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 Table of Contents  
Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 78-83

Joshi's external stabilization system fixator – A mini solution to avert major disabilities in hand injuries

1 Department of Orthopaedics, King George Hospital, Visakhapatnam, Andhra Pradesh, India
2 Department of Orthopaedics, Gayatri Vidya Parishad Institute of Health Science and Medical Technology, Visakhapatnam, Andhra Pradesh, India
3 Department of Orthopaedics, NIMRA Institute of Medical Sciences, Vijayawada, Andhra Pradesh, India
4 Department of Orthopaedics, Chaitra Hospital, Eluru, Andhra Pradesh, India
5 Department of Orthopaedics, Sai Sudha Hospital, Kakinada, Andhra Pradesh, India
6 Department of Orthopaedics, Golden Jubilee Hospital, Visakhapatnam, Andhra Pradesh, India

Date of Submission23-Aug-2022
Date of Decision07-Oct-2022
Date of Acceptance19-Nov-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Soma Sekhar Mecharla
Department of Orthopaedics, Gayatri Vidya Parishad Institute of Health Science and Medical Technology, Visakhapatnam, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_71_22

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Background: Fractures of hand bones are often considered minor injuries and treatment is either delayed or neglected. These fractures are usually treated conservatively that leaves behind a residual functional deficit. Surgical intervention should be considered for open, unstable, multiple, comminuted, or intra-articular fractures. Standard surgical treatment includes the use of K-wire, plate, or mini-screws which are associated with unsatisfactory results and high complication rates. Joint stiffness is a commonly reported complication with most of the existing devices used for hand bone fractures. There is a deficit of data pertaining to the effectiveness of Joshi's External Stabilization System (JESS) in avoiding joint stiffness. Joshi's external fixator is a reliable treatment of phalangeal and metacarpal fractures of the hand. It is an economical, simple, lightweight, and stable contract. Patients and Methods: We report a prospective cohort study of 30 patients of hand bone fracture, 10–60-year age range, treated by JESS. Functional evaluation was made using the Duncan et al. scoring. Results: The results recorded were excellent in 31.58% of cases, good in 42.11% of cases, fair in 21.05%, and poor in 5.26% of patients. Conclusion: JESS ex-fix for hand is a useful construct that allows early mobilization of nearby joints. It can be considered a suitable choice for the management of phalangeal and metacarpal fractures of hand to deliver good functional outcome.

Keywords: Ligamentotaxis, pin tract infection, thermal necrosis

How to cite this article:
Thadiparthi VK, Chinnapothula K, Mecharla SS, Paka VK, Shaik J, Talluri SS, Pilaka RS. Joshi's external stabilization system fixator – A mini solution to avert major disabilities in hand injuries. J Orthop Dis Traumatol 2023;6:78-83

How to cite this URL:
Thadiparthi VK, Chinnapothula K, Mecharla SS, Paka VK, Shaik J, Talluri SS, Pilaka RS. Joshi's external stabilization system fixator – A mini solution to avert major disabilities in hand injuries. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:78-83. Available from: https://jodt.org/text.asp?2023/6/1/78/365288

  Introduction Top

Human hand is vulnerable to variety of injuries of varying degree caused by road traffic accidents, industrial accidents, assaults, and other causes.[1],[2] Hand injuries are common in the age group of 10–40 years with a male predominance.[3] Metacarpals and phalangeal injuries account for 10% of the total upper limb fractures.[4] These fractures are mostly comminuted, associated with tiny fragments and nearby combined dislocations. Reduction is difficult to achieve in most of the patients. A distracting force from adjacent joints usually causes loss of reduction leading to malunion, incongruity, or joint space narrowing. Outcome is affected by the severity of damage to ligaments, tendons, or articular capsule. Surgical intervention is necessary in few unstable, multiple, intra-articular fractures, or open fractures to achieve optimal reduction during bone healing and allow early movement.[5] External fixation is useful for highly comminuted or complex intra-articular fractures.[6] This study was intended to find out the role of Joshi's External Stabilization System (JESS) in the management of hand bone fractures and the associated complications of the device.

