THE PINS AND RUBBERS TRACTION SYSTEM FOR

TREATMENT OF COMMINUTED INTRAARTICULAR

FRACTURES AND FRACTURE-DISLOCATIONS IN THE HAND

Y. SUZUKI, T. MATSUNAGA, S. SAT0 and T. YOKOI

From the Departments of Orthopaedic Surgery, Gifu Prefectural Gifu Hospital, and Gifu University School of Medicine,
Gzjii City, Japan

The authors have developed a new skeletal traction system for cornminuted intraarticular fractures
and fracture-dislocations in the hand. The system consists of two or three Kirschner wires and
rubber bands, and is easy to assemble. It is more compact and comfortable than the banjo splint,
and equally effective, and it allows early motion of the affected digits.
A description of the technique is followed by the clinical results of seven cases of severe articular
injuries in the hand. At the time of follow-up, the average range of the affected PIP joint motion
was about SO”. The final active motion of the injured DIP joint ranged from 0 to 40” in flexion
and that of the affected thumb (trapezia1 fracture) was not limited. The average follow-up period
was 13.1 months.
Journal of Hand Surgery (British and European Volume, 1994) 19B: 98-107

Distal traction for displaced phalangeal fractures or the phalanx, but they must be proximal and distal to
dislocations can be used to reposition the fragments, the fracture (Fig 2).
and various traction systems have been reported. The This system is most stable when the rubber bands
banjo frame is effective, but bulky and uncomfortable reach maximum contraction and the axial traction pin
to wear. A new skeletal traction system is described, and rubber bands come in line (Fig 3a). Mobility of the
consisting of two or three Kirschner wires and rubber distracted joint changes according to the insertion point
bands. It is called the “pins and rubbers traction system” of the axial traction pin. When the axial traction pin is
(P&R traction system). It is compact and easy to apply. inserted at the centre of motion of the affected joint,
active range of motion will be maintained completely
with no consideration of the extensor apparatus
METHODS (Fig 3b). In practice, a Kirschner wire inserted trans-
versely into the middle or proximal phalanx perforates
Operative technique the extensor apparatus or interferes in its excursion
A long Kirschner wire (1.2 mm in diameter) is inserted (Quigley and Urist, 1947) so the range of motion is
transversely through the injured or adjoining phalanx limited to some extent (Fig 6). When the axial traction
pin is inserted far from the centre of motion of the joint,
proximal to the injury. On both sides of the finger, the
wire is bent 90” near the skin in the direction of the the traction force keeps the joint in extension, and
fingertip. Each end of the wire must be long enough to permits only a small range of active flexion (Fig 3~).
reach about 3 cm distal to the fingertip, and is bent as
a hook. This is the “axial traction pin” (Fig la). Modification of this system
A second Kirschner wire (1 mm in diameter) is For the treatment of fracture-dislocations of the proxi-
inserted transversely through the injured or adjoining mal interphalangeal joint, a third Kirschner wire named
phalanx distal to the injury. Each end of the second the “reduction pin” is inserted at the base of dorsally
Kirschner wire is also bent in shape of a hook just displaced middle phalanx in addition to the original
external to the skin. The second wire is called the “hook traction system (Fig 4). In this modified system, three
pin” (Fig lb). Kirschner wires are drilled through the phalanges in the
Rubber bands are now applied between the hooks of same places as those for pins of the three dimensional
these wires on both sides of the finger (Fig lc), and the traction system recommended by Robertson et al (1946).
reduction is checked radiographically. If it is unsatisfac- When the rubber bands are applied to this system,
tory, rubber bands are added or removed to control the the axial traction pin suppresses the reduction pin to
traction force. The traction force acting on the injured reduce the displaced fragment. This system converts the
portion can be controlled by the length and number of contraction force of the rubber bands into an axial
the rubber bands. traction force and a palmar compression force to the
displaced fragment. The distribution of these forces can
be varied by bending the axial traction pin. When the
Sites for pins and range of movement of the joint
axial traction pin is bent dorsally, the palmar com-
The points of insertion of the two wires (axial traction pression force increases, and when it is bent toward the
pin and hook pin) vary according to the injured part of palm, the palmar compression force decreases (Fig 5).

98
PiNS AND RUBBERS TRACTIOK

Fig 1 The operative technique. (a) Axial traction pin. (b) Hook pin. (c) Rubber bands. Pins need not be inserted perpendicular to the axis of
the finger precisely, nor be completely symmetrical. The direction of traction can be controlled by bending the axial traction pin, and
the traction force also can be balanced by the size and number of rubber bands.

