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The s-Quattro in the Management of Acute Intraarticular Phalangeal Fractures of the Hand
ARTICLE IN PRESS THE S-QUATTRO IN THE MANAGEMENT OF ACUTE INTRAARTICULAR PHALANGEAL FRACTURES OF THE HAND W. KHAN and N. FAHMY From the Department of Orthopaedics & Trauma, Stepping Hill Hospital, Stockport, UK
Intraarticular phalangeal fractures of the hand are difficult and challenging to manage. Dynamic external fixation devices offer the advantages of allowing distraction of the impacted fracture and early joint mobilization. We present our study of 100 patients with a variety of fractures who were treated with the S-Quattro technique over a 6-year period, with an average follow-up of 10.5 months. The mean active range of motion regained was 921 for proximal interphalangeal joints (81 fractures), 821 for distal interphalangeal joints (10 fractures), 911 for metacarpophalangeal joints (6 fractures) and 801 for interphalangeal joints of the thumb (3 fractures). Only nine patients complained of mild or moderate pain. Postoperative radiographic appearances were satisfactory in all but five out of the 100 patients. This device is a simple and effective technique for the management of these difficult fractures. It offers advantages in terms of versatility, ease of application, good tolerance by patients, few complications and good outcome. Journal of Hand Surgery (British and European Volume, 2006) 31B: 1: 79–92 Keywords: S-Quattro, external fixation, intraarticular fractures, phalangeal fractures
INTRODUCTION The management of displaced intraarticular phalangeal fractures of the small joints of the hand is difficult, challenging and controversial. These joints are uniquely susceptible to injury due to their limited, singular plane of motion (Blazar and Steinberg, 2000). Commonly encountered problems include angulation, flexion deformity, malrotation, malunion, joint stiffness and joint subluxation. A spectrum of joint injury pattern occurs depending on the direction, rate and force of loading. If the loading force is severe and axially directed, a pilon-type injury can occur (Hasting and Ernst, 1993). Pilon fractures are characterized by comminution involving the entire base of the phalanx and are associated with central depression or splaying of the concave articular surface in the coronal plane, sagittal plane or both (Syed et al., 2003). If the force is directed from the dorsal or palmar direction, then a fracture of the corresponding lip of the articular surface is likely. This may be associated with a dislocation or a subluxation. Subluxation occurs when the fracture involves a significant proportion of the articular surface. Other fracture patterns include unicondylar and bicondylar fractures. Non-operative management, comprising of immobilization with splintage, produces poor results with pain, stiffness and reduced range of motion (Stern et al., 1991). To obtain the best functional result, it is important that any subluxation is reduced and early mobilization instituted. Although these fractures can usually be reduced by the traction principle, methods of maintaining reduction until the fracture has united are difficult and often compromise joint movement.
Fig 1 Components of the S-Quattro system and their application. 79
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Surgical treatment is problematic for two reasons. Firstly, the fracture fragments are small and, often, comminuted. This makes anatomical reconstruction difficult. Secondly, there is a need for joint mobilization during the healing period to prevent long-term stiffness. Immobilization for longer than 3 weeks can result in permanent loss of motion (Blazar and Steinberg, 2000). Open reduction and internal fixation with K-wire fixation (Gaul and Rosenberg, 1998; Hasting and Ernst, 1993; Syed et al., 2003; Viegas, 1992), intraosseous wiring of the palmar fragment (Safoury, 2001; Weiss, 1996) and palmar plate advancement (Eaton and Malerich, 1980) have been described but are technically demanding and time consuming. Fahmy (1990) and Stern et al. (1991) recommended distraction on the basis that it allowed early mobilization which, theoretically, resulted in improved cartilage and soft tissue nutrition and prevented extensor tendon adherence. Over the past three decades, old methods of treatment have been combined with new concepts including intradigital traction, capsuloligamentotaxis (Vidal et al., 1975) and the beneficial effects of early motion on articular remodelling (Gaul and Rosenberg, 1998). Several techniques of distraction have been described with variable results. These include external
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fixation devices (Allison, 1996; Hynes and Giddins, 2001) using a force couple splint (Agee, 1987; Buchanan, 1994), dynamic longitudinal traction (Dennys et al., 1992; Morgan et al., 1995; Schenck, 1986), compass hinges (Bain et al., 1998; Krakauer and Stern, 1996), pins and rubber traction systems (DeSoras et al., 1997; Majumder et al., 2003; Suzuki et al., 1994) and dynamic springs (Blazar and Steinberg, 2000; Inanami et al., 1993; Johnson et al., 2004). All existing techniques have their advantages and disadvantages. The disadvantages include complexity of the systems, the inconvenience experienced by the patients, loosening and infection. Nevertheless, dynamic traction splintage is now established in the treatment of intraarticular phalangeal fractures. Fahmy (1990) recommended distraction of the joint using pins and springs, which allows limited movement of the injured joint and free movement of the other digital joints. This allows quick recovery after the removal of the external fixator. The Stockport Serpentine Spring System, abbreviated to ‘‘S-Quattro’’, was developed as an external fixator (Fig 1) (Fahmy, 1990). It consists of a unique, dual, parallel but opposing action, spring column system. This system was devised by the senior author and has been used successfully in
Fig 2 (a and b) Pre-operative AP and lateral radiographs of case 30 from Table 1.
Sex
M M
F F M M M M M M
M
M M M M
M F F M F M M F M M
F F M F M M M M M M
Case number
1 2
3 4 5 6 7 8 9 10
11
12 13 14 15
16 17 18 19 20 21 22 23 24 25
26 27 28 29 30 31 32 33 34 35
Fall Fall RTA Fall RTA Sports Fall Sports RTA Sports
Sports Fall Fall Industrial accident Fall Fall Assault Sports Fall Sports Sports RTA Sports Assault
Fall Industrial accident Assault Fall Assault RTA Assault Sports RTA Industrial accident RTA
Mode of injury
Right Ring Left Ring Right Middle Left Index Right Little Left Index Right Middle Left Middle Left Ring Right Ring
Left Middle Left Little Left Index Right Ring Right Little Right Ring Right Little Left Middle Left Ring Left Little
Left Ring Right Middle Right Index Right Index
Right Ring
Right Little Left Little Right Ring Left Ring Left Little Right Middle Right Little Right Middle
Right Ring Left Index
Injured digit
Palmar lip Pilon Pilon Dorsal lip Bicondylar Dorsal lip Palmar lip Dorsal lip Pilon Pilon
Dorsal lip Palmar lip Pilon Dorsal lip Pilon Unicondylar Dorsal lip Dorsal lip Dorsal lip Pilon
Pilon Dorsal lip Pilon Pilon
Pilon
Pilon Pilon Pilon Dorsal lip Pilon Bicondylar Pilon Palmar lip
Pilon Dorsal lip
Fracture type
Yes No No Yes Yes No Yes Yes No No
Yes No No Yes No No Yes No No No
No Yes No No
No
No No No Yes No No No Yes
No Yes
Subluxation
7 20 12 1 2 5 4 3 7 4
2 5 25 1 8 16 5 3 6 12
3 2 4 4
9
25 16 3 9 7 2 2 30
4 2
Time lapse from injury to surgery (days)
9 7 7 8 12 10 10 11 14 9
10 12 8 7 12 10 10 14 12 13
5 13 12 12
4
6 12 7 16 13 5 12 10
12 6
Last follow-up (months)
70 90 120 85 90 110 100 70 100 95
110 90 85 95 90 85 95 105 90 85
85 110 95 90
100
100 65 80 95 80 120 90 100
80 100
Postoperative range of motion (deg)
230 265 275 255 250 280 265 245 265 265
