Novel External Fixation Device for the Treatment of Hallux Distal Phalanx Fractures

Abstract

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: The great toe plays a large role in activity, including maintenance of balance and substantial weight bearing capabilities. Fractures of the hallux distal phalanx, especially when displaced or unstable, can lead to significant dysfunction of the interphalangeal joint (IP) and pain and may need operative intervention. Surgical options include wire pinning, screw fixation, external fixation, arthrodesis, or amputation. For patients with significant comminution and shortening who would like to attempt toe salvage without fusion, external fixation can lead to great outcomes. Unfortunately, the use of these devices is hindered by cost, size, and availability. We recommend the use of a novel low cost external fixation device that can be made intraoperatively using common materials found in the operative room. Methods: A 27-year-old female, with a severely comminuted right distal phalanx fracture with interphalangeal (IP) joint dislocation, presented 4 days after a skiing accident. We discussed treatment may require IP joint arthrodesis or partial amputation, however, salvage fixation could be attempted initially. First, a transverse percutaneous wire was placed through the distal phalanx tip since the fragment was still mostly intact. The wire exited the skin medially. Two Kocher clamps to each side of the wire were applied for distraction of the fracture site while simultaneous manual manipulation of the more proximal fragments was performed. Once reduced, three more proximal transverse wires were placed through a 3cc syringe, which acted as a rail to hold the fracture length stable. The distal transverse wire was then impaled through the rail so that all four wires were within the rail providing two points of fixation in the distal phalanx and proximal phalanx. Results: The patient's weight-bearing status was non-weight bearing to the right lower extremity for 6 weeks. This was actually being dictated by the more proximal tibial plateau fracture for which she was non-weight bearing. With regard specifically to the hallux fracture, she could have been heel weight beared immediately. At her most recent post-operative visit at 6 weeks, she was doing well with minimal pain. The external fixation device was removed in clinic and she was transitioned to a post-op shoe and allowed to weight bear as tolerated. She was motor and sensate intact with the ability to actively range her IP joint. Radiographs at the most recent visit revealed excellent alignment of the toe with minimal articular step off. Conclusion: With severely unstable hallux distal phalanx fractures, operative intervention should be considered. For those with a significant degree of comminution who still would like to undergo salvage fixation, external fixation is an excellent option. Unfortunately, the use of these devices is hindered by cost, size, and availability. Hand surgeons solved this problem by introducing small, low cost external fixators composed of common materials such as needle sheaths, IV cannulas, and syringes. We adapted their model to the toes and were able to obtain great clinical outcomes with low cost, all the while maintaining the patient's expectations for cosmesis.