When the axial traction pin is inserted through the weeks. The traction device is removed after 4 to 6 weeks
centre of motion of the PIP joint, this modified system when radiographic confirmation of union is obtained.
also allows early active motion of the PIP joint to some Even if the rubber bands break on one side, those on
extent (Fig 6). the other side should remain intact and will retain the
traction force.
Post-operative care
MATERIAL
A small amount of dressing around the insertions of the
Kirschner wires is used, avoiding any disturbance of the Two cases of comminuted intraarticular fracture (burst
active range of motion. Active motion of the affected fracture at the phalangeal base; one DIP joint and one
finger is allowed immediately after the operation if pain PIP joint) and a case of comminuted fracture of the
in the wound is tolerable. trapezium were treated with the original P&R traction
AP and lateral X-rays are obtained after 1 and 2 system. Four cases of fracture-dislocation of the PIP
100 THE JOURNAL OF HAND SURGERY VOL. 19B No. 1 FEBRUARY 1994

joint were treated with the modified system. In one

aqe patient (Case 7) open reduction and internal fixation
through a palmar approach was performed with this
device on to make the injured joint stable throughout
the operation and to facilitate the reduction and fixation
of the palmar fragment (Fig 7).
The patients ranged in age from 16 to 61 years at the
time of the injury (Table 1).

RESULTS

The interval between the injury and the time of operation

ranged from 1 to 33 days (average 10 days). After the
operation the system was kept on for 4.8 weeks on
average, excluding the case of trapezia1 fracture. The
average follow-up period was 13.1 months (range: 5 to
20 months).
In the cornminuted intra-articular fractures, the final
active motion of the injured DIP joint (Case 1) was
from 0 to 40” of flexion and that of the injured PIP
Fig 2 Examples of site for pins. .:::::: injured part of a phalanx,
(a) distal (b) midshaft (c) proximal. 0: axial traction pin. joint (Case 2) was from 15 to 75” of flexion. In the
0: hook pin. trapezia1 fracture (Case 3), the motion of the affected

Fig 3 (a) The axial traction pin is inserted at the centre of motion of the joint. The contraction force of the rubber bands induces the axial
traction pin and rubber bands to form a straight line. In the position of flexion (shaded), the axial traction pin must flex to the same
angle as the finger, or the finger must be in extension. (b) The length of rubber bands “L” is the same in every position. If it were not
for the extensor apparatus, active range of motion would be maintained completely in this form of P&R traction system. (c) The axial
traction pin is inserted far from the centre of motion of the joint. The more the joint flexes, the longer the rubber band becomes.
Therefore the distracted joint will be kept in extension by the rubber bands.
PINS AND RUBBERS TRACTION

Fig 4 Modified system; one more Kirschner wire (reduction pin) is

added to the original traction system. (a) Reduction pin (*)
should be inserted at the base of middle phalanx in order to
be suppressed by the axial traction pin. (b) When rubber
bands are attached between the hooks of the axial traction
pin and the hook pin, the dorsally displaced middle phalanx
is reduced by the axial traction pin through the reduction
pin (-1).

b Fig 6 Early active motion of the affected joint with the modified
P&R traction system. (a) Extension (b) Flexion.

the age of the patient. In follow-up of these patients,

only one patient with a fracture-dislocation of the PIP
joint of her right index finger complained of pain in the
injured joint when overused (Table 1).

CASE REPORTS
C

Case f
Fig 5 Force distribution of the modified system. (a) Basic form; the A 52-year-old man sustained a comminuted fracture at
axial traction pin is straight. The contraction force of the
rubber bands (-) can be divided into the distraction force
the base of distal phalanx with central dislocation of
and the palmar compression force (= = b). (b) Dorsal bend- the DIP joint of his left ring finger in a traffic accident.
ing of the axial traction pin may strengthen the palmar He was seen 8 days after the injury (Fig ga). At his out-
compression force and weaken the distraction force. patient first visit, the P&R traction system was attached.
(c) Bending the axial traction pin towards the palm reduces X-ray 1 week after the operation showed persistent
the palmar compression force.
dislocation of the affected joint (Fig 8b). The traction
force was increased by adding rubber bands, and the
thumb was not limited at the time of follow-up. In four displaced fragments were reduced (Fig 8~). He wore
cases of fracture-dislocation of the PIP joint (Case 4, 5, this system for 5 weeks. As he refused to receive regular
6 and 7), the average range of active post-operative out-patient treatment, the hand therapy program was
motion in the PIP joints was 80”. The recovery of joint not completed.
motion was influenced by the severity of the injury and At the time of follow-up of 14 months after injury,
 THE JOURNAL OF HAND SURGERYVOL. 19BNo. 1 FEBRUARY 1994

