Articular fractures of the digits: a prospective study

A scoping review of applications and outcomes of traction orthoses and constructs for the management of intra-articular fractures and fracture dislocations in the hand

INTRODUCTION

Intra-articular hand fractures can have devastating consequences for movement and function. The unique nature of the injury and diverse management strategies are a challenge for conducting trials.

PURPOSE OF THE STUDY

To conduct a scoping review of traction constructs for the management of intra-articular hand fractures.

METHODS

We conducted a systematic search of the literature, extracting data on the scope and nature of the evidence for traction constructs.

RESULTS

Our search yielded 87 articles addressing 3 traction constructs: (1) static traction (n = 17), (2) dynamic external fixation (n = 53), and (3) dynamic orthoses (n = 17). Active range of motion of the target joint was the most frequently reported outcome. Study designs included 36 cohorts, 21 case series, and 9 case studies: 24% contained only technical information.

CONCLUSIONS

The current literature addressing traction constructs consists primarily of small and low-quality studies. Evidence synthesis could improve the estimation of range of motion outcomes but would not be able to identify the best treatment. Consensus on classification of fracture patterns, routine use of outcome measures, and randomized trials are needed to compare different traction constructs and inform evidence-based care.

STUDY DESIGN

Scoping review.

LEVEL OF EVIDENCE

N/A.

Open fractures of the hand with soft tissue loss

The evaluation, initial treatment, and definitive reconstruction of open fractures of the hand with associated soft tissue loss are reviewed. Specific attention is given to the literature on open fracture antibiotic prophylaxis in the hand; the timing of bone and soft tissue reconstruction; and options for soft tissue coverage, including local, regional, and distant tissue transfer. Factors that have shown association with outcomes in these injuries are also discussed, and the authors' preferred management is summarized.

External fixation of closed metacarpal and phalangeal fractures of digits. A prospective study of one hundred consecutive patients

Stable and undisplaced phalangeal and metacarpal fractures treated with strapping or functional splinting and controlled active exercises offer from about 70 to 80% of good results. The goal of treatment of closed unstable and displaced fractures should be to achieve similar or better outcome. External fixation combines the simplicity of time-honoured fixation with K-wires and an external frame to increase rigidity. This combination was used in a prospective study of 100 consecutive patients with closed fractures of the proximal and middle phalanges and the distal three-quarters of the metacarpal bones. Good clinical results (TAM > or = 230 degrees) were obtained in 76% of isolated phalangeal fractures, in all metacarpal fractures and in 89% of multiple fractures.

[Treatment of phalangeal neck fractures in children: technical suggestion]

INTRODUCTION

Phalangeal neck fractures in children are not very frequent lesions. The purpose of this study is to bring out results of treatment of these fractures and provide an adequate procedure.

PATIENTS AND METHODS

Twenty-three patients with 24 phalangeal neck fractures were reviewed. Seventeen boys and six girls with a mean age of 7 years and 6 months. Open wound fractures were noted in 13 cases. A direct trauma was noted in 17 cases and an indirect trauma in seven cases. Treatment consisted of a closed reduction and cast immobilization in four cases. A closed reduction and percutaneous pinning in seven cases. Open reduction and osteosynthesis in 13 cases.

RESULTS

All patients were reviewed with a mean follow-up of 16 months and functional results were evaluated by measuring the Total Active Motion. Fractures treated orthopedically (4) gave Good results; percutaneous pinning (seven cases) gave one Poor, one Fair and five Good results; open reduction and osteosynthesis gave zero Good, six Fair and seven Poor results. Phalangeal head osteonecrosis was noted in four cases treated by open reduction.

DISCUSSION

Closed reduction and percutaneous treatment of these fractures give the best functional results. This study demonstrates that open surgical reduction of these fractures leads to phalangeal head osteonecrosis and poor functional result. We propose here a technical improvement of percutaneous reduction with intrafocal pining and osteosynthesis.

CONCLUSION

This technical improvement of percutaneous reduction and pinning allow to combine the advantages of a closed reduction and to avoid distal epiphyseal necrosis.