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Pins and Rubber Band Traction for Treatment of Comminuted Intra-Articular Fractures in the Hand
SCIENTIFIC ARTICLE
Pins and Rubber Band Traction for Treatment of Comminuted Intra-Articular Fractures in the Hand Ahmet Kiral, MD, H. Yener Erken, MD, Ibrahim Akmaz, MD, Cengiz Yildirim, MD, Kaan Erler, MD
Purpose To determine the efficacy of pins and rubber band traction for treatment of comminuted intra-articular fractures in the hand. Methods We performed a retrospective study from 1994 to 2013 to evaluate 33 patients in whom pins and rubber band traction was employed. We clinically evaluated the active range of motion of the affected fingers after surgery. Eleven of the 33 fractures were at the proximal interphalangeal joint, 10 at the distal interphalangeal joint, 5 at the thumb interphalangeal joint, and 2 at the metacarpophalangeal joint of the thumb. The remaining 5 patients had complex fracture-dislocation of the proximal interphalangeal joints. Results The mean follow-up period was 24 months. The average active motion of the metacarpophalangeal joints of the fingers was 91 (range, extension 0 e10 /flexion 85 e90 ), proximal interphalangeal joints was 92 (range, extension/flexion 0 e10 /85 e100 ), and distal interphalangeal joints was 73 (range, extension/flexion 0 e10 /60 e80 ). The overall average of all active motion of the injured fingers except thumbs was 255 (range, 240 e270 ). The average active motion of the of the thumb metacarpophalangeal joint was 56 (range, extension 5 e10 /flexion 50 e55 ), and interphalangeal joint was 74 (range, extension 0 e10 /flexion 75 e80 ). The average of active motion of the injured thumb metacarpal and interphalangeal joints combined was 130 (range, 125 e135 ). Conclusions Pins and rubber band traction is a treatment option for comminuted displaced intra-articular fractures of the digits that offers satisfactory clinical results. (J Hand Surg Am. 2014;39(4):696e705. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Pins and rubber band traction, intra-articular fractures, hand.
A
normal anatomy and permits early active joint motion and tendon gliding is necessary to obtain optimal results for treatment of comminuted displaced TECHNIQUE THAT RESTORES THE
From the Department of Orthopaedic Surgery, Anadolu Medical Center, Kocaeli; and the Department of Orthopaedic Surgery, GATA Haydarpas¸a Education Hospital, Istanbul, Turkey. Received for publication September 16, 2013; accepted in revised form December 27, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: H. Yener Erken, MD, Department of Orthopaedic Surgery, Anadolu Medical Center, Cumhuriyet Mahallesi 2255 Sokak No. 3 Gebze 41400, Kocaeli, Turkey; e-mail: [email protected]. 0363-5023/14/3904-0013$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.12.038
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intra-articular fractures of the digits.1 Various distal traction systems that combine traction with early motion can be used to reposition the fragments. These systems aim to reduce fracture fragments by ligamentotaxis while preventing joint stiffness.2e4 The banjo frame is effective but bulky and uncomfortable to wear.2,4 Recently, light, straightforward, and effective systems such as the force couple splint, various dynamic external fixator systems, and the pins and rubber band traction have been reported.1e3,5e8 Pins and rubber band traction described by Suzuki et al5 is one of these systems and offers several advantages. The goal of this study was to determine the efficacy of pins and rubber band traction that we used for
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FIGURE 1: A London classification for proximal and middle phalanx condylar fractures. B Seno classification for middle phalanx base fractures.
treatment of comminuted intra-articular fractures in the hand.
male. The mean age of the patients was 23 years (range, 16e57 y). The mean follow-up period was 24 months (range, 12e72 mo).
MATERIALS AND METHODS After obtaining institutional review board approval, we performed a retrospective study on patients who had operative treatment between 1994 and 2013 for comminuted intra-articular fractures and fracturedislocations in the hand. We employed pins and rubber band traction, described by Suzuki et al,5 in all 33 patients. We used the London classification9 for the proximal and middle phalanx condylar fractures of the fingers and the Seno classification10 for the middle phalanx base fractures of the in order to evaluate them radiologically (Fig. 1). We also used the London classification for the proximal phalanx condylar fractures of the thumb. All of the clinical and radiological findings were evaluated retrospectively. We evaluated the active motion of the affected fingers with a goniometer. The mean interval between the injury and the time of the operation was 5 days (range, 1e20 d). Eleven of 33 fractures were at the proximal interphalangeal (PIP) joint, 10 were at the distal interphalangeal (DIP) joint, 5 were at the thumb interphalangeal (IP) joint, and 2 were at the thumb metacarpophalangeal (MCP) joint. The remaining 5 patients had complex fracturedislocation of the PIP joint, which were classified as Seno type 1 fractures (Table 1). A modified pins and rubber band traction technique was used for these 5 patients. Six of the patients had open fractures that were clean with less than 1 cm skin open wounds. The others had closed fractures. The etiologies of the injuries were from falling (17), direct blow (7), crush injury (8), and a gunshot (1). All of the patients were J Hand Surg Am.
Surgical technique We used the technique described by Suzuki et al5 in all patients as outpatients and under digital block anesthesia. We inserted a long Kirschner wire (1.2 mm in diameter) transversely through the injured or adjoining phalanx proximal to the injury (axial traction pin) (Fig. 2). The wire was bent 90 near the skin on both sides of the finger in the direction of the fingertip. Each end of the wire was long enough to reach about 3 cm distal to the fingertip. The ends were bent into hooks with needle nose pliers. A second Kirschner wire (1 mm in diameter) was inserted transversely through the injured or adjoining phalanx distal to the injury (hook pin). We placed a hook bend into each end of the hook pin just external to the skin. Both Kirschner wires needed to be placed in the coronal plane of the finger; otherwise a rotational deformity of the finger would occur. The rubber bands were placed between the pins 2 hours after the effects of the digital block anesthesia had worn off. The rubber bands were wrapped around the pins until the patient noted tension in the finger. X-rays were taken 1 hour and 24 hours after placement of the rubber bands. For the size and strength we sought, we used Universal brand rubber bands in size 32 (UNV00132, Universal, Thailand). The rubber bands had to be thin enough to wrap around the pins several times and strong enough to hold the tension once wrapped. As for the brand, they had to be readily available in case we needed more. Depending on the status of the reduction of the fractures noted radiographically, the tension on the finger was either increased or decreased by increasing r
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TABLE 1.
