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. 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. 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. 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. 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.
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