Книга_574_Библиотеки_им_академика_М_И_Перельмана

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Closed Fracture

Extensively comminuted closed fractures of the phalanges and metacarpalsmay defy even themostmeticuloussurgeon’s ability to achieve alignment and rigidity by open or closed means. For extra-articular fractures, the distraction afforded by external ﬁxationcan correct translational, rotational, and angular deformity with minimal impact on the biology of the healing fracture. With intra-articular fracturesorfracture dislocations, comminution and small fragment size often preclude open operative stabilization (26). Indirectreduction of these injuries by the principle of ligamentotaxis can provide reasonable jointcongruency.Limitedopenreductionofarticular fragments when they are largeenough to make interfragmentary ﬁxation feasible can also be combined with an external ﬁxator (34). There are several reports of these techniques for comminuted fracture dislocations of the thumb metacarpal base (34–36).Repeatedsurgery afterafailed attempt at fracture ﬁxation is also an indication for use of an external ﬁxator as it can bypass some of the mechanical (comminution) and biological (infection) factors that may have led to recurrent fracture instability (26).

Malunion

When combined with acorrective osteotomy,anexternal ﬁxator canfacilitateachieving alignmentand maintainingskeletal stability (2,37).

Osteomyelitis, Delayed Union, and Established Nonunion

Bone infections presentone of themostdifﬁculttreatment dilemmas in orthopedicsand hand surgery.Infectionscan frequently coexist andbethe underlying causeofdelayed unionand nonunionsofthe hand. External ﬁxation allows maintenance of length and alignment of the bone–soft tissue unit after debridement so that subsequent bone grafting and even soft tissue coverage, when necessary,can be more readily accomplished (38). Depending on the status of the wound, bone grafting canbeaccomplishedasadelayedprimary or secondaryprocedure (29).Inaddition, this stabilitycan be conferredfrom asite distant from the actual infection.

Arthrodesis

Seitz et al. adapted the Charnley’s technique of compression arthrodesisand careful cup and conepreparationofthe joint surface to achieve astable arthrodesis in 95% of their

FIGURE 1 An exampleofaminiaturizedmodular external ﬁxator system thatpermits construction of awide variety of uniplanar and multiplanarframes(Hoffmann II MicrofromStryker Orthopaedics, Mahwah, NJ, USA).

(A)

(B)

FIGURE 2 Extensively comminuted open multiple metacarpal fractures treated by debridement, applicationofamultiplanarexternal ﬁxator which spanned the metacarpals by pins into the proximal phalanx, and carpus supplementalK-wire ﬁxation was also utilized. ( A )Preoperative Xray and(B )postoperative clinical appearance. Abbreviation:K-wire, Kirschner wire. Source:Courtesy of David J. Bozentka, M.D.

Monaghan

patients (39). The avoidance of asecond anesthetic for hardware removal or tenolysis, the ability to compressand/or adjust the arthrodesis after the initial application, and the functional use of the hand and adjacent joints during healing are distinct advantagesofthistechniqueoveropenprocedureswith hardware placement.

Joint and Soft Tissue Stabilization

External ﬁxation has been described as an adjunct for extensor tendonreconstruction and to stabilize the digits to prevent tension on across-ﬁnger ﬂap (26). It can also be used for joint stabilization in selected settings, particularly in the ﬁrst ray and web space (Fig. 3).

Distraction Osteogenesis

This is the preferred reconstructive option for amputation of the ﬁrst ray around the level of the metacarpophalangeal (MP) joint (e.g., the proximal half of the middle thirdofthe thumb).

CONTRAINDICATIONS

External ﬁxation is aversatile method of skeletal ﬁxation that should be apartofeachhandsurgeon’sarmamentarium. Several authors evenreportroutine useofthisdevicefor

closed fractures. Nagy believes that preservation of the integrity of agliding surface, which is tantamount to good hand function, is better achieved with external ﬁxation than percutaneous and open methods (26). To that end, there are no absolute contraindications to this method of bony ﬁxation of the hand. The decision of whether to pursue an open or minimally invasive method of bony stabilizationshouldbepredicated upon the extent of soft tissue injury and contamination, the fracture pattern and the likelihood of achieving sufﬁcient bony stability for early motion by each treatment option, and the experience of the individual surgeon with each technique.

