5 Principles of internal fixation as applied to the hand and wrist

Synopsis

Most minimally or nondisplaced fractures can be managed nonoperatively.

Careful preoperative planning facilitates safe and expeditious surgery.

Ligamentotaxis relies on the application of linear traction to indirectly reduce fragments via the intact periosteum and soft tissues.

A myriad of fracture fixation options are available; selecting the most appropriate depends on a careful assessment of the fracture and patient related factors.

Postoperative care should allow for early mobilization if fixation permits.

Introduction

Fracture care was significantly advanced in the 20th century with the introduction of new techniques and instrumentation for internal and external fixation.¹ Today’s capable hand surgeon must be well versed in the spectrum of available techniques of fracture fixation to provide optimum care for the myriad of bony injuries that occur within the purview of a hand surgery practice. Fixation of fractures in the hand is notoriously difficult given the relatively small size of the osseous structures and complexity of the surrounding anatomy.² The aim of this chapter is not to review every possible technique of fracture fixation in the hand, but rather, to present basic concepts and general techniques useful in routine fracture care.

Much of the credit for these advances in fracture management should go to the Arbeitsgemeinschaft fur Osteosynthesefragen (AO) who devised a set of principles (Table 5.1) that, in its modified form, provides the basic tenets that underlie appropriate fracture care.³

Table 5.1 Arbeitsgemeinschaft fur Osteosynthesefragen (AO) principles

Anatomical fracture reduction

Appropriate stability of the fixation construct

Preservation of blood supply and soft tissue attachments to fracture fragments

Early and safe mobilization

Patient selection

Fracture assessment

Any consideration of fracture fixation must begin with a careful, complete history and physical examination. Was this the sequelae of high or low energy trauma? Is this an isolated injury or is the patient polytraumatized? Are there open wounds? Does the patient require early return to functional activities or are their daily demands limited? How much time has elapsed since the fracture and the current presentation? Is there angular or rotational displacement? The vast majority of fractures that are non- or minimally displaced are amenable to treatment with nonoperative methods.

Host factors

The decision to treat a fracture with internal fixation requires a commitment from the patient to comply and participate in appropriate postoperative care. Failure to comply with splinting regimens, follow-up care, therapy recommendations, or weight-bearing restrictions may result in compromised outcomes.

Certain host factors imply an increased susceptibility to wound healing problems or infection. Systemic factors include: diabetes mellitus,⁴ an immunocompromised state, advanced age, and smoking, amongst many others. Local factors include: skin quality, volume/quality of soft tissues available for closure, type of hardware elected, and tension across the wound. Failure to recognize and address these factors may result in compromised outcomes. Patients with elevated risk for wound problems should be counseled accordingly and managed with alternative strategies where appropriate.

Preoperative imaging

Radiographic assessment requires a minimum of two orthogonal views with the X-ray beam centered near the fracture to minimize distortion. Factors to carefully evaluate include:

1. Location of fracture (articular, metaphyseal, diaphyseal)

2. Pattern (transverse, oblique, spiral)

3. Presence of comminution

4. Displacement

5. Angulation (sagittal, coronal, and axial (rotational) planes)

6. Potential deforming forces acting across the fracture site.

Occasionally, as with a complex or suspected occult fracture, three-dimensional imaging with computed tomography (CT) scans or magnetic resonance imaging (MRI) may be indicated. After careful consideration of the fracture pattern in the context of the injured patient, a decision must be made regarding nonoperative versus operative treatment.

Treatment/surgical technique

Preoperative planning

Once a decision has been made to treat a fracture operatively, the surgeon begins the planning phase. Similar to the “reconstructive ladder” concept for management of soft tissue defects, the surgeon should, in general, use the simplest method that will reliably produce excellent clinical results. Planning should include every detail of the planned operation. This includes patient positioning, operating room setup, implants needed, operative approach, type of imaging (fluoroscopy) desired, and consideration of backup plans. Time spent planning pays off by saving operative time, decreasing staff frustration, and ensuring that the appropriate tools are present for the safest, most successful and most efficient surgery possible.

Fracture reduction

Fracture reduction may be obtained by numerous means. If done in a closed fashion, this reduction is usually in the form of pulling linear traction across the fracture site. This utilizes the phenomenon of ligamentotaxis,^5,⁶ whereby any intact periosteum and/or ligaments help realign attached bony fragments as they are stretched. When open reduction is elected, reduction is obtained usually through a combination of external manipulation and instruments placed within the fracture site. The reduction may be held with reduction forceps or provisional Kirschner wires. The concept of reducing the number of fragments by temporary or final fixation of fragments to other fragments is critical in achieving a satisfactory reduction in the face of comminution. Forceps or wires used for temporary fixation should be carefully thought out so as to not interfere with the planned definitive fixation.

