra-articular fracture dislocation of the PIP joint of the right little finger. The external fixator described here was placed on his involved finger. Hand therapy was initiated, and active motion exercises were introduced immediately. The fixator was removed after three weeks, and therapy continued until full motion was achieved. The patient demonstrated 5–90° of extension–flexion at the PIP joint and 0–75° of motion at the DIP joint at follow-up evaluation. Discussion. The authors maintain that early mobilization of the PIP joint after fracture dislocation is critical to avoid stiffness and permanent ankylosis. The literature describes many techniques for this including Inanami’s dynamic external fixator and the compass hinge as reported by Bain et al. and others. However, many complications (infection and breakage) have been reported with these devices. Other methods utilize rubber bands for traction, which the authors maintain, are susceptible to plastic deformation and/or deforming forces. The authors recommend their procedure as the best method for treatment of fracture dislocation of the PIP joint because it is an easy to apply, inexpensive, and time-efficient procedure, without major complications for the patient. As hand therapists treating difficult PIP joint injuries, we understand the benefits of early mobilization. The external device described maintains the PIP joint space and allows for early flexion and extension motion. It is held in place for a relatively short time, only three to four weeks. This is important information because the external pin protrusion makes full fist making and tendon gliding exercises difficult. No description of pin site care is offered (two patients developed pin tract infection and were treated with oral antibiotics). Information regarding
protective splinting and positioning for in-between exercise sessions and at night is lacking. Despite the satisfactory functional outcomes reported, the small sample size of six patients is a limitation of this study as well.
DEBORAH A. SCHWARTZ, OTR/L, CHT
What Can Handgrip Strength Tell the Therapist about Hand Function? Tyler H, Adams J, Ellis B. Br J Hand Ther. 2005; 10:4–9. Can the measure of grip strength serve as an indicator of an individual’s ability to use his or her hands in activities of daily living? This is the topic explored in this brief, yet engaging article from the British Journal of Hand Therapy. The authors investigate the important issues involved in measuring grip strength and examine its usefulness to us as clinicians. Instruments used in the measurement of grip strength and the correct protocols for doing so are discussed. Adapted sphygmomanometers are still used in several departments, but this measures grip pressure, which is not as reliable a measure as force to record grip. The ASHT recommends use of the Jamar dynamometer because of its welldocumented reliability and validity. This instrument may be difficult to grasp for individuals with weakness in their hands. The scale may not pick up small changes in strength as well. There are newer, more sensitive tools that measure grip in newtons. This makes it easier to record small changes between trials. The authors suggest frequent recalibration of instruments to ensure their accuracy. The mean value from three grip strength recordings should be used as suggested by the literature. The patient’s positioning is standardized with the shoulder adducted, elbow flexed to 90°, the forearm in neutral, the wrist in 0–30° of extension, and 0–15° of ulnar deviation. The authors briefly discuss the issue of submaximal (feigned) effort and conclude that the amount of variation between
trials may in itself not be a good and reliable indicator of submaximal effort. We often compare our patients’ grip strengths with normative data. But we need to be confident that the norms we use are applicable to our patient population. Hand function has been described as the ability to use the hand to perform daily tasks. Hand function includes range of motion, sensation, coordination, dexterity, fine motor skills, as well as grip. So what does grip strength actually tell the clinician about hand function? The authors review the research concerning grip strength and hand function and divide the studies into three categories according to the research methods used: 1. Studies that compare participants’ grip strength with performance on a particular activity of daily living. 2. Studies that compare grip strength with performance on a series of tasks resulting in an overall score. 3. Studies that compare grip strength with participants’ subjective evaluations of their ability to complete daily living tasks. Comparing grip strength with performance on an activity of daily living: One study explored the relationship between grip strength and a person’s ability to open six different containers. Grip strength for each individual was recorded, and his or her ability to open the containers was noted. In a study of college students, greater grip strength did not correlate with better performance at opening containers. The study was repeated with older participants, and a fair correlation was established between power grip and the ability to open two of six containers. This suggests that reduced grip strength may lead to difficulties with opening everyday containers. Comparing grip strength with performance on a series of tasks resulting in an overall score: Several studies have been conducted on small samples comparing grip strength with overall upper extremity performance. Hand function as measured by the Jebsen Hand Function Test and the Purdue Pegboard Test was compared with Jamar dynamometer grip strength recordings. Moderate to weak correlations have been reported on a variety of patient
populations. Due to small sample sizes, the information may not be generalized to other populations. Comparing grip strength with participants’ subjective evaluations of their ability to complete daily living tasks: The authors mention several studies that compared grip strength measurements with patients’ subjective evaluation of their ability to perform activities of daily living. The subjective evaluations used included the self-report Health Assessment Questionnaire, the Disabilities of the Arm, Shoulder and Hand Outcome Questionnaire (DASH questionnaire), and the Michigan Hand Outcome Questionnaire. The studies varied in their use of grip strength– measuring instruments. All studies had small sample sizes and were patient-diagnosis specific. In general, a range of correlations was found between grip strength and functional outcomes as measured by patient self-report assessments. The authors report on newer research comparing dynamic grip strength with static grip strength and raise the question of which more accurately represents the force used in hand function. But here the instrument used to measure grip strength was designed specifically for the research and has not yet appeared in the clinic. In summary, the authors raise important questions concerning our measurements of grip strength and how we use this information. Further studies are required to provide knowledge regarding the usefulness of grip strength as an overall indicator of hand function.
