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Four-Point Bending Strength of Transverse Osteotomies Stabilized with Various Kirschner Wire and Tension Wire Band Configurations
ARTICLE IN PRESS FOUR-POINT BENDING STRENGTH OF TRANSVERSE OSTEOTOMIES STABILIZED WITH VARIOUS KIRSCHNER WIRE AND TENSION WIRE BAND CONFIGURATIONS O¨. PEHLIVAN, A. KIRAL, M. MAHIROGULLARI, O. KOKSAL and H. KAPLAN From the Department of Orthopaedics and Traumatology, Gulhane Military Medical Faculty, Haydarpasa Training Hospital, Istanbul, Turkey
Four different fixation configurations of K-wires of two different diameters were used to stabilize a transverse osteotomy in chicken humerus bones. Four-point bending was applied to these to assess their apex dorsal bending rigidity. The configurations of K-wires included intramedullary, crossed and two with different tension wire band designs. One of these consisted of two transverse K-wires which did not cross the fracture line, around which the tension wire band was placed. The results showed that there was no statistical significance between the two different tension band wiring techniques and that both were superior to the intramedullary and crossed K-wire fixation techniques. Journal of Hand Surgery (British and European Volume, 2005) 30B: 4: 428–431 Keywords: four-point bending, transverse osteotomies
saw. These were then fixed with one of four different configurations of Kirschner and tension band wires (Fig 2). Two different sizes of K-wires were used for each configuration, resulting in eight groups. The K-wires were inserted with a battery operated wire driver and all of the fixations were performed by the first author. The treatment groups were as follows: Group 1: two intramedullary 0.9 mm smooth K-wires. Group 2: two intramedullary 1.2 mm smooth K-wires. Group 3: two crossed 0.9 mm smooth K-wires. Group 4: two crossed 1.2 mm smooth K-wires. Group 5: a tension wire band with two crossed 0.9 mm smooth K-wires. Group 6: a tension wire band with two crossed 1.2 mm smooth K-wires. Group 7: a tension wire band with two transverse 0.9 mm smooth K-wires which did not cross the osteotomy. Group 8: a tension wire band with two transverse 1.2 mm smooth K-wires which did not cross the osteotomy. The tension wire band was 26-gauge monofilament stainless steel applied dorsally in a figureof-eight configuration.
INTRODUCTION The most common method of fixation of unstable phalangeal and metacarpal fractures is K-wire fixation which can be applied in various configurations (Alexander et al., 1981; Viegas et al., 1988). In order to avoid malunion and joint stiffness, the configuration should provide rigid fixation to allow early motion without loss of the reduction (Alexander et al., 1981; Black et al., 1985; Viegas et al., 1988). We have reported the clinical results of a tension band wiring technique for unstable transverse fractures of the proximal and middle phalanges of the hand (Pehlivan et al., 2004). In this technique, a dorsal longitudinal approach was used and the tension band wire which was dorsally applied beneath the tendon was tightened in a figure of eight configuration around the two transverse K-wires, which did not cross the fracture line (Fig 1). Previously, we have not compared the rigidity of this configuration with the other K-wire and tension band wiring configurations.
Mechanical testing MATERIALS AND METHODS
A four-point bending test was performed using an ‘‘Instron 1195’’ testing machine (Fig 3). Loads were applied in the apex-dorsal orientation because the phalanges are mainly stressed by flexion forces and the forces applied to a reduced phalangeal fracture by the flexor tendons cause compressive forces at the palmar cortex and distraction at the dorsal cortex (Agee, 1992; Greene et al., 1987; Safoury, 2001; Thakore, 1986). It is important to remember that this principle is true only during functional use of the hand (Jones, 1987). The load application speed for each specimen was 2 mm/minute. The bending rigidity of each specimen was determined by a standard equation in order
The chicken humerus bone was chosen as the test model because of its similarity to the tubular bones of the hand. Forty chicken humerus from 20 healthy chickens which had not been used in other experiments were utilized. All the chickens were from a chicken farm where all had standardized feeding and were sacrificed at a certain age and weight. The bones were stored in normal saline for a maximum of 36 hours until completion of the study. The bones were randomly divided into eight groups of five bones each. A transverse mid-diaphyseal osteotomy was performed in all of the bones with an oscillating 428
ARTICLE IN PRESS FOUR-POINT BENDING TEST IN TRANSVERSE OSTEOTOMIES
to eliminate the influences of specimen geometry (Alexander et al., 1981; Viegas et al., 1988).