Perhaps more than percutaneous and open methods of fracture ﬁxation, external ﬁxation requires signiﬁcant patient compliancepostoperative pincareand cooperationwitha directed rehabilitationprogram. Arelative contraindication, therefore, would be any behavioral, physical, or neurological impairment that would interfere with the patient’s ability to assist in the postoperative regimen.

CONSIDERATION FOR PRE-OPERATIVE PLANNING

Preoperativeplanning foracute injuries shouldinclude a directedexamination of the neurovascular status and concomitant injuries to other digits and more proximally in the extremity that might alter surgical management. In general, standard anteroposterior,lateral, and any pertinent specialized plain radiographs (hyperpronated, Brewerton, or Bora view) shouldbeobtainedtofully assess theextentand pattern of bony injury.Occasionally,additional imaging of thejoint surface by computed tomographyscanning or tomography may add useful information for articular reconstruction. Scintigraphic (i.e., Ceretec scanning) or magnetic resonance imaging should be reserved to situations where localizing an area of infection may guide the extent of bony and soft tissue debridement.

SURGICAL TECHNIQUE

Operating Room Setup and Equipment

Application of an external ﬁxation to ametacarpal or phalanx is best accomplished under regional or general anesthetic, with theinjured extremityabducted90 8 at theshoulderontoa radiolucent hand table. Real-time ﬂuoroscopy is employed to accurately assess pin placement and bony reduction. Asimple external ﬁxator can be fashioned from material readily available in any operating room (K-wires, needle caps, bone cement, and suction catheter). Standard miniature external ﬁxator systems, however,offer more stableand versatile constructsfor any situation that may be encountered in the hand (Fig. 1).

In planning the construction of an external ﬁxator in the metacarpal or phalanx, it is important to consider radiographic assessment of the outcome even before the placement of the ﬁrst pin. The diminutive size of the bone relative to the components of even the most miniaturized external ﬁxator can obscure one’s abilitytoevaluate bony reductionradiographically. Every component, therefore, shouldbeassembled with maximum care being taken to allow clear visualization by ﬂuoroscopy.

Operative Approach—Fractures

The complex gliding relationship between the bone and the extensor apparatusmust be understoodand respected to minimize the likelihood of soft tissue tethering. Behrens has

FIGURE 3 This external ﬁxator is being utilized to stabilize abasilar joint arthroplasty in a47-year-old female who has failed three other reconstructions of the thumb carpal metacarpal joint. The frame allows for rapid mobilization and proper positioningofthe ﬁrst web space.

ExternalFixation of the Metacarpalsand Phalangesand DistractionOsteogenesis

divided limb segments into longitudinal regions or corridors baseduponthe soft tissue elements present (40).Inasafe corridor,the bone is subcutaneous and no neurovascularor musculotendinous structures are at risk with pin placement. A hazardous corridorisone in whichamusculotendinous structure is at risk. Aneurovascularstructure is at risk in an unsafe corridor. Sinceatthe level of themetacarpals and phalangesalmost theentirecircumference of theboneis surrounded by tendinous and neurovascular elements, no safe corridor for pin placement exists. The appropriate hazardous corridor,therefore, should be selected with forethought for the structure at risk and aplan to minimize the potential tethering effect of the pin (Fig. 4).

The ﬁrst, second, and ﬁfth metacarpal can be approached through amidlateral or dorsolateral incision (26,32). Pins in the thumb metacarpal can be placed just radial to the extensor pollicis brevis tendon. For metacarpal neck fractures, the distal pins can be placed within the collateral recess, but through a limited open incision to assure that the sagittal ﬁbers about the MP joint are not tethered. The thirdand fourth metacarpals requirepin placementinadorsolateral plane to prevent extensor tendon tethering. Apercutaneous insertion of the pin or drill with agentle sweep to displace the tendon out of harm’s way prior to predrilling may also prevent extensor mechanism binding (Fig. 5A,B).

Theproximal aspect of theproximal phalanx is best approached through adorsolateral limited approach as well (41).Ashort incision in theextensor hood at this level is well tolerated and its ﬁbers allow for aclean longitudinal split that does not inhibit digital motion. In the distal aspect of the proximal phalanx and the middle phalanx avoidance of lateral band impingement can be accomplished by astraight midlateral approach to pin placement. Straight dorsal placement in the middle phalanx and the distal phalanx, with care be taken to avoid the germinal matrix, is also an acceptable, although a rarely employed, pin location (26).

