ORIGINAL ARTICLE
Kirschner-Wire Fixation for Postburn Flexion Contracture
Deformity and Consequences on Articular Surface
Nezih Sungur, MD,* Mustafa Gürhan Ulusoy, MD,* Süreyya Boyacıgil, MD,‡
Hülya Ortaparmak, MD,§ Mihriban Akyüz,† Turgut Ortak, MD,† Uğur Koçer, MD,*
and Ömer Şensöz, MD†
Abstract: Kirschner-wire (K-wire) fixation for 3– 6 weeks is an
approved method for stabilization of the fingers after the release of
flexion contracture deformity. On the other hand, articular surface
damage in small joints due to pin fixation is still a topic of debate.
Reports claiming permanent joint destruction due to this procedure
exist in the literature.
To clarify this doubt, a prospective study was carried out in 72
patients with flexion contracture of the hand fingers. After the
surgical release of the deformity, immobilization of the interphalan-
geal (IP) and metacarpophalangeal (MCP) joints was carried out
with K-wire fixation for 3 weeks. Clinical evaluation of the patients
was accomplished with total active motion (TAM), grip, and pinch
force measurements, whereas magnetic resonance (MR) and radio-
nuclide imaging were used as radiodiagnostic tools. Mean follow-up
period of the patients was 32 months. Satisfactory results were
obtained in terms of functional and esthetic aspects. Evaluation of
the data derived from the clinical and radiologic measurements
revealed no permanent articular surface damage.
K-wire fixation was documented to be an invaluable therapeutic
approach not only to prevent recurrence of the contracture deformity
but also to stabilize the skin graft effectively. This technique was
concluded to provide effective immobilization without permanent
articular damage.
Key Words: Kirschner, flexion contracture, joint damage
(Ann Plast Surg 2006;56: 128 –132)
T reatment of a burned hand aims for prevention of scar
formation, early coverage of the defect, and preserving
mobility of the joints.1
Received May 2, 2005, and accepted for publication September 3, 2005.
From the *Plastic and Reconstructive Surgery Department, Ankara Training
and Research Hospital, Ankara, Turkey; and the †Plastic and Recon-
structive Surgery Department, ‡Radiology Department, and §Nuclear
Medicine Department, Numune Training and Research Hospital, Ankara,
Turkey.
Reprints: Nezih Sungur, MD, Gülseren Sokak, 15/7, Maltepe, Ankara Türk
ı̇iye. E-mail: drnezihsungur@yahoo.com.
Copyright © 2006 by Lippincott Williams & Wilkins
ISSN: 0148-7043/06/5602-0128
DOI: 10.1097/01.sap.0000192029.78667.c6
128
Burn injuries require prompt and deliberately planned
intervention both in the acute and chronic phases because of
the serious acute complications that may lead to death or the
chronic complications that may result in severe functional
deficit. Hand burns are common in severely burned pa-
tients,2,3 and contracture formation is the most common
deformity of the burned hand, which is usually preceded by
usage of insufficient or thin skin grafts, hypertrophic scar or
keloid formation, inadequate exercise program, or inappro-
priate splinting in the antideformity position.2,4 On the other
hand, secondary reconstructive procedures may be inevitable
for complications such as partial or total finger necrosis and
contracture formation, even if all principles of acute inter-
vention are carried out meticulously.4,5
Postburn deformities of the hand can be examined
under 4 main titles: (1) flexion contractures involving the
digits, (2) palmar contractures, (3) contractures of the hand
dorsum, and (4) interdigital syndactyly.3,6
Flexion contracture of the digits presents a challenging
problem as several factors such as skin deficiency, contrac-
ture of the tendon sheet, adhesion of the volar plate to the
phalangeal head, and shortening of the collateral ligament
contribute to the ethyopathogenesis.7,8
The problem in postburn contracture deformity is even
more complicated in the presence of syndactyly and web-
space contractures. Many different procedures were sug-
gested to correct these complex deformities resulting from
scar formation.4 Basically, surgical procedures may be cate-
gorized as (1) Z plasty: this technique is helpful especially in
narrow contracture bands surrounded by healthy skin; (2)
V-Y advancement: although contracture release may be
achieved without skin grafting, presence of undamaged elas-
tic skin is vital for the success of this technique; (3) excision
of the contracture band and skin grafting. Among these
treatment modalities, excision and grafting is the most com-
monly used procedure.4,6
After complete release of the contracture, gradual
shortening of the collateral ligaments, flexor tendons, and
neurovascular structures may cause recurrence of the defor-
mity. To prevent this situation, immobilization is mandatory
in the postoperative period, which can effectively be carried
out with K-wire fixation.
