What is the step-by-step procedure for treating a fracture of the proximal 5th phalanx of the right hand using a Joint External Stabilization System (JESS) fixator?

Step-by-Step Procedure for JESS Fixator Application in Proximal 5th Phalanx Fracture

The JESS (Joshi's External Stabilization System) fixator is an effective treatment option for unstable fractures of the proximal 5th phalanx, providing stable fixation while allowing early mobilization and good functional outcomes.

Pre-operative Preparation

• Obtain appropriate imaging including 3-view radiographs (posteroanterior, lateral, and 45° semipronated oblique views) to evaluate fracture pattern 1
• Consider CT scan for complex fractures with intra-articular extension for better surgical planning 1
• Prepare the surgical field with standard antiseptic protocol
• Administer appropriate anesthesia (regional or general)

Surgical Procedure

Step 1: Patient Positioning and Setup

• Position patient supine with the affected hand on a radiolucent hand table
• Apply tourniquet to the upper arm and inflate after limb exsanguination
• Prepare and drape the hand in sterile fashion

Step 2: Fracture Reduction

• Perform closed reduction under fluoroscopic guidance
• If closed reduction is inadequate, proceed with limited open reduction through a dorsal or lateral approach
• The goal is to achieve anatomic reduction with <2mm articular step-off to prevent long-term complications 1

Step 3: K-wire Insertion

• Select appropriate K-wires (typically 1.2-1.5mm diameter)
• Insert two K-wires in the proximal fragment (metacarpal)
  • Place wires perpendicular to the long axis of the metacarpal
  • Ensure wires are parallel to each other and 5-10mm apart
• Insert two K-wires in the distal fragment (middle/distal portion of proximal phalanx)
  • Place wires perpendicular to the long axis of the phalanx
  • Ensure wires are parallel to each other and 5-10mm apart
• Confirm wire placement with fluoroscopy in multiple planes

Step 4: JESS Fixator Assembly

• Cut the K-wires leaving 2-3cm protruding from the skin
• Bend the protruding ends of K-wires at 90° to prevent migration
• Connect the proximal K-wires with a transverse connecting rod using clamps
• Connect the distal K-wires with another transverse connecting rod using clamps
• Connect the two transverse rods with longitudinal rods using additional clamps
• Adjust the connecting rods to achieve and maintain proper fracture reduction
• Tighten all clamps securely once optimal reduction is confirmed

Step 5: Distraction and Final Adjustments

• Apply gentle distraction if needed to maintain fracture reduction
• Confirm final alignment with fluoroscopy in multiple planes
• Ensure the metacarpophalangeal (MCP) joint is positioned in slight flexion (10-15°) to prevent extensor lag

Step 6: Wound Closure and Dressing

• For open reduction cases, close the surgical wound in layers
• Apply sterile dressing around pin sites
• Apply light compressive bandage

Post-operative Management

• Begin early active range of motion exercises of the interphalangeal joints within 24-48 hours
• Provide pin site care instructions to prevent infection
• Schedule regular follow-up visits (typically weekly for the first 2-3 weeks)
• Monitor for signs of pin tract infection or loosening
• Maintain the external fixator for approximately 4-6 weeks until radiographic evidence of fracture healing 2
• Remove the fixator under local anesthesia once healing is confirmed
• Initiate intensive physical therapy after fixator removal to restore full range of motion

Potential Complications and Management

• Pin tract infection: Treat with oral antibiotics and meticulous pin site care
• K-wire loosening: May require repositioning or replacement
• Joint stiffness: Address with aggressive physical therapy after fixator removal
• Malunion: May require corrective osteotomy if functionally significant
• Nonunion: Rare, but may require bone grafting and internal fixation

Important Considerations

• The JESS fixator provides stable fixation while allowing early mobilization of adjacent joints
• This technique is particularly useful for comminuted or unstable fractures where internal fixation may be difficult 2
• The fixator should maintain fracture reduction while allowing tendon gliding to prevent stiffness
• Regular follow-up is essential to monitor fracture healing and detect complications early

The JESS fixator offers advantages of being lightweight, stable, and allowing for adjustments during the healing process, making it an excellent option for complex proximal phalanx fractures 3.