ORIGINAL ARTICLE

Proximal Interphalangeal Joint Fractures of the HandTreatment With an External Dynamic Traction Device

Kanthan Theivendran, BSc, MBBS, MRCS, Jonathan Pollock, BMBS, MRCS,and Vaikunthan Rajaratnam, FRCS, Dip Hand Surg(Eur)

Abstract: The authors present a series of 11 consecutive patientswho sustained an intra-articular fracture of the proximal interpha-langeal (PIP) joint and 1 patient with a fracture of the interphalan-geal joint of the thumb treated with a Kirschner wire externaldynamic traction device. Range of motion and grip strength weremeasured. We used the Michigan Hand Outcome Questionnaire(MHQ) to obtain a subjective response to the treatment. Averagerange of motion of the PIP joint was 64° and distal interphalangealjoint was 52°. The average grip strength was 86% with a mean MHQscore of 90. Two patients had pin site infections treated successfullywith antibiotics. All fractures had united at final follow up with�1-mm articular step present. Our series highlights that these aredifficult injuries to treat and that anatomic reduction is not alwayspossible. However, this technique is simple and quick to performwhile allowing early joint mobilization. The subjective response totreatment is comparable with other studies using a similar device.

Key Words: dynamic, external fixation, fracture, proximalinterphalangeal joint

(Ann Plast Surg 2007;58: 625–629)

Proximal interphalangeal joint (PIP) joint fractures arerelatively rare but can be severely disabling for the patient

and lead to stiffness and persistent pain if inadequatelytreated.

The stability of the PIP joint is provided by the articularcongruency and soft tissue supports. Soft tissue stability isprovided by collateral ligaments, volar plate, joint capsule,dorsal expansion, and extensor tendon as well as the flexortendons.1 These fractures commonly occur when an axialload is applied to the finger tip causing hyperextensionleading to a dorsal fracture and/or dislocation.2

Intra-articular PIP joint fractures can be treated withvarious techniques. This is dependent on the articular surfaceinvolvement of the base of the middle phalanx and the degreeof comminution. It is generally accepted that if there is lessthan 40% involvement of the joint surface, then the fractureis stable and can be treated nonoperatively.3 However, greaterthan 40% of joint surface is unstable and requires surgicalintervention.3

Treatment modalities include extension block splint-ing,4 open reduction and internal fixation,5,6 closed reductionand percutaneous fixation, and volar plate arthroplasty. Thereare 2 main problems with comminuted fractures at the PIPjoint: 1) the articular bony fragments are too small to openlyreduce and internally fix to gain anatomic reduction; and 2) ifthe joint is immobilized, the fibrotic changes that occur afterinjury will cause stiffness.

These problems can be overcome by early mobilizationafter anatomic reduction of the fracture using the principle ofligamentotaxis.7,8 There have been various techniques de-scribed in the literature using these principles.4,7,9–11 Wereport a series of 11 patients with intra-articular PIP jointfractures 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

METHODSWe reviewed 11 consecutive patients who sustained an

intra-articular fracture of the PIP joint and 1 patient of the IPjoint of the thumb. All were treated with a dynamic externalfixator frame by the senior author (V.R.) between 2004 and2005. We used the classification system by Seno et al (Fig. 1)to describe the fracture configuration at the base of the middlephalanx.12 Objective measurements of the active range ofmotion (AROM) of the distal interphalangeal (DIP) and PIPjoints of the affected finger or thumb were measured using astandard goniometer. The grip strength was also measuredusing the Jamar dynamometer and was compared with theuninjured side. We used the Michigan Hand Outcome Ques-tionnaire13 (MHQ) to obtain a subjective response to thetreatment. Duration of the procedure was obtained fromoperating room records. Bony union was confirmed by re-view of the radiographs at the latest follow up.

Statistical analysis was performed using the Pearsoncorrelation test to identify if there was any significant rela-

Received June 27, 2006, and accepted for publication, after revision, August30, 2006.