429
where EI is the bending rigidity (Nm2), P the applied load (N), d the deflection of the beam at the load point (m), L the span length (m), a the (L – distance between load points)/2 (m). The applied load (P) was the value obtained at the maximum resistance point for each specimen. The load
per deflection ðP=dÞ ranged from 34,298 to 133,895 N/m with an average of 74,080 N/m. For each specimen the values of ‘‘L’’ and the ‘‘distance between load points’’ were the same, respectively 4 and 2 cm. Thus, we also minimized the effect of small length differences of the bones. Non-parametric statistical tests (Kruskal–Wallis and Mann–Whitney U-Test) were used to compare the results in the different groups, as the number of specimens was small and group variances were not homogeneous.
Fig. 1 Dorsally applied tension wire band across the two transverse Kwires, not crossing the fracture line, in a transverse phalangeal fracture.
Fig. 3 Application of four-point bending test with the ‘‘Instron 1195’’ testing machine.
EI ¼ ðP=dÞða3 =3 a2 L=4Þ
Fig. 2 Various fixation configurations of the osteotomized bones: (a) two intramedullary smooth K-wires, (b) two crossed smooth K-wires, (c) tension wire band to two crossed smooth K-wires, (d) tension wire band to two transverse smooth K-wires.
ARTICLE IN PRESS 430
THE JOURNAL OF HAND SURGERY VOL. 30B No. 4 AUGUST
RESULTS
2005
0.07 0.06 Median EI
Group 7 (the tension wire band with two transverse 0.9 mm smooth K-wires) had the most, and Group 3 (two crossed 0.9 mm smooth K-wires) had the least rigid fixation of the median EI values. For each configuration the diameter of the K-wires did not influence its strength, (P40:05) (Fig 4) (Table 1). Thus, we combined the data for Groups 1 and 2 (intramedullary wires), Groups 3 and 4 (crossed wires), Groups 5 and 6 (tension wire band with crossed wires) and Groups 7 and 8 (tension wire band with transverse wires). We, then, found statistically significant differences between the four fixation techniques (P ¼ 0:00001) (Fig 5) (Table 2). There was no statistically significant difference between the two techniques of tension wire band fixation (P40:05) or between the intramedullary and crossed K-wires (P40:05) but there was a statistically significant difference (Po0:01) between both of the tension wire band techniques and the intramedullary and crossed K-wire fixations.
0.05 0.04 0.03 0.02 1-2
3-4
5-6
7-8
Groups Fig. 5 Graphical distribution of the combined groups according to the median EI values.
Table 2—Median EI (range) values of the combined groups Groups Intramedullary wires Crossed wires Tension band with crossed wires Tension band with transverse wires
Median EI (range) (Nm2) 0.036 0.034 0.061 0.066
(0.024–0.065) (0.022–0.054) (0.041–0.088) (0.049–0.089)
DISCUSSION Any fracture fixation technique for phalangeal fractures should allow early motion because of the risks of joint contracture and tendon adhesion (Agee, 1992; Ebinger et al., 1999; Greene et al., 1987; Ouellette and Freeland, 1996; Page and Stern, 1998; Safoury, 2001). 0.08
Median EI
0.07 0.06 0.05 0.04 0.03 0.02 1
2
3
4 5 Groups
6
7
8
Fig. 4 Graphical distribution of the eight groups according to the median EI values.