In assembling an external ﬁxator,itisimportant to consider that each component (bone, transﬁxing pin, pin clamp, pinto-rod clamp, and connecting rod) contributes incrementally to the ultimate strength of the construct. Nevertheless, it is generally understood that pin characteristics and placement represent the single most important determinant to the ultimate stiffness of the construct (42,43). Ideally,pins of at least 1.5 to

2.0 mm in diameter should be used, although some authors feel smaller pins allow for capturing of smaller bony fragments. Low-speed predrilling with insertion of the pins by hand will limitthermal damagetothe bone and early pin loosening. Increasing the number of pins in each bony segment, increasing the inter-pin distance, placement of the connecting rod closer to thebone, and placementofasecond connectingrod will improve theultimate stabilityofthe frame.Ingeneral, a unilateralframe with fourhalf-pinswill provide sufﬁcient ﬁxation for most injuries.

After initial bicortical pinplacementineachbony segment, asecond parallel pin can be placed by using the multipin clamp as adrill guide (Fig. 5C). Most systems allow for slight convergence or divergence of these pins in small bony segments, adistance of 2.5 times the pin diameter must be left betweenfracture site andpin or between pins to prevent bony fragmentation. Asecond pair of pins is then placed in the other main bone fragment. The surgical wounds are then closed and the pins of each bony segment are then ﬁrmly tightened into amultipin clamp. Arod-to-rod coupling is placed on each pin clamp and arod is then placed loosely between each pin clamp (Fig. 5D). At this point, aclosed reduction of the metacarpal or phalanx is then performed and alignment is assessed ﬂuoroscopically.Ifacceptable, the rodis ﬁrmly tightened to each clamp. In some instances, alimited open reductionatthe fracture site canbeperformed to achieve better alignment. Residual articular incongruity can also be corrected with alimited open reduction with bone grafting afterligamentotaxis hasbeenestablishedbythe frame.After theexternal ﬁxatorisfully assembled, full passivedigital range of motionshouldbepossibleto conﬁrm the absence of tendinous tethering and the tenodesis effect should be observed to rule out subtle residual rotational deformities (Fig. 5E).

Unrestricted range of motion exercises should be initiated as soon as possible based on the ultimate stability of the bone external ﬁxation construct. Most surgeons begin within three days postoperatively under the guidance of ahand therapist. Weekly follow-up radiographs and clinical assessments conﬁrm maintenance of reduction and healing. The frame can typically be removed in an ofﬁce setting when clinical and radiographic healing has been conﬁrmed.

Operative Approach—Distraction Osteogenesis

Distraction osteogenesis employs asimilar surgical technique. The pins are placed and the frame is preassembled on the intact

(A)

(B)

FIGURE 4 Appropriate placement of pins and soft tissue release is essential to prevent limitationsof(A )extension and ( B )ﬂexion.

Monaghan

bone with aspecialized connecting rodthat allows controlled distractioninintervals as smallas0.125 mm (lengthener) according to the principles delineated above (distraction lengthener). The specialized lengthener and clamps are removed and an osteotomy is performed through an open incision, with an attempt made to preserve aperiosteal sleeve for closure. If a bony segment on the one side of the proposed osteotomy site is too small to allow for two longitudinal pins perpendicular to the axis of the osteotomy,they can be placed as atransﬁxing pin. Alternatively,atechnique where distraction osteogenesis occurs

using aframe with asingle pin over alongitudinally placed K-wire hasbeen described(19). Afterwoundclosure, the external ﬁxatorisreappliedand tightened.Mostsurgeons commence lengthening between the thirdand seventh postoperative day (14,17–23).Daily lengtheningrateof0.125 to

1.0 mm/day has been utilized. Once the desired magnitude of lengthening has been attained, the frame is left in place to stabilize the bone untilradiographic andclinicalunion is present(Fig. 6).Typically,thiswill requiretwice thetime required forlengthening in children and three times that

(A)

(C)

(E)

(D)

(B)

