Management of mangled hand injuries with JESS fixator in a tertiary care hospital in North East India: A prospective study

Abstract

Introduction

Mangled hand injuries have proved to be a tough challenge for both the patients and surgeons alike. Severe bony and soft tissue injuries necessitate the requirement of a multidisciplinary approach.

Materials

In our tertiary care facility, a prospective study was done on the use of the Joshi's external stabilization system (JESS) fixator in the treatment of 31 instances with mangled hand injuries from November 2019 to November 2020. The cases were evaluated for functional outcome at the end of 12 months of follow up.

Results

31 cases of mangled hand injuries with 43 fractures were treated with the said intervention. The mean age of the patients was 33.7 ± 4.2 years and almost 90% patients were males. Machinery injuries were the most frequent type of injury (55%). Cases were intervened at an emergency basis within 24 h of the injury. Functional evaluation was done by Modified Mayo Wrist Score with an average score of 84 ± 10. Good results were seen in about 60% of cases and there were no Poor results.

Conclusion

The application of JESS fixator for the prompt treatment of mangling hand injuries yielded satisfactory results in the working population with an early return to function. The strict adherence to the principles of ligamentotaxis, appropriate wound care and post-operative physiotherapy are other variables in the final outcome of such injuries.

Level of evidence

II.

1. Introduction

The cornerstone for the hand's control, symmetrical action and nuance is its intricate anatomy. It is an organ for receiving important sensory data about the environment outside as well as for expressing ideas, thoughts and emotions through gestures and signs as an adjunct to speech.¹ Despite the fact that we frequently take our hands' versatility for granted in daily life, they are susceptible to the forces of industrial, agricultural and domestic machinery.² One in every five visits to the emergency room is for a hand injury, which makes up around 15% of all visits.³ With a prevalence of 10–15% of all fractures, metacarpal and phalangeal fractures are the most frequently injured.⁴

The mangled hand injury poses as one of the most demanding challenge to an orthopaedic surgeon.⁵ It is by definition a severe hand injury with a crushing component and typically significant alteration of the normal anatomy.⁶ The words “mangled” and “mutilating” stem from the Latin words “to cut or lop off” and “maimed” respectively, and the French term “mangled” means “cut to pieces.” Together, they imply an injury with crucial loss of tissue and loss of function.⁵ Pinal⁷ addressed the idea of what makes an “acceptable hand”. He theorized that a hand with minimum three digits with near normal length & sensation and a functioning thumb would comprise an “acceptable hand”. This is an important fundamental basic to keep in mind when assessing and treating a mangling hand injury. Mangling injuries, or what the author refers to as a “severe hand injury,” are those that leave a hand with less functionality than is “acceptable."⁷

Joshi's External Stabilization System (JESS) is a widely used external fixation device for various fractures. JESS has been utilised to treat a variety of conditions, including post-burn contractures of the hand and wrist,⁸ leprosy-related interphalangeal joint contractures,⁹ intra-articular distal radial fractures,¹⁰ idiopathic clubfoot,¹¹ hand fractures and their sequelae,¹² calcaneal fractures,¹³ and congenital talipes equinovarus.¹⁴

JESS, working on the principle of distraction histogenesis, has been widely employed in cases of open fractures including those involving bone losses.¹⁵ Due to its simple construction, small weight, manoeuvrability, and affordability, JESS provides a sturdy fixation while avoiding damage to the already injured tissue thereby reducing the prospect of infection. Moreover, it permits movement of adjacent joints and permits secondary procedures while not perturbing the fracture thereby reducing the instances of joint stiffness and resulting in achievement of early functional outcome.⁴

Though other operative techniques including simple K-wiring have historically been done for hand fractures and injuries, they have been accompanied by complications like joint stiffness, malunion and ultimately loss of function.

There is very limited available literature on the use of Joshi's External Stabilization fixator in the treatment of mangled hand injuries, which has prompted us to further study and evaluate the outcomes of JESS fixator in the management of such debilitating injuries.

