ORIGINAL ARTICLE
The Suzuki Frame for Complex Intra-articular Fractures of
the Proximal Interphalangeal Joint of the Fingers
Evangelos Keramidas, MD, EBOPRAS, Markos Solomos, MRCS, Robert E. Page, FRCS,
and Gavin Miller, FRCS (Plast) Eng
Abstract: In 1994, Suzuki et al proposed the pins-and-rubbers
traction system, a new dynamic distraction technique for difficult
complex intra-articular fractures of the digits of the hand. From
February 1999 to April 2003, we used the Suzuki frame for 15
complex fractures of the proximal interphalangeal joint of the
fingers. The mean follow-up period was 18 months. Four patients
missed their follow-up. In the remaining 11 patients, the mean active
range of motion achieved following treatment was 84° in the
proximal interphalangeal joint finger injuries.
Key Words: Suzuki frame, intra-articular digital fractures,
fracture-dislocation PIP joint
(Ann Plast Surg 2007;58: 484 – 488)
C omplex fracture-dislocations or comminuted intra-artic-
ular fractures with joint surface misalignment are chal-
lenging hand injuries. The ideal combination of anatomic
reduction and stable fixation of the fracture fragments, fol-
lowed by early mobilization to prevent joint stiffness, is the
ideal treatment. Suboptimal treatment of these injuries can
lead to the difficult complications of joint stiffness, pain, and
degenerative arthrosis. Of the many and varied treatment
modalities available, those involving distraction-mobilization
of the involved joint to maintain articular integrity through
capsuloligamentotaxis (traction on capsular and periarticular
soft tissues resulting in reduction of displaced fracture frag-
ments) seem logical and relatively noninvasive. The early
devices were often unwieldy and difficult to fabricate until
Suzuki et al1 in 1994 described a new and compact skeletal
traction system for comminuted intra-articular fractures and
fracture-dislocations of the proximal interphalangeal joint
(PIPJ) of the hand, the pins-and-rubbers traction system
(PRTS).
Received April 1, 2006, and accepted for publication, after revision, July 27,
2006.
From the Department of Plastic and Reconstructive Surgery, Sheffield
Teaching Hospitals, Northern General Hospital, Sheffield, UK.
Reprints: Evangelos Keramidas, MD, EBOPRAS, 3 Cheviot Court, Luxbor-
ough Str, London, W1U 5BH UK. E-mail: plastker@yahoo.com.
Copyright © 2007 by Lippincott Williams & Wilkins
ISSN: 0148-7043/07/5805-0484
DOI: 10.1097/01.sap.0000244975.89885.c7
484
PATIENTS AND METHODS
From February 1999 to April 2003, 15 patients in our
unit had a Suzuki frame applied for complex finger fractures.
Four patients were lost to follow-up. Of the remaining 11
patients, 6 had a comminuted PIPJ fracture and 5 a PIPJ
fracture-dislocation. Five of the fractures occurred playing
cricket, 4 playing rugby, 1 from a fall, and 1 from ice hockey.
The most common injured finger was the middle finger (6
cases). The mean age was 30 years (range, 18 –52) and there
were 9 men and 2 women. The mean time between injury and
surgery was 3 days. Seven operations were performed under
digital-block anesthesia and 4 under general anesthesia. Ex-
ternal traction was applied for 4 weeks under the supervision
of the hand therapists. The mean follow-up period was 18
months.
Surgical Technique
The technique used for the application of the Suzuki
frame was exactly as described by Suzuki et al1 in their
original paper. A long 1.2-mm-diameter Kirschner wire is
inserted transversely through the skeleton proximal to the
fracture as close as possible to the axis of rotation of the
involved joint. This is the “axial traction pin.” A shorter
thinner wire (eg, 0.9- or 1.0-mm diameter) is placed in the
skeleton distal to the fracture. This is the “hook pin.” The
ends of both pins are bent into hooks, with the assistance of
strong forceps and a suction cannula, so that rubber bands can
be applied on both sides of the finger to apply traction. The
strength of the elastic traction can be adjusted by the thick-
ness and a number of the elastic bands used. All the wires
must be parallel to the axis of the finger (Fig. 1A–E). We
recommend placing small squares of Elastoplast (Beiersdotf
AG, Hamburg, Germany) on the sharp ends of the cut wires
to prevent accidental injury occurring while the frame is in
situ. The 2 K-wire device is suitable for comminuted frac-
tures (Fig. 2A–D) For dorsal fracture-dislocations of the
PIPJ of the fingers, a third type of pin, the “reduction pin”
(0.9- or 1.0-mm diameter) is inserted through the base of the
dorsally displaced middle phalanx. The 2 ends of this short
pin are bent upwards so that this pin lies underneath the limbs
of the axial traction pin, producing a palmar-directed force on
the displaced fragment (Fig. 3A–E).
Postoperative Care
Patients were normally discharged the first postopera-
tive day and after they had seen the physiotherapists. All
Annals of Plastic Surgery • Volume 58, Number 5, May 2007
Annals of Plastic Surgery • Volume 58, Number 5, May 2007 Suzuki Frame for Complex Intra-articular Finger Fractures

