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Modified Suzuki frame for the treatment of difficult Rolando fractures
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ScienceDirect www.sciencedirect.com Hand Surgery and Rehabilitation 35 (2016) 335–340
Original article
Modified Suzuki frame for the treatment of difficult Rolando fractures Le cadre de Suzuki modifié pour le traitement des fractures de Rolando difficiles T. Giesen *, L. Neukom, R. Fakin, V. Beckamm-Fries, M. Calcagni Department of plastic surgery and hand surgery, university hospital Zurich, 100, Rämistrasse, 8006 Zurich, Switzerland Received 2 May 2016; received in revised form 17 July 2016; accepted 28 July 2016 Available online 15 September 2016
Abstract Fifteen consecutive patients with severely comminuted Rolando fractures were treated by closed reduction and fixation with a modified Suzuki frame without rubber bands, followed by immediate mobilization. All the fractures healed within 5 weeks. At 3 months, no rotational deformity was observed. The Kapandji score was equal that of the contralateral thumb in eight cases. No residual pain was recorded. Grip strength was 78% and pinch strength was 78% of the contralateral hand. One patient needed the frame tension modified. One patient developed a sensory deficit in the area of the superficial branch of the radial nerve that resolved spontaneously in 3 months. One patient healed with a 2-mm articular step-off, but the clinical outcome was good. Our retrospective study suggests that the small modification we made to the Suzuki frame provides a relatively simple and minimally invasive technique for the treatment of comminuted Rolando fractures. # 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved. Keywords: Suzuki frame; Rolando fracture; Intra-articular fracture of the hand; Dynamic fixation; Early mobilization
Résumé Quinze patients consécutifs soufrant de sévères fractures comminutives de Rolando ont été traités par réduction à foyer fermé, avec le cadre de Suzuki modifié sans bandes élastiques et avec une mobilisation immédiate. Toutes les fractures ont consolidé dans les cinq semaines. À trois mois, aucune déformation rotatoire n’a été observée. Dans huit cas, le score de Kapandji était identique à celui du pouce controlatéral. Aucune douleur résiduelle n’a été rapportée. La force de préhension était de 78 % et la force de pince 78 % de celle de la main controlatérale. La tension du cadre a dû être modifiée pour un patient. Un autre a développé un déficit sensitif dans le territoire du rameau superficiel du nerf radial ayant régressé spontanément dans les trois mois. Un dernier a guéri avec une marche d’escalier intra-articulaire de 2 mm mais avec un bon résultat clinique. Notre étude rétrospective suggère qu’une légère modification du cadre de Suzuki, telle que nous l’avons utilisée, est une technique relativement simple et minimalement invasive pour le traitement des fractures comminutives de Rolando. # 2016 SFCM. Publié par Elsevier Masson SAS. Tous droits réservés. Mots clés : Cadre de Suzuki ; Fracture de Rolando ; Fracture intra-articulaire de la main ; Fixation dynamique ; Mobilisation précoce
1. Introduction Fractures of the base of the first metacarpal account for 4% of all hand fractures [1]. About 9–21% of those are Rolando fractures [2] with variable comminution. A variety of
* Corresponding author. E-mail address: [email protected] (T. Giesen).
treatments have been described in literature, depending on the degree of comminution. The surgical approach and final outcome depend greatly on the fracture pattern and articular surface involvement, and how well the latter is restored if damaged [3]. For non-comminuted or slightly comminuted intra-articular fractures, the prevailing fixation techniques rely on plates and screws [4]. However, there is no consensus on the treatment of profoundly comminuted Rolando fractures with fragments too
http://dx.doi.org/10.1016/j.hansur.2016.07.006 2468-1229/# 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved.
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T. Giesen et al. / Hand Surgery and Rehabilitation 35 (2016) 335–340
small to qualify for this type of internal fixation. Alternative techniques have been described for these specific cases [5–10]. Despite technical advances in plate design and instrumentation, including lower-profile titanium plates, complications occur commonly with plate fixation of metacarpal fractures. Furthermore, plate fixation often requires tenolysis and plate removal in metacarpal fractures [11]. We previously reported the preliminary results of a single patient with a Rolando fracture [12] treated with a slightly modified Suzuki frame [8,13,14]. The current study is the first ever published series evaluating outcome in patients operated using this novel surgical technique.
was performed and fixation was maintained with a modified Suzuki frame that consisted of one 1.6 mm and one 1.5 mm Kwire, but no rubber bands. The 1.6-mm K-wire was passed from palmar-radial to dorsal-ulnar through the trapezium at 908 to the axis of the metacarpal bone, with the wrist in 08 extension. The 1.5-mm K-wire was passed through the head of the first metacarpal bone, parallel to the previous wire (Fig. 1A). To hook the distal K-wire on the proximal one, the frame was constructed with a dorsal to palmar S shape in order to avoid a contact between the frame and skin when the thumb was flexed (Figs. 1(B and C)–3). The operative time was recorded in all cases.
