Successful treatment of nonunion in severe finger injury with low-intensity pulsed ultrasound (LIPUS): a case report
© Huber et al.; licensee BioMed Central Ltd. 2012
Received: 14 February 2012
Accepted: 18 July 2012
Published: 18 July 2012
Severe injuries of the hand or single fingers require immediate treatment but surgical fixation methods are limited depending on soft tissue damage. Thus, it is very common that severe soft tissue damage along with poor osteosynthetic bone fixation results in a delayed healing process or nonunion. Low-intensity pulsed ultrasound (LIPUS) has been proven to stimulate bone formation in in vitro studies and also to significantly accelerate nonunion healing in animal studies and clinical trials but to date there are no data with respect to nonunion in phalanx fracture.
We report a case in which we successfully used LIPUS in a 19-year-old Caucasian man with a nonunion of his ring finger after injury and first treatment with K-wire osteosynthesis.
We recommend that LIPUS be considered as an option to treat nonunions in fractures of the hand, especially because it is a soft tissue conserving method with a good functional result.
In recent years, low intensity pulsed ultrasound (LIPUS) has been the focus of several studies examining how to help stimulate bone formation in fractures and nonunions [1–3]. However, to the best of our knowledge, there have been no reported studies dealing with the use of LIPUS to treat fractures or nonunion of the fingers.
Up to now in cases of nonunions, trauma surgeons have had to perform additional surgery with a more stable osteosynthesis and bone grafting. This can cause additional complications to the already pre-damaged soft tissue with further loss of function [4, 5]. In this case we successfully used LIPUS, a non invasive treatment, to investigate its applicability in treating nonunion of fingers.
The patient was seen five months after initial treatment in our Out-Patient Clinic and reported painful moving of the right ring finger. The examination showed an instability of the middle phalanx with a passive lateral movement. Twenty degrees ulnar deviation of the ring finger with decreased ROM of the PIP joint (E/F 0-0-60˚) was apparent. In addition, the ring finger tended to cross over and overlap the adjacent finger when making a fist. The patient reported that ulna deviation of the ring finger started when K-wires had been removed by an office-based orthopedic surgeon two months after the initial surgery.
Average intensity I = 30 mW/cm² (SATA), ultrasound frequency F = 1.5 MHz, signal impulse duration 200 microseconds, repetition rate 1 kHz, effective radiating area 3.88 cm2, temporal average power 117 mW.
Severe injury of the fingers or the hand with a phalanx fracture requires rigid fixation with anatomical reduction to achieve appropriate bone healing. In addition, stable fracture fixation facilitates exercise very soon after surgical treatment avoiding restricted movement. The initial soft tissue damage, however, can limit the approach of osteosynthesis [4–6]. Using K-wires reduces the risk of further damage to the surrounding tissue while accepting less compression of the fracture that might cause nonunion. Second surgery is very common in nonunion fracture healing including bone graft and plate fixation  but second surgical intervention causes new or repeated soft tissue damage, leading to further loss of function. However, phalanx fracture fixation is needed in most cases and should be limited to a short period of time in order to achieve a ROM without restriction. Thus, low-intensity ultrasound seems to be an additional favorable tool for nonunion since it is effective and non-invasive [2, 3]. Gebauer et al. reported in a randomized prospective trial that daily therapy of 20 minutes with low-intensity ultrasound achieved bone healing in 85 % of cases  which was confirmed by other studies [9–12]. In a recently published Cochrane Review about ultrasound and shockwave therapy, in which 12 studies were evaluated, the authors concluded that the evidence of the analyzed clinical trials is insufficient to support the routine use of LIPUS . In this case, there had been a three month splinting without success, so we decided to use LIPUS instead of bone grafting and osteosynthesis.
LIPUS is a pain free therapy performed daily at home by the patient with the possibility of avoiding a second surgical procedure. This out-patient treatment reduces the length of hospital stays for patients and the expenses of the health care system .
We report successful ultrasound treatment after inadequate bone healing with insufficient stability of the middle phalanx. The patient suffered from reduced ROM in the DIP and PIP joints. The patient also had an ulnar deviation associated with pain owing to the instability of the fracture. Based on this case report we suggest LIPUS as a possible approach for nonunion in finger injuries, however further clinical trials are necessary to confirm these preliminary findings.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The written consent is available for review by the Editor-in-Chief of this journal.
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