Table 1—Median EI (range) values of the eight groups Median EI (range) (Nm2)
Groups Group Group Group Group Group Group Group Group
1 2 3 4 5 6 7 8
0.037 0.036 0.030 0.037 0.057 0.065 0.069 0.062
(0.024–0.065) (0.024–0.065) (0.024–0.039) (0.022–0.054) (0.049–0.078) (0.041–0.088) (0.049–0.089) (0.053–0.075)
In this study we compared the rigidity of four different wire configurations, with two different diameters of K-wires, against the apex dorsal bending forces. This is a clinically relevant model as one of the most important reasons for fixation failures in phalangeal fractures is the bending forces (Alexander et al., 1981) and the chicken humerus bone is similar to the small tubular bones of the hand. Three of the four configurations (intramedullary K-wires, crossed K-wires, dorsally applied tension band around crossed K-wires) are commonly used for unstable mid-diaphyseal transverse phalangeal fractures. The fourth configuration (dorsally applied tension band around transverse K-wires) is sufficiently rigid to allow early active finger motion, is less invasive and technically easier than the application of a dorsal tension band around crossed K-wires (Pehlivan et al., 2004). The biomechanical rigidity of various implants and wire configurations used for the fixation of hand fractures have previously been reported. However, comparisons between studies is difficult because they utilize different bones (human cadaver, pig, chicken), osteotomies, fixation configurations, implants and testing models (Jones, 1987; Viegas et al., 1988). The common conclusion of such studies is that the most rigid fixation is achieved by osteosynthesis with miniplates and screws and the least rigid fixation with K-wires (Jones, 1987; Black et al., 1985; Rayhack et al., 1984; Viegas et al., 1988). The rigidity of percutaneous or open K-wire fixation is not always adequate for early motion and postoperative immobilization is frequently required
ARTICLE IN PRESS FOUR-POINT BENDING TEST IN TRANSVERSE OSTEOTOMIES
(Collins et al., 2002; Pun et al., 1991; Thakore, 1986; Viegas et al., 1988). Although osteosynthesis with miniplates and screws offers rigid fixation, the functional outcome may be unsatisfactory because of the high incidence of extensor tendon adhesion and joint contracture (Page and Stern, 1998; Pun et al., 1991). As a result, plate fixation is not recommended for phalangeal fractures which can be stabilized with less invasive methods. Right-angled intraosseous loops also provide rigid stability, but single transverse intraosseous loops do not provide sufficient resistance to bending and frequently require supplementation with K-wires (Jones, 1987; Vanik et al., 1984). Tension band wiring provides stable fixation and is minimally invasive. Early motion is possible and the functional outcome is usually satisfactory (Greene et al., 1987; Pehlivan et al., 2004; Safoury, 2001). In comminuted fractures, neutralization of interfragmentary forces cannot be achieved by tension banding and some other form of fixation is required (Greene et al., 1987). Otherwise, the rigid fixation of this technique allows active motion without external immobilization within a few days of surgery, there is less surgical trauma to the soft tissues and the risk of tendon adhesions is reduced by the small bulk of implanted material. In our surgical practice, we have experienced two major difficulties with the usual technique of tension band wiring for transverse phalangeal fracture fixation. The first is holding the fracture fragments reduced during placement of the crossed K-wires and the second is accurate placement of the crossed K-wires. We devised our technique with two transverse K-wires because of these problems and found that its use reduced the length of our surgical incisions. As in the usual technique, the tension wire band is applied dorsally and, thus, neutralizes the distracting forces on the dorsal cortex and the compressive ones at the palmar cortex. In this study, the four-point bending rigidity against apex dorsal forces of transverse osteotomies was not influenced by the diameter of the K-wires. K-wires with a dorsal tension wire band had better rigidity than two intramedullary or two crossed K-wires. Gould et al. (1984) and Rayhack et al. (1984) have previously reported the superiority of standard tension band wiring to the other K-wire configurations in their experimental transverse osteotomy models tested by four-point bending and we found that our wiring technique with transverse K-wires has similar rigidity to these.