A vast number of studies concerning the use of K-wires
for stabilization have been reported in the literature. Effect of
Annals of Plastic Surgery • Volume 56, Number 2, February 2006
Annals of Plastic Surgery • Volume 56, Number 2, February 2006 Kirschner-Wire Fixation for Postburn Flexion Contracture Deformity
K-wire on the tissues applied was also studied thoroughly.
However, detailed clinical assessment of the finger joints that
K-wires are inserted through has not been performed yet.
In this study, K-wire application was investigated in
terms of articular surface damage and efficiency of immobi-
lization in postburn flexion contractures. Clinical parameters
were total active motion (TAM), grip, and pinch force mea-
surements, and radiodiagnostic parameters were magnetic
resonance (MR) and radionuclide imaging.
PATIENTS AND METHODS
Between 1999 and 2004, 165 patients with postburn
flexion contracture deformity were accepted to our clinic.
Fifty-four patients with concurrent bone and joint deformity
and 59 patients who were lost for follow-up were excluded
from the study. The study was carried out on 198 fingers of
72 patients. Thirty-seven patients were male and 35 were
female. Mean age was 11.3 years (range, 2–22 years). Most
common etiologic factor was thermal injury, whereas the
middle finger was the most commonly involved. In 33 pa-
tients, the left hand, in 30 patients, the right hand, and in 9
patients, both hands were involved. Metacarpophalangeal
(MCP) joint involvement was the most common, followed by
PIP involvement. Mean follow-up period of the patients was
32 months.
Motion range and extension limitations of the MCP,
PIP and DIP joints were recorded by using a finger goniom-
eter. The lack of extension in each joint is added and the sum
is subtracted from the total amount of flexion to calculate
TAM. Results were graded according to criteria outlined by
the American Society for Surgery of the Hand. In comparison
with the TAM of the unaffected hand, 100% was evaluated as
excellent, 75%–99% as good, 50%–74% as fair, and less than
50% as poor. Grip and pinch forces were evaluated using a
hand dynamometer and pinch meter, respectively. Mean
value of 3 consecutive measurements was recorded for each
joint. Dominant-hand grip force was accepted to be 100%–
120% of the nondominant side. Hence, a grip force value of
80% and above of the unaffected hand was claimed to be “good”
in the presence of dominant hand involvement, whereas 60% of
the unaffected hand was adequate to be classified as “good”
when the nondominant hand was involved.
All the patients underwent MRI preoperatively and
postoperatively at 6th and 24th months, excluding children
aged under 10 years in whom technical merits limited the use
of this technique. On the other hand, radionuclide imaging of
the digital joints was performed preoperatively and postop-
eratively at the 6th month and 2nd year in all age groups.
MRI consisted of saggital and coronal images with
T1-weighted (spin echo, TR450/TE25) and T2 (gradient
echo, TR500/TE 25) images. All scans were performed with
a GE Vectra 0.5 Tesla scanner using a 3-inch surface coil.
Elscint SPX-6 gamma camera and general-purpose par-
allel hole collimator were used for scintigrams. During the
radionuclide evaluation, the patients were seated in front of
the gamma camera with their palms down on the face of the
collimator. A bolus injection of 10 –20 mCi of Tc-99m MDP
(Tc-99m-methylene diphosphonate) was made via an antecu-
© 2006 Lippincott Williams & Wilkins
bital vein of the unaffected side. Sequential 1-second images
were obtained from bilateral hands, wrist, and forearm for
64 seconds. Without altering the position, a 500,000-count
blood-pool image was then taken immediately. Three to 4
hours after the injection, delayed 500,000-count images were
taken with the same collimator.
