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Stabilising severe phalangeal fractures
Stabilising Seveie Phalangeal Fractures M. M. Scott and P. J. Mulligan
STABILISING SEVERE P H A L A N G E A L FRACTURES M. M. SCOTT and P. J. M U L L I G A N , Birmingham SUMMARY A technique is described for treating severe compound injuries of the phalanges either single or multiple, with transverse Kirschner wires bonded with acrylic cement. The operative procedure, post-operative management and advantages of the technique are described. INTRODUCTION The use of transverse Kirschner wires in the treatment of metacarpal fractures has been described by many authors. (Berkman 1943; Waugh 1943; James 1966). Lamb 1973, presented a series of sixty-six patients with metacarpal fractures, where transverse Kirschner wire fixation to the intact metacarpal was used with good results. An adaptation of this procedure was used by Dickson (1975), in his report of a case of fractures of the three ulnar metacarpals, in which he bonded a vertical wire with acrylic cement between the two transverse wires to give rigid fixation. Acrylic cement bonded to oblique wires had first been described by Crockett (1974) for phalangeal arthrodesis. This report shows that this method of bonding transverse Kirschner wires with acrylic cement need not be limited to metacarpal fractures, but can also be applied to severe compound phalangeal fractures, either single or multiple. By this method it is possible to achieve confident stabilisation of the fingers which promotes healing of the soft tissues, and allows immediate mobilisation. Six cases are described; three of multiple compound phalangeal injuries, and three of single compound injuries of the proximal phalanx of the thumb (Table 1). A full description of the injuries and treatment is given for one of the cases of multiple phalangeal injuries (Case 1), and one of the single digit injuries (case 4). CASE 1 A fifty-nine year old production operator, caught his left hand in a metal grinding press. He had traumatic amputations through the middle phalanx of the little and ring fingers. In the index and middle fingers, he had grossly comminuted fractures of the middle and distal phalanges, involving bofh the proximal interphalangeal joints. The fractures were compound over the dorsal surface and were unstable, and consequently both the index and middle fingers were shortened and deformed. The amputations of the little and ring fingers were terminalised. In order to maintain the length and give stability to the index and middle fingers, two transverse wires were inserted through both fingers using the power drill, one wire went through the base of the terminal phalanx and the other through the base of the middle phalanx. With traction on the transverse wires to correct the deformity and P. J. Mulligan, F.R.C.S., Royal Orthopaedic Hospital, Woodlands Northfield, Birmingham B31 2AP. 9 1980 British Society for Surgery of the Hand 44
0072-968X-80-00060044
$02.00
The H a n d - - Volume 12
No. 1
1980
Stabilising Severe Phalangeal Fractures M. M. Scott and P. J. Mulligan
Fig. 1. Post-operative x-ray in Case 1, showing the gantry of Kirschner wires in position. Fig. 2. Case 1 showing the a m o u n t of flexion obtained in the first week.
TABLE 1 THUMB INJURY Casel
AvulsionofNail
FINGERS TREATMENT
Dressings
INJURY
.
TREATMENT
Traumatic amputations ofring Terminalised and little finger Compound fractures of middle Two transverse wires and and distal phalanges of index outrigger and middle finger
Case 2 Compound fracture of Primary arthrodesis proximal phalanx with disruption of DIP joint
Compound fractures and joint Amputation of index through injuries to all fingers PIP joint. Transverse wires and outrigger to index, middle and ring
Case 3 Uninjured
Gross compound fractures and Amputation of the Index at the joint injuries to all fingers PIP at 3 weeks. Transverse wires and outrigger to index, middle and ring
--
Case4 Compound fractureof Two transverse wires Uninjured proximal phalanx with and outrigger division of extensor pollicis longus Case5
Compound fractureof Two transverse wires Uninjured proximal phalanx and outrigger
Case 6 Compound 'T' shaped fracture of proximal phalanx to metacarpal phalangealjoint
The H a n d - - Volume 12
Two transverse wires Uninjured and outriggers
No. 1
1980
45
Stabilising Severe Phalangeal Fractures M. M. Scott and P. J. Mulligan
Fig. 3. Case l showing the result at eight weeks.
~i!~li~
ii
~
....