Summary of Patient Data and Results
Finger or Thumb
LOF
SOI
Classification
Sytem Used
Age (y)/Sex
DOI
DOT
Follow-Up (mo)
MCP ROM ( ) Ext/Flex
PIP ROM ( ) Ext/Flex
DIP ROM ( ) Ext/Flex
IP ROM ( ) Ext/Flex
Total ROM ( ) Ext/Flex
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Finger Middle phalanx base
R middle PIP
Seno 1
Modified
21/M
17
7
15
0/90
0/100
0/80
270
2
Finger Middle phalanx base
R middle PIP
Seno 1
Modified
23/M
14
7
14
0/90
0/100
0/80
270
3
Finger Middle phalanx base
R index PIP
Seno 1
Modified
25/M
1
7
22
0/90
10/85†
0/75
240
4
Finger Middle phalanx base
L index PIP
Seno 1
Modified
20/M
5
6
17
0/85
5/85†
0/75
240
5
Finger Middle phalanx base
L little PIP
Seno 1
Modified
34/M
11
5
18
0/90
5/100†
0/80
265
6
Finger Middle phalanx base
L little PIP
Seno 2
Original
57/M
2
6
20
þ10/90*
0/95
0/75
270
7
Finger Middle phalanx base
R index PIP
Seno 2
Original
16/M
2
4
60
þ10/85*
5/95†
0/80
265
8
Finger Middle phalanx base
L little PIP
Seno 3
Original
33/M
1
5
16
0/85
10/100†
0/75
250
9
Finger Middle phalanx base
L index PIP
Seno 3
Original
21/M
1
6
16
0/90
5/90†
0/75
250
10
Finger Middle phalanx base
R ring PIP
Seno 3
Original
20/M
5
6
72
þ10/85*
5/90†
0/75
255
11
Finger Proximal phalanx condylar
R little PIP
London 2
Original
18/M
1
5
16
þ10/90*
0/95
0/75
270
12
Finger Proximal phalanx condylar
L ring PIP
London 3
Original
21/M
20
6
16
0/90
10/90
0/80
260
13
Finger Proximal phalanx condylar
R index PIP
London 3
Original
21/M
1
5
16
0/90
5/95†
0/75
255
14
Finger Proximal phalanx condylar
R little PIP
London 3
Original
21/M
1
5
16
þ5/90*
0/85
0/65
245
15
Finger Proximal phalanx condylar
L index PIP
London 3
Original
21/M
1
8
16
þ5/90*
0/80
0/75
250
(Continued)
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1
TABLE 1.
No.
Summary of Patient Data and Results (Continued)
Finger or Thumb
LOF
SOI
Classification
Sytem Used
Age (y)/Sex
DOI
DOT
Follow-Up (mo)
MCP ROM ( ) Ext/Flex
PIP ROM ( ) Ext/Flex
DIP ROM ( ) Ext/Flex
IP ROM ( ) Ext/Flex
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Finger Proximal phalanx condylar
L little PIP
London 3
Original
33/M
2
4
24
0/90
0/95
260
17
Finger Middle phalanx condylar
L ring DIP
London 2
Original
21/M
9
6
18
0/85
0/100
10/75†
250
18
Finger Middle phalanx condylar
R ring DIP
London 3
Original
21/M
1
6
22
0/90
0/100
10/80†
260
19
Finger Middle phalanx condylar
R ring DIP
London 3
Original
21/M
4
6
20
0/90
0/90
10/75†
245
20
Finger Middle phalanx condylar
R index DIP
London 3
Original
20/M
13
8
17
21
Finger Middle phalanx condylar
L middle DIP
London 3
Original
20/M
3
6
15
22
Finger Middle phalanx condylar
R middle DIP
London 3
Original
21/M
1
6
23
Finger Middle phalanx condylar
L ring DIP
London 3
Original
21/M
3
24
Finger Middle phalanx condylar
R ring DIP
London 3
Original
21/M
25
Finger Middle phalanx condylar
R little DIP
London 3
Original
26
Finger Middle phalanx condylar
L ring DIP
London 3
27
Thumb Proximal phalanx condylar
L thumb IP
28
Thumb Proximal phalanx condylar
29 30
0/95
0/65
250
0/90
0/100
5/85†
270
16
0/90
0/95
5/60†
240
7
12
0/90
0/100
10/80†
260
1
6
21
0/85
0/95
5/65†
240
21/M
10
6
15
0/90
0/95
0/70
255
Original
21/M
1
4
17
0/90
0/100
5/80†
265
London 3
Original
21/M
1
7
18
þ5/50*
-
-
0/75
130
L thumb IP
London 3
Original
21/M
1
8
36
0/55
-
-
5/75†
125
Thumb Proximal phalanx condylar
L thumb IP
London 3
Original
21/M
10
8
19
þ5/55*
-
-
10/80†
130
Thumb Proximal phalanx condylar
R thumb IP
London 3
Original
21/M
3
6
48
þ10/55*
-
-
5/75†
135
THE PINS AND RUBBER BAND TRACTION SYSTEM
J Hand Surg Am.
16
þ10/90*
0/75
Total ROM ( ) Ext/Flex
(Continued)
699
700
-
0/80
130
or decreasing the number of times the rubber band was wrapped around the axial traction pin and the hook pin. We used the same type of rubber band in all cases. The radiological evaluation determined the degree of tension. In the x-rays taken 1 hour later after placement of the rubber bands, we usually observed either an underdistraction or an overdistraction. We defined a distraction of more than 1 mm between the distal and the proximal fragments after application of the rubber bands as overdistraction. After the first adjustment of the tension on the rubber bands, proper reduction was generally achieved. For fracture-dislocations of the PIP joints, a third type pin, the “reduction pin,” was inserted through the base of the displaced middle phalanx. It was placed volar to the proximal pin in order to create a volarly directed reduction force. The ends of this pin were bent upward (Fig. 3). This modified pins and rubber band traction allowed early active motion of the PIP joint as well. Figures 4 and 5 demonstrate different configurations of the system according to the fracture site. We applied the same pins and rubber band traction for fractures of the thumb IP and MCP joints.
DOI, days from injury to operation; DOT, duration of traction (wk); Ext, extension; Flex, flexion; LOF, location of the fracture; SOI, site of the injury. *Plus (þ) degrees mean hyperextension of active joint extensions. †Minus () degrees mean restriction of active joint extensions.
0/50 6 L thumb MCP Thumb Proximal phalanx base 33
Original
18/M
9
72
125 0/80 6 L thumb MCP Thumb Proximal phalanx base 32
Original
26/M
5
36
5/50†
-
135 10/80† þ10/55* 17 6 1 Original London 3 R thumb IP Thumb Proximal phalanx condylar 31
Classification SOI LOF No.
21/M
DOT DOI Age (y)/Sex Sytem Used Finger or Thumb
Summary of Patient Data and Results (Continued) TABLE 1.
