Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 32:
Bony Fixation in Replantation
  The Kirschner unthreaded sharp-point wire remains a common method for fracture fixation in the hand, owing to the ubiquitous nature of the equipment, the inexpensive cost of the implant, and the resulting adequate and rapid immobilization provided to the fracture. In most cases, the ease of application has added to its popularity, although K-wire fixation in complex fractures may be both difficult and time-consuming. Disadvantages are a possible distraction of the fracture during multiple wire placement and the impingement on surrounding soft tissue when placed percutaneously. Moderate to poor stabilization with later loosening can occur, requiring protective splinting. The external pin sites in percutaneous wires provide a site for infection that may progress into soft tissue and bone. Buried subcutaneous pins, particularly if destined to remain in place for an extended period, may be desirable but require incision for removal.

FIG. 32-01. A. Extensor tendon, B. Flexor tendon, C. Lumbrical.

K-wire placement can be carried out in any number of ways: The wire is positioned across the fracture site with impingement on as few adjacent tissues as possible. Controlled, low-speed drilling with adequate wire size provides the most secure placement. Crossed K-wire fixation allows bicortical purchase, provides reasonable stability, limits rotation, and leaves adjacent joints and tendons free. Care must be taken to prevent fracture distraction. Parallel K-wires, although controlling the same forces, often require crossing a joint surface and limit early mobilization. In some complex injuries, wires must be placed across one or more joints. Early removal with protected motion and splinting is started when possible. A single K-wire may be ideal in distal amputations, or in children, because of size constraints, with soft tissue closure controlling rotational forces.



Many different wire loop techniques are listed in the literature, 3,5,15,17 and can be grouped into two main types, those with and those without tension band function.

Nontension band wires are usually 26- or 28-gauge steel wire placed through drilled holes in the proximal and distal fracture fragments with minimal periosteal dissection. Comminuted fractures may have to be wired fragment to fragment with fine wire before the major parts are fixed. Advantages include commonly available equipment, quick placement, reasonable strength, and minimal implant bulk. Disadvantages include the prolonged presence of a buried foreign body, slightly increased soft tissue dissection compared with K-wires, and wire fatigue and breakage that may result in loss of fracture reduction.

Cerclage or encircling wire loops are useful with oblique, tubular, or diaphyseal fractures, containing multiple fracture fragments and reducing the area of required callus. They may be combined with other implants and are not compressive. Care should be taken to groove or drill the cortex to anchor the loop in place and to place the twist or knot closure away from gliding tissue.

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