Treatment of extra-articular proximal and middle phalangeal fractures of the hand: a systematic review

Strategies in Trauma and Limb Reconstruction, Mar 2017

The aim of the study was to systematically review the patient reported and functional outcomes of treatment for extra-articular proximal or middle phalangeal fractures of the hand in order to determine the best treatment options. The review methodology was registered with PROSPERO. A systematic literature search was conducted in electronic bibliographic databases. Two independent reviewers performed screening and data extraction. The evaluation of quality of the included studies was performed using the Structured Effectiveness Quality Evaluation scale. The initial search yielded 2354 studies. The full text manuscripts of 79 studies were evaluated of which 16 studies met the inclusion criteria. In total, 513 extra-articular proximal and middle phalangeal fractures of the hand were included of which 118 (23%) were treated non-operatively, 188 (37%) were treated by closed reduction internal fixation (CRIF) and 207 (40%) by open reduction internal fixation. It can be recommended that closed displaced extra-articular phalangeal fractures can be treated non-operatively, even fractures with an oblique or complex pattern, provided that closed reduction is possible and maintained. Conservative treatment is preferably performed with a cast/brace allowing free mobilization of the wrist. No definite conclusion could be drawn upon whether closed reduction with extra-articular K-wire pinning or transarticular pinning is superior; however, it might be suggested that extra-articular K-wire pinning is favoured. When open reduction is necessary for oblique or spiral extra-articular fractures, lag screw fixation is preferable to plate and screw fixation. But, similar recovery and functional results are achieved with transversally inserted K-wires compared to lag screw fixation. Type of study/level of evidence: therapeutic III.

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Treatment of extra-articular proximal and middle phalangeal fractures of the hand: a systematic review