2. Patients and methods
2.3. Postoperative care
2.1. Patients
The patients were encouraged to move the thumb immediately and began a controlled active mobilization regimen without splinting within one week after the procedure.
From July 2012 to November 2015, 15 adult patients with a Rolando fracture having variable displacement and severe comminution were referred to our hand surgery department. Open fractures and complex traumas such as amputations, subtotal amputations and crush injuries were excluded from the study. Thirteen patients were men and two were women, with an average age of 40 years (range 18–86 years, SD 19.1). Eight fractures involved the dominant hand and seven the non-dominant hand. The histories given by the patients included a fall onto the hand in 11 cases, direct trauma in 3 cases and polytrauma with an unclear mechanism of the injury in 1 case. The mean time from injury to the surgical treatment was 3.5 days (range 1–10 days, SD 2.1). The surgical treatment was discussed with the patient at the time of arrival and a modified Suzuki frame was proposed as a fixation strategy to all patients. New anterior-posterior (AP), oblique and lateral (LL) plain digital X-rays were taken in all cases prior to surgery. 2.2. Surgical technique We used a modified Suzuki frame as previously described by Giesen et al. [12]. All procedures were performed by the same surgeon. Anesthesia was based on the patient’s preference and/or need to surgically repair other injuries in polytrauma patients. Regional anesthesia was used in five cases, general anesthesia in six cases and local anesthesia in four cases. Closed reduction
2.4. Postoperative follow-up All patients underwent their first clinical and radiological follow-up within 1 week of the surgery to verify the amount of distraction across the fracture and if necessary, modify it by changing the curvature of the frame’s arms. In two cases, a CT-scan of the thumb 2 weeks post-surgery with the frame in place was performed in order to verify joint congruity (Fig. 4). The next follow-up was planned at 5 weeks postoperative (mean 33.8 days, range 27–41 days, SD 3.7). At this point, if bone union was visible on the radiographs, the K-wires were removed in an ambulatory setting without anesthesia. Follow-up was planned for all patients at a minimum of 3 months postoperative (mean 95 days, range 35–294 days, SD 66). All patients were seen by the surgeon at each follow-up. X-ray views were taken in a standardized manner to measure any postoperative articular step-off. 2.5. Assessment At each follow-up, function of the affected thumb was measured using the Kapandji score [15] and was compared to the contralateral side. Grip strength (Jamar Dynamometer position 2) and pinch strength were also recorded and compared to the uninjured thumb.
Fig. 1. Drawing of surgical technique (palmar view) showing the scaphoid (1) and the insertion of the proximal (2) and distal (3) K-wires (A). Bending of K-wires to hook the distal K-wire on the proximal K-wire (B and C).
T. Giesen et al. / Hand Surgery and Rehabilitation 35 (2016) 335–340
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Fig. 2. Rolando fracture with small comminution (A and B). Intraoperative view of the modified Suzuki frame (C and D).
Patients were assessed for early postoperative complications such as inadequate fixation, loss of reduction with formation of articular step-off, malrotation, infection and K-wire migration. Late complications such as rotational deformity, delayed union or tendon adhesions were also recorded. 3. Results
Fig. 3. The clinical appearance of the frame in the same patient as Fig. 2 who is performing active opposition: contact between the frame’s bars and the skin only occurs in full thumb opposition.
All fractures healed and the K-wires were removed after a mean of 33.8 days (range 27–41 days, SD 3.7). No evidence of inadequate fixation, loss of reduction, early or late rotational deformity or delayed fracture union was found. There were no articular step-offs of more than 1 mm on the final X-rays except for one case with a consolidated 2 mm stepoff. This patient did not require any further surgery and was pain free at the last follow-up with a Kapandji score of 8/9. This patient’s grip strength was 20 kg in the operated hand and 38 kg in the contralateral hand. Pinch strength was 10 kg vs. 10 kg for the contralateral side. Slight lateral migration of the proximal K-wires was observed in two patients. Two patients had a superficial pin site infection, which was successfully treated with a 1-week course of oral antibiotics. One patient had a slight form of neurapraxia of the superficial branch of the radial nerve (SBRN), which resolved spontaneously within 3 months.
