Hand fractures: a review of current treatment strategies

A Systematic Review of Conservatively Managed Isolated Extra-Articular Proximal Phalanx Finger Fractures in Adults

Study design

Systematic review.

Background

Proximal phalangeal fractures of the hand are challenging to treat, and significantly impact hand function and quality of life if poorly managed.

Purpose

A systematic review to determine the efficacy of conservatively managed extra-articular proximal phalanx fractures to optimise recovery and prevent the need for surgical intervention and its associated risks.

Methods

A literature search that included variations of the phrases 'proximal phalanx', 'fracture' and 'conservative management' was performed on 17 December 2023 using seven electronic databases and trial registries. Article screening, data extraction and critical appraisal using the Structured Effectiveness Quality Evaluation scale was performed independently.

Results

Seven studies that captured 389 fractures from 356 unique patients were included. Studies were of level II to IV evidence and included one comparative cohort study and six prospective case series. Interventions involved timely rehabilitation, a plaster or orthotic device, controlled metacarpophalangeal joint flexion and free mobilisation of the interphalangeal joints. A weighted mean total active motion score of 249° was achieved, with 99.5% (387/389) of fractures achieving union.

Conclusions

This systematic review cautions against definitive recommendations on conservative techniques for managing proximal phalanx fractures due to limitations of the available literature. However, our findings tentatively supports non-operative approaches as an alternative to surgery.

The impact on time between injury and semi-acute surgery for hand fractures after virtual fracture clinic implementation

The aim of this before-and-after study was to evaluate the implementation of a virtual fracture clinic (VFC) on the time between injury and surgery in patients presenting with a phalangeal or metacarpal fracture and in need of semi-acute surgical treatment. Between 1 January and 30 September 2018 (pre-VFC) and in the same period in 2022 (VFC), 101 and 113 patients were included, respectively. Before VCF implementation, the time between injury and surgery was 8.9 days (95% confidence interval [CI]: 8.1 to 9.6), while after VCF implementation it was 7.6 days (95% CI: 7.0 to 8.3). In 2018, 7% of operations were unacceptably delayed beyond 14 days from injury, which was reduced to 5% in 2022, despite patient-presentation delays of up to 10 days. VFC implementation was associated with a reduction in time until semi-acute surgery for phalangeal or metacarpal fractures and improved the quality of semi-acute surgery planning.Level of evidence: Level III.

Percutaneous transverse pinning for metacarpal fractures: a clinical trial

INTRODUCTION

Metacarpal fractures account for 25%-50% of all hand fractures and may negatively impact hand function and ability to work. Percutaneous transverse pinning of non-articular metacarpal fractures allows mobilisation immediately after the procedure.

METHODS

Between March 2017 and February 2022, 56 patients undergoing percutaneous transverse pinning for unstable metacarpal fractures were prospectively recruited. We investigated surgical outcomes in terms of Patient-rated Wrist/Hand Evaluation (PRWHE) and pre-and post-operative radiographic evaluation. The Student t-test was used to compare the means of PRWHE values after surgery. Statistical significance was set at p < 0.05.

RESULTS

The mean age was 40.21 ± 17.9 years (range of 16 to 86 years). The average operating time was 27.96 min. The mean follow-up period was 14.3 ± 6.4 months (from 2 to 41 months). The mean PRWHE score was 6.5 ± 1.8. None of the patients had clinically observable rotational deformities, and the functional outcomes were satisfactory.

CONCLUSION

Percutaneous transverse pinning for non-articular metacarpal fractures restores excellent function, and imaging results are satisfactory. Further high-quality clinical trials are required to validate these results on a larger scale.

LEVEL OF EVIDENCE

II, prospective cohort study.

The Modified Five-Item Frailty Index to Predict Hand and Wrist Surgical Repair Postoperative Outcomes: An ACS-NSQIP Analysis of 11 369 Patients

BACKGROUND

Hand and wrist injuries can cause painful, everyday obstacles for patients. Carefully indexing preoperative patient health conditions may better inform surgical care, leading to improved postoperative outcomes. The purpose of the present study is to evaluate if the Modified Five-Item Frailty Index (mFI-5) can accurately predict postoperative complications for hand and wrist surgical repair.

METHODS

A retrospective review of the American College of Surgeons' National Surgical Quality Improvement Program database was conducted to investigate patients who underwent hand and wrist surgical repair from January 2013 to December 2019. Patient demographics, comorbidities, surgical logistics, and 30-day readmission due to postoperative complications were extracted. Surgical risk proxies including the mFI-5, age, body mass index (BMI), smoking status within 1 year, the Modified Charlson Comorbidity Index (mCCI), comorbidities, and American Society of Anaesthesiologists Physical Status Classification (ASA class) were calculated.

RESULTS

A total of 11 369 patients were included. Thirty-day readmission for total postoperative complications (n = 258) was significantly associated with all surgical risk proxies. However, age, mFI-5 > 2, mCCI > 2, comorbidities > 1, and ASA class 2/3 had the highest statistical significance (P = <.001). Thirty-day readmission rates for surgical site infections (n = 118) had the highest statistical significance with age, BMI, mFI-5 > 2, and ASA class 2/3 (P = <.001). A Clavien-Dindo score > 1 (n = 224) had the highest statistical significance with age, mCCI > 2, comorbidity of 1, and an ASA class 3 (P = <.001).

CONCLUSIONS

The mFI-5 may have value in predicting 30-day readmission due to postoperative complications after surgical repair of hand and wrist injuries.

Screw Position Following Percutaneous Versus Mini-Open Intramedullary Retrograde Screw Fixation of Metacarpal Fractures

BACKGROUND

Metacarpal fracture fixation using the retrograde intramedullary screw technique can be performed through two different approaches. The mini-open approach requires greater soft tissue dissection but allows for direct visualization of the metacarpal head compared with the percutaneous approach. Our aim was to determine which approach resulted in optimal screw position.

METHODS

Eighty-one consecutive patients that underwent intramedullary screw fixation for metacarpal fractures from 2016 to 2021 were identified. Patients were treated by 4 fellowship-trained orthopedic hand surgeons who employed the mini-open or percutaneous approach. Postoperative radiographs were reviewed for screw position.

RESULTS

A total of 81 patients (41 mini-open, 40 percutaneous) were included in this study. There were no significant differences between the two groups in age, sex, hand dominance, or affected digit. Postoperative screw position at first postoperative visit was not significantly different between the two groups on anteroposterior or lateral radiographs.

CONCLUSION

Postoperative screw position is not significantly different between the mini-open and percutaneous approaches for intramedullary screw fixation of metacarpal fractures.

LEVEL OF EVIDENCE

Level III, therapeutic.

Early Return of Motion in Patients With Intramedullary Screw Placement for Metacarpal and Phalangeal Fracture Fixation

INTRODUCTION

Hand fractures are associated with significant morbidity. Current management standards often result in prolonged immobilization, stiffness, and delayed return to functional use. Intramedullary (IM) compression screws offer minimal soft tissue disruption and early postoperative active motion. In this study, we describe our outcomes after intraosseous fracture fixation using IM cannulated headless screws for a multitude of fracture patterns.