FIGURE 1. Construction of the Su-

zuki frame. A, The axial traction,
the hook, and the reduction pin in
place. The strong forceps and the
suction cannula for the creation of
the hooks. B, C, The creation of the
hooks. D, The rubber bands and
the protective Elastoplast in place.
E, Good mobility of the finger with
the Suzuki frame in place.

FIGURE 2. A, Comminuted intra-

articular fracture of the PIP joint of
the little finger. B, Application of
the Suzuki frame. C, D, One-year
postoperative results.

© 2007 Lippincott Williams & Wilkins 485

Keramidas et al
FIGURE 3. A, Fracture-dislocation
of the PIP joint of the ring finger.
B, Suzuki frame in place. C, D,
Thirteen-month-postoperative re-
sults. E, Lateral radiographic view
of the healing fracture.
patients were advised about pin-site care before discharge.
Patients were followed up clinically and radiologically every
week for 4 weeks. “Overdistraction” was easily recognizable
on x-ray and rectified by adjusting tension in the elastic
bands. Our physiotherapists started active mobilization as
soon as possible postoperatively. Patients underwent physio-
therapy twice weekly for 4 weeks, at which point the device
was removed (in the dressing clinic and without the need for
anesthesia). Patients continued to receive physiotherapy ev-
ery 2 weeks for an additional 4 – 6 weeks or until no further
improvement was detected. At that stage, referral was made
to the occupational therapists for fabrication of custom-made
pressure garments or for static splintage of joint contractures.
RESULTS
The mean follow-up period was 18 months. There were
2 cases of infection that were treated successfully with oral
antibiotics, without removal of the frame. The device was
tolerated by patients, without any major complaints. The
mean total active range of motion for PIP fractures of the
fingers was 84 degrees (range, 50 –105°) (Table 1). Radio-
logic evidence of post-traumatic osteoarthrosis with joint
space narrowing was observed in 5 cases (Fig. 4), although
none of these patients complained of pain or stiffness of the
486
Annals of Plastic Surgery • Volume 58, Number 5, May 2007
joints. All patients were pain-free except for one who under-
went arthrodesis of the injured joint 1 year postinjury. All the
other patients were happy with the functional results of the
treatment with the Suzuki frame.
DISCUSSION
The treatment of complex intra-articular fractures af-
fecting the hand remains controversial. This is possibly be-
cause there is no universally accepted method of treatment
that can produce predictably good results in every case.
Patients are understandably intolerant of an unsatisfactory
result following treatment of their injury if they develop
significant problems with pain and stiffness of their hands. Of
the many different treatment modalities that have been sug-
gested for these injuries, open reduction and internal fixation2
or distraction-mobilization would seem to be the most attrac-
tive options as both methods allow early mobilization, which
usually prevents joint stiffness. However, open reduction and
internal fixation is most successful in 2-part fractures without
comminution and large fracture fragments (this is unusual,
and most fractures are more comminuted than this). Even in
ideal circumstances, the surgical dissection involved in fixing
these fractures increases the tissue trauma load and may
further increase any joint stiffness and functional impairment
© 2007 Lippincott Williams & Wilkins
Annals of Plastic Surgery • Volume 58, Number 5, May 2007 Suzuki Frame for Complex Intra-articular Finger Fractures

