Outcome of unstable fractures of metacarpal and phalangeal bones treated by bone tie.

BACKGROUND: Unstable fractures of the metacarpal and phalangeal bones of the hand need surgical stabilization which should be rigid enough for early active mobilization. Conventional methods of open reduction and stabilization in the form of composite fixation or screws with or without plates have served the purpose but can be definitely improvised addressing both biological and mechanical principles of fixation. MATERIALS AND METHODS: 34 patients (29 males and 5 females) with an average age of 32 years (range 10-64 years) with unstable fractures of the metacarpal and phalangeal bones of hand who were treated with the modified bone tie between June 2009 and June 2013 were included in this study. 42 fractures, involving the 31 metacarpals and 11 phalanges were included. We have not used this technique in fractures involving the terminal phalanges. Thirty nine of the fractures were treated with K-wires along with the modified bone tie, whereas the other two cases were treated with modified bone tie alone and in one case the bone tie has been used along with the external fixator. The nature of injuries were Road Traffic Accident (n = 24), domestic/industrial injuries (n = 8) and blast (n = 2) injuries. Etiology was crush (n = 24), blunt (n = 7) and incised (n = 3) injuries, respectively. Twenty seven patients were involved with single fractures (either metacarpal or the phalanges), 6 patients had two fractures (both metacarpals or phalanges or one each of metacarpal and phalanx), and 1 patient had three fractures in this study. Dominant hand was involved in 14 patients (40%). RESULTS: We achieved excellent to good results in 83% of 42 fractures within an average period of 10 weeks. Postoperative grip strength of 85% was achieved with in an average period of 12 weeks. Twenty six (20 metacarpals and 6 phalanges) of the 42 fractures regained >85% of the total active movements (TAMs) compared to the contralateral side were considered excellent results. All patients were followed up for a minimum of 1 year. CONCLUSION: This method of composite fixation allowed the surgeon to remove the concomitantly used axial K-wire at or <3 weeks clearly explaining the biomechanical basis for better results with minimum complication rates.

A novel method of using mini external fixator for maintaining web space after the release of contracture and syndactyly.

Syndactyly and postburn contracture of the digits are the common cases seen in a hand clinic. Their management can be roughly divided into 3 stages. In stage 1, syndactyly/postburn contracture of the digits are surgically released; in stage 2, surgical wound care is provided; and in stage 3, the patient undergoes physiotherapy (rehabilitation). The most common method of immobilizing the digit after the release is by plaster of Paris splints. Its demerit includes loss of correction, painful postoperative dressing, and suboptimal graft uptake due to improper immobilization and maceration. We describe a simple and effective method of mitigating the above-mentioned drawbacks using a mini external fixator, after the release of the contracted fingers. The use of this fixator also helps during the surgery (stage 1) as resurfacing of the raw areas becomes quick because 2 surgeons can perform this simultaneously. The web can be further opened up using the fixator to facilitate the suturing of the FTG/flap, after which it can be brought back to its normal position. As the dimension of the raw area created is fully defined it becomes easier to suture the flap/graft with appropriate tension and tie-over dressing. The postoperative dressings become easier and pain free. The maceration of the skin graft and skin margin is reduced as the compressive dressing can be applied to individual fingers rather than a collective dressing. It is advantageous even in stage 3 as it allows the surgeon to customize the splint for each finger.

Soft tissue coverage in open fractures of tibia.

BACKGROUND: The treatment of Gustilo Anderson type 3B open fracture tibia is a major challenge and it needs aggressive debridement, adequate fixation, and early flap coverage of soft tissue defect. The flaps could be either nonmicrovascular which are technically less demanding or microvascular which has steep learning curve and available only in few centers. An orthopedic surgeon with basic knowledge of the local vascular anatomy required to harvest an appropriate local or regional flap will be able to manage a vast majority of open fracture tibia, leaving the very few complicated cases needing a free microvascular flap to be referred to specialized tertiary center. This logical approach to the common problem will also lessen the burden on the higher tertiary centers. We report a retrospective study of open fractures of leg treated by nonmicrovascular flaps to analyze (1) the role of nonmicrovascular flap coverage in type 3B open tibial fractures; (2) to suggest a simple algorithm of different nonmicrovascular flaps in different zones and compartment of the leg, and to (3) analyze the final outcome with regards to time taken for union and complications. MATERIALS AND METHODS: One hundered and fifty one cases of Gustilo Anderson type 3B open fracture tibia which needed flap cover for soft tissue injury were included in the study. Ninety four cases were treated in acute stage by debridement; fracture fixation and early flap cover within 10 days. Thirty-eight cases were treated between 10 days to 6 weeks in subacute stage. The rest 19 cases were treated in chronic stage after 6 weeks. The soft tissue defect was treated by various nonmicrovascular flaps depending on the location of the defect. RESULTS: All 151 cases were followed till the raw areas were covered. In seven cases secondary flaps were required when the primary flaps failed either totally or partially. Ten patients underwent amputation. Twenty-two patients were lost to followup after the wound coverage. Out of the remaining 119 patients, 76 achieved primary acceptable union and 43 patients went into delayed or nonunion. These 43 patients needed secondary reconstructive surgery for fracture union. CONCLUSION: open fracture of the tibia which needs flap coverage should be treated with high priority of radical early debridement, rigid fixation, and early flap coverage. A majority of these wounds can be satisfactorily covered with local or regional nonmicrovascular flaps.