METHODS

This study is a retrospective review of patients who underwent IM screw placement for fixation of metacarpal and phalangeal fractures by a single surgeon from 2017 to 2022. Data were collected to include patient demographics, fracture details, postoperative complications, and follow-up. Time to range of motion and return to unrestricted motion was recorded.

RESULTS

There were 69 patients with 92 fractures (n = 54 metacarpal, n = 38 phalanx). The median patient age was 45 years (range, 18-89 years) with 75.4% males. Majority presented with a single fracture (n = 50, 72.5%), and 38 patients (55.1%) had open fractures. Small finger was the most affected digit (n = 35, 37.6%). The median time to allow range of motion from surgery was 8.7 days (interquartile range, 0-32) with 32 days (interquartile range, 10-62) for unrestricted use of the hand. Thirty-five patients (50.7%) were allowed controlled motion from the first postoperative day. One patient had loss of reduction requiring reintervention for hardware removal, and 1 patient had superficial skin infection managed with oral antibiotics.

CONCLUSIONS

Our findings indicate that the IM screw provides reliable fixation for a wide variety of fracture patterns with a low complication rate and offers early return to functional use.

Trends in the Management of Fifth Metacarpal Neck Fractures

PURPOSE

To describe management trends of fifth metacarpal neck (5MCN) fractures within a large health care system. We aimed to define patient and surgeon factors associated with nonsurgical versus surgical treatment, as well as to identify factors associated with receiving care only in the emergency department (ED).

METHODS

We identified all 5MCN fractures within our system for the years 2012-2020 and recorded baseline demographics for cases. Injury, treatment, and fracture characteristics were all recorded. For fractures treated nonsurgically, we determined the type of immobilization used (if any) and recorded whether patients were seen only in the ED or received subsequent outpatient follow-up. Demographic comparisons were made between groups, and adjusted logistic regression models were generated to predict the odds of having a surgical 5MCN fracture or being seen in the ED only.

RESULTS

There were 611 5MCN fractures over an 8-year period, of which 10% were treated surgically. During the first half of the study period, 8% of isolated cases were treated surgically compared with 7% of cases in the second half. Soft dressings were increasingly used. There were no nonsurgically managed cases that underwent subsequent surgical procedures for symptomatic nonunion or malunion. Twenty-one percent of patients were seen only in the ED. Fracture angulation, associated injuries, insurance status, and treatment by a hand surgeon were all significantly associated with an increased likelihood of surgery.

CONCLUSIONS

Of the 611 5MCN fractures identified, 90% were treated nonsurgically. Patient and surgeon factors were associated with increased odds of surgery. Of patients who sought care for 5MCN injuries, >20% received no follow-up care outside of the ED. These data can be used to assess future changes in management trends and suggest that nonunion and symptomatic malunions are uncommon occurrences.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Choosing the proper implant for extra-articular fractures of proximal phalanges: A study on 75 cases

INTRODUCTION

Phalangeal fractures are the most common fractures of the hand and in particular the proximal phalanx of the long fingers is the most involved. These fractures can ben conservatively managed but, when the fracture pattern is considered unstable, surgical treatment is recommended. However, there is no consensus in literature about the proper surgical option for extra-articular proximal phalanx fractures.

MATERIAL AND METHODS

We compared clinical and radiographical results after treatment of 75 cases of extra-articular proximal phalanx fractures using three different surgical techniques: closed reduction and internal fixation (CRIF) with Kirschner wires (G1 group), open reduction internal fixation (ORIF) with plates and screws or lag screws (G2 group), and closed reduction and intramedullary screw fixation (CRIMEF)(G3 group).

RESULTS

We found no significant differences in term of union rate and time to fracture healing between the three groups. However, we found a significant reduction in time to return at work and in TAM at the final follow-up examination in G3 group (treated with CRIMEF) when compared with both G1 and G2. No differences in complications rate were found between three groups.

DISCUSSION

The surgical variability in the management of extra-articular phalanx fractures create lacks on standard guide for treatment.

CONCLUSIONS

In conclusion, our results showed good clinical and radiographical results with all the three surgical options. However, the closed reduction and internal fixation with intramedullary screws (CRIMEF) seems to be better in terms of time to return to work and TAM at the final follow-up, probably due to good primary stability and little risk of soft tissue adherence development.

Risks of Reoperation in Surgically Treated Fractures of the Proximal Phalanx

Purpose

The objective of this study was to determine the risk factors and the rate of reoperation after closed reduction percutaneous pinning (CRPP) of isolated closed single-digit proximal phalanx fractures.

Methods

A retrospective cohort study was conducted for patients who underwent CRPP of non-thumb closed proximal phalanx fractures between 2010 and 2020 at two level-I trauma centers and two community teaching hospitals. Demographics, fracture, and treatment characteristics were collected. The primary outcome measure was reoperation. Secondary outcome measures were complication and reoperation specifically for digital stiffness.

Results

Of the 115 patients who underwent surgical treatment, 46 patients (40.0%) had a complication and 13 patients (11.3%) underwent reoperation at a mean of 6.7 months-most of which (84.6%) were for digital stiffness.

Conclusions

Surgeons and patients may be aware that CRPP of closed extra-articular proximal phalanx fractures carries considerable rates of complication and reoperation.

Type of study/level of evidence

Therapeutic III.

Metacarpal Shortening with Intramedullary Screw Fixation: A Cadaveric Study

Background  Intramedullary screw fixation is a commonly used technique for the management of metacarpal fractures. However, compression across the fracture site can lead to unintentional shortening of the metacarpal. Questions/Purposes  Our aim was to evaluate the risk of overshortening with differing intramedullary device designs for fixation of metacarpals. Methods  The small finger metacarpal of nine fresh-frozen cadavers were included. A metacarpal neck fracture was simulated with a 5-mm osteotomy. Three different intramedullary screw designs were compared. Each screw was placed in a retrograde fashion into the intramedullary canal and the amount of shortening measured. Screws were reversed and the number of reverse turns with the screwdriver needed to release overshortening were measured. Results  The average shortening at the osteotomy site was 2.5 mm. The mean shortening was 80%, 58%, and 12% for the partially threaded screw, fully threaded screw, and threaded nail, respectively. The mean differences of the distance shortened were statistically significant for the threaded nail compared with the partially and fully threaded screws. The partially threaded screw had the most shortening, while the threaded nail provided the least amount of shortening. When the screws were reversed, the screws did not disengage until the screw was fully removed from the osteotomy site. Conclusion  The fully threaded nail demonstrates less shortening and possibly minimizes overshortening of fractures compared with partially threaded and fully threaded screw designs. Overshortening cannot be corrected by unscrewing the screw unless completely removed from the distal fragment. Clinical Relevance  Orthopaedic surgeons may select intermedullary screws based on the design that is suited for the particular metacarpal fracture pattern.

Outcomes Following Fully Threaded Intramedullary Nailing of Metacarpal Fractures

Purpose

Intramedullary screw fixation has emerged as a popular approach for the treatment of displaced metacarpal fractures. The purpose of this study was to investigate the functional and radiographic outcomes of a newly designed, headless noncompressive fully threaded intramedullary nail (TIMN) for the treatment of metacarpal fractures.