From The Birmingham Hand Centre, University Hospital Birmingham SellyOak Hospital, Birmingham, U.K.

Reprints: Kanthan Theivendran, BSc, MBBS, MRCS, 81 Pennine Way,Ashby-de-la-Zouch, Leicestershire LE65 1EZ, United Kingdom. E-mail:kanthan@hotmail.co.uk.

Copyright © 2007 by Lippincott Williams & WilkinsISSN: 0148-7043/07/5806-0625DOI: 10.1097/01.sap.0000245132.14908.9d

Annals of Plastic Surgery • Volume 58, Number 6, June 2007 625

tionship between the time of delay to operation, the age of thepatient, or the outcome of treatment. The SPSS 14.0 (SPSSInc., Chicago, IL) statistical software was used to perform theanalysis with P values of less than 0.05 considered to besignificant.

Surgical TechniqueAll of the patients had local anesthetic for the proce-

dure. A radiographic image intensifier (II) was used to visu-alize fracture manipulation and reduction. A 1.1-mm K-wirewas inserted percutaneously and perpendicular to the longaxis of the phalanx. This wire was directed to the center ofrotation of the head of the proximal phalanx while avoidingbreaching the joint capsule. A second longer K-wire wasinserted distally and at right angles to the middle phalanxthrough the center of rotation of the head of the middlephalanx while avoiding breaching the joint capsule. Bothwires were used to manipulate and reduce the fracture underII guidance. The proximal wire was bent into a hook approx-imately 5 mm from the skin. The distal K-wire was bentparallel to the long axis of the phalanx pointing toward theproximal K-wire and shaped into a parabolic curve. Thispreloaded curve was then made into a hook at its distal endand interlocked with the hook from the proximal wire whileapplying traction to the digit (Fig. 2). This provided tension

and distraction across the fracture site. Early active move-ment was encouraged within 24 hours and all patients re-ceived hand therapist input.

RESULTSThe mean follow up was 24 weeks (range, 12–56 weeks)

and the average age of the patient was 35 years (range, 18–60years). There were 10 men and 2 women who sustained intra-articular digital fractures. Table 1 outlines the demographicdetails. The device was left in situ for an average of 4 weeks andthe mean time from injury to operation was 8 days. The meanAROM of the injured PIP joint was 64° and DIP joint (includingthe IP joint of the thumb) was 52°. The mean grip strengthof the injured side compared with the uninjured hand was86%. The average duration of the procedure was 12 minutes(range, 10–16 minutes). The mean MHQ score was 90. Eightpatients were employed before their injury and all havereturned to their original occupations.

The time delay to operation correlated negatively withthe grip strength (r � �0.556, P � 0.061); however, this wasnot significant. There was no significant correlation betweentime delay to operation and the AROM of the PIP joint (r �0.176, P � 0.583) or the delay to operation and the MHQscore (r � 0.084, P � 0.795). No significant correlation was

FIGURE 1. Classification of base ofmiddle phalanx fractures by Senoet al.12 Reproduced with permis-sion and copyright of the BritishEditorial Society of Bone and JointSurgery.

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 theproximal wire is bent forward. D, A preloaded dorsal curve is created from the distal wire. E, Wire ends are shaped into hooksthat engage and maintain in-line traction. F, Fracture is reduced and maintained while allowing movement at the hooks ofthe K-wire.

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© 2007 Lippincott Williams & Wilkins626

found between age of the patient and the outcome (r �0.04, P � 0.903 for the grip strength; r � 0.443, P � 0.149for the AROM of the PIP joint; and r � 0.292, P � 0.357for the MHQ).

Two patients developed minor pin track infection suc-cessfully treated with oral antibiotics. One patient knockedthe device on the gearshift of a car. It became loose andneeded reapplication at 4 weeks. In this case, the disengage-ment of the construct occurred as a result of a technical errorof inadequate crimping of the ends of the wire. All patientswere pain-free at the latest follow up, and there was noclinical or radiologic evidence of osteomyelitis. All fractureswere united at final follow up with an average extensor lag atthe PIP joint of 11° with pain-free range of motion. However,all our patients had less than a 1-mm intra-articular step presenton radiographs with no evidence of reduction in joint space atfinal follow up. Case no. 12 (Fig. 3) shows a Seno type 3 baseof the middle phalanx fracture that shows bony union at 3months postinjury with an intra-articular step present.