275 260 260 250 260 245 250 280 245 250
240 265 265 250
265
275 225 235 255 245 275 250 270
245 275
Total active motion (deg)
Mild No No No No No No Mild No No
No No No No No No No No No No
No No No No
No
No Moderate No No No No No No
No No
Pain
None None None None None None None None None None
None None None None None None None None None None
None None None None
None
None None None None None None None None
None None
Complications
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes
Yes
Yes No Yes Yes Yes Yes Yes Yes
Yes Yes
Patient satisfaction
Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Incongruous articular surface Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory
Incongruous articular surface Satisfactory Satisfactory Satisfactory Satisfactory
Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory
Satisfactory Satisfactory
X-ray appearance
INTRAARTICULAR PHALANGEAL FRACTURES OF THE HAND
79 22 53 36 49 22 59 45 32 42
27 55 38 29 78 37 32 38 33 48
46 46 33 42
20
39 94 33 58 31 44 49 61
42 21
Age
Table 1—Patient details for finger proximal interphalangeal joint fractures
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Sex
M M F M
M F F
M M
F M
M
M M F F M F F F M M M M M F M M M M
F M
Case number
36 37 38 39
40 41 42
43 44
45 46
47
48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
66 67
Sports Sports Fall Fall Fall Fall Assault Fall RTA Fall Sports Sports Fall Fall Sports Fall Fall Industrial accident Sports RTA
Right Ring Left Index
Left Ring Left Ring Right Index Left Index Left Middle Right Little Right Middle Left Little Right Middle Right Index Right Index Left Index Right Middle Right Index Left Index Right Ring Left Little Right Index
Left Middle
Left Index Right Index
Right Ring Right Ring
Right Middle Left Little Left Ring
Right Middle Right Index Right Little Right Ring
Injured digit
Dorsal lip Pilon
Dorsal lip Dorsal lip Dorsal lip Pilon Dorsal lip Pilon Pilon Pilon Dorsal lip Pilon Dorsal lip Palmar lip Pilon Unicondylar Dorsal lip Pilon Palmar lip Dorsal lip
Pilon
Dorsal lip Unicondylar
Pilon Pilon
Pilon Palmar lip Pilon
Dorsal lip Dorsal lip Pilon Dorsal lip
Fracture type
Yes No
Yes Yes No No No No No No Yes No No Yes No No Yes No Yes No
No
No No
No No
No Yes No
No Yes No Yes
Subluxation
1 8
2 5 11 4 11 8 13 3 4 5 16 7 3 1 6 8 11 5
2
6 22
7 10
14 2 4
1 3 1 12
Time lapse from injury to surgery (days)
13 14
8 8 10 12 10 12 11 14 14 10 10 8 12 16 10 10 11 9
5
12 10
13 6
9 12 24
14 12 16 6
Last follow-up (months)
95 80
105 100 80 95 100 80 85 75 105 95 95 110 100 80 90 60 95 100
95
95 90
100 60
100 95 70
100 110 90 95
Postoperative range of motion (deg)
270 245
255 255 240 265 265 245 270 255 270 265 275 275 255 245 260 225 265 255
255
270 245
255 225
265 260 235
275 265 260 250
Total active motion (deg)
No No
No No No No No No No No No No No No No Mild No No No No
No
No No
No Mild
No Mild Moderate
No No No No
Pain
None None
None None None None None None None None None None None None None None None None None None
None
None None
None None None Reapplication of S-Quattro None None Secondary osteoarthritis requiring silastic joint replacement None None
Complications
Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes
Yes Yes
Yes Yes
Yes Yes No
Yes Yes Yes Yes
Patient satisfaction
Satisfactory Satisfactory
Incongruous articular surface Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory
Satisfactory Satisfactory
Satisfactory Satisfactory
Satisfactory Satisfactory Secondary osteoarthritic changes
Satisfactory Satisfactory Satisfactory Satisfactory
X-ray appearance
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19 36
26 34 67 33 44 74 23 35 36 53 32 32 29 64 23 39 23 54
Fall Industrial accident Fall Industrial accident RTA
Sports Sports Fall
Sports Fall Fall Sports
Mode of injury
82
46
58 44
33 18
21 51 50
18 48 53 46
Age
Table 1. (continued )
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F M
M M M F M
75 76
77 78 79 80 81
32 23 37 46 23
56 23
48 21 29 67 23 45 53
Assault Sports Sports Fall Fall
Fall Assault RTA Fall Fall RTA Industrial accident Fall Assault
Left Index Left Little Right Index Left Ring Right Little
Left Little Left Index
Right Little Right Little Right Ring Right Middle Left Index Left Ring Right Index
Pilon Dorsal lip Dorsal lip Dorsal lip Pilon
Palmar lip Unicondylar
Dorsal lip Pilon Pilon Dorsal lip Dorsal lip Pilon Unicondylar
No Yes No Yes No
Yes No
Yes No No No Yes No No
Sex
M
F M M M F F M
M
M
Case number
1
2 3 4 5 6 7 8
9
10
32
28
32 42 71 25 41 72 33
36
Age
Fall
Industrial accident Sports Assault Fall Sports Fall Fall Industrial accident Assault
Mode of injury
Right Ring
Left Ring
Left Index Right Ring Left Ring Right Ring Right Ring Left Middle Right Ring
Right Middle
Injured digit
Pilon
Pilon
Pilon Pilon Pilon Dorsal lip Pilon Pilon Pilon
Pilon
Fracture type
No
No
No No No Yes No No No
No
Subluxation
Table 2—Patient details for finger distal interphalangeal joint fractures
M M M M F M M
68 69 70 71 72 73 74
8
1
2 7 15 11 14 5 2
2
Time lapse from injury to surgery (days)
5 6 1 4 14
12 22
2 9 3 2 1 4 2
14
6
13 8 10 8 11 11 9
7
Last follow-up (months)
8 12 6 11 12
12 9
12 7 13 13 12 13 12
80
65
85 75 85 90 85 90 90
70
Postoperative range of motion (deg)
80 105 85 85 90
80 85
105 80 90 100 80 95 75
275
260
280 270 275 280 280 275 280
265
Total active motion (deg)
265 270 250 260 255
255 265
265 250 245 250 260 250 230
No
No
No No No No No No No
Moderate
Pain
No No Mild No No
No No
No No No No No No No
Reapplication of S-Quattro None
None None None None None None None
None
Complications
None None None None None
None None
None None None None None None None
Yes
Yes
Yes Yes Yes Yes Yes Yes Yes
Yes
Patient satisfaction
Yes Yes Yes Yes Yes
Yes Yes
Yes Yes Yes Yes Yes Yes Yes
Satisfactory
Satisfactory
Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory
Satisfactory
X-ray appearance
Satisfactory Incongruous articular surface Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory
Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory
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INTRAARTICULAR PHALANGEAL FRACTURES OF THE HAND 83
M F M
F M M
1 2 3
4 5 6
26 32 21
21 29 27
Age
Sports Fall Industrial accident Fall Sports Industrial accident
Mode of injury
Left Ring Right Index Left Index
Right Ring Left Ring Left Middle
Injured digit
Pilon Pilon Dorsal lip
Dorsal lip Dorsal lip Dorsal lip
Fracture type
Sex
M M F
Case number
1 2 3
19 28 18
Age
RTA Sports Fall
Mode of injury
Right Thumb Right Thumb Right Thumb
Injured digit
Pilon Pilon Pilon
Fracture type
No No No
Subluxation
No No Yes
No Yes Yes
Subluxation
7 11 5
Time lapse from injury to surgery (days)
5 6 4
14 5 2
Time lapse from injury to surgery (days)
5 8 11
Last follow-up (months)
8 14 16
6 8 16
Last follow-up (months)
80 80 80
Postoperative range of motion (deg)
90 90 90
90 90 95
Postoperative range of motion deg)
115 110 115
Total active motion (deg)
280 270 265
275 280 275
Total active motion (deg)
No No No
Pain
No No No
No No No
Pain
None None None
Complications
None None None
None None None
Complications
Yes Yes Yes
Patient satisfaction
Yes Yes Yes
Yes Yes Yes
Patient satisfaction
Satisfactory Satisfactory Satisfactory
X-ray appearance
Satisfactory Satisfactory Satisfactory
Satisfactory Satisfactory Satisfactory
X-ray appearance
84
Table 4—Patient details for thumb interphalangeal joint fractures
Sex
Case number
Table 3—Patient details for finger metacarpophalangeal joint fractures
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ARTICLE IN PRESS INTRAARTICULAR PHALANGEAL FRACTURES OF THE HAND
the management of intraarticular phalangeal fractures of the hand for the last 14 years (Bostock et al., 1993a,b; Fahmy, 1990; Fahmy and Harvey, 1992; Fahmy et al., 1994, 1998; Hannen Mullett et al., 1999). This study evaluates the use of this technique in 100 patients with a variety of fractures over a 6 year period.
