RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS: / DR. JASWINDER SINGH,
P.G. IN ORTHOPAEDICS,
J.S.S. HOSPITAL, RAMANUJA ROAD, MYSORE.
2. / NAME OF THE INSTITUTION: :
/ J.S.S. MEDICAL COLLEGE, MYSORE
3. / COURSE OF STUDY AND SUBJECT : / M.S. IN ORTHOPAEDICS
4. / DATE OF ADMISSION TO COURSE: / 31-05-2007
5. / TITLE OF THE TOPIC: / A STUDY OF MANAGEMENT OF CLOSED PROXIMAL PHALANGEAL FRACTURES OF HAND
6. / BRIEF RESUME OF THE INTENDED WORK ;
6.1 Need for the study:
Fractures of the metacarpals and phalanges are the most common fractures of the upper extremity, and in a series of 11,000 fractures, Emmett and Breck noted that these fractures accounted for 10% of the total1.
The proximal phalanges of fingers are fractured much more frequently than the middle or even distal phalanges. These fractures may result from either direct or indirect trauma; they may be simple or compound but generally are comminuted. Although there may be little or no displacement, deformity with considerable displacement is typical when proximal phalanx is fractured2. It is the most commonly fractured hand bone in children, especially the base, due to high incidence of Salter-Harris type 2 injuries.
The outer rays of the hand (thumb and 5th finger) are most frequently injured. Unfortunately, phalangeal fractures are often neglected or regarded as trivial hand injuries. Swanson aptly stated: “Hand fractures can be complicated by deformity from no treatment, stiffness from over treatment, and both deformity and stiffness from poor treatment1.
The closed treatment of fractures of hand has gained a poor reputation because of problems of malunion, stiffness, and sometimes loss of skin or other soft tissues. Further more, modern techniques and material for internal fixation have become incredibly sophisticated and are far superior to previously used Kirchner wire fixation. It is no wonder that with such equipments and our desire to fix things, more and more fractures of the hand are being treated by internal fixation.
6.2 Review of literature:
The incidence of metacarpal and phalangeal fractures peaks between 10 and 40 years, a time when athletic and industrial exposure is the greatest. Until the early part of 20th century, these fractures were all managed nonoperatively. Infact the entire history of operative fixation is limited to the 20th century and was pioneered by Albine Lambotte. Even today, the majority or these fractures can be successfully managed by non operative techniques. Most fractures are functionally stable either before or after closed reduction and will fare well with protective splintage and early mobilization. Certain fractures require operative fixation. Selection of the optimum treatment depends on a number of factors including fracture location (intraarticular Vs extraarticular), fracture geometry (transverse, spiral or oblique, comminuted), deformity (angular, rotational, shortening), open or closed, associated osseous and soft tissue injuries and fracture stability. Regardless of the treatment modality, the goal is full and rapid restoration of function1.
Review of the literature reflects a conservative attitude towards treatment of phalangeal fractures in children. In the largest described series of phalangeal fractures over a period of 9 years by Leonard and Dubravcik on management of fractured fingers in the child, 263 fractures (0.45%) of listed diagnosis of a phalanx occurred in children, of which 141 involved proximal phalanx. 75% of these finger fractures were treated by external immobilization, 15% by manipulation and external immobilization and 10% were operated upon3.
Closed treatment of unstable phalangeal fractures often results in poor outcome. James noted that 77% of fingers lost active range of movements at proximal interphalangeal joint and results in these cases were judged unsatisfactorily4.
In 1960, 529 patients with phalangeal fractures were reviewed by Wright. He made a distinction between unstable injuries which must be immobilized and stable fractures in which early movement gave better long term results and concluded that hand must be mobilized early if normal function is to be regained, but if immobilization is required then it must be in correct position5.
Kirchner wire, whether crossed, parallel, or, intramedullary, remain the standard by which other methods of management are judged. External fixators can be assembled from manufactured “minifixators” or improvised constructs of K-pins and polymethylmethacrylate. Several investigators report rigid fixation with the use of microscrews and bolts, screws and plates, and screws alone, while similarly secure fixation is claimed with the technique of intraosseous wiring. Even the use of “bone glue” has been reported for small, displaced fractures6.
Lister reported recovery of digital motion averaging 199 degrees or 80% of normal joint mobility, with uncomplicated fracture healing occurring over a mean period of 7.25 weeks, employing a combination of a circlage wire and 0.035inch Kirchner wire for 44 phalangeal fractures. Belsole’s experience using tension-band wires has been similarly favourable7.
In a prospective study in 1991 by Pun et al. 52 traumatic unstable fractures of proximal or middle phalanges of hand in 47 patients were fixed with A.O. miniature screws and plates. The overall results were not satisfactory and complications were frequent, with only 26.9% patients with good results8.
