Introduction
Phalangeal fractures are common, and due to tendinous or ligamentous attachments are often deformed and unstable. In particular, proximal phalanx fractures often present with volar angulation. Interossei inserting onto the base, and lumbricals into the overlying extensor expansion, flex the proximal fragment. Simultaneously both flexor and extensor tendons act to shorten and extend the distal fragment.1 The mechanism of injury causing these fractures usually involves a direct blow, rotational force or hyperextension of the phalanx2 and can be complicated by intra-articular extension proximally or distally. There is also a risk of dislocation of the metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joints due to avulsion or fracture involving the ligamentous attachments of these joints.
The balance between the early mobilisation afforded by operative intervention and minimally invasive techniques aiming to prevent soft tissue trauma or implant use is delicate, and not unique to any specific bone or joint. However, the use of one’s hands in day-to-day work, sport or leisure justifies an emphasis on return to function minimising long-term disability. Closed methods of reduction using the soft tissue envelope for fracture stabilisation, including traction splints, have been found to be effective in the treatment of proximal phalanx fractures.3
A skin traction method utilising rigid sports tape, elastic and hand-based thermoplastic splint termed ‘early active vector adjustable skin traction’ (EAVAST)4 is a non-operative technique that exploits ligamentotaxis to tension the soft tissue envelope surrounding a phalangeal fracture (Figure 1 and Figure 2).5 A case series of 54 finger phalange traction cases treated with EAVAST demonstrated excellent outcomes in 37 cases, good in 14 cases and poor outcomes in three.4 Furthermore, EAVAST is easy to apply, non-invasive and, crucially, allows early passive and active movement: preventing long-term stiffness. In addition to these positive outcomes for patients, this non-invasive method of treatment is predicted to be less costly to the healthcare system, taking place in an outpatient setting using the skills of highly trained hand therapists.
The aim of this study was to compare a series of patients who underwent traction using the EAVAST protocol for proximal phalanx fractures with a cohort of patients who underwent operative fixation with either K-wires or open reduction internal fixation (ORIF) by reporting short-term functional outcomes for both groups. Included were patients with proximal phalanx fractures of the hand who presented to a tertiary hand injury unit from 2018–2020. The null hypothesis was that there would be a difference in TAM score, Q-DASH score or strength per cent between the operative group in comparison to the EAVAST group.
Methods
Chart reviews of patients who presented to the plastic surgery outpatient department between January 2018 and January 2020 were conducted. Patients who had undergone traction, operative fixation or proximal phalanx fractures were selected. Initial treatment was non-randomised and decisions were implemented on a case-by-case basis, based on the type of fracture (simple versus comminuted) and the mechanism of injury (crush/blunt force trauma versus hyperextension/ fall onto outstretched hand). These patients were then assessed within three months post injury for strength, range of motion and overall function. Measurements were conducted by independent clinicians who did not participate in management and patients wore gloves to blind the assessor by concealing signs of intervention. The TAM score was measured on both the affected digit and the unaffected contralateral side, and expressed as a percentage. The Q-DASH self-reported questionnaire was conducted to assess symptoms and range of motion (ROM) at three months post-injury. The strength of the affected hand was also compared to the strength of the contralateral side and expressed as a percentage. Statistical analyses were conducted using the Mann–Whitney U test, due to lack of equal variance. The study aimed to assess strength, ROM and overall functional outcomes for a non-operative EAVAST cohort compared to operatively managed patients and to explore the potential alternative to operative management for proximal phalanx fractures.
Results
A total of 38 patients were identified for inclusion in the study, of whom 15 underwent operative fixation and 23 underwent traction alone (Table 1). Twenty-six patients presented with a proximal phalanx base fracture, eight with an oblique fracture, two with midshaft fractures and two with comminuted fractures.
The mean patient age was 35 years in the operative group compared to 48 years in the traction group (p = 0.07). Prevalence of diabetes was equal between both groups at 13 per cent (p = 0.56); however, the proportion of general comorbidities was higher at 61 per cent in the traction group compared to 27 per cent in the operative group (p = 0.04). There was a higher proportion of smokers in the operative group at 60 per cent compared with 26 per cent in the traction group (p < 0.001%).
The mean TAM per cent score for the traction group was 90.8 per cent compared to 90.7 per cent for the operative group (p = 0.97) (Figure 3). The mean strength per cent for the traction group was 84 per cent compared to 79 per cent for the operative group (p = 0.58) (Figure 4). One patient was found to have greater strength in the affected digit, hence an outlier of 127 per cent and therefore deemed plausible.
