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Kirschner Wires Versus Titanium Plates and Screws in Management of Unstable Phalangeal Fractures: A Randomized, Controlled Clinical Trial
SCIENTIFIC ARTICLE
Kirschner Wires Versus Titanium Plates and Screws in Management of Unstable Phalangeal Fractures: A Randomized, Controlled Clinical Trial Mohamed El-Saeed, MSc,* Asser Sallam, MD, PhD,† Mohamed Radwan, MD,† Ahmed Metwally, MD†
Purpose To compare clinical, radiological and functional outcomes of percutaneous K-wires and lateral titanium plates and screws in the management of unstable extra-articular proximal and middle phalangeal fractures. Methods In a randomized controlled clinical trial, 40 patients with unstable transverse, long oblique or spiral diaphyseal fractures of the proximal and middle phalanges were divided into 2 groups: the K-wire group (20 patients), which included 12 proximal and 8 middle phalangeal fractures fixed by percutaneous K-wires; and the plate group (20 patients), which included 13 proximal and 7 middle phalangeal fractures treated with open reduction and internal fixation with a lateral titanium plate and screws. The patients were observed for at least 6 months (mean [range], 6.9 [6e8] months). Results were evaluated by total active motion (TAM), grip strength, fracture union, pain assessed by visual analog scale and the QuickeDisabilities of the Arm, Shoulder, and Hand questionnaire, and complications. Results Clinical and radiological union was achieved in all patients except one in the K-wire group. Mean TAM was significantly better in the plate group than in the K-wire group. Both groups were similar in terms of postoperative loss of grip strength compared with the opposite healthy hand, and as assessed by visual analog scale and the QuickeDisabilities of the Arm, Shoulder, and Hand questionnaire. Fewer complications occurred in the plate group (2 of 20 patients) compared with the K-wire group (5 of 20 patients). Conclusions Fixation of unstable proximal and middle phalangeal fractures using a titanium plate and screws through a midlateral approach is a reliable and safe method for most fracture types and is associated with higher TAM and fewer complications. (J Hand Surg Am. 2019;-(-):1.e1-e9. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic II. Key words K-wire, middle phalanx, phalangeal fracture, plate, proximal phalanx.
P
hand injuries. They can be treated nonsurgically, with good results,2 or surgically, depending on the nature of injury, fracture pattern, and fracture stability.3 HALANGEAL FRACTURES ARE COMMON 1
Closed reduction and internal fixation by K-wires has been widely used to treat simple, closed hand fractures because it is technically easy and minimizes interference with fracture blood supply.4 However, their use in unstable fractures remains challenging
From the *Department of Orthopedic Surgery, Port Said Hospital for Health Insurance, Port Said; and the †Department of Orthopedic Surgery and Trauma, Suez Canal University Hospitals, Ismailia, Egypt.
Corresponding author: Asser Sallam, MD, PhD, Department of Orthopedic Surgery and Trauma, Suez Canal University Hospitals, Kilo 4.5 Ring Road, 41111 Ismailia, Egypt; e-mail: [email protected].
Received for publication November 9, 2017; accepted in revised form January 14, 2019.
0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.01.015
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Ó 2019 ASSH
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Published by Elsevier, Inc. All rights reserved.
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because they do not allow rigid fixation and usually need postoperative immobilization until the fracture is sufficiently healed. Internal fixation using a plate and screws is an alternative option for unstable fractures of the hand because it may provide good stability, allow early joint mobilization, and avoid complications associated with protruding K-wires.5,6 However, there are drawbacks including postoperative pain and stiffness and the potential requirement for a later tenolysis.7 Belsky et al8 reported that percutaneous wiring provides good finger range of motion (ROM) for phalangeal fractures, except in cases where there is severe comminution. Takigami et al9 stated that although the use of either percutaneous K-wires or plates resulted in good ROM, low-profile plate fixation requires a much shorter time in an orthosis. Few prospective studies have been published on the treatment of unstable phalangeal fractures by titanium plate and screws.10 Pun et al11 reported a prospective study of 52 unstable phalangeal fractures treated with plate and screws and concluded that there was no significant improvement in results compared with K-wire fixation. Kurzen et al12 found that plate fixation of unstable phalangeal fractures allowed early mobilization, but stiffness was frequent. Scarring and adhesions may result from either the nature and severity of the injury or the implant itself.12 Previous biomechanical studies13,14 showed that plate fixation provides stability equal to or greater than that of the K-wires and interosseous wiring. The strategy of plate fixation may offer substantial advantages because of its ability to control the anatomic alignment of fractures as well as allow early joint mobilization.13,15,16 Because both methods of treatment have advantages and disadvantages, there is uncertainty regarding the best way to treat unstable phalangeal fractures. The goal of this study was to compare the clinical, radiological, and functional outcomes of percutaneous K-wires and lateral titanium plates in the management of unstable phalangeal fractures.
November, 2014 and October, 2016 were enrolled in the study. Inclusion criteria were patients who presented with fractures displaced or angulated more than 10 in the anteroposterior view and 20 in the lateral view, or which were rotated, multi-fragmentary, irreducible, or unstable. Fractures were transverse, long oblique, or spiral in nature and affecting the diaphysis of the middle and proximal phalanges. Patients with previous surgeries in the finger or medical contraindications to surgery, or who were unwilling to provide an informed consent were excluded. Moreover, exclusion criteria were patients with intra-articular, open, or pathological fractures, associated tendon or nerve injuries, as well as preexisting finger joint stiffness, nonunion, or arthritic changes. All skeletally immature patients were excluded from the study as well (Fig. 1). Patients were divided randomly into 2 groups of 20 patients each. In the K-wire group, closed reduction and percutaneous K-wire fixation was performed. In the plate group, patients underwent open reduction and internal fixation (ORIF) with titanium plates and screws applied through a midlateral approach. Each participant was randomly assigned using sealed white envelopes. All participants were enrolled and randomized before surgery and no participant was recruited afterward. Surgical technique Surgery was undertaken at one hospital, under regional anesthesia (interscalene or axillary block) using the same technique. In the K-wire group, closed reduction was achieved by applying longitudinal traction to the finger. Rotational malalignment was also corrected. Any angular deviation was checked by comparison with the adjacent fingers and reduced as necessary. The accuracy of reduction was checked using the image intensifier. Through a fine drill guide, a K-wire was then drilled into the near fragment through a small stab incision in the coronal plane, and after confirmation of reduction, advanced into the far fragment. Multiple midlateral wires, either crossing or parallel, were placed to hold the fracture. The entry point was in the midlateral aspect of the finger and dorsal to the neurovascular bundle. The tip of the wire engaged the opposite cortex but did not project beyond it. K-wires were left protruding and bent 90 (Fig. 2). A sterile dressing was applied; then the finger was placed in an orthosis in the intrinsic-plus position with the metacarpophalangeal joint flexed and the interphalangeal joints extended.
