|Year : 2023 | Volume
| Issue : 1 | Page : 41-47
Joshi's external stabilization system and K-wire fixation in the management of hand fractures – A prospective comparative study
Vivek Singh1, Sabeel Ahmad2, Gobinder Singh3, Sukhmin Singh4, Kshitij Gupta1, RB Kalia1
1 Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Orthopaedics, F. H. Medical College and Hospital, Agra, Uttar Pradesh, India
3 Department of Orthopaedics, DMC, Ludhiana, Punjab, India
4 Department of Orthopaedics, Subharti Medical College and Hospital, Dehradun, Uttarakhand, India
|Date of Submission||27-Apr-2022|
|Date of Decision||05-Jul-2022|
|Date of Acceptance||17-Jul-2022|
|Date of Web Publication||27-Dec-2022|
529D/308, Kalyanpur West Ring Road, Lucknow - 226 022, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Hand fractures can be treated conservatively or surgically, depending on the severity, location, and type of fracture, as in conservative management chance of nonunion, malunion, and stiffness is more if it is displaced or angulated fracture. Various modes of treatment have been used which include K-wire fixation, mini plates, and external fixator application. A modified form of mini-external fixator devised in India is Joshi's External Stabilization System (JESS). Aim: This prospective study was conducted to compare the functional and radiological outcomes following metacarpal/phalangeal fracture fixed with either K-wire or JESS. Materials and Methods: Forty patients with hand fractures (58 fractures – 18 metacarpal and 40 phalanges) were prospectively studied. Twenty patients underwent K-wire fixation and 20 were fixed with JESS, functional and radiological outcomes were assessed, grip strength using dynamometer, visual analog scale (VAS) score, disabilities of the arm, shoulder, and hand (DASH) score, range of motion (ROM) using the American Society for Surgery of the hand scale, tip pinch strength. Student's t-test, Wilcoxon test, Fisher's exact test, and Chi-squared test were used. Results: At 6 months' follow-up, patients fixed with either of the fixation modality showed statistically significant improvement in different outcome variables such as ROM (P < 0.001), quick DASH score (P < 0.001), VAS score (P < 0.001), tip pinch strength (P < 0.001), and hand grip (P < 0.001). All the fractures united at an average 6 weeks. Functional outcomes were excellent in closed fracture fixed with either JESS or K-wire and good to moderate in open injuries. However, overall comparison between K-wire and JESS, no significant difference in these outcome measures was found. Conclusions: K-wires as well as JESS both provide adequate stability and satisfactory results in fractures of the metacarpal and phalanges. This study could not find the superiority of JESS over traditional K-wire fixation.
Keywords: Disabilities of the arm, Joshi's External Stabilization System, Kirschner wire, metacarpal and phalanx fracture, shoulder and hand
|How to cite this article:|
Singh V, Ahmad S, Singh G, Singh S, Gupta K, Kalia R B. Joshi's external stabilization system and K-wire fixation in the management of hand fractures – A prospective comparative study. J Orthop Dis Traumatol 2023;6:41-7
|How to cite this URL:|
Singh V, Ahmad S, Singh G, Singh S, Gupta K, Kalia R B. Joshi's external stabilization system and K-wire fixation in the management of hand fractures – A prospective comparative study. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:41-7. Available from: https://jodt.org/text.asp?2023/6/1/41/365279
| Introduction|| |
Wrist and hand fractures account for approximately 15%–19% of fractures in adults. Fifty-nine percent of these occur in the phalanges, 33% in the metacarpals, and 8% in the carpal bones. Some of the common causes are crush injuries, blunt trauma, fall, road traffic accidents (RTAs), machinery injury, sports-related activity, and explosions/firearm injuries. Among them, RTAs (motor vehicle accidents) with open injuries (crush, blunt) are the most common., Hand fractures can be treated conservatively or surgically, depending on the severity, location, and type of fracture. The incidence is more in the younger age group with male dominance. For an acutely injured hand, the main objective of management is to provide fracture stability for early mobilization. Various modes of treatment have been used which include K-wire fixation, mini plates, and external fixator application.,, A modified form of mini-external fixator devised in India by Dr. B. B Joshi is Joshi's External Stabilization System (JESS). Few studies,, in the literature have shown its utility in the management of hand fractures but no study till date, as per authors' knowledge exists in English literature which has compared this modality of fixation with traditional K-wires. This prospective study was conducted to compare the functional and radiological outcomes following metacarpal/phalangeal fracture fixation with either K-wire or JESS.
