Original Article

Joshi’s External Stabilization System Fixator – A Mini Solution

to Avert Major Disabilities in Hand Injuries
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Vijaya Kumari Thadiparthi, Kartheek Chinnapothula, Soma Sekhar Mecharla1, Varun Kumar Paka2, Jameer Shaik3, Srivatsava S. D. M. Talluri4,
Ravi Sharma Pilaka5
Department of Orthopaedics, King George Hospital, 1Department of Orthopaedics, Gayatri Vidya Parishad Institute of Health Science and Medical Technology,
5
Department of Orthopaedics, Golden Jubilee Hospital, Visakhapatnam, 2Department of Orthopaedics, NIMRA Institute of Medical Sciences, Vijayawada, 3Department
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of Orthopaedics, Chaitra Hospital, Eluru, 4Department of Orthopaedics, Sai Sudha Hospital, Kakinada, Andhra Pradesh, India

Abstract
Background: Fractures of hand bones are often considered minor injuries and treatment is either delayed or neglected. These fractures are
usually treated conservatively that leaves behind a residual functional deficit. Surgical intervention should be considered for open, unstable,
multiple, comminuted, or intra‑articular fractures. Standard surgical treatment includes the use of K‑wire, plate, or mini‑screws which are
associated with unsatisfactory results and high complication rates. Joint stiffness is a commonly reported complication with most of the existing
devices used for hand bone fractures. There is a deficit of data pertaining to the effectiveness of Joshi’s External Stabilization System (JESS) in
avoiding joint stiffness. Joshi’s external fixator is a reliable treatment of phalangeal and metacarpal fractures of the hand. It is an economical,
simple, lightweight, and stable contract. Patients and Methods: We report a prospective cohort study of 30 patients of hand bone fracture,
10–60‑year age range, treated by JESS. Functional evaluation was made using the Duncan et al. scoring. Results: The results recorded were
excellent in 31.58% of cases, good in 42.11% of cases, fair in 21.05%, and poor in 5.26% of patients. Conclusion: JESS ex‑fix for hand is a
useful construct that allows early mobilization of nearby joints. It can be considered a suitable choice for the management of phalangeal and
metacarpal fractures of hand to deliver good functional outcome.

Keywords: Ligamentotaxis, pin tract infection, thermal necrosis

Introduction
Human hand is vulnerable to variety of injuries of varying degree
caused by road traffic accidents, industrial accidents, assaults,
and other causes.[1,2] Hand injuries are common in the age group
of 10–40 years with a male predominance.[3] Metacarpals and
phalangeal injuries account for 10% of the total upper limb
fractures.[4] These fractures are mostly comminuted, associated
with tiny fragments and nearby combined dislocations.
Reduction is difficult to achieve in most of the patients.
A distracting force from adjacent joints usually causes loss
of reduction leading to malunion, incongruity, or joint space
narrowing. Outcome is affected by the severity of damage to
ligaments, tendons, or articular capsule. Surgical intervention
is necessary in few unstable, multiple, intra‑articular fractures,
or open fractures to achieve optimal reduction during bone
healing and allow early movement.[5] External fixation is useful
for highly comminuted or complex intra‑articular fractures.[6]
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This study was intended to find out the role of Joshi’s External
Stabilization System (JESS) in the management of hand bone
fractures and the associated complications of the device.
Patients and Methods
A prospective cohort study was carried out on 30 patients with
hand fractures, aged between 10 and 60 years, admitted to the
department of orthopedics of our institute from November
2018 to October 2020. Patients with unstable, intra‑articular,
Address for correspondence: Dr. Soma Sekhar Mecharla,
Department of Orthopaedics, Gayatri Vidya Parishad Institute of Health
Science and Medical Technology, Visakhapatnam, Andhra Pradesh, India.
E‑mail: drmssekhar@gmail.com
Received: 23‑08‑2022 Accepted: 19‑11‑2022
Revised: 07‑10‑2022 Published Online: 27-12-2022
This is an open access journal, and articles are distributed under the terms of the Creative
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For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

How to cite this article: Thadiparthi VK, Chinnapothula K, Mecharla SS,

DOI: Paka VK, Shaik J, Talluri SS, et al. Joshi’s external stabilization system
10.4103/jodp.jodp_71_22 fixator – A mini solution to avert major disabilities in hand injuries. J Orthop
Dis Traumatol 2023;6:78-83.