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Fig. 4. CT-scan 2 weeks after the surgery to exclude the presence of articular step-offs (A and B). Bone healing 5 weeks post-surgery (C).
In one patient, the frame’s tension had to be modified 1 week after surgery to reduce the distraction and restore the reduction. The patient’s postoperative course was uneventful. At the final follow-up, the Jamar grip strength on the injured side was 23 kg on average (range 9–55, SD 11), which was 78% of the uninjured side. Pinch strength was 7.6 kg on average (range 2–16, SD 3.1), which was 78% of the uninjured side. The Kapandji score was equal to that of the contralateral side in eight patients and was of one point less in seven patients (Fig. 5). Results are given in Table 1. All patients reported that they would undergo the same procedure again and that they would recommend it to others. 4. Discussion Fig. 5. Clinical result 2 months postoperatively (the left hand is the operated hand).
Rolando fractures are frequently seen in the hand surgery units, accounting for 9–21% of all fractures of the first
Table 1 Quantitative results of the 15 treated cases. Case
Age
Days to removal of frame
Follow-up (days)
Grip strength injured side (kg)
Grip strength uninjured side (kg)
Grip strength inj./uninj. side (%)
Key-pinch strength injured side (kg)
Key-pinch strength uninjured side (kg)
Key-pinch strength inj./uninj. side (%)
Kapandji score injured side (kg)
Kapandji score uninjured side (kg)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Average SD
34 19 56 55 39 18 43 23 33 86 57 55 22 29 36 40.3 18.8
32 35 38 36 34 32 33 28 38 27 31 35 35 32 41 33.8 3.7
95 35 294 98 186 81 92 59 70 73 72 56 35 102 77 95 65.5
21 19 20 21 11 24 21 55 28 9 12 25 20 36 25 23.1 11.1
28 25 18 32 15 39 27 62 31 11 17 24 38 48 32 29.8 13.2
75 76 111 66 73 62 78 89 90 82 71 104 53 75 78 78
10 8 6 8 9 10 7 8 12 2 6 6.5 10 8 16 8.4 3.1
13 11 6.5 14 10 18 9 12 12 3.5 4.5 7 10 11 20 10.7 4.5
77 73 92 57 90 56 78 67 100 57 133 93 100 73 80 78
9 10 10 9 10 9 9 10 9 8 8 9 8 10 9
9 10 10 10 10 10 10 10 9 9 10 9 9 10 10
Inj.: injured; uninj.: uninjured.
T. Giesen et al. / Hand Surgery and Rehabilitation 35 (2016) 335–340
metacarpal [2]. The main aim of surgical treatment is to achieve stable fixation that allows early mobilization and prevents stiffness of the carpometacarpal joint and the thumb in general. The fixation techniques in this bone segment mainly consist of plates and screws. However, internal fixation of very small intra-articular fragments is extremely difficult and has a high overall complication rate [11]. Different authors have suggested using static external fixation. Unlike Buchler et al., who used a quadrilateral fixator in 1991, more recent studies relied on a simple, unilateral fixator [9,10]. The main disadvantage of this system is that active mobilization of the thumb cannot be started right after surgery. A valid alternative was described by El-Sharkawy et al. in 2009: a dynamic external fixator that does not rely on rubber bands but uses three K-wires to control rotational forces [8]. Giesen et al. further attempted to modify and simplify the frame using only two K-wires [12]. The first clinical assessment in a single patient found no rotational deformities up to 3 months post-surgery. Risk of damage to the radial artery and the SBRN limits the percutaneous use of K-wires in this area. We observed temporary palsy of the SBRN in one patient. We have no specific suggestions to avoid this risk completely, however careful and slow insertion of the K-wires is key. There was no evidence of SBRN or radial artery damage in any other patient. Pin tract infection is a risk and this technique requires high patient compliance. In our study, this kind of dynamic external fixation proved to be stable enough to allow early mobilization with no further protection needed. This may be an additional advantage of this technique, as the minimal invasiveness and early rehabilitation may produce a lower rate of adhesions and joint stiffness compared to plate and screw fixation. The risk of extensor tendon adhesion and scarring seems to be minimized by the absence of a surgical incision and the absence of metal under the tendons. No patient in our study required tenolysis, however the follow-up was rather short. One patient, who healed with a 2 mm articular step-off, had a satisfactory outcome and did not require any further surgical procedures. We do not know if this was an isolated case or an indication of enhanced tolerance of this joint. The results of the current study are limited due to the rather short follow-up period in which long-term complications such as osteoarthritis cannot be detected. Further studies with longer follow-up periods are needed in order to assess potential long-term unfavorable events. However, as the amount of foreign material is minimal, especially when compared to open reduction and internal fixation with plates and screws, we assume that the rate of secondary osteoarthritis will be substantially lower when compared to previous studies that reported it in up to 70% of cases [16]. Abi et al. [17] published a technique that conceptually is close to the technique we described here. But in the Abi study, the amount of traction that can be applied to the base of the metacarpal to reduce the fragments in comminuted fractures is questionable. Furthermore, the movement of the first metacarpal could be restricted by transfixation between the first and second metacarpal.
