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Kirschner wire placement in the emergency room
KIRSCHNER
WIRE PLACEMENT
IN THE EMERGENCY
ROOM
Is t h e r e a risk? I. STARKER and R. G. EATON
From The Roosevelt Hospital C. V. Starr Hand Surgery Center, New York, USA To evaluate the safety of inserting Kirschner wires into bones or across joints in a setting other than a completely sterile operating theatre, a prospective study of all hand fractures treated by closed reduction and internal fixation was conducted in a mid-city Emergency Department. Indications for percutaneous fixation were displaced, unstable long bone fractures of the hand. 71 fractures in 68 patients were treated, and in 91% the fixation crossed a joint. No patient developed osteomyelitis or pyarthrosis, and there was no deep pin track sepsis. Seven patients with open fractures healed without infection or delayed union. Patients in whom data were available obtained 90% to 95% of the motion of the contralateral digit. The taboo against percutaneous fixation of fractures in a non-operating theatre setting is not warranted. The procedure can be performed with minimal complications in an out-patient setting. Journal of Hand Surgery (British and European Volume, 1995) 20B: 4:535-538
Fractures of the long bones of the hand are common, and are ideally suited for treatment in an out-patient setting. Closed reduction and percutaneous internal fixation (CRIF) using Kirschner wires inserted under local anaesthesia has been shown to provide a simple, reliable and cost-effective method of managing displaced and or unstable fractures of the hand (Brown, 1973; Green and Anderson~ 1973; Barton, 1979; Belsky et al, t984; Meals and Meuli, 1985; Pun et al, 1989; Raskin et al, 1991). The equipment required can be found in any wellequipped accident department or private clinic where X-ray facilities are available. Despite this, many emergency departments in the USA have regulations prohibiting procedures that include introduction of hardware such as Kirschner wires into bone, and particularly across joints, for reasons of potential sepsis. In our Emergency Department CRIF has been the treatment of choice for long bone fractures of the hand for more than 10 years. This report is a review of our experience with CRIF in the Emergency Department of an innercity hospital.
The operation is performed in a procedure room of the air-conditioned emergency department, equipped with a FluoroscanTM imager. The patient's arm is prepped with povidine iodine solution and isolated with sterile drapes. The imager is used primarily to confirm reduction, with very little real-time monitoring of the reduction and wire insertion. Reduction is frequently maintained with percutaneously applied fracture clamps prior to final percutaneous passage of smooth Kirschner wires using a battery operated K-wire driver (Fig 1). When reduction and fixation are judged to be satisfactory (while still maintaining a sterile field), permanent X-rays are obtained. If these are satisfactory, the pins are trimmed and a well moulded cast is applied, if not, the reduction is repeated in the still sterile field. Adequate immobilization is imperative, particularly with a non-compliant, indigent mid-city population. Plaster should be extended distally to immobilize one bone beyond the fractured one. Proximal-distal skin motion at the Kirschner wire puncture site produces local marginal necrosis which serves as a culture medium for skin bacterial flora and may cause pin tract sepsis. Patients with open fractures or non-communicating wounds adjacent to a fracture or pin insertion undergo extensive wound irrigation and d6bridement in association with the CRIF technique. These patients are admitted to hospital for 2 to 3 days of intravenous antibiotic treatment following the CRIF procedure in the Emergency Department. X-ray films are obtained through the cast after 5 to 7 days to confirm maintenance of reduction and to review the condition of the cast and immobilization. The cast and Kirschner wires are removed following 3 to 4 weeks of fixation. Absence of clinical tenderness and X-ray films showing early callus are considered indicative of sufficient healing, to allow wire removal and commencement of protected motion. Any uncertainty regarding healing is an indication for an additional week of immobilization. Usually all Kirschner wires are removed by 4 weeks and removable splints are used for an