78 © 2022 Journal of Orthopaedic Diseases and Traumatology | Published by Wolters Kluwer - Medknow
 Thadiparthi, et al.: JESS fixator for hand injuries

juxta‑articular, and open or multiple fractures were included
in the study. Patients with severely crushed hand injuries,
fractures with associated tendon or neurovascular injuries were
excluded from the study. Informed, written consent was taken
from all the patients included in the study. Prior approval of
the institutional ethics committee was taken before initiating
the study.
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speed [Figure 3]. The clamps and side rods were applied
after pin insertion. The distractor/compression device was
applied and compression or distraction at the fracture site
was done as per the need to reduce the fracture. The frame
was then tightened. Connecting rods were then placed. After
the formation of the planned frame, the digit was put through
a full range of passive movements, and the stability of the

frame was checked. In case of intra‑articular fracture, we

Statistical methods
followed the principles of ligamentotaxis. The connecting
Descriptive statistical analysis has been carried out in the
present study. Data analysis was performed using IBM rods should be 5–7 mm away from the skin surface, to allow
SPSS Statistics for Windows, version V27.0 (IBM corp. for wound and pin tract care [Figure 4]. This gap is necessary
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Released 2020, Armonk, New York, USA). Results on to accommodate postoperative edema and reduce undue
continuous measurements are presented on mean/standard discomfort. The frame was constructed consisting of minimum
deviation (Min‑Max) and results on categorical measurements
are presented in number (%). Significance is assessed at 5%
level of significance. Student’s t‑test (two‑tailed, dependent)
has been used to find the significance of study parameters on
continuous scale within each group. Chi‑square/Fisher’s exact
test has been used to find the significance of study parameters
on a categorical scale between two or more groups.
Since most of the fractures of hand are caused by road traffic
Figure 1: Preoperative clinical images of various degrees of hand injury
accidents, it is imperative to assess both the fracture and the
patient as whole. Primary evaluation for and management
of shock if coexistent was done. The assessment of injury of
hand [Figure 1] was next done based on grading provided by
Swanson et al.,[7] while meticulously ruling out injury to adjacent
tendons, nerves, and blood vessels. Radiographs [Figure 2]
were taken in two views as anteroposterior and oblique (OBL)
and if necessary, lateral (LAT) views. The level and pattern of
fracture, amount of displacement, and angulation were noted
on the X‑ray. Radiography of other parts was taken when
indicated for associated injury. The pain was alleviated by
use of analgesics. Broad‑spectrum antibiotics and anti‑tetanus
prophylaxis were started in case of open injuries. JESS
application was then considered after stabilization of general
condition. A below‑elbow slab was applied initially in all patients
up to the time of surgical stabilization of the fracture. Swanson
et al.[7] classification for open fractures of hand was used. Out
of 30 patients, 12 were found to be open, of which five patients Figure 2: Preoperative radiographic images of hand including AP and
had type I (13.33%) fracture and seven patients had type II oblique views. AP: Antero‑posterior
injury (20%). No injuries with vascular impairment were noted.
Operative technique of Joshi’s external stabilization
system fixation
Most of the patients were operated under wrist block.
General anesthesia was used in some patients (younger
patients <16 years, those intolerant to pain, and hypersensitive
to pain). Pin placements and frame configurations were decided
first depending on the fracture pattern. Prior pin site selection
was done in advance, as per the safe zones to avoid damage
to important structures and enables good access to wound for
dressing postoperatively. Preliminary wound debridement was
done followed by fracture reduction and alignment.
Skin and fascia were incised before pin insertion. Pins were Figure 3: Basic armamentarium needed for JESS fixator application.
inserted directly using a hand drill or power drill with slow JESS: Joshi’s External Stabilization System

Journal of Orthopaedic Diseases and Traumatology ¦ Volume 6 ¦ Issue 1 ¦ January-April 2023 79