431
References Agee J (1992). Treatment principles for proximal and middle phalangeal fractures. Orthopedic Clinics of North America, 23: 35–40. Alexander H, Langrana N, Massengill JB, Weiss AB (1981). Development of new methods for phalangeal fracture fixation. Journal of Biomechanics, 14: 377–387. Black D, Mann RJ, Constine R, Daniels AU (1985). Comparison of internal fixation techniques in metacarpal fractures. The Journal of Hand Surgery, 10A: 466–472. Collins AL, Timlin M, Thornes B, O’Sullivan T (2002). Old principles revisited – traction splinting for closed proximal phalangeal fractures. Injury, 33: 235–237. Ebinger T, Erhard N, Kinzl L, Mentzel M (1999). Dynamic treatment of displaced proximal phalangeal fractures. The Journal of Hand Surgery, 24A: 1254–1262. Gould WL, Belsole RJ, Skelton WH (1984). Tension-band stabilization of transverse fractures: an experimental analysis. Plastic and Reconstructive Surgery, 73: 111–116. Greene TL, Noellert RC, Belsole RJ (1987). Treatment of unstable metacarpal and phalangeal fractures with tension band wiring techniques. Clinical Orthopaedics and Related Research, 214: 78–84. Jones WW (1987). Biomechanics of small bone fixation. Clinical Orthopaedics and Related Research, 214: 11–18. Ouellette EA, Freeland AE (1996). Use of minicondylar plate in metacarpal and phalangeal fractures. Clinical Orthopaedics and Related Research, 327: 38–46. Page SM, Stern PJ (1998). Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. The Journal of Hand Surgery, 23A: 827–832. Pehlivan O, Kiral A, Solakoglu C, Akmaz I, Kaplan H (2004). Tension band wiring of unstable transverse fractures of the proximal and middle phalanges of the hand. The Journal of Hand Surgery, 29B: 130–134. Pun WK, Chow SP, Luk KDK, Ip FK (1991). Unstable phalangeal fractures: treatment by AO screw and plate fixation. The Journal of Hand Surgery, 16A: 113–117. Rayhack JM, Belsole RJ, Skelton WH (1984). A strain recording model: analysis of transverse osteotomy fixation in small bones. The Journal of Hand Surgery, 9A: 383–387. Safoury Y (2001). Treatment of phalangeal fractures by tension band wiring. The Journal of Hand Surgery, 26B: 50–52. Thakore HKD (1986). Osteosynthesis for the unstable fracture of the hand. The Journal of Hand Surgery, 11B: 417–421. Vanik RK, Weber RC, Matloub HS, Sanger JR, Gingrass RP (1984). The comparative strengths of internal fixation techniques. The Journal of Hand Surgery, 9A: 216–221. Viegas SF, Ferren EL, Self J, Tencer AF (1988). Comparative mechanical properties of various Kirschner wire configurations in transverse and oblique phalangeal fractures. The Journal of Hand Surgery, 13A: 246–253. Received: 27 September 2004 Accepted after revision: 1 April 2005 O¨zcan Pehlivan, MD, Ilyas Bey Cd. No:49/51 D.5, 34310 Yedikule, Istanbul, Turkey. Tel.: +90 212 589 4258; Fax: +90 212 632 9352. E-mail: [email protected]
r 2005 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2005.04.002 available online at http://www.sciencedirect.com
Four different fixation configurations of K-wires of two different diameters were used to stabilize a transverse osteotomy in chicken humerus bones. Four-point bending was applied to these to assess their apex dorsal bending rigidity. The configurations of K-wires included intramedullary, crossed and two with different tension wire band designs. One of these consisted of two transverse K-wires which did not cross the fracture line, around which the tension wire band was placed. The results showed that there was no statistical significance between the two different tension band wiring techniques and that both were superior to the intramedullary and crossed K-wire fixation techniques. Journal of Hand Surgery (British and European Volume, 2005) 30B: 4: 428–431 Keywords: four-point bending, transverse osteotomies
saw. These were then fixed with one of four different configurations of Kirschner and tension band wires (Fig 2). Two different sizes of K-wires were used for each configuration, resulting in eight groups. The K-wires were inserted with a battery operated wire driver and all of the fixations were performed by the first author. The treatment groups were as follows: Group 1: two intramedullary 0.9 mm smooth K-wires. Group 2: two intramedullary 1.2 mm smooth K-wires. Group 3: two crossed 0.9 mm smooth K-wires. Group 4: two crossed 1.2 mm smooth K-wires. Group 5: a tension wire band with two crossed 0.9 mm smooth K-wires. Group 6: a tension wire band with two crossed 1.2 mm smooth K-wires. Group 7: a tension wire band with two transverse 0.9 mm smooth K-wires which did not cross the osteotomy. Group 8: a tension wire band with two transverse 1.2 mm smooth K-wires which did not cross the osteotomy. The tension wire band was 26-gauge monofilament stainless steel applied dorsally in a figureof-eight configuration.