-
Total ROM ( ) Ext/Flex PIP ROM ( ) Ext/Flex Follow-Up (mo)
MCP ROM ( ) Ext/Flex
DIP ROM ( ) Ext/Flex
IP ROM ( ) Ext/Flex
THE PINS AND RUBBER BAND TRACTION SYSTEM
Postoperative care We used a light dressing around the Kirschner wires to avoid any disturbance of the active motion. Active motion of the affected finger was started immediately after the procedure under the control of a skilled hand therapist. Patients were educated about pin-site care by self-application of antibiotic ointment using a cotton applicator twice a day. X-rays were obtained 1 and 2 weeks after the operation to check reduction; tension on the rubber bands was adjusted as needed. A static night splint was used to protect the mechanism while the patient was asleep. We removed the traction device at 4 to 8 weeks after surgery after we obtained radiographic confirmation of fracture union. After termination of the traction device, patients continued therapy for 3 to 6 more weeks. We checked the patients 4 and 6 weeks and 3 and 6 months after surgery with clinical and radiological examinations. RESULTS We obtained anatomical union in all patients. Malunion, pin-track infection, and osteomyelitis were not seen. Although we detected a lateral shift of the frame in 5 patients in the first postoperative week, we successfully realigned the pins under a digital block anesthesia while confirming the proper reduction of the fracture under fluoroscopy. J Hand Surg Am.
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FIGURE 4: Application of pins and rubber band traction for middle phalanx condylar fractures.
FIGURE 2: The pins and rubber band traction consists of (a) axial traction pin, (b) hook pin, and (c) rubber band.
FIGURE 5: Application of pins and rubber band traction for proximal phalanx condylar fractures.
FIGURE 3: Modified system; the reduction pin is placed volar to the proximal pin in order to create a volarly directed reduction force. The axial traction pin suppresses the reduction pin to reduce the displaced fragment.
At the completion of treatment, the average active motion of the MCP joints of the fingers was 91 (range, extension 0 e10 /flexion 85 e90 ). The average active motion of the PIP joints was 92 (range, extension/flexion 0 e10 /85 e100 ). The average active motion of the DIP joints was 73 (range, extension/flexion 0 e10 /60e80 ). The overall average of all active range of motion (ROM) of the injured fingers except thumbs was 255 (range,
There were PIP joint contractures, average of 29 (range, 15 e50 ), in 7 patients and DIP joint contractures, average 22 (range, 15 e30 ), in 3 patients. With an intensive therapy program, these joint contractures resolved after an average of 36 days of physical therapy (range, 20e60 d). J Hand Surg Am.
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FIGURE 6: A A 21-year-old man (case 18 in Table 1) with a right ring finger middle phalanx London type 3 condylar fracture. B, C The healed fracture 6 weeks and 6 months after surgery, respectively.
240 e270 ). The average active motion of the MCP joints of the thumbs was 56 (range, extension 5 e10 /flexion 50 e55 ). The average active motion of the IP joints of the thumbs was 74 (range, extension 0 e10 /flexion 75 e80 ). The overall average of all active ROM of the injured thumbs was 130 (range, 125 e135 ). The radiological and clinical outcomes of 2 patients (cases 8 and 18 in Table 1) are shown in Figures 6 and 7.
delayed arthrodesis and resorption at the fracture site owing to disrupted blood supply during the open reduction and rigid internal fixation of the intra-articular fractures. Distraction uses ligamentotaxis to provide reduction and has been reported to provide satisfactory results. Various traction systems have been used to treat these fractures.1e7 Agee1 developed the force couple splint, which uses phalangeal Kirschner wires to provide a volar reduction force on the base of the middle phalanx. This technique does not provide traction and ligamentotaxis and cannot be used for comminuted fractures with a loss of dorsal buttress. The rhomboid bilateral spring-loaded external fixator developed by Inanami et al2 provides distraction and places a volardirected force on the base of the middle phalanx to maintain reduction of the PIP joint. These systems, designed for unstable fracture-dislocations of the PIP joint, are similar to but more complicated than the Suzuki frame.13 Although these systems are effective and straightforward, they can be applied only on PIP joint fractures. The Compass Hinge fixator (Smith & Nephew, Memphis, TN), developed by Kasparyn and Hotchkiss,16 is designed to be applied after primary reconstruction in order to allow early controlled PIP joint motion. It is a radiolucent unilateral hinged external fixator, which maintains stability of the joint and has a worm gear to provide controlled passive motion. This gear can be disengaged to allow active mobilization. Hastings and Ernst3 reported the use of a bilateral external fixator, which has a pin at the anatomical axis of the proximal phalanx and 2 pins in the middle phalanx. This fixator provides distraction
DISCUSSION Comminuted intra-articular fractures or fracturedislocations of digits can be problematic. Pain, joint stiffness, instability, and degenerative arthritis are common outcomes of comminuted displaced intraarticular fractures and fracture-dislocations of the PIP joint.11 Although literature suggests various modalities for treatment of these injuries, open reduction and internal fixation12 or distraction-mobilization seem to be the most valuable options because both methods allow early mobilization of the joint. Open reduction and internal fixation generally produces satisfactory results in cases of 2-part large fracture fragments, which are rare. Dissection of soft tissue around the joint may deprive smaller fragments of their blood supply and increase the risk of joint stiffness and functional impairment resulting from the injury.13 Lubahn and Hood14 recommended open reduction and fixation with Kirschner wires for distal intra-articular fractures of the middle phalanx including the DIP joint, and they also reported the need for DIP joint arthrodesis for cases that developed joint stiffness. Brennwald15 reported the possibility of J Hand Surg Am.
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FIGURE 7: A, B A 33-year-old man (case 8 in Table 1) with a left little finger middle phalanx Seno type 3 base fracture. C, D The reduction of the fracture after application of pins and rubber band traction. E, F The healed fracture before the pins and rubber band traction system is removed 5 weeks after surgery. G, H The radiological outcomes of the healed fracture at 2 years after surgery.
and allows some correction of the instability while providing isometric mobilization. All systems mentioned previously are compact and designed for unstable fracture-dislocations of the PIP joint. Another system, which can be applied to all types of displaced fracture-dislocations of the digits while allowing range of active motion, is the S Quattro device, which does not apply continuous elastic traction.17 Pins and rubber band traction is applicable not only to phalangeal injuries but also to carpal injuries. Suzuki et al5 have used it to treat an intra-articular comminuted fracture of the DIP joint and a comminuted fracture of the trapezium. Although the anatomy and deforming forces on the thumb are different from those of the fingers, the literature supports the use of pins and rubber band traction on thumbs. De Soras et al18 used pins and rubber band traction to treat similar injuries and, at the end of their discussion, stated that the system can also be used for thumb IP joints and DIP joints, but J Hand Surg Am.