2. Materials and methods

2.1. Patient selection

We conducted a prospective study consisting of 31 cases with mangled hand injuries during the period of November 2019 till November 2020 which were treated with JESS fixator in our institution, a tertiary care hospital in North East India. Prior to the start of the study, institutional ethics committee approval for the trial was acquired. Informed consent was obtained from all the cases before they were included in to the study in a bilingual written format. The patients were monitored for a year.

2.1.1. Inclusion criteria

• •Age group 18–60 years
• •Mangled hand injuries
• •Duration <72 h post injury
• •Patients who have formally consented to the operation in writing

2.1.2. Exclusion criteria

• •Patients with spondyloarthropathy involving hands
• •Mangled extremity severity score (MESS) > 7

After ruling out other life-threatening associated injuries, adequate history taking was done. Time since injury, mechanism of trauma, hand dominance, prior hand trauma or surgery, functional condition of the limb, and employment were important details in the history. Initial thorough wound wash was done with normal saline and disinfectant like hydrogen peroxide. After initial evaluation, x-rays of the injured parts were done along with the basic preoperative investigations. Till the patient was taken up for surgery, the wound was covered with a sterile dressing. In order to lessen the edema in the soft tissues, the hand was maintained firmly elevated while being supported by a splint.

2.2. Operative protocol

The patients were operated under regional/wrist block anaesthesia in supine position.

Exposed and fractured bony fragments were reduced under direct vision and maintained temporarily by K-wire fixation. In case of the phalanges, percutaneous K-wires (1.2 mm, 1.5 mm, and 1.8 mm) were introduced proximal and distal to the fracture site in order to preserve reduction. In situations of peri-articular or intra-articular fractures, K-wires were inserted into the neighbouring phalanx or metacarpal bone and secured to the external connecting rod using link joints. Interphalangeal joints were fixed in extension. In fractures around the metacarpophalangeal joints, the fixators were applied with metacarpophalangeal joints at 90° of flexion (in functional position). The K- wires were applied following the safe zones as advised by Dr. B. B. Joshi¹² and associates. K-wires were put in the dorsolateral plane in case of proximal and middle phalangeal fractures of 2nd to 4th digits while transverse wires were used for border rays. We placed dorsal or dorsolateral pins in metacarpals while being careful to avoid superficial veins, which were readily pulled away with the slack overlying skin. While the wires were being passed, the tendons on each side of the wires were recognised and retracted without being transfixed. Pins were placed in juxtra-articular and intra-articular fractures with the use of an image intensifier as a guide, which was also used to properly assess the intraoperative fracture reduction.

Debridement of the dead and infected tissue was done with trimming of the skin edges. These were then apposed with the help of tensionless non-absorbable sutures. Larger soft tissue gaps were overcome with the help of local flaps and split skin grafts, which was done with association of the Plastic Surgery team of the institute (Fig. 1).

Fig. 1.

Tendon repair followed by flap being done for a case of mangled hand with associated tendon injury.

Patients were instructed for strict hand elevation and mobilization of the free joints immediately after the procedure to reduce the soft tissue edema. Postoperatively pin tract and wound dressing was done daily. Patients were given intravenous antibiotics for the initial period of 3–7 days followed by oral antibiotics for the next 7–10 days.

The patients with associated tendon injuries underwent a second surgery for tendon repair within 1st week of the injury. These patients were immobilized for a longer period compared to the rest.

Post-operatively, the joints proximal and distal to the fixed segments were actively mobilised under supervision from day one, followed by daily mobilisation exercises at home after the patient was discharged. The exercises involved stretching of the individual joints during flexion and extension of the fingers so as to open and make a tight fist respectively. The wrist joint was similarly actively mobilised.

2.3. Follow up

JESS frame was usually removed at an average of around 4 weeks post operatively. Active movement of fingers were advised to the patients immediately after fixator removal. Range of movements was assessed on removal of fixator after 28 days and monthly thereafter for 12 months. Functional assessment was done with the help of Modified Mayo Wrist score.

