Safe corridors for K-wiring in phalangeal fractures

Abstract

Background: Unstable phalangeal fractures are commonly treated with K-wire fixation. Operative fixation must be used judiciously and with the expectation that the ultimate outcome should be better than the outcome after nonoperative management. It is necessary to achieve a stable fracture fixation and early mobilization. In order to achieve this goal, one should closely understand the safe portals/corridors in hand for K-wire entry for fractures of the phalanges. Safe corridors were defined and tested using a pilot cadaveric and a clinical case study by assessing the outcome.

Materials and methods: In our prospective case series, 50 patients with 64 phalangeal fractures were treated with closed reduction and K-wires were inserted through safe portals identified by a pilot cadaveric study. On table active finger movement test was done and the results were analyed using radiology, disabilities of the arm, shoulder, and hand (DASH) score and total active motion (TAM). In our study, little finger (n = 28) was the most commonly involved digit. In fracture pattern, transverse (n = 20) and spiral (n = 20) types were common. Proximal phalanx (n = 38) was commonly involved and the common site being the base of the phalanx (n = 28).

Results: 47 (95%) patients had excellent TAM and the mean postoperative DASH score was 58.05. All patients achieved excellent and good scores proving the importance of the safe corridor concept.

Conclusion: K-wiring through the safe corridor has proved to yield the best clinical results because of least tethering of soft tissues as evidenced by performing "on-table active finger movement test" at the time of surgery. We strongly recommend K-wiring through safe portals in all phalangeal fractures.

Keywords: K-wire; Phalanges of fingers; fracture fixation; fractures; hand injuries; metacarpo-phalangeal joint; phalanges; proximal interphalangeal joint.

Figure 1

Clinical photograph of dissection on cadaveric finger showing multiple K-wire passed through safe corridors under direct vision

Figure 2

Safe corridors marked in each phalanx in flexion (green color). (b) Safe corridors marked in interphalangeal joint in extension (green). (c) Safe corridors in the distal phalanx

Figure 3

Clinical photograph showing surgical tip to visualize by lifting the base of proximal phalanx as shown for easy introduction of K-wire

Figure 4A

(a) X-ray of hand oblique view showing displaced proximal phalanx fracture. (b and c) Clinical photograph showing introduction of two K-wires from the base of proximal phalanx and performance of full flexion and extension-“on-table active finger movement test.”

Figure 4B

Postoperative X-ray anteroposterior (a) and oblique view (b) of hand showing phalanx fracture fixed with K-wire

Figure 4C

(a) X-ray anteroposterior view of hand showing distal phalangeal fracture (b) X-ray of little finger lateral view showing distal phalangeal fracture (c) Postoperative x-ray showing K-wire in distal phalangeal fracture (d) Lateral view of postoperative showing K-wire in position

Figure 5

(a) Line diagram depicting K-wires

Figure 6

X-rays of hand anteroposterior view (a) and lateral view (b) showing fracture of middle phalanx (c and d) Postoperative x-rays showing middle phalanx fixed with K-wire