Fig. 4. Post-operative x-ray in Case 4, showing the gantry of Kirschner wires in position. Fig, 5. The result in Case 4 at eight weeks. 46
The H a n d - - Volume 12
No. 1
1980
Stabilising Severe Phalangeal Fractures M. M. Scott and P. J. Mulligan
Fig. 6a & 6b. Range of movements in Case 2 at eight weeks.
Fig. 7. The initial injury in Case 3. Fig. 8. Case 3, the wires and cement in position, maintaining the length of the fingers. The H a n d - - V o l u m e 12
No. 1
1980
47
Stabilising Severe Phalangeal Fractures M. M. Scott and P. J. Mulligan
Fig. 9a & 9b. The range of movement in Case 3 at eight weeks.
shortening, two vertical wires were bonded on with acrylic cement to maintain the reduction. Another transverse wire was bonded to the top of the vertical wires to increase the stability (Fig. 1). This arrangement of wires not only gave confident fixation of the fractures, but also permitted mobilisation, both active and passive, of the fingers to be started next day (Fig. 2). By the end of the first week, there was a good range of active m o v e m e n t in both the index and middle fingers. The wires were removed after twenty-five days. Two months after the injury, there was full active movement of the proximal interphalangeal joints of both the index and middle fingers, although there were flexion contractures of 30 degrees in both distal interphalangeal joints. On making a fist, he could get his fingers to within a centimetre of the pulp of his hand. The stumps of the ring and little fingers were pain free and he was beginning to develop a good grip (Fig. 3).
CASE 4 A thirty-six year old labourer caught his right thumb in a concrete mixer, sustaining a c o m p o u n d fracture of the proximal phalanx, with division of extensor pollicis longus. At operation a transverse Kirschner wire was inserted with the power drill on either side of the fracture. With the fracture held reduced, two vertical wires were then bonded on with acrylic cement, (Fig. 4). The extensor pollicis longus was repaired and the wound closed. A volar plaster slab was applied to protect the tendon repair, but was removed after two weeks, by which time the wounds were 48
The H a n d - - Volume 12
No. 1
1980
Stabilising Severe Phalangeal Fractures M. M. Scott and P. J. Mulligan
healed, and active mobilisation was started. At five weeks there was full movement of the metacarpo-phalangeal joint and the carpo-metacarpal joint, but only a jog of movement in the interphalangeal joint. The Kirschner wires were removed at this stage. He returned to work at eight weeks and, although the interphalangeal joint only had about 10 ~ o f active movement, the overall use of the thumb was normal (Fig. 5). DISCUSSION This method has many features to recommend it and few complications. It may be used in either multiple or single injuries and is easy to apply, with instruments available in most orthopaedic theatres; Kirschner wires, an accurate motorised wire drill and acrylic cement. Early mobilisation of severe finger fractures is often difficult or impossible by other means. Application of dressings, plasters, malleable splints or banjo frames has proved unsuccessful and sometimes dangerous while waiting for soft tissues to heal. Fingers stiffen rapidly in the first days after injury and attempts at later manipulation cause pain with poor results. Using this technique, there may be more chance o f severely injured fingers, as in Case 2, becoming actively mobile within three days of injury, and by eight weeks achieving a painfree useful hand (Figs. 6a and 6b). A prime indication for this technique, therefore, is the need for early mobilisation. These injuries often result from catching the hands in machinery and there is frequently injury to skin and tendons as well as fractures. Repair of the soft tissues and maintenance of finger length can be achieved in a position o f stability and at the same time allow rehabilitation and healing to take place. In these injuries, the extensor mechanism, joint capsules and nerves were repaired where indicated. There was no division of flexor tendons in any of these cases, though there was disruption of the sheaths in all of the cases, but early mobilisation prevented the tendons becoming tethered down. Even with marked shortening and instability as in Case 3 (Fig. 7), the wires can be introduced to lengthen the digits in alignment without any further disruption of the soft tissues (Fig. 8). During this period, dressings can be placed in and around the wires as required, but it is often more important to allow the patient to see his fingers move so that he gains confidence. The photographs of the same case (Figs. 9a and 9b), at eight weeks indicate the mobility that can be achieved, and amputation of the necrotic index finger stump was done without removing all the wires. Other methods of fixing multiple phalangeal fractures have been difficult to apply in such massive injuries, and stabilisation of the bone by small fragment sets may require further dissection of the tissues and yet not achieve stabilisation of the whole digit. The techniques o f plating of such fractures were recently discussed by Steel, (1978) and, not surprisingly the application o f compression techniques gave poor results in the phalanges. Even this technique will not restore the hand to normal after multiple and severe injuries, but the failure of the other methods to provide a quick and reliable method of stabilising the hand has pointed to a re-thinking of all previous ideas. In the small number of severe injuries described in this paper, the patients have, within weeks, achieved a functional result and avoided the common outcome of a stiff, immobile hand in a frightened patient months after such an injury. The H a n d - - Volume 12
No. 1
1980
49
Stabilising Severe Phalangeal Fractures M. M. Scott and P. J. Mulligan
ACKNOWLEDGEMENTS W e are i n d e b t e d to the C o n s u l t a n t s at the G e n e r a l H o s p i t a l , B i r m i n g h a m , a n d T h e A c c i d e n t H o s p i t a l , B i r m i n g h a m f o r r e f e r r i n g t h e s e c a s e s t o us.
