Percutaneous Kirschner Wire Fixation Research Articles

Pediatric Floating Elbow

A retrospective review of 16 patients with floating elbow injuries over a 9-year period at a tertiary care children's hospital confirms that these injuries are associated with substantial swelling and the potential to develop compartment syndrome, particularly when circumferential cast immobilization is used. Among 10 patients in whom the forearm was treated with closed reduction and plaster immobilization, a compartment syndrome developed in 2, and 4 patients had incipient compartment syndrome that responded to splitting of the cast; 3 of these subsequently required remanipulation of the distal radius. One patient with compartment syndrome had Volkmann ischemic contracture. Six patients underwent stabilization of both the distal humeral and forearm fractures with percutaneously inserted Kirschner wires, thereby allowing postreduction immobilization in a split cast. None of these patients had problems with excessive swelling or compartment syndrome. Percutaneous Kirschner wire fixation of both the humeral and forearm fractures in pediatric floating elbow injuries allows noncircumferential immobilization, thereby reducing the risk of compartment syndrome.

Radiocarpal dislocations: classification and proposal for treatment. A review of twenty-seven cases.

The radiographic characteristics and treatment of radiocarpal dislocation are not well defined. There have been only two reported series of more than eight patients. Thus, there are many questions concerning treatment and functional results. Two groups of patients were defined. Group 1 included all patients with pure radiocarpal dislocation and patients with only a fracture of the tip of the radial styloid process. Group 2 included patients with radiocarpal dislocation and an associated fracture of the radial styloid process that involved more than one-third of the width of the scaphoid fossa. A retrospective review and a clinical evaluation were performed. From 1975 to 1998, we observed twenty-seven cases of radiocarpal dislocation. Four were displaced volarly, and twenty-three were displaced dorsally. Fourteen patients presented with associated lesions. Four patients were treated with closed reduction and immobilization in a plaster cast; five, with percutaneous Kirschner wire fixation and cast immobilization; and two, with an external fixator. Eleven patients had open reduction with Kirschner wire fixation and cast immobilization. The seven patients in Group 1 had a highly unstable injury, and four of the seven patients presented with ulnar translation of the carpus. At the time of follow-up, at an average of 26.8 months, pronation averaged 76 degrees; supination, 66 degrees; wrist flexion, 54 degrees; wrist extension, 54 degrees; radial inclination, 15 degrees; and ulnar inclination, 18 degrees. The average grip strength was 27 kg. Group 2 included twenty patients. Only thirteen, with dorsal dislocation, were evaluated at the time of follow-up, which averaged fifty-one months. At that time, six reported no pain; four, slight pain; and two, moderate pain. Pronation averaged 63 degrees; supination, 76 degrees; wrist flexion, 51 degrees; wrist extension, 56 degrees; radial inclination, 21 degrees; and ulnar inclination, 39 degrees. Grip strength averaged 38 kg. Seven patients had complications. On the basis of our experience and a review of the literature, we believe that patients with pure radiocarpal dislocation or with radiocarpal dislocation with a fracture of the tip of the radial styloid process should be treated with reattachment of the ligaments through a volar approach. In patients with radiocarpal dislocation and a fracture of the radial styloid process that involves more than one-third of the width of the scaphoid fossa, the ligaments are still attached to the radial fragment. We believe that in this group of patients, exact articular reduction should be performed through a dorsal approach. Additional studies are needed to support these hypotheses.

Fractures of the base of the first metacarpal: current treatment options.

Fractures of the thumb metacarpal occur most frequently at the base. These fractures can be subdivided into intra-articular and extra-articular types. Intra-articular fractures present treatment challenges because they have a tendency to displace due to deforming forces acting at the base of the thumb. An understanding of the anatomy, biomechanics, and fracture pattern will aid in deciding on the best treatment option for each fracture type. Surgical treatment is recommended for unstable fractures. Anatomic restoration of the articular surface in Bennett and Rolando fractures is not essential to obtain a good functional result. However, reduction should be 1 mm or less to reduce the risk of radiographic arthritis. Malunion of these fractures may result in long-term disability. Closed reduction and percutaneous Kirschner-wire fixation is generally the appropriate treatment for a Bennett fracture. Rolando fractures can be treated with either open reduction and internal fixation or external fixation, depending on the size of the fracture fragments. In the case of severely comminuted intra-articular fractures, articular impaction has been implicated as one of the causes of posttraumatic arthritis. It is difficult to restore the articular surface in these injuries. Therefore, external fixation can be considered when the fracture fragments are small and there is significant soft-tissue injury.

