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  1. 1. ORIGINAL ARTICLE Proximal Interphalangeal Joint Fractures of the Hand Treatment With an External Dynamic Traction Device Kanthan Theivendran, BSc, MBBS, MRCS, Jonathan Pollock, BMBS, MRCS, and Vaikunthan Rajaratnam, FRCS, Dip Hand Surg(Eur) Intra-articular PIP joint fractures can be treated with Abstract: The authors present a series of 11 consecutive patients who sustained an intra-articular fracture of the proximal interpha- various techniques. This is dependent on the articular surface langeal (PIP) joint and 1 patient with a fracture of the interphalan- involvement of the base of the middle phalanx and the degree geal joint of the thumb treated with a Kirschner wire external of comminution. It is generally accepted that if there is less dynamic traction device. Range of motion and grip strength were than 40% involvement of the joint surface, then the fracture measured. We used the Michigan Hand Outcome Questionnaire is stable and can be treated nonoperatively.3 However, greater (MHQ) to obtain a subjective response to the treatment. Average than 40% of joint surface is unstable and requires surgical range of motion of the PIP joint was 64° and distal interphalangeal intervention.3 joint was 52°. The average grip strength was 86% with a mean MHQ Treatment modalities include extension block splint- score of 90. Two patients had pin site infections treated successfully ing,4 open reduction and internal fixation,5,6 closed reduction with antibiotics. All fractures had united at final follow up with and percutaneous fixation, and volar plate arthroplasty. There 1-mm articular step present. Our series highlights that these are are 2 main problems with comminuted fractures at the PIP difficult injuries to treat and that anatomic reduction is not always joint: 1) the articular bony fragments are too small to openly possible. However, this technique is simple and quick to perform reduce and internally fix to gain anatomic reduction; and 2) if while allowing early joint mobilization. The subjective response to the joint is immobilized, the fibrotic changes that occur after treatment is comparable with other studies using a similar device. injury will cause stiffness. These problems can be overcome by early mobilization Key Words: dynamic, external fixation, fracture, proximal after anatomic reduction of the fracture using the principle of interphalangeal joint ligamentotaxis.7,8 There have been various techniques de- (Ann Plast Surg 2007;58: 625– 629) scribed in the literature using these principles.4,7,9 –11 We report a series of 11 patients with intra-articular PIP joint fractures and 1 patient with an intra-articular interphalangeal (IP) joint fracture of the thumb treated with a Kirschner (K) wire dynamic external fixation device.10 P roximal interphalangeal joint (PIP) joint fractures are relatively rare but can be severely disabling for the patient and lead to stiffness and persistent pain if inadequately treated. METHODS The stability of the PIP joint is provided by the articular We reviewed 11 consecutive patients who sustained an congruency and soft tissue supports. Soft tissue stability is intra-articular fracture of the PIP joint and 1 patient of the IP provided by collateral ligaments, volar plate, joint capsule, joint of the thumb. All were treated with a dynamic external dorsal expansion, and extensor tendon as well as the flexor fixator frame by the senior author (V.R.) between 2004 and tendons.1 These fractures commonly occur when an axial 2005. We used the classification system by Seno et al (Fig. 1) load is applied to the finger tip causing hyperextension to describe the fracture configuration at the base of the middle leading to a dorsal fracture and/or dislocation.2 phalanx.12 Objective measurements of the active range of motion (AROM) of the distal interphalangeal (DIP) and PIP joints of the affected finger or thumb were measured using a standard goniometer. The grip strength was also measured Received June 27, 2006, and accepted for publication, after revision, August using the Jamar dynamometer and was compared with the 30, 2006. From The Birmingham Hand Centre, University Hospital Birmingham Selly uninjured side. We used the Michigan Hand Outcome Ques- Oak Hospital, Birmingham, U.K. tionnaire13 (MHQ) to obtain a subjective response to the Reprints: Kanthan Theivendran, BSc, MBBS, MRCS, 81 Pennine Way, treatment. Duration of the procedure was obtained from Ashby-de-la-Zouch, Leicestershire LE65 1EZ, United Kingdom. E-mail: operating room records. Bony union was confirmed by re- kanthan@hotmail.co.uk. Copyright © 2007 by Lippincott Williams & Wilkins view of the radiographs at the latest follow up. ISSN: 0148-7043/07/5806-0625 Statistical analysis was performed using the Pearson DOI: 10.1097/01.sap.0000245132.14908.9d correlation test to identify if there was any significant rela- Annals of Plastic Surgery • Volume 58, Number 6, June 2007 625
