|Year : 2015 | Volume
| Issue : 4 | Page : 965-970
Results of management of recent fractures of phalanges of the hand by a mini external fixator
Ahmad F El-Shaer MBChB 1, Ahmad F Shams El-Deen2, Ashraf S El-Deen Abu Hussein2, Hassan A Neenaa2
1 Department of Orthopedic Surgery, Al-Menshawy Hospital, Tanta, Egypt
2 Department of Orthopedic Surgery, Faculty of Medicine, Menufiya University, Menofia, Egypt
|Date of Submission||12-Nov-2014|
|Date of Acceptance||15-Mar-2015|
|Date of Web Publication||12-Jan-2016|
Ahmad F El-Shaer
Department of Orthopedic Surgery, El Menshawy Hospital, Tanta, 31512
Source of Support: None, Conflict of Interest: None
This study focused on the management of patients with phalangeal fractures by a mini external fixator from April 2010 to October 2014. All procedures were performed under regional anesthesia. There were 10 open and 10 closed fractures and 15 comminuted and five oblique fractures.
These fractures can be treated conservatively or operatively depending on the nature of injuries, fracture pattern, and fracture stability.
Materials and methods
In this study, fractures were managed by a mini external fixator; 80% were managed on the same day of injury. The mean time of removal of the fixator was 18.4 days and the mean follow-up was 2.5 years. Complications occurred in nine fractures; 95% of fractures healed and just one case of nonunion was present. There was no need for removal of the fixator in the other complication.
It is obvious that patients with closed fractures show better results than those with open fractures; our result was markedly better in extra-articular fractures than intra-articular fractures. All patients above 60 years old had poor resulrs and the unstisfactory results (poor and fair) were increased when the time of application of fixator increase. In all cases, patients' satisfaction was high.
External fixation proved to be a suitable and alternative technique for stabilization of comminuted, oblique, and open fractures.
Keywords: fingers, hand, mini external fixator, phalanges
|How to cite this article:|
El-Shaer AF, Shams El-Deen AF, El-Deen Abu Hussein AS, Neenaa HA. Results of management of recent fractures of phalanges of the hand by a mini external fixator. Menoufia Med J 2015;28:965-70
|How to cite this URL:|
El-Shaer AF, Shams El-Deen AF, El-Deen Abu Hussein AS, Neenaa HA. Results of management of recent fractures of phalanges of the hand by a mini external fixator. Menoufia Med J [serial online] 2015 [cited 2020 Apr 2];28:965-70. Available from: http://www.mmj.eg.net/text.asp?2015/28/4/965/173689
| Introduction|| |
Phalangeal fractures, either closed or open, are common injuries of the hand. These injuries are encountered every day , . These fractures can be treated conservatively or operatively depending on the nature of injuries, fracture pattern, and fracture stability , .
The principal management involves restoration of articular congruity and fixation of the fracture with an internal or an external fixation device  . Anatomical reduction and stable fixation, followed by early mobilization represent the key treatment of these fractures. Inadequate treatments can lead to poor outcomes including chronic pain, stiffness, deformity, and premature degenerative arthritis , .
In comminuted and intra-articular fractures, open reduction with internal fixation simply using Kirschner's wire usually leads to incapability of early mobilization secondary to the smaller size of bone fragments or less fastness in fixation dragged by local ligament. It is also not ideal when there is a risk of infection because of open wounds and when further soft-tissue damage has to be avoided , .
External fixation offers an effective treatment option in the management of these difficult fractures and a variety of external fixators are available for this purpose  and act through distraction mobilization of the involved joint to maintain articular integrity through capsuloligamentotaxis  . Also, external fixators offer significant advantages in the form of minimal surgical trauma, preservation of fracture hematoma, short operative time, and minimal anesthetic complications, especially among old patients not fit for general anesthesia, and the removal of the fixator as a simple outpatient procedure  .
The current study reviewed the functional results in a group of patients with phalangeal fractures and either open wounds or severe soft-tissue injuries treated by external fixation.
| Materials and methods|| |
A total of randomized 20 prospective patients were admitted to Menufiya University hospital and El Menshawy Hospital, Egypt, from April 2010 to October 2014. The patients' age ranged between 21 and 62 years, with a mean age of 36.6 years. All the patients were men. Of 20 patients, 11 were right handed and nine were left handed and the distribution of fractures are shown in [Figure 1].
Inclusion criteria included comminuted, open, unstable fractures of phalanges, either intra-articular or extra articular, and patients with any underlying medical problems contraindicated to general anesthesia. Exclusion criteria for the use of a mini external fixator were skeletally immature patients and associated neurovascular injury and pathological fracture.
Between April and October 2010, 20 consecutive patients who fulfilled these inclusion criteria were referred to Menoufia University Hospitals and Al-Menshawy Hospital and were included in the current study. There were 10 (50%) open fractures and 10 (50%) closed fractures. There were 13 (65%) extra-articular fractures and seven (35%) intra-articular fractures.
