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Use of Static Distraction External Fixation for Pediatric, Unstable Comminuted Middle Phalanx Pilon Fracture
Ramon DeJesus, MD1; Christopher Forthman, MD2; Rachel Pigott, OT, CHT, OT1
1Upper Chesapeake/Union Memorial Hospital, Bel Air; 2Hand Surgery, Union Memorial Hospital, Lutherville

Introduction
A pilon fracture of the proximal interphalangeal (PIP) joint is an uncommon intraarticular fracture resulting in comminution, central depression and splay, sagittaly and coronally of the base of the middle phalanx. Unstable Pilon fractures remain a difficult management problem , often leading to stiffness, deformity, limited range of motion(ROM), recurrent instability and residual pain.

Methods
Thirteen year old, suffered a severe pilon fracture of the base of the middle phalanx of the ring digit. A static distraction external fixation device was utilized. At 5 days postoperatively a thermoplast protective splint was fabricated and AROM for the uninvolved digits was initiated. At 6.5 weeks the external fixator was removed and AROM to the affected digit was initiated. At 8 weeks, he was advanced to PROM. At 9 weeks a static progressive splint was fabricated and at 10 weeks postoperatively strengthening was initiated.

Results
The patient was discharged from therapy at 12 weeks with full range of motion and strength. Clinical and Radiographical measurements at 4 years postoperative demonstrate a similar distance between the fractured middle phalanx of the ring digit when compared with the contralateral ring middle phalanx.

Conclusion
Comminuted intra-articular fractures involving the PIP joint are commonly known to present a therapeutic dilemma, often with less than ideal results for either maintenance of range of motion or preservation of articular symmetry, and leading to arthritis. Controversy exists over the optimal methods to employ to achieve these goals. Dynamic traction is the most commonly utilized method and it certainly makes the most physiological sence maintaing traction while preserving motion at one of the joints most difficult to treat when stiffness sets in. Applying the concepts of ligamentotaxis through traction and combining it with early motion affords the best opportunity for reestablishment of motion.

We are proponents of dynamic traction but in this particular case the severity of the comminution , depression and retraction was so severe that amount of traction force necessary to distract the fracture elements to its anatomical length was not going to be enough using one of the existing methods of dynamic distraction. The pediatric population can tolerate a longer period of PIP immobilization in this case the immobilization was 44 days. We propose that the larger distraction force may have played a role in the patient regaining full ROM by stretching the anatomical elements at the joint that can lead to stiffness and making them more lax.


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