  2. 2. Theivendran et al Annals of Plastic Surgery • Volume 58, Number 6, June 2007 FIGURE 1. Classification of base of middle phalanx fractures by Seno et al.12 Reproduced with permis- sion and copyright of the British Editorial Society of Bone and Joint Surgery. tionship between the time of delay to operation, the age of the and distraction across the fracture site. Early active move- patient, or the outcome of treatment. The SPSS 14.0 (SPSS ment was encouraged within 24 hours and all patients re- Inc., Chicago, IL) statistical software was used to perform the ceived hand therapist input. analysis with P values of less than 0.05 considered to be significant. RESULTS Surgical Technique The mean follow up was 24 weeks (range, 12–56 weeks) All of the patients had local anesthetic for the proce- and the average age of the patient was 35 years (range, 18 – 60 dure. A radiographic image intensifier (II) was used to visu- years). There were 10 men and 2 women who sustained intra- alize fracture manipulation and reduction. A 1.1-mm K-wire articular digital fractures. Table 1 outlines the demographic was inserted percutaneously and perpendicular to the long details. The device was left in situ for an average of 4 weeks and axis of the phalanx. This wire was directed to the center of the mean time from injury to operation was 8 days. The mean rotation of the head of the proximal phalanx while avoiding AROM of the injured PIP joint was 64° and DIP joint (including breaching the joint capsule. A second longer K-wire was the IP joint of the thumb) was 52°. The mean grip strength inserted distally and at right angles to the middle phalanx of the injured side compared with the uninjured hand was through the center of rotation of the head of the middle 86%. The average duration of the procedure was 12 minutes phalanx while avoiding breaching the joint capsule. Both (range, 10 –16 minutes). The mean MHQ score was 90. Eight wires were used to manipulate and reduce the fracture under patients were employed before their injury and all have II guidance. The proximal wire was bent into a hook approx- returned to their original occupations. imately 5 mm from the skin. The distal K-wire was bent The time delay to operation correlated negatively with parallel to the long axis of the phalanx pointing toward the the grip strength (r 0.556, P 0.061); however, this was proximal K-wire and shaped into a parabolic curve. This not significant. There was no significant correlation between preloaded curve was then made into a hook at its distal end time delay to operation and the AROM of the PIP joint (r and interlocked with the hook from the proximal wire while 0.176, P 0.583) or the delay to operation and the MHQ applying traction to the digit (Fig. 2). This provided tension score (r 0.084, P 0.795). No significant correlation was FIGURE 2. Operative technique: A, Proximal K-wire through the center of the head of proximal phalanx. B, Another distal K- wire parallel to proximal wire through center of the head of middle phalanx. C, The distal wire is bent backward and the proximal wire is bent forward. D, A preloaded dorsal curve is created from the distal wire. E, Wire ends are shaped into hooks that engage and maintain in-line traction. F, Fracture is reduced and maintained while allowing movement at the hooks of the K-wire. 626 © 2007 Lippincott Williams & Wilkins
  3. 3. Annals of Plastic Surgery • Volume 58, Number 6, June 2007 External Fixation of PIP Joint Fractures found between age of the patient and the outcome (r Pin site infection Pin site infection Questionnaire Complications 0.04, P 0.903 for the grip strength; r 0.443, P 0.149 Disassembly for the AROM of the PIP joint; and r 0.292, P 0.357 for the MHQ). Two patients developed minor pin track infection suc- Nil Nil Nil Nil Nil Nil Nil Nil Nil cessfully treated with oral antibiotics. One patient knocked the device on the gearshift of a car. It became loose and Michigan Outcome Hand needed reapplication at 4 weeks. In this case, the disengage- 88 93 93 96 98 82 95 85 83 89 80 94 ment of the construct occurred as a result of a technical error of inadequate crimping of the ends of the wire. All patients were pain-free at the latest follow up, and there was no Joint Extensor Strength Grip clinical or radiologic evidence of osteomyelitis. All fractures (%) 100 100 77 75 80 80 92 85 86 95 75 90 were united at final follow up with an average extensor lag at the PIP joint of 11° with pain-free