| Materials and Methods|| |
Prior institutional ethical approval (Ref. No. 258/1EC/PGM/2018/Letter No-AIIMS/IEC/19/590) was obtained before start of the study. It was a prospective comparative study done for 2 years (February 2018–February 2020). Informed consent was obtained from all study participants by explaining the operative and postoperative complications. In this study, randomly 40 patients of hand fracture satisfying the inclusion criteria were studied. Inclusion criteria were adult patients between the age of 18–60 years, closed or open fractures without neurovascular injury, fracture angulation >30°–35° and displacement >50%, and having rotational malalignment. Exclusion criteria were pathological fractures and those who are not fit in inclusion criteria. Twenty patients underwent K-wire fixation and 20 were fixed with JESS. The study duration was 2 years, from April 2018 to March 2020. Fractures are broadly classified as closed or open, closed fractures could be intra- or extra-articular, and extra-articular fractures further divided into four types such as transverse, oblique, spiral, and comminuted. Tippet table used for randomization.
All the cases were operated under regional (block) or local anesthesia. Open fractures were initially debrided. Under fluoroscopy (C-arm) reduction of the fractures was achieved. A small incision was given over the epiphysiometaphyseal area of the bone. The proximal or distal location of the incision was decided by the antegrade or retrograde insertion technique. The pre-bent 2 K-wires, 1.5–2 mm thick, either over automated drill or manually over T-handle were passed percutaneously in the metacarpal or phalanx in crossed fashion over the dorsolateral aspect so that it does not interfere with extensor tendons or ligaments (acts as TENS nailing which provide rotation stability also) and with JESS by passing 2 pins proximal and 2 pins distal to the fracture site and stabilized by a variety of connecting rods (L, S, Z shaped). Mini-distractors in JESS set were used. For massive soft-tissue injury split skin thickness grafting was done, once healthy granulation tissues appeared.
All patients were followed up postoperatively in the outpatient department at regular basis for physiotherapy (active and passive range of motion [ROM] at metacarpophalangeal and interphalangeal joints to prevent stiffness and edema in the hand), at 2, 6, 12 weeks, and at 6 months interval for clinical and radiological evaluation further to note any complications such as pin tract infections, construct loosening, stiffness, or wound infection. K-wire removal was done at 4–6 weeks, which differed from case to case, and JESS fixator was removed at 6 weeks. After construct removal physiotherapy was continued to prevent stiffness. The assessment of functional outcome was done in terms of visual analog scale (VAS) score, which is a standard scale to evaluate the pain intensity in the patients, it is a horizontal scale used here, quick disabilities of the arm, shoulder, and hand (DASH) score, it is standard score to calculate the disability in orthopedics patients, hand grip [Figure 1], total active ROM-by (ASSH) [handmade animation, showing how the ROM at interphalangeal and metacarpophalangeal joints were calculated using goniometer - [Figure 2]], and tip pinch strength by self-assessment with comparison with normal hand, at different time points (2, 6, 12 weeks and at 6 months). Similarly, radiological outcome assessed by looking the radiographs (anteroposterior and oblique views) of hand at different follow-ups. Total active ROM was assessed by the American Society for Surgery of the Hand (ASSH) scale [Table 1]. Term fair, good, excellent used for functional outcome which is mainly defined by total active ROM-by (ASSH) and other scales used in this study [Table 1]. Radiological outcome seen on radiograph by looking at the callus (anteroposterior and oblique views) at subsequent follow-ups.
|Figure 1: Picture of dynamometer used for assessing the hand grip in this study.|
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|Figure 2: An animation which is depicting the metacarpophalangeal and interphalangeal joints and their angles which are measured by goniometer used to assess the total active range of motion at every follow-ups|
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|Table 1: Functional grading of range of motion at metacarpophalangeal joints of hand (American Society for Surgery of the Hand Scale)|
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Data were analyzed by IBM SPSS Statistics, 23.0, AIX, HP-UX, Linux, iOS, Solaris, Windows. Mean and median (standard deviation) were presented in frequency (percentage), for continuous variable “Student's t-test” (normal distribution) and “Wilcoxon sign rank test” (non-normal distribution) were used, and for categorical variable “Fisher's exact test” was applied. P < 0.05 was considered statistically significant and the Tippet's table used for randomization.