MATERIALS AND M E T H O D S
A 12-month prospective study was conducted of all patients in our Emergency Department treated by percutaneous Kirschner wire insertion for the treatment of fractures of the hand. Data sheets were maintained recording location and description of the fracture and follow-up concerning the fracture, the condition of the skin, and any untoward event until the fracture was healed. The comprehensive results of this system of fracture management have been published previously (Belsky et al, 1984), and this review involves only the details and complications of CRIF in an out-patient setting. Technique
Closed reduction of long bone fractures is accomplished under local anaesthesia using strict sterile technique. 535
536
T H E J O U R N A L OF H A N D SURGERY VOL. 20B No. 4 A U G U S T 1995
K-WIRESIN THEEMERGENCYROOM
537
additional week. The patient is encouraged to use the involved finger and hand as vigorously as possible. Referral for formal therapy is made according to the type of fracture and the patient's natural motivation. RESULTS A total of 75 patients with 78 unstable fractures of the metacarpals or phalanges were treated by Emergency R o o m C R I F during a 1-year period (Table 1). There were ten open fractures, and two fractures associated with adjacent but non-communicating wounds. A total of 45 metacarpal, 22 proximal phalangeal, five middle phalangeal, and six distal phalangeal fractures were treated. 92% of the fractures involved transarticular Kirschner wire insertion, 64 across the MP joint, five across the DIP joint, and two across the IP joint of the thumb. Since wires for metacarpal and phalangeal fractures were usually inserted proximally or distally across the M P joint, no patient had a wire deliberately passed across the PIP joint. Of the 75 patients treated, 68 patients, accounting for 71 fractures (91%), were available for follow-up. The patients' ages ranged from 17 to 89 years, with a mean of 34 years. No cases of pintrack infection were noted, and there were no cases of osteomyelitis, pyarthrosis, or cellulitis noted at the time of K-wire removal (Table 2). None of the patients who presented with compound fractures, or with wounds close to the Kirschner wires, developed infections. Two patients developed superficially excoriated pin sites, and one patient was noted to have developed a localized Table 1 Fractured bone
Metacarpal Proximal phalanx Middle phalanx Distal phalanx Total
Number
DISCUSSION
45 22 5 6 78
Table 2
Complication
Excoriated pin site Granulating pin track Revision in operating theatre Non-union Malunion Osteomyelitis Pyarthrosis Total
3 mm nidus of granulation tissue at the insertion site when she returned for her first follow-up visit 9 weeks after pinning. Three patients required operating theatre treatment subsequent to emergency department CRIF. One of these was for an unsatisfactory initial reduction, treated successfully by C R I F in the operating theatre; one for removal of a K-wire that had migrated proximally across a carpometacarpal joint and was only accessible via the metacarpal base; and one which required open reduction and bone grafting for elevation of a comminuted proximal phalangeal base fracture. Seven patients with open fractures or potentially contaminated wounds were admitted to hospital for intravenous antibiotics immediately following emergency department CRIF. One patient was admitted to the psychiatric department after sustaining multiple bilateral upper extremity fractures trying to stop a subway train barehanded. Following K-wire removal, follow-up visits were sporadic and less dependable, making assessment of final range of motion difficult. In those for whom final data were available, total active motion (TAM) of the treated finger was between 90% to 95% of the contralateral finger. N o patients required tenolysis or capsular releases. There were no cases of malunion, delayed union, or non-union. O f the six patients lost to followup, two were substance abusers (alcohol and iv drugs) whose compliance was unpredictable. The remaining patients had no identifiable reason to suspect unreliability. Three additional known alcohol abusers were poorly compliant with follow-up and accounted for two of the three cases of superficial pin-site irritation. One patient known to be HIV positive at the time of treatment had an uneventful course of fracture healing.
Number
2 1 3 0 0 0 0 6
The object of this study was to evaluate prospectively the complications of percutaneous and transarticular Kirschner wire fixation of hand fractures in an outpatient setting. The results of our percutaneous fracture fixation technique have previously been reported (Belsky et al, 1984), and the results of CRIF have been well documented (Brown, 1973; Green and Anderson, 1973; Barton, 1979; Meals and Meuli, 1985; Pun et al, 1989; Raskin et al, 1991). It is considered to be an acceptable form of hand fracture management. CRIF is predominantly an out-patient procedure at our institution. Elsewhere a strong general bias exists against performing invasive procedures such as percutaneous and/or transarticular fracture fixation in a clinic or emergency department setting because of the perceived risks of septic complications. A recent retrospective review (Botte et al, 1992) has described an
Fig 1 (a) A percutaneouslyapplied fracture clamp maintains position during the fluoroscopiccheck of reduction. The points of the clamp may be used as guides in the placement of Kirschner wires. (b) Percutaneousfixation of this oblique fracture with multiple Kirschner wires.
538
18% complication rate associated with K-wire fixation of hand fractures. A significant difference in technique and subsequent management, however, makes comparison with our study somewhat difficult. For example, fractures were immobilized in a light dressing rather than a conforming cast, inviting motion at both the fracture and pin exit sites. The authors acknowledge this point and suggest that immobilization, as employed in our protocol, may yield a lower complication rate. Raskin recently reviewed results of CRIF for unstable metacarpal fractures and also reported no pin-track related complications (Raskin et al, 1991). The importance of adequate adjunctive cast immobilization was again emphasized. The low complication rate of this 1-year prospective study of CRIF performed in the emergency department of a mid-city hospital, strongly suggests that concern for septic complications is unwarranted. When properly performed, emergency department CRIF should assure an uneventful post-operative course even when fixation involves trans-articular passage. It would follow, therefore, that percutaneous fixation can be safely applied to other out-patient facilities such as clinics or private offices. Several specific technical points, however, must be emphasized. There should be a strict adherence to sterile atraumatic technique, an external cast extending one bone beyond the fracture should be used to prevent adjacent joint and skin motion, and sterile dressings should be placed at the pin site throughout immobilization. Accurate assessment of reduction and fixation using a device such as the FluoroscanTM imager is also vital.
THE JOURNAL OF HAND SURGERY VOL. 20B No. 4 AUGUST 1995
Simple, early treatment of displaced hand fractures is highly desirable. Delay in reduction and fixation due to unavailability of operating theatre facilities is not necessary when the same procedure can be done safely and immediately in a primary facility such as an emergency department. With present concerns for cost-effective treatment, CRIF in an outpatient setting offers a safe, minimally expensive form of treatment for the frequently occurring displaced and unstable fractures of the hand. References BARTON, N. J. (1979). Fractures of the shafts of the phalanges of the hand. The Hand, 11: 2: 119-133. BELSKY, M. R., EATON, R. G. and LANE, L. B. (1984). Closed reduction and internal fixation of proximal phalangeal fractures. Journal of Hand Surgery, 9A: 725-729. BOTTE, M. J., DAVIS, J. L. W., ROSE, B. A. et al. (1992). Complication of smooth pin fixation of fractures and dislocations in the hand and wrist. Clinical Orthopaedics and Related Research, 276: 194-201. BROWN, P. W. (1973). The management of phalangeal and metacarpal fractures. Surgical Clinics of North America, 53: 6:1393 1437. GREEN, D. P. and ANDERSON, J. R. (1973). Closed reduction and percutaneous pin fixation of fractured phalanges. Journal of Bone and Joint Surgery, 55A: 1651-1654. MEALS, R. A. and MEULI, H. C. (1985). Carpenters nails, phonograph needles, piano wires, and safety pins: The history of operative fixation of metacarpal and phalangeal fractures. Journal of Hand Surgery, 10A: 144-150. PUN, W. K., CHOW, S. P., SO, Y. C. et al. (1989). A prospective study on 248 digital fractures of the hand. Journal of Hand Surgery, 14A: 474-481. RASKIN, K. B., MELONE, C. P., FRAZIER, J. L. and SEGALMAN, K. ( 1991). Closed pinning of unstable metacarpal fractures. Presented at 46th Annual Meeting of ASSH, Orlando, USA.
Accepted: 22 February 1995 Richard G. Eaton, MD, C.V. Starr Hand Surgery Center, 1000 Tenth Avenue--3rd Floor, New York, NY 10019, USA. © 1995 The British Society for Surgery of the Hand
WIRE PLACEMENT
IN THE EMERGENCY
ROOM
Is t h e r e a risk? I. STARKER and R. G. EATON
From The Roosevelt Hospital C. V. Starr Hand Surgery Center, New York, USA To evaluate the safety of inserting Kirschner wires into bones or across joints in a setting other than a completely sterile operating theatre, a prospective study of all hand fractures treated by closed reduction and internal fixation was conducted in a mid-city Emergency Department. Indications for percutaneous fixation were displaced, unstable long bone fractures of the hand. 71 fractures in 68 patients were treated, and in 91% the fixation crossed a joint. No patient developed osteomyelitis or pyarthrosis, and there was no deep pin track sepsis. Seven patients with open fractures healed without infection or delayed union. Patients in whom data were available obtained 90% to 95% of the motion of the contralateral digit. The taboo against percutaneous fixation of fractures in a non-operating theatre setting is not warranted. The procedure can be performed with minimal complications in an out-patient setting. Journal of Hand Surgery (British and European Volume, 1995) 20B: 4:535-538
Fractures of the long bones of the hand are common, and are ideally suited for treatment in an out-patient setting. Closed reduction and percutaneous internal fixation (CRIF) using Kirschner wires inserted under local anaesthesia has been shown to provide a simple, reliable and cost-effective method of managing displaced and or unstable fractures of the hand (Brown, 1973; Green and Anderson~ 1973; Barton, 1979; Belsky et al, t984; Meals and Meuli, 1985; Pun et al, 1989; Raskin et al, 1991). The equipment required can be found in any wellequipped accident department or private clinic where X-ray facilities are available. Despite this, many emergency departments in the USA have regulations prohibiting procedures that include introduction of hardware such as Kirschner wires into bone, and particularly across joints, for reasons of potential sepsis. In our Emergency Department CRIF has been the treatment of choice for long bone fractures of the hand for more than 10 years. This report is a review of our experience with CRIF in the Emergency Department of an innercity hospital.
The operation is performed in a procedure room of the air-conditioned emergency department, equipped with a FluoroscanTM imager. The patient's arm is prepped with povidine iodine solution and isolated with sterile drapes. The imager is used primarily to confirm reduction, with very little real-time monitoring of the reduction and wire insertion. Reduction is frequently maintained with percutaneously applied fracture clamps prior to final percutaneous passage of smooth Kirschner wires using a battery operated K-wire driver (Fig 1). When reduction and fixation are judged to be satisfactory (while still maintaining a sterile field), permanent X-rays are obtained. If these are satisfactory, the pins are trimmed and a well moulded cast is applied, if not, the reduction is repeated in the still sterile field. Adequate immobilization is imperative, particularly with a non-compliant, indigent mid-city population. Plaster should be extended distally to immobilize one bone beyond the fractured one. Proximal-distal skin motion at the Kirschner wire puncture site produces local marginal necrosis which serves as a culture medium for skin bacterial flora and may cause pin tract sepsis. Patients with open fractures or non-communicating wounds adjacent to a fracture or pin insertion undergo extensive wound irrigation and d6bridement in association with the CRIF technique. These patients are admitted to hospital for 2 to 3 days of intravenous antibiotic treatment following the CRIF procedure in the Emergency Department. X-ray films are obtained through the cast after 5 to 7 days to confirm maintenance of reduction and to review the condition of the cast and immobilization. The cast and Kirschner wires are removed following 3 to 4 weeks of fixation. Absence of clinical tenderness and X-ray films showing early callus are considered indicative of sufficient healing, to allow wire removal and commencement of protected motion. Any uncertainty regarding healing is an indication for an additional week of immobilization. Usually all Kirschner wires are removed by 4 weeks and removable splints are used for an
MATERIALS AND M E T H O D S
A 12-month prospective study was conducted of all patients in our Emergency Department treated by percutaneous Kirschner wire insertion for the treatment of fractures of the hand. Data sheets were maintained recording location and description of the fracture and follow-up concerning the fracture, the condition of the skin, and any untoward event until the fracture was healed. The comprehensive results of this system of fracture management have been published previously (Belsky et al, 1984), and this review involves only the details and complications of CRIF in an out-patient setting. Technique