MATERIALS AND METHODS This study was carried out prospectively as a randomized, controlled clinical trial (Pan African Clinical Trial Registry ID: PACTR201412000947268) after institutional research board granted approval. A total of 40 patients attending our specialized hand and microsurgery unit for treatment of unstable middle or proximal phalangeal fractures, between J Hand Surg Am.
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Enrollment
1.e3
Assessed for eligibility (n= 55)
Excluded (n=15) ♦ Not meeting inclusion criteria (n=13): - Open fractures (n=5) - Associated tendon injuries (n=3) - Intra-articular fractures (n=4) - Joint arthritis and stiffness (n=1) ♦ Declined to participate (n=2) ♦ Other reasons (n=0) Randomized
Allocaon Allocated to fixation by K-wires (n=20) ♦ Received allocated intervention (n=20) ♦
Allocated to fixation by titanium miniplate and screws (n=20) ♦ Received allocated intervention (n=20)
Did not receive allocated intervention (give reasons) (n=0)
♦
Did not receive allocated intervention (give reasons) (n=0)
Follow -Up Lost to follow-up (give reasons) (n=0)
Lost to follow-up (give reasons) (n=0)
Discontinued intervention (give reasons) (n=0)
Discontinued intervention (give reasons) (n=0)
Analysis ♦
Analysed (n=20)
♦ Analysed
♦
Excluded from analysis (give reasons) (n=0)
♦ Excluded
(n=20) from analysis (give reasons) (n=0)
FIGURE 1: Flow diagram showing the progress of subjects at each stage of the clinical trial.
In the plate group, we used a midlateral approach. The lateral band and oblique retinacular portion of the extensor hood were incised and later repaired. The plane between the extensor hood and the periosteum was disturbed as little as possible, and periosteal stripping was limited to that required only for visualization of the fracture fragments. Direct reduction was performed using reduction forceps. The accuracy of reduction was checked using the image intensifier. A K-wire was inserted for provisional fixation. Then, 4- to 5-hole, 1.5- to 2-mm titanium plates and screws were inserted. Plates were applied laterally and the temporary K-wire was removed (Fig. 3).
In the plate group, the immediate postoperative dressing was a bulky compressive bandage. Three days after surgery, the bandage was removed. No orthosis was needed, and patients started active ROM after 1 week. For both groups, a protective thermoplastic orthosis was used during vigorous activities until complete fracture healing (at the end of the remodeling phase, at the 10th week). Unrestricted activities were permitted when the fracture and soft tissues were completely healed (usually 3 months after surgery). A static night orthosis was recommended for patients with an extension lag in the injured finger. Hand therapy was discontinued when there was no further increase in finger ROM and grip strength; (usually 3 months after surgery).
Postoperative care In the K-wire group, a forearm-based orthosis was applied for 3 weeks. The patient removed the orthosis daily for pin site cleaning and to perform protected active ROM exercises. The pins were removed at 3 to 4 weeks. Patients then started unrestricted active ROM exercises. J Hand Surg Am.
Outcome measures Total active motion (TAM)17 was our primary outcome measure. Secondary outcome measures included fracture union, visual analog scale (VAS) for pain,18 grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score,19 and complications such as infection, stiffness, r
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FIGURE 2: Percutaneous pinning in the K-wire group. AeC Preoperative and postoperative x-rays of long oblique fracture of the proximal phalanx of the right index finger fixed with crossing K-wires. D, E Range of motion at 6 months after surgery.
implant loosening, deformity caused by malunion, and nonunion.
measured using a Jamar Hydraulic Hand Dynamometer and Jamar Hydraulic Pinch Gauge (Saehan Corporation, Masan, South Korea). We corrected for hand dominance. For right-handed patients, the dominant hand was assumed to be 10% stronger; for left-handed persons, grip strength was considered to be equivalent in both hands.20,21
Radiological evaluation: Patients were routinely evaluated in our clinic on a weekly basis after surgery. Radiographs were taken at 1, 4, 8, and 12 weeks, and at 6 months after surgery to assess fracture healing. Bone union was defined as the disappearance of fracture lines.
Functional outcome: The Arabic version of the QuickDASH score was used.19
Clinical evaluation: Clinical union was determined by the presence or absence of tenderness at the fracture site. Postoperative pain was assessed using a VAS. For pain intensity, the scale was anchored by no pain (score of 0) and worst imaginable pain (score of 100 [100-mm scale]).18 A hand therapist measured the ROM of the affected digit using a standard goniometer and evaluated it as a proportion of TAM relative to the contralateral side. The final range of TAM was graded as excellent (percent TAM > 85%), good (70% to 84%), fair (50% to 69%), and poor (<50%) according to criteria defined by Duncan et al.17 Other objective assessments included measurement of grip and pinch strengths and the presence of postsurgical complications. Grip and pinch strength (in kilograms) were J Hand Surg Am.
Statistical analysis A sample size of 20 patients in each group allowed demonstration of a difference in TAM of 28 , assuming an SD of 31 , at an a level of .05 and a power set of 80%.22 The data were evenly distributed. Quantitative data were expressed as mean SD. Categorical data were expressed as frequency and percentage. Mann-Whitney U test was used to compare 2 means. Chi-square test was used to compare proportions, but when an expected cell value was lower than 5, Fisher exact test was applied. A difference was considered significant at P < .05. r
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FIGURE 3: Open reduction and internal fixation in the plate group. AeD Preoperative and postoperative x-rays of transverse fracture of the proximal phalanx of the left middle finger fixed with lateral titanium plate and screws. E, F Range of motion at 6 months after surgery.
RESULTS Initially, 55 patients presented with unstable proximal or middle phalangeal fractures. Thirteen patients were excluded from the study because of an associated tendon injury (n ¼ 3), open fracture (n ¼ 5), intra-articular fracture (n ¼ 4), and stiffness or arthritis before fracture (n ¼ 1). Two patients declined to participate. This left a total of 40 patients (20/group) available for analysis (Fig. 1). J Hand Surg Am.
Baseline demographic and clinical data were collected and included age, sex, operative side, dominant hand, affected phalanx, affected digit, fracture pattern, time from injury to surgery, and follow-up duration (Table 1). All patients were observed for a minimum of 6 months; mean follow-up was 6.9 months (range, 6e8 months). Mean time from injury to surgery was 8.9 days (range, 4e12 days).
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TABLE 1.
K-WIRES VERSUS PLATES IN PHALANGEAL FRACTURES
Patients’ Demographic and Clinical Data Characteristic
K-Wire Group
Plate Group
Mean age, y
39.1 (24e56)
37.85 (24e50)
Male/female
17/3
16/4
Affected right/left hand
17/3
15/5
Affected dominant/nondominant hand
17/3
15/5
Proximal/middle phalanx
12/8
13/7
Index
3 (15%)
4 (20%)
Little
5 (25%)
5 (25%)
Middle
3 (15%)
3 (15%)
Ring
6 (30%)
4 (20%)
Thumb
3 (15%)
4 (20%)
Transverse
8 (40%)
7 (35%)
Oblique
6 (30%)
6 (30%)
Affected digit
Fracture pattern
Spiral Mean time from injury to surgery, d Mean follow-up, mo
TABLE 2.
6 (30%)
7 (35%)
8.60 (4e11)
9.25 (5e12)
6.5 (6e8)
7.2 (6e8)
Comparison of Mean Operative Time and Time to Union Between Groups Time
K-Wire Group
Plate Group
41.25 (30e65)
77.2 (55e90)
3
8 (40)
10 (50)
6
15 (75)
17 (85)
12
20 (100)
20 (100)
24
20 (100)
20 (100)
3
0
5 (20)
6
4 (20)
7 (35)
12
14
17
24
20
20
Mean operative time, min Time to clinical union, wk, n (%)
Time to radiological union, wk, n (%)
Mean operative time was shorter in the K-wire group than in the plate group. Regarding time to clinical and radiological union, both groups were similar (Table 2). Mean TAM was significantly better (P < .05) in the plate group than in the K-wire group at final follow-up (Fig. 4). Both groups were similar in terms of grip strength, postoperative loss of grip strength compared with the opposite healthy hand, VAS and Quick-DASH (Table 3).
J Hand Surg Am.
Fewer complications existed in the miniplate group (2 of 20 patients) compared with the K-wire group (5 of 20 patients). In the plate group, one patient developed PIP joint stiffness (TAM<180 ) and another developed a postoperative infection. In the Kwire group, one patient developed proximal interphalangeal joint (PIP) joint stiffness after infection, another patient had a postoperative infection, one patient had a mild angular malunion (less than 10 ), one had a nonunion, and one experienced loss of fixation in which 1 of the 2 wires lost purchase 2
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shorter healing time and length of hospital stay, and a lower infection rate and incidence of complication, although surgical time was longer with plate fixation than with K-wires. Biomechanically, many studies have also shown that internal fixation provided by plates and screws is stronger than K-wire fixation in fractures of phalanges.27e29 Closed reduction and percutaneous K-wire fixation is often used to treat unstable fractures of the proximal phalanx, despite many studies that have reported relatively high complication rates (eg, finger stiffness,30 PIP contractures, nonunion, and malunion31,32). Using percutaneous K-wires, Belsky et al8 achieved a TAM of greater than 215 in only 61% of patients. Similarly, Pun et al30 reported a TAM of greater than 210 in 60% of patients. Al-Qattan33 compared percutaneous K-wire fixation with open reduction and internal fixation of unstable proximal phalangeal fractures and reported a higher complication rate; only 63% achieved a TAM of greater than 220 in the percutaneous K-wire fixation group. Our results were similar, with a mean TAM of 218 in the K-wire group. The popularity of this fixation method is probably related to the simplicity of the technique and shorter operative time. In addition, K-wires can be inserted with minimal soft tissue stripping, thus preserving the blood supply to bone and enhancing healing. In this study, we used multiple midlateral wires perpendicular to the fracture site and tried as much as possible to insert the wires away from the lateral bands of the extensor hood. Other authors have driven the wires across the flexed metacarpophalangeal or interphalangeal joints; hence, these joints were completely immobilized for 4 to 5 weeks. These factors probably contributed to the worse outcomes.31e33 Berman et al34 performed a retrospective analysis of titanium plate fixation of phalangeal fractures using an extensor tendon-splitting approach over 7 years. They reported a complication rate of about 25% consisting of pain, flexion contracture at the PIP joint, and extension lag. Applying TAM for joint motion assessment, 9 digits were graded as excellent, another 6 were categorized as good, and only one digit was judged as poor. In the study of Bosscha and Snellen,35 92% of patients regained excellent total active flexion. The poor recovery of total active flexion in 3 patients was the result of either infection or a long delay between injury and surgery. Our results agree with all of these studies, in which TAM was significantly better after plate fixation (249 ) compared with K-wires (218 ). Favorable outcomes with ORIF by plates may also be the result of the approach we used. Because fine
FIGURE 4: Mean TAM in both groups (P < .05). Error bars represent standard error of the mean.
TABLE 3. Postoperative Outcome Measures of Patients in Both Groups (Mean [Range]) Outcome Measure Mean VAS Mean grip strength, kg
K-Wire Group
Plate Group
0.55
0.4
45.8 (40.5e49) 50.2 (48e57)
Mean percent loss of grip strength compared with opposite healthy hand
7.4 (5e19)
6.3 (1e11)
Mean Quick-DASH
6.3 (2e12)
6.2 (2e9)
weeks after surgery. In both groups, the infection was treated successfully with antibiotics and wound dressings. DISCUSSION Clinical and radiological union was achieved in all patients except one in the K-wire group. When we used lateral plates, better ROM and TAM were obtained. Although there are various methods of managing unstable phalangeal shaft fractures, less favorable outcomes often occurred.23 Some authors have reported no difference between nonsurgical treatment by orthoses, K-wires, and plates in the treatment of phalangeal fractures.22,24 Others described a higher reoperation rate after plate fixation than K-wires or screws.7,25 However, in agreement with our study, Xia26 conducted a prospective randomized study of plate versus K-wire internal fixation to treat metacarpal and phalangeal fractures and concluded that the plate fixation was superior to K-wires for the treatment of phalangeal fractures. This was attributed to better hand function, J Hand Surg Am.