Case 4

A 4%year-old woman fell and sustained a fracture-

dislocation of the PIP joint of her left index finger
(Fig 1Oa). The finger was swollen, and active motion
was markedly restricted because of severe pain in the
PIP joint. 3 days after the injury, the patient underwent
closed reduction and percutaneous pinning to maintain
the base of middle phalanx in a reduced position (K-
wire extension block method; Sugawa et al, 1979).
The palmar fragment of the middle phalanx showed
slight rotational displacement with palmar and distal
migration (Fig lob), so the modified P&R traction
system was applied 7 days after the injury (Fig 10~).
Rotational displacement of the palmar fragment of the
middle phalanx still remained, but congruity of the PIP
joint was restored (Fig 1Od and e). Active motion was
permitted immediately after the operation. The system
was removed 6 weeks after the second operation. 18
months after the injury, X-ray showed complete consoli-
dation of the palmar fragment and good congruity of
the PIP joint (Fig 1Of). Active motion of the PIP joint
was from 10 to 95” with no pain and no limitation
of ADL.

DISCUSSION
Distal traction for displaced comminuted phalangeal
Fig 7 The P&R traction system was applied at the time of open
fractures is resisted by tension in the surrounding struc-
reduction and internal fixation for a fracture-dislocation of
the PIP joint. The fragment was reduced and fixed with tures, therefore various traction techniques for the treat-
K-wires, and was covered with the flexor tendon sheath ment of displaced comminuted intraarticular phalangeal
(Case 7). fractures have been reported (Fowler, 1931; Haggart,
1934; Robertson et al, 1946; Quigley and Urist, 1947;
Moberg, 1950; Schenck, 1986). These methods are com-
plex to apply, and are inconvenient because of a bulky
an X-ray showed good congruity of the injured DIP
joint (Fig Sd). Active motion of the injured joint was short arm cast and a large wire frame for traction.
from 0 to 40” without pain. Recently, light and simple systems applicable to the
digit itself have been reported. The force couple splint
(Agee, 1978;1987) and the dynamic external finger fix-
Case 3 ator (Inanami et al, 1993) are compact systems designed
A 17-year-old student presented 2 days after a traffic for unstable fracture dislocations of the PIP joint. These
accident with a compression fracture of the right tra- are very simple and effective, but are only applicable to
pezium. The height of the trapezium was remarkably that injury. The P&R traction system is applicable not
reduced (Fig 9a). The P&R traction system was applied, only to phalangeal injuries but also to carpal injuries.
with the axial traction pin through the distal radius and The “S” Quattro (Fahmy, 1990) is designed for all
the hook pin in the neck of the first metacarpal. The types of displaced fracture-dislocations of the digits, and
height of the trapezium was restored after the application allows a considerable range of active movement of the
of this system (Figs 9b and c). He was able to use his injured joint, but it does not apply continuous elastic
thumb for light tasks with the system in place. It was traction.
removed 2 months later, and the range of motion of his The P&R traction system has three advantages. It is
right thumb returned to within normal limits soon simple and requires only two widely available compo-
afterwards. nents, Kirschner wires and rubber bands. Secondly, the
After 1 year, X-ray showed an obvious central Kirschner wires are small in diameter, so the injured
depression deformity of the distal joint surface of the part is not hidden in X-ray studies. Using fluoroscopy,
trapezium (Fig 9d), but there was no limitation of the percutaneous and intramedullary reduction to the
function of his right thumb (Figs 9e and f). intraarticular fragments, reported by Hintringer and
Table l-Data of the patients

Typeof Case no. Age (years) Site of Cuuse of Days from i@ry Treatment Duration of Duration of Final ROM (degrees) Pain*
injury /Sex itzjury injury to operation traction ,fbllow-up Ext. /Flex. *
System used ORIF

Comminuted 1 52/M L-Ring Bicycle 8 Original 5 weeks 14 months o/40 None

intraarticular (DIP)
fracture 2 51/M R-Little Softball 12 Original 4 weeks 12 months - 15175 None
(PIP)
3 17/M R-Trapezium Motorcycle 2 Original 2 months 11 months Full range None

Fracture- 4 48/F L-Index Fall 8 Modified 6 weeks 18 months ~-lo/95 None

dislocation of
the PIP joint 5 17/P R-Index Softball 6 Modified 4 weeks 20 months ~ 5195 Sometimes

6 16/M R-Ring Baseball I Modified 4 weeks 12 months -- 10/95 None

7 61/M R-Middle Softball 33 Modified 6 weeks 5 months - 15185 None

*in the affected pint

 THE JOURNAL OF HAND SURGERY VOL. 19B No. 1 FEBRUARY 1994

Fig 8 X-rays of a 52-year-old man who sustained a comminuted fracture at the base of distal phalanx with central dislocation of the DIP joint
to his left ring finger. (a) At the first visit. (b) Dislocation of the DIP joint had remained 1 week after surgery. (c) 2 weeks after surgery.
(d) Good congruity of the injured DIP joint was shown 14 months after surgery.