PATIENTS AND METHODS A retrospective study was conducted on the use of SQuattro for acute intraarticular phalangeal fractures of the hand. One hundred patients with a variety of fractures underwent the described procedure over a 6 year period. All fractures involved a single joint and were closed injuries. There were 81 fractures of the
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proximal interphalangeal joint (Table 1), 10 fractures of the distal interphalangeal joint (Table 2), six fractures of the metacarpophalangeal joint (Table 3) and three fractures of the interphalangeal joint of the thumb (Table 4). The sex, age, mode of injury, injured digit, type of fracture and subluxation and time lapse to surgery are detailed in the tables. In total, 71 of the patients were men and 29 were women. The mean age for all the patients was 39.3 (range 18–94) years. The mode of injury was a fall in 39 fractures, sports in 26 fractures, road traffic accidents in 13 fractures, industrial accidents in 11 fractures and assault in 11 fractures. Fifty-six fractures involved the right hand and 44 fractures involved the left hand. There were 33 fractures of the ring finger, 26 fractures of the index finger, 19 fractures of the middle finger, 19
Fig 3 (a and b) Pre-operative AP and lateral radiographs of case 64 from Table 1.
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fractures of the little finger and three fractures of the thumb. Figs 2a, 2b, 3a, 3b, 4a and 4b show pre-operative AP and lateral radiographs of two patients with proximal interphalangeal joint fractures (cases 30 and 63 in Table 1) and one patient with an interphalangeal fracture of the thumb (case 3 in Table 4). All patients were operated on by the senior author (N.F.). The procedure has been described previously (Fahmy, 1990). The required components consist of two modified K-wires (pins) and two serpentine springs (Fig 1). The pins are shouldered with a sharp point of various lengths to allow for bicortical placement. The pins are also notched at 1 cm intervals to allow placement of the springs at various positions. Distraction is achieved by inserting the pins percutaneously into normal phalangeal bone on either side of the injured joint after making percutaneous stab incisions in the skin with a size 15 blade. Dorsal pin placement is suitable for all finger joints. However, depending on the nature of the facture, the pins could be introduced via the lateral approach. The injured joint is distracted by gentle manipulation, correcting associated rotational and angular deformity. In the case of dorsal approach for the proximal interphalangeal joint fractures, the distal pin is inserted into the bare area just distal to the
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insertion of the central slip on the middle phalanx. The proximal pin requires a 2–3 mm longitudinal slit in the extensor tendon to avoid transfixing it with the pin. The pins are then power-drilled into the bone, passing through both cortices whilst maintaining traction at the fracture site in some flexion. The pins are placed in the same sagittal plane to avoid rotation. One of the serpentine springs is inserted between the two pins to fit the first or second grooves near the bone (Fig 1). The free ends of the pins are then brought closer together whilst stabilizing the spring onto the grooves on the pins, thus applying distraction between the sharp ends by a levering action on the first spring. The second serpentine spring is then applied across the grooves, one or two notches higher than the first spring to maintain the distraction. A check X-ray is taken with an image intensifier in theatre. The pin–spring interface is secured with adhesive and excess spring or pin length cut off. A watertight sufratulle dressing is applied at the base of the pins, at their junction with skin. This is left undisturbed for the duration of the S-Quattro application. In the final position, the pins should be diverging from the blunt to the pointed end. The distraction force, with the pins in a diverging direction from blunt to pointed ends, will act on the pins to push them deeper into the bone but this will be prevented by the undercut
Fig 4 (a and b) Pre-operative AP and lateral radiographs of case 3 from Table 4.
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shoulders of the pins. This gives the system inherent stability and guards against backing out of the pins. Postoperative radiographs were obtained for all patients. Figs 5a, 5b, 6a, 6b, 7a and 7b show the radiographs for three patients (cases 30 and 63 in Table 1; case 3 in Table 4). All operations are performed under local anaesthetic and all patients are discharged on the same day. They were encouraged to mobilize the digit and are reviewed weekly for 3 weeks for check X-rays. The fixators are removed between 4 to 6 weeks postoperatively in the Out-patient Clinic by cutting the springs and then pulling the pins without the need of local anaesthetic. The patients are advised on active exercises to carry out by themselves. Physiotherapy is occasionally needed. If recovery is slow, manipulation of the joint under local anaesthetic can speed recovery. For proximal interphalangeal joint fractures, the technique of proximal and distal pin insertion described previously ensures that the extensor tendon is not pinned to the underlying bone, so creating adhesion and limiting finger flexion after removal of the S-Quattro. Clinical outcome was assessed by measurement of joint ranges of motion, pain and patient satisfaction. The ranges of motion were measured for all the joints of the injured digit with a standard goniometer. Pain was
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measured as no pain, mild, moderate and severe pain. The range of motion, pain and patient satisfaction were assessed at the last follow-up appointment. Radiographs were evaluated for fracture union, articular congruity and joint space narrowing.
RESULTS Eighty-one patients sustained fractures of the proximal interphalangeal joint (Table 1). These patients underwent surgery, on average, 7.1 days after sustaining the injury and were followed up for an average of 10.7 months. Objective analysis revealed an average arc of movement of the affected joint of 921 (range 60–1201) at last follow-up. The total active motion (TAM) of all the joints in the injured digit was 2551 (range 225–2801). Six patients reported mild or occasional pain and two patients reported moderate pain at final follow-up. Only the two patients who reported moderate pain were not satisfied with the result. One of these patients was a 94 year-old lady who had a 651 arc of movement. The Xray appearance in her case was satisfactory. The other patient was a 50 year-old woman who had a 701 arc of movement but developed secondary osteoarthritis, requiring a silastic joint replacement in view of the
Fig 5 (a and b) AP and lateral radiographs with the S-Quattro in situ in case 30 from Table 1.
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Fig 6 (a and b) AP and lateral radiographs with the S-Quattro in situ in case 64 from Table 1.
clinical symptoms of pain and swelling. There was one further complication in this group: the external fixation device was knocked off and required re-application. Postoperative radiographic appearances showed restoration of the articular contour in all but five out of the 81 patients. One was the patient who required the silastic joint replacement. The others were asymptomatic. The postoperative AP and lateral X-rays for two patients (cases 30 and 63 in Table 1) are shown in Figs 8a, 8b, 9a and 9b. Ten patients sustained fractures of the distal interphalangeal joint (Table 2). These patients underwent surgery, on average, 6.7 days after sustaining the injury and were followed-up for an average of 9.7 months. Objective analysis revealed an average arc of movement of the affected joint of 821 (range 65–1001) at final follow-up. The TAM for all the joints in the injured digit was 2741 (range 260–2801). Nine out of the 10 patients reported no pain. One patient reported moderate pain but was satisfied with the results. He was a 36 year-old
man who sustained the injury in an industrial accident. At final follow-up, he had a 701 arc of movement and the radiographic appearances were satisfactory. There was one complication: the external fixation device was knocked off and required re-application. Postoperative radiographic appearances showed restoration of the articular contour in all 10 patients. Six patients sustained fractures of the metacarpophalangeal joint (Table 3). These patients underwent surgery, on average, 6 days after sustaining the injury and were followed-up for an average of 11.3 months. Objective analysis revealed an average arc of movement of the affected joint of 911 (range 90–951) at last followup. The TAM for all the joints in the injured digit was 2741 (range 265–2801). None of the patients reported any pain and there were no complications. Postoperative radiographic appearances showed restoration of the articular contour in all six patients. Three patients sustained fractures of the interphalangeal joint of the thumb (Table 4). These patients
ARTICLE IN PRESS INTRAARTICULAR PHALANGEAL FRACTURES OF THE HAND
Fig 7 (a and b) AP and lateral radiographs with the S-Quattro in situ in case 3 from Table 4.
Fig 8 (a and b) AP and lateral radiographs at last follow-up in case 30 from Table 1.
