553139
research-article2014
JHS0010.1177/1753193414553139Journal of Hand SurgeryJiang et al.
JHS(E)
Short report letter
The Journal of Hand Surgery (European Volume) XXE(X) 1–2 jhs.sagepub.com
The treatment of bony mallet fingers using a triple K-wire fixation technique Dear Sir, The role of surgery for bony mallet injuries is unclear (Giddins, 2014). We favour surgical stabilization. Various surgical techniques for bony mallet finger deformity have been reported, accurate reduction and stable fixation remains challenging. We have treated 25 consecutive patients with bony mallet injuries with a bone fragment of >33% according to the criteria of Webhé and Schneider (1984). Distal interphalangeal (DIP) joint subluxation was observed in some patients. We used a triple K-wire fixation technique through a small curved transverse
incision over the dorsal aspect of the DIP joint. The terminal extensor mechanism and the fracture site were exposed. After the excision of the soft tissue between the dorsal fracture fragment and distal phalanx, the bone fragment was reduced. A 0.6 mm or 0.8 mm K-wire was drilled vertically across the fracture line in a dorsal to palmar direction. A second same-diameter K-wire was then inserted 2–3 mm apart from, and parallel to, the first. The two small K-wires were pulled with an electric drill from the finger pulp. The dorsal ends of the K-wires were external to the dorsal cortex (1–2 mm) and the volar ends were bent. Finally, a 1.0 mm K-wire was drilled into the distal phalanx volar to the fracture line and across the DIP joint to hold it in slight hyperextension (Figure 1). Neither protective splint nor plaster of Paris (POP) bandage was used. At 6 weeks postoperatively, the three K-wires were removed in all patients. Full active
Figure 1. Schematic drawing of the surgical technique. (A) Arced line represents the incision. (B) A flap was raised to expose the dorsal fracture site of the distal phalanx. (C) Two small K-wires fixed the reduced fragment. (D) A transarticular K-wire was drilled into the distal phalanx volar to the fracture line. Downloaded from jhs.sagepub.com at The University of Iowa Libraries on June 9, 2015
2
The Journal of Hand Surgery (Eur)
Figure 2. A 24-year-old male patient with a mallet fracture of the little finger of the right hand. (A) Preoperative radiograph. (B) The dorsal ends of the two K-wires were external to the dorsal cortex (1 mm). (C, D) Lateral radiographs obtained immediately and 6 months postoperatively.
and passive exercises of the DIP joints were initiated immediately after removal of the K-wires (Figure 2). The patients were reviewed by a specialist surgeon. Follow-up was extended from a period of 6 to 17 months, with a mean time of 10 months. We reviewed all 25 patients. There were 15 men and 10 women with a mean age of 34 years (range 20–58). The mean size of the fracture fragments was 43% (range 37%–62%). The results were excellent in 15, good in eight and fair in two, using the Crawford’s evaluation criteria (1984). No severe complications, such as infection, skin necrosis or K-wire breakage, were noted. There were three cases of mild nail deformity. Three patients had mild degenerative changes on radiographs at 2 months postoperatively, which did not limit their daily activities. Mild pulp discomfort occurred in two cases, but resolved at a mean of 1 month after the K-wires were removed. None of these patients reported pain at the final follow-up. It is a challenging surgery performed in treatment of bony mallet finger. Our technique provides not only the anatomical reduction of the fracture fragment but also secures reliable fixation. During the procedure, we need to be more attentive when we get the two small K-wires through the minute and fragile bone fragment, it requires a delicate surgical technique.
Conflict of interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References Crawford GP. The molded polythene splint for mallet finger deformities. J Hand Surg Am. 1984, 9: 231–7. Giddins GEB. The non-operative treatment of hand fractures. J Hand Surg Eur. Epub ahead of print 12 September 2014. DOI: 10.1177/1753193414548170. Wehbé MA, Schneider LH. Mallet fractures. J Bone Joint Surg Am. 1984, 66: 658–69.
B. Jiang, P. J. Wang and J. J. Zhao Department of Hand and Foot Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China. Corresponding author: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193414553139 available online at http://jhs.sagepub.com
Downloaded from jhs.sagepub.com at The University of Iowa Libraries on June 9, 2015
research-article2014
JHS0010.1177/1753193414553139Journal of Hand SurgeryJiang et al.