FIGURE 5 ( A )Placement of auniplanar external ﬁxator on the proximal phalanx. An incision is made through skin and alongitudinal rent in the extensor mechanism is created to prevent tendinous binding with postoperative motion. ( B )Placementofauniplanarexternalonthe proximal phalanx. After low-speed drilling, abicortical ﬁxation pin is placed and the position is conﬁrmed ﬂuoroscopically. Alternatively, aself-tapping, self-drillingpin can be utilized. ( C )Placement of auniplanar external on the proximal phalanx. Parallel pin placementusing apin clamp as aguide. ( D )Placementofauniplanarexternalonthe proximal phalanx. In amodular external ﬁxator, the pins in each bony segment are connected to each other by clamps and each of the clamps is connected by aradiolucent rod. ( E )Placement of auniplanar external on the proximal phalanx. Full passive motion after complete assemblyof the frame assures the absence of extensor mechanism impingement.

ExternalFixation of the Metacarpalsand Phalangesand DistractionOsteogenesis

period in adults. Forexample, if 3cmoflengthening was achieved in 45 days, the external ﬁxator may be required for an additional 90 to 135 days in order to achieve stable osseous union. Some authors shorten the period of external ﬁxation, by bone graftingand even internal ﬁxation when thedesired length has been achieved.

Illustrative Case Example

An 82-year-old housewife sustained an open middle phalanx and distal tuft fractures of her dominant right index ﬁnger and an open bony mallet fracture of her left ring ﬁnger as aresult of adog bite.While thefractureofthe indexﬁngerwas a minimally comminuted displaced transverse fracture through the base, there was arelatively extensive soft tissue injury.The extensor mechanismwas shreddedalong theradiallateral band, but was functionallyintact (Fig. 7A). It was felt that percutaneous ﬁxation and immobilization would lead to signiﬁcant stiffness, and formal open reduction and internal ﬁxation would lead to further injury to the extensor mechanism. The patient underwent application of abiplanar external ﬁxator, closed reduction of the middle phalanx fracture, and wound debridement and closure; the size of the proximal fragment dictated that orthogonal pins be placed forstable ﬁxation (Fig. 7B). She underwent K-wire ﬁxation of the contralateral bony mallet. She was begun on active and active-assisted range of motion on theﬁrst postoperative dayand wasableto

achieve 1008 of proximal interphalangeal joint active motion (Fig. 7C). The external ﬁxator was removed uneventfully after four weeks.

FIGURE 6 Radiographic appearance during distraction phase. Clinical example of alengthening frame for distractionosteogenesis after a thumbblast injury in achild.Afterdesiredlengtheni ng has been achieved, the frame provides stability until bony consolidation has been achieved. Source:Courtesy of Pedro K. Beredjiklian, M.D.

(A)

(B)

(C)

FIGURE 7 ( A )Externalﬁxation of an open middle phalanx fracture as a result of adog bite. Extensive soft tissue injury with relative sparing of the extensor mechanism.(B )External ﬁxation of an open middle phalanx fracture as aresult of adog bite. Application of multiplanarexternal ﬁxation. Orthogonal pins were necessary in proximal fragment because of fragmentsize. ( C )External ﬁxation of an open middle phalanx fracture as aresult of adog bite. Range of motion observed after assembly of frame and fracture reduction.

Monaghan

COMPLICATIONS

Perceived complications may be theprimary reason that external ﬁxation remains arelatively underutilized technique in hand trauma. Margic believes that this technique has not gained popularity for treatment of closed fractures in the hand because of the possibility of infection, pin loosening, loss of reduction, interferencewiththe glidingcapabilitiesofthe extensor mechanism, difﬁculty in application, andover exposuretoXray during application (13).

It is generally felt that pin loosening is the antecedent to pin site infection morethan the converse (43). Meticulous attention to details in pin placement with low-speed drilling, bicortical pin ﬁxation, and areduction that allows sufﬁcient bony contact to minimize dynamic stresses on the bone–pin interface will help to prevent pin loosening, infection, and loss of reduction. Patient compliance with an appropriate regimen of pin care is also essential. Oral antibiotics should be initiated if pin care does not eradicate pin site drainage or erythema. Occasionally, pin removal and new pin placement may be required. Margic believes that in about half of his patients who developed deep bone infections, technicalerrors with pinplacement were responsible (13).

Acomplication that can occur intra- or perioperatively is a fractureatthe half-pin site. This can happen if the half-pin is eccentrically placed, causing astress riser in the bone. After the external ﬁxator is removed,there is atheoretical risk of fracture through the half-pin hole(s).