REFERENCES BERKMAN, E. F. and MILES, G. H. (1943) Internal Fixation of Metacarpal Fractures Exclusive of the Thumb. The Journal of Bone and Joint Surgery, 25: 816-821. CROCKETT, D. J. (1974) Rigid Fixation of Bones of the Hand Using K. Wires, Bonded with Acrylic Resin. The Hand, 6" 106-107. DICKSON, R. A. (1975) Rigid Fixation of Unstable Metacarpal Fractures Using Transverse K. Wires, Bonded with Acrylic Resin. The Hand, 7: 284-286. JAMES, J. 1. P. (1966) Fractures of the Phalanges and Metacarpals. The Second Hand Club, The British Society for Surgery of the Hand, 1975:379-381 LAMB, D. W., ABERNETHY, P. A. and RAINE, P. A. M. Unstable Fractures of the Metacarpals. A Method of Treatment by Transverse Wire Fixation to Intact Metacarpals. The Hand, 5: 43-48. STEEL, W, M. (1978) The A-O Small Fragment Set in Hand Fractures. The Hand, 10: 246-253. WAUGH, R. L. and FERRAZZANO, G. P. (1943) Fractures of the Metacarpals Exclusive of the Thumb - - A New Method of Treatment. American Journal of Surgery, 59:186-194.
50
The H a n d - - Volume 12
No. 1
1980
STABILISING SEVERE P H A L A N G E A L FRACTURES M. M. SCOTT and P. J. M U L L I G A N , Birmingham SUMMARY A technique is described for treating severe compound injuries of the phalanges either single or multiple, with transverse Kirschner wires bonded with acrylic cement. The operative procedure, post-operative management and advantages of the technique are described. INTRODUCTION The use of transverse Kirschner wires in the treatment of metacarpal fractures has been described by many authors. (Berkman 1943; Waugh 1943; James 1966). Lamb 1973, presented a series of sixty-six patients with metacarpal fractures, where transverse Kirschner wire fixation to the intact metacarpal was used with good results. An adaptation of this procedure was used by Dickson (1975), in his report of a case of fractures of the three ulnar metacarpals, in which he bonded a vertical wire with acrylic cement between the two transverse wires to give rigid fixation. Acrylic cement bonded to oblique wires had first been described by Crockett (1974) for phalangeal arthrodesis. This report shows that this method of bonding transverse Kirschner wires with acrylic cement need not be limited to metacarpal fractures, but can also be applied to severe compound phalangeal fractures, either single or multiple. By this method it is possible to achieve confident stabilisation of the fingers which promotes healing of the soft tissues, and allows immediate mobilisation. Six cases are described; three of multiple compound phalangeal injuries, and three of single compound injuries of the proximal phalanx of the thumb (Table 1). A full description of the injuries and treatment is given for one of the cases of multiple phalangeal injuries (Case 1), and one of the single digit injuries (case 4). CASE 1 A fifty-nine year old production operator, caught his left hand in a metal grinding press. He had traumatic amputations through the middle phalanx of the little and ring fingers. In the index and middle fingers, he had grossly comminuted fractures of the middle and distal phalanges, involving bofh the proximal interphalangeal joints. The fractures were compound over the dorsal surface and were unstable, and consequently both the index and middle fingers were shortened and deformed. The amputations of the little and ring fingers were terminalised. In order to maintain the length and give stability to the index and middle fingers, two transverse wires were inserted through both fingers using the power drill, one wire went through the base of the terminal phalanx and the other through the base of the middle phalanx. With traction on the transverse wires to correct the deformity and P. J. Mulligan, F.R.C.S., Royal Orthopaedic Hospital, Woodlands Northfield, Birmingham B31 2AP. 9 1980 British Society for Surgery of the Hand 44
0072-968X-80-00060044
$02.00
The H a n d - - Volume 12
No. 1
1980
Stabilising Severe Phalangeal Fractures M. M. Scott and P. J. Mulligan
Fig. 1. Post-operative x-ray in Case 1, showing the gantry of Kirschner wires in position. Fig. 2. Case 1 showing the a m o u n t of flexion obtained in the first week.