Methods

A retrospective chart review was performed on patients who were treated with the INnate TIMN (ExsoMed) at a single academic institution with a minimum of 1-year follow-up. Patient-reported functional outcomes included Quick Disabilities for the Arm, Shoulder, and Hand (QuickDASH) questionnaires, return to work and physical activity time, and overall satisfaction. Radiographs were retrospectively reviewed to determine radiographic union, change in angulation, and metacarpal shortening.

Results

A total of 49 patients (58 fractures) with a mean age of 36 years (range: 17-75 years) were included. The mean follow-up time was 2.7 years (range: 1.4-4.3 years). Overall, the mean patient satisfaction rating was 4.9 of 5 (range: 3-5). The mean return to work time was 7.2 weeks (range: 0.14-28 weeks), and the mean return to sport or activity was 8.3 weeks (range: 1-28 weeks). Average QuickDASH scores across all patients were 4 (range: 0-56.9). The median radiographic healing time was 6.1 weeks (range: 4.7-15.4 weeks). Mean postoperative shortening in the fifth metacarpal fracture was 3 mm (range: -4.2 to 8 mm) at the initial postoperative visit and 3.6 mm (range: -3.3 to 7.9 mm) at the final radiographic follow-up. Subgroup analysis showed that postoperative shortening was similar, regardless of the fracture pattern. The following four complications were reported: one case of persistent pain and stiffness, one case of carpal tunnel syndrome, one nonunion, and one fractured intramedullary nail.

Conclusions

Our findings suggest that the TIMN allows for a reliable return to work and physical activity, high patient satisfaction, low complication rate, and minimal shortening at the final radiographic follow-up.

Type of study/level of evidence

Therapeutic IV.

The Treatment of Closed Finger and Metacarpal Fractures

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.

Intramedullary K-wires versus Alternate Techniques for Metacarpal Shaft and Neck Fractures: A Systematic Review and Meta-analysis

Intramedullary K-wire (IMKW) fixation is one of the mainstays for surgically treating metacarpal shaft and neck fractures. However, there remains a lack of literature comparing outcomes of the various available surgical repair techniques in all indicated metacarpals. Therefore, we conducted a systematic review and meta-analysis to investigate the clinical advantages and drawbacks of IMKW compared with alternate fracture repair techniques. A comprehensive systematic literature review was performed to identify studies that compared clinical outcomes of IMKW to alternate metacarpal fixation modalities. Outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH/ quick DASH) scores, grip strength, union rate, visual analog scale pain, operative time, and complications. A random-effects model was used to compare IMKW to the pooled effect of other fixation techniques. A total of 10 studies were included in our analysis, comprising 497 metacarpal fractures (220 shafts and 277 necks). IMKW fixation was identified as the control group in all studies. The pooled experimental group included plates, transverse K-wires (TKWs), interfragmentary screws (IFSs), and K-wire cross-pinning (CP). In treating metacarpal shaft fractures, IMKW showed significantly shorter operative time ( p  = 0.04; mean difference = - 13; 95% confidence interval = -26 to -0.64). No significant differences were observed in treating metacarpal neck fractures for disability, grip strength, healing rate, pain, operative time, or complication rate. This systematic review and meta-analysis found no difference in clinical outcomes among various surgical techniques for treating metacarpal shaft and neck fractures. Further high evidence studies are required that investigate the efficacy and safety of IFS, CP, TKW, and intramedullary screws versus IMKW for treating closed, unstable metacarpal fractures.

Principles of management of hand fractures

The optimal management of hand fractures requires a multidisciplinary approach. Initial assessment should include a thorough medical history and clinical examination, followed by appropriate radiological imaging. These are crucial in determining the appropriate management. Following joint stabilisation to allow fractures to unite, early mobilisation is needed to maximise the functional restoration of the hand. In this review, the principles of operative and non-operative management of these injuries are discussed.

Telerehabilitation Technology Used for Remote Wrist/Finger Range of Motion Evaluation: A Scoping Review

Background

Monitoring finger/wrist range of motion (ROM) is an important component of routine hand therapy after surgery. Telerehabilitation is a field that may potentially address various barriers of in-person hand therapy appointments. Therefore, the purpose of this scoping review is to identify telerehabilitation technologies that can be feasibly used in a patient's home to objectively measure finger/wrist ROM.

Methods

Following PRISMA-ScR guidelines for scoping reviews, we systematically searched MEDLINE and Embase electronic databases using alternative word spellings for the following core concepts: "wrist/hand," "rehabilitation," and "telemedicine." Studies were imported into Covidence, and systematic two-level screening was done by two independent reviewers. Patient demographics and telerehabilitation information were extracted from the selected articles, and a narrative synthesis of the findings was done.

Results

There were 28 studies included in this review, of which the telerehabilitation strategies included smartphone angle measurement applications, smartphone photography, videoconference, and wearable or external sensors. Most studies measured wrist ROM with the most accurate technologies being wearable and external sensors. For finger ROM, the smartphone angle application and photography had higher accuracy than sensor systems. The telerehabilitation strategies that had the highest level of usability in a remote setting were smartphone photographs and estimation during virtual appointments.

Conclusions

Telerehabilitation can be used as a reliable substitute to in-person goniometer measurements, particularly the smartphone photography and motion sensor ROM measurement technologies. Future research should investigate how to improve the accuracy of motion sensor applications that are available on easy-to-access devices.

Comparative study of K-wire combined with screw vs. K-wire in the treatment of AO type B3.1 phalangeal fractures

PURPOSE

The purpose of this study was to introduce the surgical method of K-wire combined with screw in the treatment of Arbeitsgemeinschaftfür Osteosynthesefragen (AO) type B3.1 phalangeal fractures and to compare its clinical, radiological and functional outcomes with K-wire fixation.

METHODS

This was a retrospective comparative study. From January 2015 to February 2022, we treated 86 patients with AO type B3.1 phalangeal fractures. A total of 71 patients were finally included in the statistical analysis. Thirty-nine patients received K-wires combined with screw, and 32 patients received simple K-wires. The follow-up time was at least 6 months. Outcome measures included general information, operative time, total active motion (TAM), pinch strength, radiological union time, pain assessed by visual analog scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, cost, and complications.

RESULTS

The follow-up time was 6-12 months, with an average of 7.9 months. All patients achieved clinical and radiological union. Compared with the K-wire fixation group, the TAM, radiological union time and VAS score of the K-wire combined with screw group had obvious advantages. Compared with the opposite healthy hand, the grip strength of the two groups was similar, and there was no significant difference in the QuickDASH score. The incidence rate of complications in the K-wire combined with screw group (2/39) was lower than that in the K-wire fixation group (7/32).

CONCLUSIONS

Compared with simple K-wire fixation, K-wire combined with screw in the treatment of AO type B3.1 phalangeal fractures is a safer and reliable surgical method. K-wire controls the rotation and plays a role similar to a "lock". The screw can exert pressure and fix it more firmly. It shortens the time of fracture healing and has a higher TAM and fewer postoperative complications.