As with anyﬁxationtechnique, loss of reductionand malunion canoccur (29,33).External ﬁxation,however, is moreamenable to correctionofthis problem, in that the fracture can be easily remanipulated and stability improved by placement of additional pins. Nonunions have been reportedwith this technique and can be aconsequence of the original severity of the injury,aswell as be aconsequence of the treatment (e.g., over distraction) (28,29,33). An intraoperative assessment of soft tissue tension via the intrinsic tightness test and passive range of motion can give some evidence for over distraction. Careful radiographic interpretation of the ﬁnal alignment can also help to minimize over distraction and possible delayed or nonunion. An overall rate of nonunion of 1.1% for closed fracturesand 14% for open fractureshas been reported (26).

Distraction osteogenesis has risks in addition to all those stated for external ﬁxation. Extended treatment periods (more than six months in some cases) with external ﬁxation can lead to ahigher rate on pin tract infection. Rapid bone elongation has also been associated with excessive pain and digital contracture. Bosch et al. recommends pinning of the interphalangeal joint during metacarpal lengthening to minimize the risk of contracture(25). In addition, poor bone formation at the osteotomy site,delayed union, nonunion,premature closureofthe osteotomy,and fracture have also been described with distraction osteogenesis (17–19,22,23).

OUTCOMES

Fractures

Asche et al. were the ﬁrst to report their experience with the Jacquet mini-ﬁxator in the English literaturein25patients in 1979 (8). The system was versatile enough to be used in open fractures, infections, replantation, and arthrodeses.They noted that compression and distraction could be achieved. Pin site infection occurred in only one of the 100 ﬁxation pins that were inserted. Riggs and Cooney utilized the same ﬁxator in 10 hand fractures, three of which were open fractures (28).

Bilos and Eskestrand treated15patients with low-velocity gun shot wounds to the proximal phalanx utilizing amandibular external ﬁxationsystemwith1.1 or 1.6mmpins(33). Treatment goalswerecorrectionofdeformity,avoidanceof over distraction,bonyhealing, and stable ankylosisofthe proximal interphalangeal jointwhenitwas involved in the injury.Although 25% of digits required remanipulation of theframe,acceptablealignmentwith maintenance of MP motion was achieved in 86% of the patients.

Freeland utilized an Arbeitsgemeinshaft fu¨rOsteusynthesefr (AO) external ﬁxator for 20 open fracturesofthe hand in 12 patients (29). Delayed bone grafting and early bone grafting (within one week of injury) wereboth selectively employed and resulted in an 80% primary union rate. Nevertheless, he did note a55% rate of joint ankylosis and 10% rate of angulation in this group of severely injured digits.

Seitz et al. presented their results of use of an external ﬁxator for 28 hand fractures, of which 18 wereopen (30). They reported achieving an 85% fractureunion rate at eight weeks postinjury and 70% of expected motion, although they also experienced a23% complication rate; most of these complications were attributed to the severity of injury.Parsons et al. presented their results of the Shearer micro-external ﬁxator in 37 unstable metacarpal and phalangeal fractures in 30 patients; 24% of these injuries were open (44). Four 1.8-mm threaded pins wereplaced prior to placement of the frame. With immediate postoperative motion initiated, they achieved good or excellent results in 94% of metacarpal injuries and 85% of phalangeal injuries.Delayed unionoccurred in threecases,pin tract infections occurred in two cases and malunion resulted in two instances. The authors commented that immediate painless and stable ﬁxationprovided theperfect circumstance for rapid mobilization of the digits. Ashmead et al. employed external ﬁxation for 27 acute injuries and eight reconstructive cases in the hand (45). Of the 12 open fractures, 10 healed primarily,20 of 22 acute fractures united, and all arthrodeses proceeded to fusion without complications. This method of treatment was also effective in helping to eradicate three infected nonunions and in obtaining union in two of them.