| Results|| |
We had 40 patients, randomly divided into two groups (20 for K-wire fixation and 20 for JESS). Male were in majority, for good functional outcome we had operated all cases within 24 h. There were different modes of injuries; majorities of fractures belong to the metacarpals and proximal phalanx. Types of fractures were mentioned in the methodology section [Table 2]. The minimum follow-up was 6 months and maximum 2 years. In 9 fractures, some complications such as pin tract infection, stiffness, persistent pain, and malunion were noted but there was no significant difference in the two modalities of fixation in terms of complications.
Comparison of change in VAS score in any of the fixation modality individually over time (2, 6, 12 weeks, and 6 months) showed a significant improvement (P < 0.001) [Table 3], but on comparison between the two fixation modalities (JESS versus K-wires), no significant difference was found (P = 0.803) [Table 4]. Similarly, a comparison of Quick DASH score at different time points over time (2, 6, 12 weeks, and 6 months) showed significant improvement (P < 0.001) [Table 3], but on comparison between these two groups, no significant difference was found (P = 0.447). Comparison of change in ROM and hand grip strength in both modalities of treatment individually showed a significant improvement (P < 0.001) [Table 3], but on comparison between these two groups, no significant difference was found (P = 0.885 and P = 0.529, respectively) [Table 4]. Individually, both the groups showed significant improvement in tip pinch strength (P < 0.001) [Table 3], but the overall change in tip pinch strength over time on comparing both the groups was not significant (P = 0.119) [Table 4]. Within-group analysis of all five variables at different time points is given in [Table 3].
|Table 3: Within-group analysis of all five variables at different time points of follow-ups|
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|Table 4: Comparison of functional outcome at different time points between two modalities of fixation|
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Further comparison of both the modalities of fixation by subclassifying injuries into open and closed subgroups was also done using outcome measures such as VAS score, Quick DASH score, ROM, hand grip, and tip pinch strength. All these five parameters showed a significant improvement in closed hand injury group over time as compared to open injuries.
In terms of radiological outcome, 38 out of 40 showed bony union on subsequent follow-ups radiographs. About 80% (16 out of 20) patients fixed with K-wire had excellent, 10% (2 out of 20) good, and 5% (1 out of 20) fair results. 75% (15 out of 20) fixed by JESS had excellent, 15% (3 out of 20) good, and 10% (2 out of 20) fair results (functional outcome), complications are mentioned in [Table 5], except one open K-wire case have had mal-union, which was later treated with osteotomy. Clinical pictures with radiography at the time of fixation and bony union at 6 weeks follow-up are shown in [Figure 3] and [Figure 4] (JESS) and [Figure 5] (K-wire).
