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Comminuted intra-articular fractures of the metacarpophalangeal joint (MCPJ) of the thumb are difficult to treat because of challenges with anatomical fixation. The pins and rubbers traction system (PRTS), described by Suzuki et al., is a minimally invasive technique that enables early range-of-motion training while maintaining joint congruency. PRTS exhibits advantages relative to other dynamic external fixation techniques due to its simplicity, low cost and compact design. It has been used mainly in treating primarily proximal interphalangeal joint (IPJ) fractures. We present two patients where we used a PRTS for comminuted intra-articular fractures of the thumb MCPJ with good outcomes. We temporarily pinned the carpometacarpal joint (CMCJ) in maximum abduction to avoid skin irritation from the ulnar aspect of the axial traction wire in thumb adduction.

Level of Evidence: Level V (Therapeutic)

Treatment of Rolando fractures remains a challenge for hand surgeons. We present a case series of 16 comminuted Rolando type fractures treated by controlled capsuloligamentous distraction (and over distraction by 2 mm) using the Pennig mini-external fixation system. Additional Kirschner wire(s) were used to maintain fracture reduction and stability. Average time of injury to surgery time was five days. Mean age of patients was 26 years. The mean follow-up was 20 months. Excellent fracture union was achieved in all cases. All except two patients were pain free at the final consultation. The mean grip and pinch strength of the affected thumb was 96% and 93%, respectively, of the unaffected thumb with a minimal loss of movements. This technique is simple and effective. It enables immediate mobilisation of the unaffected joints and prevents stiffness. We recommend this distraction technique for the treatment of significantly comminuted Rolando type fractures.

Nonunion of phalangeal fractures is uncommon and even rarer in the paediatric age group. There is paucity of literature relating to the treatment of atrophic non-union of phalangeal fractures in the paediatric age group. We present a case of five years old atrophic non-union of the middle phalanx of the index finger of the dominant hand in a nine-year-old male child, managed with a staged treatment protocol of initial fracture site distraction with a threaded external fixator followed by delayed bone grafting. This treatment was successful in attaining length and bony union in case of atrophic non-union of the middle phalanx with a good pinch strength and gaining a good range of motion at the proximal interphalangeal joint with little soft tissue dissection.

We present a 58-year-old right-handed man, who consulted us with an 11-year history of Dupuytren’s disease. To correct contracture of the little finger, we performed regional fasciectomy, skin grafting, and distraction arthrolysis of the proximal interphalangeal (PIP) joint using an external fixator. Preoperative or postoperative skeletal traction has been advocated to treat potential or residual stiffness of the PIP joint in Dupuytren’s contracture, but its intraoperative use has not been reported before. Our method has the advantage of treating each problem caused by Dupuytren’s disease. A good range of painless PIP joint motion is achieved by our intraoperative distraction technique without interfering with the skin graft and without reducing extensor tone, while the healing period is shortened by performing all procedures simultaneously.

Fibrous dysplasia (FD) is a congenital skeletal disorder characterized by the replacement of the bone marrow with fibrous tissue. FD may occur in isolation or association with endocrinopathies, and in that case, labeled McCune–Albright syndrome (MAS). FD can cause bone deformities or/and limb length discrepancies. The surgical intervention aims to correct limb deformities and length discrepancies while improving regional aesthetics.

We report a case of a 14-year-old girl with FD that had affected her upper limbs. More characteristic had been the shortening of the right humerus (10 cm discrepancy from the left humerus) and the gun-stock deformity of the elbow. On the X-ray, a prominent feature was the shortening of the humerus and the valgus deformity of its distal end. The lengthening and correction of the deformity of the right humerus had been performed using the Taylor spatial frame (TSF) system. The software program had provided us with the estimated minimum correction time of 143 days for 7 cm humeral lengthening. A total of 157 days had been needed to lengthen and correct the deformity.

The TSF system allows the simultaneous lengthening and correction of all the components of a multiplanar malformation of a limb and minimizes the required time.