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9. Takigami H, Sakano H, Saito T. Internal fixation with the low profile plate system compared with Kirschner wire fixation: clinical results of treatment for metacarpal and phalangeal fractures. Hand Surg. 2010;15(1):1e6. 10. Agarwal AK, Pickford MA. Experience with a new ultralow-profile osteosynthesis system for fractures of the metacarpals and phalanges. Ann Plast Surg. 2006;57(2):206e212. 11. Pun WK, Chow SP, So YC, et al. Unstable phalangeal fractures: treatment by A.O. screw and plate fixation. J Hand Surg Am. 1991;16(1):113e117. 12. Kurzen P, Fusetti C, Bonaccio M, Nagy L. Complications after plate fixation of phalangeal fractures. J Trauma. 2006;60(4):841e843. 13. Lu WW, Furumachi K, Ip WY, Chow SP. Fixation for comminuted phalangeal fractures: a biomechanical study of five methods. J Hand Surg Br. 1996;21(6):765e767. 14. Roure P, Ip WY, Lu W, Chow SP, Gogolewski S. Intramedullary fixation by resorbable rods in a comminuted phalangeal fracture model: a biomechanical study. J Hand Surg Br. 1999;24(4): 476e481. 15. Curtin CM, Chung KC. Use of eight-hole titanium miniplates for unstable phalangeal fractures. Ann Plast Surg. 2002;49(6): 580e586. 16. Vanik RK, Weber RC, Matloub HS, Sanger JR, Gingrass RP. The comparative strengths of internal fixation techniques. J Hand Surg Am. 1984;9(2):216e221. 17. Duncan RW, Freeland AE, Jabaley ME, Meydrech EF. Open hand fractures: an analysis of the recovery of active motion and of complications. J Hand Surg Am. 1993;18(3):387e394. 18. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011;63(suppl 11): S240eS252. 19. Kennedy CA, Beaton DE, Solway S, McConnell S, Bombardier C. Disabilities of the Arm, Shoulder and Hand (DASH): The DASH and QuickDASH Outcome Measure User’s Manual. 3rd ed. Toronto, Ontario, Canada: Institute for Work & Health; 2011. 20. Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of grip and pinch strength evaluations. J Hand Surg Am. 1984;9(2):222e226. 21. Petersen P, Petrick M, Connor H, Conklin D. Grip strength and hand dominance: challenging the 10% rule. Am J Occup Ther. 1989;43(7): 444e447. 22. Wutphiriya-Angkul S. Comparison of Miniplate and K-wire in treatment of metacarpal and phalangeal fractures. Thai J Surg. 2009;30(1):5e10. 23. Wong H-k, Lam C, Wong K, Ip W, Fung K. Treatment of phalangeal and metacarpal fractures: a review. J Orthop. 2008;10(1):1e9. 24. Ahmad M, Hussain SS, Rafiq Z, Tariq F, Khan MI, Malik SA. Management of phalangeal fractures of hand. J Ayub Med Coll Abbottabad. 2006;18(4):38e41. 25. Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg Am. 1998;23(5):827e832. 26. Xia X-m. Kirschner wire and mini-plate fixation in repair of metacarpal and phalangeal fractures: hand function and adverse reactions. Journal of Clinical Rehabilitative Tissue Engineering Research. 2015;19(17):2741e2744. 27. Adams JE, Miller T, Rizzo M. The biomechanics of fixation techniques for hand fractures. Hand Clin. 2013;29(4):493e500. 28. Gupta R, Singh R, Siwach R, Sangwan S, Magu NK, Diwan R. Evaluation of surgical stabilization of metacarpal and phalangeal fractures of hand. Indian J Orthop. 2007;41(3):224e229.
dissection is important to avoid soft tissue trauma, the plane between the extensor hood and the periosteum was disturbed as little as possible, and periosteal stripping was limited only to that required for fracture visualization. This in accordance with the study done by Abubeih et al,36 who reported better TAM and grip strength when using an extensor tendonesparing rather than splitting approach. The strength of this study includes the fact that no patient was lost to follow-up. Moreover, we prospectively compared 2 randomized groups with similar follow-up plans and used objective outcome measures. Study limitations were potential biases that may have been introduced by a lack of blinding. Also, we did not use block randomization. Other limitations of the study were the small sample, strict selection criteria, and relatively short follow-up. However, clinical and radiological union, if they happen, should be achieved 3 months after surgery. Finally, although this was a single-center study, our hand unit serves a population of more than 5 million people. We serve a broad spectrum of social and ethnic groups and believe that our data are relevant to the wider community. We found that ORIF of unstable proximal and middle phalangeal fractures using a titanium plate and screws through a midlateral extensor tendon-sparing approach is a reliable, safe method for most fracture types and allows early mobilization resulting in better TAM, although the surgery time was longer than in the K-wire group. REFERENCES 1. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26(5):908e915. 2. Barton N. Conservative treatment of articular fractures in the hand. J Hand Surg Am. 1989;14(2 part 2):386e390. 3. Ip WY, Ng KH, Chow SP. A prospective study of 924 digital fractures of the hand. Injury. 1996;27(4):279e285. 4. Bernstein ML, Chung KC. Hand fractures and their management: an international view. Injury. 2006;37(11):1043e1048. 5. Waris E, Ashammakhi N, Happonen H, et al. Bioabsorbable miniplating versus metallic fixation for metacarpal fractures. Clin Orthop Relat Res. 2003;410:310e319. 6. Mumtaz MU, Farooq MA, Rasool AA, Kawoosa AA, Badoo AR, Dhar SA. Unstable metacarpal and phalangeal fractures: treatment by internal fixation using AO mini-fragment plates and screws. Ulus Travma Acil Cerrahi Derg. 2010;16(4):334e338. 7. von Kieseritzky J, Nordström J, Arner M. Reoperations and postoperative complications after osteosynthesis of phalangeal fractures: a retrospective cohort study. J Plast Surg Hand Surg. 2017;51(6): 458e462. 8. Belsky MR, Eaton RG, Lane LB. Closed reduction and internal fixation of proximal phalangeal fractures. J Hand Surg Am. 1984;9(5):725e729.
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transverse fractures of the shaft of the proximal phalanx of the fingers in industrial workers. J Hand Surg Eur Vol. 2008;33(5): 552e556. 34. Berman KS, Rothkopf DM, Shufflebarger JV, Silverman R. Internal fixation of phalangeal fractures using titanium miniplates. Ann Plast Surg. 1999;42(4):408e410. 35. Bosscha K, Snellen JP. Internal fixation of metacarpal and phalangeal fractures with AO minifragment screws and plates: a prospective study. Injury. 1993;24(3):166e168. 36. Abubeih HM, Saleh WR, Thabet MA, Ibrahim A-KH. Extensor tendon splitting versus extensor tendon sparing approach for miniplate fixation of extraarticular proximal phalangeal fractures. Curr Orthop Pract. 2016;27(6):623e632.
29. Trevisan C, Morganti A, Casiraghi A, Marinoni EC. Lowseverity metacarpal and phalangeal fractures treated with miniature plates and screws. Arch Orthop Trauma Surg. 2004;124(10):675e680. 30. Pun WK, Chow SP, So YC, et al. A prospective study on 284 digital fractures of the hand. J Hand Surg Am. 1989;14(3):474e481. 31. Elmaraghy MW, Elmaraghy AW, Richards RS, Chinchalkar SJ, Turner R, Roth JH. Transmetacarpal intramedullary K-wire fixation of proximal phalangeal fractures. Ann Plast Surg. 1998;41(2):125e130. 32. Hornbach EE, Cohen MS. Closed reduction and percutaneous pinning of fractures of the proximal phalanx. J Hand Surg Br. 2001;26(1):45e49. 33. Al-Qattan MM. Closed reduction and percutaneous K-wires versus open reduction and interosseous loop wires for displaced unstable
J Hand Surg Am.