they did not offer any clinical examples. Keramidas and Miller19 applied pins and rubber band traction at the IP joint of the thumb in 5 patients and achieved satisfactory clinical outcomes. Pins and rubber band traction has several advantages. It is straightforward and includes only 2 or 3 Kirschner wires and rubber bands. The diameter of the wires is small and does not interfere with radiological imaging. This system also allows early active motion of the injured joint. Suzuki et al5 explained that, despite the limitation of active motion, the results could still be deemed satisfactory because even the slightest ROM may stimulate the nutrition and remodeling of the joint surface and prevent intraarticular adhesions and capsuloligamentous contracture of the joint. Agarwal et al8 reported the common pitfalls of pins and rubber band traction application. They described the proper location of the axial traction pin as the center of the head of the proximal phalanx, which corresponds to the rotation axis of the r
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THE PINS AND RUBBER BAND TRACTION SYSTEM
PIP joint and is perpendicular to the long axis of the ray. They also suggested observing the PIP joint flexion under fluoroscopy to ensure subluxation does not occur. Recently, Debus et al20 reported poorer outcomes of PIP joint intra-articular fractures treated by means of pins and rubber band traction in a series of 15 patients with a minimum of 2 years follow-up. They evaluated the reasons behind the poorer outcomes of some of the patients treated with this system and performed a literature review showing an average of 78 of active PIP joint motion (range, 64 e95 ). Their mean active motion was 56 (range, 0 e95 ), which was lower than that reported in the literature. They stated the reasons for this difference was due to preoperative delay, technical deficiencies, the learning curve, a lack of postoperative physiotherapy, and degenerative changes owing to longer follow-up. Although there is not enough information in literature regarding the results of pins and rubber band traction at the DIP joints or IP and MCP joints of the thumb, the results of our study for the fractures involving the PIP joint (average of 89 of PIP motion) are better than the results of other studies, which showed an average of 80 , 84 , 66 , 74 , 84%, and 86 of active PIP motion.5,13,18,20e22 Our results regarding the use of the system on the thumb are also comparable with the study of Keramidas and Miller19 in which they applied pins and rubber band traction at the IP and MCP joints of the thumb in 5 patients. They stated that the system could be used to treat difficult intra-articular fractures of the thumb with very good functional results. The reason we had better results in our series when compared with the literature may be attributed to certain points we noted during our learning curve. These points include ensuring the proper placement of the pins, which was highlighted in the literature,8,20 taking careful intraoperative fluoroscopic control images in anteroposterior and true lateral positions after application of the system to ensure reduction of the fragments in all positions of flexion and changing the traction force when necessary, taking radiological images at weekly intervals to check for necessary readjustments on the system, educating the patient about pin-site care in order to avoid pin-track infections, and having a skilled hand therapist provide the postoperative therapy. Infection has been a major complication of dynamic external fixation of the digits especially at the traction pin, which is subject to rotation.8,20 In our series, we saw no pin-site infection or osteomyelitis, which might require earlier removal of the system. To minimize irritation, we minimally enlarge the skin J Hand Surg Am.
incision at each entry point of the pins with a scalpel. This helps the skin move freely during exercise and avoids excessive tension at the pin entry sites. We remove the frame as soon as there is radiological evidence of fracture healing, which allows a more active rehabilitation and ends the risk of pin-site infections. Educating the patient about performing twice-daily pin-site care is also important. The 2 main limitations of this study are its retrospective nature and the relatively short follow-up (an average of 24 mo), which is not a sufficient amount of time to evaluate possible arthrosis. REFERENCES 1. Agee J. Treatment principles for proximal and middle phalangeal fractures. Orthop Clin North Am. 1992;23(1):35e40. 2. Inanami H, Ninomiya S, Okustu I, Tarui T. Dynamic external fixator for fracture dislocation of the proximal interphalangeal joint. J Hand Surg Am. 1993;18(1):160e164. 3. Hastings H II, Ernst JM. Dynamic external fixation for fractures of the proximal interphalangeal joint. Hand Clin. 1993;9(4):659e674. 4. Schenck RR. Dynamic traction and early passive movement for fractures of the proximal interphalangeal joint. J Hand Surg Am. 1986;11(6):850e858. 5. Suzuki Y, Matsunaga T, Sato S, Yokoi T. The pins and rubbers traction system for treatment of comminuted intra-articular fractures and fracture-dislocations in the hand. J Hand Surg Br. 1994;19(1): 98e107. 6. Agee JM. Unstable fracture dislocations of the proximal interphalangeal joint. Treatment with the force couple splint. Clin Orthop Relat Res. 1987;214:101e112. 7. Syed AA, Agarwal M, Boome R. Dynamic external fixator for pilon fractures of the proximal interphalangeal joints: a simple fixator for a complex fracture. J Hand Surg Br. 2003;28(2):137e141. 8. Agarwal AK, Karri V, Pickford MA. Avoiding pitfalls of the pins and rubbers traction technique for fractures of the proximal interphalangeal joint. Ann Plast Surg. 2007;58(2):489e495. 9. London PS. Sprains and fractures involving the interphalangeal joint. Hand. 1971;3(2):155e158. 10. Seno N, Hashizume H, Inoue H, Imatani J, Morito Y. Fractures of the base of the middle phalanx of the finger, classification, management and long-term results. J Bone Joint Surg Br. 1997;79(5): 758e763. 11. Bain GI, Mehta JA, Heptinstall RJ, Bria M. Dynamic external fixation for injuries of the proximal interphalangeal joint. J Bone Joint Surg Br. 1998;80(6):1014e1019. 12. Green A, Smith J, Redding M, Akelman E. Acute open reduction and rigid internal fixation of proximal interphalangeal joint fracture dislocation. J Hand Surg Am. 1992;17(3):512e517. 13. Keramidas E, Solomos M, Page RE, Miller G. The Suzuki frame for complex intra-articular fractures of the proximal interphalangeal joint of the fingers. Ann Plast Surg. 2007;58(5):484e488. 14. Lubahn JD, Hood JM. Fractures of the distal interphalangeal joint. Clin Orthop Relat Res. 1996;327:12e20. 15. Brennwald J. Fracture healing in the hand. A brief update. Clin Orthop Relat Res. 1996;327:9e11. 16. Kasparyan NG, Hotchkiss RN. Dynamic skeletal fixation in the upper extremity. Hand Clin. 1997;13(4):643e663. 17. Fahmy NR. The Stockport Serpentine Spring System for the treatment of displaced comminuted intrarticular phalangeal fractures. J Hand Surg Br. 1990;15(3):303e311. 18. De Soras X, De Mourgues P, Guinard D, Moutet F. Pins and rubbers traction system. J Hand Surg Br. 1997;22(6):730e735.
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19. Keramidas EG, Miller G. The Suzuki frame for complex intraarticular fractures of the thumb. Plast Reconstr Surg. 2005;116(5): 1326e1331. 20. Debus G, Courvoisier A, Wimsey S, Pradel P, Moutet F. Pins and rubber traction system for intraarticular proximal interphalangeal joint fractures revisited. J Hand Surg Eur Vol. 2010;35(5):396e401.
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21. Majumder S, Peck F, Watson JS, Lees VC. Lessons learned from the management of complex intraarticular fractures at the base of the middle phalanges of fingers. J Hand Surg Br. 2003;28(6):559e565. 22. Duteille F, Pasquier P, Lim A, Dautel G. Treatment of complex interphalangeal joint fractures with dynamic external traction: a series of 20 cases. Plast Reconstr Surg. 2003;111(5):1623e1629.