Nineteen patients were operated under local anesthesia
and 53 under general anesthesia. Severity of the deformity
was the key factor in determining the surgical procedure to be
performed; Z-plasty, local flaps, or excision and skin grafting
was used for contracture release. Volar plate was detached
from the phalanx when adhesion formation between the volar
plate and the condylar head of the proximal phalanx was
observed. As well as that, collateral ligaments were excised in
the presence of contracture of the collateral ligaments. Then,
a trocar type K-wire was inserted to the distal fingertip and
driven to the distal phalanx with the aid of a hand perforator.
After passing through the DIP, PIP, and MCP joints, com-
plete immobilization of the digit in full extension was
achieved. A bulky noncompressive wrap was applied to the
hand, and the operation was finalized. Mean hospitalization
period was 2.3 days.
Major infection was not noted during the postoperative
follow-up of the patients. Partial flap necrosis necessitated
reoperation in 5 patients. Dermal sloughing of the flaps in 9
patients and partial graft loss in 12 patients healed second-
arily with daily wound care.
After the removal of K-wires at the end of the postop-
erative third week, a home program of active assistive exer-
cise was begun in all patients.
A Kleinert type volar dynamic splint was applied,
maintaining the wrist in 40 – 45 degrees of extension and
MCP, PIP, and DIP joints in neutral position.
In conjunction with the home exercise program, splints
were used continuously all through the day for the first 3
months, followed by night splinting for an additional 3
months to maintain operative gains.
TAM values of all patients were calculated based on
goniometric measurements at the 6th month. Grip and pinch
force measurements were also repeated.
MRI and radionuclide studies were repeated at postop-
erative 6th and 24th months.
Statistic analysis of the data derived from goniometric,
grip, and pinch force measurements was made using Wil-
coxon signed rank test, and P ⬍ 0.05 was considered to be
statistically significant.
RESULTS
Mean pre- and postoperative TAM values were 84.3 ⫾
28.3 and 253.6 ⫾ 34.1, respectively. Statistically significant
difference put forward the efficiency of the treatment pro-
gram (P ⬍ 0.05) (Table 1).
Pre- and postoperative grip-force values were 2.1 ⫾ 1.2
and 4.3 ⫾ 1.3, respectively (P ⬍ 0.01) (Table 2).
Mean pre- and postoperative pinch-force values were
3.1 ⫾ 2.1 and 6.0 ⫾ 2.5, respectively (P ⬍ 0.05) (Table 3).
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Sungur et al Annals of Plastic Surgery • Volume 56, Number 2, February 2006

tional recovery has the priority in the treatment of these

TABLE 1. Pre- and Postoperative TAM Values
patients, and early intervention is essential to prevent func-
n Mean SD Wilcoxon ␹2 P tional impairment.9 On the other hand, patients admitted with
Preop TAM 72 84.3 28.3 a severely deformed hand should undergo an aggressive
Postop TAM 72 253.6 34.1 2.39 0.02* treatment protocol after determining the etiologic factor and
*P ⬍ 0.05. the extent of the deformity.
K-wires for graft immobilization after the excision of
mild contractures is among of the most commonly applied
TABLE 2. Pre- and Postoperative Grip-Force Values procedures. However, reconstruction is more challenging
n Mean SD Wilcoxon ␹2 P when the underlying tendon is exposed. Cross-finger or
Preop grip 72 2.1 1.2
various other local and distant flaps were successfully used to
Postop grip 72 4.3 1.3 2.39 0.01* overcome this problem.7,10 Smith11 used the skin graft as a
biologic dressing to minimize further damage and deferred
*P ⬍ 0.01.
the performance of a more definitive procedure until the
general condition of the patient and the condition of the local
TABLE 3. Pre- and Postoperative Pinch-Force Values tissues are conducive.
Gradual shortening of the collateral ligaments, flexor
n Mean SD Wilcoxon ␹2 P
tendons, and neurovascular structures is responsible for the
Preop pinch 72 3.1 2.1 recurrence of the deformity after complete release of the
Postop pinch 72 6.0 2.5 2.37 0.02* contracture. Effective stretching of these structures with
*P ⬍ 0.05. the insertion of K-wire satisfactorily overcomes this prob-
lematic situation.