TABLE 1. Range of Motion of Proximal Interphalangeal Joint

Full Range of
Follow-up Flexion of PIPJ Extension of PIPJ Movement Type of
Patient No. (Months) (Degrees) (Degrees) (Degrees) Injury
1 26 100 0 100 FD
2 26 105 0 105 FD
3 24 70 ⫺20 50 CIF
4 22 85 ⫺10 75 CIF
5 20 90 0 90 CIF
6 20 85 0 85 FD
7 18 95 ⫺10 85 FD
8 12 90 ⫺20 70 CIF
9 12 90 0 90 CIF
10 09 95 ⫺15 80 FD
11 09 100 0 100 CIF
Mean 18 91.36 ⫺6.818 84.54
CIF, comminuted intra-articular fracture; FD, fracture-dislocation; PIPJ, proximal interphalangeal joint.

Nevertheless, early mobilization of a damaged joint is

FIGURE 4. Left, Anteroposterior and (right) lateral radio-
graphic views of the PIP joint of the ring finger at 16
months’ follow-up. Evidence of post-traumatic osteoarthro-
sis, osteophyte formation, joint space narrowing, and sub-
chondral sclerosis.
resulting from the injury. There is also uncertainty as to
whether articular congruity following treatment is essential
for the minimal load-bearing joints of the hand.3,4
Most of the other available techniques, such as a static
splintage, dorsal extension block splintage,5 and closed re-
duction with K wire fixation,6 involve immobilizing the joint
for a significant period of time. This is usually considered to
be undesirable by most hand surgeons. However, the evi-
dence for selecting one treatment modality in preference to
another is lacking for this type of injury, and the results of
some studies seem somewhat counterintuitive. For example,
one of the very few comparative studies that have been
published in this area7 showed that closed reduction and
transarticular K-wire fixation of dorsal fracture-dislocations
of the PIPJ did as well as open reduction and internal fixation
followed by early mobilization. This is despite the fact that
the joint was transfixed by a K wire for 3– 4 weeks before
movements could commence.
likely to promote osteochondral remodeling and reduce the
formation of intra- and periarticular adhesions, reducing the
incidence of stiffness and late joint contracture.8 In addition
“traction” capsuloligamentotaxis also prevents collapse of frac-
ture fragments and contractures of the collateral ligaments and
volar plate, thus further reducing the risk of joint stiffness.3
Therefore, for complex intra-articular fractures involving the
hand, distraction-mobilization using some form of external de-
vice would theoretically appear to be a better alternative to any
therapeutic alternative that involves immobilization.
Many different external dynamic splintage devices
have been described, usually for the treatment of fracture-
dislocation and intra-articular fractures of the PIPJ of the
finger. The banjo system9 was the prototype distraction de-
vice, but compared with newer devices it is very bulky. The
force couple splint of Agee10 does not produce capsuloliga-
mentotaxis and, like the extension block pin technique,11
cannot be used for comminuted fractures of the PIPJ. The
Inanami device12 is similar to the Suzuki frame but is more
complicated. The “S” Quattro13 is again relatively compli-
cated technically and does not allow much joint movement.
Gaul and Rosenberg14 and Hynes and Giddins15 both used a
very similar type of a simple dynamic external fixator, but
they used it only for pilon fractures. Other devices have been
described by Syed et al16 and Allison.17
We used the Suzuki frame to treat 6 comminuted
intra-articular fractures and 5 fracture-dislocations of the PIP
joint of the fingers. The results are comparable with the
results of other studies1,3,18 –20 (Table 2). In our study, we had
a functional total mean range of PIPJ motion of 84.5 degrees.
Closely looking the results, we see that the fracture-disloca-
tion injuries have a better joint movement than the commi-
nuted fractures, 91 degrees as opposed to 79 degrees. The
frame failed in one patient who had sustained a comminuted
fracture. This patient developed a fixed flexion deformity and
pain. He underwent arthrodesis of the PIP joint 1 year
postoperatively. Five of our patients developed radiographic
evidence of osteoarthritis but with no pain.