Closed reduction of long bone fractures is accomplished under local anaesthesia using strict sterile technique. 535
536
T H E J O U R N A L OF H A N D SURGERY VOL. 20B No. 4 A U G U S T 1995
K-WIRESIN THEEMERGENCYROOM
537
additional week. The patient is encouraged to use the involved finger and hand as vigorously as possible. Referral for formal therapy is made according to the type of fracture and the patient's natural motivation. RESULTS A total of 75 patients with 78 unstable fractures of the metacarpals or phalanges were treated by Emergency R o o m C R I F during a 1-year period (Table 1). There were ten open fractures, and two fractures associated with adjacent but non-communicating wounds. A total of 45 metacarpal, 22 proximal phalangeal, five middle phalangeal, and six distal phalangeal fractures were treated. 92% of the fractures involved transarticular Kirschner wire insertion, 64 across the MP joint, five across the DIP joint, and two across the IP joint of the thumb. Since wires for metacarpal and phalangeal fractures were usually inserted proximally or distally across the M P joint, no patient had a wire deliberately passed across the PIP joint. Of the 75 patients treated, 68 patients, accounting for 71 fractures (91%), were available for follow-up. The patients' ages ranged from 17 to 89 years, with a mean of 34 years. No cases of pintrack infection were noted, and there were no cases of osteomyelitis, pyarthrosis, or cellulitis noted at the time of K-wire removal (Table 2). None of the patients who presented with compound fractures, or with wounds close to the Kirschner wires, developed infections. Two patients developed superficially excoriated pin sites, and one patient was noted to have developed a localized Table 1 Fractured bone
Metacarpal Proximal phalanx Middle phalanx Distal phalanx Total
Number
DISCUSSION
45 22 5 6 78
Table 2
Complication
Excoriated pin site Granulating pin track Revision in operating theatre Non-union Malunion Osteomyelitis Pyarthrosis Total
3 mm nidus of granulation tissue at the insertion site when she returned for her first follow-up visit 9 weeks after pinning. Three patients required operating theatre treatment subsequent to emergency department CRIF. One of these was for an unsatisfactory initial reduction, treated successfully by C R I F in the operating theatre; one for removal of a K-wire that had migrated proximally across a carpometacarpal joint and was only accessible via the metacarpal base; and one which required open reduction and bone grafting for elevation of a comminuted proximal phalangeal base fracture. Seven patients with open fractures or potentially contaminated wounds were admitted to hospital for intravenous antibiotics immediately following emergency department CRIF. One patient was admitted to the psychiatric department after sustaining multiple bilateral upper extremity fractures trying to stop a subway train barehanded. Following K-wire removal, follow-up visits were sporadic and less dependable, making assessment of final range of motion difficult. In those for whom final data were available, total active motion (TAM) of the treated finger was between 90% to 95% of the contralateral finger. N o patients required tenolysis or capsular releases. There were no cases of malunion, delayed union, or non-union. O f the six patients lost to followup, two were substance abusers (alcohol and iv drugs) whose compliance was unpredictable. The remaining patients had no identifiable reason to suspect unreliability. Three additional known alcohol abusers were poorly compliant with follow-up and accounted for two of the three cases of superficial pin-site irritation. One patient known to be HIV positive at the time of treatment had an uneventful course of fracture healing.
Number
2 1 3 0 0 0 0 6
The object of this study was to evaluate prospectively the complications of percutaneous and transarticular Kirschner wire fixation of hand fractures in an outpatient setting. The results of our percutaneous fracture fixation technique have previously been reported (Belsky et al, 1984), and the results of CRIF have been well documented (Brown, 1973; Green and Anderson, 1973; Barton, 1979; Meals and Meuli, 1985; Pun et al, 1989; Raskin et al, 1991). It is considered to be an acceptable form of hand fracture management. CRIF is predominantly an out-patient procedure at our institution. Elsewhere a strong general bias exists against performing invasive procedures such as percutaneous and/or transarticular fracture fixation in a clinic or emergency department setting because of the perceived risks of septic complications. A recent retrospective review (Botte et al, 1992) has described an
Fig 1 (a) A percutaneouslyapplied fracture clamp maintains position during the fluoroscopiccheck of reduction. The points of the clamp may be used as guides in the placement of Kirschner wires. (b) Percutaneousfixation of this oblique fracture with multiple Kirschner wires.