DEBORAH A. SCHWARTZ, OTR/L, CHT
Psychological Factors Associated with Idiopathic Arm Pain. Ring D et al. J Bone Joint Surg. 2005;87:374–9.
Introduction. Psychological and personality factors may be as important as, or more important than, pathological processes in the experience of pain. This is especially true in those
October–December 2005 457
Abstracts from the Literature editor is Greg Hritzo, MPT, CHT [email protected] Dynamic Intradigital External Fixation for Proximal Interphalangeal Joint Fracture Dislocations. Badia A et al. J Hand Surg [Am]. 2005;30A:154–60. The authors present modifications to a previously described skeletal traction device used to treat fracture dislocations of the proximal interphalangeal (PIP) joint. Their design improves the stability of the fixation and provides satisfactory functional results. Their report is based on a sample of six patients with fracture dislocations of the PIP joint. Fracture dislocations of the PIP joint are common injuries. Without proper treatment, pain, stiffness, and posttraumatic arthritis often occur. Dorsal dislocations are more common than volar dislocations and are often seen in ball-handling athletes. Treatment for these fracture dislocations is either nonsurgical or surgical, depending on the severity of the comminution and the stability of the PIP joint. Surgical treatment is required when the fracture is unstable and/or when there is significant fragment displacement. There are many surgical treatment techniques described: closed reduction and percutaneous pinning, dorsal extension block pinning, open reduction and internal fixation, and traction fixation. Early mobilization of the PIP joint along with traction and stable fixation offers the most favorable functional outcomes. Gaul and Rosenberg devised a simple frame that provided traction without rubber bands or complicated connecting pieces. The authors introduce their own modification to the frame created by Gaul and Rosenberg and describe its use in six patients with fracture dislocation of the PIP joint. Methods. The authors treated six patients (four male, two female) who sustained fracture dislocations of the PIP joint with a dynamic external fixator. Fracture dislocation was caused by crush injury in all patients, and the fractures were all closed. The
456
JOURNAL OF HAND THERAPY
average age of the patients was 27 years (range 21–42 yr). The middle finger was involved in three patients, the little finger in two patients, and the ring finger in one patient. The average follow-up period was 24 months (7–43 mo). Surgical Technique. Digital block anesthesia is administered, and a 1.4-mm K wire (K1) is placed transversely through the center of the head of the proximal phalanx under fluoroscopy. Another K wire (K2) is driven through the head of the middle phalanx. The K1 wire actually protrudes out on each side of the PIP joint and is bent at a 90° angle there so that the ends lay parallel and 1 cm away from the middle phalanx. The original description by Gaul and Rosenberg outlined a volar direction and longer lever arm of this K1 wire. The modifications by the author ensure a traction force parallel to the middle phalanx that will not lead to a loss of distraction force over time. The K1 wire is bent to 90° again at the level of the base of the distal phalanx where it loops into and hooks around the K2 wire. This is how the traction force is applied and maintained. The amount of distraction of the joint space is then evaluated and confirmed by x-ray. Open reduction is only necessary when articular fragments remain displaced. Fluroscopy is used to monitor flexion and extension of the PIP joint with the external fixator in place. Soft, minimally bulky dressings are applied for the first postoperative day. But immediate active PIP joint motion, supervised by a hand therapist, is initiated on the following day. The fixator provides traction and maintains joint space while allowing for active motion. It remains in place for three to four weeks. Results. The average range of motion of the PIP joint at the follow-up evaluation was 5–89° (range 0–100°). The average range of motion of the distal interphalangeal joint (DIP) was 2–80° (range 0–90°). At final evaluation, no instability of the PIP joint was noted.
Case Report. The authors include the case report of a 21-year-old male who sustained an intra-articular fracture dislocation of the PIP joint of the right little finger. The external fixator described here was placed on his involved finger. Hand therapy was initiated, and active motion exercises were introduced immediately. The fixator was removed after three weeks, and therapy continued until full motion was achieved. The patient demonstrated 5–90° of extension–flexion at the PIP joint and 0–75° of motion at the DIP joint at follow-up evaluation. Discussion. The authors maintain that early mobilization of the PIP joint after fracture dislocation is critical to avoid stiffness and permanent ankylosis. The literature describes many techniques for this including Inanami’s dynamic external fixator and the compass hinge as reported by Bain et al. and others. However, many complications (infection and breakage) have been reported with these devices. Other methods utilize rubber bands for traction, which the authors maintain, are susceptible to plastic deformation and/or deforming forces. The authors recommend their procedure as the best method for treatment of fracture dislocation of the PIP joint because it is an easy to apply, inexpensive, and time-efficient procedure, without major complications for the patient. As hand therapists treating difficult PIP joint injuries, we understand the benefits of early mobilization. The external device described maintains the PIP joint space and allows for early flexion and extension motion. It is held in place for a relatively short time, only three to four weeks. This is important information because the external pin protrusion makes full fist making and tendon gliding exercises difficult. No description of pin site care is offered (two patients developed pin tract infection and were treated with oral antibiotics). Information regarding
protective splinting and positioning for in-between exercise sessions and at night is lacking. Despite the satisfactory functional outcomes reported, the small sample size of six patients is a limitation of this study as well.
