External fixation for phalangeal and

metacarpal fractures
D. J. Drenth, H. J. Klasen
From the University Hospital, Groningen, The Netherlands

rom 1987 to 1993 we treated 33 patients with 29 Our retrospective study reviewed the functional results in
F phalangeal and seven metacarpal fractures by
external fixation using a mini-Hoffmann device. There
a group of patients with phalangeal or metacarpal fractures
and either open wounds or severe soft-tissue injuries treated
were 27 open and 25 comminuted fractures. In 12 by external fixation.
patients one or more tendons was involved.
The mean follow-up was 4.4 years. Complications Patients and Methods
occurred in ten fractures; two required repositioning
of the fixator. All the fractures healed. The functional From 1987 to 1993, 33 such patients (27 men and 6
results after metacarpal fractures were better than women) with 36 fractures were treated by external fixation.
those after phalangeal fractures and fractures of the Their mean age was 35 years (15 to 69). Most had blunt
middle phalanx had better recovery than those of the injuries; nine were caused by traffic accident, nine by
proximal phalanx. Twenty-eight of the 33 patients machinery, ten by falling or cutting objects, two by phys-
were satisfied with their result. ical violence, one by a gunshot wound, one by a fall and
External fixation proved to be a suitable technique one by an explosion. In 30% of the cases the dominant
for stabilising unstable, open fractures with severe hand was involved. The distribution of the 29 phalangeal
soft-tissue injuries. and seven metacarpal fractures is shown in Figure 1; the
J Bone Joint Surg [Br] 1998;80-B:227-30. proximal phalanx of the ring finger was more often
Received 7 July 1997; Accepted after revision 10 November 1997 involved than that of the other fingers. There were several
types of fracture; 25 were comminuted, six transverse, three
oblique, one spiral and one intra-articular. There were 27
Phalangeal and metacarpal fractures are common: from open fractures and 25 with severe soft-tissue injuries. In 12
1987 to 1993, totals of 2407 patients with phalangeal and patients, one or more tendons was partially (> 50%) or
1554 with metacarpal fractures were treated in our Accident completely divided.
Department.
Most of these fractures can be treated conservatively, but
in a relatively small number of patients with unstable
fractures operative treatment is indicated. There are two
types of fixation: internal according to AO standards, and
external for a selected group with open unstable fractures
or severe soft-tissue injuries. The use of an external device
reduces further damage to the delicate soft tissues and
bone, allows wound care and enables exercise of the finger
joints at an early stage. There have been few reports of the
1-12
use of external fixation for these injuries.

D. J. Drenth, MD, Assistant

Department of Cardiothoracic Surgery
H. J. Klasen, MD, PhD, Professor
Department of Surgery
University Hospital Groningen, PO Box 30.001, 9700 RB Groningen, The
Netherlands.
Correspondence should be sent to Professor H. J. Klasen.
Fig. 1
©1998 British Editorial Society of Bone and Joint Surgery
0301-620X/98/28131 $2.00 The distribution of 36 fractures in 33 patients.