3. Results

In the present prospective study, we described 31 cases of hand injuries with 43 fractures that were treated with JESS fixator. The average age of the patients was 33.7 ± 4.2 years and majority were right-handed. Almost 90% patients in the study were males. Industrial accidents including machinery injuries and fall of heavy objects were the most common modes of injury during the period of the study (Table 1).

Table 1.

Demographic profile of the cases.

Side affected	Left 32%	Right 68%
Distribution of gender	Female 13%	Male 87%
Mode of injury	Machinery injury 55%
	RTA 20%
	Self-fall 13%
	Physical assault 9%
	Others 3%
Region fractured	Shaft 68%
	Juxta-articular 22%
	Intra-articular 10%
Type of fracture	Open 94%
	Closed 6%
Follow up period (Range)	48 ± 6 weeks
Cases requiring soft tissue coverage	9 (Skin grafting 6; Flap cover 3)
Duration of Hospital stay (Range)	4–9 days
Total active flexion of operated digits (Flexion at DIP + PIP + MCP) [in degrees]	198.3 ± 27.04°

The border digits (2nd and 5th) were seen to be the most commonly affected in our study. Most of the cases were operated for bony and soft tissue stabilization within the first 24 h of injury while 9 cases underwent a second surgery for tendon repair within the next 3–5 days. Average operating time in our study was 42 ± 10 min.

17 cases were operated within 6 h, after the traumatic event. Cases that were operated after 24 h were mainly associated with other systemic injuries and required prior stabilization.

There were only 2 cases of loss of reduction leading to malunion seen in the present study. Fixator removal was done on an average of 30 ± 4 days depending on the stability and the soft tissue condition. In the 9 cases which underwent a tendon repair procedure, fixator was removed at an average of 39 ± 5 days. Patients were followed up regularly for at least a period of 12 months. The mean follow up period was of 48 ± 6 weeks.

Modified Mayo Wrist Scores ranged from 65 to 100 with the average of 84 ± 10. 55% of the cases had good results, 22% had excellent results while the rest had fair results as per Modified Mayo Wrist Score. There were no poor results seen in our study (Fig. 2).

Fig. 2.

Outcomes based on Modified Mayo Wrist Score.

Of the 9 cases which underwent a delayed second tendon repair procedure following primary stabilization, 4 cases had good outcome while the other 5 cases had a fair outcome as per Modified Mayo Wrist Score, emphasizing the need for early intervention in these cases. Those 5 patients could return to their work with certain amount of stiffness (Fig. 3).

Fig. 3.

Progression of Outcome score in cases with additional tendon repair surgery.

Finger stiffness was the most common complication seen in our study. There was 1 case of pin tract infection and 2 cases of malunion seen in our study respectively (Table 2).

Table 2.

List of complications.

Complications	Number of cases
1. Stiffness	3
2. Malunion	2
3. Pin site loosening	1
4. Pin tract infection	1

Joint stiffness was dealt with aggressive physiotherapy with wax bath after removal of the fixator frame with acceptable outcome in the long run. Pin tract infection was treated with superficial debridement and curettage alongwith antibiotics. There were no instances of osteomyelitis in our study. Those cases with malunion regained their acceptable level of function with minimal cosmetic deformity.

(Fig. 4, Fig. 5 show cases of mangled hand injuries treated with JESS fixator.)

Fig. 4.

A, B- Preoperative clinical photo and X-ray; C, D- Post-operative clinical photo and X-ray; E: Follow up at 12 months.

Fig. 5.

A, B- Preoperative clinical photo and X-ray; C, D- Post-operative clinical photo and X-ray; E− Follow up at 12 months.

4. Discussion

The demographic profile of the cases in our study was consistent with higher physical activity, with males of the age group 20–40 years more vulnerable to injuries of the hand. The most common mode of injury in the present study was machinery injury and not motor vehicle accident. Though incidents of road traffic accidents were less due to the nationwide lockdown imposed at the time of the study, agricultural and industrial workers were still exposed to mechanical hardware during their daily essential work-related activities.