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5. Conclusion Although open fixation with plate and screws of comminuted fractures of the base of the first metacarpal is stable and allows early mobilization, when small fragments are present, it can be extremely difficult to perform and can also cause tendon adhesions. Percutaneous fixation with K-wires is minimally invasive but is often followed by secondary displacement. It often requires some sort of immobilization. The modified Suzuki frame used in this study combines the advantages of both techniques. It is an effective, relatively simple, cost efficient, and minimally invasive technique that allows immediate mobilization of Rolando fractures. Funding The study was not funded by any organizations. No approval required from the local ethics committee. Disclosure of interest The authors declare that they have no competing interest. Acknowledgement We thank the Hand Therapy Department of the University Hospital of Zurich for their support in this study. References [1] Stanton JS, Dias JJ, Burke FD. Fractures of the tubular bones of the hand. J Hand Surg Eur Vol 2007;32:626–36. [2] Proubasta IR, Sanchez A. Rolando’s fracture: treatment by closed reduction and external fixation. Tech Hand Up Extrem Surg 2000;4:251–6. [3] Liverneaux PA, Ichihara S, Hendriks S, Facca S, Bodin F. Fractures and dislocation of the base of the thumb metacarpal. J Hand Surg Eur Vol 2015;40:42–50. [4] Foster RJ, Hastings 2nd H. Treatment of Bennett, Rolando, and vertical intraarticular trapezial fractures. Clin Orthop Relat Res 1987;214:121–9. [5] Gelberman RH, Vance RM, Zakaib GS. Fractures at the base of the thumb: treatment with oblique traction. J Bone Joint Surg Am 1979;61:260–2. [6] Buchler U, McCollam SM, Oppikofer C. Comminuted fractures of the basilar joint of the thumb: combined treatment by external fixation, limited internal fixation, and bone grafting. J Hand Surg [Am] 1991;16: 556–60. [7] Byrne AM, Kearns SR, Morris S, Kelly EP. S’’ Quattro external fixation for complex intra-articular thumb fractures. J Orthop Surg (Hong Kong) 2008;16:170–4. [8] El-Sharkawy AA, El-Mofty AO, Moharram AN, Abou Elatta MM, Asal F. Management of Rolando fracture by modified dynamic external fixation: a new technique. Tech Hand Up Extrem Surg 2009;13:11–5. [9] Marsland D, Sanghrajka AP, Goldie B. Static monolateral external fixation for the Rolando fracture: a simple solution for a complex fracture. Ann R Coll Surg Engl 2012;94:112–5. [10] Houshian S, Jing SS. Treatment of Rolando fracture by capsuloligamentotaxis using mini external fixator: a report of 16 cases. Hand Surg 2013;18:73–8. [11] Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg [Am] 1998;23:827–32. [12] Giesen T, Cardell M, Calcagni M. Modified Suzuki frame for the treatment of a difficult Rolando’s fracture. J Hand Surg Eur Vol 2012;37:905–7.
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[13] Suzuki Y, Matsunaga T, Sato S, Yokoi T. The pins and rubbers traction system for treatment of comminuted intraarticular fractures and fracturedislocations in the hand. J Hand Surg [Br] 1994;19:98–107. [14] Badia A, Riano F, Ravikoff J, Khouri R, Gonzalez-Hernandez E, Orbay JL. Dynamic intradigital external fixation for proximal interphalangeal joint fracture dislocations. J Hand Surg [Am] 2005;30:154–60. [15] Kapandji A. Clinical test of apposition and counter-apposition of the thumb. Ann Chir Main 1986;5:67–73.
[16] Brüske J, Bednarski M, Niedz´wiedz´ Z, Zyluk A, Grzeszewski S. The results of operative treatment of fractures of the thumb metacarpal base. Acta Orthop Belg 2001;67:368–73. [17] Adi M, Miyamoto H, Taleb C, Zemirline A, Gouzou S, Facca S, et al. Percutaneous fixation of first metacarpal base fractures using locked K-wires: a series of 14 cases. Tech Hand Up Extrem Surg 2014;18: 77–81.