  Patients and Methods Top

A prospective cohort study was carried out on 30 patients with hand fractures, aged between 10 and 60 years, admitted to the department of orthopedics of our institute from November 2018 to October 2020. Patients with unstable, intra-articular, juxta-articular, and open or multiple fractures were included in the study. Patients with severely crushed hand injuries, fractures with associated tendon or neurovascular injuries were excluded from the study. Informed, written consent was taken from all the patients included in the study. Prior approval of the institutional ethics committee was taken before initiating the study.

Statistical methods

Descriptive statistical analysis has been carried out in the present study. Data analysis was performed using IBM SPSS Statistics for Windows, version V27.0 (IBM corp. Released 2020, Armonk, New York, USA). Results on continuous measurements are presented on mean/standard deviation (Min-Max) and results on categorical measurements are presented in number (%). Significance is assessed at 5% level of significance. Student's t-test (two-tailed, dependent) has been used to find the significance of study parameters on continuous scale within each group. Chi-square/Fisher's exact test has been used to find the significance of study parameters on a categorical scale between two or more groups.

Since most of the fractures of hand are caused by road traffic accidents, it is imperative to assess both the fracture and the patient as whole. Primary evaluation for and management of shock if coexistent was done. The assessment of injury of hand [Figure 1] was next done based on grading provided by Swanson et al.,[7] while meticulously ruling out injury to adjacent tendons, nerves, and blood vessels. Radiographs [Figure 2] were taken in two views as anteroposterior and oblique (OBL) and if necessary, lateral (LAT) views. The level and pattern of fracture, amount of displacement, and angulation were noted on the X-ray. Radiography of other parts was taken when indicated for associated injury. The pain was alleviated by use of analgesics. Broad-spectrum antibiotics and anti-tetanus prophylaxis were started in case of open injuries. JESS application was then considered after stabilization of general condition. A below-elbow slab was applied initially in all patients up to the time of surgical stabilization of the fracture. Swanson et al.[7] classification for open fractures of hand was used. Out of 30 patients, 12 were found to be open, of which five patients had type I (13.33%) fracture and seven patients had type II injury (20%). No injuries with vascular impairment were noted.
Figure 1: Preoperative clinical images of various degrees of hand injury

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Figure 2: Preoperative radiographic images of hand including AP and oblique views. AP: Antero-posterior

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Operative technique of Joshi's external stabilization system fixation

Most of the patients were operated under wrist block. General anesthesia was used in some patients (younger patients <16 years, those intolerant to pain, and hypersensitive to pain). Pin placements and frame configurations were decided first depending on the fracture pattern. Prior pin site selection was done in advance, as per the safe zones to avoid damage to important structures and enables good access to wound for dressing postoperatively. Preliminary wound debridement was done followed by fracture reduction and alignment.

Skin and fascia were incised before pin insertion. Pins were inserted directly using a hand drill or power drill with slow speed [Figure 3]. The clamps and side rods were applied after pin insertion. The distractor/compression device was applied and compression or distraction at the fracture site was done as per the need to reduce the fracture. The frame was then tightened. Connecting rods were then placed. After the formation of the planned frame, the digit was put through a full range of passive movements, and the stability of the frame was checked. In case of intra-articular fracture, we followed the principles of ligamentotaxis. The connecting rods should be 5–7 mm away from the skin surface, to allow for wound and pin tract care [Figure 4]. This gap is necessary to accommodate postoperative edema and reduce undue discomfort. The frame was constructed consisting of minimum of one K-wire (1.8 mm) in each fragment not spanning across the adjacent joints to allow mobilization of nearby joint of fractured bone. The two K-wires were connected to connecting rod placed 5–7 mm away from the skin using JESS clamps.
Figure 3: Basic armamentarium needed for JESS fixator application. JESS: Joshi's External Stabilization System

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Figure 4: Postoperative clinical and radiographic images of JESS external fixator applied to hand. JESS: Joshi's External Stabilization System

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All the wires were trimmed, and only 4–5 mm wire was allowed to be left protruding beyond the link joints, and the protruding wires were capped with plastic tubings. The limb should be brought above the level of heart and adjacent joints should be kept in continued range of motion to facilitate gravitation of body fluids into circulation. The dressing was changed on the 2nd postoperative day, and check radiographs were taken at least in two views to study the reduction. Pin insertion sites and wound are regularly dressed at every follow-up. Every joint that was not involved in the frame was immediately mobilized.