In their clinical study, Jackson and Brown7 argued with
In the view of these data, a statistically significant earlier findings of electron microscopic studies demonstrating
improvement in terms of TAM, grip, and pinch force was permanent epiphyseal plaque and articular surface damage
achieved with our treatment protocol (Table 4). due to fibrosis and scar formation with the K-wire penetration
Morphometric study was carried out with the MRI of of the joint. They strongly denied this phenomenon based on
the finger joints. All preoperative, postoperative 6th-month, their clinical and radiographic observations. As well as that,
and 2nd-year MR images were evaluated by the same radi- McGregor and Jackson12 failed to show any digital growth
ology specialist devoid of any clinical information, and de- abnormality and damage to joints. Their findings were also
generative lesions on the articular surface, joint space nar- supported by Stern et al.8 Alexander et al3 also reported
rowing, effusion formation, or other findings of articular normal digital growth pattern in 68 children with postburn
surface damage were investigated. However, findings of per- flexion contracture deformity. In all of these studies, K-wire
manent articular surface damage that might be attributable to was claimed to be an efficient and safe procedure for the
K-wire fixation could not be documented with MRI.
treatment of flexion contractures.
Preoperative and postoperative 6th- and 24th-month
Larson13 affirmed the beneficial effects of K-wire usage
scintigrams were evaluated by the same nuclear medicine
in complete graft take in burned hands, but Boswick14 re-
specialist unaware of the clinic of the patients. Radionuclide
stricted the use of internal fixation to ankylosis and arthro-
uptake of the affected digital joints was compared with
desis only. Gronley15 stressed higher incidence of infection in
unaffected adjacent or contralateral finger joints. Three-phase
burn patients. Nevertheless, in a discussion of an article by
radionuclide scintigraphy of the hand demonstrated metabolic
activity of the bone, vascularity, and perfusion of the bone. McCormick, Frackelton16 declared successful results with
Postoperative scintigrams failed to document findings of low complication rate in early PIP internal fixation. Achauer
permanent articular damage after K-wire removal. et al17 mentioned the importance of daily wound care and
hydrotherapy for the prevention of infection in patients un-
dergoing K-wire fixation.
DISCUSSION
Today, K-wire fixation of the affected joints for 2 or 3
Contracture deformity and joint stiffness are among the
weeks, followed by long-term night splinting, is the standard
most common complications following hand injury. Func-
treatment protocol for severe postburn deformity in the ma-
jority of the plastic and reconstructive surgery clinics.2
TABLE 4. Pre- and Postoperative TAM, Grip- and Pinch- Smith11 stressed the importance of K-wire fixation in
Force Values Indicating the Efficiency of the Treatment pediatric postburn flexion contractures to prevent the recur-
Protocol rence of the deformity and encouraged joint immobilization
Preoperative Postoperative with Kirschner pins for 5 to 6 weeks, without any risk of
Parameter (n ⴝ 72) (n ⴝ 72) P permanent joint stiffness. The author strongly emphasized
TAM 84.3 ⫾ 28.3 253.6 ⫾ 34.1 ⬍0.05
that K-wire removal in the very early stages of wound
Grip 2.1 ⫾ 1.2 4.3 ⫾ 1.3 ⬍0.01
healing would inevitably result in recurrence owing to the
Pinch 3.1 ⫾ 2.1 6.0 ⫾ 2.5 ⬍0.05
effort of the child to obtain a pain-relieving position, so
advocated postponing the removal of K-wires until heal-

130 © 2006 Lippincott Williams & Wilkins

Annals of Plastic Surgery • Volume 56, Number 2, February 2006 Kirschner-Wire Fixation for Postburn Flexion Contracture Deformity
ing was more complete. As well as that, wound dressing
change was claimed to be unnecessary for 2–3 weeks,
unless findings of infection was observed.11
As wound healing is a dynamic process which encom-
passes a long period, risk of recurrence cannot be eliminated
with absolute immobilization for 3 weeks in the very early
phases. Many previous studies pointed out this risk and
recommended usage of long-term splinting with or without
additional surgical procedures.18 –21
In this study, continuous splinting for 3 months, fol-
lowed by night splinting for another 3 months, was preferred
after the removal of the K-wires. Constant corrective force
was applied via elastic rubber bands assembled to the dy-
namic splint. The aim of this procedure was to create a vector
opposite to the contracture forming forces, while limited
passive finger motion is permitted to prevent permanent joint
stiffness.13
Dynamic splinting accompanied by the daily physio-
therapy program is also essential to prevent late postoperative
deformities and to preserve hand functions.4
Many different techniques were proposed to reveal
inflammatory or noninflammatory cartilage lesions.22–25 Di-
rect radiographs are reliable in demonstrating bony lesions
but give poor or indirect information about the lesions of the
soft tissue and cartilage. MR imaging of the finger has been
studied thoroughly in recent years.26 –29 Erickson et al26
documented normal finger anatomy, including the joint space,
and proposed MRI as the only noninvasive technique that
could visualize cartilage in 3 dimensions in arbitrary orien-
tations. The consistency of high-resolution images was sup-
ported in various reports.26 –29 Wong et al30 measured carpal
tunnel, carpal bones, and proximal interphalangeal dimen-
sions in healthy volunteers. Lahn et al31 suggested the effi-
cacy of MRI before and after arthroscopic management of
osteochondral lesions of talus.