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Kirschner Wires Versus Titanium Plates and Screws in Management of Unstable Phalangeal Fractures: A Randomized, Controlled Clinical Trial Mohamed El-Saeed, MSc,* Asser Sallam, MD, PhD,† Mohamed Radwan, MD,† Ahmed Metwally, MD†
Purpose To compare clinical, radiological and functional outcomes of percutaneous K-wires and lateral titanium plates and screws in the management of unstable extra-articular proximal and middle phalangeal fractures. Methods In a randomized controlled clinical trial, 40 patients with unstable transverse, long oblique or spiral diaphyseal fractures of the proximal and middle phalanges were divided into 2 groups: the K-wire group (20 patients), which included 12 proximal and 8 middle phalangeal fractures fixed by percutaneous K-wires; and the plate group (20 patients), which included 13 proximal and 7 middle phalangeal fractures treated with open reduction and internal fixation with a lateral titanium plate and screws. The patients were observed for at least 6 months (mean [range], 6.9 [6e8] months). Results were evaluated by total active motion (TAM), grip strength, fracture union, pain assessed by visual analog scale and the QuickeDisabilities of the Arm, Shoulder, and Hand questionnaire, and complications. Results Clinical and radiological union was achieved in all patients except one in the K-wire group. Mean TAM was significantly better in the plate group than in the K-wire group. Both groups were similar in terms of postoperative loss of grip strength compared with the opposite healthy hand, and as assessed by visual analog scale and the QuickeDisabilities of the Arm, Shoulder, and Hand questionnaire. Fewer complications occurred in the plate group (2 of 20 patients) compared with the K-wire group (5 of 20 patients). Conclusions Fixation of unstable proximal and middle phalangeal fractures using a titanium plate and screws through a midlateral approach is a reliable and safe method for most fracture types and is associated with higher TAM and fewer complications. (J Hand Surg Am. 2019;-(-):1.e1-e9. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic II. Key words K-wire, middle phalanx, phalangeal fracture, plate, proximal phalanx.
P
hand injuries. They can be treated nonsurgically, with good results,2 or surgically, depending on the nature of injury, fracture pattern, and fracture stability.3 HALANGEAL FRACTURES ARE COMMON 1
Closed reduction and internal fixation by K-wires has been widely used to treat simple, closed hand fractures because it is technically easy and minimizes interference with fracture blood supply.4 However, their use in unstable fractures remains challenging
From the *Department of Orthopedic Surgery, Port Said Hospital for Health Insurance, Port Said; and the †Department of Orthopedic Surgery and Trauma, Suez Canal University Hospitals, Ismailia, Egypt.
Corresponding author: Asser Sallam, MD, PhD, Department of Orthopedic Surgery and Trauma, Suez Canal University Hospitals, Kilo 4.5 Ring Road, 41111 Ismailia, Egypt; e-mail: [email protected].
Received for publication November 9, 2017; accepted in revised form January 14, 2019.
0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.01.015
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Ó 2019 ASSH
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because they do not allow rigid fixation and usually need postoperative immobilization until the fracture is sufficiently healed. Internal fixation using a plate and screws is an alternative option for unstable fractures of the hand because it may provide good stability, allow early joint mobilization, and avoid complications associated with protruding K-wires.5,6 However, there are drawbacks including postoperative pain and stiffness and the potential requirement for a later tenolysis.7 Belsky et al8 reported that percutaneous wiring provides good finger range of motion (ROM) for phalangeal fractures, except in cases where there is severe comminution. Takigami et al9 stated that although the use of either percutaneous K-wires or plates resulted in good ROM, low-profile plate fixation requires a much shorter time in an orthosis. Few prospective studies have been published on the treatment of unstable phalangeal fractures by titanium plate and screws.10 Pun et al11 reported a prospective study of 52 unstable phalangeal fractures treated with plate and screws and concluded that there was no significant improvement in results compared with K-wire fixation. Kurzen et al12 found that plate fixation of unstable phalangeal fractures allowed early mobilization, but stiffness was frequent. Scarring and adhesions may result from either the nature and severity of the injury or the implant itself.12 Previous biomechanical studies13,14 showed that plate fixation provides stability equal to or greater than that of the K-wires and interosseous wiring. The strategy of plate fixation may offer substantial advantages because of its ability to control the anatomic alignment of fractures as well as allow early joint mobilization.13,15,16 Because both methods of treatment have advantages and disadvantages, there is uncertainty regarding the best way to treat unstable phalangeal fractures. The goal of this study was to compare the clinical, radiological, and functional outcomes of percutaneous K-wires and lateral titanium plates in the management of unstable phalangeal fractures.
November, 2014 and October, 2016 were enrolled in the study. Inclusion criteria were patients who presented with fractures displaced or angulated more than 10 in the anteroposterior view and 20 in the lateral view, or which were rotated, multi-fragmentary, irreducible, or unstable. Fractures were transverse, long oblique, or spiral in nature and affecting the diaphysis of the middle and proximal phalanges. Patients with previous surgeries in the finger or medical contraindications to surgery, or who were unwilling to provide an informed consent were excluded. Moreover, exclusion criteria were patients with intra-articular, open, or pathological fractures, associated tendon or nerve injuries, as well as preexisting finger joint stiffness, nonunion, or arthritic changes. All skeletally immature patients were excluded from the study as well (Fig. 1). Patients were divided randomly into 2 groups of 20 patients each. In the K-wire group, closed reduction and percutaneous K-wire fixation was performed. In the plate group, patients underwent open reduction and internal fixation (ORIF) with titanium plates and screws applied through a midlateral approach. Each participant was randomly assigned using sealed white envelopes. All participants were enrolled and randomized before surgery and no participant was recruited afterward. Surgical technique Surgery was undertaken at one hospital, under regional anesthesia (interscalene or axillary block) using the same technique. In the K-wire group, closed reduction was achieved by applying longitudinal traction to the finger. Rotational malalignment was also corrected. Any angular deviation was checked by comparison with the adjacent fingers and reduced as necessary. The accuracy of reduction was checked using the image intensifier. Through a fine drill guide, a K-wire was then drilled into the near fragment through a small stab incision in the coronal plane, and after confirmation of reduction, advanced into the far fragment. Multiple midlateral wires, either crossing or parallel, were placed to hold the fracture. The entry point was in the midlateral aspect of the finger and dorsal to the neurovascular bundle. The tip of the wire engaged the opposite cortex but did not project beyond it. K-wires were left protruding and bent 90 (Fig. 2). A sterile dressing was applied; then the finger was placed in an orthosis in the intrinsic-plus position with the metacarpophalangeal joint flexed and the interphalangeal joints extended.