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Pins and Rubber Band Traction for Treatment of Comminuted Intra-Articular Fractures in the Hand Ahmet Kiral, MD, H. Yener Erken, MD, Ibrahim Akmaz, MD, Cengiz Yildirim, MD, Kaan Erler, MD
Purpose To determine the efficacy of pins and rubber band traction for treatment of comminuted intra-articular fractures in the hand. Methods We performed a retrospective study from 1994 to 2013 to evaluate 33 patients in whom pins and rubber band traction was employed. We clinically evaluated the active range of motion of the affected fingers after surgery. Eleven of the 33 fractures were at the proximal interphalangeal joint, 10 at the distal interphalangeal joint, 5 at the thumb interphalangeal joint, and 2 at the metacarpophalangeal joint of the thumb. The remaining 5 patients had complex fracture-dislocation of the proximal interphalangeal joints. Results The mean follow-up period was 24 months. The average active motion of the metacarpophalangeal joints of the fingers was 91 (range, extension 0 e10 /flexion 85 e90 ), proximal interphalangeal joints was 92 (range, extension/flexion 0 e10 /85 e100 ), and distal interphalangeal joints was 73 (range, extension/flexion 0 e10 /60 e80 ). The overall average of all active motion of the injured fingers except thumbs was 255 (range, 240 e270 ). The average active motion of the of the thumb metacarpophalangeal joint was 56 (range, extension 5 e10 /flexion 50 e55 ), and interphalangeal joint was 74 (range, extension 0 e10 /flexion 75 e80 ). The average of active motion of the injured thumb metacarpal and interphalangeal joints combined was 130 (range, 125 e135 ). Conclusions Pins and rubber band traction is a treatment option for comminuted displaced intra-articular fractures of the digits that offers satisfactory clinical results. (J Hand Surg Am. 2014;39(4):696e705. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Pins and rubber band traction, intra-articular fractures, hand.
A
normal anatomy and permits early active joint motion and tendon gliding is necessary to obtain optimal results for treatment of comminuted displaced TECHNIQUE THAT RESTORES THE
From the Department of Orthopaedic Surgery, Anadolu Medical Center, Kocaeli; and the Department of Orthopaedic Surgery, GATA Haydarpas¸a Education Hospital, Istanbul, Turkey. Received for publication September 16, 2013; accepted in revised form December 27, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: H. Yener Erken, MD, Department of Orthopaedic Surgery, Anadolu Medical Center, Cumhuriyet Mahallesi 2255 Sokak No. 3 Gebze 41400, Kocaeli, Turkey; e-mail: [email protected]. 0363-5023/14/3904-0013$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.12.038
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intra-articular fractures of the digits.1 Various distal traction systems that combine traction with early motion can be used to reposition the fragments. These systems aim to reduce fracture fragments by ligamentotaxis while preventing joint stiffness.2e4 The banjo frame is effective but bulky and uncomfortable to wear.2,4 Recently, light, straightforward, and effective systems such as the force couple splint, various dynamic external fixator systems, and the pins and rubber band traction have been reported.1e3,5e8 Pins and rubber band traction described by Suzuki et al5 is one of these systems and offers several advantages. The goal of this study was to determine the efficacy of pins and rubber band traction that we used for
THE PINS AND RUBBER BAND TRACTION SYSTEM
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FIGURE 1: A London classification for proximal and middle phalanx condylar fractures. B Seno classification for middle phalanx base fractures.
treatment of comminuted intra-articular fractures in the hand.
male. The mean age of the patients was 23 years (range, 16e57 y). The mean follow-up period was 24 months (range, 12e72 mo).
MATERIALS AND METHODS After obtaining institutional review board approval, we performed a retrospective study on patients who had operative treatment between 1994 and 2013 for comminuted intra-articular fractures and fracturedislocations in the hand. We employed pins and rubber band traction, described by Suzuki et al,5 in all 33 patients. We used the London classification9 for the proximal and middle phalanx condylar fractures of the fingers and the Seno classification10 for the middle phalanx base fractures of the in order to evaluate them radiologically (Fig. 1). We also used the London classification for the proximal phalanx condylar fractures of the thumb. All of the clinical and radiological findings were evaluated retrospectively. We evaluated the active motion of the affected fingers with a goniometer. The mean interval between the injury and the time of the operation was 5 days (range, 1e20 d). Eleven of 33 fractures were at the proximal interphalangeal (PIP) joint, 10 were at the distal interphalangeal (DIP) joint, 5 were at the thumb interphalangeal (IP) joint, and 2 were at the thumb metacarpophalangeal (MCP) joint. The remaining 5 patients had complex fracturedislocation of the PIP joint, which were classified as Seno type 1 fractures (Table 1). A modified pins and rubber band traction technique was used for these 5 patients. Six of the patients had open fractures that were clean with less than 1 cm skin open wounds. The others had closed fractures. The etiologies of the injuries were from falling (17), direct blow (7), crush injury (8), and a gunshot (1). All of the patients were J Hand Surg Am.
Surgical technique We used the technique described by Suzuki et al5 in all patients as outpatients and under digital block anesthesia. We inserted a long Kirschner wire (1.2 mm in diameter) transversely through the injured or adjoining phalanx proximal to the injury (axial traction pin) (Fig. 2). The wire was bent 90 near the skin on both sides of the finger in the direction of the fingertip. Each end of the wire was long enough to reach about 3 cm distal to the fingertip. The ends were bent into hooks with needle nose pliers. A second Kirschner wire (1 mm in diameter) was inserted transversely through the injured or adjoining phalanx distal to the injury (hook pin). We placed a hook bend into each end of the hook pin just external to the skin. Both Kirschner wires needed to be placed in the coronal plane of the finger; otherwise a rotational deformity of the finger would occur. The rubber bands were placed between the pins 2 hours after the effects of the digital block anesthesia had worn off. The rubber bands were wrapped around the pins until the patient noted tension in the finger. X-rays were taken 1 hour and 24 hours after placement of the rubber bands. For the size and strength we sought, we used Universal brand rubber bands in size 32 (UNV00132, Universal, Thailand). The rubber bands had to be thin enough to wrap around the pins several times and strong enough to hold the tension once wrapped. As for the brand, they had to be readily available in case we needed more. Depending on the status of the reduction of the fractures noted radiographically, the tension on the finger was either increased or decreased by increasing r
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TABLE 1.