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Fig 9 (a and b) AP and lateral radiographs at last follow-up in case 64 from Table 1.
underwent surgery, on average, 7.7 days after sustaining the injury and were followed-up for an average of 8 months. Objective analysis revealed an average arc of movement of the affected joint of 801 for all three patients at last follow-up. The TAM for the metacarpophalangeal joint and the interphalangeal joint in the thumb was 1131 (range 110–1151) degrees. None of the patients reported any pain and there were no complications. Postoperative radiographic appearances showed restoration of the articular contour in all three patients. The postoperative AP and lateral radiographs for one patient (case 3 in Table 4) are shown in Figs 10a and 10b.
DISCUSSION There are two main principles in the management of intraarticular fractures. The first is to obtain good congruency of the joint by reduction and stabilization of fragments. This helps minimize the long-term sequelae of pain and arthritis. Ligamentotaxis helps to reduce the fragments by its action on the attached ligaments and the capsular structures. This may also improve some central depression (Schenck, 1994). The second principle involves early motion to prevent joint stiffness and promote pain free movements by allowing free gliding of adjacent tendons. Early joint motion reduces swelling and facilitates joint nutrition, surface remodelling,
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Fig 10 (a and b) AP and lateral radiographs at last follow-up in case 3 from Table 4.
contouring and healing (Salter, 1994; Schenck, 1994). It guards against tendon adherence and subsequent joint stiffness. It also prevents fibrous thickening of collateral ligaments and contractures of the palmar plate with subsequent restriction of extension (Hasting and Ernst, 1993). The traction prevents shortening of the ligaments, which would contribute to joint stiffness. Intermittent compression of cartilage during normal joint motion is necessary to provide nutrition from synovial joint diffusion (Salter, 1994). Continuous compression by immobilizing a joint prevents diffusion of synovial fluid and results in pathological changes in the cartilage (Agee, 1987). The challenge in treating intraarticular phalangeal fractures has been to obtain, then maintain, anatomical alignment and stable fixation to permit early motion. The S-Quattro external fixation device works on the principle of ligamentotaxis. It has the advantage of restoration of the articular surface and early joint motion. Although the S-Quattro allows limited movement of the injured joint, it allows free movement of the other digital joints. This reduces swelling, prevents tendon adherence and allows quick recovery after the removal of the external fixator. The distraction stretches the collateral ligaments and the joint capsule. This also
contributes to the increased postoperative range of movement. It has been designed to deal with all types of displaced fracture dislocation of the digit and can fit across any of the finger joints. It is a versatile system in terms of the number of positions in which its pins and springs can be positioned. Depending on the nature of the fracture, the pins could be introduced via the lateral approach rather than the dorsal approach. Although this allows more movement of the injured joint, the dorsal approach is easier and allows the patients to use their hands with minimal discomfort. Due to the inherent elasticity of the system, some movement of the injured joint is possible while maintaining reduction and allowing free movements of the uninjured joints. This helps mould the irregular joint surfaces and prevents, adherence and, hence, joint stiffness. This also allows a quick recovery after removal of the external fixator. It can be applied easily and quickly. It is light and is well tolerated by patients. It is relatively free of complications and the results are good. It is particularly suitable in cases where the fragments are too small to fix and there is comminution involving the articular surface. The device achieves good reduction of the fracture without interfering with the fracture site.
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Our results compare favourably with those in other published series. Although the reported follow-up period in this study was 6 months, or less in 12 out of the 100 cases, we have noted, in this study, that patients regained more movement and less pain after the second 6 months of the first year. This trend was also shown by Fahmy (1990) and O’Rourke et al. (1989). More favourable results are expected if the patients are less than 40 years of age, have no associated osteoarthritis and are treated within 1 week of injury (Fahmy, 1990). References Agee JM (1987). Unstable fracture dislocation of the proximal interphalangeal joint: treatment with a force couple splint. Clinical Orthopaedics and Related Research, 214: 101–112. Allison DM (1996). Fractures of the base of the middle phalanx treated by a dynamic external fixation device. Journal of Hand Surgery, 21B: 305–310. Bain GI, Mehta JA, Heptinstall RJ, Bria M (1998). Dynamic external fixation for injuries of the proximal interphalangeal joint. Journal of Bone and Joint Surgery, 80B: 1014–1019. Blazar PE, Steinberg DR (2000). Fractures of the proximal interphalangeal joint. Journal of American Academy of Orthopaedic Surgery, 8: 383–390. Bostock S, Fahmy NRM, Nee P (1993a). The ‘S’ Quattro- results of treatment in eleven cases of sports injury. British Journal of Sports Medicine, 27: 268–270. Bostock S, Nee PA, Fahmy NR (1993b). The ‘S’ Quattro: a new system for the management of difficult intra-articular fractures of the phalanges. Archives of Emergency Medicine, 10: 55–59. Buchanan RT (1994). Mechanical requirements for application and modification of the dynamic force couple method. Hand Clinics, 10: 221–228. Dennys LJ, Hurst LN, Cox J (1992). Management of proximal interphalangeal joint fractures using a new dynamic traction splint and early active movements. Journal of Hand Therapy, 1: 16–24. DeSoras X, DeMourgues P, Guinard D, Moutet F (1997). Pins and rubbers traction system. Journal of Hand Surgery, 22B: 730–735. Eaton RG, Malerich MM (1980). Volar plate arthroplasty of the proximal interphalangeal joint: a review of ten year’s experience. Journal of Hand Surgery, 5: 260–268. Fahmy NRM (1990). The Stockport Serpentine Spring System for the treatment of displaced comminuted intraarticular phalangeal fractures. Journal of Hand Surgery, 15B: 303–311. Fahmy NRM, Harvey RA (1992). The ‘S’ Quattro in the management of fractures in the hand. Journal of Hand Surgery, 17B: 321–331. Fahmy NRM, Kehoe N, Warner JG, Courtman N (1998). The ‘S’ Quattro Turbo in the management of neglected dorsal interphalangeal dislocations. Journal of Hand Surgery, 23B: 248–251. Fahmy NRM, Kenny N, Kehoe N (1994). Chronic fracture dislocations of the proximal interphalangeal joint- treatment by the ‘S’ Quattro. Journal of Hand Surgery, 19B: 783–787. Gaul Jr, JS, Rosenberg SN (1998). Fracture dislocation of the middle phalanx at the proximal interphalangeal joint: repair with a simple intra-digital traction fixation device. American Journal of Orthopaedics, 27: 682–688. Hannen Mullett J, Synnott K, Noel J, Kelly EP (1999). Use of the ‘S’ Quattro dynamic external fixator in the treatment of difficult hand fractures. Journal of Hand Surgery, 24B: 350–354. Hasting II H, Ernst JMJ (1993). Dynamic external fixation for fractures of the proximal interphalangeal joint. Hand Clinics, 9: 659–674.