Hints and tips

Reduction forceps

Reduction forceps may be useful to attain and maintain fracture reduction in fixation of larger fragments. One tine of the forceps is introduced firmly onto a fragment and the other tine is used to tease another fragment into the appropriately reduced position. Careful pronation and supination movements while applying the forceps may allow for the restoration of length to difficult fractures. One has to take care not to crush or shatter the fragments with excessive compression of the clamps.

Hints and tips

Kirschner wires (K-wires)

These are discussed in detail, in a separate section below. In fracture reduction, K-wires can be used to temporarily secure fractures that are already reduced. Alternatively, they may be applied in a unicortical fashion and utilized as “joysticks” or “handles” to manipulate pieces into the appropriate position. After attaining this position, they are often advanced across the fracture to transition them from a reduction aid into a tool of temporary or definitive fixation.

Hints and tips

Kapandji (intrafocal) pinning ⁷^–¹¹

This is a special type of utilization of K-wire commonly utilized in distal radial fractures. The wire is introduced through the fracture site (intrafocally). The pin is then tilted in the desired direction of the reduction, then advanced through the far cortex. This has particular applicability to the restoration of volar tilt and radial inclination in distal radial fracture. This may be employed as either definitive or temporary fixation.

Hints and tips

Temporary/supplemental external fixation

For select, extremely difficult fractures, an external fixator may be utilized to apply ligamentotaxis to assist with fracture reduction while other methods are utilized.

Intraoperative imaging

Fluoroscopy provides a valuable adjunct to many fracture fixation surgeries. A complete review of fluoroscopic physics and principles is beyond the scope of this chapter, but a few points are worth mentioning. For upper extremity surgery, either an image intensifier or a “mini” fluoroscopic unit may be employed. For the vast majority of hand surgery cases a “mini” fluoro provides adequate visualization with greater mobility and less radiation.¹²^–¹⁵

Many different operating room setups may be employed, but patient positioning should be confirmed preoperatively to allow for adequate fluoroscopic visualization during surgery. We typically position the mini-fluoroscopic unit parallel to the bed, oriented from the foot toward the axilla, so that the patient’s arm can be adducted off of the hand table to provide unobstructed views.

The region being examined should always be centered on the detector of the fluoroscopic unit to minimize the distortion from the “parallax” effect. Multiple views are helpful to determine fracture reduction or hardware position in all planes. It may also be helpful to orient the beam directly down a placed K-wire or screw to precisely visualize its placement. Specific knowledge of certain anatomic regions may also be helpful. For instance, in the distal radius, inclining the wrist approximately 20–30° from a true lateral can provide better visualization of the cortex of the lunate facet to evaluate for screw penetration into the radiocarpal joint.¹⁶ Live, dynamic fluoroscopy may be useful to examine for stability across a fracture site with controlled motion or in other, select instances.

Fixation options

Absolute versus relative stability

Key concept

Absolute versus relative stability

Bone healing following fracture fixation depends on the stability of the fixation technique chosen. With absolute stability, very rigid, internal fixation is utilized. This typically is in the form of lag screws or compression plates. This requires anatomical reduction of fracture fragments and is often the goal with articular fractures and simple diaphyseal fractures. Interfragmentary compression, as discussed below, facilitates healing with this type of fixation. Typically, absolute stability is possible only with simple fracture patterns or with minimally comminuted fractures with relatively large comminuted fragments (i.e., a “butterfly” segment). Primary bone healing with absolute stability is achieved histologically with “cutting cones” (Fig. 5.1) that facilitate direct healing of one fragment to another. No fracture callus is observed.

Fig. 5.1 Compressed osteotomy site. Note the migration of osteocytes across the fracture line, an example of contact healing (H&E: magnification ×100).

The concept of relative stability is important either when treating comminuted diaphyseal fractures where anatomical reduction is deemed impossible or in cases where closed reduction is elected. With relative stability, the primary focus is on achieving anatomical alignment of the neighboring articular surfaces in the coronal, sagittal, and axial planes. Some micro-motion occurs at the fracture site, and, in fact, is conducive to this type of healing (secondary bone healing). Stability, however, must be adequate to maintain the alignment. In contrast to primary bone healing via absolute stability, secondary bone healing occurs via progression through cartilaginous intermediaries and fracture callus is observed. Relative stability is typically achieved with external fixation, bridge plating, or intramedullary fixation. This concept, in general, is not commonly applied to articular fractures.

Interfragmentary compression

Interfragmentary compression is a critical component of fixation when the surgeon attempts to achieve absolute stability.^17,¹⁸ This compression, when combined with anatomical reduction, leads to microscopic interdigitation of fracture ends, thus minimizing the distance required for cells to travel from one side of the fracture to the other. This may be achieved via a variety of methods discussed below, including lag screws, compression plates, and tension bands. Interfragmentary compression may be detrimental in certain situations. For instance, in highly comminuted fractures, overzealous compression may lead to excessive shortening.