DISCUSSIONThe treatment goals for intra-articular PIP joint frac-

tures are to restore anatomic alignment of the joint and toallow early active movement to avoid stiffness. These chal-lenging goals have sparked renewed interest in the techniquesfor treating these difficult fractures. Previous attempts withopen reduction and internal fixation have proved difficultwith small fragments, resulting in high complication rates andreduced ability to gain joint congruency.9,14 Stern et alperformed a comparative study looking at splinting, skeletaltraction with early mobilization, and open reduction andinternal fixation (ORIF) of pilon fractures of PIP joint.9 Theyfound that ORIF can achieve anatomic reduction in somecases, but concluded that severely comminuted subchondralfragments are almost impossible to reduce and may be un-necessary. ORIF can cause extensive soft tissue disruptionleading to reduced blood supply to the fracture fragmentsresulting in joint stiffness.9 To avoid these problems, manyauthors have devised innovative techniques using the princi-ple of ligamentotaxis to provide stable reduction and earlyactive movement of the PIP joint. Schenck used a dynamiccircular frame, which allowed passive finger flexion andextension at regular intervals.15 This device was large andcumbersome and was worn for at least 7 weeks. Smallerfixators using springs and pulleys are often difficult to con-struct.8,16 The Pins and Rubber Traction System (PRTS) bySuzuki et al11 used rubber bands that could be tensioneddifferentially to correct valgus and varus deformity. How-ever, although they reported excellent results, it was com-monly known that rubber bands were subjected to plasticdeformation and could become loose. The senior authorfound that rubber bands were difficult to manage postopera-tively and found it cumbersome to apply and maintain be-cause the elasticity was not constant. Simple external dy-namic fixators using K-wires only to provide ligamentotaxishave been described by Hynes and Giddins10 and Gaul andRosenberg.17 Our surgical technique is based on a similarconfiguration of K-wires. This frame, if applied properly,TA

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maintains constant distraction and, if overdistraction oc-curred, can be reduced by crimping the wire. A similar studyby Deshmukh et al,18 who used a modified PRTS of Suzukiet al,11 produced an average AROM of the PIP joint of 85°,an average grip strength of 92%, and a mean normalizedMHQ of 84 at an average follow up of 34 months. Our studyshowed a better average MHQ score of 90 as compared withthat achieved in the study by Deshmukh et al. The meanAROM of the PIP joint from our study was lower comparedwith other studies using a similar K-wire external fixator.19,20

This may be the result of the shorter follow-up period of 6months in our study compared with similar fixators by Badiaet al (89° at 24 months) and Syed et al (79° at 2.2 years).19,20

Importantly, all those patients who were employed before theinjury have now returned to their original jobs. All patientswere satisfied with the treatment and reported pain-free rangeof motion. Fracture union had occurred in all patients at finalfollow up with less than a 1-mm intra-articular step present atthe PIP joint. Our series highlights that these are difficultinjuries to treat and that anatomic reduction is not alwayspossible as compared with open reduction with rigid internalfixation. However, internal fixation can be technically de-manding and often require extensive soft tissue dissectionthat may contribute to complications and the need for sec-ondary operative procedures.21

The main limitation to this study is the small samplesize and short follow-up period. Long-term follow up will berequired to identify if patients develop post-traumatic arthritiswithin these joints. Despite the current limitations, we believethat this system provides a simple and cost-effective methodof treatment of these difficult fractures. The application of theexternal fixator is quick (average operative time of 12 min-utes), is done under local anesthetic, and is acceptable to thepatient. Our case series shows a comparable subjective re-

sponse to treatment with other studies using a similar dy-namic external fixation device.