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Hynes MC, Giddins GEB (2001). Dynamic external fixation for pilon fractures of the interphalangeal joint. Journal of Hand Surgery, 26B: 122–124. Inanami H, Ninomiya S, Okutsu I, Tarui T, Fujiwara N (1993). Dynamic external finger fixator for fracture dislocation of the proximal interphalangeal joint. Journal of Hand Surgery, 18A: 160–164. Johnson D, Tiernan E, Richards AM, Cole RP (2004). Dynamic external fixation for complex intra-articular phalangeal fractures. Journal of Hand Surgery, 29B: 76–81. Krakauer JD, Stern PJ (1996). Hinged device for fractures involving the proximal interphalangeal joint. Clinical Orthopaedic Related Research, 327: 29–37. Majumder S, Peck F, Watson JS, Lees VC (2003). Lessons learned from the management of complex intra-articular fractures at the base of the middle phalanges of fingers. Journal of Hand Surgery, 28B: 559–565. Morgan JP, Gordan DA, Klug MS, Perry PE, Barre PS, Dayton OH (1995). Dynamic digital traction for unstable comminuted intraarticular fracture dislocations of the proximal interphalangeal joint. Journal of Hand Surgery, 20A: 565–573. O’Rourke SK, Gaur S, Barton NJ (1989). Long-term outcome of articular fractures of the phalanges: an eleven year follow-up. Journal of Hand Surgery, 14B: 183–193. Safoury Y (2001). Treatment of phalangeal fractures by tension band wiring. Journal of Hand Surgery, 26B: 50–52. Salter RB (1994). The physiological basis of continuous passive motion for articular cartilage healing and regeneration. Hand Clinics, 10: 211–219. Schenck RR (1994). The dynamic traction method—combining movement and traction for intra-articular fractures of the phalanges. Hand Clinics, 10: 187–198. Schenck RR (1986). Dynamic traction and early passive movement for fractures of the proximal interphalangeal joint. Journal of Hand Surgery, 11A: 850–858. Stern PJ, Roman RJ, Keifhaber TR, McDonough JJ (1991). Pilon fractures of the proximal interphalangeal joint. Journal of Hand Surgery, 16A: 844–850. Suzuki Y, Matsunaga T, Sato S, Yokoi T (1994). The pins and rubbers traction system for treatment of comminuted intraarticular fractures and fracture-dislocations in the hand. Journal of Hand Surgery, 19B: 98–107. Syed AA, Agarwal M, Boome R (2003). Dynamic external fixator for pilon fractures of the proximal interphalangeal joint: a simple fixator for a complex fracture. Journal of Hand Surgery, 28B: 137–141. Vidal J, Buscayret C, Connes H. Treatment of articular fractures by ‘ligamentotaxis’ with external fixation. In: Brooker AF, Edwards CC (Eds) External fixation – the current state of the art, Williams & Jenkins, Baltimore, 1975: 75–81. Viegas SF (1992). Extension block pinning for proximal interphalangeal joint fracture dislocations: preliminary report of a new technique. Journal of Hand Surgery, 17A: 896–901. Weiss APC (1996). Cerclage fixation for fracture dislocation of the proximal interphalangeal joint. Clinical Orthopaedics and Related Research, 327: 21–28. Received: 14 October 2004 Accepted after revision: 15 September 2005 Mr W. Khan, 3 Lower Brook Lane, Worsley, Manchester, M28-2LL, UK. Tel.: +161 727 9331 E-mail: [email protected]
r 2005 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2005.09.014 available online at http://www.sciencedirect.com
Intraarticular phalangeal fractures of the hand are difficult and challenging to manage. Dynamic external fixation devices offer the advantages of allowing distraction of the impacted fracture and early joint mobilization. We present our study of 100 patients with a variety of fractures who were treated with the S-Quattro technique over a 6-year period, with an average follow-up of 10.5 months. The mean active range of motion regained was 921 for proximal interphalangeal joints (81 fractures), 821 for distal interphalangeal joints (10 fractures), 911 for metacarpophalangeal joints (6 fractures) and 801 for interphalangeal joints of the thumb (3 fractures). Only nine patients complained of mild or moderate pain. Postoperative radiographic appearances were satisfactory in all but five out of the 100 patients. This device is a simple and effective technique for the management of these difficult fractures. It offers advantages in terms of versatility, ease of application, good tolerance by patients, few complications and good outcome. Journal of Hand Surgery (British and European Volume, 2006) 31B: 1: 79–92 Keywords: S-Quattro, external fixation, intraarticular fractures, phalangeal fractures
INTRODUCTION The management of displaced intraarticular phalangeal fractures of the small joints of the hand is difficult, challenging and controversial. These joints are uniquely susceptible to injury due to their limited, singular plane of motion (Blazar and Steinberg, 2000). Commonly encountered problems include angulation, flexion deformity, malrotation, malunion, joint stiffness and joint subluxation. A spectrum of joint injury pattern occurs depending on the direction, rate and force of loading. If the loading force is severe and axially directed, a pilon-type injury can occur (Hasting and Ernst, 1993). Pilon fractures are characterized by comminution involving the entire base of the phalanx and are associated with central depression or splaying of the concave articular surface in the coronal plane, sagittal plane or both (Syed et al., 2003). If the force is directed from the dorsal or palmar direction, then a fracture of the corresponding lip of the articular surface is likely. This may be associated with a dislocation or a subluxation. Subluxation occurs when the fracture involves a significant proportion of the articular surface. Other fracture patterns include unicondylar and bicondylar fractures. Non-operative management, comprising of immobilization with splintage, produces poor results with pain, stiffness and reduced range of motion (Stern et al., 1991). To obtain the best functional result, it is important that any subluxation is reduced and early mobilization instituted. Although these fractures can usually be reduced by the traction principle, methods of maintaining reduction until the fracture has united are difficult and often compromise joint movement.
Fig 1 Components of the S-Quattro system and their application. 79
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Surgical treatment is problematic for two reasons. Firstly, the fracture fragments are small and, often, comminuted. This makes anatomical reconstruction difficult. Secondly, there is a need for joint mobilization during the healing period to prevent long-term stiffness. Immobilization for longer than 3 weeks can result in permanent loss of motion (Blazar and Steinberg, 2000). Open reduction and internal fixation with K-wire fixation (Gaul and Rosenberg, 1998; Hasting and Ernst, 1993; Syed et al., 2003; Viegas, 1992), intraosseous wiring of the palmar fragment (Safoury, 2001; Weiss, 1996) and palmar plate advancement (Eaton and Malerich, 1980) have been described but are technically demanding and time consuming. Fahmy (1990) and Stern et al. (1991) recommended distraction on the basis that it allowed early mobilization which, theoretically, resulted in improved cartilage and soft tissue nutrition and prevented extensor tendon adherence. Over the past three decades, old methods of treatment have been combined with new concepts including intradigital traction, capsuloligamentotaxis (Vidal et al., 1975) and the beneficial effects of early motion on articular remodelling (Gaul and Rosenberg, 1998). Several techniques of distraction have been described with variable results. These include external
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fixation devices (Allison, 1996; Hynes and Giddins, 2001) using a force couple splint (Agee, 1987; Buchanan, 1994), dynamic longitudinal traction (Dennys et al., 1992; Morgan et al., 1995; Schenck, 1986), compass hinges (Bain et al., 1998; Krakauer and Stern, 1996), pins and rubber traction systems (DeSoras et al., 1997; Majumder et al., 2003; Suzuki et al., 1994) and dynamic springs (Blazar and Steinberg, 2000; Inanami et al., 1993; Johnson et al., 2004). All existing techniques have their advantages and disadvantages. The disadvantages include complexity of the systems, the inconvenience experienced by the patients, loosening and infection. Nevertheless, dynamic traction splintage is now established in the treatment of intraarticular phalangeal fractures. Fahmy (1990) recommended distraction of the joint using pins and springs, which allows limited movement of the injured joint and free movement of the other digital joints. This allows quick recovery after the removal of the external fixator. The Stockport Serpentine Spring System, abbreviated to ‘‘S-Quattro’’, was developed as an external fixator (Fig 1) (Fahmy, 1990). It consists of a unique, dual, parallel but opposing action, spring column system. This system was devised by the senior author and has been used successfully in
Fig 2 (a and b) Pre-operative AP and lateral radiographs of case 30 from Table 1.