Severalauthors presentedtheir experienceswith an external ﬁxator as aprimary treatment for closed metacarpal and phalangeal fractures. Pritsch et al. reported their results of treatment of 36 closed metacarpal fractures using asimple external ﬁxatorcomposedoftwo 1.5-mm K-wiresdrilled dorsallythrough themetacarpaland bondedtogetherby acrylic resin (5). Immediate postoperative motion was encouraged and the ﬁxators were removed after an average of ﬁve weeks. They reported a100% union rate and 80% range of motioncomparedwiththe contralateral unaffected digit. Shehadi also treated 30 closed hand fractures with an external ﬁxator consistingoffour K-wires(0.9–1.1mmindiameter) bonded by polymethylmethacrylatebonecement. Active range of motion exercises were initiated one week postoperatively and about 50% of patients required more than four weeks of formal therapy.Hereported an average of 84% of expected range of motionfor phalangealfractures and96% for metacarpal fractures.

Margic recently reported the largest series of external ﬁxation in 100 closed hand injuries (13). His indication for placing this device was failuretoachieve stable reduction with more than oneK-wireorrequiring more than two attempts at closed reduction. These were40metacarpal fractures, 40 phalangeal fractures, and 20 combined injuries. The pins employed were 1.2 and 1.4 mm in diameter; in 17% of the cases, an adjunctive open reduction was needed. Active range of motion wasencouragedassoonaspossible

ExternalFixation of the Metacarpalsand Phalangesand DistractionOsteogenesis&79

postoperatively.Agood outcome, which was described as greater than 2308 of active digital motion, was achieved in 76% of phalangeal fractures, 89% of combined fractures, and 100% of metacarpal fractures. Seven phalangeal fractureswere felt to have poor stability,yet only three of these fractureshad apoor outcome. An overall pin site infection rate of 11%was found and 2% ultimately developed osteomyelitis. Pressure necrosis of the skin of adjacent digits due to interference with the apparatus was observed in three cases. There was a5% refracture rate observed with high-riskactivitiesand/or noncompliance;nodelayed unions or nonunionswere observed. The author felt his outcomes werecomparable to thosereported in theliterature forpercutaneous or open methods of ﬁxation of these fractures.

Bu¨chler et al. presented 12 cases of comminuted fractures of the thumb metacarpal base and one trapezial fracture treated with aspanning external ﬁxator,limited internal ﬁxation, and bone grafting (34). In spite of radiographic evidence of joint irregularities in 44% of the cases, about 80% of range of motion and 88% of pinch strength of the contralateral thumb were observed at an average of 37 months postinjury.Soyer reiterated that anatomic restoration of the articular surface is desired, but not essential for agood functional result (46). Kontakis et al. reported excellent results in seven of 11 patients, good results in three patients and apoor result in one patient treated with an external ﬁxator,with two pins in the thumb metacarpal and onepin in thetrapezium; a44% incidence of radiographic osteoarthritis was observed at 30-month follow-up (36). Nonnemacher utilized aquadrilateral frame between the ﬁrst and secondmetacarpalstostabilize20thumb metacarpalbase fractures, 60% of whichwereintra-articular (35).Ofthose with sufﬁcient follow-up, 77% were pain free and 23% demonstrated only intermittent pain.

Distraction Osteogenesis

Matev reportedhis experience with thumb reconstruction by metacarpal lengthening after amputation in 35 adult patients (14).Henoted complete consolidationatthe distraction osteotomysitein25patients and that10patients required supplemental bone graft to achieve union. Elongation of the amputated stump of 2to4cm was achieved and the results weremaintained at afollow-up of four to eight years after the procedure. He laterrecommendedthat lengthening of more than 3cminanadult requires the addition of bone graft at the distraction site. He also showed favorable results in seven children (15,16).

Tohetal. presented 26 cases of thumb and digital lengtheninginadultsand observed better results with aproximal metaphyseal osteotomy; ﬁve patients required bone grafting and four patients sustained afracture (23). The disadvantages of the technique werestated to be the length of time for treatment and external ﬁxator,ahigher rate of complication than other reconstructive techniques, and the bulky,complicated external apparatus required. Seitz reported lengthening of 2to3.5 cm in 14 patients with various posttraumatic and congenital digital deﬁciencies (18). Prematureclosure of osteotomy site was not observed and only one patient required supplemental bone graft. Minguella reported on 15 cases of metacarpal lengthening in alarger series of 31 congenital shortenings of the hand and foot (21). An overall complication rate of 22.5% (mostly selfresolving) was reported, leading the authors to recommend that afastlengthening period (1 mm/day)followedbybone grafting with pin ﬁxation would minimize the length of external ﬁxation use and, therefore, the rate of complication. Pensler et al.