This study included 15 (75%) comminuted fractures and 5 (25%) oblique fractures. A total of 70% of the fractures were in the proximal phalanges and 30% were in the middle phalanges. The most common mechanism of injury was trauma by falling on the hand and animal bite, representing 25% of all fractures. The other injuries were caused by falling of a heavy object on the hand, a sharp object, physical violence, and finally, gunshot injuries. Manual workers were the most affected occupation, 40%.
In this study, 16 fractures (80%) were managed by a mini external fixator on the same day of injury, three fractures (10%) were managed after 2 days, and one fracture (5%) was managed after 3 days of injury.
Surgery was carried out with the patient lying in a supine position under regional anesthesia. Under Image two transverse pins were applied (one on each side of the fracture) from the dorsiulnar or the dorsiradial direction after debridement of the wound if it was open fracture. The pins were then provisionally connected by a bar and the fracture was reduced. In most cases, simple traction was sufficient, and after reduction, the pins were fixed firmly to the connecting bar.
A very unstable fracture required more than one pin on each side and we crossed the joint in some cases ([Figure 2]). In open fractures, reduction was performed under direct vision, whereas reduction was performed under an image intensifier in closed fractures.
In intra-articular comminuted fractures, distraction was applied until reduction was acceptable, and then the interfragmentary wire was applied. ([Figure 3]).
In one fracture (5%), two pins were applied on either side of the fracture. The diameter of k-wires ranged from 1.0 to 1.6 mm. In two fractures (10%), one fragment was too small to include more than one pin; here, one pin was used to ensure good stability of the fixator. In 17 fractures (85%), low stability was found and so the nearby joint was crossed to introduce the pins in the nearby segment. In 14 fractures (70%), two pins were applied on both sides of the fracture (seven intra-articular fractures) and in three fractures (15%), one pin was applied on each side of the fracture. In this study, we used an interfragmentary Kirschner's wire in seven fractures (35%), six of these (30%) with intra-articular extension and one (5%) with oblique fracture. Interfragmentary k-wires were removed after 14-26 days, with a mean time of removal of 18.4 days. The external fixator was removed after 21-36 days, with a mean time of removal of 24.75 days. For every case, a check radiograph was taken postoperatively. The follow-up examination was performed every 2 weeks until radiological union was detected. All radiographs were evaluated for signs of loosening of implants and occurrences of deformity as well as fracture union.
In all fractures, exercise treatment was started within the first 24 h postoperatively. Exercises were delayed in cases of massive soft-tissue injury and severe bone comminution. Shoulder, elbow, and all nonaffected and nonsplinted finger joints were included by active exercises. The total active range of motion was considered the main method of end result evaluation. Total active range of motion is the sum of the angles formed by metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints in the maximum flexion in the fist position minus the total extension deficit of these joints (hyperextension of these joints was disregarded)  ([Table 1]).
|Table 1 Total active range of motion (Strickland-Glogovac finger function rating scale)  |
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| Results|| |
The mean follow-up duration was 2.5 (1-4) years and the mean period of treatment was 2 months. The devices had been removed at a mean of 26.85 days after a phalangeal fracture (21-70). Nine fractures (45%) presented with complications from a total of 20 fractures. Infection was observed in one fracture (5%), which showed a pin-tract infection, and was managed by regular dressing and antibiotics. Union was observed in 19 (95%) of 20 fractures and one fracture (5%) was complicated by nonunion ([Figure 4]). This fracture was managed by bone grafting after 4 months. The fracture was then fixed by alternative methods of fixation. Four fractures (20%) were complicated by stiffness in one or more joints; two of these fractures (10%) presented with intra-articular fractures, two fractures (10%) presented with an extra-articular fracture, two fractures showed stiffness in only one joint, and the other two fractures showed stiffness in more than one joint. The proximal interphalangeal joint was affected in four cases, and the distal interphalangeal joint was affected in two cases. Loosening of the mini external fixator was observed in five cases (25%) and, in three of these (15%), the fracture was collapsed and required distraction of the fixator, one (5%) showed angulation, and one (5%) showed side-to-side displacement.
|Figure 4 Male patient, 35 years old, farmer, who presented with an open comminuted intra-articular fracture of the proximal phalanx of the left thumb because of an injury during struggle. (a) Preoperative. (b) Intraoperative. (c) Nonunion of fracture after 3 months|
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Of 20 patients, the results obtained were excellent in six (30%) as shown in [Figure 5] and [Figure 6], good in four patients (20%) as shown in [Figure 7], fair in four patients (30%), and poor in six patients (20%). If we consider excellent and good results as satisfactory and fair and poor results as unsatisfactory, then overall satisfactory results were observed in 10 patients (50%) and unsatisfactory results in 10 patients (50%) ([Table 2]). All patients with at least 60 showed a poor result [Table 3]. It is obvious that patients with closed fractures have better results than those with open fractures ([Table 4]).Our result was considerably better in extra-articular fractures than intra-articular fractures. ([Table 5]) shows that all results in oblique fractures were satisfactory, whereas unsatisfactory results were achieved in 10 patients with comminuted fractures. from [Table 6] it was obvious that the unstisfactory results ( poor and fair) were increased when the time of application of fixator increase.