JHS(E)
Short report letter
The Journal of Hand Surgery (European Volume) XXE(X) 1–2 jhs.sagepub.com
The treatment of bony mallet fingers using a triple K-wire fixation technique Dear Sir, The role of surgery for bony mallet injuries is unclear (Giddins, 2014). We favour surgical stabilization. Various surgical techniques for bony mallet finger deformity have been reported, accurate reduction and stable fixation remains challenging. We have treated 25 consecutive patients with bony mallet injuries with a bone fragment of >33% according to the criteria of Webhé and Schneider (1984). Distal interphalangeal (DIP) joint subluxation was observed in some patients. We used a triple K-wire fixation technique through a small curved transverse
incision over the dorsal aspect of the DIP joint. The terminal extensor mechanism and the fracture site were exposed. After the excision of the soft tissue between the dorsal fracture fragment and distal phalanx, the bone fragment was reduced. A 0.6 mm or 0.8 mm K-wire was drilled vertically across the fracture line in a dorsal to palmar direction. A second same-diameter K-wire was then inserted 2–3 mm apart from, and parallel to, the first. The two small K-wires were pulled with an electric drill from the finger pulp. The dorsal ends of the K-wires were external to the dorsal cortex (1–2 mm) and the volar ends were bent. Finally, a 1.0 mm K-wire was drilled into the distal phalanx volar to the fracture line and across the DIP joint to hold it in slight hyperextension (Figure 1). Neither protective splint nor plaster of Paris (POP) bandage was used. At 6 weeks postoperatively, the three K-wires were removed in all patients. Full active
Figure 1. Schematic drawing of the surgical technique. (A) Arced line represents the incision. (B) A flap was raised to expose the dorsal fracture site of the distal phalanx. (C) Two small K-wires fixed the reduced fragment. (D) A transarticular K-wire was drilled into the distal phalanx volar to the fracture line. Downloaded from jhs.sagepub.com at The University of Iowa Libraries on June 9, 2015
2
The Journal of Hand Surgery (Eur)
Figure 2. A 24-year-old male patient with a mallet fracture of the little finger of the right hand. (A) Preoperative radiograph. (B) The dorsal ends of the two K-wires were external to the dorsal cortex (1 mm). (C, D) Lateral radiographs obtained immediately and 6 months postoperatively.
and passive exercises of the DIP joints were initiated immediately after removal of the K-wires (Figure 2). The patients were reviewed by a specialist surgeon. Follow-up was extended from a period of 6 to 17 months, with a mean time of 10 months. We reviewed all 25 patients. There were 15 men and 10 women with a mean age of 34 years (range 20–58). The mean size of the fracture fragments was 43% (range 37%–62%). The results were excellent in 15, good in eight and fair in two, using the Crawford’s evaluation criteria (1984). No severe complications, such as infection, skin necrosis or K-wire breakage, were noted. There were three cases of mild nail deformity. Three patients had mild degenerative changes on radiographs at 2 months postoperatively, which did not limit their daily activities. Mild pulp discomfort occurred in two cases, but resolved at a mean of 1 month after the K-wires were removed. None of these patients reported pain at the final follow-up. It is a challenging surgery performed in treatment of bony mallet finger. Our technique provides not only the anatomical reduction of the fracture fragment but also secures reliable fixation. During the procedure, we need to be more attentive when we get the two small K-wires through the minute and fragile bone fragment, it requires a delicate surgical technique.
Conflict of interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References Crawford GP. The molded polythene splint for mallet finger deformities. J Hand Surg Am. 1984, 9: 231–7. Giddins GEB. The non-operative treatment of hand fractures. J Hand Surg Eur. Epub ahead of print 12 September 2014. DOI: 10.1177/1753193414548170. Wehbé MA, Schneider LH. Mallet fractures. J Bone Joint Surg Am. 1984, 66: 658–69.
B. Jiang, P. J. Wang and J. J. Zhao Department of Hand and Foot Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China. Corresponding author: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193414553139 available online at http://jhs.sagepub.com
Downloaded from jhs.sagepub.com at The University of Iowa Libraries on June 9, 2015