presented 12 congenital deformities in nine patients who were treated with distraction osteogenesis (17). Although all osteotomieshealedwithout grafting, tworequiredoperative manipulationfor angular deformities.Housian andIpsen reported their experience with distraction osteogenesis in 14 patients (20). Lengthening rates averaged 0.5 mm/day and they reported one nonunion requiring grafting. Dhalla compared traditional distraction using four transﬁxingpinsand a lengthening frame to lengthening over aK-wire with two transﬁxing pins and aframe that was necessitated by the size of the bone (19). While the latter technique was successful, it carried asubstantially higher complication rate.

Bosch, in his reportofreconstruction of thumb amputations by this method in 18 patients, emphasized that the patient should be well informed of the expected duration and results of the procedure (25). In his population, the external ﬁxator was required for an average of 6.8 months. Zimmerman reported a functional outcome of 12 patients undergoing posttraumatic distraction osteogenesis of the thumb (24). All patients could pick up apencil, could write, and could hold aglass of water. About 70% of patients could employ the reconstructed thumb for ﬁne motor skills and heavy grasping.

SUMMARY

External ﬁxation is aminimally invasive technique that has clearapplications andindicationsthroughout orthopedics; however,itremains relatively underemployed in the treatment of phalangeal and metacarpal injuries. External ﬁxation can be considered for:

open fractureswithsigniﬁcant soft tissueloss or contamination

comminuted closed fractures that are not amenable to stable open ﬁxation

delayed union, nonunion,and osteomyelitis which may require signiﬁcant bony reconstruction after debridement

small joint arthrodesis

joint stabilization

skeletal lengthening (distraction osteogenesis).

With the advent of modern, miniaturized external ﬁxation systems,the hand surgeon nowpossessesthe capability of achieving excellent skeletal stability with alimited open technique that allows mobilization of all the joints of the injured digits. More importantly,because the ﬁxator does not impede the gliding of the extensor apparatus, it helps to facilitate a rapid recovery of digital motion and functional outcome.

ACKNOWLEDGMENTS

Iwould liketothank Drs. PedroBeredjiklianand David Bozentka for the contribution of clinical cases to this chapter and Mr.TroyJordan of Stryker Orthopedicsfor his technical assistance.

REFERENCES

1. Mears DC. History of external ﬁxation. In: Brooker AF, Edwards CC, eds. External Fixation: The Current State of the Art. Baltimore, MD: Williams and Wilkins, 1979:3–12.

2. Crockett DJ. Rigid ﬁxation of bones of the hand using K-wires bonded with acrylic resin. Hand 1974; 6(1):106–7.

3. Dickson R. Rigid ﬁxation of unstable metacarpal fractures using K-wires bonded with acrylic resin. Hand 1975; 7(3):284–6.

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4. Shehadi S. External ﬁxation of metacarpal and phalangeal fractures. JHand Surg [Am] 1991; 16(3):544–50.

5. Pritsch M, Engel J, Farina I. Manipulation and external ﬁxation of metacarpal fractures. JBone Joint Surg[Am] 1981; 63(8):1289–91.

6. RosenbergL,Kon M. An external ﬁxator for ﬁnger reconstruction. JHand Surg [Br] 1986; 11(1):147–8.

7. Babu V, Lenin B, Kocialkowski A. External ﬁxation of ﬁnger fractures made simple. Acta Orthop Belg 2005; 71(3):347–8.

8. Asche G, Haas HG, Klemm K. The external mini-ﬁxator: application and indications in hand surgery.In: Brooker AF, EdwardsCC, eds. External Fixation: The Current State of the Art. Baltimore, MD: Williams and Wilkins, 1979:105–13.

9. Chappell DA, Saba MM. Aminiature external ﬁxator for metacarpals and phalanges. JMed Eng Technol 1986; 10(2):62–4.

10. Sochart DS, Paul S. Asimple external ﬁxator for use in metacarpal and phalangeal fractures: atechnique paper.JOrthop Trauma 1995; 9(4):333–5.

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ExternalFixation of the Metacarpalsand Phalangesand DistractionOsteogenesis

Percutaneous Release of the Post-traumatic Finger Joint Contracture: ANew Technique

Joseph F. Slade III

Hand and Upper Extremity Service, Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, U.S.A.