Sex
M M
F F M M M M M M
M
M M M M
M F F M F M M F M M
F F M F M M M M M M
Case number
1 2
3 4 5 6 7 8 9 10
11
12 13 14 15
16 17 18 19 20 21 22 23 24 25
26 27 28 29 30 31 32 33 34 35
Fall Fall RTA Fall RTA Sports Fall Sports RTA Sports
Sports Fall Fall Industrial accident Fall Fall Assault Sports Fall Sports Sports RTA Sports Assault
Fall Industrial accident Assault Fall Assault RTA Assault Sports RTA Industrial accident RTA
Mode of injury
Right Ring Left Ring Right Middle Left Index Right Little Left Index Right Middle Left Middle Left Ring Right Ring
Left Middle Left Little Left Index Right Ring Right Little Right Ring Right Little Left Middle Left Ring Left Little
Left Ring Right Middle Right Index Right Index
Right Ring
Right Little Left Little Right Ring Left Ring Left Little Right Middle Right Little Right Middle
Right Ring Left Index
Injured digit
Palmar lip Pilon Pilon Dorsal lip Bicondylar Dorsal lip Palmar lip Dorsal lip Pilon Pilon
Dorsal lip Palmar lip Pilon Dorsal lip Pilon Unicondylar Dorsal lip Dorsal lip Dorsal lip Pilon
Pilon Dorsal lip Pilon Pilon
Pilon
Pilon Pilon Pilon Dorsal lip Pilon Bicondylar Pilon Palmar lip
Pilon Dorsal lip
Fracture type
Yes No No Yes Yes No Yes Yes No No
Yes No No Yes No No Yes No No No
No Yes No No
No
No No No Yes No No No Yes
No Yes
Subluxation
7 20 12 1 2 5 4 3 7 4
2 5 25 1 8 16 5 3 6 12
3 2 4 4
9
25 16 3 9 7 2 2 30
4 2
Time lapse from injury to surgery (days)
9 7 7 8 12 10 10 11 14 9
10 12 8 7 12 10 10 14 12 13
5 13 12 12
4
6 12 7 16 13 5 12 10
12 6
Last follow-up (months)
70 90 120 85 90 110 100 70 100 95
110 90 85 95 90 85 95 105 90 85
85 110 95 90
100
100 65 80 95 80 120 90 100
80 100
Postoperative range of motion (deg)
230 265 275 255 250 280 265 245 265 265
275 260 260 250 260 245 250 280 245 250
240 265 265 250
265
275 225 235 255 245 275 250 270
245 275
Total active motion (deg)
Mild No No No No No No Mild No No
No No No No No No No No No No
No No No No
No
No Moderate No No No No No No
No No
Pain
None None None None None None None None None None
None None None None None None None None None None
None None None None
None
None None None None None None None None
None None
Complications
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes
Yes
Yes No Yes Yes Yes Yes Yes Yes
Yes Yes
Patient satisfaction
Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Incongruous articular surface Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory
Incongruous articular surface Satisfactory Satisfactory Satisfactory Satisfactory
Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory
Satisfactory Satisfactory
X-ray appearance
INTRAARTICULAR PHALANGEAL FRACTURES OF THE HAND
79 22 53 36 49 22 59 45 32 42
27 55 38 29 78 37 32 38 33 48
46 46 33 42
20
39 94 33 58 31 44 49 61
42 21
Age
Table 1—Patient details for finger proximal interphalangeal joint fractures
ARTICLE IN PRESS 81
Sex
M M F M
M F F
M M
F M
M
M M F F M F F F M M M M M F M M M M
F M
Case number
36 37 38 39
40 41 42
43 44
45 46
47
48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
66 67
Sports Sports Fall Fall Fall Fall Assault Fall RTA Fall Sports Sports Fall Fall Sports Fall Fall Industrial accident Sports RTA
Right Ring Left Index
Left Ring Left Ring Right Index Left Index Left Middle Right Little Right Middle Left Little Right Middle Right Index Right Index Left Index Right Middle Right Index Left Index Right Ring Left Little Right Index
Left Middle
Left Index Right Index
Right Ring Right Ring
Right Middle Left Little Left Ring
Right Middle Right Index Right Little Right Ring
Injured digit
Dorsal lip Pilon
Dorsal lip Dorsal lip Dorsal lip Pilon Dorsal lip Pilon Pilon Pilon Dorsal lip Pilon Dorsal lip Palmar lip Pilon Unicondylar Dorsal lip Pilon Palmar lip Dorsal lip
Pilon
Dorsal lip Unicondylar
Pilon Pilon
Pilon Palmar lip Pilon
Dorsal lip Dorsal lip Pilon Dorsal lip
Fracture type
Yes No
Yes Yes No No No No No No Yes No No Yes No No Yes No Yes No
No
No No
No No
No Yes No
No Yes No Yes
Subluxation
1 8
2 5 11 4 11 8 13 3 4 5 16 7 3 1 6 8 11 5
2
6 22
7 10
14 2 4
1 3 1 12
Time lapse from injury to surgery (days)
13 14
8 8 10 12 10 12 11 14 14 10 10 8 12 16 10 10 11 9
5
12 10
13 6
9 12 24
14 12 16 6
Last follow-up (months)
95 80
105 100 80 95 100 80 85 75 105 95 95 110 100 80 90 60 95 100
95
95 90
100 60
100 95 70
100 110 90 95
Postoperative range of motion (deg)
270 245
255 255 240 265 265 245 270 255 270 265 275 275 255 245 260 225 265 255
255
270 245
255 225
265 260 235
275 265 260 250
Total active motion (deg)
No No
No No No No No No No No No No No No No Mild No No No No
No
No No
No Mild
No Mild Moderate
No No No No
Pain
None None
None None None None None None None None None None None None None None None None None None
None
None None
None None None Reapplication of S-Quattro None None Secondary osteoarthritis requiring silastic joint replacement None None
Complications
Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes
Yes Yes
Yes Yes
Yes Yes No
Yes Yes Yes Yes
Patient satisfaction
Satisfactory Satisfactory
Incongruous articular surface Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory
Satisfactory Satisfactory
Satisfactory Satisfactory
Satisfactory Satisfactory Secondary osteoarthritic changes
Satisfactory Satisfactory Satisfactory Satisfactory
X-ray appearance
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19 36
26 34 67 33 44 74 23 35 36 53 32 32 29 64 23 39 23 54
Fall Industrial accident Fall Industrial accident RTA
Sports Sports Fall
Sports Fall Fall Sports
Mode of injury
82
46
58 44
33 18
21 51 50
18 48 53 46
Age
Table 1. (continued )
ARTICLE IN PRESS 2006
F M
M M M F M
75 76
77 78 79 80 81
32 23 37 46 23
56 23
48 21 29 67 23 45 53
Assault Sports Sports Fall Fall
Fall Assault RTA Fall Fall RTA Industrial accident Fall Assault
Left Index Left Little Right Index Left Ring Right Little
Left Little Left Index
Right Little Right Little Right Ring Right Middle Left Index Left Ring Right Index
Pilon Dorsal lip Dorsal lip Dorsal lip Pilon
Palmar lip Unicondylar
Dorsal lip Pilon Pilon Dorsal lip Dorsal lip Pilon Unicondylar
No Yes No Yes No
Yes No
Yes No No No Yes No No
Sex
M
F M M M F F M
M
M
Case number
1
2 3 4 5 6 7 8
9
10
32
28
32 42 71 25 41 72 33
36
Age
Fall
Industrial accident Sports Assault Fall Sports Fall Fall Industrial accident Assault
Mode of injury
Right Ring
Left Ring
Left Index Right Ring Left Ring Right Ring Right Ring Left Middle Right Ring
Right Middle
Injured digit
Pilon
Pilon
Pilon Pilon Pilon Dorsal lip Pilon Pilon Pilon
Pilon
Fracture type
No
No
No No No Yes No No No
No
Subluxation
Table 2—Patient details for finger distal interphalangeal joint fractures
M M M M F M M
68 69 70 71 72 73 74
8
1
2 7 15 11 14 5 2
2
Time lapse from injury to surgery (days)
5 6 1 4 14
12 22
2 9 3 2 1 4 2
14
6
13 8 10 8 11 11 9
7
Last follow-up (months)
8 12 6 11 12
12 9
12 7 13 13 12 13 12
80
65
85 75 85 90 85 90 90
70
Postoperative range of motion (deg)
80 105 85 85 90
80 85
105 80 90 100 80 95 75
275
260
280 270 275 280 280 275 280
265
Total active motion (deg)
265 270 250 260 255
255 265
265 250 245 250 260 250 230
No
No
No No No No No No No
Moderate
Pain
No No Mild No No
No No
No No No No No No No
Reapplication of S-Quattro None
None None None None None None None
None
Complications
None None None None None
None None
None None None None None None None
Yes
Yes
Yes Yes Yes Yes Yes Yes Yes
Yes
Patient satisfaction
Yes Yes Yes Yes Yes
Yes Yes
Yes Yes Yes Yes Yes Yes Yes
Satisfactory
Satisfactory
Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory
Satisfactory
X-ray appearance
Satisfactory Incongruous articular surface Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory
Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory
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INTRAARTICULAR PHALANGEAL FRACTURES OF THE HAND 83
M F M
F M M
1 2 3
4 5 6
26 32 21
21 29 27
Age
Sports Fall Industrial accident Fall Sports Industrial accident
Mode of injury
Left Ring Right Index Left Index
Right Ring Left Ring Left Middle
Injured digit
Pilon Pilon Dorsal lip
Dorsal lip Dorsal lip Dorsal lip
Fracture type
Sex
M M F
Case number
1 2 3
19 28 18
Age
RTA Sports Fall
Mode of injury
Right Thumb Right Thumb Right Thumb
Injured digit
Pilon Pilon Pilon
Fracture type
No No No
Subluxation
No No Yes
No Yes Yes
Subluxation
7 11 5
Time lapse from injury to surgery (days)
5 6 4
14 5 2
Time lapse from injury to surgery (days)
5 8 11
Last follow-up (months)
8 14 16
6 8 16
Last follow-up (months)
80 80 80
Postoperative range of motion (deg)
90 90 90
90 90 95
Postoperative range of motion deg)
115 110 115
Total active motion (deg)
280 270 265
275 280 275
Total active motion (deg)
No No No
Pain
No No No
No No No
Pain
None None None
Complications
None None None
None None None
Complications
Yes Yes Yes
Patient satisfaction
Yes Yes Yes
Yes Yes Yes
Patient satisfaction
Satisfactory Satisfactory Satisfactory
X-ray appearance
Satisfactory Satisfactory Satisfactory
Satisfactory Satisfactory Satisfactory
X-ray appearance
84
Table 4—Patient details for thumb interphalangeal joint fractures
Sex
Case number
Table 3—Patient details for finger metacarpophalangeal joint fractures
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ARTICLE IN PRESS INTRAARTICULAR PHALANGEAL FRACTURES OF THE HAND
the management of intraarticular phalangeal fractures of the hand for the last 14 years (Bostock et al., 1993a,b; Fahmy, 1990; Fahmy and Harvey, 1992; Fahmy et al., 1994, 1998; Hannen Mullett et al., 1999). This study evaluates the use of this technique in 100 patients with a variety of fractures over a 6 year period.