|Table 5: The complications in Joshi's external stabilization system and K-wire fixations cases|
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|Figure 3: Clinical pictures of JESS fixator (a) with corresponding Xrays of postoperative (showing proximal interphalangeal fracture of left index finger, b) and postoperative at 6 weeks showing healed wound with bony union (c,d) and excellent range of motion at interphalangeal and metacarpophalangeal joint at the end of 6 months in the last clinical pics (e,f)|
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|Figure 4: Xrays (anteroposterior and oblique) showing 5th metacarpal fracture of the left hand (a) and after JESS fixator (5th metacarpal) fixation (b) clinical picture showing healed wound at 4th web space without any complication (c)|
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|Figure 5: Radiograph of 2nd and 3rd proximal phalanx of righthand fractures with Kwire fixation showing bony union at 5 weeks before and after removal of Kwire (a,b) and below clinical pictures showing excellent ROM at metacarpophalangeal and interphalangeal joints at 12 weeks (c,d,e). ROM: Range of motion|
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| Discussion|| |
This study was designed to compare the results of K-wire and JESS application in fractures of metacarpal and phalanges in 40 patients (58 fractures – 18 metacarpal and 40 phalanges). The most common modes of injury were RTA or machinery crush injuries. Other studies also have shown these to be the most common modes of injury., The average age of the study population was 32.4 years with male predominance. Other studies have also found almost similar trend. Metacarpal and phalangeal fractures are the most common fractures in the upper limb and are often neglected as minor injuries either by the patient himself or by the treating physician. Most of them can be treated conservatively., Cases with gross displacement, angulation, intra-articular extension, and open fractures need operative intervention. The aim of treatment is to provide adequate stability with minimal breach of soft-tissue envelope. Stable fixation helps in reducing edema and early start of ROM exercises. Early reduction of edema as well as early ROM helps in preventing scar formation and hence free tendon gliding. Various studies in the literature on fixations of these fractures by K-wire have shown mixed results, few have described over here, Farias et al. in 2017 have taken 70 patients in their study which showed 96.4% union, 96% had full ROM, high satisfaction score, good hand grip with some complications like pin tract loosening and infection, in our 95% union in k wire fixation, 90% full ROM (good to excellent), high satisfaction score with good hand grip, one patient had pin tract infection. Reformat et al. in 2018 took 158 patients (192 fractures out of which 90 metacarpal and 102 phalangeal fractures) which showed 93% union rate, total ROM was good to excellent, significant improvement of VAS score, as compare to our study, we had 95% % union, full ROM, drastic improvement of vas score and hand grip. Rest other studies are shown in [Table 6] with comparison of this study.
|Table 6: Studies on K-wire fixation of metacarpal and phalangeal fracture of the hand|
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An indigenous modality of fixation which is cheap and modular in nature is JESS; any fracture configuration can be fixed adequately and with minimal invasion of soft tissue. Fractures can be distracted or compressed when required. It is lightweight, universally available and can be applied by anybody taking care of these cases. The biggest advantage of JESS in this study was when applied in cases of open fractures, intra-articular extension, and crush injuries of hand, it provided adequate stability. Few studies available in the literature like, Butala et al. in 2016 has taken 20 patients (28 fractures – 14 phalanges, 4 metacarpal, and rest carpals) it showed that all 12 phalangeal fractures had excellent result, 8 had good, 1 fair, and 2 fractures had poor outcome, 29% complication rate in the form of pin tract infections, stiffness of hand due to reflex sympathetic comparing with our study 40 patients (total 58 fractures – 18 MC and 40 phalanges) showed excellent ROM (237°), 96% hand grip, tip pinch strength 96.30% with good improvement in VAS and DASH scores with 100% union and complications in the form of pin tract infection, stiffness, and one patient had mal-union which was corrected by osteotomy later on. Another study by Mishra et al. in 2019 have taken 38 patients (21 MC and 17 phalangeal fractures) out of which 73.70% excellent and 26.30% has good active ROM, no poor results and complications was in the form of pin tract infection in 7 patients, 2 had loosening of pin (23.70%) as compare to our study we had excellent ROM, 96% hand grip and tip pinch strength, 100% union with one pin tract infection, stiffness, and malunion. Rest other studies are shown in [Table 7] with a comparison of this study. It is the first study of its kind where the traditional method of K-wire fixation has been compared with JESS, but we could not find any significant difference in functional outcome in both modalities of fixations. Small sample size and selection bias are the limitations of this study.
|Table 7: Studies of Joshi's external stabilization system fixator application for metacarpal and phalangeal fracture of the hand|
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| Conclusions|| |
K-wire as well as JESS both provides adequate stability and good results in fractures of the hand. On further evaluation, JESS was not found to be superior over K-wire in open or closed metacarpal and phalangeal fractures individually.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
van Onselen EB, Karim RB, Hage JJ, Ritt MJ. Prevalence and distribution of hand fractures. J Hand Surg Br 2003;28:491-5.
Alphonsus CK. Principles in the management of a mangled hand. Indian J Plast Surg 2011;44:219-26.
Tintle SM, Baechler MF, Nanos GP 3rd
, Forsberg JA, Potter BK. Traumatic and trauma-related amputations: Part II: Upper extremity and future directions. J Bone Joint Surg Am 2010;92:2934-45.
de Jonge JJ, Kingma J, van der Lei B, Klasen HJ. Fractures of the metacarpals. A retrospective analysis of incidence and aetiology and a review of the English-language literature. Injury 1994;25:365-9.