Thomas J. Gillon

Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, U.S.A.

INTRODUCTION

Finger joint stiffness can result in severe impairment of hand function and is adifﬁcult problem to treat. Stiffness can result from injury,infection,excessimmobilization,and inappropriate splinting (1). An accumulation of ﬂuid or blood within the capsule after trauma will subsequently lead to stiffness. The open surgical management of joint contractures hasled to unpredictableresults,with someconditions actually worsening postoperatively (2). The lack-luster results of open release of the proximal interphalangeal (PIP) joint have led some surgeons to try less invasive or indirect means of contracturerelease. These methods, such as external ﬁxators, have shown some early promise in regaining some motion, but are associated with high complication rates (3). It has been suggested that the results of open surgical release of ﬂexion contractures greater than 608 (1) is so poor that arthrodesis is the preferred treatment. We describe aminimally invasive technique for the surgical release of selected joint contractures, through percutaneous surgical release of pathologic structures alone, avoiding injury to normal structures and re du cing postsurgicalswellingand pain. The reduction in pain and swelling allows for an accelerated rehabilitationprogram andamore completerecoveryof hand function.

Anatomy

The PIP joint is aconstrained hinge joint whose stability is conferred by both the matched bone contouring at the joint interface and the capsular complex composed of stout lateral cords and mobile volar plate (4–7). The head of the proximal phalanx is cam-shaped and composed of abicondylar head with acentral groove. The doubly concave surface of the base of the middle phalanx is divided by amidline tongue to guide the joint through its eccentric arc of motion. The main lateral stabilizer of this joint is the proper collateral ligament (4,8,9). This ligament originates from the head of the proximal phalanx and inserts into the base of the middle phalanx. The volar plate is athick ﬁbrocartilagenous structure distally and athin membranous structure proximally (9). Distally,it has aﬁrm attachment to the base of the middle phalanx. Proximally,ithas amembranous central attachment with radial- and ulnar-sided thickened bands, the checkrein ligaments (9–11). The proper collateral ligament is joined to the volar plate by shroud-like ﬁbers of the accessory collateral

ligament. These two structures function as acomposite unit to resist both the lateral and hyperextension stresses on the joint. In extension, the volar plate is tight and the collateral ligament is moderately lax. As the joint ﬂexes, the collateral ligament tightens over the larger volar condyles to seat the base of themiddle phalanx ﬁrmlyaga inst theproximal phalangeal head. In ﬂexion,the volarplate is lax. The dorsal capsule is thin and bordersthe proper collateral ligaments laterally. The dorsal capsule is reinforcedand intimately in contact with the central tendon dorsally (9). The average range of motion at the PIP joint is approximately 110 8 (12).

The metacarpophalangeal (MCP) joint is acondyloid or

cam joint. The metacarpal head is eccentric, the radius and width increasing towardits palmar base (4). The MCP joint has adorsal capsule that extends from the neck of the metacarpal to the base of the proximal phalanx and is reinforced by aloose insertion to the extensor tendon. The volar plate inserts on the base of the proximal phalanx with astout attachment. Proximally,the volar plate is thin as it attaches to the neck of the metacarpal. Laterally,the volar plate is stabilized by the deep transverse intermetacarpal ligaments. The collateral ligaments complete thesides of thecapsularbox andare taut with ﬂexion of the MCP joint. The stability of the MCP joint is ensured by this box-like construct. The MCP joint is weakest dorsally and ulnarly,making it vulnerable to dislocations in these directions.

Etiology

In 1954, Curtis described the pathoanatomical tissues that may be involved in both ﬂexion and extension contractures of the PIP joint (8). Extension contractures of the PIP joint can be due to traumatic global scarring of multiple structures, extensor tendon adhesions, interosseous contractures or adhesions, capsular or ligament contractures, and osteophytes or exostosis. Flexion contracture of the PIP joint can be due to volar skin contracture,fascial cord contracture as in Dupytren’s disease, ﬂexor tendon adhesion or sheath contracture,contractureofthe volar plateorthe capsular structures,collateralligament contracture or adorsal bony block (8). Trauma to the ﬁnger or hand causes soft tissue edema and hematomas that can impair hand function (9).

The PIP joints’ volume is also affected by position. The PIP

joint in moderate ﬂexion permits maximum joint volume and is

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