For open injuries, the daily dressing was done. Pin insertion sites were cleaned daily with betadine. Gauze pieces were placed at pin tract sites to prevent pin tract infection. Immediate active and passive movements of joints proximal and distal to the fixator were started.


Active and passive movements of the joints proximal and distal to the fracture were continued up to 3 weeks. Usually, the contraction of soft tissues begins approximately 72 h following injury. Early mobilization of joints improves the outcome. The patient was reviewed again every week. The fracture was found to be stable from 3 weeks and above postoperatively, and the frame was removed based on the stability attained except for cases with considerable bone loss. Immediately, the joint spanned previously was mobilized. If in repeat X-ray, any instability is noticed, either JESS was reapplied, or secondary methods of fixation were considered based on the status of wound healing and the fracture mechanics. Fracture stability is defined as the maintenance of fracture reduction when the adjacent joints are taken through at least 30% of their normal motion. Fixator was retained for longer time in patients with bone loss to account for longer time needed for callus formation and to attain stability. Active range of motion was encouraged. After about a week, repeat X-ray was taken to confirm stability. Physiotherapy was started once stability was ascertained on radiographic images. Associated injuries were treated simultaneously and the patient was followed regularly for a further period of about 1 year.


As shown in [Figure 5], patients were followed up once weekly up to 1 month, monthly for up to 6 months, and later once for 6 months. The minimum follow-up was up to 6 months in this study. Most patients were followed for 1 year. Functional evaluation was done using scoring by Shah et al.[8]
Figure 5: Clinical evaluation of hand movements at follow up

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  Results Top

A total of 30 patients were enrolled in the study and all of them were successfully followed up for the minimum predetermined period. The maximum follow-up in this study was about 54 weeks. The study included 30 patients, age ranging from 10 to 60 years, with 25 phalangeal and 13 metacarpal fractures treated by external mini fixation using JESS fixator.

Majority of the patients in the study were of the age group of 21–40 years (69%). The average age of the patient was 32.97 ± 10.41 years. Ninety percent (27) of the patients were male and 10% (3) cases were female. Forty percent of the patients were workers.

Most of the soft-tissue injuries (Gustilo-Anderson types I and II) healed in the first 2 weeks (50.33%), 43.33% of the cases healed in 3–4 weeks and 6.33% after 4 weeks. The average soft-tissue healing was 2.32 weeks. In our study, fixator was removed in 63.33% of the cases during 5–6 weeks, 33.33% in 3–4 weeks, and 3.33% in 6–8 weeks. The mean duration of JESS fixation in situ was 4.42 ± 0.70 weeks.

Functional assessment was done by based on total active range of movements in degrees of each injured finger separately according to Duncan et al.[9] This adds the active flexion of metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints, then subtracting the sum of extension deficits of these three joints. Results are recorded based on Duncan et al.'s criteria for fingers. The results recorded were excellent in 31.58% of cases, good in 42.11% cases, fair in 21.05%, and poor in 5.26% of patients.

Complications observed in the study were pin tract infection, mal union, pin loosening, Sudeck's osteodystrophy, and joint stiffness. Pin tract infection was observed in five fractures, which healed promptly by antibiotic use in all of them. Malunion was noticed in two patients (comminuted fractures and multiple fractures) due to a lack of accurate reduction or postreduction collapse. None of the malunited fractures cause any significant disabilities. Pin loosening was noticed in three patients which did not affect the healing of the fractures. All the cases of pin loosening had prior infection of pin site which led to loosening after 3 weeks. One patient who had fracture of the proximal phalanx of the left thumb developed Sudeck's osteodystrophy which ultimately led to stiffness of thumb.