The average Q-DASH score for the traction group was 1.48 compared to 2.5 for the operative group, where a lower score indicates a better functional outcome (Figure 5). The mean difference of 1.02 suggests that a slightly poorer outcome in the operative group was not statistically significant (p = 0.54). Twenty-four of 28 traction patients and eight of 10 operative patients returned a Q-DASH score of zero, indicating a self-reported full return of pre-morbid function. The Mann-Whitney U test was used to determine statistical significance for this data set (Table 2).
Discussion
This study prospectively analysed outcomes from a cohort managed in two ways: operative and traction splinting (EAVAST). Traction splinting using the EAVAST protocol has already been shown to be a minimally invasive and effective technique for fixation of proximal phalanx fractures,4 but this is the first study to compare the technique to operative management. Furthermore, this small study suggests that EAVAST has equivalent outcomes to operative management for proximal phalanx fractures. In particular, proximal phalanx fractures that are simple and have not been caused by a crushing mechanism or blunt force trauma are more likely to be amenable to traction splinting with the EAVAST protocol than those that are comminuted. Avoiding operative management is time-and cost-effective and minimizes anaesthetic risk, thus EAVAST may emerge as first-line therapy for proximal phalanx fractures.
Of those patients treated with K-wire fixation, seven per cent were reported to have an infection, which resulted in additional treatment with oral antibiotics, early pin removal or reoperation related to a pin site infection.6 Additionally, the soft tissue surrounding the proximal phalanx is thin and fragile. Damage to flexor or extensor apparatus, postoperative infection or stiffness have to be considered if electing to manage a fracture surgically. The rate of distal interphalangeal joint stiffness following fixation immobilisation has been reported as high as 50 per cent.7 Extensor apparatus tethering causing stiffness is a recognised complication of both K-wires and ORIF, often requiring tenolysis in a second surgical procedure.8
The current EAVAST protocol is 3.5 weeks of traction but in certain cases has been effectively ceased at two weeks, or sometimes extended beyond when clinically indicated.5 During this time both passive and active exercises continue, maintaining action of flexor and extensor tendons, as well as keeping joints supple.
Total active motion per cent and strength testing are clinician-administered tests, but the Q-DASH is a patient-reported questionnaire assessing symptoms and functionality. The use of a site-specific patient reported-outcome measuring tool such as the Q-DASH improves the validity of this assessment of surgical and non-surgical interventions. Such tools are increasingly seen as a logical choice in surgical studies where conditions involve detriment of function or cosmesis.9
Although the results are encouraging for the implementation of the EAVAST protocol of traction splinting in proximal phalanx fractures, with comparable measurable outcomes and improved functional outcomes, this study is small in number. A cost–benefit analysis comparing operative fixation with traction splinting may be undertaken in the future to demonstrate additional financial benefits for the healthcare system. As the traction splint can be applied in an outpatient setting, there are additional benefits for patients including limiting time off work for one or more operations, reducing the risk of infection, adhesions and adverse consequences of a general anaesthetic. All of these areas should be further explored in a larger study to fully ascertain the true efficacy of traction splinting.
Limitations
Patients were not randomised and the sample size was small such that any benefit of one procedure over another may not have been detected due to underpowering. Nevertheless, it is our hypothesis that, for carefully selected patients, non-operative management of these fractures may confer an advantage over surgical intervention. The study having been done in a single centre, applicability to multiple centres is untested.
Strengths include independence and blinding of the assessor (with respect to the treatment undertaken as well as the actual digit involved). It is also a consecutive series in a single unit, hence homogeneity of procedures, in particular the EAVAST protocol.
Conclusion
Traction splinting is a non-operative method of fracture fixation that can be considered as an alternative for K-wires/ORIF in appropriate patients. Unlike operative fixation—which increases the risk of infection, adhesions and damage to surrounding structures—traction is easy to apply, non-invasive and allows early movement, preventing long-term stiffness. The results of this study support the further study of traction splinting for patients with proximal phalanx fractures preferably in a selected cohort of randomised patients across multiple centres specialised in the techniques described.
Acknowledgements
Thanks to Jason Fairclough for permission to reproduce figures 1 and 2.
Presented at the 12th Asian Pacific Federation of Societies for Surgery of the Hand, and the 8th Asian-Pacific Federation of Societies for Surgery of the Hand (APFSSH) triennial meeting, 2020.
Disclosure
The authors have no financial or commercial conflicts of interest to disclose.
Funding declaration
The authors received no financial support for the research, authorship, and/or publication of this article.
Revised: 2021 January 1; February 12 AEST