Treating Posttraumatic Stiffness Using the Suzuki Frame for Proximal Interphalangeal Joint Fractures

Abstract

Fractures involving the proximal interphalangeal joint (PIPJ) are common and can significantly impact the function of the hand. These injuries often result from trauma, such as direct axial impact, and require appropriate management to restore mobility and prevent complications. The Suzuki frame application is a minimally invasive external fixation technique that permits early mobilization while maintaining joint stability. A 26-year-old male presented with pain and stiffness in the PIPJ of the third phalanx of his right hand, following a traumatic injury 3 weeks earlier. Clinical examination and radiographic evaluation confirmed a comminuted intra-articular fracture. The Suzuki frame was applied to facilitate fracture reduction and allow controlled joint movement during healing. Over a 6-week follow-up period, the patient demonstrated significant improvement in joint function, with good pain relief and restored mobility. The Suzuki frame fixation is an effective treatment modality for complex PIPJ fractures with stiffness, offering a balance between stability and early movement. Its minimally invasive nature, ease of application, and good functional outcomes make it a valuable option for managing these injuries.

INTRODUCTION

Proximal interphalangeal joint (PIPJ) fractures are among the most common hand injuries, often resulting from direct trauma, such as falls, road traffic accidents, or sports-endured impacts.[1] Such fractures can vary in severity, ranging from simple stable fractures to complex intra-articular fracture-dislocations. Due to the crucial role of the PIPJ in hand function, improper management can lead to stiffness, chronic pain, and functional impairment.[2]

Traditional treatment methods include buddy strapping, extension block splints, and open reduction of the fracture with internal fixation (ORIF). However, these approaches may not always ensure optimal joint stability and early mobilization, which are essential for preventing long-term complications like joint stiffness.[3] Dynamic external fixation techniques, such as the Suzuki frame, have been developed to address these challenges by maintaining joint congruity while allowing controlled movement during the healing process.[4]

Primarily described by Suzuki et al. in 1994, this technique utilizes percutaneous Kirschner (K) wires and elastic rubber loops to provide distraction and dynamic traction. The system enables early range-of-motion exercises, minimizing joint stiffness and promoting better functional outcomes.[5] Various studies have demonstrated that the Suzuki frame is an effective, minimally invasive option for managing intra-articular fractures and stiffness of the PIPJ, offering a balance between stabilization and rehabilitation.[6]

This case report highlights the successful use of the Suzuki frame in managing an intra-articular fracture and stiffness at the PIPJ, demonstrating its advantages in preserving joint function while ensuring stable fracture healing.

CASE REPORT

History and clinical examination

A 26-year-old male presented to the outpatient department with complaints of persistent pain and stiffness in the PIPJ of the third digit of his right hand. The symptoms had been present for 3 weeks following a traumatic injury. The patient reported that he had sustained the injury while engaging in a sporting activity, during which he experienced an axial impact at his extended digit. There was no history of open wounds, dislocations, or prior treatment attempts. The patient had no known comorbidities or previous hand injuries.

On clinical examination, mild swelling was noted at the right third PIPJ. The joint was tender on palpation, and the active and passive movement’s elicited pain. The range of movement was significantly restricted because of discomfort and stiffness, dorsal subluxation was observed, and there was no neurovascular compromise.

Investigations

Radiographic evaluation of the right hand showed an intra-articular fracture involving the base of the middle phalanx of the third digit. Preoperative X-rays [Figure 1a and b] demonstrated gross instability of the PIPJ with dorsal subluxation. The degree of displacement and stiffness necessitated a dynamic fixation technique to restore joint alignment and allow early mobilization.

Figure 1.

(a) Preoperative AP radiograph of the hand (b) Preoperative lateral radiograph of the hand

Given the complexity of the nature of the fracture and preoperative stiffness, a decision was made to proceed with Suzuki frame application. Postoperative imaging [Figure 2a and b] confirmed successful reduction and stabilization of the fracture with percutaneous Kirschner (K) wire fixation and elastic traction, allowing controlled movement of the PIPJ. The Suzuki frame maintained distraction across the joint, facilitating proper alignment and early functional rehabilitation.

Figure 2.

(a) Post-operative Antero-posterior radiograph showing Suzuki frame fixation (b) Post-operative lateral radiograph

Management

The patient was counseled regarding the nature of the injury, treatment options, potential complications, and expected outcomes. After obtaining a thorough informed consent, the procedure was done under stringent aseptic precautions. A ring block was administered using a local anesthetic to ensure adequate pain control during the intervention.

Under fluoroscopic guidance, a Suzuki frame was applied to stabilize the fracture while allowing controlled joint movement.

Construction of suzuki frame

The first pin, referred to as the axial traction pin (P1), was a 9-inch-long, 1.2 mm K-wire passed transversely, with the help of a drill, through the head of the proximal phalanx, at right angle to the phalangeal axis. This wire was then bent at a 90° angle toward the fingertip, maintaining a 0.5 cm gap from the skin on both sides and leaving 3 cm of wire on each end. The tips of the K-wire were further bent to create hooks directed toward the fingertip.

