Global Academic Journal of Medical Sciences

Available online at https://www.gajrc.com/

DOI: 10.36348/gajms.2021.v03i02.006

ISSN: 2706-9028 (O)

ISSN: 2707-2533 (P)

Original Research Article

“Evaluation of External Fixation of Unstable Phalanges Fractures of Hand

by JESS (Joshis External Stabilization System) Fixation Technique”
Md. Rashed Hasan1*, A. K. M. Latiful Bari2, Md. Wares Ali3, Md. Anisur Rahman4, A. K. Al Miraj5, Mohammad
Khurshed Alam6, Md. Arifuzzaman 7, Gazi Ahsan Ul-Munir8
1Junior Consultant, Orthopaedic Surgery, Kushtia Medical College Hospital, Kushtia Bangladesh
2Medical Officer, Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka,
Bangladesh
3Junior consultant, Orthopedic and Trauma surgery Department, Mugda Medical college Hospital, Dhaka, Bangladesh
4Lecturer, Forensic Medicine, Kushtia Medical College, Kushtia Bangladesh
5Research Assistant, Department of Vascular surgery, BSMMU, Dhaka, Bangladesh
6Associate Professor, Department of Orthopedics, Dhaka Medical College, Dhaka, Bangladesh
7Junior Consultant, Orthopedic Surgery, Kushtia Medical College Hospital, Kushtia, Bangladesh
8Assistant Professor, Orthopaedic Surgery, Kushtia Medical College Hospital, Kushtia, Bangladesh

*Corresponding Author Abstract: Introduction: Phalangeal fractures either closed or open, are common
Md. Rashed Hasan injuries of the hand. These injuries are encountered every day. These fractures can be
treated conservatively or operatively depending on the nature of injuries, fracture
Article History
pattern, and fracture stability. Various methods are used for this purpose including
Received: 15.03.2021
Accepted: 26.04.2021 internal fixation by ‘K’ wires and external fixation by JESS technique. Objective: To find
Published: 30.04.2021 out the Evaluation of External fixation of Unstable Phalanges fractures of hand by JESS
(Joshis External Stabilization System) fixation technique. Material and Methods: This
study was conducted by the Department of orthopedics at Kushtia Medical College
Hospital, Kushtia Bangladesh during the period of two years (January 2018- December
2019). A total of 60 cases of compound and or unstable fractures of metacarpal and
phalangeal were included into the study. The stable fractures and hand injuries without
fractures were excluded from the study. On the arrival at the hospital, primary
resuscitative measures were taken such as recording of vital parameters and rapid
systemic evaluation. The wounds were cleaned with dilute hydrogen peroxide, normal
saline and Betadine and covered with sterile dressings. Suitable splints were placed onto
the hand. Detailed radiological study was carried out and systemic, clinical examination
was made and charted. The patients were divided into two groups, Group I who were
treated with internal fixation and Group 2 were treated with JESS fixation. Results: Out
of the total 60 cases, internal fixation was done in about 44 cases and JESS being
performed on 26 patients. Transverse and comminuted were the most common type of
fractures, together accounting for about 50% of the cases. The outcome of the treatment
was excellent in 50% of the cases among those who were treated with JESS, while less
than 40% had excellent outcomes and many had poor outcomes among the patients
treated by internal fixation. Conclusion: In the compound fractures, the use of JESS
method would be more useful in the repair of hand fractures.
Keywords: fingers, hand, mini external fixator, phalanges.
Copyright © 2021 The Author(s): This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0
International License (CC BY-NC 4.0) which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use
provided the original author and source are credited.

INTRODUCTION treated conservatively or operatively depending on

Phalangeal fractures either closed or open, the nature of injuries, fracture pattern, and fracture
are common injuries of the hand. These injuries are stability [2, 3]. The principal management involves
encountered every day [1, 2]. These fractures can be restoration of articular congruity and fixation of the
Citation: Rashed Hasan et al (2021). “Evaluation of External Fixation of Unstable Phalanges Fractures of Hand by JESS (Joshis
External Stabilization System) Fixation Technique”. Glob Acad J Med Sci; Vol-3, Iss-2 pp-49-53.
49
Md. Rashed Hasan et al; Glob Acad J Med Sci; Vol-3, Iss- 2 (Mar-Apr, 2021): 49-53.