INTRODUCTION The most common method of fixation of unstable phalangeal and metacarpal fractures is K-wire fixation which can be applied in various configurations (Alexander et al., 1981; Viegas et al., 1988). In order to avoid malunion and joint stiffness, the configuration should provide rigid fixation to allow early motion without loss of the reduction (Alexander et al., 1981; Black et al., 1985; Viegas et al., 1988). We have reported the clinical results of a tension band wiring technique for unstable transverse fractures of the proximal and middle phalanges of the hand (Pehlivan et al., 2004). In this technique, a dorsal longitudinal approach was used and the tension band wire which was dorsally applied beneath the tendon was tightened in a figure of eight configuration around the two transverse K-wires, which did not cross the fracture line (Fig 1). Previously, we have not compared the rigidity of this configuration with the other K-wire and tension band wiring configurations.
Mechanical testing MATERIALS AND METHODS
A four-point bending test was performed using an ‘‘Instron 1195’’ testing machine (Fig 3). Loads were applied in the apex-dorsal orientation because the phalanges are mainly stressed by flexion forces and the forces applied to a reduced phalangeal fracture by the flexor tendons cause compressive forces at the palmar cortex and distraction at the dorsal cortex (Agee, 1992; Greene et al., 1987; Safoury, 2001; Thakore, 1986). It is important to remember that this principle is true only during functional use of the hand (Jones, 1987). The load application speed for each specimen was 2 mm/minute. The bending rigidity of each specimen was determined by a standard equation in order
The chicken humerus bone was chosen as the test model because of its similarity to the tubular bones of the hand. Forty chicken humerus from 20 healthy chickens which had not been used in other experiments were utilized. All the chickens were from a chicken farm where all had standardized feeding and were sacrificed at a certain age and weight. The bones were stored in normal saline for a maximum of 36 hours until completion of the study. The bones were randomly divided into eight groups of five bones each. A transverse mid-diaphyseal osteotomy was performed in all of the bones with an oscillating 428
ARTICLE IN PRESS FOUR-POINT BENDING TEST IN TRANSVERSE OSTEOTOMIES
to eliminate the influences of specimen geometry (Alexander et al., 1981; Viegas et al., 1988).
429
where EI is the bending rigidity (Nm2), P the applied load (N), d the deflection of the beam at the load point (m), L the span length (m), a the (L – distance between load points)/2 (m). The applied load (P) was the value obtained at the maximum resistance point for each specimen. The load
per deflection ðP=dÞ ranged from 34,298 to 133,895 N/m with an average of 74,080 N/m. For each specimen the values of ‘‘L’’ and the ‘‘distance between load points’’ were the same, respectively 4 and 2 cm. Thus, we also minimized the effect of small length differences of the bones. Non-parametric statistical tests (Kruskal–Wallis and Mann–Whitney U-Test) were used to compare the results in the different groups, as the number of specimens was small and group variances were not homogeneous.
Fig. 1 Dorsally applied tension wire band across the two transverse Kwires, not crossing the fracture line, in a transverse phalangeal fracture.
Fig. 3 Application of four-point bending test with the ‘‘Instron 1195’’ testing machine.
EI ¼ ðP=dÞða3 =3 a2 L=4Þ
Fig. 2 Various fixation configurations of the osteotomized bones: (a) two intramedullary smooth K-wires, (b) two crossed smooth K-wires, (c) tension wire band to two crossed smooth K-wires, (d) tension wire band to two transverse smooth K-wires.
ARTICLE IN PRESS 430
THE JOURNAL OF HAND SURGERY VOL. 30B No. 4 AUGUST
RESULTS
2005
0.07 0.06 Median EI
Group 7 (the tension wire band with two transverse 0.9 mm smooth K-wires) had the most, and Group 3 (two crossed 0.9 mm smooth K-wires) had the least rigid fixation of the median EI values. For each configuration the diameter of the K-wires did not influence its strength, (P40:05) (Fig 4) (Table 1). Thus, we combined the data for Groups 1 and 2 (intramedullary wires), Groups 3 and 4 (crossed wires), Groups 5 and 6 (tension wire band with crossed wires) and Groups 7 and 8 (tension wire band with transverse wires). We, then, found statistically significant differences between the four fixation techniques (P ¼ 0:00001) (Fig 5) (Table 2). There was no statistically significant difference between the two techniques of tension wire band fixation (P40:05) or between the intramedullary and crossed K-wires (P40:05) but there was a statistically significant difference (Po0:01) between both of the tension wire band techniques and the intramedullary and crossed K-wire fixations.
