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Results of a vertical figure-of-eight tension band suture for comminuted middle phalanx fracture: Case Report
INITIAL X-RAY FINAL X-RAY
Mechanism of Injury:
In October 2015, Chris sustained a crush injury to his right index finger, resulting in an open comminuted fracture of the middle phalanx. There was no nail bed damage, vascular compromise or nerve damage. Chris was taken to Sandton Clinic and was seen by Dr Juan Marin, Orthopaedic Surgeon. Dr Marin informed Chris that the fracture would need to be fixated with K Wires. Chris would not give consent to the use of K Wires or Plate & Screw Fixation as he wanted to return to sporting activities as soon as possible.
Noval Surgical Procedure:
Dr Marin was aware of the use of a figure of eight tension band suture to stabilise nail bed and distal phalangeal fractures (Memon, 2012, Patanker, 2007, Bristol & Verchere, 2007 and Bindra, 1997) but these sutures were placed dorsally over the skin and nail bed injury. The multi-fragment fracture of the middle phalanx required reduction and internal fixation. Therefore Dr Marin adapted the previously described technique to provide internal fracture fixation by using a K Wire to drill diagonally across the middle phalanx in both directions. A figure-of eight tension band using Fiber Wire 2 was then threaded through the holes drilled by the K wire to internally fixate the fracture.
Chris was referred to Hand Therapy 2 weeks after surgery. An orthosis was applied dorsally to the right index finger to provide support and pain relief. In the absence of K wires, early active mobilisation of the index finger PIP and DIP joints could be performed. Treatment included wound and scar management, active and passive mobilisation of the right index finger and strength re-training. Chris attended 12 hand therapy appointments over a period of 4 months.
Chris can achieve a composite fist, but is unable to make a tight fist die to the scar tissue that is present over the dorsum of the DIPJ. He has regained full functional use of the hand. Grip and pinch strength are normal in the right hand when compared to the left. Chris is very satisfied with the outcome of the intervention and is grateful that his hand surgeon respected his wish to not have K wire fixation and rather applied an innovative technique.
The technique was successful and should be considered in the future management of comminuted fractures of the finger.
In the event of a serious traumatic amputation of the hand, patients currently have one of 3 options available to them:
1. Hand replantation if the tissues are viable and if the severed hand is professionally cared for immediately after the accident.This procedure is carried out of if the hand can function without pain and the goal would be to give the patient back as much function as possible.
2. Amputation if the tissues are too damaged and the hand cannot be replanted. A cosmetic or prosthetic hand may be offered to improve the cosmetic appearance and function of the hand.
3. Hand transplantation if a hand replantation is not an option, surgeons can offer the patient a hand transplantation whereby a donor hand is transplanted onto the recipient's forearm. Am operation such as this requires a team of up to 20 surgeons who connect the arteries, veins, tensonds and bones. Immune suppresant drugs are used to prevent the rejection of the donor hand by the body.
All thre options above will require a highly skilled hand therapist to rehabilitate the injured person to ensure maximum return to function.
Now researchers are developing a robotic hand which has intricate motion capabilities. In additin, the researchers are planning to grow human tissue onto the robotic hand, which would mean that a person could be provided with and entirely NEW hand in the event of an accident. Researchers put the hand through a laser scanner and then 3D printed artificial bones to match. The hand can be operated remotely by wearing a glove covered in sensors.
For more information on this incredible scientific development, please click on the following link:
Allow me to introduce you to Bryce. Bryce is a wonderful family man and Electrician. He suffered a devastating injury which challenged him in many ways. His commitment to hand therapy and determination to regain full use of his hand meant that he achieved a result that far exceeded my expectations. He is a patient who has been the highlight of my career so far.
Bryce has requested that I tell his story with the hope that his experience may help someone else out there who has been in a similar situation and needs some inspiration or insight into what therapy may involve.
A year ago Bryce and his family were enjoying a fun day riding an off-road, open top 4 x 4 when the vehicle overturned. Bryce instinctively put out his left hand to protect himself but it was crushed between the the 4 x 4 and the gravel road, resulting in 6 hand fractures. Bryce panicked and withdrew his hand from underneath the bar causing a secondary degloving injury to the hand.He was rushed to Hospital where he spent 10 weeks having numerous operations to save his hand.
Fortunately Bryce was under the care of an excellent Plastic & Reconstructive Surgeon Dr Chetan Patel.
Dr Patel reconstructed the degloved left hand by performing a free tissue transfer using an antero-lateral thigh flap (ALT). The free tissue transfer provided cover for the exposed tendons, soft tissue and neuromuscular structures. An ALT permits more supple and pliable soft tissue cover when compared to skin grafts and makes it easier to perform secondary procedures such as tendon transfers and scar releases later on. A dermal substitute was used over the thumb area where no vital structures were exposed. Dermal substitutes provide a framework for blood vessels and dermal skin cells to remodel damaged skin, thereby facilitating adequate donor site recovery. A split skin graft was performed 21 days after the dermal substitute application.
When Bryce was referred to Hand Therapy 10 weeks after the injury, he had absolutely NO movement in his wrist, fingers or thumb. His wrist was fixed in a flexed position and had an85% functional impairment in his hand, including sensory loss due to nerve damage. His treatment plan was complicated by the fact that he lives 150 km from Hand Therapy Consulting. A round trip would take him 4 hours of travelling time in addition to therapy time. Bryce would need to attend hand therapy for at least a year in order to regain full hand function. He is the owner of a business and time away from work was an additional challenge.
Due to the geographical constraints I had to offer Bryce a treatment plan that would be both time and cost effective without compromising his treatment. In cases such as this a patient would have to attend therapy at least 3 times per week in order to make progress. We applied the Casting Motion to Mobilise Stiffness Technique as described by Judy Colditz OT/L, CHT, FAOTA . This technique uses plaster of paris to selectively immobilise mobile joints in an ideal position while constraining stiff joints so that they move in a desired direction.
Over 12 months, Bryce attended an average of 2 hand therapy appointments a month and achieved a full fist by 6 months. He currently has 35% functional impairment and has recently undergone an Opponens Plasty which will enable him to oppose his thumb to his middle finger and further improve his functional ability. His nerve function continues to improve.
I am extremely proud to present Bryce' results. We would not have been able to achieve this result with traditional therapy or without a patient who trusted the process. Well done Bryce!