|Figure 5 Male patient, 41 years old, farmer, who presented with an open oblique fracture of the proximal phalanx of the right thumb because of animal bite. (a) Preoperative. (b) At the time of removal of fixator after 21 days. (c) Follow-up after 1 year (excellent result).|
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|Figure 6 Male patient, 28 years old, Carpenter, who presented with a comminuted proximal phalanx of the right ring finger because of an injury during struggle. (a) Preoperative and intraoperative. (b) At the time of removal of the mini external fixator after 25 days. (c) Follow-up after 1 year (excellent result).|
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|Figure 7 Male patients, 39 years old, Carpenter, who presented with a comminuted intra-articular fracture of the middle phalanx of the left ring finger because of an injury during struggle. (a) Preoperative and intraoperative. (b) After removal of the mini external fixator after 26 days. (c) Follow-up after 2 years (good result).|
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| Discussion|| |
Patients with comminuted, oblique, and open fractures of the phalanges require operative reduction and stabilization to achieve the optimal position for bone healing and to enable good healing of soft tissue. In this study, we used external fixation to avoid any additional injury to the bone and soft tissues. The technique is relatively simple, especially with the help of an image intensifier; thus, the best site for pin introduction can be chosen easily.
In the study by Lenehan and colleagues, 17 (68%) patients underwent general anesthesia. In the study by Dailiana and colleagues, all procedures were performed under regional anesthesia, except in two patients with multiple traumas, who received general anesthesia , . In the present study, in 16 cases (80%), surgery was carried out under regional anesthesia (wrist block or ring block) and four cases (20%) were operated under general anesthesia because of the presence of associated injuries, which were managed at the same time.
Drenth and Klasen reported 41.7% excellent results, 27.8% good results, 8.3 fair results, and 22.2% poor results. In the study by Ma and colleagues, for 28 patients who achieved fracture healing, the results were excellent in 7 (25%) cases, good in 12 (42.9%) cases, fair in 5 (17.9%) cases, and poor in 4 (14.2%) cases , . In this study, the results obtained from 20 patients were excellent in six patients (30%), good in four patients (20%), fair in four patients (30%), and poor in six patients (20%); the mean follow-up duration was 2.5 (1-4) years.
Schuind and colleagues reported system failure in 7.5% of cases in his mixed study and 10.5% in open cases. In the study by Ashmead and colleagues, no system failure was reported. In the study by Lenehan and colleagues, one patient developed a complication of fixator loosening that required adjustment in the outpatient department ,, . In this study, loosening of fixators was observed in 5 (25%) patients and this was higher than that in other studies, but loosening of fixators did not markedly affect the outcome results.
In this study, loosening of pins was not reported, perhaps because of the use of threaded pins instead of smooth k-wires, and this has been reported with the use of threaded pins in other studies. Threaded pins were used to allow good purchase in bone and the pins were introduced in the dorsilateral or the dorsiulnar direction to avoid interference with adjacent fingers, which may restrict postoperative rehabilitation.
In the study by Drenth et al.  , nine fractures of the middle phalanges healed with a better functional result (eight were excellent or good) than those of the proximal phalanges (12 excellent/good, three fair, six poor). In this study, 70% of the fractures were in the proximal phalanges, whereas 30% were in the middle phalanges, and the middle phalanges healed with a better functional result.
Li et al.  reported on 26 patients with only intra-articular fractures, and the results were excellent in 8 (30.9%) cases, good in 13 (50%) cases, fair in 3 (11.5%) cases, and poor in 2 (7.6%) cases. In this study, 7 (35% of all) fractures were intra-articular and of these, 2 (28.6%) showed good results, 1 (14.3%) showed fair results, and 4 (57.1%) showed poor results. These results were worse than those reported by Li and colleagues, but this may have been because of the presence of five open and six comminuted fractures among the seven intra-articular fractures in the present study.
Dernth and colleagues reported that 28 (85%) of 33 patients were satisfied with their results. In the study by Lenehan and colleagues, all patients expressed satisfaction with both the final treatment result and the treatment method , . In this study, 95% of the patients were satisfied with their results and so they stop the follow-up program when the hand function reached a plateau. None of the patients changed their jobs or personal activities.
| Conclusion|| |
The findings of this series proved that the external fixator is a suitable alternative technique for stabilizing comminuted, oblique, and open fractures of the phalanges. It is simple, can be performed under local anesthesia, and its learning curve is comparatively small.
The external fixator enables easy postoperative care of soft tissue and provides an adequate time for healing of both bone and soft-tissue healing, but without good functional outcomes.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]