Management of Displaced-Extension Type Supracondylar Fractures of Humerus in Children

From June 1996 to February 1998, we reviewed the cases of 27 patients who had a displaced extension type supracondylar fracture of the humerus retrospectively. The mean length of follow-up was 1.3 years. According to Gartland classification, type II was 7 cases (26%), type III-A was 11 cases (41%), type III-B was 9 cases (33%). We treated with three different methods, including closed reduction and percutaneous Kirschner-wire fixation, skeletal traction, and cast application after closed reduction. In type II fractures, we used two parallel lateral pins. In type III fractures, we used 2 lateral parallel pins followed by 1 medial crossed pin predominantly. The results of treatment were assessed using the criteria of Flynn et al. We graded cosmetic and functional factors separately. Satisfactory results were achieved by percutaneous K-wire fixation(96%). There were seven neural lesions. These were the result of injury and not of the treatment, with exception of one case. Neural injuries spontaneously resolved at a mean of 2.5 months(range 1.5 to 5 months) after injury. Varus deformity was present in one patient. There was no Volkman’s ischemic contracture. Percutaneous Kirschnerwire fixation is advocated as the method of choice for the majority of displaced-extension type

The Effect of Elbow Position on the Radial Pulse Measured by Doppler Ultrasonography After Surgical Treatment of Supracondylar Elbow Fractures in Children

We performed a prospective study of 20 patients with displaced extension supracondylar humerus fractures and evaluated the effect of elbow flexion, forearm supination, and forearm pronation on blood flow to the injured arm after closed reduction and Kirschner wire fixation. Ten patients had a Gartland type II fracture and 10 patients had a Gartland type III fracture. After closed reduction and percutaneous pinning, the radial pulse was examined with Doppler ultrasonography starting with the elbow in extension. The elbow was slowly flexed, and the angle of elbow flexion at which the radial pulse disappeared was determined. This angle of elbow flexion was measured with the forearm in both supination and pronation. Gartland type III fractures demonstrated less elbow flexion prior to radial pulse ablation compared to Gartland type II fractures when the forearm was placed in supination (p = 0.001) and in pronation (p = 0.005). Supination allowed > or = 5 degrees of elbow flexion prior to radial pulse ablation in six Gartland type II and four Gartland type III fractures. We concluded that after closed reduction and percutaneous Kirschner wire fixation of displaced extension supracondylar fractures, vascular safety is enhanced by extending the elbow and supinating the forearm. The ideal position of elbow immobilization depends on the amount of swelling and the presence of a radial pulse.

Percutaneous intramedullary Kirschner wiring for displaced diaphyseal forearm fractures in children

Displaced fractures of the forearm in children are often treated conservatively, but there is a relatively high incidence of redisplacement, malunion and consequent limitation of function. We have performed percutaneous Kirschner (K) wire fixation in 72 such children under the age of 14 years, of which 57 were reviewed for our study. Both the radius and ulna were fractured in 45 (79%), the radius only in eight and the ulna only in four. The mean initial angulation was 19 degrees in the lateral plane and 9 degrees in the anteroposterior plane for the radius and 15 degrees and 9 degrees, respectively, for the ulna. In 42 patients (74%) we performed closed reduction. In the remaining 15 (26%) closed reduction failed and an open reduction, through a minimal approach, was required before K wiring. At a mean follow-up of 20 months all patients had good functional results with an excellent range of movement. Only five had angulation of from 10 degrees to 15 degrees and none had nonunion, premature epiphyseal closure or deep infection. Percutaneous intramedullary K wiring for forearm diaphyseal fracture is a convenient, effective and safe operation, with minimal complications.

Percutaneous intramedullary Kirschner wiring for displaced diaphyseal forearm fractures in children

Displaced fractures of the forearm in children are often treated conservatively, but there is a relatively high incidence of redisplacement, malunion and consequent limitation of function. We have performed percutaneous Kirschner (K) wire fixation in 72 such children under the age of 14 years, of which 57 were reviewed for our study. Both the radius and ulna were fractured in 45 (79%), the radius only in eight and the ulna only in four. The mean initial angulation was 19° in the lateral plane and 9° in the anteroposterior plane for the radius and 15° and 9°, respectively, for the ulna. In 42 patients (74%) we performed closed reduction. In the remaining 15 (26%) closed reduction failed and an open reduction, through a minimal approach, was required before K wiring. At a mean follow-up of 20 months all patients had good functional results with an excellent range of movement. Only five had angulation of from 10° to 15° and none had nonunion, premature epiphyseal closure or deep infection. Percutaneous intramedullary K wiring for forearm diaphyseal fracture is a convenient, effective and safe operation, with minimal complications.