Summary of Patient Data and Results
Finger or Thumb
LOF
SOI
Classification
Sytem Used
Age (y)/Sex
DOI
DOT
Follow-Up (mo)
MCP ROM ( ) Ext/Flex
PIP ROM ( ) Ext/Flex
DIP ROM ( ) Ext/Flex
IP ROM ( ) Ext/Flex
Total ROM ( ) Ext/Flex
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Finger Middle phalanx base
R middle PIP
Seno 1
Modified
21/M
17
7
15
0/90
0/100
0/80
270
2
Finger Middle phalanx base
R middle PIP
Seno 1
Modified
23/M
14
7
14
0/90
0/100
0/80
270
3
Finger Middle phalanx base
R index PIP
Seno 1
Modified
25/M
1
7
22
0/90
10/85†
0/75
240
4
Finger Middle phalanx base
L index PIP
Seno 1
Modified
20/M
5
6
17
0/85
5/85†
0/75
240
5
Finger Middle phalanx base
L little PIP
Seno 1
Modified
34/M
11
5
18
0/90
5/100†
0/80
265
6
Finger Middle phalanx base
L little PIP
Seno 2
Original
57/M
2
6
20
þ10/90*
0/95
0/75
270
7
Finger Middle phalanx base
R index PIP
Seno 2
Original
16/M
2
4
60
þ10/85*
5/95†
0/80
265
8
Finger Middle phalanx base
L little PIP
Seno 3
Original
33/M
1
5
16
0/85
10/100†
0/75
250
9
Finger Middle phalanx base
L index PIP
Seno 3
Original
21/M
1
6
16
0/90
5/90†
0/75
250
10
Finger Middle phalanx base
R ring PIP
Seno 3
Original
20/M
5
6
72
þ10/85*
5/90†
0/75
255
11
Finger Proximal phalanx condylar
R little PIP
London 2
Original
18/M
1
5
16
þ10/90*
0/95
0/75
270
12
Finger Proximal phalanx condylar
L ring PIP
London 3
Original
21/M
20
6
16
0/90
10/90
0/80
260
13
Finger Proximal phalanx condylar
R index PIP
London 3
Original
21/M
1
5
16
0/90
5/95†
0/75
255
14
Finger Proximal phalanx condylar
R little PIP
London 3
Original
21/M
1
5
16
þ5/90*
0/85
0/65
245
15
Finger Proximal phalanx condylar
L index PIP
London 3
Original
21/M
1
8
16
þ5/90*
0/80
0/75
250
(Continued)
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1
TABLE 1.
No.
Summary of Patient Data and Results (Continued)
Finger or Thumb
LOF
SOI
Classification
Sytem Used
Age (y)/Sex
DOI
DOT
Follow-Up (mo)
MCP ROM ( ) Ext/Flex
PIP ROM ( ) Ext/Flex
DIP ROM ( ) Ext/Flex
IP ROM ( ) Ext/Flex
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Finger Proximal phalanx condylar
L little PIP
London 3
Original
33/M
2
4
24
0/90
0/95
260
17
Finger Middle phalanx condylar
L ring DIP
London 2
Original
21/M
9
6
18
0/85
0/100
10/75†
250
18
Finger Middle phalanx condylar
R ring DIP
London 3
Original
21/M
1
6
22
0/90
0/100
10/80†
260
19
Finger Middle phalanx condylar
R ring DIP
London 3
Original
21/M
4
6
20
0/90
0/90
10/75†
245
20
Finger Middle phalanx condylar
R index DIP
London 3
Original
20/M
13
8
17
21
Finger Middle phalanx condylar
L middle DIP
London 3
Original
20/M
3
6
15
22
Finger Middle phalanx condylar
R middle DIP
London 3
Original
21/M
1
6
23
Finger Middle phalanx condylar
L ring DIP
London 3
Original
21/M
3
24
Finger Middle phalanx condylar
R ring DIP
London 3
Original
21/M
25
Finger Middle phalanx condylar
R little DIP
London 3
Original
26
Finger Middle phalanx condylar
L ring DIP
London 3
27
Thumb Proximal phalanx condylar
L thumb IP
28
Thumb Proximal phalanx condylar
29 30
0/95
0/65
250
0/90
0/100
5/85†
270
16
0/90
0/95
5/60†
240
7
12
0/90
0/100
10/80†
260
1
6
21
0/85
0/95
5/65†
240
21/M
10
6
15
0/90
0/95
0/70
255
Original
21/M
1
4
17
0/90
0/100
5/80†
265
London 3
Original
21/M
1
7
18
þ5/50*
-
-
0/75
130
L thumb IP
London 3
Original
21/M
1
8
36
0/55
-
-
5/75†
125
Thumb Proximal phalanx condylar
L thumb IP
London 3
Original
21/M
10
8
19
þ5/55*
-
-
10/80†
130
Thumb Proximal phalanx condylar
R thumb IP
London 3
Original
21/M
3
6
48
þ10/55*
-
-
5/75†
135
THE PINS AND RUBBER BAND TRACTION SYSTEM
J Hand Surg Am.
16
þ10/90*
0/75
Total ROM ( ) Ext/Flex
(Continued)
699
700
-
0/80
130
or decreasing the number of times the rubber band was wrapped around the axial traction pin and the hook pin. We used the same type of rubber band in all cases. The radiological evaluation determined the degree of tension. In the x-rays taken 1 hour later after placement of the rubber bands, we usually observed either an underdistraction or an overdistraction. We defined a distraction of more than 1 mm between the distal and the proximal fragments after application of the rubber bands as overdistraction. After the first adjustment of the tension on the rubber bands, proper reduction was generally achieved. For fracture-dislocations of the PIP joints, a third type pin, the “reduction pin,” was inserted through the base of the displaced middle phalanx. It was placed volar to the proximal pin in order to create a volarly directed reduction force. The ends of this pin were bent upward (Fig. 3). This modified pins and rubber band traction allowed early active motion of the PIP joint as well. Figures 4 and 5 demonstrate different configurations of the system according to the fracture site. We applied the same pins and rubber band traction for fractures of the thumb IP and MCP joints.
DOI, days from injury to operation; DOT, duration of traction (wk); Ext, extension; Flex, flexion; LOF, location of the fracture; SOI, site of the injury. *Plus (þ) degrees mean hyperextension of active joint extensions. †Minus () degrees mean restriction of active joint extensions.
0/50 6 L thumb MCP Thumb Proximal phalanx base 33
Original
18/M
9
72
125 0/80 6 L thumb MCP Thumb Proximal phalanx base 32
Original
26/M
5
36
5/50†
-
135 10/80† þ10/55* 17 6 1 Original London 3 R thumb IP Thumb Proximal phalanx condylar 31
Classification SOI LOF No.
21/M
DOT DOI Age (y)/Sex Sytem Used Finger or Thumb
Summary of Patient Data and Results (Continued) TABLE 1.