range of motion. However, Interphalangeal Lag (degrees) all our patients had less than a 1-mm intra-articular step present Proximal on radiographs with no evidence of reduction in joint space at 8 12 10 8 9 12 10 8 12 15 16 12 final follow up. Case no. 12 (Fig. 3) shows a Seno type 3 base of the middle phalanx fracture that shows bony union at 3 months postinjury with an intra-articular step present. Interphalangeal Interphalangeal Joint Active Range of (degrees) Motion Distal DISCUSSION 60 50 52 25 72 60 50 55 60 52 30 60 The treatment goals for intra-articular PIP joint frac- tures are to restore anatomic alignment of the joint and to allow early active movement to avoid stiffness. These chal- lenging goals have sparked renewed interest in the techniques Joint Active Proximal Range of (degrees) Motion for treating these difficult fractures. Previous attempts with 20 32 62 60 78 75 82 78 69 90 40 80 open reduction and internal fixation have proved difficult with small fragments, resulting in high complication rates and reduced ability to gain joint congruency.9,14 Stern et al performed a comparative study looking at splinting, skeletal Removal of Fracture Operative Operative (minutes) Time traction with early mobilization, and open reduction and 15 10 16 12 10 9 16 14 12 10 12 10 internal fixation (ORIF) of pilon fractures of PIP joint.9 They found that ORIF can achieve anatomic reduction in some cases, but concluded that severely comminuted subchondral (days) Delay 2 3 11 8 10 3 9 6 11 2 14 14 fragments are almost impossible to reduce and may be un- TABLE 1. Demographic Details and Results of Patients Treated necessary. ORIF can cause extensive soft tissue disruption leading to reduced blood supply to the fracture fragments (Seno et al) resulting in joint stiffness.9 To avoid these problems, many Type 1 1 2 5 1 2 3 3 2 1 1 3 authors have devised innovative techniques using the princi- ple of ligamentotaxis to provide stable reduction and early active movement of the PIP joint. Schenck used a dynamic circular frame, which allowed passive finger flexion and (weeks) Device extension at regular intervals.15 This device was large and 4 5 4 4 4 5 4 4 5 2 4 5 cumbersome and was worn for at least 7 weeks. Smaller fixators using springs and pulleys are often difficult to con- Follow Up struct.8,16 The Pins and Rubber Traction System (PRTS) by (weeks) 16 52 15 12 16 16 28 20 20 56 20 16 Suzuki et al11 used rubber bands that could be tensioned differentially to correct valgus and varus deformity. How- ever, although they reported excellent results, it was com- R middle L middle L middle Injured L thumb Finger monly known that rubber bands were subjected to plastic R little R little R little R little R ring R ring R ring L ring deformation and could become loose. The senior author found that rubber bands were difficult to manage postopera- (years) Sex M M M M M M M M M M tively and found it cumbersome to apply and maintain be- F F cause the elasticity was not constant. Simple external dy- Age namic fixators using K-wires only to provide ligamentotaxis 35 19 40 38 49 26 25 22 48 60 18 40 have been described by Hynes and Giddins10 and Gaul and Rosenberg.17 Our surgical technique is based on a similar Case No. 1 2 3 4 5 6 7 8 9 10 11 12 configuration of K-wires. This frame, if applied properly, © 2007 Lippincott Williams & Wilkins 627
  4. 4. Theivendran et al Annals of Plastic Surgery • Volume 58, Number 6, June 2007 FIGURE 3. Case no. 12: A, Preoperative radiograph showing a Seno type 3 fracture. B, Seven-day postoperative radiograph with the frame in situ. C, Three-month postoperative radiograph with fracture union with articular step. D, E, Range of mo- tion at 3 months follow up. maintains constant distraction and, if overdistraction oc- sponse to treatment with other studies using a similar dy- curred, can be reduced by crimping the wire. A similar study namic external fixation device. by Deshmukh et al,18 who used a modified PRTS of Suzuki et al,11 produced an average AROM of the PIP joint of 85°, REFERENCES an average grip strength of 92%, and a mean normalized 1. Liss FE, Green SM. Capsular injuries of the proximal interphalangeal MHQ of 84 at an average follow up of 34 months. Our study joint. Hand Clin. 1992;8:755–768. showed a better average MHQ score of 90 as compared with 2. Glickel SZ, Barron OA. Proximal interphalangeal joint fracture disloca- that achieved in the study by Deshmukh et al. The mean tions. Hand Clin. 2000;16:333–344. AROM of the PIP joint from our study was lower compared 3. Glickel SZ, Barron OA, Eaton RG. Dislocations and Ligament Injuries in the Digits, 4th ed. New York: Churchill Livingstone; 1999:772– 808. with other studies using a similar K-wire external fixator.19,20 4. McElfresh EC, Dobyns JH, O’Brien ET. Management of fracture– This may be the result of the shorter follow-up period of 6 dislocation of the proximal interphalangeal joints by extension-block months in our study compared with similar fixators by Badia splinting. J Bone Joint Surg Am . 