The second pin, designated as the hook pin (P2), was a 6-inch-long, 1.2 mm K-wire passed transversely through the distal part of the middle phalanx, also at right angle to the phalangeal axis. This wire was similarly bent at a 90° angle and then further curved to form hooks facing the fingertip. Elastic traction was applied using sterile IV drip set rubber tubing, which was placed between the hooks. Fracture reduction was verified under fluoroscopy, ensuring a satisfactory alignment with approximately 1 mm of joint space visible.

The third pin, known as the reduction pin (P3), was another 6-inch-long, 1.2 mm K-wire drilled at the base of the middle phalanx, just distal to the fracture site and slightly dorsal compared to P1 and P2. P3 was then positioned volar to the bent P1 and subsequently bent to hook around P1, securing the alignment of the fracture. Reduction was again confirmed using fluoroscopy, and the position was deemed satisfactory [Figure 3].

Figure 3.

Construction of the Suzuki frame

Postoperative care and follow-up

Active and assisted flexion and extension exercises were initiated immediately to restore joint mobility. At 6 weeks, radiographic evaluation showed signs of healing with good fracture reduction, allowing for frame removal [Figure 4a and b] and the patient demonstrated a PIPJ active flexion range of 0°–70° and distal interphalangeal joint active flexion of 0°–30° [Figure 5a and b]. Grip strength had significantly improved, enabling the patient to hold and manipulate objects with ease. Radiographic assessment confirmed good fracture union, aiding the effectiveness of the Suzuki frame in the treatment of intra-articular fractures and stiffness of the PIPJ.

Figure 4.

(a) Radiograph at 6 weeks post-operative showing fracture healing (Antero-posterior view) (b) Radiograph at 6 weeks post-operative (Lateral view)

Figure 5.

(a) Clinical image showing finger extension at 6 weeks postoperative (b) Clinical image showing finger flexion at 6 weeks post-operative

DISCUSSION

Untreated hand fractures can lead to significant deformities and functional impairments. A common challenge in managing hand fractures is the development of stiffness. The most effective strategy to prevent this complication or treat it is initiating an early range of motion exercises, which help maintain joint flexibility and improve functional recovery.[7] Swanson highlighted that if not properly managed, fractures involving the digits may result in malunion, stiffness, and compromised hand function.[8]

Traditional treatment modalities for intricate intra-articular fractures of the PIPJ include ORIF and rigid external fixation. While ORIF aims to attain anatomical reduction and rigid fixation, it often necessitates extensive dissection, which can disrupt soft-tissue structures and increase the risk of adhesions and joint stiffness.[9] Stern et al. reported that ORIF of pilon fractures of the PIPJ yielded optimal results; however, complications such as joint stiffness were noted.[10]

Static external fixators provide stavbilization without extensive dissection but restrict joint mobility during the healing process, potentially leading to joint stiffness. A randomized study evaluating dynamic and rigid external fixation for distal radial fractures found that dynamic fixation, which allows partial wrist movement during healing, resulted in better early functional outcomes compared to static fixation.[11]

Early mobilization is crucial in hand fracture management to avoid joint stiffness and enhance functional recovery. Salter et al. demonstrated that persistent passive motion facilitated articular cartilage recovery, emphasizing the importance of early joint movement.[6]

The Suzuki frame, a dynamic external fixation system, has been employed to address the need for stabilization while permitting early mobilization. Suzuki et al. introduced the k-wires and rubber band traction system for treating comminuted intra-articular fractures and fracture-dislocations in the hand, allowing controlled joint motion during healing.[1]

Subsequent studies have reported favorable outcomes with the Suzuki frame. Keramidas et al. observed that patients with complex intra-articular fractures of the PIPJ treated with the Suzuki frame achieved satisfactory joint function and range of motion.[2] Similarly, Deshmukh et al. reported successful management of intricate fracture-dislocations of the PIPJ using a modified pins and rubber traction system, highlighting the benefits of dynamic traction and early mobilization.[5] Richter and Brüser conducted a chronic phase evaluation as a follow-up study on fracture dislocations and comminuted fractures of the PIPJ treated with the Suzuki’s pin and rubber traction system, confirming sustained functional improvements and minimal complications.[3]

The Suzuki frame offers a viable treatment option for complex intra-articular fractures of the PIPJ. It combines fracture stabilization with the advantage of early mobilization. This approach aligns with the objective of preserving joint function and minimizing stiffness, as evidenced by multiple studies demonstrating its efficacy and favorable outcomes.

CONCLUSION

The Suzuki frame external fixator provides an efficient therapeutic approach for complex intra-articular fractures with stiffness of the PIPJ, securing both stabilization and early mobilization. By maintaining traction while permitting controlled movement, it minimizes joint stiffness and promotes functional recovery. Compared to traditional fixation methods, the dynamic nature of the Suzuki frame enhances outcomes by reducing the risk of adhesions and improving the range of motion. Clinical studies have consistently reported favorable results, reinforcing its role as a reliable technique in managing fractures of the hand. This case highlights the importance of dynamic fixation in preserving hand function and underscores the Suzuki frame as a valuable tool in orthopedic and reconstructive surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.