Joint stiffness was either partial or total. A joint was considered partially stiff when the range of motion in that particular finger was <180° in case of fingers and <100° in case of thumb. Moreover, those patients with range of motion <130° in case of fingers and <70° in case of thumb were considered to be having total joint stiffness. Seven patients in this study (6 partial and 1 total) developed joint stiffness. Most of the patients who developed stiffness were having open injuries, multiple fractures, or intra-articular comminuted fractures and presenting late.

  Discussion Top

Human hand is a versatile structure which carries out a wide variety of functions. Fractures of hand are often overlooked due to common perception of them being minor injuries with resultant major disabilities.[10] They account for 5%–10% of emergency department trauma cases. The majority of these are treated conservatively. Dr. Alfred B. Swanson statement “Hand fractures can be complicated by deformity from no treatment, stiffness from overtreatment and both deformity and stiffness from poor treatment” still holds true in present times.[11]

Operative treatment is recommended for unstable, intra-articular, and open fractures to achieve proper healing and early mobilization.[12] Two commonly used surgical fixations for metacarpal and phalangeal fractures are K-wires and plate and screw fixation. K-wire fixation is a less invasive technique but is relatively unstable. Plates are associated with joint stiffness and induce more damage to soft tissue. JESS frameworks on the principle of ligamentotaxis and provides quality reduction and early mobilization of neighboring joints Gupta et al.[13] Bakki et al.[14] reported over 75% excellent or good outcome with <6% of poor outcome in their study on 30 patients (37 fractures of metacarpal and phalanges) treated by JESS fixator. Plate and screw fixation are associated with further soft-tissue damage with joint stiffness and delay in regain of joint function.[15]

Leading cause of injury was road traffic accidents (RTA) (40%) followed by industrial accidents (30%) and agricultural accidents (16.67%). 26.67% of the patients had associated injuries involving the other systems or other bones. 66.67% (20 out of 30 patients) of fractures involved the dominant hand. 55.26% of patients had proximal phalanx [Table 1] fractures followed by 34.21% in metacarpal and 10.55% middle phalanx. 55% of fractures were noticed in the shaft [Table 2]. Comminution was noticed in around 51.53% of fractures. 86.67% of the patients were operated within the first 3 days, 13.33% were operated between 4 and 7 days after injury. In majority of patients, fractures healed by 12 weeks (52.63%).
Table 1: Distribution based on the part of hand (including thumb)

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Table 2: Distribution based on the site of fractures

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Basic principles of JESS fixator (static frames) are applicable for all fracture patterns except intra-articular and juxta-articular fractures. A minimum of two K-wires should be passed in each bone segment, except for small bone such as middle and terminal phalanges where one K-wire is allowed. The stability of frame can be increased by adding more pin and spacing them. The minimum distance between the wires must be 6 mm and 7 mm when using alpha and beta clamps, respectively.

Dr. B. B. Joshi advocates use of sharp, trocar-tipped K-wires for tough cortical bone. Threaded pins are associated with loosening. Low-speed high-torque motorized drills are preferred over hand drills to prevent pin loosening and thermal necrosis. Hand drills tend to drill large holes with subsequent pin loosening. Drenth and Klasen[16] have used pre-bent (40°–60°) their threaded pins to prevent interference of other finger movements.

Behrens[17] concept of corridors is useful to plan for pin insertion site selection. Safe corridors are regions where no neurovascular or myotendinous structures are present. Hazardous corridor contains musculotendinous units but no neurovascular structures. All external mini fixators applied in metacarpals, metatarsals, and phalanges are in a hazardous zone. Unsafe corridors have both musculotendinous and neurovascular structures. Based on this knowledge in central digits, a dorsolateral or dorso-OBL pin placement is good, but for border fingers, LAT pin placement can as well be used. Any configuration other than dorsolateral pins are precluded in III and IV metacarpals and II, III, and IV metatarsals, but LAT pins can be placed in other metacarpals and metatarsals.

In juxta-articular and intra-articular fractures, we utilized Vidal's principle of ligamentotaxis to provide reduction. In one case of compound proximal phalanx fracture left thumb with bone loss, we have used biplanar frame. Reinforcement of the assembly was achieved in most of the cases by adding another connecting rod parallel to the first. Soft-tissue healing was delayed in patients with multiple fractures and open fracture associated with severe soft-tissue injury and in those who presented late.