TABLE 1 THUMB INJURY Casel
AvulsionofNail
FINGERS TREATMENT
Dressings
INJURY
.
TREATMENT
Traumatic amputations ofring Terminalised and little finger Compound fractures of middle Two transverse wires and and distal phalanges of index outrigger and middle finger
Case 2 Compound fracture of Primary arthrodesis proximal phalanx with disruption of DIP joint
Compound fractures and joint Amputation of index through injuries to all fingers PIP joint. Transverse wires and outrigger to index, middle and ring
Case 3 Uninjured
Gross compound fractures and Amputation of the Index at the joint injuries to all fingers PIP at 3 weeks. Transverse wires and outrigger to index, middle and ring
--
Case4 Compound fractureof Two transverse wires Uninjured proximal phalanx with and outrigger division of extensor pollicis longus Case5
Compound fractureof Two transverse wires Uninjured proximal phalanx and outrigger
Case 6 Compound 'T' shaped fracture of proximal phalanx to metacarpal phalangealjoint
The H a n d - - Volume 12
Two transverse wires Uninjured and outriggers
No. 1
1980
45
Stabilising Severe Phalangeal Fractures M. M. Scott and P. J. Mulligan
Fig. 3. Case l showing the result at eight weeks.
~i!~li~
ii
~
....
Fig. 4. Post-operative x-ray in Case 4, showing the gantry of Kirschner wires in position. Fig, 5. The result in Case 4 at eight weeks. 46
The H a n d - - Volume 12
No. 1
1980
Stabilising Severe Phalangeal Fractures M. M. Scott and P. J. Mulligan
Fig. 6a & 6b. Range of movements in Case 2 at eight weeks.
Fig. 7. The initial injury in Case 3. Fig. 8. Case 3, the wires and cement in position, maintaining the length of the fingers. The H a n d - - V o l u m e 12
No. 1
1980
47
Stabilising Severe Phalangeal Fractures M. M. Scott and P. J. Mulligan
Fig. 9a & 9b. The range of movement in Case 3 at eight weeks.
shortening, two vertical wires were bonded on with acrylic cement to maintain the reduction. Another transverse wire was bonded to the top of the vertical wires to increase the stability (Fig. 1). This arrangement of wires not only gave confident fixation of the fractures, but also permitted mobilisation, both active and passive, of the fingers to be started next day (Fig. 2). By the end of the first week, there was a good range of active m o v e m e n t in both the index and middle fingers. The wires were removed after twenty-five days. Two months after the injury, there was full active movement of the proximal interphalangeal joints of both the index and middle fingers, although there were flexion contractures of 30 degrees in both distal interphalangeal joints. On making a fist, he could get his fingers to within a centimetre of the pulp of his hand. The stumps of the ring and little fingers were pain free and he was beginning to develop a good grip (Fig. 3).