Cost Comparison of Kirschner Wire Versus Intramedullary Screw Fixation of Metacarpal and Phalangeal Fractures

BACKGROUND

Intramedullary screw fixation is a relatively new technique for fixation of metacarpal and phalangeal fractures. The objective of this study was to compare health care-associated costs and outcomes for intramedullary screw versus Kirschner wire (K-wire) fixation of hand fractures.

METHODS

A retrospective review of patients undergoing intramedullary screw fixation of hand fractures at a single center during 2016-2019 inclusive was conducted. Health care-associated costs were compared with age-matched and fracture pattern-matched controls who underwent K-wire fixation.

RESULTS

Fifty patients met the study inclusion criteria, incorporating 62 fractures (29 K-wire, 33 intramedullary screw fixation). The median age was 34.6 years (18.0-90.1 years). There was no significant difference in primary operative costs (£1130.4 ± £162.7 for K-wire vs £1087.0 ± £104.2 for intramedullary screw), outpatient follow-up costs (£958.7 ± £149.4 for K-wire vs £782.4 ± £143.8 for intramedullary screw), or total health care-associated costs (£2089.1 ± £209.0 for K-wire vs £1869.4 ± £195.3 for intramedullary screw). However, follow-up costs were significantly lower for the uncomplicated intramedullary screw cohort (£847.1 ± £109.1 for K-wire vs £657.5 ± £130.8 for intramedullary screw, P = .05). Subgroup analysis also revealed that overall costs were significantly higher for buried K-wire techniques. Complication rates, time to return to active work, and Disabilities of the Arm, Shoulder, and Hand scores were similar.

CONCLUSIONS

This study identified significantly lower outpatient follow-up costs for uncomplicated intramedullary screw fixation of hand fractures compared with K-wires, along with a trend toward lower overall health care-associated costs. In addition, buried K-wire techniques were also found to carry a significantly higher financial burden. Higher powered prospective studies are required to determine indirect costs.

[Osteosynthesis by intramedullary headless screw in digital fractures: A retrospective scannographic and anatomical study]

INTRODUCTION

Long finger skeletal fractures are common injuries. In displaced forms, surgical treatment is required. With the advent of headless cannulated screws, the technique has been simplified and allows reduction in both planes. The objective of our study was to evaluate the functional recovery of patients operated on by this technique.

MATERIAL AND METHOD

We conducted a retrospective single-center study between 2019 and 2022. Eleven patients were followed and 12 fractures analyzed. A radio-clinical follow-up was carried out at 1 month then at the last follow-up with an evaluation of the articular amplitudes and a quality of life score (QuickDash, QD). The time to return to professional and sporting activities, pain (EVA) was collected. An anatomical/scannographic evaluation was performed to assess tendon and cartilage damage.

RESULTS

At the last follow-up, the average global flexion was 266° and the extension was total. An average QD score of 15.9 and a Jamar force of 106% compared to the healthy side were observed. The return to physical and professional activities was earlier and the pain quickly tolerable. No secondary displacement was objectified and all were consolidated at the last follow-up, without malunion. No patient had been operated on secondarily.

CONCLUSION

This technique seems to be a safe and non-traumatic. It allows a faster return to sports and professional activities with fewer complications and no need to remove the material.

A Comparative Analysis of Nonthumb Metacarpal Fracture Treatments in New York City Civilians and Incarcerated Individuals

Nonthumb metacarpal (NTMC) fractures are common in the incarcerated and the underinsured civilian populations. However, certain social challenges contribute to high rates of follow-up noncompliance and complications in these unique populations. We conducted a retrospective review of the treatments, outcomes, and complications in the incarcerated and civilian patient population who were treated at a tertiary public hospital for NTMC fractures. Even though incarcerated patients were more likely than their civilian counterparts to undergo operative interventions, both populations showed similar complication profiles as well as low rates of treatment compliance and follow-up. This article affirms that incarcerated individuals do not receive inferior care compared with civilians, and both the incarcerated and underinsured civilians would benefit from careful consideration of treatment algorithms and additional access to hand therapy.

Posttreatment Imaging of the Wrist and Hand: Update 2022

Common indications for surgical procedures of the wrist and hand include acute fractures or fracture-dislocations; nonunited fractures; posttraumatic, degenerative, and inflammatory arthritides and tendinopathies; injuries to tendons, ligaments, and the triangular fibrocartilage complex; and entrapment neuropathies. Soft tissue or osseous infections or masses may also need surgical treatment. Several of these procedures require surgical hardware placement, and most entail clinical follow-up with periodic imaging. Radiography should be the first imaging modality in the evaluation of the postoperative wrist and hand. Computed tomography, magnetic resonance imaging, diagnostic ultrasonography, and occasionally nuclear medicine studies may be performed to diagnose or better characterize suspected postoperative complications. To provide adequate evaluation of postoperative imaging of the wrist and hand, the interpreting radiologist must be familiar with the basic principles of these surgical procedures and both the imaging appearance of normal postoperative findings as well as the potential complications.

Biomechanical Modeling of Connecting Intermetacarpal K-Wires in the Treatment of Metacarpal Shaft Fractures

BACKGROUND

Clinical series have been published using the configuration of 2 intercarpal Kirschner wires (K-wires) adjacent to the fracture being connected, but biomechanical analysis is lacking. The objective of this pilot biomechanical study was to model and compare the effects of externally connecting 2 intermetacarpal K-wires for the stabilization of transverse metacarpal shaft fractures. Our research hypothesis was that the connected constructs would be stiffer than the unconnected K-wires.

METHODS

A 3-dimensional computer-based model of small finger transverse metacarpal fracture stabilization was designed with 3 transverse 1.1 mm K-wires being anchored to the adjacent metacarpal. Three arrangements were tested: all 3 K-wires in parallel, the middle K-wire angled toward the proximal wire, and the middle angled K-wire being rigidly fixed to the proximal K-wire. The proximal wire was proximal to the fracture. A finite element analysis was performed by applying a cantilever force of 100 N at the head of the metacarpal. The metacarpal was considered to be uniform in composition with parameters typical for human bone. Kirschner wire parameters for stainless steel were used. Force (N) versus displacement was measured.

RESULTS

The configuration with the middle angled K-wire being rigidly fixed to the proximal K-wire showed greater stiffness (12 N/mm) than nonattached constructs. The connected construct was 2.3 times more stiff than the unattached parallel construct and 2.5 times more stiff than angling the middle K-wire without attachment.

CONCLUSIONS

In a computer model simulation, our results show that attaching 2 K-wires adjacent to the fracture provides more than twice the stiffness of unconnected K-wires.

An Unusual Appearance of Base of First Metacarpal Fracture: A Case Report

We present the case of an unusual base of the first metacarpal fracture. The presentation and radiological images are provided to demonstrate a first metacarpal base fracture but with a concurrent appearance at first glance of a trapeziectomy mimic on plain radiographs. The CT scan however demonstrates the true nature of the injury - a comminuted fracture with carpometacarpal subluxation. The radiological and clinical findings presented a diagnostic and therapeutic dilemma. We elected to not intervene surgically with a good resulting clinical outcome, reminding us of the need to treat the patient and not their radiographic images.