ScienceDirect www.sciencedirect.com Hand Surgery and Rehabilitation 35 (2016) 335–340
Original article
Modified Suzuki frame for the treatment of difficult Rolando fractures Le cadre de Suzuki modifié pour le traitement des fractures de Rolando difficiles T. Giesen *, L. Neukom, R. Fakin, V. Beckamm-Fries, M. Calcagni Department of plastic surgery and hand surgery, university hospital Zurich, 100, Rämistrasse, 8006 Zurich, Switzerland Received 2 May 2016; received in revised form 17 July 2016; accepted 28 July 2016 Available online 15 September 2016
Abstract Fifteen consecutive patients with severely comminuted Rolando fractures were treated by closed reduction and fixation with a modified Suzuki frame without rubber bands, followed by immediate mobilization. All the fractures healed within 5 weeks. At 3 months, no rotational deformity was observed. The Kapandji score was equal that of the contralateral thumb in eight cases. No residual pain was recorded. Grip strength was 78% and pinch strength was 78% of the contralateral hand. One patient needed the frame tension modified. One patient developed a sensory deficit in the area of the superficial branch of the radial nerve that resolved spontaneously in 3 months. One patient healed with a 2-mm articular step-off, but the clinical outcome was good. Our retrospective study suggests that the small modification we made to the Suzuki frame provides a relatively simple and minimally invasive technique for the treatment of comminuted Rolando fractures. # 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved. Keywords: Suzuki frame; Rolando fracture; Intra-articular fracture of the hand; Dynamic fixation; Early mobilization
Résumé Quinze patients consécutifs soufrant de sévères fractures comminutives de Rolando ont été traités par réduction à foyer fermé, avec le cadre de Suzuki modifié sans bandes élastiques et avec une mobilisation immédiate. Toutes les fractures ont consolidé dans les cinq semaines. À trois mois, aucune déformation rotatoire n’a été observée. Dans huit cas, le score de Kapandji était identique à celui du pouce controlatéral. Aucune douleur résiduelle n’a été rapportée. La force de préhension était de 78 % et la force de pince 78 % de celle de la main controlatérale. La tension du cadre a dû être modifiée pour un patient. Un autre a développé un déficit sensitif dans le territoire du rameau superficiel du nerf radial ayant régressé spontanément dans les trois mois. Un dernier a guéri avec une marche d’escalier intra-articulaire de 2 mm mais avec un bon résultat clinique. Notre étude rétrospective suggère qu’une légère modification du cadre de Suzuki, telle que nous l’avons utilisée, est une technique relativement simple et minimalement invasive pour le traitement des fractures comminutives de Rolando. # 2016 SFCM. Publié par Elsevier Masson SAS. Tous droits réservés. Mots clés : Cadre de Suzuki ; Fracture de Rolando ; Fracture intra-articulaire de la main ; Fixation dynamique ; Mobilisation précoce
1. Introduction Fractures of the base of the first metacarpal account for 4% of all hand fractures [1]. About 9–21% of those are Rolando fractures [2] with variable comminution. A variety of
* Corresponding author. E-mail address: [email protected] (T. Giesen).
treatments have been described in literature, depending on the degree of comminution. The surgical approach and final outcome depend greatly on the fracture pattern and articular surface involvement, and how well the latter is restored if damaged [3]. For non-comminuted or slightly comminuted intra-articular fractures, the prevailing fixation techniques rely on plates and screws [4]. However, there is no consensus on the treatment of profoundly comminuted Rolando fractures with fragments too
http://dx.doi.org/10.1016/j.hansur.2016.07.006 2468-1229/# 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved.
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T. Giesen et al. / Hand Surgery and Rehabilitation 35 (2016) 335–340
small to qualify for this type of internal fixation. Alternative techniques have been described for these specific cases [5–10]. Despite technical advances in plate design and instrumentation, including lower-profile titanium plates, complications occur commonly with plate fixation of metacarpal fractures. Furthermore, plate fixation often requires tenolysis and plate removal in metacarpal fractures [11]. We previously reported the preliminary results of a single patient with a Rolando fracture [12] treated with a slightly modified Suzuki frame [8,13,14]. The current study is the first ever published series evaluating outcome in patients operated using this novel surgical technique.
was performed and fixation was maintained with a modified Suzuki frame that consisted of one 1.6 mm and one 1.5 mm Kwire, but no rubber bands. The 1.6-mm K-wire was passed from palmar-radial to dorsal-ulnar through the trapezium at 908 to the axis of the metacarpal bone, with the wrist in 08 extension. The 1.5-mm K-wire was passed through the head of the first metacarpal bone, parallel to the previous wire (Fig. 1A). To hook the distal K-wire on the proximal one, the frame was constructed with a dorsal to palmar S shape in order to avoid a contact between the frame and skin when the thumb was flexed (Figs. 1(B and C)–3). The operative time was recorded in all cases.