-
Total ROM ( ) Ext/Flex PIP ROM ( ) Ext/Flex Follow-Up (mo)
MCP ROM ( ) Ext/Flex
DIP ROM ( ) Ext/Flex
IP ROM ( ) Ext/Flex
THE PINS AND RUBBER BAND TRACTION SYSTEM
Postoperative care We used a light dressing around the Kirschner wires to avoid any disturbance of the active motion. Active motion of the affected finger was started immediately after the procedure under the control of a skilled hand therapist. Patients were educated about pin-site care by self-application of antibiotic ointment using a cotton applicator twice a day. X-rays were obtained 1 and 2 weeks after the operation to check reduction; tension on the rubber bands was adjusted as needed. A static night splint was used to protect the mechanism while the patient was asleep. We removed the traction device at 4 to 8 weeks after surgery after we obtained radiographic confirmation of fracture union. After termination of the traction device, patients continued therapy for 3 to 6 more weeks. We checked the patients 4 and 6 weeks and 3 and 6 months after surgery with clinical and radiological examinations. RESULTS We obtained anatomical union in all patients. Malunion, pin-track infection, and osteomyelitis were not seen. Although we detected a lateral shift of the frame in 5 patients in the first postoperative week, we successfully realigned the pins under a digital block anesthesia while confirming the proper reduction of the fracture under fluoroscopy. J Hand Surg Am.
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FIGURE 4: Application of pins and rubber band traction for middle phalanx condylar fractures.
FIGURE 2: The pins and rubber band traction consists of (a) axial traction pin, (b) hook pin, and (c) rubber band.
FIGURE 5: Application of pins and rubber band traction for proximal phalanx condylar fractures.
FIGURE 3: Modified system; the reduction pin is placed volar to the proximal pin in order to create a volarly directed reduction force. The axial traction pin suppresses the reduction pin to reduce the displaced fragment.
At the completion of treatment, the average active motion of the MCP joints of the fingers was 91 (range, extension 0 e10 /flexion 85 e90 ). The average active motion of the PIP joints was 92 (range, extension/flexion 0 e10 /85 e100 ). The average active motion of the DIP joints was 73 (range, extension/flexion 0 e10 /60e80 ). The overall average of all active range of motion (ROM) of the injured fingers except thumbs was 255 (range,
There were PIP joint contractures, average of 29 (range, 15 e50 ), in 7 patients and DIP joint contractures, average 22 (range, 15 e30 ), in 3 patients. With an intensive therapy program, these joint contractures resolved after an average of 36 days of physical therapy (range, 20e60 d). J Hand Surg Am.
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THE PINS AND RUBBER BAND TRACTION SYSTEM
FIGURE 6: A A 21-year-old man (case 18 in Table 1) with a right ring finger middle phalanx London type 3 condylar fracture. B, C The healed fracture 6 weeks and 6 months after surgery, respectively.
240 e270 ). The average active motion of the MCP joints of the thumbs was 56 (range, extension 5 e10 /flexion 50 e55 ). The average active motion of the IP joints of the thumbs was 74 (range, extension 0 e10 /flexion 75 e80 ). The overall average of all active ROM of the injured thumbs was 130 (range, 125 e135 ). The radiological and clinical outcomes of 2 patients (cases 8 and 18 in Table 1) are shown in Figures 6 and 7.
delayed arthrodesis and resorption at the fracture site owing to disrupted blood supply during the open reduction and rigid internal fixation of the intra-articular fractures. Distraction uses ligamentotaxis to provide reduction and has been reported to provide satisfactory results. Various traction systems have been used to treat these fractures.1e7 Agee1 developed the force couple splint, which uses phalangeal Kirschner wires to provide a volar reduction force on the base of the middle phalanx. This technique does not provide traction and ligamentotaxis and cannot be used for comminuted fractures with a loss of dorsal buttress. The rhomboid bilateral spring-loaded external fixator developed by Inanami et al2 provides distraction and places a volardirected force on the base of the middle phalanx to maintain reduction of the PIP joint. These systems, designed for unstable fracture-dislocations of the PIP joint, are similar to but more complicated than the Suzuki frame.13 Although these systems are effective and straightforward, they can be applied only on PIP joint fractures. The Compass Hinge fixator (Smith & Nephew, Memphis, TN), developed by Kasparyn and Hotchkiss,16 is designed to be applied after primary reconstruction in order to allow early controlled PIP joint motion. It is a radiolucent unilateral hinged external fixator, which maintains stability of the joint and has a worm gear to provide controlled passive motion. This gear can be disengaged to allow active mobilization. Hastings and Ernst3 reported the use of a bilateral external fixator, which has a pin at the anatomical axis of the proximal phalanx and 2 pins in the middle phalanx. This fixator provides distraction
DISCUSSION Comminuted intra-articular fractures or fracturedislocations of digits can be problematic. Pain, joint stiffness, instability, and degenerative arthritis are common outcomes of comminuted displaced intraarticular fractures and fracture-dislocations of the PIP joint.11 Although literature suggests various modalities for treatment of these injuries, open reduction and internal fixation12 or distraction-mobilization seem to be the most valuable options because both methods allow early mobilization of the joint. Open reduction and internal fixation generally produces satisfactory results in cases of 2-part large fracture fragments, which are rare. Dissection of soft tissue around the joint may deprive smaller fragments of their blood supply and increase the risk of joint stiffness and functional impairment resulting from the injury.13 Lubahn and Hood14 recommended open reduction and fixation with Kirschner wires for distal intra-articular fractures of the middle phalanx including the DIP joint, and they also reported the need for DIP joint arthrodesis for cases that developed joint stiffness. Brennwald15 reported the possibility of J Hand Surg Am.
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FIGURE 7: A, B A 33-year-old man (case 8 in Table 1) with a left little finger middle phalanx Seno type 3 base fracture. C, D The reduction of the fracture after application of pins and rubber band traction. E, F The healed fracture before the pins and rubber band traction system is removed 5 weeks after surgery. G, H The radiological outcomes of the healed fracture at 2 years after surgery.
and allows some correction of the instability while providing isometric mobilization. All systems mentioned previously are compact and designed for unstable fracture-dislocations of the PIP joint. Another system, which can be applied to all types of displaced fracture-dislocations of the digits while allowing range of active motion, is the S Quattro device, which does not apply continuous elastic traction.17 Pins and rubber band traction is applicable not only to phalangeal injuries but also to carpal injuries. Suzuki et al5 have used it to treat an intra-articular comminuted fracture of the DIP joint and a comminuted fracture of the trapezium. Although the anatomy and deforming forces on the thumb are different from those of the fingers, the literature supports the use of pins and rubber band traction on thumbs. De Soras et al18 used pins and rubber band traction to treat similar injuries and, at the end of their discussion, stated that the system can also be used for thumb IP joints and DIP joints, but J Hand Surg Am.