538
18% complication rate associated with K-wire fixation of hand fractures. A significant difference in technique and subsequent management, however, makes comparison with our study somewhat difficult. For example, fractures were immobilized in a light dressing rather than a conforming cast, inviting motion at both the fracture and pin exit sites. The authors acknowledge this point and suggest that immobilization, as employed in our protocol, may yield a lower complication rate. Raskin recently reviewed results of CRIF for unstable metacarpal fractures and also reported no pin-track related complications (Raskin et al, 1991). The importance of adequate adjunctive cast immobilization was again emphasized. The low complication rate of this 1-year prospective study of CRIF performed in the emergency department of a mid-city hospital, strongly suggests that concern for septic complications is unwarranted. When properly performed, emergency department CRIF should assure an uneventful post-operative course even when fixation involves trans-articular passage. It would follow, therefore, that percutaneous fixation can be safely applied to other out-patient facilities such as clinics or private offices. Several specific technical points, however, must be emphasized. There should be a strict adherence to sterile atraumatic technique, an external cast extending one bone beyond the fracture should be used to prevent adjacent joint and skin motion, and sterile dressings should be placed at the pin site throughout immobilization. Accurate assessment of reduction and fixation using a device such as the FluoroscanTM imager is also vital.
THE JOURNAL OF HAND SURGERY VOL. 20B No. 4 AUGUST 1995
Simple, early treatment of displaced hand fractures is highly desirable. Delay in reduction and fixation due to unavailability of operating theatre facilities is not necessary when the same procedure can be done safely and immediately in a primary facility such as an emergency department. With present concerns for cost-effective treatment, CRIF in an outpatient setting offers a safe, minimally expensive form of treatment for the frequently occurring displaced and unstable fractures of the hand. References BARTON, N. J. (1979). Fractures of the shafts of the phalanges of the hand. The Hand, 11: 2: 119-133. BELSKY, M. R., EATON, R. G. and LANE, L. B. (1984). Closed reduction and internal fixation of proximal phalangeal fractures. Journal of Hand Surgery, 9A: 725-729. BOTTE, M. J., DAVIS, J. L. W., ROSE, B. A. et al. (1992). Complication of smooth pin fixation of fractures and dislocations in the hand and wrist. Clinical Orthopaedics and Related Research, 276: 194-201. BROWN, P. W. (1973). The management of phalangeal and metacarpal fractures. Surgical Clinics of North America, 53: 6:1393 1437. GREEN, D. P. and ANDERSON, J. R. (1973). Closed reduction and percutaneous pin fixation of fractured phalanges. Journal of Bone and Joint Surgery, 55A: 1651-1654. MEALS, R. A. and MEULI, H. C. (1985). Carpenters nails, phonograph needles, piano wires, and safety pins: The history of operative fixation of metacarpal and phalangeal fractures. Journal of Hand Surgery, 10A: 144-150. PUN, W. K., CHOW, S. P., SO, Y. C. et al. (1989). A prospective study on 248 digital fractures of the hand. Journal of Hand Surgery, 14A: 474-481. RASKIN, K. B., MELONE, C. P., FRAZIER, J. L. and SEGALMAN, K. ( 1991). Closed pinning of unstable metacarpal fractures. Presented at 46th Annual Meeting of ASSH, Orlando, USA.
Accepted: 22 February 1995 Richard G. Eaton, MD, C.V. Starr Hand Surgery Center, 1000 Tenth Avenue--3rd Floor, New York, NY 10019, USA. © 1995 The British Society for Surgery of the Hand