2. Patients and methods
2.3. Postoperative care
2.1. Patients
The patients were encouraged to move the thumb immediately and began a controlled active mobilization regimen without splinting within one week after the procedure.
From July 2012 to November 2015, 15 adult patients with a Rolando fracture having variable displacement and severe comminution were referred to our hand surgery department. Open fractures and complex traumas such as amputations, subtotal amputations and crush injuries were excluded from the study. Thirteen patients were men and two were women, with an average age of 40 years (range 18–86 years, SD 19.1). Eight fractures involved the dominant hand and seven the non-dominant hand. The histories given by the patients included a fall onto the hand in 11 cases, direct trauma in 3 cases and polytrauma with an unclear mechanism of the injury in 1 case. The mean time from injury to the surgical treatment was 3.5 days (range 1–10 days, SD 2.1). The surgical treatment was discussed with the patient at the time of arrival and a modified Suzuki frame was proposed as a fixation strategy to all patients. New anterior-posterior (AP), oblique and lateral (LL) plain digital X-rays were taken in all cases prior to surgery. 2.2. Surgical technique We used a modified Suzuki frame as previously described by Giesen et al. [12]. All procedures were performed by the same surgeon. Anesthesia was based on the patient’s preference and/or need to surgically repair other injuries in polytrauma patients. Regional anesthesia was used in five cases, general anesthesia in six cases and local anesthesia in four cases. Closed reduction
2.4. Postoperative follow-up All patients underwent their first clinical and radiological follow-up within 1 week of the surgery to verify the amount of distraction across the fracture and if necessary, modify it by changing the curvature of the frame’s arms. In two cases, a CT-scan of the thumb 2 weeks post-surgery with the frame in place was performed in order to verify joint congruity (Fig. 4). The next follow-up was planned at 5 weeks postoperative (mean 33.8 days, range 27–41 days, SD 3.7). At this point, if bone union was visible on the radiographs, the K-wires were removed in an ambulatory setting without anesthesia. Follow-up was planned for all patients at a minimum of 3 months postoperative (mean 95 days, range 35–294 days, SD 66). All patients were seen by the surgeon at each follow-up. X-ray views were taken in a standardized manner to measure any postoperative articular step-off. 2.5. Assessment At each follow-up, function of the affected thumb was measured using the Kapandji score [15] and was compared to the contralateral side. Grip strength (Jamar Dynamometer position 2) and pinch strength were also recorded and compared to the uninjured thumb.
Fig. 1. Drawing of surgical technique (palmar view) showing the scaphoid (1) and the insertion of the proximal (2) and distal (3) K-wires (A). Bending of K-wires to hook the distal K-wire on the proximal K-wire (B and C).
T. Giesen et al. / Hand Surgery and Rehabilitation 35 (2016) 335–340
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Fig. 2. Rolando fracture with small comminution (A and B). Intraoperative view of the modified Suzuki frame (C and D).
Patients were assessed for early postoperative complications such as inadequate fixation, loss of reduction with formation of articular step-off, malrotation, infection and K-wire migration. Late complications such as rotational deformity, delayed union or tendon adhesions were also recorded. 3. Results
Fig. 3. The clinical appearance of the frame in the same patient as Fig. 2 who is performing active opposition: contact between the frame’s bars and the skin only occurs in full thumb opposition.
All fractures healed and the K-wires were removed after a mean of 33.8 days (range 27–41 days, SD 3.7). No evidence of inadequate fixation, loss of reduction, early or late rotational deformity or delayed fracture union was found. There were no articular step-offs of more than 1 mm on the final X-rays except for one case with a consolidated 2 mm stepoff. This patient did not require any further surgery and was pain free at the last follow-up with a Kapandji score of 8/9. This patient’s grip strength was 20 kg in the operated hand and 38 kg in the contralateral hand. Pinch strength was 10 kg vs. 10 kg for the contralateral side. Slight lateral migration of the proximal K-wires was observed in two patients. Two patients had a superficial pin site infection, which was successfully treated with a 1-week course of oral antibiotics. One patient had a slight form of neurapraxia of the superficial branch of the radial nerve (SBRN), which resolved spontaneously within 3 months.
