The template was transferred to the thermoplastic stock and the material cut and subsequently softened in a heated hydrocollator. These were again transferred to the template material, permitting development of a 2-dimensional representation of the device to be designed. Additional anatomic points were obtained MCP obliquity to the wrist crease, the 2nd and 3rd digit webspace and the distance from the MCP to the tip of the 3rd digit. A 50% circumference of proximal forearm, distal anterior wrist crease and MCP joints were transferred to a template along with their respective longitudinal separation distances. Additionally, allowance was made in the splint for a potential increase in edema and the application of postoperative dressings.Īppropriate anatomic landmarks were obtained by the hand therapist using direct reference on the limb to determine dimensions of the device ( Fig. A removable piece of thermoplastic material is attached on the ulnar aspect of the splint providing further support to the hand and device limiting collapse when drilling the MC (green arrow in Fig. An integral component positioning the thumb in radial abduction was employed to assist maintaining forearm pronation when on the operating table (red arrow in Fig. This permitted the hand intrinsic muscles to be in a mid-range length minimizing load on the fracture site or through the metacarpophalangeal (MCP) joints. Final adjustments were made by the clinical specialist hand therapist at the time of fabrication to ensure appropriate positioning of the wrist and hand in a position of comfort balancing tensions across joints and musculotendinous structures, in preference to James’ POSI. The device was custom fabricated preoperatively molded directly on the patient to provide a suitable base of support for the hand.
This splint will be used preoperatively to immobilize the fracture as a customized stabilizing tool during the operation and then will serve as a resting splint postoperatively ( Figs. The patients that fit the above characteristics when seen in the clinic are reviewed by the specialist hand therapist who measures and fabricates a modification of the POSI splint. We developed a novel care pathway for patients deemed appropriate for MC ORIF fracture stabilization. In our institution, all the patients with MC fractures that undergo ORIF will be followed up by our hand therapy colleagues and a thermoplastic splint will be custom fabricated based on the anatomy of the patient with variants upon the position of safe immobilization (POSI). Customized patient-precise instruments for hand surgery have been described before and are developed using additive manufacturing technology such as 3-dimensional printing, but there is no description of a device that inhibits the hand from supinating. These solutions are frequently inadequate as the hand is repositioned multiple times throughout the procedure due to the natural tendency of the arm to supinate. Some surgeons resort to a sterile crepe bandage or a “kidney” dish as a makeshift stand to help the assistant hold the hand in a fixed position.
Every time C-arm radiography is used the assistant must reposition the hand which is both time consuming and impairs the fluency of the procedure. C-arm radiography is required during this procedure for visualization of fracture site and confirmation of metal work placement. Ĭurrently, the ORIF technique for MC fracture fixation is performed with the use of an assistant who holds the hand in a static pronated position for the operating surgeon, allowing ease of access to the fracture site. Multiple studies have shown that open reduction and internal fixation (ORIF) allows for early mobilization compared to intramedullary pinning fixation and is a frequent procedure performed for MC fractures. Fractures of the metacarpal (MC) bones account for a significant part of fractures in the hand up to 40% as described in the literature with a shaft versus neck ratio of roughly 1:2.
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