Fifth metacarpal neck fracture fixation: Locking plate versus K-wire?

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.

Metacarpal Fracture Fixation with Intramedullary Screws

Background: Intramedullary screws (IMS) have become a viable option for metacarpal fracture fixation. To further appraise their utility, this study assessed clinical and patient-reported short- and medium-term outcomes of IMS fixation for extra-articular metacarpal fractures. Methods: A retrospective cohort study was performed in a series of 32 patients (with a total of 37 fractures) who underwent metacarpal fracture fixation over a 42-month period between January 2020 and July 2023. Results: Mean time for return to work was 39.8 days; mean time for return to full function was 88.4 days; total active motion was 250.7° (range: 204.9-270.9); Quick Disabilities of the Arm, Shoulder and Hand score was 2.3 (range: 0-22.7); mean visual analogue pain score was 0.9 out of 10 (range: 0-6) and a single complication was observed. Conclusions: The use of IMS in metacarpal fracture fixation is a practicable surgical option. IMS fixations yields a satisfactory duration for return to function, good postoperative range of movement, modest pain scores and low rates of complications. Level of Evidence: Level IV (Therapeutic).

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.

Conservative treatment versus transverse pinning in fifth metacarpal neck fractures in active adults: a randomized controlled trial

PURPOSE

Compare two simple ways for treating boxer's fractures in active adults; conservative management by ulnar gutter slab and transverse pinning in fixation of fifth metacarpal's neck fracture regarding union, functional outcomes, and complications.

PATIENTS AND METHODS

Ninety patients with fifth metacarpals' neck fractures with palmar angulation (30-70°) were managed either conservatively by an ulnar gutter slab or surgically by transverse pinning technique from January 2020 to December 2021. Only 84 patients completed a 1-year follow-up. Patients with old, open, or mal-rotated fractures were excluded. The block-randomization method was used to create equal groups. Patients were evaluated clinically and radiologically every 2-3 weeks until union, then at 6 and 12 months. Functional assessment at the final visit was done using the quick DASH score, total active motion (TAM), and total Active Flexion (TAF).

RESULTS

The mean radiological union time for the conservative group in this study was 7.76 weeks, while for the transverse pinning group, it was 7.38 weeks. There was no statistically significant difference between the two techniques regarding union rates and functional outcomes. All patients returned to their pre-injury jobs and level of activity.

CONCLUSION

Both conservative management in ulnar gutter slab and percutaneous transverse pinning are considered effective methods in the treatment of simple extra-articular fifth metacarpal neck fractures with angulation between 30 and 70 degrees (AO: 77 A3.1). The functional and radiological results using both methods were satisfactory and statistically comparable.

Retro-Antegrade Technique in the Management of Severely Angulated Fourth and Fifth Metacarpal Neck Fractures: A Case Series

Background: This study introduces a novel method for the management of closed metacarpal neck fractures. Kirschner wires (K-wire) are introduced in a retrograde and the wires withdrawn through skin proximally at the base of the metacarpal. The fracture is reduced using traction and the reduction is maintained by antegrade advancement of the K-wires. The aim of this study is to report the outcomes of this technique. Methods: A total of 36 patients with severely angulated closed metacarpal neck fractures underwent reduction and fixation using this novel method from January 2017 to December 2020 in centres in Ireland and Saudi Arabia. We performed a retrospective review of these patients' clinical data examining their outcomes. Results: Six months postoperatively, all fractures demonstrated bony union and correction of angulation. All patients exhibited excellent range of motion (ROM) with no significant impairment of hand function. Conclusions: The method detailed here is a simple, minimally invasive and reliable technique that has not previously been described. It is suitable for use in the management of closed metacarpal neck fractures of the fourth and fifth metacarpal, with dorsal angulation greater than 60°. Level of Evidence: Level IV (Therapeutic).

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.

Single Buried Intramedullary K-Wire Fixation in Nonthumb Metacarpal Shaft Fractures with Immediate Postoperative Mobilization without Any Immobilization

Objective

This study aims to evaluate the outcomes of single intramedullary K-wire fixation in nonthumb, metacarpal shaft fractures with immediate postoperative hand mobilization without any immobilization.