they did not offer any clinical examples. Keramidas and Miller19 applied pins and rubber band traction at the IP joint of the thumb in 5 patients and achieved satisfactory clinical outcomes. Pins and rubber band traction has several advantages. It is straightforward and includes only 2 or 3 Kirschner wires and rubber bands. The diameter of the wires is small and does not interfere with radiological imaging. This system also allows early active motion of the injured joint. Suzuki et al5 explained that, despite the limitation of active motion, the results could still be deemed satisfactory because even the slightest ROM may stimulate the nutrition and remodeling of the joint surface and prevent intraarticular adhesions and capsuloligamentous contracture of the joint. Agarwal et al8 reported the common pitfalls of pins and rubber band traction application. They described the proper location of the axial traction pin as the center of the head of the proximal phalanx, which corresponds to the rotation axis of the r
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THE PINS AND RUBBER BAND TRACTION SYSTEM
PIP joint and is perpendicular to the long axis of the ray. They also suggested observing the PIP joint flexion under fluoroscopy to ensure subluxation does not occur. Recently, Debus et al20 reported poorer outcomes of PIP joint intra-articular fractures treated by means of pins and rubber band traction in a series of 15 patients with a minimum of 2 years follow-up. They evaluated the reasons behind the poorer outcomes of some of the patients treated with this system and performed a literature review showing an average of 78 of active PIP joint motion (range, 64 e95 ). Their mean active motion was 56 (range, 0 e95 ), which was lower than that reported in the literature. They stated the reasons for this difference was due to preoperative delay, technical deficiencies, the learning curve, a lack of postoperative physiotherapy, and degenerative changes owing to longer follow-up. Although there is not enough information in literature regarding the results of pins and rubber band traction at the DIP joints or IP and MCP joints of the thumb, the results of our study for the fractures involving the PIP joint (average of 89 of PIP motion) are better than the results of other studies, which showed an average of 80 , 84 , 66 , 74 , 84%, and 86 of active PIP motion.5,13,18,20e22 Our results regarding the use of the system on the thumb are also comparable with the study of Keramidas and Miller19 in which they applied pins and rubber band traction at the IP and MCP joints of the thumb in 5 patients. They stated that the system could be used to treat difficult intra-articular fractures of the thumb with very good functional results. The reason we had better results in our series when compared with the literature may be attributed to certain points we noted during our learning curve. These points include ensuring the proper placement of the pins, which was highlighted in the literature,8,20 taking careful intraoperative fluoroscopic control images in anteroposterior and true lateral positions after application of the system to ensure reduction of the fragments in all positions of flexion and changing the traction force when necessary, taking radiological images at weekly intervals to check for necessary readjustments on the system, educating the patient about pin-site care in order to avoid pin-track infections, and having a skilled hand therapist provide the postoperative therapy. Infection has been a major complication of dynamic external fixation of the digits especially at the traction pin, which is subject to rotation.8,20 In our series, we saw no pin-site infection or osteomyelitis, which might require earlier removal of the system. To minimize irritation, we minimally enlarge the skin J Hand Surg Am.
incision at each entry point of the pins with a scalpel. This helps the skin move freely during exercise and avoids excessive tension at the pin entry sites. We remove the frame as soon as there is radiological evidence of fracture healing, which allows a more active rehabilitation and ends the risk of pin-site infections. Educating the patient about performing twice-daily pin-site care is also important. The 2 main limitations of this study are its retrospective nature and the relatively short follow-up (an average of 24 mo), which is not a sufficient amount of time to evaluate possible arthrosis. REFERENCES 1. Agee J. Treatment principles for proximal and middle phalangeal fractures. Orthop Clin North Am. 1992;23(1):35e40. 2. Inanami H, Ninomiya S, Okustu I, Tarui T. Dynamic external fixator for fracture dislocation of the proximal interphalangeal joint. J Hand Surg Am. 1993;18(1):160e164. 3. Hastings H II, Ernst JM. Dynamic external fixation for fractures of the proximal interphalangeal joint. Hand Clin. 1993;9(4):659e674. 4. Schenck RR. Dynamic traction and early passive movement for fractures of the proximal interphalangeal joint. J Hand Surg Am. 1986;11(6):850e858. 5. Suzuki Y, Matsunaga T, Sato S, Yokoi T. The pins and rubbers traction system for treatment of comminuted intra-articular fractures and fracture-dislocations in the hand. J Hand Surg Br. 1994;19(1): 98e107. 6. Agee JM. Unstable fracture dislocations of the proximal interphalangeal joint. Treatment with the force couple splint. Clin Orthop Relat Res. 1987;214:101e112. 7. Syed AA, Agarwal M, Boome R. Dynamic external fixator for pilon fractures of the proximal interphalangeal joints: a simple fixator for a complex fracture. J Hand Surg Br. 2003;28(2):137e141. 8. Agarwal AK, Karri V, Pickford MA. Avoiding pitfalls of the pins and rubbers traction technique for fractures of the proximal interphalangeal joint. Ann Plast Surg. 2007;58(2):489e495. 9. London PS. Sprains and fractures involving the interphalangeal joint. Hand. 1971;3(2):155e158. 10. Seno N, Hashizume H, Inoue H, Imatani J, Morito Y. Fractures of the base of the middle phalanx of the finger, classification, management and long-term results. J Bone Joint Surg Br. 1997;79(5): 758e763. 11. Bain GI, Mehta JA, Heptinstall RJ, Bria M. Dynamic external fixation for injuries of the proximal interphalangeal joint. J Bone Joint Surg Br. 1998;80(6):1014e1019. 12. Green A, Smith J, Redding M, Akelman E. Acute open reduction and rigid internal fixation of proximal interphalangeal joint fracture dislocation. J Hand Surg Am. 1992;17(3):512e517. 13. Keramidas E, Solomos M, Page RE, Miller G. The Suzuki frame for complex intra-articular fractures of the proximal interphalangeal joint of the fingers. Ann Plast Surg. 2007;58(5):484e488. 14. Lubahn JD, Hood JM. Fractures of the distal interphalangeal joint. Clin Orthop Relat Res. 1996;327:12e20. 15. Brennwald J. Fracture healing in the hand. A brief update. Clin Orthop Relat Res. 1996;327:9e11. 16. Kasparyan NG, Hotchkiss RN. Dynamic skeletal fixation in the upper extremity. Hand Clin. 1997;13(4):643e663. 17. Fahmy NR. The Stockport Serpentine Spring System for the treatment of displaced comminuted intrarticular phalangeal fractures. J Hand Surg Br. 1990;15(3):303e311. 18. De Soras X, De Mourgues P, Guinard D, Moutet F. Pins and rubbers traction system. J Hand Surg Br. 1997;22(6):730e735.
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19. Keramidas EG, Miller G. The Suzuki frame for complex intraarticular fractures of the thumb. Plast Reconstr Surg. 2005;116(5): 1326e1331. 20. Debus G, Courvoisier A, Wimsey S, Pradel P, Moutet F. Pins and rubber traction system for intraarticular proximal interphalangeal joint fractures revisited. J Hand Surg Eur Vol. 2010;35(5):396e401.
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21. Majumder S, Peck F, Watson JS, Lees VC. Lessons learned from the management of complex intraarticular fractures at the base of the middle phalanges of fingers. J Hand Surg Br. 2003;28(6):559e565. 22. Duteille F, Pasquier P, Lim A, Dautel G. Treatment of complex interphalangeal joint fractures with dynamic external traction: a series of 20 cases. Plast Reconstr Surg. 2003;111(5):1623e1629.
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