Treatment of extra-articular proximal and middle phalangeal fractures of the hand: a systematic review D. Verver 0 1 2 L. Timmermans 0 1 2 R. A. Klaassen 0 1 2 C. H. van der Vlies 0 1 2 D. I. Vos 0 1 2 N. W. L. Schep 0 1 2 0 Department of Surgery, Maasstad Hospital , P.O. Box 9100, 3007 AC Rotterdam , The Netherlands 1 Department of Surgery, Erasmus Medical Center , P.O. Box 2040, 3000 CA Rotterdam , The Netherlands 2 Department of Surgery, Amphia Hospital , P.O. Box 90157, 4800 RL Breda , The Netherlands The aim of the study was to systematically review the patient reported and functional outcomes of treatment for extra-articular proximal or middle phalangeal fractures of the hand in order to determine the best treatment options. The review methodology was registered with PROSPERO. A systematic literature search was conducted in electronic bibliographic databases. Two independent reviewers performed screening and data extraction. The evaluation of quality of the included studies was performed using the Structured Effectiveness Quality Evaluation scale. The initial search yielded 2354 studies. The full text manuscripts of 79 studies were evaluated of which 16 studies met the inclusion criteria. In total, 513 extra-articular proximal and middle phalangeal fractures of the hand were included of which 118 (23%) were treated non-operatively, 188 (37%) were treated by closed reduction internal fixation (CRIF) and 207 (40%) by open reduction internal fixation. It can be recommended that closed displaced extra-articular phalangeal fractures can be treated non-operatively, even fractures with an oblique or complex pattern, provided that closed reduction is possible and maintained. Conservative treatment is preferably performed with a cast/brace allowing free mobilization of the wrist. No definite conclusion could be drawn upon whether closed reduction with extra-articular K-wire pinning or transarticular pinning is superior; however, it might be suggested that extra-articular K-wire pinning is favoured. When open reduction is necessary for oblique or spiral extra-articular fractures, lag screw fixation is preferable to plate and screw fixation. But, similar recovery and functional results are achieved with transversally inserted K-wires compared to lag screw fixation. Type of study/level of evidence: therapeutic III. Extra-articular phalangeal fractures; Fracture treatment; ORIF; Systematic review - Introduction Methods Eligibility criteria Outcome measures Data extraction Statistical analysis Results Study selection Fig. 1 Flow chart Quality assessment Treatment O V V L I I T C K I N ) ) ) 5 9 2 3 2 2 5 ( 0 ( 2 ( 3 2 2 t t s r r . e o . o ro ir o h t e .rso cho tr o e s e c R P R ] n n 3 tta tta [1 a ] a ] r a l-Q [24 l-Q [21 ¸s a feo laecg irse p r w y e % n 0 r 0 tte eu (1 ap ilq rse trceu gob lra senv a n i a r o p r F L S T l l a a a ir ir t t m s s u u u ra d d n n T I I b 1 1 P P P ) .t ) ) c 5 8 a rfa 5 (1 8 (7 N ( 1 7 t tu n se . ro s ig .s ir o h ed se ro se tre co fi D P R i t n e d s I e n n le2 rcen ttaa ] ttaa ] b f l-Q [23 l-Q [20 e a e T R A A e % rs 8 ) ev (2 7% ) eu ltrssaaan rrsseeanv il(equ1b lir(a6p% rrsseeanv tlirobqoh B T O S T S ) % ) e 3 % 5 % rs (1 ) (4 n % ) r 9 ) tte (3 % 2% a 9 2 p se (3 ( re re e ex tu sv qu lp . c n li ra ra b om .D F T O C N V I I I V I V V I I ;s r e o c r s ie so t en p n in t b e l x 2 la la t p e ,) v s ex s J o r P m a g e n i IP re lm andb labvo ra t a ,rfee ir-ew ;saep seek ltrae rem /sepo seek JP K ice 4w la ,s w w y C ,s p l n a h 3 M ek 3 av io d c T M D T R H D a b c d s N,tn itten isev i a n jo p te c l g x ffi ts ea in re . trad icedn lagn lcdu ryo .D ao ac ah ex ju N R po re in rp tf n a a o 0% 0% ac is nd 01 tem lsay ttee ino ,1 2P 1 JP ann ()2P lep tsnu P P C i m o M s le o c )3 )0 ,tin treu idd tcu ,ing 23 (2 10 (1 ljo frca rom itoh iran ae d ) w ts g n 1 :s , .treo irssee .treo irssee laahpn tisean l(aPm trcaeu llifagn R R re ta ix rf : ]82 itlan igpn :rop enpo tilcyo an [sa tisd ian laxn Ie ev ilv ]7 m J em ah py ow eh [2 ho IP R P T L Discussion Outcomes CRIF Outcomes ORIF Outcomes CRIF versus ORIF CRIF with transarticular or extra-articular inserted K-wires % : 0 5 ) : 0 7 % ) : 5 % ) ([) 7 0 % ten 47% (50– ) 5–5 25 ll ( % (2 (\ d 6 r cex 17 oo (2 ir o a o E G F P 6 D 8 S C A 2 B 4 P 6 A 5% 14 .2 * , : . . 3 5 A th 2 0 3 .0 T , M SH = ip .6 .6 B s r 8 4 R ay A A P g f ± ± T d T D ,8 T o s M ) D D e A D S S ( ( , . 5 D sv . e 81 ,)5 5 S s .D and lau :JA –10 :JA ,)5N eek eN .03 ian vP P 5 IP 9 w lu = p , I 2 – P ( . D (0 3 av P on SD n Limitations Table 4 Pooled results Treatment CRIF ORIF Total N 117 Non-union Poor TAM (\180 ) Good TAM ([240 ) Infection 2.1% (2/94) 14.8% (12/81) 13.1% (19/145) 10.3% (33/320) 52.1% (49/94) 28.8% (15/52) 44.0% (51/116) 43.7% (115/263) N.A. 4.1% (6/146) 2.9% (5/175) 3.4% (11/321) Failurea 3.4% (4/117) 3.2% (6/186) 3.5% (7/198) 3.4% (17/501) 3.4% (4/117) 7.5% (14/186) 12.1% (24/198) 8.4% (42/501) Table 5 Most important conclusions Conclusions CRIF LOE level of evidence Recommendations Compliance with ethical standards Informed consent For this type of study formal consent is not required. 1. Karl JW , Olson PR , Rosenwasser MP ( 2015 ) The epidemiology of upper extremity fractures in the United States 2009 . J Orthop Trauma 29 ( 8 ): e242 - e244 . doi:10.1097/bot.0000000000000312 2. Onselen EBHV , Karim RB , Hage JJ ( 2003 ) Prevalence and distribution of hand fractures . J Hand Surg Eur 28 : 491 - 495 3. 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D. Verver, L. Timmermans, R. A. Klaassen, C. H. van der Vlies, D. I. Vos, N. W. L. Schep. Treatment of extra-articular proximal and middle phalangeal fractures of the hand: a systematic review, Strategies in Trauma and Limb Reconstruction, 2017, 63-76, DOI: 10.1007/s11751-017-0279-5