MATERIALS AND METHODS This study was carried out prospectively as a randomized, controlled clinical trial (Pan African Clinical Trial Registry ID: PACTR201412000947268) after institutional research board granted approval. A total of 40 patients attending our specialized hand and microsurgery unit for treatment of unstable middle or proximal phalangeal fractures, between J Hand Surg Am.
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Enrollment
1.e3
Assessed for eligibility (n= 55)
Excluded (n=15) ♦ Not meeting inclusion criteria (n=13): - Open fractures (n=5) - Associated tendon injuries (n=3) - Intra-articular fractures (n=4) - Joint arthritis and stiffness (n=1) ♦ Declined to participate (n=2) ♦ Other reasons (n=0) Randomized
Allocaon Allocated to fixation by K-wires (n=20) ♦ Received allocated intervention (n=20) ♦
Allocated to fixation by titanium miniplate and screws (n=20) ♦ Received allocated intervention (n=20)
Did not receive allocated intervention (give reasons) (n=0)
♦
Did not receive allocated intervention (give reasons) (n=0)
Follow -Up Lost to follow-up (give reasons) (n=0)
Lost to follow-up (give reasons) (n=0)
Discontinued intervention (give reasons) (n=0)
Discontinued intervention (give reasons) (n=0)
Analysis ♦
Analysed (n=20)
♦ Analysed
♦
Excluded from analysis (give reasons) (n=0)
♦ Excluded
(n=20) from analysis (give reasons) (n=0)
FIGURE 1: Flow diagram showing the progress of subjects at each stage of the clinical trial.
In the plate group, we used a midlateral approach. The lateral band and oblique retinacular portion of the extensor hood were incised and later repaired. The plane between the extensor hood and the periosteum was disturbed as little as possible, and periosteal stripping was limited to that required only for visualization of the fracture fragments. Direct reduction was performed using reduction forceps. The accuracy of reduction was checked using the image intensifier. A K-wire was inserted for provisional fixation. Then, 4- to 5-hole, 1.5- to 2-mm titanium plates and screws were inserted. Plates were applied laterally and the temporary K-wire was removed (Fig. 3).
In the plate group, the immediate postoperative dressing was a bulky compressive bandage. Three days after surgery, the bandage was removed. No orthosis was needed, and patients started active ROM after 1 week. For both groups, a protective thermoplastic orthosis was used during vigorous activities until complete fracture healing (at the end of the remodeling phase, at the 10th week). Unrestricted activities were permitted when the fracture and soft tissues were completely healed (usually 3 months after surgery). A static night orthosis was recommended for patients with an extension lag in the injured finger. Hand therapy was discontinued when there was no further increase in finger ROM and grip strength; (usually 3 months after surgery).
Postoperative care In the K-wire group, a forearm-based orthosis was applied for 3 weeks. The patient removed the orthosis daily for pin site cleaning and to perform protected active ROM exercises. The pins were removed at 3 to 4 weeks. Patients then started unrestricted active ROM exercises. J Hand Surg Am.
Outcome measures Total active motion (TAM)17 was our primary outcome measure. Secondary outcome measures included fracture union, visual analog scale (VAS) for pain,18 grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score,19 and complications such as infection, stiffness, r
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FIGURE 2: Percutaneous pinning in the K-wire group. AeC Preoperative and postoperative x-rays of long oblique fracture of the proximal phalanx of the right index finger fixed with crossing K-wires. D, E Range of motion at 6 months after surgery.
implant loosening, deformity caused by malunion, and nonunion.
measured using a Jamar Hydraulic Hand Dynamometer and Jamar Hydraulic Pinch Gauge (Saehan Corporation, Masan, South Korea). We corrected for hand dominance. For right-handed patients, the dominant hand was assumed to be 10% stronger; for left-handed persons, grip strength was considered to be equivalent in both hands.20,21
Radiological evaluation: Patients were routinely evaluated in our clinic on a weekly basis after surgery. Radiographs were taken at 1, 4, 8, and 12 weeks, and at 6 months after surgery to assess fracture healing. Bone union was defined as the disappearance of fracture lines.
Functional outcome: The Arabic version of the QuickDASH score was used.19
Clinical evaluation: Clinical union was determined by the presence or absence of tenderness at the fracture site. Postoperative pain was assessed using a VAS. For pain intensity, the scale was anchored by no pain (score of 0) and worst imaginable pain (score of 100 [100-mm scale]).18 A hand therapist measured the ROM of the affected digit using a standard goniometer and evaluated it as a proportion of TAM relative to the contralateral side. The final range of TAM was graded as excellent (percent TAM > 85%), good (70% to 84%), fair (50% to 69%), and poor (<50%) according to criteria defined by Duncan et al.17 Other objective assessments included measurement of grip and pinch strengths and the presence of postsurgical complications. Grip and pinch strength (in kilograms) were J Hand Surg Am.
Statistical analysis A sample size of 20 patients in each group allowed demonstration of a difference in TAM of 28 , assuming an SD of 31 , at an a level of .05 and a power set of 80%.22 The data were evenly distributed. Quantitative data were expressed as mean SD. Categorical data were expressed as frequency and percentage. Mann-Whitney U test was used to compare 2 means. Chi-square test was used to compare proportions, but when an expected cell value was lower than 5, Fisher exact test was applied. A difference was considered significant at P < .05. r
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FIGURE 3: Open reduction and internal fixation in the plate group. AeD Preoperative and postoperative x-rays of transverse fracture of the proximal phalanx of the left middle finger fixed with lateral titanium plate and screws. E, F Range of motion at 6 months after surgery.
RESULTS Initially, 55 patients presented with unstable proximal or middle phalangeal fractures. Thirteen patients were excluded from the study because of an associated tendon injury (n ¼ 3), open fracture (n ¼ 5), intra-articular fracture (n ¼ 4), and stiffness or arthritis before fracture (n ¼ 1). Two patients declined to participate. This left a total of 40 patients (20/group) available for analysis (Fig. 1). J Hand Surg Am.
Baseline demographic and clinical data were collected and included age, sex, operative side, dominant hand, affected phalanx, affected digit, fracture pattern, time from injury to surgery, and follow-up duration (Table 1). All patients were observed for a minimum of 6 months; mean follow-up was 6.9 months (range, 6e8 months). Mean time from injury to surgery was 8.9 days (range, 4e12 days).
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TABLE 1.