PATIENTS AND METHODS A retrospective study was conducted on the use of SQuattro for acute intraarticular phalangeal fractures of the hand. One hundred patients with a variety of fractures underwent the described procedure over a 6 year period. All fractures involved a single joint and were closed injuries. There were 81 fractures of the
85
proximal interphalangeal joint (Table 1), 10 fractures of the distal interphalangeal joint (Table 2), six fractures of the metacarpophalangeal joint (Table 3) and three fractures of the interphalangeal joint of the thumb (Table 4). The sex, age, mode of injury, injured digit, type of fracture and subluxation and time lapse to surgery are detailed in the tables. In total, 71 of the patients were men and 29 were women. The mean age for all the patients was 39.3 (range 18–94) years. The mode of injury was a fall in 39 fractures, sports in 26 fractures, road traffic accidents in 13 fractures, industrial accidents in 11 fractures and assault in 11 fractures. Fifty-six fractures involved the right hand and 44 fractures involved the left hand. There were 33 fractures of the ring finger, 26 fractures of the index finger, 19 fractures of the middle finger, 19
Fig 3 (a and b) Pre-operative AP and lateral radiographs of case 64 from Table 1.
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fractures of the little finger and three fractures of the thumb. Figs 2a, 2b, 3a, 3b, 4a and 4b show pre-operative AP and lateral radiographs of two patients with proximal interphalangeal joint fractures (cases 30 and 63 in Table 1) and one patient with an interphalangeal fracture of the thumb (case 3 in Table 4). All patients were operated on by the senior author (N.F.). The procedure has been described previously (Fahmy, 1990). The required components consist of two modified K-wires (pins) and two serpentine springs (Fig 1). The pins are shouldered with a sharp point of various lengths to allow for bicortical placement. The pins are also notched at 1 cm intervals to allow placement of the springs at various positions. Distraction is achieved by inserting the pins percutaneously into normal phalangeal bone on either side of the injured joint after making percutaneous stab incisions in the skin with a size 15 blade. Dorsal pin placement is suitable for all finger joints. However, depending on the nature of the facture, the pins could be introduced via the lateral approach. The injured joint is distracted by gentle manipulation, correcting associated rotational and angular deformity. In the case of dorsal approach for the proximal interphalangeal joint fractures, the distal pin is inserted into the bare area just distal to the
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insertion of the central slip on the middle phalanx. The proximal pin requires a 2–3 mm longitudinal slit in the extensor tendon to avoid transfixing it with the pin. The pins are then power-drilled into the bone, passing through both cortices whilst maintaining traction at the fracture site in some flexion. The pins are placed in the same sagittal plane to avoid rotation. One of the serpentine springs is inserted between the two pins to fit the first or second grooves near the bone (Fig 1). The free ends of the pins are then brought closer together whilst stabilizing the spring onto the grooves on the pins, thus applying distraction between the sharp ends by a levering action on the first spring. The second serpentine spring is then applied across the grooves, one or two notches higher than the first spring to maintain the distraction. A check X-ray is taken with an image intensifier in theatre. The pin–spring interface is secured with adhesive and excess spring or pin length cut off. A watertight sufratulle dressing is applied at the base of the pins, at their junction with skin. This is left undisturbed for the duration of the S-Quattro application. In the final position, the pins should be diverging from the blunt to the pointed end. The distraction force, with the pins in a diverging direction from blunt to pointed ends, will act on the pins to push them deeper into the bone but this will be prevented by the undercut
Fig 4 (a and b) Pre-operative AP and lateral radiographs of case 3 from Table 4.
ARTICLE IN PRESS INTRAARTICULAR PHALANGEAL FRACTURES OF THE HAND
shoulders of the pins. This gives the system inherent stability and guards against backing out of the pins. Postoperative radiographs were obtained for all patients. Figs 5a, 5b, 6a, 6b, 7a and 7b show the radiographs for three patients (cases 30 and 63 in Table 1; case 3 in Table 4). All operations are performed under local anaesthetic and all patients are discharged on the same day. They were encouraged to mobilize the digit and are reviewed weekly for 3 weeks for check X-rays. The fixators are removed between 4 to 6 weeks postoperatively in the Out-patient Clinic by cutting the springs and then pulling the pins without the need of local anaesthetic. The patients are advised on active exercises to carry out by themselves. Physiotherapy is occasionally needed. If recovery is slow, manipulation of the joint under local anaesthetic can speed recovery. For proximal interphalangeal joint fractures, the technique of proximal and distal pin insertion described previously ensures that the extensor tendon is not pinned to the underlying bone, so creating adhesion and limiting finger flexion after removal of the S-Quattro. Clinical outcome was assessed by measurement of joint ranges of motion, pain and patient satisfaction. The ranges of motion were measured for all the joints of the injured digit with a standard goniometer. Pain was
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measured as no pain, mild, moderate and severe pain. The range of motion, pain and patient satisfaction were assessed at the last follow-up appointment. Radiographs were evaluated for fracture union, articular congruity and joint space narrowing.
RESULTS Eighty-one patients sustained fractures of the proximal interphalangeal joint (Table 1). These patients underwent surgery, on average, 7.1 days after sustaining the injury and were followed up for an average of 10.7 months. Objective analysis revealed an average arc of movement of the affected joint of 921 (range 60–1201) at last follow-up. The total active motion (TAM) of all the joints in the injured digit was 2551 (range 225–2801). Six patients reported mild or occasional pain and two patients reported moderate pain at final follow-up. Only the two patients who reported moderate pain were not satisfied with the result. One of these patients was a 94 year-old lady who had a 651 arc of movement. The Xray appearance in her case was satisfactory. The other patient was a 50 year-old woman who had a 701 arc of movement but developed secondary osteoarthritis, requiring a silastic joint replacement in view of the
Fig 5 (a and b) AP and lateral radiographs with the S-Quattro in situ in case 30 from Table 1.