Modified bone tie: a new method to achieve interfragmentary compression in unstable oblique metacarpal and phalangeal fractures.

Oblique fractures of the metacarpal and phalanx are inherently unstable especially when there is comminution at the fracture site. Nonoperative management of these fractures requires prolonged immobilization and results in poor outcome. Internal fixation is the preferred method of treatment for these fractures. The various methods used for internal fixation are the Kirschner wires, intraosseous wiring, tension band wiring, minifragment screws and plates. Kirschner wires are the most commonly used fixation device because of their versatility and easy availability. The main disadvantage is lack of rigid fixation as it does not provide interfragmentary compression and pin track infection, if left outside the skin. To overcome these problems intraosseous wiring and tension band wiring were used. The main disadvantage of these procedures is the need for multiple drilling and extensive soft tissue dissection which is detrimental for a comminuted oblique fracture. Minifragment screws and plates provide rigid fixation but the screw can split the small bone fragment and also does not allow any adjustment once it is inserted. Plates tend to be bulky. Bone tie was described as a method of interfragmentary compression with some advantages over the interosseous wiring techniques and tension band wiring. We have modified the original bone tie to make it easier to use and to provide more stable fixation. We present our experience with its use in unstable oblique fractures of the metacarpal and phalanges, which are challenging to treat.

Three unusual factors contributing to compressive median neuropathy in the distal forearm in a single patient.

Although there are varied aetiological factors responsible for compressive neuropathy of the median nerve in the carpal tunnel syndrome, it is rare to encounter several aetiological factors in a single case. This article reports a case in which three aetiological factors were present.

Current concepts in managing fractures of metacarpal and phalangess.

Fractures of the metacarpal and phalanges constitute 10% of all fractures. No where in the body, the form and function are so closely related to each other than in hand. Too often these fractures are treated as minor injuries resulting in major disabilities. Diagnosis of skeletal injuries of the hand usually does not pose major problems if proper clinical examination is supplemented with appropriate radiological investigations. Proper preoperative planning, surgical intervention wherever needed at a centre with backing of equipment and implants, selection of appropriate anaesthesia and application of the principle of biological fixation, rigid enough to allow early mobilisation are all very important for a good functional outcome. This article reviews the current concepts in management of metacarpal and phalangeal fractures incorporating tips and indications for fixation of these fractures. The advantages and disadvantages of various approaches, anaesthesia, technique and mode of fixation have been discussed. The take-home message is that hand fractures are equally or more worthy of expertise as major extremity trauma are, and the final outcome depends upon the fracture personality, appropriate and timely intervention followed by proper rehabilitation. Hand being the third eye of the body, when injured it needs a multidisciplinary approach from the beginning. Though the surgeon's work appears to be of paramount importance in the early phase, the contribution from anaesthetist, physiotherapist, occupational therapist, orthotist and above all a highly motivated patient cannot be overemphasised.

Innovative nerve approximator from external fixator: a quick fix solution.

The outcome of primary and secondary neurorrhaphy depends on the technical precision followed during the procedure. The aim of the surgery is to establish near-anatomic coaptation and to maintain it without tension at the anastomotic site. A nerve approximator can aid in peripheral neurorrhaphy with optimal tension at the anastomotic site and better maintenance of coaptation of fascicles, but their use is limited because of the high price of the commercially available ones. We describe a simple and inexpensive nerve approximator that can be prepared any time, and according to the need using the universal mini external fixator system. This fixator system is almost always available in an orthopedic and hand operation theater. It is an extremely handy, inexpensive, atraumatic, and user-friendly nerve approximator that can be used clinically to aid and augment the final results of peripheral neurorrhaphy. Its use can also be extrapolated for simulated tendon and nerve repair during microvascular laboratory training.

New technique of imaging and treatment of pediatric supracondylar humeral fracture without moving the injured limb.

The management of closed, displaced supracondylar fracture of humerus in children can be divided into 3 stages. In stage 1 closed reduction is achieved whose acceptability is confirmed, on table, in stage 2 using an image intensifier. This reduction is maintained in stage 3 by immobilization in slab/cast or by percutaneous Kirschner wire fixation. Although enough literature for proper technique in stage 1 and stage 3 are available, there are certain practical problems encountered in the equally important stage 2, which needs a closer look. Most of the C-arm compatible tables have their metallic base toward the head end of the table with metal bar on the sides for additional attachments. These interfere with the rotation of the image intensifier and also with the quality of the image obtained. As a result, to obtain lateral image many surgeons rotate the fractured upper limb instead of the C arm. This practice is unacceptable, as rotating the fractured limb cannot only add to the injury but it can also cause loss of reduction. Similarly, many surgeons strongly condemn using the image intensifier as an operating table. We are proposing a new surgeon and anesthetist friendly method of positioning the patient in which both anteroposterior and lateral views can be obtained without moving the fractured upper limb. In addition, if required the surgeon can proceed to open reduction without the need to reposition or re drape the patient.

Ideas and innovations: a simple biplanar double Kessler core stitch for flexor tendon repair.

Quest for a technique to get a stronger repair to allow early mobilization after primary flexor tenorraphy continues in the field of hand surgery. A new, easy, and surgeon-friendly method of tenorraphy has been described based on strong mechanical and biological principles with the advantage of enabling the surgeon to mobilize actively in early postoperative period to obtain better overall results.