WALANT technique versus locoregional anesthesia in the surgical management of metacarpal and phalangeal fractures: Lessons from the Covid-19 crisis

Wide Awake Local Anesthesia No Tourniquet (WALANT) is an anesthetic method which uses a local injection of anesthetic and epinephrine, avoiding use of a tourniquet. During the COVID-19 pandemic, human and logistic resources had to be reorganized, and WALANT ensured resilience in our department to maintain access to surgical care. The objective of the present study was to compare hand function recovery 3 months after surgery for unstable metacarpal or phalangeal fracture under regional anesthesia versus WALANT. From November 2020 to May 2021, 36 patients presenting a metacarpal or phalangeal fracture requiring surgical treatment were included in a single-center study in a university hospital center. Nineteen patients underwent surgery under locoregional anesthesia with tourniquet, and 17 under WALANT. The main endpoint was functional recovery at 3 months on QuickDASH score. Need for complementary anesthesia, surgery duration, analgesic consumption, reintervention rate, and patient satisfaction were also assessed. There was no significant difference between groups in functional recovery at 3 months or on the secondary endpoints. In the COVID-19 context, WALANT proved to be a safe and effective method in hand fracture surgery, ensuring access to surgical care. It should be included in surgical training to optimize day-to-day surgical care and face future crises.

Analysis of 1430 hand fractures and identifying the 'Red Flags' for cases requiring surgery: Head: Hand Fracture Treatment

BACKGROUND

Hand fractures constitute 20% of hand injury patients who apply to emergency services. Conservative approaches are satisfactory in the majority of the cases. However, the minority group in need of surgery reaches a serious number of patients considering the frequency of these injuries. Retrospective questioning of the indications of the performed surgeries is a proper way of understanding the decisional process for surgery.

PATIENTS/METHODS

Patients treated for hand fractures were retrospectively reviewed. Patient gender, age, finger/fingers involved, soft tissue involvement, treatment method (conservative/surgery) and if operated, devices used for fixation were noted. Plain radiographs of the patient were evaluated. Descriptive statistics of these variables and the effect of each variable on the decision for surgery were analyzed.

RESULTS

The study involved 1430 fractures of 1303 patients (1016 male and 287 female). Fifth finger was the most commonly injured digit (31%). Comminuted fractures (29%) followed by transverse fractures (29%) and spiral/oblique fractures (22%) were commonly diagnosed fracture types. Thirteen percent (13%) of the study group needed tendon/nerve/vessel repairs. Male patients, cases with soft tissue involvement, second, third and fourth finger fractures, fractures involving multiple digits, fractures with an intra-articular component, fractures with dislocation more than 4 mm and angulation more than 15° had a significantly higher rate of surgery.

CONCLUSION

Less than half of the hand fractures require surgery, and conservative treatment is usually preferred. Certain variables that indicate surgical treatment were identified with our study. These findings may help to weigh the options and choose the right path in doubtful conditions.

LEVEL OF EVIDENCE

Level 4, Case-control study.

Synostosis of the interphalangeal joint: an uncommon cause of post-fracture digital stiffness

Loss of motion and stiffness after fracture of the digits are most commonly a result of soft tissue contracture and adhesions. However, stiffness can also have a bony etiology. We present a case of synostosis of the thumb interphalangeal joint after non-operative treatment of a closed fracture.

Outcomes of 173 metacarpal and phalangeal fractures treated by intramedullary headless screw fixation with a 4-year follow-up

Surgical treatment of extra-articular metacarpal and phalangeal fractures should be considered when there is instability or in patients with high demand. To overcome the issues related to the use of Kirschner wires, external fixators, and open reduction and internal fixation procedures, intramedullary headless screw fixation (IHSF) is an alternative technique to achieve primary fracture stability and early return to daily activities. We report the data of the Italian Multicentric Intra-Medullary Experience, which includes 173 cases of extra-articular unstable fractures (38 phalanges and 135 metacarpals) treated with the IHSF. After surgery, patients underwent early mobilization without splinting. The results confirm the reliability of IHSF in cases with non-articular involvement, showing a good recovery rate in terms of bone healing and range of motion.Level of evidence: IV.

Minimally Invasive Intramedullary Screw Versus Plate Fixation for Proximal Phalanx Fractures: A Biomechanical Study

PURPOSE

To compare the maximum interfragmentary displacement of short oblique proximal phalanx (P1) fractures fixed with an intramedullary headless compression screw (IMHCS) versus a plate-and-screws construct in a cadaveric model that generates finger motion via the flexor and extensor tendons of the fingers.

METHODS

We created a 30° oblique cut in 24 P1s of the index, middle, ring, and little fingers for 3 matched pairs of cadaveric hands. Twelve fractures were stabilized with an IMHCS using an antegrade, dorsal articular margin technique at the P1 base. The 12 matched-pair P1 fractures were stabilized with a radially placed 2.0-mm plate with 2 bicortical nonlocking screws on each side of the fracture. Hands were mounted to a frame allowing a computer-controlled, motor-driven, linear actuator powered movement of fingers via the flexor and extensor tendons. All fingers underwent 2,000 full-flexion and extension cycles. Maximum interfragmentary displacement was continuously measured using a differential variable reluctance transducer.

RESULTS

The observed mean displacement differences between IMHCS and plate-and-screws fixation was not statistically significant throughout all time points during the 2,000 cycles. A 2 one-sided test procedure for paired samples confirmed statistical equivalence in fracture displacement between fixation methods at the final 2,000-cycle time point.

CONCLUSIONS

The IMHCS provided biomechanical stability equivalent to plate-and-screws for short oblique P1 fractures at the 2,000-cycle mark in this cadaveric model.

CLINICAL RELEVANCE

Short oblique P1 fracture fixation with an IMHCS may provide adequate stability to withstand immediate postoperative active range of motion therapy.

An Evidence-Based Guide for Managing Phalangeal Fractures

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe treatment options for phalangeal fractures. 2. Choose an appropriate fracture management plan that optimizes patient goals and range of motion. 3. Describe closed and open reduction techniques of commonly encountered phalangeal fracture patterns.

SUMMARY

Phalangeal fractures are the second most common upper extremity fracture. Although many can be treated with splinting, operative intervention may be required for unstable fracture patterns and those involving the articular surface. Failure to appropriately treat these fractures can result in finger stiffness, loss in range of motion, and functional deficits. The type of fixation method can range from percutaneous pinning to open reduction and internal fixation. This article presents a series of cases to illustrate the appropriate management of phalangeal fractures using an evidence-based approach.