fracture with an internal or an external fixation fractures of metacarpal and phalangeal were
device [4]. Anatomical reduction and stable fixation, included into the study. The stable fractures and
followed by early mobilization represent the key hand injuries without fractures were excluded from
treatment of these fractures. Inadequate treatments the study. On the arrival at the hospital, primary
can lead to poor outcomes including chronic pain, resuscitative measures were taken such as recording
stiff ness, deformity, and premature degenerative of vital parameters and rapid systemic evaluation.
arthritis [5, 6]. In comminuted and intra-articular The wounds were cleaned with dilute hydrogen
fractures, open reduction with internal fixation peroxide, normal saline and Betadine and covered
simply using Kirschner’s wire usually leads to with sterile dressings. Suitable splints were placed
incapability of early mobilization secondary to the onto the hand. Detailed radiological study was
smaller size of bone fragments or lessfastness in carried out and systemic, clinical examination was
fixation dragged by local ligament. It is also not ideal made and charted. Appropriate drugs were
when there is a risk of infection because of open administered for the alleviation of the pain, shock
wounds and when further soft-tissue damage has to and anxiety. Antitetanus and antigas gangrene
be avoided [4, 5]. Fixation techniques involve the use vaccinations were also administered. All the patients
of K-wires, intramedullary nails, cerclage wires, were subjected to Blood tests for hemoglobin
plating, lag screws, tension band wires, and/or evaluation, complete blood picture, Erythrocyte
external fixators. ‘K’ wires are the most versatile, sedimentation Rate, Blood grouping, Random blood
simplest and cheapest method of fixing the hand sugar and urine tests for sugar. Anteroposterior and
injuries [6, 9]. They can be introduced lateral X-rays were taken for the hand. The fractures
percutaneously without exposing the fractures. It is were classified, and site, nature of the fracture and
sufficiently stable to allow early motion without type of the wound. Based on the type of fracture, the
subjecting the hand to surgical trauma of open patients are divided into 2 groups, Group I who
reduction. JESS is a simple, versatile and light weight underwent standard internal fixation methods and
fixation with the added possibility of incorporation the Group II underwent external fixation by Joshi’s
of splints or conversion to dynamic mobilization External Stabilization System (JESS). At the
units. JESS provides rigid fixation of bones in which operation Table, the necrosis skin was excised at
other forms of immobilization are not appropriate wound margins and necrosed muscle excision was
e.g. open fracture. It is possible to compress, done. Very small size loose bone pieces were
neutralize or distract a fractures fragment and also removed. Large pieces were washed with saline and
allowing aggressive and simultaneous treatment of preserved. Foreign particles were removed and
bone and soft tissue lesions. It is possible to swabs were taken for culture and sensitivity. For
immediately move the proximal and the distal joints, internal fixation, ‘K’ wire or ‘SS’ wire fixation by
thereby reducing edema, preventing capsular standard method was done. For JESS technique, the
fibrosis, joint stiffness and muscular atrophy. first wire is passed in the coronal plane in the distal
External fixation offers an effective treatment option radius about 2.3cm proximal to the radial styloid,
in the management of these difficult fractures and a engaging both cortices of the radius. The second
variety of external fixators are available for this wire was passed in the same plane at the junction of
purpose [3], and act through distraction upper third and lower two third of the radius to
mobilization of the involved joint to maintain engage both cortices. The next two wires are passed
articular integrity through capsuloligamentotaxis at similar levels though the ulna in the coronal plane.
[5]. Also, external fixators offer significant A ‘K’ wire was passed in the base of the second
advantages in the form of minimal surgical trauma, metacarpal in the coronal plane and advanced to
preservation of fracture hematoma, short operative engage the third metacarpal. A ‘K’wire is passed in
time, and minimal anesthetic icomplications, the neck of the second metacarpal in the same place
especially among old patients not fit for general and advanced to engage the third metacarpal if
anesthesia, and the removal of the fixator as a simple possible. The next two wires are passed similarly
outpatient procedure [7]. The current study from the 5 th and 4th metacarpal from the ulnar side
reviewed the functional results in a group of patients in the coronal plane, one in the base and other in the
with phalangeal fractures and either open wounds neck. A 300 mm connecting rod is bent at 200 after
or severe soft-tissue injuries treated by external measuring the approximate level of the wrist joint.
fixation. One such bent connecting rod is applied to the two
radial pins and to metacarpal pins from the radial
MATERIALS AND METHODS side keeping the wrist in the dorsiflexion position.
This study was conducted by the Link clams are used to clamp the connecting rod to
Department of orthopedics at Kushtia Medical the ‘K’ wire. Similarly another rod is applied to the
College Hospital, Kushtia Bangladesh. During the ulnar side. A biaxial hinge is fixed to both these
period of two years (January 2018- December 2019). connecting rods at the level of metacarpo phalangeal
A total of 60 cases of compound and or unstable joint. The ends of the two extended connecting rods
© 2021: Global Academic Journal’s Research Consortium (GAJRC) 50
Md. Rashed Hasan et al; Glob Acad J Med Sci; Vol-3, Iss- 2 (Mar-Apr, 2021): 49-53.

