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Cavalcanti Kussmaul A, Kuehlein T, Langer MF, Ayache A, Unglaub F. The Treatment of Closed Finger and Metacarpal Fractures. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:855-862. [PMID: 37963039 PMCID: PMC10840131 DOI: 10.3238/arztebl.m2023.0226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/11/2023] [Accepted: 10/11/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Fractures of the fingers and metacarpal bones are the most common fracture type in the upper limb, with an incidence of 114 to 1483 per 100 000 persons per year. The clinical importance of closed finger and metacarpal fractures is often underestimated; inadequate diagnostic and therapeutic measures may result in serious harm. This review concerns the basic elements of the diagnosis and treatment of finger and metacarpal fractures. METHODS This review of the incidence, diagnosis and treatment of finger and metacarpal fractures is based on pertinent publications retrieved by a selective search of the literature. RESULTS The main focus of treatment lies on restoration of hand function in consideration of the requirements of the individual patient. The currently available evidence provides little guidance to optimal treatment (level II evidence). Although most closed fractures can be managed conservatively, individualized surgical treatment is advisable in comminuted fractures and fractures with a relevant degree of torsional malposition, axis deviation, or shortening, as well as in intra-articular fractures. Minimally invasive techniques are, in principle, to be performed wherever possible, yet open surgery is sometimes needed because of fracture morphology. Postsurgical complication rates are in the range of 32-36%, with joint fusion accounting for 67-76% of the complications. 15% involve delayed fracture healing and pseudarthrosis. CONCLUSION Individualized treatment for finger and metacarpal fractures can improve patients' outcomes, with major socioeconomic and societal benefits. Further high-quality studies evaluating the relative merits of the available treatments are needed as a guide to optimized therapy.
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Affiliation(s)
- Adrian Cavalcanti Kussmaul
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich
| | - Titus Kuehlein
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, LMU Munich
| | - Martin F. Langer
- Dept. for Trauma, Hand and Reconstructive Surgery, University Hospital of Muenster, Muenster
| | - Ali Ayache
- Department of Hand Surgery, Vulpius Clinic, Bad Rappenau
| | - Frank Unglaub
- Department of Hand Surgery, Vulpius Clinic, Bad Rappenau
- Mannheim Faculty of Medicine of the Ruprecht-Karls Heidelberg University, Mannheim
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Heifner JJ, Rubio F. Fractures of the phalanges. J Hand Surg Eur Vol 2023; 48:18S-26S. [PMID: 37704026 DOI: 10.1177/17531934231185219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Fractures of the phalanges encompass a wide range of injury patterns with variable articular and soft tissue involvement. The goals of treatment whether conservative or surgical are the restoration of function while limiting the risk of complications. An armamentarium of fixation options allows the surgeon to appropriately treat these fractures with the intention of initiating early postoperative mobilization. Previous publications report variable rates of complications following internal fixation of phalangeal fractures which represents an unsolved problem. It is incumbent on the surgeon to utilize meticulous surgical technique, achieve anatomic reduction with stable fixation and initiate early postoperative mobilization where indicated. In the following text, we review the management of most types of phalangeal fractures, except fracture-dislocations of the proximal interphalangeal joint. These injuries comprise a wide spectrum of presentation; thus, an understanding of anatomical and mechanical principles is integral to achieving a successful outcome.
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di Summa PG, Sapino G, Wagner D, Maruccia M, Guillier D, Burger H. Combined Free Flaps for Optimal Orthoplastic Lower Limb Reconstruction: A Retrospective Series. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050859. [PMID: 37241091 DOI: 10.3390/medicina59050859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/10/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: Open fracture of the lower limb can lead to substantial bone and soft tissue damage, resulting in a challenging reconstructive scenarios, especially in presence of bone or periosteal loss, with a relevant risk of non-union. This work analyzes outcomes of using a double approach for orthoplastic reconstruction, adopting the free medial condyle flap to solve the bone defects, associated to a second free flap for specific soft tissue coverage. Indications, outcomes and reconstructive rationales are discussed. Materials and Methods: A retrospective investigation was performed on patients who underwent complex two-flap microsurgical reconstruction from January 2018 to January 2022. Inclusion criteria in this study were the use of a free femoral condyle periostal/bone flap together with a second skin-only flap. Only distal third lower limb reconstructions were included in order to help equalize our findings. Out of the total number of patients, only patients with complete pre- and post-operative follow-up (minimum 6 months) data were included in the study. Results: Seven patients were included in the study, with a total of 14 free flaps. The average age was 49. Among comorbidities, four patients were smokers and none suffered from diabetes. Etiology of the defect was acute trauma in four cases and septic non-union in three cases. No major complications occurred, and all flaps healed uneventfully with complete bone union. Conclusions: Combining a bone periosteal FMC to a second skin free flap for tailored defect coverage allowed achievement of bone union in all patients, despite the lack of initial bone vascularization or chronic infection. FMC is confirmed to be a versatile flap for small-to-medium bone defects, especially considering its use as a periosteal-only flap, with minimal donor site morbidity. Choosing a second flap for coverage allows for a higher inset freedom and tailored reconstruction, finally enhancing orthoplastic success.
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Affiliation(s)
- Pietro G di Summa
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
| | - Gianluca Sapino
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
| | - Daniel Wagner
- Department of Orthopedic Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
| | - Michele Maruccia
- Department of Plastic Surgery and Reconstructive Surgery, University Hospital of Bari, 70100 Bari, Italy
| | - David Guillier
- Department of Plastic Reconstructive and Hand Surgery, Department of Oral and Maxillofacial Surgery-University Hospital, 21231 Dijon, France
| | - Heinz Burger
- Privat Clinic Maria Hilf, 9010 Klagenfurt, Austria
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Wong YYR, Ho AWH, Ho ST. Retrospective review on tenolysis after phalangeal fractures: A Hong Kong local center experience. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2023. [DOI: 10.1177/22104917231166720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Background/Purpose: This is a local retrospective review on the outcomes of tenolysis after phalangeal fracture. Methods: The clinical outcome of nine patients (mean age 51.9 years) with finger fractures and subsequent tenolysis performed were reviewed. Range of motion was evaluated. Results: Extensor tenolysis, capsulotomy with or without flexor tenolysis was performed at a mean of 8.2 months after hand fracture with fracture fixation done. The total active motion (TAM) improved from 121° preoperatively to 173° postoperatively ( p = 0.02). Significant improvement of motion was observed at the proximal interphalangeal joint ( p = 0.012). All patient's range of motion improved after surgery. Conclusion: The gain of motion of 52° is comparable to other series. Release of all pathological anatomy and aggressive mobilization may improve the result further. Tenolysis can provide an encouraging improvement of active motion for stiff finger after phalangeal fractures. Recent results using WALANT technique showed satisfactory outcome. Future study on WALANT technique may further consolidate its potential benefit.
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Affiliation(s)
- Yan Yu Ruby Wong
- Department of Orthopaedics and Traumatology, Caritas Medical Centre, Hong Kong SAR, China
| | - Angela Wing-Hang Ho
- Department of Orthopaedics and Traumatology, Caritas Medical Centre, Hong Kong SAR, China
| | - Sheung Tung Ho
- Department of Orthopaedics and Traumatology, Caritas Medical Centre, Hong Kong SAR, China
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Christen T, Krähenbühl SM, Müller CT, Durand S. Periosteal medial femoral condyle free flap for metacarpal nonunion. Microsurgery 2021; 42:226-230. [PMID: 34636060 PMCID: PMC9292408 DOI: 10.1002/micr.30826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/07/2021] [Accepted: 09/28/2021] [Indexed: 11/12/2022]
Abstract
Background Metacarpal nonunion is a rare condition. The osteogenic capacity of periosteal free flap was investigated in five patients with metacarpal nonunion and impaired bone vascularization. Patients and methods Surgery was performed between 64 and 499 days after the initial bone osteosynthesis. The average age was 27.6 (range 16–32) years. Nonunion was caused by excessive periosteal removal in two patients, extensive open trauma in three. Four nonunions were diaphyseal, one metaphyseal. A periosteal medial femoral condyle free flap was raised on the descending genicular artery for four patients, the superomedial genicular artery for one. After osteosynthesis with a plate, the flap was wrapped around the metacarpal, overlapping the bone proximally and distally. The recipient vessel were the dorsal branch of the radial artery and a vena comitans in the anatomical snuffbox in four patients, at the base of the first webspace in one. Results The flap size ranged from 5 × 3.5 cm to 8 × 4 cm. No postoperative complication occurred. Radiological bone union was achieved 3 to 8 months after surgery. One patient had a full range of motion, one a slight extension lag of the proximal interphalangeal joint, two moderate joint stiffness of the proximal interphalangeal or metacarpophalangeal joint (one requiring plate removal and extensor tenolysis), one severe stiffness that allowed using a hook grip which was the aim of the surgery. Conclusion In case of metacarpal nonunion with impaired bone vascularization, the periosteal medial femoral condyle free flap provides an effective and biomimetic approach to bone healing.
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Affiliation(s)
- Thierry Christen
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Swenn M Krähenbühl
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Camillo T Müller
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Sébastien Durand
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Neumeister MW, Winters JN, Maduakolum E. Phalangeal and Metacarpal Fractures of the Hand: Preventing Stiffness. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3871. [PMID: 34729287 PMCID: PMC8553242 DOI: 10.1097/gox.0000000000003871] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/24/2021] [Indexed: 11/26/2022]
Abstract
Fractures of the phalangeal or metacarpal bones of the hand are common. Many of these fractures are treated without surgery. However, both conservative and operative management of fractures of the hand can result in stiffness. Stiffness is the most common complication in the management of hand fractures. The key to preventing stiffness is early range of motion exercises. This article challenges many of the current treatment regimens offered to patients with the so-called unstable fractures. The evaluation of the patients' function is the primary factor that should determine the course of conservation versus operative management. X-rays do not demonstrate function and therefore act as an adjunct only to the care of the patient. The goal of treating hand fractures is to restore function. Early motion may not only improve healing but may also hasten the return to normal hand function. The tenets of how to prevent stiffness are described in this review.