0.05 0.04 0.03 0.02 1-2
3-4
5-6
7-8
Groups Fig. 5 Graphical distribution of the combined groups according to the median EI values.
Table 2—Median EI (range) values of the combined groups Groups Intramedullary wires Crossed wires Tension band with crossed wires Tension band with transverse wires
Median EI (range) (Nm2) 0.036 0.034 0.061 0.066
(0.024–0.065) (0.022–0.054) (0.041–0.088) (0.049–0.089)
DISCUSSION Any fracture fixation technique for phalangeal fractures should allow early motion because of the risks of joint contracture and tendon adhesion (Agee, 1992; Ebinger et al., 1999; Greene et al., 1987; Ouellette and Freeland, 1996; Page and Stern, 1998; Safoury, 2001). 0.08
Median EI
0.07 0.06 0.05 0.04 0.03 0.02 1
2
3
4 5 Groups
6
7
8
Fig. 4 Graphical distribution of the eight groups according to the median EI values.
Table 1—Median EI (range) values of the eight groups Median EI (range) (Nm2)
Groups Group Group Group Group Group Group Group Group
1 2 3 4 5 6 7 8
0.037 0.036 0.030 0.037 0.057 0.065 0.069 0.062
(0.024–0.065) (0.024–0.065) (0.024–0.039) (0.022–0.054) (0.049–0.078) (0.041–0.088) (0.049–0.089) (0.053–0.075)
In this study we compared the rigidity of four different wire configurations, with two different diameters of K-wires, against the apex dorsal bending forces. This is a clinically relevant model as one of the most important reasons for fixation failures in phalangeal fractures is the bending forces (Alexander et al., 1981) and the chicken humerus bone is similar to the small tubular bones of the hand. Three of the four configurations (intramedullary K-wires, crossed K-wires, dorsally applied tension band around crossed K-wires) are commonly used for unstable mid-diaphyseal transverse phalangeal fractures. The fourth configuration (dorsally applied tension band around transverse K-wires) is sufficiently rigid to allow early active finger motion, is less invasive and technically easier than the application of a dorsal tension band around crossed K-wires (Pehlivan et al., 2004). The biomechanical rigidity of various implants and wire configurations used for the fixation of hand fractures have previously been reported. However, comparisons between studies is difficult because they utilize different bones (human cadaver, pig, chicken), osteotomies, fixation configurations, implants and testing models (Jones, 1987; Viegas et al., 1988). The common conclusion of such studies is that the most rigid fixation is achieved by osteosynthesis with miniplates and screws and the least rigid fixation with K-wires (Jones, 1987; Black et al., 1985; Rayhack et al., 1984; Viegas et al., 1988). The rigidity of percutaneous or open K-wire fixation is not always adequate for early motion and postoperative immobilization is frequently required
ARTICLE IN PRESS FOUR-POINT BENDING TEST IN TRANSVERSE OSTEOTOMIES
(Collins et al., 2002; Pun et al., 1991; Thakore, 1986; Viegas et al., 1988). Although osteosynthesis with miniplates and screws offers rigid fixation, the functional outcome may be unsatisfactory because of the high incidence of extensor tendon adhesion and joint contracture (Page and Stern, 1998; Pun et al., 1991). As a result, plate fixation is not recommended for phalangeal fractures which can be stabilized with less invasive methods. Right-angled intraosseous loops also provide rigid stability, but single transverse intraosseous loops do not provide sufficient resistance to bending and frequently require supplementation with K-wires (Jones, 1987; Vanik et al., 1984). Tension band wiring provides stable fixation and is minimally invasive. Early motion is possible and the functional outcome is usually satisfactory (Greene et al., 1987; Pehlivan et al., 2004; Safoury, 2001). In comminuted fractures, neutralization of interfragmentary forces cannot be achieved by tension banding and some other form of fixation is required (Greene et al., 1987). Otherwise, the rigid fixation of this technique allows active motion without external immobilization within a few days of surgery, there is less surgical trauma to the soft tissues and the risk of tendon adhesions is reduced by the small bulk of implanted material. In our surgical practice, we have experienced two major difficulties with the usual technique of tension band wiring for transverse phalangeal fracture fixation. The first is holding the fracture fragments reduced during placement of the crossed K-wires and the second is accurate placement of the crossed K-wires. We devised our technique with two transverse K-wires because of these problems and found that its use reduced the length of our surgical incisions. As in the usual technique, the tension wire band is applied dorsally and, thus, neutralizes the distracting forces on the dorsal cortex and the compressive ones at the palmar cortex. In this study, the four-point bending rigidity against apex dorsal forces of transverse osteotomies was not influenced by the diameter of the K-wires. K-wires with a dorsal tension wire band had better rigidity than two intramedullary or two crossed K-wires. Gould et al. (1984) and Rayhack et al. (1984) have previously reported the superiority of standard tension band wiring to the other K-wire configurations in their experimental transverse osteotomy models tested by four-point bending and we found that our wiring technique with transverse K-wires has similar rigidity to these.