 Thadiparthi, et al.: JESS fixator for hand injuries
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Figure 4: Postoperative clinical and radiographic images of JESS external fixator applied to hand. JESS: Joshi’s External Stabilization System
of one K‑wire (1.8 mm) in each fragment not spanning across
the adjacent joints to allow mobilization of nearby joint of
fractured bone. The two K‑wires were connected to connecting
rod placed 5–7 mm away from the skin using JESS clamps.
All the wires were trimmed, and only 4–5 mm wire was
allowed to be left protruding beyond the link joints, and the
protruding wires were capped with plastic tubings. The limb
should be brought above the level of heart and adjacent joints
should be kept in continued range of motion to facilitate
gravitation of body fluids into circulation. The dressing was
changed on the 2nd postoperative day, and check radiographs
were taken at least in two views to study the reduction. Pin
insertion sites and wound are regularly dressed at every
follow‑up. Every joint that was not involved in the frame was
immediately mobilized.
For open injuries, the daily dressing was done. Pin insertion
sites were cleaned daily with betadine. Gauze pieces were
placed at pin tract sites to prevent pin tract infection. Immediate
active and passive movements of joints proximal and distal to
the fixator were started.
Rehabilitation
Active and passive movements of the joints proximal and distal
to the fracture were continued up to 3 weeks. Usually, the
contraction of soft tissues begins approximately 72 h following
injury. Early mobilization of joints improves the outcome.
The patient was reviewed again every week. The fracture was
found to be stable from 3 weeks and above postoperatively,
and the frame was removed based on the stability attained
except for cases with considerable bone loss. Immediately,
the joint spanned previously was mobilized. If in repeat
X‑ray, any instability is noticed, either JESS was reapplied, or
secondary methods of fixation were considered based on the
status of wound healing and the fracture mechanics. Fracture
stability is defined as the maintenance of fracture reduction
when the adjacent joints are taken through at least 30% of
their normal motion. Fixator was retained for longer time in
patients with bone loss to account for longer time needed for
callus formation and to attain stability. Active range of motion
80 Journal of Orthopaedic Diseases and Traumatology ¦ Volume 6 ¦ Issue 1 ¦ January-April 2023
was encouraged. After about a week, repeat X‑ray was taken to
confirm stability. Physiotherapy was started once stability was
ascertained on radiographic images. Associated injuries were
treated simultaneously and the patient was followed regularly
for a further period of about 1 year.
Follow‑up
As shown in Figure 5, patients were followed up once weekly
up to 1 month, monthly for up to 6 months, and later once for
6 months. The minimum follow‑up was up to 6 months in
this study. Most patients were followed for 1 year. Functional
evaluation was done using scoring by Shah et al.[8]
Results
A total of 30 patients were enrolled in the study and all of them
were successfully followed up for the minimum predetermined
period. The maximum follow‑up in this study was about
54 weeks. The study included 30 patients, age ranging from
10 to 60 years, with 25 phalangeal and 13 metacarpal fractures
treated by external mini fixation using JESS fixator.
Majority of the patients in the study were of the age group
of 21–40 years (69%). The average age of the patient was
32.97 ± 10.41 years. Ninety percent (27) of the patients were
male and 10% (3) cases were female. Forty percent of the
patients were workers.
Most of the soft‑tissue injuries (Gustilo‑Anderson types I and
II) healed in the first 2 weeks (50.33%), 43.33% of the cases
healed in 3–4 weeks and 6.33% after 4 weeks. The average
soft‑tissue healing was 2.32 weeks. In our study, fixator was
removed in 63.33% of the cases during 5–6 weeks, 33.33%
in 3–4 weeks, and 3.33% in 6–8 weeks. The mean duration of
JESS fixation in situ was 4.42 ± 0.70 weeks.
Functional assessment was done by based on total active range
of movements in degrees of each injured finger separately
according to Duncan et al.[9] This adds the active flexion of
metacarpophalangeal, proximal interphalangeal, and distal
interphalangeal joints, then subtracting the sum of extension
deficits of these three joints. Results are recorded based on
 Thadiparthi, et al.: JESS fixator for hand injuries
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Figure 5: Clinical evaluation of hand movements at follow up
Duncan et al.’s criteria for fingers. The results recorded were