are spanned using the 150mm connecting rod and RESULTS

clamped by standard link joints. The anchor points All the patients were between 5-50 years of
are set for positioning the fingers (Fig. 1). Antibiotics age, but the most common age group seemed to be
are administered in all the cases and subsequent the younger age group .i.e. below 30 years of age.
changes were made according to the culture and Males were more affected than females probably due
sensitivity pattern. to the different lifestyles of the males and females.
Right hand side was more easily affected than the
left hand, being the dominating hand with 60% of
the injuries. Road traffic accidents were the most
common cause followed by assault injuries and
violence (Table-1).

Table-1: General parameters of the patients

General Parameter No. (%)
Age:
5-20 Years 17 (28.3%)
21-30 Years 18 (30%)
31-40 Years 13 (21.7%)
41-50 Years 5 (8.3%)
51-60 Years 7 (11.7%)
Sex:
Males 49 (81.67%)
Females 11 (18.33%)
Side of fracture:
Right 46 (76.67%)
Left 14 (23.33%)
Causative Agents of Trauma:
Road Traffic Accident 34 (56.67%)
Assault Injuries 17 (28.33%)
Industrial/Domestic Violence 9 (15%)

Out of the total 60 cases, internal fixation

was done in about 44 (63%) of the cases and JESS
being performed on 26 (37%). Transverse and
comminuted were the most common type of
fractures, together accounting for about 50% of the
cases (Fig-3).

Fig-1: Comminuted intra-articular fracture of

proximal phalanx right thumb stabilized with
JESS basic frame (before and after surgery).

Fig-3: Type of fixation for different types of

fractures.

The period that was required for internal

fixation was predominantly 4 weeks in both the
cases though in many cases of JESS, the fixation time
was only 3 weeks. In all the patients fixed by JESS
method, adjoining joints were mobilized from the
Fig-2: Use of the hand on 1st post-operative day first day itself. Tendon injury and neurovascular

© 2021: Global Academic Journal’s Research Consortium (GAJRC) 51

Md. Rashed Hasan et al; Glob Acad J Med Sci; Vol-3, Iss- 2 (Mar-Apr, 2021): 49-53.

injuries were the most commonly associated injuries fractures with severe soft tissue injuries. ‘K’ wire or
in these cases (Fig-4). ‘SS’ wire alone cannot provide a stable fixation as
they need to be further supplemented with external
splints to avoid complications like malunion. In
addition, with these internal fixation methods, there
may be a secondary displacement at fracture site,
stiffness at wrist, MP and PIP joint. All ‘K’ wires,
whether used in the external or internal fixations
could be easily removed after the fracture healing,
without additional surgery or anesthesia, at the OPD
itself. Moreover JESS is more cost effective than the
other types of external fixators. In the present study,
the mean age of patients was 31, with most of the
patients being less than 40 years of age. Males were
more prone to fractures in the hand. In a similar
Fig-4: Associated injuries
study by Ashmead et al., [10] the mean age was
found to be 32 years and it was 39 years in a study
by Drenth et al., [11]. In both the studies, males were
the predominant gender to be affected. The most
common mode of injury was road traffic accident,
which was the same in these studies also, [10,11]
among the post-surgical complications, the most
common ones observed in our study was skin
necrosis in the patients treated with JESS and
malunion in the patients treated with internal
fixation (44.67%). Malunion was seen in one case in
the treatment with JESS accounting for 6.3% of the
Fig-5: Postoperative complications overall complications seen in this mode of
treatment. In similar studies conducted by Joshi et
Skin necrosis and malunion were the most al., [12] Duffield et al., [10] and Drenth et al., [11]
common complications observed (Fig. 5). The malunion was found to be leading cause of
outcome of the treatment was excellent in more than complications. The overall outcome with JESS was
50% of the cases among those who were treated far better than with the internal fixation technique.
with JESS, while less than 40% had excellent It was excellent in 57.7% of the cases and good in
outcomes and many had poor outcomes among the more than 26% of the cases, with more than 75% of
patients treated by internal fixation (Table-2). the patients satisfied with the treatment with
external fixation. With internal fixation only 50% of
Table-2: Overall outcomes of the two surgeries them had an excellent to good result. The number of
JESS Internal fixation poor results were also more in this group, could be
Excellent 15 (57.7%) 15 (34.1%) due to the fact that there were more malunions in
this method. Joshi et al., reported 90% excellent
Good 7 (26.9%) 7 (15.9%)
results among patients who were treated with
Fair 1 (3.8%) 9 (20.5%) external fixation [12]. Duffield et al., also reported a
Poor 3 (11.5%) 13 (29.5%) very high success rate of 91% while the rate was
55% in the study by Drenth et al., [11]. Our study
DISCUSSION showed only 34% of the patients with excellent
The management of hand injuries has results in internal fixation. This was in accordance to
always been the topic of controversy as there are so a study by Chow et al., [13] who observed a 25.2%
many different types of treatment with advantages excellent result and 30% by Pun et al., [14]. Although
and disadvantages. Most phalangeal and metacarpal Mark Richard et al., reported an excellent rate of
fractures are treated conservatively. Patients with 61% [15].
unstable fractures require operative reduction and
stabilization to obtain the optimal positioning for CONCLUSION
bone healing and to allow early movement. The main Though ‘K’ wire is the preferred treatment,
objective of management is early skeletal the external fixation method by JESS is much more
stabilization and immediate motion of adjacent stable with very good results. Therefore in the
joints to prevent long term complications like joint compound fractures, the use of JESS method would
stiffness. JESS external fixation is proved to be a be more useful in the repair of hand fractures.
suitable technique for stabilizing unstable, open
© 2021: Global Academic Journal’s Research Consortium (GAJRC) 52
Md. Rashed Hasan et al; Glob Acad J Med Sci; Vol-3, Iss- 2 (Mar-Apr, 2021): 49-53.