© 2007 Lippincott Williams & Wilkins 487

Keramidas et al Annals of Plastic Surgery • Volume 58, Number 5, May 2007

5. Hamer DW, Quinton DN. Dorsal fracture subluxation of the proximal

TABLE 2. Review of Studies After the Application of interphalangeal joints treated by extension block splintage. J Hand Surg
Suzuki Frame (Br). 1992;17:586.
Mean Mean Active 6. Newington DP, Davis TRC, Barton NJ. The treatment of dorsal fracture-
Follow-up Range of dislocation of the proximal interphalangeal joint by closed reduction and
Studies No. Cases (Months) Motion Kirschner wire fixation: a 16 year follow-up. J Hand Surg. 2001;26B:
537–540.
Suzuki et al, 19941 5 13.1 80° 7. Aladin A, Davis TRC. Dorsal fracture-dislocation of the proximal
de Soras et al, 199718 11 9.7 84% interphalangeal joint: a comparative study of percutaneous Kirschner
Duteille et al, 200319 13 18 85.9° wire fixation versus open reduction and internal fixation. J Hand Surg.
Majumder et al, 20033 13 20 74° 2005;30:120 –128.
8. Salter RB, Simmonds DF, Malcolm BS, et al. The biological effect of
Present study 11 18 84°
continuous passive motion on the healing of full-thickness defects in
articular cartilage: an experimental investigation in the rabbit. J Bone
Surg (Am). 1980;62:1232.
The Suzuki frame is a distraction-mobilization device 9. Schenck RR. Dynamic traction and early passive movement for fractures
that uses the principles of capsuloligamentotaxis and early of the proximal interphalangeal joint. J Hand Surg (Am). 1986;11:850.
mobilization to achieve articular realignment and healing. 10. Agee JM. Unstable fracture dislocation of the proximal interphalangeal
joint of the fingers: a preliminary report of a new treatment technique.
The device is capable of treating a wide range of complex J Hand Surg (Am). 1978;3:386.
intra-articular fractures involving the hand, including the 11. Twyman RS, David HG. The doorstop procedure. J Hand Surg (Br).
interphalangeal joint (IPJ) fractures of the fingers and IPJ, 1993;18:714.
metacarpophalangeal joint (MCPJ), and first carpometacarpal 12. Inanami H, Ninomiya S, Okutsu I, et al. Dynamic external finger fixator
joint (CMCJ) fractures of the thumb.1,21 for fracture dislocation of the proximal interphalangeal joint. J Hand
Surg. 1993;23A:368 –380.
Most patients can be treated under local anesthesia. Al-
13. Fahmy MR. The Stockport serpentine spring system for the treatment of
though pin-tract care is important, infection can be controlled displaced comminuted intra-articular phalangeal fractures. J Hand Surg
with oral antibiotic therapy if it develops. The Suzuki frame is (Br). 1990;15:303.
usually well tolerated, although we recommend covering the 14. Gaul SJ, Rosenberg SN. Fracture-dislocation of the middle phalanx at
sharp end of the device with small squares of Elastoplast to the proximal interphalangeal joint: repair with a simple intradigital
prevent scratches or other injuries or problems dressing/undress- traction-fixation device. Am J Orthopaed. 1998;10:682.
15. Hynes MC, Giddins EB. Dynamic external fixation for pilon fractures of
ing. Regular physiotherapy or occupational therapy supervision the interphalangeal joints. J Hand Surg (Br). 2001;26B:122–124.
postoperatively is required to optimize the results and to identify 16. Syed AA, Agarwal M, Boome R. Dynamic external fixator for pilon
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complex fracture. J Hand Surg (Br). 2003;28B:137.
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