Comparison of 2 Methods of Percutaneous Fixation of Proximal Phalanx Fractures

Abstract

Purpose: Short oblique or transverse extra-articular fractures at the proximal phalanx are very common. Stabilization and early motion are critical to support good results. No single operative method has been shown to be superior in clinical studies. Traditionally, these fractures were treated with percutaneous pinning. Latter intramedullary nailing (IMN) became popular. During the past years, a new technique using intramedullary placed Herbert screws (HSs) showed satisfactory outcome. The aim of this study is to assess the complications and outcomes of these last 2 techniques performing postoperative early digital motion. Our hypothesis is that HSs have less complications rates and better outcomes than IMN. Methods: Over a 2-year period, a prospective study was conducted at our service. Radiological (reduction, consolidation time, secondary displacement) and clinical (Visual Analogue Scale [VAS]-Total Active Motion [TAM]-Quick Disabilities of Arm, Shoulder and Hand [QuickDASH]) results of 20 patients having 25 displaced extra-articular fractures of the proximal phalanges were recorded through a minimum follow-up of 3 months. Short oblique or transverse types were included. Intra-articular fractures, thumb fractures, and concomitant injuries of the tendons or collateral ligaments were excluded from this study. All fractures were reduced closed and fixed. Aggressive active full range of motion was encouraged 48 hours after surgery. Surgical Techniques: We performed percutaneous IMN with 2 crossed 1-mm rods in Eiffel tower configuration using 2 portals at the base of the phalange in 12 fractures; we left the rods outside the skin, and they were removed at consolidation time. We placed percutaneous 3-mm HSs, 1 in each fracture inserted in antegrade fashion in 13 cases. For statistical analysis, the quantitative variables were reported as mean values. The Student t test was used for continuous data. For all analyses, P < .05 was considered statistically significant. Results: Radiographically there was a statistically significance ( P = .01) in the average consolidation time between the 2 groups—IMN: 107 (±60) days; HS: 63 (±10) days. We got anatomical reduction and no secondary displacement in both groups. The mean TAM for the IMN and HS groups was 161 (±36) and 218 (±27), respectively ( P = .001). Average VAS was similar at discharge in both groups, but during the first postoperative month, patients with HS referred less pain. Mean final QuickDASH was 18 (±12) for IMN group and 15 (±14) for HS group. Regarding complications, we recorded a mild superficial infection at the entrance of the wires in 1 patient that healed with oral antibiotics (ATB). The volar cortex in shaft fractures treated with IMN showed a delayed union in 48% of cases. No complications were recorded in HS group. Conclusions: It is generally agreed that closed fixation minimizes additional soft tissue injury and allows for early motion. Percutaneous intramedullary placed HS was a superior method compared with IMN in terms of the measured parameters.