In clinical practice, bone healing is monitored with X-rays and manipulation. Its assessment is thus subjective, depending on the skills of the operator. Alternative and quantitative approaches have been proposed, generally based on the estimation of bone stiffness, which is known to increase with the healing process.

The present study investigates the application of experimental modal analysis to fracture healing assessment focusing on fractures treated with an external fixator. The aim is to ascertain the capability of this approach to detect changes in the bone-callus stiffness as variations in the resonant frequencies despite the presence of the fixator, which might hide the bone response. In vitro tests were performed on a tibia phantom where the healing process was simulated creating three different types of callus surrogates, using glue and resin. The resonant frequencies of the phantom with screwed pins and of the phantom with the complete fixator were estimated. Results confirm an increase in the frequencies as the simulated bone-callus stiffness increases, encouraging the application of experimental modal analysis to fracture healing monitoring. This approach can offer remarkable advantages with respect to the actual standards: being non-invasive and quantitative, it would allow a more frequent healing monitoring.

Background: Within hand trauma, the management of unstable, intra-articular fractures of the base of the middle phalanx remains highly controversial. The objective of this research was to determine which operation gives the best outcome in the management of displaced, intra-articular fractures of the base of the middle phalanx causing instability of the proximal interphalangeal joint.

Methods: A scoping study was performed to determine the evidence available and the terminology used. A Systematic Review was then performed along PRISMA guidelines. This Systematic Review looked specifically for papers available in English, published over the last ten years, with clinical data for at least five cases of acute unstable fractures of the base of the middle phalanx. There must be two years follow-up with less than 30% loss to follow-up.

Results: There were no Systematic Reviews or Cochrane reviews. There were no randomized controlled trials and the best studies were simply cohort studies with level III or IV evidence. There was a paucity of high quality studies, with small, heterogeneous groups, short length of follow-up and high loss to follow up. Only seven papers met the Systematic Review criteria.

Conclusions: General trends show excellent return of grip strength and good function despite some ongoing pain and stiffness. There were high complication rates for all techniques and the possible reasons for different outcomes are discussed.

Background: This study aimed to investigate whether the distance between the radial nerve and rotational center of the elbow joint when observing from the lateral surface of the humerus changes according to passive elbow joint flexion for safe external fixation with a hinged fixator of the elbow joint.

Methods: Twenty fresh-frozen cadaveric arms were dissected. The points where the radial nerve crosses over the posterior aspect of the humerus, crosses through the lateral center, and crosses over the anterior aspect of the humerus were defined in the lateral view of the elbow joint, using fluoroscopy, as R1, R2, and R3, respectively. The distances between the rotational center and each point on the radial nerve were measured when the flexion angle of the elbow joint was 10°, 50°, 90°, and 130°.

Results: The distances between the rotational center and R1, R2, and R3 were 118 mm, 94 mm, and 65 mm, respectively, when the flexion angle was 10°; 112 mm, 93 mm, and 74 mm, respectively, for 50°; 108 mm, 93 mm, and 77 mm, respectively, for 90°; and 103 mm, 94 mm, and 83 mm, respectively, for 130°. The distance between the rotational center and R2 was constant regardless of the flexion angle. With elbow joint extension, the distances between R1 and R3 increased; the safe zone, a region where the radial nerve would not be located on the humerus, was the smallest in extension. When the elbow joint was flexed, the distances between R1 and R3 decreased; the safe zone was the largest in flexion.

Conclusions: This study showed that the radial nerve location on the humerus varied based on the flexion angle of the elbow joint; the safe zone may change. A half-pin can be likely inserted safely, avoiding the elbow joint extension position.

Background: This is a retrospective case series investigating the outcomes using a dynamic external fixator (DEF) for treatment on severe flexion contractures at the proximal interphalangeal (PIP) joint. Severe flexion contractures of the PIP joint occurring after multiple operations and neglected over a long period of time are difficult to treat. The recurrence of contracture, even after successful treatment, is inevitable in patients with severe cases. In this study, we defined the severity of PIP joint contracture based on the active range of motion (ROM), soft tissue condition, and duration of the contracture. We also illustrated the strategy, results, and complications of using a DEF with rubber bands in these severe cases.