Transverse wires were used for border rays in which neurovascular bundles lie antero-laterally in the current study. Dorsolateral K-wires at the proximal and middle phalanges could impale the lateral band or oblique retinacular ligament, but these structures recover their function after the frame is removed.

We also noted that the duration of surgery in case of JESS was longer when a similar case was treated using only K-wires. However, the benefit of early rehabilitation outweighs the increase in surgery duration.

The fundamental idea behind external fixation used in this study was the same as Ilizarov's suggestion.¹⁶ While regulated differential distraction gradually corrects the abnormalities and realigns the osseous structures, physiological traction and stress imparted to the tissue encourages histogenesis and osteogenesis.¹⁷

The Joshi External Stabilization System (JESS) has been used for fracture fixation in South-East Asian subcontinent for over 30 years.¹⁸ It has been utilised for a variety of purposes because to its straightforward design, light weight, ease of mobility, and inexpensive cost as previously noted. The dynamic JESS fixator acts via slow distraction and allows the lengthening of the contracted tissues. This causes minimal secondary surgical insult.

The main crux is to achieve bony union via ligamentotaxis while trying to avoid immobilization of adjacent joints. Experimental research has shown that whereas tendon injury alone is inadequate to cause adhesions, tendon injury coupled with synovial sheath damage and immobilization always results in adhesions. Therefore, post-operative rehabilitation can be started usually immediately in most cases treated by JESS, leading to a better functional outcome. According to Schuind and colleagues,¹⁹ the fracture pieces are not devascularized nor deprived of their periosteal blood supply, hence promoting healing. They are adaptable and sturdy enough to allow for quick mobility. When there has been concurrent soft tissue damage, external fixation makes it simple to easily access and debride the wound and further reconstruction of tendons, nerves, and blood vessels.

JESS fixator is an effective, inexpensive, readily available and easily applicable implant that can be used for the early total management of mangled hand injuries. It can be easily assembled with common items like K-wires that are available in the OT. However, there is a dearth of available literature with adequate data analysis on the management of such injuries with the said device.

It was found that the cases which were intervened early with surgical debridement and fixation, as early as less than 6 h post trauma, had a much quicker soft tissue healing rate compared to cases that were operated after 24 h had elapsed since the time of injury.

In JESS, the joint can be immobilized in the optimal functional position avoiding joint stiffness and early recovery as compared to immobilization in a POP slab.²⁰ Though the loosening of K-wires and infection are known complications of external fixation, they are thought to be related to thermal necrosis of the bone ⁽²¹⁾. According to Hastings,²⁰ external fixation can lead to a number of complications, such as pin track infection, osteomyelitis, fractures through pin holes after removal, neurovascular injury during insertion, over-distraction with subsequent non-union, loss of reduction, restriction of tendon gliding and motion, and fixator encroachment on nearby digits.

In the present study, the patients have been followed up post operatively for a mean period of 48 ± 6 weeks only. Thus, with a longer follow up period, better results could be expected.

5. Conclusion

One of the biggest challenges for the hand surgeon is a mangled hand. The key to a good outcome is early effective diagnosis and prompt treatment. Our study concludes that intervention with JESS fixator for the hand has good functional outcome. The procedure, being relatively simple has a simpler learning curve. Following the fundamental operating principles can have a significant impact on the final result. It is crucial to understand that therapy starts with the initial consultation, progresses via surgical intervention, and ends with rehabilitation. However, it is advised to use a bigger sample size and a longer follow-up time to provide more solid results. We recommend the management of mangled hand injuries with JESS fixator for better results and early return to functional state.

Institutional ethical committee approval

Taken from the competent governing authority.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors contribution

Hafizur Rahman: Conceptualization, Methodology, Software, Visualization, Supervision, Writing-Original draft preparation, Writing- Reviewing and Editing:

Bishal Kumar Deka: Investigation, Data curation, Writing-Original draft preparation, Software, Validation, Writing - review & editing.

Informed consent

Informed written consent taken on inclusion into the study.

Declaration of competing interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Appendix A. Supplementary data

The following is the Supplementary data to this article: