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Trial registered on ANZCTR

Registration number
Ethics application status
Date submitted
Date registered
Date last updated
Date data sharing statement initially provided
Type of registration
Prospectively registered

Titles & IDs
Public title
The Plate or Screw in Proximal Phalangeal Fractures [POSI-P1]
Scientific title
A randomised controlled trial assessing total active motion in dorsal plating, lateral plating and intramedullary screws for displaced extra-articular proximal phalangeal fractures: the POSI-P1 Trial.
Secondary ID [1] 302608 0
Universal Trial Number (UTN)
Trial acronym
POSI-P1 trial
Linked study record

Health condition
Health condition(s) or problem(s) studied:
Proximal phalangeal fractures 319497 0
Condition category
Condition code
Surgery 317460 317460 0 0
Surgical techniques

Study type
Description of intervention(s) / exposure
The exposure will be extra-articular proximal phalangeal fractures in adult patients [>18 years old], assessing extensor tendon splitting dorsal plating, extensor tendon sparing lateral plating and extensor tendon sparing intra-medullary screw fixation. In terms of the interventions administered:

1. Lateral plating involves a skin incision, and subluxation of the tendon to visualise the fracture. The plate is placed on the side of the bone [lateral position] and appropriate screws are used to fix the fracture, before the skin is closed. The operation will take roughly an hour, and will be performed by either qualified surgeons, or registrars under the guidance of surgeons

2. Intramedullary screw fixation involves a small percutaneous skin incision, before a guide wire is passed either antegrade [through the base of the proximal phalanx] or retrograde [through the end of the proximal phalanx] past the fracture. The fracture is reduced into an appropriate position, and a cannulated screw is inserted over the wire into the medullary canal of the phalanx to secure the fracture. The percutaneous skin incision is then closed. The operation will take roughly an hour, and will be performed by either qualified surgeons, or registrars under the guidance of surgeons
Intervention code [1] 318893 0
Treatment: Surgery
Comparator / control treatment
Dorsal plating is the current standard of care. Dorsal plating involves a skin incision and a longitudinal extensor tendon split, which allows access to the fracture. A plate is placed underneath the tendon [dorsal on the bone] with appropriate screws to fixate the fracture, before the tendon is repaired. This surgery takes roughly one hour, and will be administered once by trained orthopaedic or plastic surgeons, or training / non-training plastics and orthopaedic registrars under the guidance of trained surgeons.
Control group

Primary outcome [1] 325492 0
Total active digital motion, as measured by a hand therapist using a goniometer
Timepoint [1] 325492 0
This will be measured at 6 weeks, 3 months, 6 months and 12 months post-operative. The primary timepoint will be the 12 month measurement
Secondary outcome [1] 388150 0
Patient reported outcome measures [The Quick Disabilities of Arm, Shoulder & Hand (QuickDASH) and the Michigan Hand Questionnaire (MHQ)], as a composite secondary outcome
Timepoint [1] 388150 0
This will be measured at 6 weeks, 3 months, 6 months and 12 months post-operative. The major timepoint of interest will be the 12 month measurement
Secondary outcome [2] 388151 0
Complications [infection, malunion or non-union], as assessed during the routine follow-up at 6 weeks, 3 months, 6 months and 12 months post-operative, as well as via review of the patient medical records
Timepoint [2] 388151 0
This will be measured at 6 weeks, 3 months, 6 months and 12 months post-operative. If the patient returns at any other time point due to one of these issues, this, too, will be recorded.The major timepoint of relevance will be the 12 month measurement
Secondary outcome [3] 388152 0
Rates of hardware removal, again as assessed during the routine follow-up as well as review of the patient medical records
Timepoint [3] 388152 0
Again, this will be measured and recorded at the 6 week, 3 month, 6 month and 12 month post-operative visits, with the major timepoint of relevance being the 12 month assessment.