Surgical outcome of upper extremity fractures in patients with Parkinson's disease

Patients with Idiopathic Parkinson’s Disease (PD) have an increased risk for fractures. Currently, many studies have reported inferior outcomes in PD patients after orthopedic procedures. However, there are very few studies assessing the outcome of upper extremity fractures (UEF) in PD patients. In this study, we reviewed 40 patients with PD that received surgical intervention for an UEF. We retrospectively reviewed patients with PD that received surgical fixation for an UEF at a tertiary trauma center. The primary objective was to determine the treatment failure rate after surgical fixation. The secondary outcomes include mode of failure, time to treatment failure, length of hospital stay, readmission rate, reoperation rate, and postoperative complications. A total of 40 patients with PD (42 fractures) underwent surgery. The most common fracture type was radius fracture (n = 19), followed by humerus fracture (n = 15), metacarpal/phalangeal fracture (n = 5), clavicle fracture (n = 2) and olecranon fracture (n = 1). The overall treatment failure rate was 40.5% (n = 17). The time to treatment failure was 1.24 ± 3.1 months and length of hospital stay was 6 ± 3.9 days, the readmission rate within 30 days was 14% (n = 6), and reoperation rate was 14% (n = 6). The complication rate was 16.6% (n = 7) and patients with humeral fractures appeared to have the longest hospital stays (6.6 days) and increased complication rates (13%, n = 2). Patients with PD have high treatment failure rates despite surgical fixation of an UEF. These patients often have a frail status with multiple comorbidities which may complicate their postoperative course.

Level of evidence level 4 case series.

Osteosynthesis of Phalangeal Fractures: Biomechanical Comparison of Kirschner Wires, Plates, and Compression Screws

PURPOSE

The aim of this study was to compare several osteosynthesis techniques (intramedullary headless compression screws, T-plates, and Kirschner wires) for distal epiphyseal fractures of proximal phalanges in a human cadaveric model.

METHODS

A total of 90 proximal phalanges from 30 specimens (index, ring, and middle fingers) were used for this study. After stripping off all soft tissue, a transverse distal epiphyseal fracture was simulated at the proximal phalanx. The 30 specimens were randomly assigned to 1 fixation technique (30 per technique), either a 3.0-mm intramedullary headless compression screw, locking plate fixation with a 2.0-mm T-plate, or 2 oblique 1.0-mm Kirschner wires. Displacement analysis (bending, distraction, and torsion) was performed using optical tracking of an applied random speckle pattern after osteosynthesis. Biomechanical testing was performed with increasing cyclic loading and with cyclic load to failure using a biaxial torsion-tension testing machine.

RESULTS

Cannulated intramedullary compression screws showed significantly less displacement at the fracture site in torsional testing. Furthermore, screws were significantly more stable in bending testing. Kirschner wires were significantly less stable than plating or screw fixation in any cyclic load to failure test setup.

CONCLUSIONS

Intramedullary compression screws are a highly stable alternative in the treatment of transverse distal epiphyseal phalangeal fractures. Kirschner wires seem to be inferior regarding displacement properties and primary stability.

CLINICAL RELEVANCE

Fracture fixation of phalangeal fractures using plate osteosynthesis may have the advantage of a very rigid reduction, but disadvantages such as stiffness owing to the more invasive surgical approach and soft tissue irritation should be taken into account. Headless compression screws represent a minimally invasive choice for fixation with good biomechanical properties.

Premeasured Intramedullary Nails for the Treatment of Metacarpal Fractures: Novel Instrumentation and Technique

With nearly 36% of hand fractures occurring at the metacarpal, a variety of treatment interventions have been developed. Although many nondisplaced metacarpal fractures can be treated with conservative management, displaced, unstable, open, and extra-articular fractures require surgical attention. Compared with open reduction with plate fixation, closed reduction with intramedullary fixation has shown advantages of a simplified technique, minimal soft tissue dissection, and reduced tendon irritation and scar formation. The current study reports on the improved surgical technique associated with the use of novel instrumentation for the closed reduction and intramedullary fixation of extra-articular metacarpal fractures. The design and surgical technique of the premeasured Secure Intramedullary Nail improves fracture fixation, minimizing rotation and backing out, while reducing concerns for soft tissue irritation complications at the base of the metacarpal. Our reported case series suggests procedural efficiency, a low complication rate, and fast recovery for those with indicated extra-articular fractures.

Intramedullary screw fixation for metacarpal shaft fractures: a biomechanical human cadaver study

Intramedullary cannulated compression screws have been introduced for the fixation of unstable metacarpal fractures. In the present study, this technique was compared with dorsal compression plating to evaluate its biomechanical performance in stabilizing metacarpal shaft fractures. In a first set of experiments, the biomechanical characteristics of the screws were analysed in an artificial bone model. In subsequent experiments, midshaft osteotomies were performed in human cadaver metacarpals, followed by plating or intramedullary screw osteosynthesis. The metacarpals were tested to failure in cantilever bending, following a stepwise increasing cyclic loading protocol. We found a significantly lower load at failure and a significantly lower number of cycles to failure in the intramedullary screw group, but both methods offered sufficient stability under these loads. With reference to published loads on the metacarpals during use of the hand, we conclude that intramedullary osteosynthesis yields sufficient strength and stiffness for early active motion. A difference in its fixation stability is noted compared with plate fixation, which may not be clinically relevant.

Retrograde intramedullary headless compression screws for treatment of extra-articular thumb metacarpal base fractures

The purpose of the study was to evaluate clinical and radiological outcomes of extra-articular fractures involving the base of the thumb metacarpal treated with fixation using a retrograde intramedullary cannulated headless screw. A review of prospectively collected data was conducted on a consecutive series of 13 patients, treated with headless screw fixation for acute displaced fractures. All workers resumed full duties, while non-workers returned to unlimited leisure activities within a mean of 42 days. At 3 months follow-up, all range of motion measurements in the treated and untreated thumb were similar. Mean visual analogue pain score was 0.8 at rest and 1.4 during exercise and mean Quick Disabilities of the Arm, Shoulder, and Hand score was 5. All patients achieved radiographic union by 8 weeks. We conclude that the intramedullary headless screw fixation is safe and reliable for base of thumb metacarpal fractures, allowing for early postoperative motion and good functional recovery. Level of evidence: IV.

Epidemiology and treatment of phalangeal fractures: conservative treatment is the predominant therapeutic concept

Purpose

Despite the high number of patients with phalangeal fractures, evidence-based recommendations for the treatment of specific phalangeal fractures could not be concluded from the literature. The purpose of the present study was to assess current epidemiological data, classification of the fracture type, and mode of treatment.

Methods

This study presents a retrospective review of 261 patients with 283 phalangeal fractures ≥ 18 years of age who were treated in our level I trauma centre between 2017 and 2018. The data were obtained by the analysis of the institution’s database, and radiological examinations.

Results

The average age of the patients was 40.4 years (range 18–98). The ratio of male to female patients was 2.7:1. The two most typical injury mechanisms were crush injuries (33%) and falls (23%). Most phalangeal fractures occurred in the distal phalanx (P3 43%). The 4th ray (D4 29%) was most frequently affected. The P3 tuft fractures, and the middle phalanx (P2) base fractures each accounted for 25% of fracture types. A total of 74% of fractures were treated conservatively, and 26% required surgery, with Kirschner wire(s) (37%) as the preferred surgical treatment. The decision for surgical treatment correlated with the degree of angular and/or rotational deformity, intraarticular step, and sub-/luxation of specific phalangeal fractures, but not with age and gender.