CASE 4 A thirty-six year old labourer caught his right thumb in a concrete mixer, sustaining a c o m p o u n d fracture of the proximal phalanx, with division of extensor pollicis longus. At operation a transverse Kirschner wire was inserted with the power drill on either side of the fracture. With the fracture held reduced, two vertical wires were then bonded on with acrylic cement, (Fig. 4). The extensor pollicis longus was repaired and the wound closed. A volar plaster slab was applied to protect the tendon repair, but was removed after two weeks, by which time the wounds were 48
The H a n d - - Volume 12
No. 1
1980
Stabilising Severe Phalangeal Fractures M. M. Scott and P. J. Mulligan
healed, and active mobilisation was started. At five weeks there was full movement of the metacarpo-phalangeal joint and the carpo-metacarpal joint, but only a jog of movement in the interphalangeal joint. The Kirschner wires were removed at this stage. He returned to work at eight weeks and, although the interphalangeal joint only had about 10 ~ o f active movement, the overall use of the thumb was normal (Fig. 5). DISCUSSION This method has many features to recommend it and few complications. It may be used in either multiple or single injuries and is easy to apply, with instruments available in most orthopaedic theatres; Kirschner wires, an accurate motorised wire drill and acrylic cement. Early mobilisation of severe finger fractures is often difficult or impossible by other means. Application of dressings, plasters, malleable splints or banjo frames has proved unsuccessful and sometimes dangerous while waiting for soft tissues to heal. Fingers stiffen rapidly in the first days after injury and attempts at later manipulation cause pain with poor results. Using this technique, there may be more chance o f severely injured fingers, as in Case 2, becoming actively mobile within three days of injury, and by eight weeks achieving a painfree useful hand (Figs. 6a and 6b). A prime indication for this technique, therefore, is the need for early mobilisation. These injuries often result from catching the hands in machinery and there is frequently injury to skin and tendons as well as fractures. Repair of the soft tissues and maintenance of finger length can be achieved in a position o f stability and at the same time allow rehabilitation and healing to take place. In these injuries, the extensor mechanism, joint capsules and nerves were repaired where indicated. There was no division of flexor tendons in any of these cases, though there was disruption of the sheaths in all of the cases, but early mobilisation prevented the tendons becoming tethered down. Even with marked shortening and instability as in Case 3 (Fig. 7), the wires can be introduced to lengthen the digits in alignment without any further disruption of the soft tissues (Fig. 8). During this period, dressings can be placed in and around the wires as required, but it is often more important to allow the patient to see his fingers move so that he gains confidence. The photographs of the same case (Figs. 9a and 9b), at eight weeks indicate the mobility that can be achieved, and amputation of the necrotic index finger stump was done without removing all the wires. Other methods of fixing multiple phalangeal fractures have been difficult to apply in such massive injuries, and stabilisation of the bone by small fragment sets may require further dissection of the tissues and yet not achieve stabilisation of the whole digit. The techniques o f plating of such fractures were recently discussed by Steel, (1978) and, not surprisingly the application o f compression techniques gave poor results in the phalanges. Even this technique will not restore the hand to normal after multiple and severe injuries, but the failure of the other methods to provide a quick and reliable method of stabilising the hand has pointed to a re-thinking of all previous ideas. In the small number of severe injuries described in this paper, the patients have, within weeks, achieved a functional result and avoided the common outcome of a stiff, immobile hand in a frightened patient months after such an injury. The H a n d - - Volume 12
No. 1
1980
49
Stabilising Severe Phalangeal Fractures M. M. Scott and P. J. Mulligan
ACKNOWLEDGEMENTS W e are i n d e b t e d to the C o n s u l t a n t s at the G e n e r a l H o s p i t a l , B i r m i n g h a m , a n d T h e A c c i d e n t H o s p i t a l , B i r m i n g h a m f o r r e f e r r i n g t h e s e c a s e s t o us.
REFERENCES BERKMAN, E. F. and MILES, G. H. (1943) Internal Fixation of Metacarpal Fractures Exclusive of the Thumb. The Journal of Bone and Joint Surgery, 25: 816-821. CROCKETT, D. J. (1974) Rigid Fixation of Bones of the Hand Using K. Wires, Bonded with Acrylic Resin. The Hand, 6" 106-107. DICKSON, R. A. (1975) Rigid Fixation of Unstable Metacarpal Fractures Using Transverse K. Wires, Bonded with Acrylic Resin. The Hand, 7: 284-286. JAMES, J. 1. P. (1966) Fractures of the Phalanges and Metacarpals. The Second Hand Club, The British Society for Surgery of the Hand, 1975:379-381 LAMB, D. W., ABERNETHY, P. A. and RAINE, P. A. M. Unstable Fractures of the Metacarpals. A Method of Treatment by Transverse Wire Fixation to Intact Metacarpals. The Hand, 5: 43-48. STEEL, W, M. (1978) The A-O Small Fragment Set in Hand Fractures. The Hand, 10: 246-253. WAUGH, R. L. and FERRAZZANO, G. P. (1943) Fractures of the Metacarpals Exclusive of the Thumb - - A New Method of Treatment. American Journal of Surgery, 59:186-194.
50
The H a n d - - Volume 12
No. 1
1980