Percutaneous Kirschner wire fixation through the snuff box: an anatomic study

We undertook this study to better define the anatomy of the radial aspect of the wrist and to establish a zone of safety for the placement of Kirschner wires, cannulated screws, and arthroscopes within the anatomic snuff box. Twenty fresh frozen cadaver upper extremities underwent placement of three percutaneous Kirschner wires under fluoroscopic guidance through the anatomic snuff box. In each extremity, one Kirschner wire was placed into the radial styloid, one across the scaphocapitate joint, and one across the scapholunate joint. A safe zone of mean 0.68 sq cm was found deep to the subcutaneous tissue bordered by the radial styloid, the first dorsal compartment, the radial artery, and the superficial radial nerve. Kirschner wires placed distal, dorsal, or palmar to the borders of the safe zone were at great risk of injuring neurovascular structures. To minimize the risk of injury to adjacent structures, we advise a limited incision in the safe zone with blunt dissection to the wrist capsule. Though improved anatomic understanding, we established a new location for the arthroscopic 1,2 portal within the snuff box.

Dislocation of the trapezium: open reduction by the dorsal approach

Case 1 A 24-year-old right-handed man sustained a hyperextension injury to his thumb in a motorcycle accident. He was seen in the casualty department where a diagnosis of fracture of the scaphoid was made. He was seen in the fracture clinic 3 days after his injury when a diagnosis of dislocation of the trapezium was made after reviewing the radiographs taken at the time of injury (Fisre I). Under anaesthesia, the dislocation was found to be very unstable. A percutaneous Kirschner wire (K-wire) fixation failed to keep an anatomical reduction. The scaphotrapezium joint was therefore explored from a dorsolateral approach.

Traumatic axial dislocations of the carpus

Among 1140 patients treated in the last 16 years for any type of carpal fracture, dislocation, or subluxation, 16 (1.4%) patients seen with a traumatic axial disruption of both the carpus and metacarpus were identified. Most of these were crush or blast injuries. According to the direction of instability, the cases were classified into three groups: axial-ulnar disruptions (4 patients), axial-radial disruptions (11 patients), and combined axial-radial-ulnar disruption (1 patient). Treatment consisted of open reduction and percutaneous Kirschner-wire fixation in most cases. The results were less optimistic than suggested in the literature. An average follow-up of 61 months showed that prognosis was determined more by the associated soft tissue injuries than by the carpal derangement itself. Early management of both the skeletal and soft tissue components of the injury seems most effective.

Multiple carpo-metacarpal dislocations

Ten patients with closed multiple carpo-metacarpal dislocations have been reviewed. Closed manipulation was found to be successful if performed within two days of the injury. Plaster cast immobilisation supplemented by percutaneous Kirschner wire fixation is recommended to maintain the reduction, due to the unstable nature of the dislocation. Early appropriate treatment of these injuries carries a good prognosis.

Management of displaced extension-type supracondylar fractures of the humerus in children.

The cases of 230 patients who had a displaced extension-type supracondylar fracture of the humerus were reviewed retrospectively. The results of treatment by four different methods were assessed clinically and compared. The mean length of follow-up was 4.6 years (range, one to nine years). The highest percentages of excellent results were achieved by percutaneous Kirschner-wire fixation (78 per cent), skeletal traction (67 per cent), and open reduction with internal fixation (67 per cent). Closed reduction and application of a cast was associated with a significantly lower percentage of early and late complications, including Volkmann ischemic contracture and cubitus varus. It is recommended that treatment with a cast be reserved for undisplaced fractures only. Percutaneous Kirschner-wire fixation is advocated as the method of choice for the majority of displaced fractures.

Isolated Dislocation of Carpal Scaphoid

The functional role of the scaphoid in stabilising the wrist joint is discussed and the literature on scaphoid dislocations reviewed. A case of isolated dislocation of the scaphoid has been presented with the salient diagnostic features and preferred line of management which includes percutaneous Kirschner-wire fixation to ensure maintenance of the reduction.

Isolated dislocation of carpal scaphoid

The functional role of the scaphoid in stabilising the wrist joint is discussed and the literature on scaphoid dislocations reviewed. A case of isolated dislocation of the scaphoid has been presented with the salient diagnostic features and preferred line of management which includes percutaneous Kirschner-wire fixation to ensure maintenance of the reduction.