Conclusions

Our findings demonstrated the popularity of conservative treatment of phalangeal fractures, while surgery was only required in properly selected cases. The correct definition of precise fracture pattern in addition to topography is essential to facilitate treatment decision-making.

Corrective Metacarpal Osteotomy With Intramedullary Screw Fixation: Technique and Case Report

Metacarpal malunion with significant angulation leading to symptoms from bony prominence in the palm or dorsum and decreased grip strength occur rarely, but may lead to patients requiring surgical correction. Corrective osteotomy procedures with plate fixation are commonly performed for these patients. Localizing the correct site of osteotomy and the required amount of bone removal for precise correction is difficult even with adequate preoperative planning. After osteotomy, plate osteosynthesis is the most common fixation method to allow for early mobilization; however, plate osteosynthesis can lead to soft tissue irritation, which may necessitate secondary surgeries for tenolysis and implant removal. This case study highlights our use of an intramedullary wire as an additional guide to the ideal site of osteotomy and then the use of an intramedullary screw for stabilization of the osteotomy site.

Pin Insertion to the Interosseous Hood Minimize the Finger Motion Restriction for the Proximal Phalangeal Percutaneous Fixation: A Cadaveric Study

Background: The purpose of this study was to identify the optimal pin insertion point to minimize finger motion restriction for proximal phalangeal fixation in cadaver models. Methods: We used 16 fingers from three fresh-frozen cadavers (age, 82-86 years). Each finger was dissected at the level of the carpometacarpal joint and fixated to a custom-built range of motion (ROM)-measuring apparatus after skin removal. The pin was inserted into the bone through four gliding soft tissues: the interosseous hood, dorsal capsule, lateral band, and sagittal band. Then, each tendon was pulled by a prescribed weight in three finger positions (flexion, extension, and intrinsic plus position). Changes in the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) angles were measured before and after pinning. We compared the differences between the insertion points using the Tukey-Kramer post hoc test. Results: Placement of pins into the sagittal band significantly restricted MCP joint flexion, while placement into the dorsal capsule and lateral band significantly restricted PIP joint flexion. Only placement into the interosseous hood showed no significant difference in joint angles between the three finger positions compared to pre-pin insertion. There were no significant effects on MCP, PIP, and DIP joint extension. Conclusions: The ROM of the MCP joint was obstructed due to pinning in most areas of insertion. However, pin insertion to the interosseous hood did not obstruct the finger flexion ROM compared to that of other gliding soft tissues; therefore, we believe that the interosseous hood may be a suitable pin insertion point for proximal phalangeal fixation.

Patient-Reported Outcomes and Complications After Surgical Fixation of 143 Proximal Phalanx Fractures

PURPOSE

Multiple methods exist to surgically fix unstable phalangeal fractures. Whereas these methods have different rates of complications or reoperation, it is not known whether these differences lead to changes in patient reported outcome. We compared patient-reported outcomes measures and complications of Kirschner wire (K-wire), lag-screw and plate fixation of proximal phalanx fractures (excluding the thumb).

METHODS

From 2010 to 2015, 159 patients with 159 proximal phalanx fractures were identified in 2 level 2 trauma centers and fixed with K-wires (44% of patients), lag-screws (26%), or plates (30%). Disabilities of the Arm, Shoulder, and Hand (DASH), and Patient-Rated Wrist/Hand Evaluation (PRWHE) and complications were assessed. In addition, subjective outcomes were assessed. Follow-up was achieved for 143 fractures (90%) and average time to follow-up was 3.4 years.

RESULTS

Mean DASH and PRWHE scores were 5.0 and 8.2, respectively. No differences in functional outcomes were found between fixation methods, although unplanned reoperation was more common in the plate fixation group (9 patients; 21%) than in the K-wire and lag-screw fixation groups (3 patients and 1 patient; 4.8 and 2.7%, respectively). We also found that K-wire fixation was associated with better aesthetic outcome than open reduction internal fixation.

CONCLUSIONS

Overall patient-reported outcomes measure scores were similar across fixation methods, and unplanned reoperation was more prevalent after plate fixation. In addition, we found that regardless of fracture pattern, percutaneous fixation with K-wires was often sufficient and associated with better aesthetic outcome than open reduction and internal fixation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Adjustment to hand injury: Cross-sectional survey exploring adjustment in relation to illness perceptions and coping strategies

STUDY DESIGN

Cross-sectional descriptive.

INTRODUCTION

Hand injuries are highly prevalent, and the impact they have on physical, emotional, and functional adjustment is well recognized. Increasingly, adjustment to health conditions including hand injuries is being understood in terms of psychological variables.

PURPOSE OF THE STUDY

To examine the role of illness beliefs and coping strategies in adjustment to hand injury. Adjustment was considered from a complete perspective including quality of life (QOL) and functional ability as well as mood and trauma symptoms.

METHODS

Cross-sectional survey whereby consecutive patients (n = 65) attending the regional plastic surgery service with hand injuries were invited to complete a questionnaire assessing illness perceptions, coping strategies, QOL, hand functioning, depression, and trauma symptoms. Data were analyzed in SPSS (IBM Corporation, Armonk, NY) by correlation and then hierarchical regression analysis.

RESULTS

Illness perceptions and coping strategies were significantly related to the adjustment outcomes (hand functioning, QOL, depression, and trauma symptoms). Specifically, poorer adjustment was associated with more negative illness beliefs (r = 0.31-0.47), greater use of denial (r = 0.24-0.53), and avoidance-based (r = 0.41-0.64) coping strategies.

DISCUSSION

Illness beliefs and coping play an important role in adjustment after hand injury. Adjustment is multifaceted with a need to consider physical and emotional functioning. More optimistic beliefs and adaptive coping styles are associated with improved adjustment.

CONCLUSION

The role of psychological variables in optimizing adjustment is an important consideration for the design of psychological interventions, but because this study was cross sectional and cannot assume directional effects, future longitudinal studies are needed.

LEVEL OF EVIDENCE

N/A.

Transverse and oblique fractures of the diaphysis of the fifth metacarpal: surgical outcomes for antegrade intramedullary pinning versus combined antegrade and retrograde intramedullary pinning

The purpose of this study was to develop a technique allowing a faster return to previous activities after surgical treatment of short transverse and oblique fractures of the diaphysis of the fifth metacarpal. It consisted of an anterograde and retrograde centromedullary double pinning connected. Our series included 40 patients of average age 25 years including 2 women. In 20 cases (group I), an anterograde centromedullary pinning with a 1.6- or 2-mm pin was performed followed by a 6-week orthosis and then 2-week self-education. In 20 cases (group II), an anterograde and retrograde centromedullary double pinning was performed using 2 1.5-mm pins connected by a connector (MétaHUS^®, Arex™). A first pin was introduced into the canal antegrade, then the second retrograde. The 2 externalized pins were connected, and self-rehabilitation was encouraged. Mean tourniquet time was 14.75 min (group I) and 15.8 min (group II), respectively. At the last follow-up, the average pain was 0.35/10 and 0.2/10, the Quick DASH 0.68/100 and 0.57/100, the strength of the hand 94.65% and 94.35%, the active flexion MCP 98.5% and 99%, respectively. MCP active extension was 98.5% and 98.75%; the sick leave was 8.4 and 6.3 weeks. All fractures healed without recovery with 3 complications: 2 infections on pins, in each group, 1 CRPS1 (group I). Our results seem to show that the technique of anterograde and retrograde centromedullary double pinning connected in the treatment of short transverse and oblique fractures of the diaphysis of the fifth metacarpal gives results at least as good as the reference technique with a non-negligible socioeconomic advantage, a less time off work.