T. Giesen et al. / Hand Surgery and Rehabilitation 35 (2016) 335–340
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Fig. 4. CT-scan 2 weeks after the surgery to exclude the presence of articular step-offs (A and B). Bone healing 5 weeks post-surgery (C).
In one patient, the frame’s tension had to be modified 1 week after surgery to reduce the distraction and restore the reduction. The patient’s postoperative course was uneventful. At the final follow-up, the Jamar grip strength on the injured side was 23 kg on average (range 9–55, SD 11), which was 78% of the uninjured side. Pinch strength was 7.6 kg on average (range 2–16, SD 3.1), which was 78% of the uninjured side. The Kapandji score was equal to that of the contralateral side in eight patients and was of one point less in seven patients (Fig. 5). Results are given in Table 1. All patients reported that they would undergo the same procedure again and that they would recommend it to others. 4. Discussion Fig. 5. Clinical result 2 months postoperatively (the left hand is the operated hand).
Rolando fractures are frequently seen in the hand surgery units, accounting for 9–21% of all fractures of the first
Table 1 Quantitative results of the 15 treated cases. Case
Age
Days to removal of frame
Follow-up (days)
Grip strength injured side (kg)
Grip strength uninjured side (kg)
Grip strength inj./uninj. side (%)
Key-pinch strength injured side (kg)
Key-pinch strength uninjured side (kg)
Key-pinch strength inj./uninj. side (%)
Kapandji score injured side (kg)
Kapandji score uninjured side (kg)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Average SD
34 19 56 55 39 18 43 23 33 86 57 55 22 29 36 40.3 18.8
32 35 38 36 34 32 33 28 38 27 31 35 35 32 41 33.8 3.7
95 35 294 98 186 81 92 59 70 73 72 56 35 102 77 95 65.5
21 19 20 21 11 24 21 55 28 9 12 25 20 36 25 23.1 11.1
28 25 18 32 15 39 27 62 31 11 17 24 38 48 32 29.8 13.2
75 76 111 66 73 62 78 89 90 82 71 104 53 75 78 78
10 8 6 8 9 10 7 8 12 2 6 6.5 10 8 16 8.4 3.1
13 11 6.5 14 10 18 9 12 12 3.5 4.5 7 10 11 20 10.7 4.5
77 73 92 57 90 56 78 67 100 57 133 93 100 73 80 78
9 10 10 9 10 9 9 10 9 8 8 9 8 10 9
9 10 10 10 10 10 10 10 9 9 10 9 9 10 10
Inj.: injured; uninj.: uninjured.
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metacarpal [2]. The main aim of surgical treatment is to achieve stable fixation that allows early mobilization and prevents stiffness of the carpometacarpal joint and the thumb in general. The fixation techniques in this bone segment mainly consist of plates and screws. However, internal fixation of very small intra-articular fragments is extremely difficult and has a high overall complication rate [11]. Different authors have suggested using static external fixation. Unlike Buchler et al., who used a quadrilateral fixator in 1991, more recent studies relied on a simple, unilateral fixator [9,10]. The main disadvantage of this system is that active mobilization of the thumb cannot be started right after surgery. A valid alternative was described by El-Sharkawy et al. in 2009: a dynamic external fixator that does not rely on rubber bands but uses three K-wires to control rotational forces [8]. Giesen et al. further attempted to modify and simplify the frame using only two K-wires [12]. The first clinical assessment in a single patient found no rotational deformities up to 3 months post-surgery. Risk of damage to the radial artery and the SBRN limits the percutaneous use of K-wires in this area. We observed temporary palsy of the SBRN in one patient. We have no specific suggestions to avoid this risk completely, however careful and slow insertion of the K-wires is key. There was no evidence of SBRN or radial artery damage in any other patient. Pin tract infection is a risk and this technique requires high patient compliance. In our study, this kind of dynamic external fixation proved to be stable enough to allow early mobilization with no further protection needed. This may be an additional advantage of this technique, as the minimal invasiveness and early rehabilitation may produce a lower rate of adhesions and joint stiffness compared to plate and screw fixation. The risk of extensor tendon adhesion and scarring seems to be minimized by the absence of a surgical incision and the absence of metal under the tendons. No patient in our study required tenolysis, however the follow-up was rather short. One patient, who healed with a 2 mm articular step-off, had a satisfactory outcome and did not require any further surgical procedures. We do not know if this was an isolated case or an indication of enhanced tolerance of this joint. The results of the current study are limited due to the rather short follow-up period in which long-term complications such as osteoarthritis cannot be detected. Further studies with longer follow-up periods are needed in order to assess potential long-term unfavorable events. However, as the amount of foreign material is minimal, especially when compared to open reduction and internal fixation with plates and screws, we assume that the rate of secondary osteoarthritis will be substantially lower when compared to previous studies that reported it in up to 70% of cases [16]. Abi et al. [17] published a technique that conceptually is close to the technique we described here. But in the Abi study, the amount of traction that can be applied to the base of the metacarpal to reduce the fragments in comminuted fractures is questionable. Furthermore, the movement of the first metacarpal could be restricted by transfixation between the first and second metacarpal.