In 1995, Peterfy et al32 proposed fat-suppressed T1-
weighted 3D MR imaging to allow precise measurement of
articular cartilage volume in the MCP joint.
Lewis and coworkers33 correlated histologic evaluation
of proximal interphalangeal lesions with MRI and demon-
strated the accuracy of MRI in even small lesions such as
osteophytes and cartilage erosions.
Radionuclide imaging has been shown to be a useful
tool for evaluating conditions affecting the hand joints since
the mid-1950s.34 –36 Although 131 I-HAS was the first agent
employed for joint imaging, poor image quality and pro-
longed immobilization restricted its clinical use. Today,
99mTc is the universally recognized agent used for this
purpose. Low radiation exposure and improved image quality
in multimillicurie doses are the main advantages.37– 41
Radionuclide joint imaging has been performed on a
routine basis at some institutions since 1964.36 Maxfield et
al42 studied normal joint pattern in patients with no joint
disease history, but a detailed definition was not given.
Martinez-Villanseňor et al43 defined the normal pattern as
“symmetrical uptake.” Afterward, many authors focused on
the definition of “scintigraphic normal pattern,” but a detailed
description has yet to be made.44 Scintigraphic appearance of
© 2006 Lippincott Williams & Wilkins
the normal joint, variations, and artifacts have been defined in
more recent studies.45 Asymmetric uptake in the paired joints
is accepted to be “abnormal” in modern practice.41
In our study, 72 patients with flexion contracture de-
formity of the hand were assessed in association with phys-
ical therapy and rehabilitation clinic, radiology, and nuclear
medicine departments. All patients underwent a standardized
treatment protocol of surgical release of the contracture,
application of K-wires for 3 weeks, and continuous use of
dynamic splints for the first 3 months, followed by night-
splinting alone for another 3 months. This protocol was
formed on the basis of the data existing in the literature and on
our clinical experiences.7,11,12,16,17,46 Infection, functional def-
icit, or articular damage due to K-wire use was not observed,
in concurrence with earlier reports regarding the reliability of
K-wires. Efficiency of the treatment protocol was evaluated
clinically by TAM, grip-, and pinch-force values obtained
from goniometric measurements. In addition, MRI and scin-
tigrams were also used. Assessment of the data obtained
emphasized that K-wire fixation did not cause any permanent
articular damage contrary to some earlier reports.10,14,15,47
Satisfactory functional recovery was accomplished in the late
operative period.
Evaluation of the postoperative MR and radionuclide
images showed no articular surface pathology that might be
attributable to K-wire use. TAM, grip, and pinch measure-
ments also supported the radiologic findings. K-wire fixation
provided effective immobilization of the fingers, which re-
sulted in complete graft take. Increased incidence of infection
with K-wire fixation that had been reported in earlier studies
was not observed in our study. K-wire fixation was well
tolerated by the patients included in the study.
As a conclusion, after the surgical release of flexion
contractures, immobilization with K-wires not only prevents
the recurrence of the deformity in the early phases of wound
healing but also facilitates complete graft take by effective
stabilization without any permanent articular damage.
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