Huber et al. Journal of Medical Case Reports 2012, 6:209 http://www.jmedicalcasereports.com/content/6/1/209 Page 2 of 3 Figure 1 Initial X-ray after injury (a) and control X-ray after the osteosynthesis (b). 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 instabil- ity 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 appar- ent. In addition, the ring finger tended to cross over and overlap the adjacent finger when making a fist. The pa- tient reported that ulna deviation of the ring finger started when K-wires had been removed by an office-based ortho- pedic surgeon two months after the initial surgery. Since that time the finger was fixed again with a splint. He also complained about tingling, coolness and numb- ness of the injured finger. Since the X-ray showed a non- union (Figure 2a) we started treatment with a LIPUS device (Fa. Melmak GmbH, Munich, Germany) three times daily for 20 minutes including the following par- ameter configuration: 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. The ring finger was immobilized with a fitted persona- lized thermoplastic splint (Figure 3a) for six weeks. Six weeks after LIPUS treatment the patient reported to be without pain when moving his ring finger and clinical examination revealed a slight persistent ulna deviation of five degrees. The clinical examination showed a stable middle phalanx compared to the result six weeks previ- ously. After four weeks of physiotherapy the ROM of the PIP joint was E/F 0-0-85° and the fist closure was full (Figure 3b), except for the pre-existent limited ROM of the DIP-Joint (E/F 0-0-15˚). An X-ray confirmed fracture healing and calcification of the soft callus was clearly evident (Figure 2b). Discussion 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 osteo- synthesis [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 [7] but sec- ond surgical intervention causes new or repeated soft tis- sue 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 ultra- sound achieved bone healing in 85 % of cases [8] which was confirmed by other studies [9-12]. In a recently pub- lished 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 [1]. In this case, there had been a three month splinting without Figure 2 Control X-ray five months after initial operation (a); X-ray six weeks after LIPUS therapy (b). Figure 3 Personalized thermoplastic splint (a) and the functional result eight months after the initial trauma (b).