K-WIRES VERSUS PLATES IN PHALANGEAL FRACTURES
Patients’ Demographic and Clinical Data Characteristic
K-Wire Group
Plate Group
Mean age, y
39.1 (24e56)
37.85 (24e50)
Male/female
17/3
16/4
Affected right/left hand
17/3
15/5
Affected dominant/nondominant hand
17/3
15/5
Proximal/middle phalanx
12/8
13/7
Index
3 (15%)
4 (20%)
Little
5 (25%)
5 (25%)
Middle
3 (15%)
3 (15%)
Ring
6 (30%)
4 (20%)
Thumb
3 (15%)
4 (20%)
Transverse
8 (40%)
7 (35%)
Oblique
6 (30%)
6 (30%)
Affected digit
Fracture pattern
Spiral Mean time from injury to surgery, d Mean follow-up, mo
TABLE 2.
6 (30%)
7 (35%)
8.60 (4e11)
9.25 (5e12)
6.5 (6e8)
7.2 (6e8)
Comparison of Mean Operative Time and Time to Union Between Groups Time
K-Wire Group
Plate Group
41.25 (30e65)
77.2 (55e90)
3
8 (40)
10 (50)
6
15 (75)
17 (85)
12
20 (100)
20 (100)
24
20 (100)
20 (100)
3
0
5 (20)
6
4 (20)
7 (35)
12
14
17
24
20
20
Mean operative time, min Time to clinical union, wk, n (%)
Time to radiological union, wk, n (%)
Mean operative time was shorter in the K-wire group than in the plate group. Regarding time to clinical and radiological union, both groups were similar (Table 2). Mean TAM was significantly better (P < .05) in the plate group than in the K-wire group at final follow-up (Fig. 4). Both groups were similar in terms of grip strength, postoperative loss of grip strength compared with the opposite healthy hand, VAS and Quick-DASH (Table 3).
J Hand Surg Am.
Fewer complications existed in the miniplate group (2 of 20 patients) compared with the K-wire group (5 of 20 patients). In the plate group, one patient developed PIP joint stiffness (TAM<180 ) and another developed a postoperative infection. In the Kwire group, one patient developed proximal interphalangeal joint (PIP) joint stiffness after infection, another patient had a postoperative infection, one patient had a mild angular malunion (less than 10 ), one had a nonunion, and one experienced loss of fixation in which 1 of the 2 wires lost purchase 2
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shorter healing time and length of hospital stay, and a lower infection rate and incidence of complication, although surgical time was longer with plate fixation than with K-wires. Biomechanically, many studies have also shown that internal fixation provided by plates and screws is stronger than K-wire fixation in fractures of phalanges.27e29 Closed reduction and percutaneous K-wire fixation is often used to treat unstable fractures of the proximal phalanx, despite many studies that have reported relatively high complication rates (eg, finger stiffness,30 PIP contractures, nonunion, and malunion31,32). Using percutaneous K-wires, Belsky et al8 achieved a TAM of greater than 215 in only 61% of patients. Similarly, Pun et al30 reported a TAM of greater than 210 in 60% of patients. Al-Qattan33 compared percutaneous K-wire fixation with open reduction and internal fixation of unstable proximal phalangeal fractures and reported a higher complication rate; only 63% achieved a TAM of greater than 220 in the percutaneous K-wire fixation group. Our results were similar, with a mean TAM of 218 in the K-wire group. The popularity of this fixation method is probably related to the simplicity of the technique and shorter operative time. In addition, K-wires can be inserted with minimal soft tissue stripping, thus preserving the blood supply to bone and enhancing healing. In this study, we used multiple midlateral wires perpendicular to the fracture site and tried as much as possible to insert the wires away from the lateral bands of the extensor hood. Other authors have driven the wires across the flexed metacarpophalangeal or interphalangeal joints; hence, these joints were completely immobilized for 4 to 5 weeks. These factors probably contributed to the worse outcomes.31e33 Berman et al34 performed a retrospective analysis of titanium plate fixation of phalangeal fractures using an extensor tendon-splitting approach over 7 years. They reported a complication rate of about 25% consisting of pain, flexion contracture at the PIP joint, and extension lag. Applying TAM for joint motion assessment, 9 digits were graded as excellent, another 6 were categorized as good, and only one digit was judged as poor. In the study of Bosscha and Snellen,35 92% of patients regained excellent total active flexion. The poor recovery of total active flexion in 3 patients was the result of either infection or a long delay between injury and surgery. Our results agree with all of these studies, in which TAM was significantly better after plate fixation (249 ) compared with K-wires (218 ). Favorable outcomes with ORIF by plates may also be the result of the approach we used. Because fine
FIGURE 4: Mean TAM in both groups (P < .05). Error bars represent standard error of the mean.
TABLE 3. Postoperative Outcome Measures of Patients in Both Groups (Mean [Range]) Outcome Measure Mean VAS Mean grip strength, kg
K-Wire Group
Plate Group
0.55
0.4
45.8 (40.5e49) 50.2 (48e57)
Mean percent loss of grip strength compared with opposite healthy hand
7.4 (5e19)
6.3 (1e11)
Mean Quick-DASH
6.3 (2e12)
6.2 (2e9)
weeks after surgery. In both groups, the infection was treated successfully with antibiotics and wound dressings. DISCUSSION Clinical and radiological union was achieved in all patients except one in the K-wire group. When we used lateral plates, better ROM and TAM were obtained. Although there are various methods of managing unstable phalangeal shaft fractures, less favorable outcomes often occurred.23 Some authors have reported no difference between nonsurgical treatment by orthoses, K-wires, and plates in the treatment of phalangeal fractures.22,24 Others described a higher reoperation rate after plate fixation than K-wires or screws.7,25 However, in agreement with our study, Xia26 conducted a prospective randomized study of plate versus K-wire internal fixation to treat metacarpal and phalangeal fractures and concluded that the plate fixation was superior to K-wires for the treatment of phalangeal fractures. This was attributed to better hand function, J Hand Surg Am.