Ouellette et al. reviewed 53 consecutive patients in whom 63 fractures (42 metacarpal and 27 phalangeal) had been treated with 1.5mm or 2mm minicondylar plates. 67 complications were associated with 40 fractures in 29 patients: primarily symptomatic plates or pullout, extensor lag, and infection 9.
6.3 Objectives of the study:
To evaluate fracture characteristics, mechanism of injury, treatment options and functional outcomes of the patients who underwent treatment for closed proximal phalangeal fractures of hand.
7. / MATERIALS AND METHODS;
7.1 Source of data:
The study will include all the cases of closed proximal phalangeal fractures (intraarticular and extraarticular) that will present to J.S.S. Hospital, Mysore and managed by conservative or surgical methods, during a period from November 2007 to June 2009.
7.2 Methods of collection of data:
Statistical analysis: Univariate analysis of the data will be worked out to present the mechanism of injury and fracture characteristics.
In case of quantitative variables, mean and standard deviation will be calculated to present the degrees of movements of different joints of fingers. Cross-tabulation will be done to show the treatment options and functional outcomes for different fracture categories. Chi square tests will be applied to find out the association between various combinations of fracture characteristics, treatment options, and functional outcomes. The tests will be carried out at 5% level of significance.
Inclusion criteria:
All cases of closed fractures proximal phalanges of hand (intraarticular and extraarticular) of any age, treated by conservative or surgical method at J.S.S Hospital are included in the study.
Exclusion criteria:
All cases of open fractures of proximal phalanges of hand.
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? if so, please describe briefly:
Yes, basic Hematological investigations and X ray of the injured hand are needed.
7.4 Has Ethical clearance been obtained from your institution in case of 7.3:
Yes, obtained from ethical committee J.S.S. Medical College, Mysore – Copy enclosed.
8. / LIST OF REFERENCES:
1. Peter J Stern. Editors Green David P MD, Hotchkiss Robert N MD, Pederson William C MD. Fractures of Metacarpals and Phalanges. Green’s Operative Hand Surgery, Textbook of Orthopaedics, 4th Edition, Churchill Livingstone, 1998; Volume 1: 711-57.
2. Donald R Pratt MD. Exposing Fractures of the Proximal Phalanx of the Finger Longitudinally Through the Dorsal Extensor Apparatus. Clinical Orthopaedics. 1956; Volume 15:22-26.
3. Leonard Morton H MD, Dubravcik Paul MD. Management of Fractured Fingers in the Child. Clinical Orthopaedics and Related Research. 1970; Volume 73: 160-68.
4. Lins Robert E MD, Myers Barry S MD, Spinner Robert J MD, et al. A Comparative Mechanical Analysis of Plate Fixation In a Proximal Phalangeal Fracture Model. The Journal of Hand Surgery. 1996; Volume 21A(6): 1059-64.
5. N J Barton. Fractures of the Hand. The Journal of Bone and Joint Surgery. 1984; Volume 66 B(2):159-67.
6. Greene Thomas L MD, Noellert Raymond C MD, Belsole Robert J MD, et al. Composite Wiring of Metacarpal and Phalangeal Fractures. The Journal of Hand Surgery. 1989; Volume 14A(4):665-69.
7. Charles P Melone MD. Rigid Fixation of Phalangeal and Metacarpal Fractures. Orthopaedics Clinics of North America. 1986; Volume 17:421-35.
8. Pun W K, Chow S P, Luk K D K, et al. Unstable Phalangeal Fractures Treatment by A.O. screw and Plate Fixation. The Journal of Hand Surgery. 1991; Volume 16A:113-17.
9. Ouellette E Anne MD, Freeland Alan E MD. Use of the Minicondylar Plate in Metacarpal and Phalangeal Fractures. Clinical Orthopaedics and Related Research, Lippincott-Raven Publishers. 1996; Volume 327:38-46.
9. / SIGNATURE OF THE CANDIDATE:
10. / REMARKS OF THE GUIDE: / This is a bonafide study of proximal phalangeal fractures of the hand done under my guidance.
11. / NAME AND DESIGNATION OF :
11.1 Guide : / DR. MRUTHYUNJAYA, D. ORTHO, DNB (ORTHO), M.S.(ORTHO),
ASSOCIATE PROFESSOR , DEPARTMENT OF ORTHOPAEDICS,
J.S.S. MEDICAL COLLEGE AND HOSPITAL, MYSORE.
11.2 Signature:
11.3 Co-guide(If any): /
NIL
11.4 Signature: /
NIL
11.5 Head of Department: / DR. RAVISHANKAR R. ,
M.S. (ORTHO),
PROFESSOR AND HEAD, DEPARTMENT OF ORTHOPAEDICS, J.S.S. MEDICAL COLLEGE AND HOSPITAL, MYSORE.
11.6 Signature:
12. / 12.1 Remarks of the Chairman and Principal:
12.2 Signature :