Key inclusion criteria
Displaced extra-articular diaphyseal proximal phalangeal fracture on radiographs
Presentation within 14 days of injury
Skeletal maturity
Aged over 18 years old
Able to provide informed consent
Minimum age
18 Years
Maximum age
No limit
Both males and females
Can healthy volunteers participate?
Key exclusion criteria
Co-morbidities precluding surgery
Associated soft tissue injury [open / tendon damage]
Pathological fracture
Fracture only amenable to one mode of fixation, as decided by consultant surgeon
Unable to be compliant with rehabilitation or follow-up

Study design
Purpose of the study
Allocation to intervention
Randomised controlled trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
Central randomisation by computer
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Simple randomisation using a randomisation table created by computer software
Masking / blinding
Blinded (masking used)
Who is / are masked / blinded?

The people assessing the outcomes
The people analysing the results/data
Intervention assignment
Other design features
Not Applicable
Type of endpoint(s)
Statistical methods / analysis
For the sample size calculation, the level of significance was 0.05 with a 2-sided test. Based on the work of Abubeih and Robinson, the standard deviation was set at 30.0. A minimum clinically important difference was judged to be 15.0 degrees in total active motion. With these parameters, a sample size of 64 per arm would be required to achieve a power of 80%. The sample size will be increased by 6 per arm to allow for early participant dropouts. Therefore, the sample size per arm will be 70, and 210 in total. It is projected that approximately 18 participants will be recruited at each site. Potential recruitment is believed to be fairly even across the sites, with no reason to believe that one site will experience increased recruitment compared to the others

Baseline demographic and injury data will be recorded and compared to ensure equality of all 3 treatment arms. This study will be assessed on an intention to treat basis, with any treatment switching reported and analysed separately. All outcomes data will be reported as means with ranges and standard deviations. All testing for associations will be 2-sided and reported with a 95% confidence interval, with the null hypothesis being rejected at a p value less than or equal to 0.05.

Recruitment status
Not yet recruiting
Date of first participant enrolment
Date of last participant enrolment
Date of last data collection
Sample size
Accrual to date
Recruitment in Australia
Recruitment state(s)
Recruitment hospital [1] 17885 0
Royal North Shore Hospital - St Leonards
Recruitment hospital [2] 17886 0
Hornsby Ku-ring-gai Hospital - Hornsby
Recruitment hospital [3] 17887 0
The Northern Beaches Hospital - Frenchs Forest
Recruitment hospital [4] 17888 0
Fairfield Hospital - Prairiewood
Recruitment hospital [5] 17889 0
Sydney Hospital and Sydney Eye Hospital - Sydney
Recruitment hospital [6] 17890 0
Gold Coast University Hospital - Southport
Recruitment hospital [7] 17891 0
Robina Hospital - Robina
Recruitment hospital [8] 17892 0
Varsity Lakes Day Hospital - Varsity Lakes
Recruitment postcode(s) [1] 31742 0
2065 - St Leonards
Recruitment postcode(s) [2] 31743 0
2077 - Hornsby
Recruitment postcode(s) [3] 31744 0
2086 - Frenchs Forest
Recruitment postcode(s) [4] 31745 0
2176 - Prairiewood
Recruitment postcode(s) [5] 31746 0
2000 - Sydney
Recruitment postcode(s) [6] 31747 0
4215 - Southport
Recruitment postcode(s) [7] 31748 0
4226 - Robina
Recruitment postcode(s) [8] 31749 0
4227 - Varsity Lakes

Funding & Sponsors
Funding source category [1] 307036 0
Name [1] 307036 0
Australian Hand Surgery Society
Address [1] 307036 0
Australian Hand Surgery Society

Level 3 Building C

St Vincent’s Hospital

41 Victoria Parade

Fitzroy, Victoria 3065
Country [1] 307036 0
Funding source category [2] 307038 0
Commercial sector/Industry
Name [2] 307038 0
Address [2] 307038 0
16727 Park Row, Houston, TX 77084, United States
Country [2] 307038 0
United States of America
Funding source category [3] 307039 0
Commercial sector/Industry
Name [3] 307039 0
Address [3] 307039 0
Hochbergerstrasse 60E
4057 Basel
Country [3] 307039 0
Funding source category [4] 307040 0
Commercial sector/Industry
Name [4] 307040 0
Address [4] 307040 0
237-239 Milton Rd
Milton QLD 4064
Country [4] 307040 0
Primary sponsor type
Royal North Shore Hospital
Reserve Rd, St Leonards, NSW 2065
Secondary sponsor category [1] 307608 0
Name [1] 307608 0
Address [1] 307608 0
Country [1] 307608 0