1972;54:1705–1711. et al (89° at 24 months) and Syed et al (79° at 2.2 years).19,20 5. Agee JM. Unstable fracture dislocations of the proximal interphalangeal joint of the fingers: a preliminary report of a new treatment technique. Importantly, all those patients who were employed before the J Hand Surg Am . 1978;3:386 –389. injury have now returned to their original jobs. All patients 6. Wilson JN, Rowland SA. Fracture– dislocation of the proximal interpha- were satisfied with the treatment and reported pain-free range langeal joint of the finger. J Bone Joint Surg Am . 1966;48:493–502. of motion. Fracture union had occurred in all patients at final 7. Agee JM. Unstable fracture dislocations of the proximal interphalangeal joint. Treatment with the force couple splint. Clin Orthop. 1987;214: follow up with less than a 1-mm intra-articular step present at 101–112. the PIP joint. Our series highlights that these are difficult 8. Allison DM. Fractures of the base of the middle phalanx treated by a injuries to treat and that anatomic reduction is not always dynamic external fixation device. J Hand Surg Br . 1996;21:305–310. possible as compared with open reduction with rigid internal 9. Stern PJ, Roman RJ, Kiefhaber TR, et al. Pilon fractures of the proximal fixation. However, internal fixation can be technically de- interphalangeal joint. J Hand Surg Am . 1991;16:844 – 850. 10. Hynes MC, Giddins GE. Dynamic external fixation for pilon fractures of manding and often require extensive soft tissue dissection the interphalangeal joints. J Hand Surg Br . 2001;26:122–124. that may contribute to complications and the need for sec- 11. Suzuki Y, Matsunaga T, Sato S, et al. The pins and rubbers traction ondary operative procedures.21 system for treatment of comminuted intraarticular fractures and frac- The main limitation to this study is the small sample ture– dislocations in the hand. J Hand Surg Br . 1994;19:98 –107. 12. Seno N, Hashizume H, Inoue H, et al. Fractures of the base of the middle size and short follow-up period. Long-term follow up will be phalanx of the finger. Classification, management and long-term results. required to identify if patients develop post-traumatic arthritis J Bone Joint Surg Br . 1997;79:758 –763. within these joints. Despite the current limitations, we believe 13. Chung KC, Pillsbury MS, Walters MR, et al. Reliability and validity that this system provides a simple and cost-effective method testing of the Michigan Hand Outcomes Questionnaire. J Hand Surg of treatment of these difficult fractures. The application of the Am . 1998;23:575–587. 14. Hastings H 2nd, Carroll CT. Treatment of closed articular fractures of external fixator is quick (average operative time of 12 min- the metacarpophalangeal and proximal interphalangeal joints. Hand utes), is done under local anesthetic, and is acceptable to the Clin. 1988;4:503–527. patient. Our case series shows a comparable subjective re- 15. Schenck RR. Dynamic traction and early passive movement for fractures 628 © 2007 Lippincott Williams & Wilkins
  5. 5. Annals of Plastic Surgery • Volume 58, Number 6, June 2007 External Fixation of PIP Joint Fractures of the proximal interphalangeal joint. J Hand Surg Am . 1986;11:850 – pins and rubbers traction system. J Bone Joint Surg Br . 2004;86:406 – 858. 412. 16. Inanami H, Ninomiya S, Okutsu I, et al. Dynamic external finger fixator 19. Syed AA, Agarwal M, Boome R. Dynamic external fixator for pilon for fracture dislocation of the proximal interphalangeal joint. J Hand fractures of the proximal interphalangeal joints: a simple fixator for a Surg Am . 1993;18:160 –164. complex fracture. J Hand Surg Br . 2003;28:137–141. 17. Gaul JS Jr, Rosenberg SN. Fracture– dislocation of the middle phalanx at 20. Badia A, Riano F, Ravikoff J, et al. Dynamic intradigital external the proximal interphalangeal joint: repair with a simple intradigital fixation for proximal interphalangeal joint fracture dislocations. J Hand traction-fixation device. Am J Orthop. 1998;27:682– 688. Surg Am . 2005;30:154 –160. 18. Deshmukh SC, Kumar D, Mathur K, et al. Complex fracture– dislocation 21. Stern PJ, Wieser MJ, Reilly DG. Complications of plate fixation in the of the proximal interphalangeal joint of the hand. Results of a modified hand skeleton. Clin Orthop. 1987;214:59 – 65. © 2007 Lippincott Williams & Wilkins 629

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