DEBORAH A. SCHWARTZ, OTR/L, CHT
What Can Handgrip Strength Tell the Therapist about Hand Function? Tyler H, Adams J, Ellis B. Br J Hand Ther. 2005; 10:4–9. Can the measure of grip strength serve as an indicator of an individual’s ability to use his or her hands in activities of daily living? This is the topic explored in this brief, yet engaging article from the British Journal of Hand Therapy. The authors investigate the important issues involved in measuring grip strength and examine its usefulness to us as clinicians. Instruments used in the measurement of grip strength and the correct protocols for doing so are discussed. Adapted sphygmomanometers are still used in several departments, but this measures grip pressure, which is not as reliable a measure as force to record grip. The ASHT recommends use of the Jamar dynamometer because of its welldocumented reliability and validity. This instrument may be difficult to grasp for individuals with weakness in their hands. The scale may not pick up small changes in strength as well. There are newer, more sensitive tools that measure grip in newtons. This makes it easier to record small changes between trials. The authors suggest frequent recalibration of instruments to ensure their accuracy. The mean value from three grip strength recordings should be used as suggested by the literature. The patient’s positioning is standardized with the shoulder adducted, elbow flexed to 90°, the forearm in neutral, the wrist in 0–30° of extension, and 0–15° of ulnar deviation. The authors briefly discuss the issue of submaximal (feigned) effort and conclude that the amount of variation between
trials may in itself not be a good and reliable indicator of submaximal effort. We often compare our patients’ grip strengths with normative data. But we need to be confident that the norms we use are applicable to our patient population. Hand function has been described as the ability to use the hand to perform daily tasks. Hand function includes range of motion, sensation, coordination, dexterity, fine motor skills, as well as grip. So what does grip strength actually tell the clinician about hand function? The authors review the research concerning grip strength and hand function and divide the studies into three categories according to the research methods used: 1. Studies that compare participants’ grip strength with performance on a particular activity of daily living. 2. Studies that compare grip strength with performance on a series of tasks resulting in an overall score. 3. Studies that compare grip strength with participants’ subjective evaluations of their ability to complete daily living tasks. Comparing grip strength with performance on an activity of daily living: One study explored the relationship between grip strength and a person’s ability to open six different containers. Grip strength for each individual was recorded, and his or her ability to open the containers was noted. In a study of college students, greater grip strength did not correlate with better performance at opening containers. The study was repeated with older participants, and a fair correlation was established between power grip and the ability to open two of six containers. This suggests that reduced grip strength may lead to difficulties with opening everyday containers. Comparing grip strength with performance on a series of tasks resulting in an overall score: Several studies have been conducted on small samples comparing grip strength with overall upper extremity performance. Hand function as measured by the Jebsen Hand Function Test and the Purdue Pegboard Test was compared with Jamar dynamometer grip strength recordings. Moderate to weak correlations have been reported on a variety of patient
populations. Due to small sample sizes, the information may not be generalized to other populations. Comparing grip strength with participants’ subjective evaluations of their ability to complete daily living tasks: The authors mention several studies that compared grip strength measurements with patients’ subjective evaluation of their ability to perform activities of daily living. The subjective evaluations used included the self-report Health Assessment Questionnaire, the Disabilities of the Arm, Shoulder and Hand Outcome Questionnaire (DASH questionnaire), and the Michigan Hand Outcome Questionnaire. The studies varied in their use of grip strength– measuring instruments. All studies had small sample sizes and were patient-diagnosis specific. In general, a range of correlations was found between grip strength and functional outcomes as measured by patient self-report assessments. The authors report on newer research comparing dynamic grip strength with static grip strength and raise the question of which more accurately represents the force used in hand function. But here the instrument used to measure grip strength was designed specifically for the research and has not yet appeared in the clinic. In summary, the authors raise important questions concerning our measurements of grip strength and how we use this information. Further studies are required to provide knowledge regarding the usefulness of grip strength as an overall indicator of hand function.
DEBORAH A. SCHWARTZ, OTR/L, CHT
Psychological Factors Associated with Idiopathic Arm Pain. Ring D et al. J Bone Joint Surg. 2005;87:374–9.
Introduction. Psychological and personality factors may be as important as, or more important than, pathological processes in the experience of pain. This is especially true in those
October–December 2005 457