Ender (1986), or percutaneous pinning can be done extensor apparatus to some extent (Quigley and Urist,
easily with this system in place. Finally, this system 1947), and the active range of motion of the joint
allows early active motion of the injured digit. distracted by this system is limited to about 40”.
Transversely inserted wires interfere with the gliding of However, even this small range of motion may stimulate
‘Ii’3 AND RUBBERS TRACTION

Fig 9 A compression fracture of the right trapezium of a 17-year-old student (case 3). (a) At first visit, the height of the trapezium was
remarkably reduced. (b, c) The height and the shape of the trapezium was regained immediately after the operation. (d. e and f) At 12
months follow-up, consolidation of the trapezium was shown. Although congruity of the CM joint was not so good, active motion of
the affected right thumb was not limited.
106 THE JOURNAL OF HAND SURGERY VOL. 19B No. 1 FEBRUARY 1994

Fig 10 A fracture-dislocation of the PIP joint in the left index finger of 4%year-old woman. (a) At the first visit. (b) Immediately after the first
operation, 3 days after injury. A Kirschner wire was inserted into the head of the proximal phalanx to maintain the PIP joint in Aexion
(K-wire extension block method). The palmar fragment of the middle phalanx was rotated to the palmar side and migrated distally.
(c) Immediately after the application of the modified P&R traction system. 1 week (d) and 6 weeks (e) after the operation, rotation of
the palmar fragment remained. (f) 18 months after the operation, congruity of the PIP joint was good.

the nutrition and remodelling of the joint surface and intra-operative usage of this system in open reduction,
may prevent intraarticular adhesions and capsuloliga- we think it will also be useful in open reduction of
mentous contracture of the joint. intraarticular fractures and fracture-dislocations.
In one case of open reduction of PIP joint fracture- In conclusion, the P&R traction system is more com-
dislocation, we used this system intra-operatively and pact and comfortable than the banjo splint, and as
post-operatively. From this very limited experience of effective. The system allows early motion of the affected
PINS AND RUBBERS TRACTION i07

INANAMI, H., NINOMIYA, S., OKUTSU, l., TARUI, T. and

digit. For comminuted fractures or fracture-dislocations FUJIWARA, N. (1993). Dynamic external finger fixator for fracture dislo-
in the hand and digit, which are difficult to treat by cation of the proximal interphalangeal joint. Journal of Hand Surgery, 18A:
open reduction and internal fixation or percutaneous 1: 160-164.
MOBERG, E. (1950). The use of traction treatment for fractures of phalanges
pinning, this system is effective in applying capsuloli- and metacarpals. Acta Chirurgica Scandinavica, 99: 34 l-352.
gamentotaxis. QUIGLEY, T. B. and URIST, M. R. (1947). Interphalangeal joints. A method
of digital skeletal traction which permits active motion. American Journal
References of Surgery, 73: 175-183.
AGEE, J. M. (1978). Unstable fracture dislocations of the proximal interphalan- ROBERTSON, R. C., CAWLEY, J. J. and FARIS, A. M. (1946). Treatment
geal joint of the fingers: A preliminary report of a new treatment technique. of fracture-dislocation of the ixterphalangeal joints of the hand. Journal of
Journal of Hand Surgen/, 3: 4: 386-389. Bone and Joint Surgery, 28: 1: 68-70.
AGEE, J. M. (1987). Unstable fracture dislocations of the proximal interphalan- SCHENCK, R. R. (1986). Dynamic traction and early passive movement for
geal joint: Treatment with the force couple splint. Clinical Orthopaedics and fractnres of the proximal interphalangeal joint. Journal of Hand Surgery,
Related Research. 214: 101-112. 11A: 6: 850-858.
FAI-IMY, N. R. M. (1990). The Stockport serpentine spring system for the SUGAWA, I., OTANI, K. and KOBAYASHI, A. (1979). Treatment of fracture
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Journal of Hand Surgery. 15B: 3: 303-311. Central Japan Journal of Orthopaedic Surgery and Traumatology, 22: 6:
FOWLER, E. B. (1931). Safety-pin “tongs” for fingers with report of case. 1409-1412.
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Yasushi Suzuki. MD, Department of Orthopaedic Surgery, Gifu Prefectural Gifu Hospital,
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356-362. 0 1994 The British Society for Surgery of the Hand