excellent in 31.58% of cases, good in 42.11% cases, fair in
21.05%, and poor in 5.26% of patients.
Complications observed in the study were pin tract infection,
mal union, pin loosening, Sudeck’s osteodystrophy, and joint
stiffness. Pin tract infection was observed in five fractures,
which healed promptly by antibiotic use in all of them.
Malunion was noticed in two patients (comminuted fractures
and multiple fractures) due to a lack of accurate reduction or
postreduction collapse. None of the malunited fractures cause
any significant disabilities. Pin loosening was noticed in three
patients which did not affect the healing of the fractures. All
the cases of pin loosening had prior infection of pin site which
led to loosening after 3 weeks. One patient who had fracture
of the proximal phalanx of the left thumb developed Sudeck’s
osteodystrophy which ultimately led to stiffness of thumb.
Joint stiffness was either partial or total. A joint was considered
partially stiff when the range of motion in that particular finger
was <180° in case of fingers and <100° in case of thumb.
Moreover, those patients with range of motion <130° in case
of fingers and <70° in case of thumb were considered to be
having total joint stiffness. Seven patients in this study (6 partial
and 1 total) developed joint stiffness. Most of the patients who
developed stiffness were having open injuries, multiple fractures,
or intra‑articular comminuted fractures and presenting late.
Discussion
Human hand is a versatile structure which carries out a wide
variety of functions. Fractures of hand are often overlooked
due to common perception of them being minor injuries with
resultant major disabilities.[10] They account for 5%–10% of
emergency department trauma cases. The majority of these are
treated conservatively. Dr. Alfred B. Swanson statement “Hand
fractures can be complicated by deformity from no treatment,
stiffness from overtreatment and both deformity and stiffness
from poor treatment” still holds true in present times.[11]
Operative treatment is recommended for unstable, intra-
articular, and open fractures to achieve proper healing and
Journal of Orthopaedic Diseases and Traumatology ¦ Volume 6 ¦ Issue 1 ¦ January-April 2023
early mobilization.[12] Two commonly used surgical fixations
for metacarpal and phalangeal fractures are K‑wires and
plate and screw fixation. K‑wire fixation is a less invasive
technique but is relatively unstable. Plates are associated with
joint stiffness and induce more damage to soft tissue. JESS
frameworks on the principle of ligamentotaxis and provides
quality reduction and early mobilization of neighboring joints
Gupta et al.[13] Bakki et al.[14] reported over 75% excellent or
good outcome with <6% of poor outcome in their study on
30 patients (37 fractures of metacarpal and phalanges) treated
by JESS fixator. Plate and screw fixation are associated with
further soft‑tissue damage with joint stiffness and delay in
regain of joint function.[15]
Leading cause of injury was road traffic accidents (RTA) (40%)
followed by industrial accidents (30%) and agricultural
accidents (16.67%). 26.67% of the patients had associated
injuries involving the other systems or other bones. 66.67% (20
out of 30 patients) of fractures involved the dominant hand.
55.26% of patients had proximal phalanx [Table 1] fractures
followed by 34.21% in metacarpal and 10.55% middle
phalanx. 55% of fractures were noticed in the shaft [Table 2].
Comminution was noticed in around 51.53% of fractures.
86.67% of the patients were operated within the first 3 days,
13.33% were operated between 4 and 7 days after injury. In
majority of patients, fractures healed by 12 weeks (52.63%).
Basic principles of JESS fixator (static frames) are applicable
for all fracture patterns except intra‑articular and juxta‑articular
fractures. A minimum of two K‑wires should be passed in
each bone segment, except for small bone such as middle and
terminal phalanges where one K‑wire is allowed. The stability
of frame can be increased by adding more pin and spacing
them. The minimum distance between the wires must be 6 mm
and 7 mm when using alpha and beta clamps, respectively.
Dr. B. B. Joshi advocates use of sharp, trocar‑tipped K‑wires
for tough cortical bone. Threaded pins are associated with
loosening. Low‑speed high‑torque motorized drills are
preferred over hand drills to prevent pin loosening and
thermal necrosis. Hand drills tend to drill large holes with
subsequent pin loosening. Drenth and Klasen[16] have used
81
 Thadiparthi, et al.: JESS fixator for hand injuries
Table 1: Distribution based on the part of hand (including
thumb)
Hand bone involved Number of cases, n (%)
Metacarpal 13 (34.21)
PP 21 (55.26)
MP 4 (10.55)