Recent studies by Johnson et al.,[18] Li et al.,[19] El-Shaer et al.,[20] Yaseen et al.,[21] are all in favor of use of mini external fixator for metacarpal and phalangeal fractures of hand based on the excellent-to-good functional outcomes derived in their studies.

Gupta R et al.[15] in their study, mini ex-fix for hand bone fractures reported around 13% poor results. Gupta et al. on the management of hand bone fractures with plate and screw fixation demonstrated that finger stiffness was the most common complication in the series. Drenth et al. reported that results of middle phalanx were better than results in proximal phalanges managed by JESS fixator. Kapur et al.[22] reported union with good joint congruency with no complications in their series on intra-articular fractures of proximal interphalangeal joint managed by JESS. However, there was some restriction of PIP joint flexion was noticed.

Complication of external fixator stated by Hastings[23] include pin tract infection, osteomyelitis, fracture at pin sites, neurovascular damage at the time of pin placement, nonunion secondary to over distraction, mal union due to loss of reduction, and interference with the activity of adjacent digits.

Naidu[24] observed complication rates of 16% K-wire loosening and 14% pin tract infection in their series of external fixator management of hand bone fractures. Burny[25] stated that JESS being a percutaneous implant has a higher chance of infection and tissue proliferation. This can be reduced by low-speed drilling, avoiding pin loosening, and postoperative antibiotics and regular dressings.

Pin anchorage depends on bone quality. Loosening is seen in osteoporotic bone. The usage of high-speed drills caused thermal necrosis and may add to pin loosening.

For simple fractures, uniplanar frames are sufficient to produce good stability. Stability can be increased using more connecting rods and by bringing the frame close to the bone.

  Conclusion Top

Meta carpal and phalangeal fractures deserve proper attention from treating surgeon to avoid unwanted, troublesome major disabilities secondary to improper management. Thorough preoperative evaluation and proper choice of implant are crucial to successful outcome. Surgical intervention is a better choice for unstable, comminuted, open, and intra-articular fractures as proved in previous studies. JESS is a cheap, easy-to-apply, simple construct, efficient for managing metacarpal and phalangeal fractures. Its main advantage is that it provides good stability at fracture site without immobilizing the neighboring joint. Early mobilization is the key for good functional results which is ensured by JESS mode of fixation. Hence, JESS should be the prime choice of hand bone fracture management to restore the functions of hand postoperatively to close to preinjury level.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Bakki S, Yennapu N, Chollangi A, Kurmana VK, Kolluru RT. Stabilisation of phalangeal and metacarpal fractures with JESS fixation. J Evid Based Med Healthc 2017;4:661-8.  Back to cited text no. 14
Gupta R, Singh R, Siwach R, Sangwan S, Magu NK, Diwan R. Evaluation of surgical stabilization of metacarpal and phalangeal fractures of hand. Indian J Orthop 2007;41:224-9.  Back to cited text no. 15
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Behrens F. General theory and principles of external fixation. Clin Orthop Relat Res 1989;(241):15-23.  Back to cited text no. 17
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Li WJ, Tian W, Tian GL, Chen SL, Zhang CQ, Xue YH, et al. Management of intra-articular fracture of the fingers via mini external fixator combined with limited internal fixation. Chin Med J (Engl) 2009;122:2616-9.  Back to cited text no. 19
El-Shaer AF, El-Deen AF, Hussein AS, Neenaa HA. Results of management of recent fractures of phalanges of the hand by a mini external fixator. Menoufia Med J 2015;28:965.  Back to cited text no. 20
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Hastings H. Open fractures and those with soft-tissue damage: Treatment by external fixation. In: Fractures of the Hand and Wrist. Edinburgh: Churchill Livingstone; 1988. p. 145-72.  Back to cited text no. 23
Naidu KD. Management of metacarpal and phalangeal fractures with JESS fixator: A prospective study. Int J Orthop Sci 2018;4:383-7.  Back to cited text no. 24
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2]


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