REFERENCES1. Liss FE, Green SM. Capsular injuries of the proximal interphalangeal

joint. Hand Clin. 1992;8:755–768.2. Glickel SZ, Barron OA. Proximal interphalangeal joint fracture disloca-

tions. Hand Clin. 2000;16:333–344.3. Glickel SZ, Barron OA, Eaton RG. Dislocations and Ligament Injuries

in the Digits, 4th ed. New York: Churchill Livingstone; 1999:772–808.4. McElfresh EC, Dobyns JH, O’Brien ET. Management of fracture–

dislocation of the proximal interphalangeal joints by extension-blocksplinting. J Bone Joint Surg �Am�. 1972;54:1705–1711.

5. Agee JM. Unstable fracture dislocations of the proximal interphalangealjoint of the fingers: a preliminary report of a new treatment technique.J Hand Surg �Am�. 1978;3:386–389.

6. Wilson JN, Rowland SA. Fracture–dislocation of the proximal interpha-langeal joint of the finger. J Bone Joint Surg �Am�. 1966;48:493–502.

7. Agee JM. Unstable fracture dislocations of the proximal interphalangealjoint. Treatment with the force couple splint. Clin Orthop. 1987;214:101–112.

8. Allison DM. Fractures of the base of the middle phalanx treated by adynamic external fixation device. J Hand Surg �Br�. 1996;21:305–310.

9. Stern PJ, Roman RJ, Kiefhaber TR, et al. Pilon fractures of the proximalinterphalangeal joint. J Hand Surg �Am�. 1991;16:844–850.

10. Hynes MC, Giddins GE. Dynamic external fixation for pilon fractures ofthe interphalangeal joints. J Hand Surg �Br�. 2001;26:122–124.

11. Suzuki Y, Matsunaga T, Sato S, et al. The pins and rubbers tractionsystem for treatment of comminuted intraarticular fractures and frac-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 middlephalanx of the finger. Classification, management and long-term results.J Bone Joint Surg �Br�. 1997;79:758–763.

13. Chung KC, Pillsbury MS, Walters MR, et al. Reliability and validitytesting of the Michigan Hand Outcomes Questionnaire. J Hand Surg�Am�. 1998;23:575–587.

14. Hastings H 2nd, Carroll CT. Treatment of closed articular fractures ofthe metacarpophalangeal and proximal interphalangeal joints. HandClin. 1988;4:503–527.

15. Schenck RR. Dynamic traction and early passive movement for fractures

FIGURE 3. Case no. 12: A, Preoperative radiograph showing a Seno type 3 fracture. B, Seven-day postoperative radiographwith 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.

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of the proximal interphalangeal joint. J Hand Surg �Am�. 1986;11:850–858.

16. Inanami H, Ninomiya S, Okutsu I, et al. Dynamic external finger fixatorfor fracture dislocation of the proximal interphalangeal joint. J HandSurg �Am�. 1993;18:160–164.

17. Gaul JS Jr, Rosenberg SN. Fracture–dislocation of the middle phalanx atthe proximal interphalangeal joint: repair with a simple intradigitaltraction-fixation device. Am J Orthop. 1998;27:682–688.

18. Deshmukh SC, Kumar D, Mathur K, et al. Complex fracture–dislocationof the proximal interphalangeal joint of the hand. Results of a modified

pins and rubbers traction system. J Bone Joint Surg �Br�. 2004;86:406–412.

19. Syed AA, Agarwal M, Boome R. Dynamic external fixator for pilonfractures of the proximal interphalangeal joints: a simple fixator for acomplex fracture. J Hand Surg �Br�. 2003;28:137–141.

20. Badia A, Riano F, Ravikoff J, et al. Dynamic intradigital externalfixation for proximal interphalangeal joint fracture dislocations. J HandSurg �Am�. 2005;30:154–160.

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Annals of Plastic Surgery • Volume 58, Number 6, June 2007 External Fixation of PIP Joint Fractures

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