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DP 0
Grand total 38 (100)
DP: Distal phalanx, MP: Middle phalanx, PP: Proximal phalanx
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Table 2: Distribution based on the site of fractures
Part of bone involved n (%)
Shaft 21 (55.26)
Juxta articular 10 (26.32)
Intra articular 7 (18.42)
Grand total 38 (100)
pre‑bent (40°–60°) their threaded pins to prevent interference
of other finger movements.
Behrens[17] concept of corridors is useful to plan for pin
insertion site selection. Safe corridors are regions where
no neurovascular or myotendinous structures are present.
Hazardous corridor contains musculotendinous units but no
neurovascular structures. All external mini fixators applied in
metacarpals, metatarsals, and phalanges are in a hazardous
zone. Unsafe corridors have both musculotendinous and
neurovascular structures. Based on this knowledge in central
digits, a dorsolateral or dorso‑OBL pin placement is good, but
for border fingers, LAT pin placement can as well be used.
Any configuration other than dorsolateral pins are precluded
in III and IV metacarpals and II, III, and IV metatarsals, but
LAT pins can be placed in other metacarpals and metatarsals.
In juxta‑articular and intra‑articular fractures, we utilized
Vidal’s principle of ligamentotaxis to provide reduction. In
one case of compound proximal phalanx fracture left thumb
with bone loss, we have used biplanar frame. Reinforcement
of the assembly was achieved in most of the cases by adding
another connecting rod parallel to the first. Soft‑tissue healing
was delayed in patients with multiple fractures and open
fracture associated with severe soft‑tissue injury and in those
who presented late.
Recent studies by Johnson et al.,[18] Li et al.,[19] El‑Shaer
et al.,[20] Yaseen et al.,[21] are all in favor of use of mini external
fixator for metacarpal and phalangeal fractures of hand based
on the excellent‑to‑good functional outcomes derived in their
studies.
Gupta R et al.[15] in their study, mini ex‑fix for hand bone
fractures reported around 13% poor results. Gupta et al. on
the management of hand bone fractures with plate and screw
fixation demonstrated that finger stiffness was the most common
complication in the series. Drenth et al. reported that results of
middle phalanx were better than results in proximal phalanges
82 Journal of Orthopaedic Diseases and Traumatology ¦ Volume 6 ¦ Issue 1 ¦ January-April 2023
managed by JESS fixator. Kapur et al.[22] reported union with
good joint congruency with no complications in their series
on intra‑articular fractures of proximal interphalangeal joint
managed by JESS. However, there was some restriction of PIP
joint flexion was noticed.
Complication of external fixator stated by Hastings[23]
include pin tract infection, osteomyelitis, fracture at pin sites,
neurovascular damage at the time of pin placement, nonunion
secondary to over distraction, mal union due to loss of
reduction, and interference with the activity of adjacent digits.
Naidu[24] observed complication rates of 16% K‑wire loosening
and 14% pin tract infection in their series of external fixator
management of hand bone fractures. Burny[25] stated that JESS
being a percutaneous implant has a higher chance of infection
and tissue proliferation. This can be reduced by low‑speed
drilling, avoiding pin loosening, and postoperative antibiotics
and regular dressings.
Pin anchorage depends on bone quality. Loosening is seen
in osteoporotic bone. The usage of high‑speed drills caused
thermal necrosis and may add to pin loosening.
For simple fractures, uniplanar frames are sufficient to produce
good stability. Stability can be increased using more connecting
rods and by bringing the frame close to the bone.
Conclusion
Meta carpal and phalangeal fractures deserve proper attention
from treating surgeon to avoid unwanted, troublesome major
disabilities secondary to improper management. Thorough
preoperative evaluation and proper choice of implant are
crucial to successful outcome. Surgical intervention is a better
choice for unstable, comminuted, open, and intra‑articular
fractures as proved in previous studies. JESS is a cheap,
easy‑to‑apply, simple construct, efficient for managing
metacarpal and phalangeal fractures. Its main advantage is that
it provides good stability at fracture site without immobilizing
the neighboring joint. Early mobilization is the key for good
functional results which is ensured by JESS mode of fixation.
Hence, JESS should be the prime choice of hand bone fracture
management to restore the functions of hand postoperatively
to close to preinjury level.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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