Epidemiology of hand fractures at a tertiary care setting in Saudi Arabia

Objectives:

To examine the epidemiology of hand fractures including common bones affected, causes, interventions, outcomes, and complications.

Methods:

This retrospective records-based study included patients who were admitted to King Saud Medical City, Riyadh, Kingdom of Saudi Arabia, with traumatic metacarpal or phalangeal fractures between January 2016 and September 2017. Carpal fractures, wrist fractures, and all pathological fractures were excluded.

Results:

A total of 82 patients (90.2% of them men with an average age of 27.6±13.4 years) with 101 fractures were included. The fifth (25.5%) and first (24.5%) rays were the most commonly affected ones. The fifth finger (27.8%) and first metacarpal (28.9%) were the most commonly affected finger and metacarpal bone. Approximately 32.7% of the fractures were open fractures. The most frequent causes of hand fractures included falls (40.5%), road traffic accidents (20.3%), crushing injuries (9.5%), and machinery injuries (9.5%). Approximately 90.1% of the patients underwent operative interventions including open reduction (50.5%) and closed reduction (34.3%). The majority of fractures (79.2%) healed, and only 14.7% of fractures developed complications.

Conclusion:

In this study of hand fractures, patients were predominantly males and the main causes of fractures were falls and road traffic accidents.

Comparison of low-profile plate-screw and Kirschner-wire osteosynthesis outcomes in extra-articular unstable proximal phalangeal fractures

BACKGROUND

We aimed to present the radiological and clinical results of Kirschner-wire (K-wire) fixation and low-profile plate-screw fixation applied to unstable proximal phalangeal fractures without extension to the joint.

METHODS

Clinical and radiological data of 22 patients who underwent fixation with open reduction and low-profile 1.5-mm titanium mini plate and unlocked screws and 18 patients who underwent fixation with K-wire due to closed, unstable extra-articular proximal phalangeal fractures were retrospectively examined. All evaluation and statistical analyses were based on sixth postoperative month evaluation parameters. Active and passive metacarpophalangeal joint and interphalangeal joint range of motions, total joint range of motion, measurement of grip strength for fractured and healthy hands, visual analog scoring, disabilities of the arm, shoulder, and hand scores, measurement of distance between the pulpa and palmar curve in the operated finger, Belsky score, reoperation, and complications were evaluated.

RESULTS

Radiological union was achieved in all patients in a mean duration of 4.2 (3-6) weeks. When the functional results of the patients were evaluated, the mean active metacarpophalangeal joint flexion was 87.3° (75°-90°), mean proximal interphalangeal joint flexion was 94.3° (65°-100°), mean distal interphalangeal joint flexion was 77.6° (75°-80°), and mean total range of motion was 259° (210°-270°). The grip strength of the fractured hand was 52.7 (40-58) kgW, whereas that of the healthy hand was 54.4 (42-60) kgW. The mean value of visual analog score was 0.8 (0-2), mean score for disabilities of the arm, shoulder, and hand was 7 (2-27), and mean distance between the finger pulpa and finger curve was 3 (0-8) mm.

CONCLUSION

Plate-screw osteosynthesis in the extra-articular, unstable fractures of the proximal phalanx, which is "small" compared with the body but has a "major function" for the hand and upper extremity, allows for rigid fixation, short immobilization, and early motion in spiral/oblique-fragmented fractures. K-wire fixation, an alternative treatment modality, applied to selected fracture patterns with appropriate indications can achieve good-excellent results radiologically and functionally.

Closed Intramedullary Locking Nailing for Metacarpal Fractures: A Retrospective Study of Sixty-Six Fractures

Introduction: Metacarpal fractures are frequent injuries in the young male working population and the majority are treated non-operatively. There is a growing trend to surgically treat these fractures, with the aim of reducing the deformity and shortening the rehabilitation period. The aim of this retrospective case series is to report on our experience and clinical outcomes of using percutaneous flexible locking nails for the management of displaced metacarpal fractures. This study is a retrospective review of 66 fractures that were managed at our centre over a 7-year period.

Materials and Methods: Records of 60 patients were retrospectively reviewed. Indications for surgery were a displaced metacarpal shaft or neck fracture with associated rotational deformity, or multiple metacarpal fractures. The fracture was reduced by closed manipulation, and a flexible pre-bent locked intramedullary nail (1.6mm diameter) was inserted through a percutaneous dorsal antegrade approach, facilitated by a specially designed pre-fabricated awl. The implant was removed at union. Patients were followed-up in clinic until the fracture had united.

Results: The mean union time was seven weeks (range 2 to 22 weeks) and there were nine (14%) delayed unions (>3 months) and no non-unions. The nail had migrated in three cases (5%) and caused skin impingement in two cases (3%). There was one infected case (2%). Rotational clinical deformity was evident for two (3%) cases.

Conclusion: The use of a minimally-invasive locked intramedullary nailing for unstable metacarpal fractures has a significantly low complication rate, with predictable union times and good functional outcomes.

[Corrective osteotomy of the hand]

Fractures of fingers and metacarpals are among the most frequent injuries. Many fractures can be successfully treated conservatively. Nevertheless, various malformations, such as malrotation, spur development, bone shortening, deviation of the axis and combinations of these individual deformities may appear in the course of time. Corrective osteotomy can correct these deformities with clinically impaired function and improve/optimize hand function. Prerequisites for corrective osteotomy are a precise analysis of the deformity, precise osteotomy, exercise stable osteosynthesis and intensive follow-up treatment of the hand. Complications, such as implant failure, postoperative tendon and joint adhesions, joint contracture and nonunion are however possible.

Early active motion after rigid internal fixation of unstable extra-articular fractures of the proximal phalanx

The purpose of this study is to describe active early rehabilitation in proximal phalanx fractures treated with rigid internal fixation. A total of 22 consecutive patients presenting with spiral, oblique or comminuted extra-articular fractures of the proximal phalanx were included in the study. All fractures were rigidly stabilized with plate and screws or screws alone and subsequently entered an active early rehabilitation programme. The mean follow-up period was 15.4 months (SD 10.1). Mean visual analogue scale pain score was 0.3 (SD 0.5) and Disability of the Arm, Shoulder and Hand score was 9.2 (SD 4.1). Mean total active motion was 241.9° (SD 18.3). According to the digital functional assessment, 86.3% of the patients had excellent results. Extension lags of the proximal interphalangeal joint were observed in seven fingers (mean lag, 3.4° (SD 5.5)). The results of this study demonstrated high patient satisfaction and good outcomes after the surgical technique and postoperative rehabilitation protocol described in open reduction and rigid internal fixation of proximal phalangeal fractures.

LEVEL OF EVIDENCE

IV.