Brüser P, Krein R, Larkin G. Fixation of metacarpal fractures using absorbable hemi-cerclage sutures. J Hand Surg Br 1999;24:683-7.
Crockett DJ. Rigid fixation of bones of the hand using K wires bonded with acrylic resin. Hand 1974;6:106-7.
Cziffer E. Static fixation of finger fractures. Hand Clin 1993;9:639-50.
Fitoussi F, Ip WY, Chow SP. External fixation for comminuted phalangeal fractures. A biomechanical cadaver study. J Hand Surg Br 1996;21:760-4.
Kaushik S. Dr. B.B. Joshi-A visionary Hand Surgeon. Indian J Plast Surg 2011;44:176-7.
Haefeli M, Elfering A. Pain assessment. Eur Spine J 2006;15 Suppl 1:S17-24.
Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): Validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord 2006;7:44.
Galal S, Safwat W. Transverse pinning versus intramedullary pinning in fifth metacarpal's neck fractures: A randomized controlled study with patient-reported outcome. J Clin Orthop Trauma 2017;8:339-43.
Drenth DJ, Klasen HJ. External fixation for phalangeal and metacarpal fractures. J Bone Joint Surg Br 1998;80:227-30.
Dhanwantary Naidu KV. Management of metacarpal and phalangeal fractures with JESS fixator: A prospective study. Int J Orthop Sci 2018;4:383-7.
Parsons SW, Fitzgerald JA, Shearer JR. External fixation of unstable metacarpal and phalangeal fractures. J Hand Surg Br 1992;17:151-5.
Barton N. Conservative treatment of articular fractures in the hand. J Hand Surg Am 1989;14:386-90.
Wright TA. Early mobilization in fractures of the metacarpals and phalanges. Can J Surg 1968;11:491-8.
Farias E, Lichterman M, Yuhas M, Thirkannad SM. Interlocking K wires followed by immediate mobilization for fractures of the hand. Tech Hand Up Extrem Surg 2018;22:3-9.
Reformat DD, Nores GG, Lam G, Cuzzone D, Hill JB, Muresan H, et al.
Outcome analysis of metacarpal and phalangeal fixation techniques at bellevue hospital. Ann Plast Surg 2018;81:407-10.
Shewring DJ, Trickett RW, Smith A. Fractures at the junction of diaphysis and metaphysis of the proximal phalanges in adults. J Hand Surg Eur Vol 2018;43:506-12.
Pandey R, Soni N, Bhayana H, Malhotra R, Pankaj A, Arora SS. Hand function outcome in closed small bone fractures treated by open reduction and internal fixation by mini plate or closed crossed pinning: A randomized controlled trail. Musculoskelet Surg 2019;103:99-105.
Kootstra TJ, Keizer J, Bhashyam A, Houwert RM, Verleisdonk EM, van Heijl M, et al.
Patient-reported outcomes and complications after surgical fixation of 143 proximal phalanx fractures. J Hand Surg Am 2020;45:327-34.
Butala R, Garg A, Singh S, Garg P, Agarwal A, Gohain N, et al
. JESS fixator for hand fractures: Our experience in 20 patients. J Evolution Med Dent Sci 2016;5:1946-9. DOI: 10.14260/jemds/2016/459.
Mishra K, Adhikari V, Chalise P, Shrestha P, Singh P. JESS fixator for Metacarpal and Phalangeal fracture. Nepal Med Coll J 2019;21:48-52.
Dailiana Z, Agorastakis D, Varitimidis S, Bargiotas K, Roidis N, Malizos KN. Use of a mini-external fixator for the treatment of hand fractures. J Hand Surg Am 2009;34:630-6.
Naidu, D. Management of metacarpal and phalangeal fractures with JESS fixator: A prospective study. Int J Orthop Sci 2018;4:383-7.
Nagi A, Mubark I, Sarhan I, Ragab A. Management of unstable phalangeal shaft fractures using external minifixator. Ortop Traumatol Rehabil 2019;21:181-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]