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Affiliation(s)
- Michael W. Neumeister
- From the Institute for Plastic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - James N. Winters
- Institute for Plastic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
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Faccioli N, Santi E, Foti G, Mansueto G, Corain M. Cost-effectiveness of introducing cone-beam computed tomography (CBCT) in the management of complex phalangeal fractures: economic simulation. Musculoskelet Surg 2020; 106:169-177. [PMID: 33211300 PMCID: PMC9130154 DOI: 10.1007/s12306-020-00687-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 11/02/2020] [Indexed: 11/30/2022]
Abstract
Purpose The purpose of this study was to evaluate the cost-effectiveness of introducing cone-beam computed tomography (CBCT) in the management of the complex finger fractures with articular involvement. Methods We created a decision tree model simulating the diagnostic pathway of complex finger fractures, suggesting the use of CBCT as alternative to multi-slice computed tomography (MSCT), and we compared their clinical outcomes, costs, and cost-effectiveness for a hypothetical cohort of 10,000 patients. Measures of effectiveness are analysed by using quality-adjusted life years, incremental cost-effectiveness ratio, and net monetary benefit. Results Diagnosis of a complex finger fracture performed with CBCT costed 67.33€ per patient, yielded 9.08 quality-adjusted life years, and gained an incremental cost-effectiveness ratio of 29.94€ and a net monetary benefit of 9.07 € at 30,000€ threshold. Using MSCT for diagnosis costed 106.23 €, yielded 8.18 quality-adjusted life years, and gained an incremental cost-effectiveness ratio of 371.15 € and a net monetary benefit of 8.09 €. CBCT strategy dominated the MSCT strategy. The acceptability curve shows that there is 98% probability of CBCT being the optimal strategy at 30,000€ threshold (1 EUR equal to 1.11 USD; updated on 02/02/2020). Conclusion CBCT in complex finger fractures management is cost saving compared with MSCT and may be considered a valuable imaging tool in preoperative assessment, allowing early detection and appropriate treatment. It shortens the time to completion of diagnostic work-up, reduces the number of additional diagnostic procedures, improves quality of life, and may reduce costs in a societal perspective.
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Affiliation(s)
- N Faccioli
- Department of Radiology, G.B. Rossi University Hospital, University of Verona, Piazzale L.A.Scuro 10, 37134, Verona, Italy.
| | - E Santi
- Department of Radiology, G.B. Rossi University Hospital, University of Verona, Piazzale L.A.Scuro 10, 37134, Verona, Italy
| | - G Foti
- IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - G Mansueto
- Department of Radiology, G.B. Rossi University Hospital, University of Verona, Piazzale L.A.Scuro 10, 37134, Verona, Italy
| | - M Corain
- Hand Surgery Department, G.B. Rossi University Hospital, Piazzale L.A.Scuro 10, 37134, Verona, Italy
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Richards T, Clement R, Russell I, Newington D. Acute hand injury splinting - the good, the bad and the ugly. Ann R Coll Surg Engl 2018; 100:92-96. [PMID: 29182002 PMCID: PMC5838697 DOI: 10.1308/rcsann.2017.0195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2017] [Indexed: 11/22/2022] Open
Abstract
Injuries to the hand comprise 20% of all emergency department attendances, with an estimated annual treatment cost of over £100 million in the UK. The initial assessment and management of hand injuries is usually undertaken by junior staff, many of whom have little or no training or experience in splinting hand fractures. In the Department of Orthopaedic Hand Surgery, Morriston Hospital, we regularly observe patients presenting to the specialist hand fracture clinics having had initial management that shows no appreciation for the treatment objectives or the safe positions for splinting. This article aims to provide guidance for frontline staff on the management of hand fractures, with particular emphasis on the appropriate nonoperative care to avoid any unnecessary morbidity.
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Affiliation(s)
- T Richards
- Department of Orthopaedic Hand Surgery, Morriston Hospital , Swansea , UK
| | - R Clement
- Department of Orthopaedic Hand Surgery, Morriston Hospital , Swansea , UK
| | - I Russell
- Department of Orthopaedic Hand Surgery, Morriston Hospital , Swansea , UK
| | - D Newington
- Department of Orthopaedic Hand Surgery, Morriston Hospital , Swansea , UK
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von Kieseritzky J, Nordström J, Arner M. Reoperations and postoperative complications after osteosynthesis of phalangeal fractures: a retrospective cohort study. J Plast Surg Hand Surg 2017; 51:458-462. [DOI: 10.1080/2000656x.2017.1313261] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Johanna von Kieseritzky
- Department of Clinical Science and Education; and the Department of Hand Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Jan Nordström
- Department of Clinical Science and Education; and the Department of Hand Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Marianne Arner
- Department of Clinical Science and Education; and the Department of Hand Surgery, Karolinska Institutet, Stockholm, Sweden
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