Methods: We studied 11 fingers of 10 patients with PIP joint contracture treated by DEF. These were fixed at a small arc and neglected for an average 4.1 years (range, 1–9 years). The temporal Kirshner wire (K-wire) fixation after achieving an extension via DEF was maintained for 9.1 weeks on average. We retrospectively reviewed the results of these patients with an average 2-year follow-up.

Results: Our method yielded favorable results upon retrospective evaluation. The average active ROM of the affected PIP joint improved from 90/96° to 34/83° with a functional arc and good patient satisfaction. The elastic force induced by strong rubber bands was safe and effective. The first step of joint space widening was the key to obtaining a successful joint extension afterwards. Serious progression of osteoarthritis at the PIP joint and pin-site fracture were a complication in each one case.

Conclusions: In this study, we evaluate the surgical strategy of using DEFs powered by elastic torque from rubber bands to treat severe cases of flexion contractures of fingers. We first created extension contracture intentionally, followed by promoting flexion movement during follow-up in this group of patients.

Background: Fracture dislocations of the proximal interphalangeal joint (PIPJ) are challenging injuries and a dynamic external fixator frame is often used. We devised a dynamic external fixator device called the Gexfinger^® that allows greater control of the degree of traction. The aim of this study is to report the mid-term outcomes of this device.

Methods: This is a retrospective study of patients with fracture dislocation of the PIPJ who were treated with the Gexfinger^® over a 3-year period. Clinical data with regard to the patient, the injury, treatment and period of follow-up were recorded. The outcome measures included time to return to work, arc of motion at the interphalangeal joints, grip strength, visual analogue score (VAS) for pain, patient satisfaction and complications.

Results: We studied 26 patients (17 men and 9 women) with an average age of 38 years. The average articular surface involvement was 56%. The mean period between injury and surgery was 6 days and the frames were maintained for 5.5 weeks on average. The mean follow-up period was 8.5 weeks. All patients returned to work at an average of 7 weeks. The mean arc of motion at the PIPJ and distal interphalangeal joint (DIPJ) were 82° and 65°, respectively and the mean grip strength was 83% of the contralateral side. 22 patients reported no pain at the final follow-up. Fifteen patients were very satisfied, 8 satisfied and 3 unsatisfied. Two patients had stiffness of the PIPJ.

Conclusions: The mid-term outcomes of the Gexfinger^® are similar to other methods of dynamic traction described in literature. It is modular, easy to assemble and allows a greater control of the degree of traction. In combination with additional screws and/or K-wires, it has allowed us to treat a wide spectrum of PIPJ fracture dislocations with good outcomes.

Level of Evidence: Level IV (Therapeutic)

Many unwanted traumas occur in daily life, the result of which may be intertrochanteric fractures in the musculoskeletal system. An intertrochanteric femoral fracture is a serious trauma which can lead to pneumonia, pulmonary embolism or death. Therefore, accurate and stable fixation of these fractures is necessary. Schanz screws with a pertrochanteric fixator body are used for the stabilization of intertrochanteric fractures. The stability of fractures created by external fixators is dependent on the frame and bone interaction. The distance between the fixator body and the bone, called "sidebar-bone spacing", is one of the most important aspects of fracture stability. The primary objective in the treatment of these fractures is to maintain the stability of the fracture in the reduction position to allow early mobilization. In this study, an intertrochanteric femoral fracture was fixed with a pertrochanteric fixator, then the effect of sidebar-bone spacing on the fracture line under axial loading was analyzed using AnsysWorkbench software. Stress and strain values on the fracture line and schanz screws were calculated to understand this effect according to the von-Mises criteria. The sidebar-bone spacing was selected as 8, 6 and 4 cm. The von-Mises stress value on the fracture line decreased as the distance between the fixator body and the bone decreased, although strain values increased. In conclusion, decreasing the sidebar-bone spacing in the pertrochanteric fixator used on hip fractures provides stronger stabilization, and demonstrates safer axial loading.