REFERENCES: intertrochanteric fracture in elderly high-risk

1. Sahin, F., YUCEL, S., Yilmaz, F., Ergoz, E., & Kuran, patients using simple external fixation. Menoufia
B. (2006). Demographic features and difficulties Medical Journal, 27(2), 249.
in rehabilitation in patients referred to hand 8. Chung, K. C., & Spilson, S. V. (2001). The
rehabilitation unit for phalangeal fractures. Acta frequency and epidemiology of hand and
Orthopaedica et Traumatologica Turcica, 40(4), forearm fractures in the United States. The
274-279. Journal of hand surgery, 26(5), 908-915.
2. Wong, H. K., Lam, C. Y., Wong, K. Y., Ip, W. Y., & 9. Ashmead IV, D., Rothkopf, D. M., Walton, R. L., &
Fung, K. K. (2008). Treatment of phalangeal and Jupiter, J. B. (1992). Treatment of hand injuries
metacarpal fractures: a review. J Orthop, 10(1), by external fixation. The Journal of hand
1-9. surgery, 17(5), 956-964.
3. Dean, B. J., & Little, C. (2011). Fractures of the 10. Drenth, D. J., & Klasen, H. J. (1998). External
metacarpals and phalanges. Orthopaedics and fixation for phalangeal and metacarpal
Trauma, 25(1), 43-56. fractures. The Journal of bone and joint surgery.
4. Thomas, R. K., Gaheer, R. S., & Ferdinand, R. D. British volume, 80(2), 227-230.
(2008). A simple external fixator for complex 11. Joshi BB. (1998). Modern concepts in hand
finger fractures. Acta Orthopædica surgery, J BioMed, 26-28.
Belgica, 74(1), 109. 12. Chow, S. P., Pun, W. K., So, Y. C., Luk, K. D. K.,
5. Li, W. J., Wen, T. I. A. N., Tian, G. L., Chen, S. L., Chid, K. Y., Ng, K. H., ... & Crosby, C. (1991). A
Zhang, C. Q., Xue, Y. H., ... & Yin, Z. H. U. (2009). prospective study of 245 open digital fractures
Management of intra-articular fracture of the of the hand. The Journal of Hand Surgery: British
fingers via mini external fixator combined with & European Volume, 16(2), 137-140.
limited internal fixation. Chinese medical 13. Pun, W. K., Chow, S. P., So, Y. C., Luk, K. D. K., Ip,
journal, 122(21), 2616-2619. F. K., Chan, K. C., & Ng, C. (1989). A prospective
6. Drenth, D. J., & Klasen, H. J. (1998). External study on 284 digital fractures of the hand. The
fixation for phalangeal and metacarpal Journal of hand surgery, 14(3), 474-481.
fractures. The Journal of bone and joint surgery. 14. Belsky, M.R., Eaton, R.G. (1989). Closed
British volume, 80(2), 227-230. reduction and internal fixation of proximal
7. Elmowafy, H., Abd Elsattar, T., Darwish, A., & phalangeal fractures, The Journal of hand
Elreweny, M. (2014). Management of surgery 14(A):474-481.

© 2021: Global Academic Journal’s Research Consortium (GAJRC) 53