Ethics approval
Ethics application status
Ethics committee name [1] 307166 0
Gold Coast Hospital and Health Services HREC
Ethics committee address [1] 307166 0
1 Hospital Blvd, Southport QLD 4215
Ethics committee country [1] 307166 0
Date submitted for ethics approval [1] 307166 0
Approval date [1] 307166 0
Ethics approval number [1] 307166 0

Brief summary
The proximal phalanges are the first bone in each finger. When people break their proximal phalanges, the break may need to be fixed surgically. The break may be fixed with a plate on the back of the bone [where the overlying tendon is cut and later repaired]; a plate on the side of the bone; or a screw through the middle of the bone. We want to find out which option gives the best result, in terms of finger movement and overall.

The main finding of this study will tell us which surgical option gives the most finger movement, which may allow better use of that finger and hand. The other findings will look at which surgical option gives the best overall result from a patient’s point of view; which option allows the patient to regain better pinching and gripping power; and which option has more frequent risks.

This knowledge, and identification of the balance of risks and benefits for each option, will help more patients receive the treatment that will give them the best chance of obtaining good function in that finger and hand, as well as help surgeons guide patients in making informed health decisions. Regaining function will be important not only for the patient [who will be able to return to work or their daily activities more rapidly], but also the health system and community as a whole.

Although a plate on the back of the bone has been commonly used to fix breaks, there are concerns that cutting the tendon and putting a plate underneath will cause scarring, diminishing finger motion and patient satisfaction. This study will compare a plate on the back of the proximal phalanx to two other options: a plate on the side of the bone and a screw through the middle of the bone. There are no studies that have previously performed such a comparison.
The objective of this study is to determine which of the three options provides the best balance of risk and benefit for the patient. The main finding assessed will be finger movement, which may allow better use of that finger and hand. Other findings will look at the overall result for the patient; pinching and gripping power; and the risks of each operation.
Trial website
Trial related presentations / publications
Public notes
Sivakumar BS, An VVG, Graham DJ, Ledgard J, Lawson RD, Furniss D. Intramedullary Compression Screw Fixation of Proximal Phalangeal Fractures: A Systematic Literature Review. Hand (N Y). 2020 Sep 28;1558944720928503. doi: 10.1177/1558944720928503. Online ahead of print.
PMID: 32988227 DOI: 10.1177/1558944720928503

Sivakumar BS, An VVG, Phan K, Graham DJ, Ledgard J, Lawson R, Furniss D. Range of Motion Following Extensor Tendon Splitting vs. Tendon Sparing Approaches for Plate Osteosynthesis of Proximal Phalangeal Fractures - A Systematic Review and Meta-Analysis. J Hand Surg Asian Pac Vol. 2020 Dec;25(4):462-468. doi: 10.1142/S2424835520500514.
PMID: 33115365 DOI: 10.1142/S2424835520500514

Principal investigator
Name 106262 0
Dr Brahman Sivakumar
Address 106262 0
Care of:

Department of Hand & Peripheral Nerve Surgery,
Royal North Shore Hospital
Reserve Rd, St Leonards, NSW 2065
Country 106262 0
Phone 106262 0
Fax 106262 0
Email 106262 0
Contact person for public queries
Name 106263 0
Dr Brahman Sivakumar
Address 106263 0
Department of Hand & Peripheral Nerve Surgery, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW 2065
Country 106263 0
Phone 106263 0
+61 299267111
Fax 106263 0
Email 106263 0
Contact person for scientific queries
Name 106264 0
Dr Brahman Sivakumar
Address 106264 0
Department of Hand & Peripheral Nerve Surgery, Royal North Shore Hospital, Reserve Rd, St Leonards, NSW 2065
Country 106264 0
Phone 106264 0
+61 299267111
Fax 106264 0
Email 106264 0

Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
What data in particular will be shared?
De-identified outcome measures will be available on request for 5 years
When will data be available (start and end dates)?
Immediately following publication for up to 5 years
Available to whom?
For other investigators who are inquiring for their own research purposes
Available for what types of analyses?
How or where can data be obtained?
by contacting the primary investigator via email: brahma.sivakumar@health.nsw.gov.au
What supporting documents are/will be available?
No other documents available
Summary results
No Results