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Fig 6 (a and b) AP and lateral radiographs with the S-Quattro in situ in case 64 from Table 1.
clinical symptoms of pain and swelling. There was one further complication in this group: the external fixation device was knocked off and required re-application. Postoperative radiographic appearances showed restoration of the articular contour in all but five out of the 81 patients. One was the patient who required the silastic joint replacement. The others were asymptomatic. The postoperative AP and lateral X-rays for two patients (cases 30 and 63 in Table 1) are shown in Figs 8a, 8b, 9a and 9b. Ten patients sustained fractures of the distal interphalangeal joint (Table 2). These patients underwent surgery, on average, 6.7 days after sustaining the injury and were followed-up for an average of 9.7 months. Objective analysis revealed an average arc of movement of the affected joint of 821 (range 65–1001) at final follow-up. The TAM for all the joints in the injured digit was 2741 (range 260–2801). Nine out of the 10 patients reported no pain. One patient reported moderate pain but was satisfied with the results. He was a 36 year-old
man who sustained the injury in an industrial accident. At final follow-up, he had a 701 arc of movement and the radiographic appearances were satisfactory. There was one complication: the external fixation device was knocked off and required re-application. Postoperative radiographic appearances showed restoration of the articular contour in all 10 patients. Six patients sustained fractures of the metacarpophalangeal joint (Table 3). These patients underwent surgery, on average, 6 days after sustaining the injury and were followed-up for an average of 11.3 months. Objective analysis revealed an average arc of movement of the affected joint of 911 (range 90–951) at last followup. The TAM for all the joints in the injured digit was 2741 (range 265–2801). None of the patients reported any pain and there were no complications. Postoperative radiographic appearances showed restoration of the articular contour in all six patients. Three patients sustained fractures of the interphalangeal joint of the thumb (Table 4). These patients
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Fig 7 (a and b) AP and lateral radiographs with the S-Quattro in situ in case 3 from Table 4.
Fig 8 (a and b) AP and lateral radiographs at last follow-up in case 30 from Table 1.
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Fig 9 (a and b) AP and lateral radiographs at last follow-up in case 64 from Table 1.
underwent surgery, on average, 7.7 days after sustaining the injury and were followed-up for an average of 8 months. Objective analysis revealed an average arc of movement of the affected joint of 801 for all three patients at last follow-up. The TAM for the metacarpophalangeal joint and the interphalangeal joint in the thumb was 1131 (range 110–1151) degrees. None of the patients reported any pain and there were no complications. Postoperative radiographic appearances showed restoration of the articular contour in all three patients. The postoperative AP and lateral radiographs for one patient (case 3 in Table 4) are shown in Figs 10a and 10b.
DISCUSSION There are two main principles in the management of intraarticular fractures. The first is to obtain good congruency of the joint by reduction and stabilization of fragments. This helps minimize the long-term sequelae of pain and arthritis. Ligamentotaxis helps to reduce the fragments by its action on the attached ligaments and the capsular structures. This may also improve some central depression (Schenck, 1994). The second principle involves early motion to prevent joint stiffness and promote pain free movements by allowing free gliding of adjacent tendons. Early joint motion reduces swelling and facilitates joint nutrition, surface remodelling,
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Fig 10 (a and b) AP and lateral radiographs at last follow-up in case 3 from Table 4.
contouring and healing (Salter, 1994; Schenck, 1994). It guards against tendon adherence and subsequent joint stiffness. It also prevents fibrous thickening of collateral ligaments and contractures of the palmar plate with subsequent restriction of extension (Hasting and Ernst, 1993). The traction prevents shortening of the ligaments, which would contribute to joint stiffness. Intermittent compression of cartilage during normal joint motion is necessary to provide nutrition from synovial joint diffusion (Salter, 1994). Continuous compression by immobilizing a joint prevents diffusion of synovial fluid and results in pathological changes in the cartilage (Agee, 1987). The challenge in treating intraarticular phalangeal fractures has been to obtain, then maintain, anatomical alignment and stable fixation to permit early motion. The S-Quattro external fixation device works on the principle of ligamentotaxis. It has the advantage of restoration of the articular surface and early joint motion. Although the S-Quattro allows limited movement of the injured joint, it allows free movement of the other digital joints. This reduces swelling, prevents tendon adherence and allows quick recovery after the removal of the external fixator. The distraction stretches the collateral ligaments and the joint capsule. This also
contributes to the increased postoperative range of movement. It has been designed to deal with all types of displaced fracture dislocation of the digit and can fit across any of the finger joints. It is a versatile system in terms of the number of positions in which its pins and springs can be positioned. Depending on the nature of the fracture, the pins could be introduced via the lateral approach rather than the dorsal approach. Although this allows more movement of the injured joint, the dorsal approach is easier and allows the patients to use their hands with minimal discomfort. Due to the inherent elasticity of the system, some movement of the injured joint is possible while maintaining reduction and allowing free movements of the uninjured joints. This helps mould the irregular joint surfaces and prevents, adherence and, hence, joint stiffness. This also allows a quick recovery after removal of the external fixator. It can be applied easily and quickly. It is light and is well tolerated by patients. It is relatively free of complications and the results are good. It is particularly suitable in cases where the fragments are too small to fix and there is comminution involving the articular surface. The device achieves good reduction of the fracture without interfering with the fracture site.
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Our results compare favourably with those in other published series. Although the reported follow-up period in this study was 6 months, or less in 12 out of the 100 cases, we have noted, in this study, that patients regained more movement and less pain after the second 6 months of the first year. This trend was also shown by Fahmy (1990) and O’Rourke et al. (1989). More favourable results are expected if the patients are less than 40 years of age, have no associated osteoarthritis and are treated within 1 week of injury (Fahmy, 1990). References Agee JM (1987). Unstable fracture dislocation of the proximal interphalangeal joint: treatment with a force couple splint. Clinical Orthopaedics and Related Research, 214: 101–112. Allison DM (1996). Fractures of the base of the middle phalanx treated by a dynamic external fixation device. Journal of Hand Surgery, 21B: 305–310. Bain GI, Mehta JA, Heptinstall RJ, Bria M (1998). Dynamic external fixation for injuries of the proximal interphalangeal joint. Journal of Bone and Joint Surgery, 80B: 1014–1019. Blazar PE, Steinberg DR (2000). Fractures of the proximal interphalangeal joint. Journal of American Academy of Orthopaedic Surgery, 8: 383–390. Bostock S, Fahmy NRM, Nee P (1993a). The ‘S’ Quattro- results of treatment in eleven cases of sports injury. British Journal of Sports Medicine, 27: 268–270. Bostock S, Nee PA, Fahmy NR (1993b). The ‘S’ Quattro: a new system for the management of difficult intra-articular fractures of the phalanges. Archives of Emergency Medicine, 10: 55–59. Buchanan RT (1994). Mechanical requirements for application and modification of the dynamic force couple method. Hand Clinics, 10: 221–228. Dennys LJ, Hurst LN, Cox J (1992). Management of proximal interphalangeal joint fractures using a new dynamic traction splint and early active movements. Journal of Hand Therapy, 1: 16–24. DeSoras X, DeMourgues P, Guinard D, Moutet F (1997). Pins and rubbers traction system. Journal of Hand Surgery, 22B: 730–735. Eaton RG, Malerich MM (1980). Volar plate arthroplasty of the proximal interphalangeal joint: a review of ten year’s experience. Journal of Hand Surgery, 5: 260–268. Fahmy NRM (1990). The Stockport Serpentine Spring System for the treatment of displaced comminuted intraarticular phalangeal fractures. Journal of Hand Surgery, 15B: 303–311. Fahmy NRM, Harvey RA (1992). The ‘S’ Quattro in the management of fractures in the hand. Journal of Hand Surgery, 17B: 321–331. Fahmy NRM, Kehoe N, Warner JG, Courtman N (1998). The ‘S’ Quattro Turbo in the management of neglected dorsal interphalangeal dislocations. Journal of Hand Surgery, 23B: 248–251. Fahmy NRM, Kenny N, Kehoe N (1994). Chronic fracture dislocations of the proximal interphalangeal joint- treatment by the ‘S’ Quattro. Journal of Hand Surgery, 19B: 783–787. Gaul Jr, JS, Rosenberg SN (1998). Fracture dislocation of the middle phalanx at the proximal interphalangeal joint: repair with a simple intra-digital traction fixation device. American Journal of Orthopaedics, 27: 682–688. Hannen Mullett J, Synnott K, Noel J, Kelly EP (1999). Use of the ‘S’ Quattro dynamic external fixator in the treatment of difficult hand fractures. Journal of Hand Surgery, 24B: 350–354. Hasting II H, Ernst JMJ (1993). Dynamic external fixation for fractures of the proximal interphalangeal joint. Hand Clinics, 9: 659–674.
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r 2005 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2005.09.014 available online at http://www.sciencedirect.com