VOL. 80-B, NO. 2, MARCH 1998 227

228
Fig. 2
The external fixator in situ. The pins are bent to prevent inter-
ference with adjacent fingers.
All the patients had an early operation using a mini-
Hoffmann device for external fixation (Fig. 2). Debride-
ment of the necrotic tissue after provisional reduction was
followed by insertion of the pins, with positioning deter-
mined by eye and image intensifier. A small incision was
made on the lateral side of the fractured bone except in one
patient with a fracture of the third metacarpal in whom the
pin was inserted as far laterally as possible. The pin-hole
track was predrilled in the transverse plane of the bone.
Two pins were inserted, one proximal and one distal to the
fracture. The pins were then provisionally connected by a
bar and the fracture reduced. In most cases, simple traction
was sufficient, and after reduction the pins were fixed
firmly to the connecting bar. A very unstable fracture
required more than two pins; this applied to 10 of the 36
fractures.
If the pins interfered with the soft tissues, they were bent
in a dorsal direction through an angle of 40 to 60° (Fig. 2).
The skin wounds were not closed and, after operation, the
injured hand was immobilised in plaster for ten days to six
weeks, according to a set protocol of ten days for an
isolated soft-tissue injury, three weeks for a flexor tendon
lesion, and six weeks for a complete extensor tendon
lesion. The patients were discharged as soon as soft-tissue
healing allowed, having been taught standard pin care.
Follow-up visits at weekly intervals allowed inspection of
the wounds and checks of the stability of the device.
Radiographs were taken immediately after surgery and at
one to two weeks and four weeks to check the position and
healing. When the bone had healed, the external fixator was
removed.
Mobilisation of the injured hand began after the plaster
splint had been removed, and if movement did not return
rapidly, physiotherapy was used. Patients were discharged
from follow-up when improvement in function had reached
a plateau. Recovery was scored on the basis of the total
active range of movement of each injured finger separately,
D. J. DRENTH, H. J. KLASEN
Table I. Functional assessment based on
total active range of movement in degrees of
each injured finger separately according to
13
Duncan et al
Finger Thumb Result
220 to 260 119 to 140 Excellent
180 to 219 98 to 118 Good
130 to 179 70 to 97 Fair
<130 <70 Poor
Table II. Results of treatment in 29 phalangeal
fractures and seven metacarpal fractures
Phalangeal Metacarpal
Excellent 10 5
Good 10 -
Fair 3 -
Poor 6 2
13
using the scoring system of Duncan et al for total active
movement. This adds the active flexion of the metacarpo-
phalangeal, proximal interphalangeal and distal interpha-
langeal joints, then subtracts the sum of the extension
deficits at these three joints (Table I).
Results
The mean follow-up was 4.4 years (2.3 to 8.2), and there
were no general complications. The device had been removed
at a mean of 5.8 weeks after a phalangeal fracture (3 to 11)
and 6.1 weeks after a metacarpal fracture (2 to 12).
Ten fractures showed complications during the period of
fixation: in six patients one of the pins became loose, in two
part of the device interfered with the soft tissues of the
adjacent finger, in one the device restricted movement of the
adjacent finger and in one the fracture became displaced.
In five patients, loosening of a pin was managed by
removal of the device because the fractures had healed. In
one case, loosening resulted in displacement of the fracture,
which required surgical revision.
Interference with other fingers was seen only before we
had made it our policy to bend the pins. The patient with a
displaced fracture required re-reduction at a second
operation.
The mean period of treatment for phalangeal fractures
was seven months and for metacarpal fractures five months.
All fractures healed without further operation and no
patient developed reflex sympathetic dystrophy. There were
no sinuses after removal of the pins.
Table II gives the functional results. None of the fingers
had rotational or axial deformities. Eight out of the nine
fractures of the middle phalanx and 12 of the proximal
phalangeal fractures including one intra-articular fracture
(n = 20) had excellent or good results. Of the eight patients
with fair or poor results, five had an injury to the tendon.
One patient with a poor result had injuries to both the
THE JOURNAL OF BONE AND JOINT SURGERY
 EXTERNAL FIXATION FOR PHALANGEAL AND METACARPAL FRACTURES 229

Fig. 3a

Fig. 3b

Fig. 3c
Radiographs before (a) during (b) and after (c) treatment.

VOL. 80-B, NO. 2, MARCH 1998

230 D. J. DRENTH,
extensor and flexor tendons, and partial amputation was
later performed at the request of the patient. Twenty-eight
patients were satisfied with the final result.
Discussion
Most phalangeal and metacarpal fractures are treated con-
servatively. Patients with unstable fractures require oper-
ative reduction and stabilisation to obtain the optimal
position for bone healing and to allow early movement. In
all our cases the fractures were open and/or accompanied
by severe soft-tissue injuries.
We used external fixation to help to avoid any additional
injury to the bone and soft tissues. The technique is rela-
tively simple, and even greater precision is added by the
use of an image intensifier. The best site for pin introduc-
tion is easily chosen. Predrilling with a drill guide has the
advantage that the site and direction of the pins are better
controlled. An image intensifier is sometimes necessary
because of the brittle nature of the phalanges and meta-
carpals: what may seem to be a perfect drill-hole may lead
to incorrect pin placement if it is not checked by the image
intensifier. In 23 of our patients two pins gave sufficient
stability to maintain position and to allow exercise (Fig. 3).
The insertion of pins in a transverse plane helps to obtain
the broadest hold on bone and is important. Another advan-
tage of this method of treatment is that it prevents further
injury to extensor or flexor tendons and other delicate soft
tissues. The transverse plane of the pins may hinder the
patient or restrict exercise, but this was solved by bending
the pins through an angle of 40 to 60° which did not
jeopardise the reduction or the stabilisation, and prevented
interference with the soft tissues (Fig. 2).
The most common complication was loosening of the
pins, which may be due to technical failure, poor quality
bone or to the other injuries, but our numbers were too
small to allow any firm conclusions. Loosening did not
affect the outcome in our series since four of the six
patients involved had a good or excellent functional result.
In only one loosening, combined with displacement of the
fracture, was further operative reduction needed. All loose
pins were removed early; this may be the reason why there
were no sinuses or sequestration.
Most of the fractures were of the proximal phalanges,
13
confirming the experience of other authors. Nine fractures
of the middle phalanges healed with a better functional
H. J. KLASEN
result (eight were excellent or good) than those of the
proximal phalanges (12 excellent/good, 3 fair, 6 poor) and
14
this has also been reported previously. Metacarpal frac-
tures gave better functional results than phalangeal frac-
tures because of the difference in the type of injury and
9,12
function. Again this has been noted by others.
External fixation provides an adequate basis for bone
healing, but does not guarantee good functional outcomes.
These seem to depend on the severity of accompanying
9,12
soft-tissue injuries, as shown by our fair or poor results
in six patients in whom a phalangeal fracture was asso-
ciated with tendon injuries.
External fixation is an adequate alternative treatment for
unstable phalangeal and metacarpal fractures which are
open or accompanied by severe soft-tissue injuries.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
article.
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