Closed reduction and internal fixation of proximal phalangeal fractures

Displaced fractures of the shaft of the proximal phalanx can lead to marked deformity and disability when poor results are obtained. Despite the attention popular concepts of open reduction and internal fixation have received, a less invasive technique has been our standard approach. A prospective study of closed reduction and percutaneous Kirschner wire fixation in 100 consecutive fractures yielded good or excellent results in 90% of cases when treated within 5 days of injury.

Percutaneous Kirschner-wire fixation of Colles fractures. A prospective study of thirty cases.

Thirty consecutive patients with a displaced Colles fracture were treated with closed reduction and percutaneous fixation with two Kirschner wires. There were no serious complications. Two of the thirty patients had a minor loss of reduction that did not compromise function. One of the twenty-eight patients who were available for one-year follow-up had a moderate loss of flexion and extension. No patient had a significant loss of rotation of the forearm. The study showed that additional fixation improves both the anatomical and the functional results after a Colles fracture. I recommend the use of percutaneous Kirschner-wire fixation if the articular surface of the radius is not comminuted into more than two fragments.

Fractures of the hand.

Fractures of the hand.

Dislocation of the Carpometacarpal Joint of the Thumb

In four cases of complete carpometacarpal dislocation of the thumb, closed reduction, although easily performed, usually had unstable results. Open reduction and internal fixation with Kirschner wires were used in two cases. The third case was stable after open reduction. The fourth patient was treated by closed reduction and percutaneous Kirschner wire fixation. The joints were immobilized in spica casts for six weeks. At follow-up examinations, two patients had asymptomatic dorsal subluxation. At two years' follow-up examinations, two of the four patients had dorsal subluxations. Open reduction and internal fixation alone were not adequate for this type of injury. The dorsal capsule and ligament should be explored during surgery and reconstructed by free tendon grafts.

Open reduction and percutaneous Kirschner wire fixation in complete disruption of the acromioclavicular joint

Open reduction and percutaneous Kirschner wire fixation was carried out in 35 patients who had sustained recent Allman type 3 dislocations of the acromioclavicular joint. At follow up, failure to maintain reduction had occurred in two patients, both over 55 years. All younger patients had returned to former sporting activities. Complications encountered were infrequent. Cosmetic results were satisfactory.

Closed Reduction and Percutaneous Kirschner Wire Fixation Combined with Plaster Cast versus Conventional Plaster Cast immobilization in the Treatment of Colles' Fracture – A Prospective Randomized Comparative Study

Purpo'e: To evaluate functional & anatomical results of the Colles’ fracture treated by two methods- i) Closed reduction & precutaneous kirschner wire (K- wire) fixation combined with plaster cast & ii) Conventional plaster cast immobilization after closed reduction.Methods: A randomized prospective comparative study was done from July 2003 to June 2005 on 52 patient with Colles' fracture in NITOR, Dhaka. 12 patients lost from follow up. Twenty patient (20) in each group were finally available for evaluation. The group treated by closed reduction & percutaneous K-wire fixation combined with plaster cast- designated as "Arm A" & another group treated conventionally by plaster cast only designated by "Arm-B". Male Female ratio was 1:3, Age range was 35 to 70 years (Mean age 52.5 years) Distribution of limbs side involvement almost equal. Mode of injuries were domestic fall & RTA (4:1) According to AO classification fracture were in both groups- A2 = 13, A3 = 10, C1 = 6, C2 = 8 & C3 = 3 (Total- 40). Follow up period was 6-14 months (mean = 6 month)Results: Union time for most of the fractures was 6-8 weeks. At final follow up Satisfactory Anatomical end results of percutuneous fixation group (Arm-A) were 80% and in conventional plaster cast group (Arm-B) were 35%. (P<0.01). Satisfactory functional end results in Arm-A group were 70% and in Arm-B group were 30% (P<0.01) Complications seen much more in conventional group (Arm-B) than percutaneous K-wire fixation group (Arm-B). Sarmiento & Latta’s criteria was used to evaluate the progress.Conclusion: The coventional plaster cast method for treatment of colles’ fracture usually can't maintain radial length & angulation in many instances and results significant anatomical difficultly and functional disability. On the other hand after close reduction additional fixation in the form of percutaneous crossed K-wire can maintain the reduction till bony union & prevent late collapse at fracture site & provides better result. Key Words: Colles' fracture; closed reduction; Plaster cast & Kirschner wire (K-wire) fixationDOI: 10.3329/jdmc.v17i2.6591J Dhaka Med Coll. 2008; 17(2) : 98-105