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9. Takigami H, Sakano H, Saito T. Internal fixation with the low profile plate system compared with Kirschner wire fixation: clinical results of treatment for metacarpal and phalangeal fractures. Hand Surg. 2010;15(1):1e6. 10. Agarwal AK, Pickford MA. Experience with a new ultralow-profile osteosynthesis system for fractures of the metacarpals and phalanges. Ann Plast Surg. 2006;57(2):206e212. 11. Pun WK, Chow SP, So YC, et al. Unstable phalangeal fractures: treatment by A.O. screw and plate fixation. J Hand Surg Am. 1991;16(1):113e117. 12. Kurzen P, Fusetti C, Bonaccio M, Nagy L. Complications after plate fixation of phalangeal fractures. J Trauma. 2006;60(4):841e843. 13. Lu WW, Furumachi K, Ip WY, Chow SP. Fixation for comminuted phalangeal fractures: a biomechanical study of five methods. J Hand Surg Br. 1996;21(6):765e767. 14. Roure P, Ip WY, Lu W, Chow SP, Gogolewski S. Intramedullary fixation by resorbable rods in a comminuted phalangeal fracture model: a biomechanical study. J Hand Surg Br. 1999;24(4): 476e481. 15. Curtin CM, Chung KC. Use of eight-hole titanium miniplates for unstable phalangeal fractures. Ann Plast Surg. 2002;49(6): 580e586. 16. Vanik RK, Weber RC, Matloub HS, Sanger JR, Gingrass RP. The comparative strengths of internal fixation techniques. J Hand Surg Am. 1984;9(2):216e221. 17. Duncan RW, Freeland AE, Jabaley ME, Meydrech EF. Open hand fractures: an analysis of the recovery of active motion and of complications. J Hand Surg Am. 1993;18(3):387e394. 18. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011;63(suppl 11): S240eS252. 19. Kennedy CA, Beaton DE, Solway S, McConnell S, Bombardier C. Disabilities of the Arm, Shoulder and Hand (DASH): The DASH and QuickDASH Outcome Measure User’s Manual. 3rd ed. Toronto, Ontario, Canada: Institute for Work & Health; 2011. 20. Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of grip and pinch strength evaluations. J Hand Surg Am. 1984;9(2):222e226. 21. Petersen P, Petrick M, Connor H, Conklin D. Grip strength and hand dominance: challenging the 10% rule. Am J Occup Ther. 1989;43(7): 444e447. 22. Wutphiriya-Angkul S. Comparison of Miniplate and K-wire in treatment of metacarpal and phalangeal fractures. Thai J Surg. 2009;30(1):5e10. 23. Wong H-k, Lam C, Wong K, Ip W, Fung K. Treatment of phalangeal and metacarpal fractures: a review. J Orthop. 2008;10(1):1e9. 24. Ahmad M, Hussain SS, Rafiq Z, Tariq F, Khan MI, Malik SA. Management of phalangeal fractures of hand. J Ayub Med Coll Abbottabad. 2006;18(4):38e41. 25. Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg Am. 1998;23(5):827e832. 26. Xia X-m. Kirschner wire and mini-plate fixation in repair of metacarpal and phalangeal fractures: hand function and adverse reactions. Journal of Clinical Rehabilitative Tissue Engineering Research. 2015;19(17):2741e2744. 27. Adams JE, Miller T, Rizzo M. The biomechanics of fixation techniques for hand fractures. Hand Clin. 2013;29(4):493e500. 28. Gupta R, Singh R, Siwach R, Sangwan S, Magu NK, Diwan R. Evaluation of surgical stabilization of metacarpal and phalangeal fractures of hand. Indian J Orthop. 2007;41(3):224e229.
dissection is important to avoid soft tissue trauma, the plane between the extensor hood and the periosteum was disturbed as little as possible, and periosteal stripping was limited only to that required for fracture visualization. This in accordance with the study done by Abubeih et al,36 who reported better TAM and grip strength when using an extensor tendonesparing rather than splitting approach. The strength of this study includes the fact that no patient was lost to follow-up. Moreover, we prospectively compared 2 randomized groups with similar follow-up plans and used objective outcome measures. Study limitations were potential biases that may have been introduced by a lack of blinding. Also, we did not use block randomization. Other limitations of the study were the small sample, strict selection criteria, and relatively short follow-up. However, clinical and radiological union, if they happen, should be achieved 3 months after surgery. Finally, although this was a single-center study, our hand unit serves a population of more than 5 million people. We serve a broad spectrum of social and ethnic groups and believe that our data are relevant to the wider community. We found that ORIF of unstable proximal and middle phalangeal fractures using a titanium plate and screws through a midlateral extensor tendon-sparing approach is a reliable, safe method for most fracture types and allows early mobilization resulting in better TAM, although the surgery time was longer than in the K-wire group. REFERENCES 1. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26(5):908e915. 2. Barton N. Conservative treatment of articular fractures in the hand. J Hand Surg Am. 1989;14(2 part 2):386e390. 3. Ip WY, Ng KH, Chow SP. A prospective study of 924 digital fractures of the hand. Injury. 1996;27(4):279e285. 4. Bernstein ML, Chung KC. Hand fractures and their management: an international view. Injury. 2006;37(11):1043e1048. 5. Waris E, Ashammakhi N, Happonen H, et al. Bioabsorbable miniplating versus metallic fixation for metacarpal fractures. Clin Orthop Relat Res. 2003;410:310e319. 6. Mumtaz MU, Farooq MA, Rasool AA, Kawoosa AA, Badoo AR, Dhar SA. Unstable metacarpal and phalangeal fractures: treatment by internal fixation using AO mini-fragment plates and screws. Ulus Travma Acil Cerrahi Derg. 2010;16(4):334e338. 7. von Kieseritzky J, Nordström J, Arner M. Reoperations and postoperative complications after osteosynthesis of phalangeal fractures: a retrospective cohort study. J Plast Surg Hand Surg. 2017;51(6): 458e462. 8. Belsky MR, Eaton RG, Lane LB. Closed reduction and internal fixation of proximal phalangeal fractures. J Hand Surg Am. 1984;9(5):725e729.
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transverse fractures of the shaft of the proximal phalanx of the fingers in industrial workers. J Hand Surg Eur Vol. 2008;33(5): 552e556. 34. Berman KS, Rothkopf DM, Shufflebarger JV, Silverman R. Internal fixation of phalangeal fractures using titanium miniplates. Ann Plast Surg. 1999;42(4):408e410. 35. Bosscha K, Snellen JP. Internal fixation of metacarpal and phalangeal fractures with AO minifragment screws and plates: a prospective study. Injury. 1993;24(3):166e168. 36. Abubeih HM, Saleh WR, Thabet MA, Ibrahim A-KH. Extensor tendon splitting versus extensor tendon sparing approach for miniplate fixation of extraarticular proximal phalangeal fractures. Curr Orthop Pract. 2016;27(6):623e632.
29. Trevisan C, Morganti A, Casiraghi A, Marinoni EC. Lowseverity metacarpal and phalangeal fractures treated with miniature plates and screws. Arch Orthop Trauma Surg. 2004;124(10):675e680. 30. Pun WK, Chow SP, So YC, et al. A prospective study on 284 digital fractures of the hand. J Hand Surg Am. 1989;14(3):474e481. 31. Elmaraghy MW, Elmaraghy AW, Richards RS, Chinchalkar SJ, Turner R, Roth JH. Transmetacarpal intramedullary K-wire fixation of proximal phalangeal fractures. Ann Plast Surg. 1998;41(2):125e130. 32. Hornbach EE, Cohen MS. Closed reduction and percutaneous pinning of fractures of the proximal phalanx. J Hand Surg Br. 2001;26(1):45e49. 33. Al-Qattan MM. Closed reduction and percutaneous K-wires versus open reduction and interosseous loop wires for displaced unstable
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