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5. Conclusion Although open fixation with plate and screws of comminuted fractures of the base of the first metacarpal is stable and allows early mobilization, when small fragments are present, it can be extremely difficult to perform and can also cause tendon adhesions. Percutaneous fixation with K-wires is minimally invasive but is often followed by secondary displacement. It often requires some sort of immobilization. The modified Suzuki frame used in this study combines the advantages of both techniques. It is an effective, relatively simple, cost efficient, and minimally invasive technique that allows immediate mobilization of Rolando fractures. Funding The study was not funded by any organizations. No approval required from the local ethics committee. Disclosure of interest The authors declare that they have no competing interest. Acknowledgement We thank the Hand Therapy Department of the University Hospital of Zurich for their support in this study. References [1] Stanton JS, Dias JJ, Burke FD. Fractures of the tubular bones of the hand. J Hand Surg Eur Vol 2007;32:626–36. [2] Proubasta IR, Sanchez A. Rolando’s fracture: treatment by closed reduction and external fixation. Tech Hand Up Extrem Surg 2000;4:251–6. [3] Liverneaux PA, Ichihara S, Hendriks S, Facca S, Bodin F. Fractures and dislocation of the base of the thumb metacarpal. J Hand Surg Eur Vol 2015;40:42–50. [4] Foster RJ, Hastings 2nd H. Treatment of Bennett, Rolando, and vertical intraarticular trapezial fractures. Clin Orthop Relat Res 1987;214:121–9. [5] Gelberman RH, Vance RM, Zakaib GS. Fractures at the base of the thumb: treatment with oblique traction. J Bone Joint Surg Am 1979;61:260–2. [6] Buchler U, McCollam SM, Oppikofer C. Comminuted fractures of the basilar joint of the thumb: combined treatment by external fixation, limited internal fixation, and bone grafting. J Hand Surg [Am] 1991;16: 556–60. [7] Byrne AM, Kearns SR, Morris S, Kelly EP. S’’ Quattro external fixation for complex intra-articular thumb fractures. J Orthop Surg (Hong Kong) 2008;16:170–4. [8] El-Sharkawy AA, El-Mofty AO, Moharram AN, Abou Elatta MM, Asal F. Management of Rolando fracture by modified dynamic external fixation: a new technique. Tech Hand Up Extrem Surg 2009;13:11–5. [9] Marsland D, Sanghrajka AP, Goldie B. Static monolateral external fixation for the Rolando fracture: a simple solution for a complex fracture. Ann R Coll Surg Engl 2012;94:112–5. [10] Houshian S, Jing SS. Treatment of Rolando fracture by capsuloligamentotaxis using mini external fixator: a report of 16 cases. Hand Surg 2013;18:73–8. [11] Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg [Am] 1998;23:827–32. [12] Giesen T, Cardell M, Calcagni M. Modified Suzuki frame for the treatment of a difficult Rolando’s fracture. J Hand Surg Eur Vol 2012;37:905–7.
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[13] Suzuki Y, Matsunaga T, Sato S, Yokoi T. The pins and rubbers traction system for treatment of comminuted intraarticular fractures and fracturedislocations in the hand. J Hand Surg [Br] 1994;19:98–107. [14] Badia A, Riano F, Ravikoff J, Khouri R, Gonzalez-Hernandez E, Orbay JL. Dynamic intradigital external fixation for proximal interphalangeal joint fracture dislocations. J Hand Surg [Am] 2005;30:154–60. [15] Kapandji A. Clinical test of apposition and counter-apposition of the thumb. Ann Chir Main 1986;5:67–73.
[16] Brüske J, Bednarski M, Niedz´wiedz´ Z, Zyluk A, Grzeszewski S. The results of operative treatment of fractures of the thumb metacarpal base. Acta Orthop Belg 2001;67:368–73. [17] Adi M, Miyamoto H, Taleb C, Zemirline A, Gouzou S, Facca S, et al. Percutaneous fixation of first metacarpal base fractures using locked K-wires: a series of 14 cases. Tech Hand Up Extrem Surg 2014;18: 77–81.