431
References Agee J (1992). Treatment principles for proximal and middle phalangeal fractures. Orthopedic Clinics of North America, 23: 35–40. Alexander H, Langrana N, Massengill JB, Weiss AB (1981). Development of new methods for phalangeal fracture fixation. Journal of Biomechanics, 14: 377–387. Black D, Mann RJ, Constine R, Daniels AU (1985). Comparison of internal fixation techniques in metacarpal fractures. The Journal of Hand Surgery, 10A: 466–472. Collins AL, Timlin M, Thornes B, O’Sullivan T (2002). Old principles revisited – traction splinting for closed proximal phalangeal fractures. Injury, 33: 235–237. Ebinger T, Erhard N, Kinzl L, Mentzel M (1999). Dynamic treatment of displaced proximal phalangeal fractures. The Journal of Hand Surgery, 24A: 1254–1262. Gould WL, Belsole RJ, Skelton WH (1984). Tension-band stabilization of transverse fractures: an experimental analysis. Plastic and Reconstructive Surgery, 73: 111–116. Greene TL, Noellert RC, Belsole RJ (1987). Treatment of unstable metacarpal and phalangeal fractures with tension band wiring techniques. Clinical Orthopaedics and Related Research, 214: 78–84. Jones WW (1987). Biomechanics of small bone fixation. Clinical Orthopaedics and Related Research, 214: 11–18. Ouellette EA, Freeland AE (1996). Use of minicondylar plate in metacarpal and phalangeal fractures. Clinical Orthopaedics and Related Research, 327: 38–46. Page SM, Stern PJ (1998). Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. The Journal of Hand Surgery, 23A: 827–832. Pehlivan O, Kiral A, Solakoglu C, Akmaz I, Kaplan H (2004). Tension band wiring of unstable transverse fractures of the proximal and middle phalanges of the hand. The Journal of Hand Surgery, 29B: 130–134. Pun WK, Chow SP, Luk KDK, Ip FK (1991). Unstable phalangeal fractures: treatment by AO screw and plate fixation. The Journal of Hand Surgery, 16A: 113–117. Rayhack JM, Belsole RJ, Skelton WH (1984). A strain recording model: analysis of transverse osteotomy fixation in small bones. The Journal of Hand Surgery, 9A: 383–387. Safoury Y (2001). Treatment of phalangeal fractures by tension band wiring. The Journal of Hand Surgery, 26B: 50–52. Thakore HKD (1986). Osteosynthesis for the unstable fracture of the hand. The Journal of Hand Surgery, 11B: 417–421. Vanik RK, Weber RC, Matloub HS, Sanger JR, Gingrass RP (1984). The comparative strengths of internal fixation techniques. The Journal of Hand Surgery, 9A: 216–221. Viegas SF, Ferren EL, Self J, Tencer AF (1988). Comparative mechanical properties of various Kirschner wire configurations in transverse and oblique phalangeal fractures. The Journal of Hand Surgery, 13A: 246–253. Received: 27 September 2004 Accepted after revision: 1 April 2005 O¨zcan Pehlivan, MD, Ilyas Bey Cd. No:49/51 D.5, 34310 Yedikule, Istanbul, Turkey. Tel.: +90 212 589 4258; Fax: +90 212 632 9352. E-mail: [email protected]
r 2005 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2005.04.002 available online at http://www.sciencedirect.com