Method

This is a retrospective case series conducted from January 2019 to December 2022. We included patients with closed, simple transverse, or short oblique metacarpal shaft fracture treated with single, 1.4 mm, intramedullary K-wire fixation. Gentle postoperative range of motion exercise was encouraged in every patient without any hand, finger, or wrist motion restriction material. Clinical outcomes were evaluated with total active flexion; grip strength; disability of arm, shoulder, and hand (DASH) score; and the American Society for Surgery of the Hand Total Active Flexion (ASSH TAF) score.

Results

This study included 34 patients, 25 males and 9 females with a mean age of 33.14 years (ranging 18-59). A total of 43 metacarpal shafts were treated. The mean DASH score at two and 6 weeks postoperative was 41.5 (ranging 19.16-60.34) and 9.58 (ranging 0.83-23.27). The mean final DASH score at last follow-up was 3.48 (ranging 0-8.33). Mean TAF at 2 weeks postoperative, 6 weeks postoperative, and at final follow-up was 203.8 (ranging 185-240), 238.2 (ranging 220-270), and 259.25 (ranging 240-270) degrees, respectively. The mean grip strength of the injured hand was 66.14 and 86.1% of the uninjured hand at 6 weeks and 3 months postoperative. There was no nonunion, malrotation, or infection. In conclusion, single intramedullary K-wire fixation gives excellent outcomes in the treatment of single or multiple, simple, metacarpal shaft fractures without the need of postoperative immobilization.

Biomechanical study of the fixation ability of the dorsal and volar locking plate for transverse metacarpal neck fractures

Metacarpal neck fracture is one of the most common types of hand fractures; the literature suggests that applying a bone plate on the dorsal side provides higher fixation strength than that provided by other fixation methods. However, bone plate fixation on the dorsal side may result in postoperative tendon adhesion. So far, no studies have investigated the fixation of metacarpal neck fractures on the volar side by using a bone plate. The objective of this study was to investigate the differences in the fixation results between bone plate fixation on the dorsal side and bone plate fixation on the volar side of the metacarpal in the case of a metacarpal neck fracture. A saw blade was used to create a transverse metacarpal neck fracture on 14 artificial metacarpal bone specimens. The specimens were divided into 2 groups depending on the fixation method: a volar locking plate (VLP) group and a dorsal locking plate (DLP) group. All specimens were subjected to a cantilever bending test on a material testing system, and a force-displacement curve was used to measure the yield force and stiffness, which served as an indicator of the fixation ability of the 2 fracture fixation methods. For the experimental results, the Mann-Whitney U test was used to compare the fixation abilities of the 2 fixation methods. In terms of yield force, the DLP group (266.9 ± 68.3 N) scored significantly higher than the VLP group (32.6 ± 2.7 N) (P < .05); expressed in terms of median, the DLP group scored 8.2 times higher than the VLP group. Similarly, in terms of stiffness, the DLP group (69.0 ± 13.4 N/mm, median ± interquartile range) scored significantly higher than the VLP group (12.9 ± 1.4 N/mm) (P < .05); expressed in terms of median, the DLP group scored 5.3 times higher than the VLP group. The fixation strength of volar bone plates is only about one-third of that of dorsal bone plates.

Metacarpal fractures

Metacarpal fractures are common and can be functionally disabling. The majority are managed non-operatively. When surgical intervention is indicated, various methods of fixation are available with the utility of each being based on injury pattern, patient function and surgeon preference. Early mobilization, especially in case of open reduction and internal fixation, is a critical component of treatment to prevent stiffness and restore function. When possible, a fixation construct that can withstand the applied forces of early postoperative motion is chosen. We provide an updated description for diagnosis, treatment options and operative fixation for metacarpal fractures.

Prospective Comparison of the Early Outcomes of Headless Compression Screw and Percutaneous K-Wire Fixation in Metacarpal Fractures

PURPOSE

The study aimed to assess early clinical outcomes achieved by headless compression screws (HCS) in fixation of metacarpal fractures, and to compare them with outcomes of percutaneous K-wire fixation. The hypothesis was that HCS would show better arc of motion and superior early clinical outcomes.

METHODS

This was a randomized study of nonthumb metacarpal neck and shaft fractures. To compare the 2 surgical techniques, 23 patients treated for metacarpal neck and shaft fractures were divided into 2 groups: 11 treated with K-wire fixation and the other 12 with HCS fixation. We followed the patients for 12 weeks. The primary objective was to compare metacarpophalangeal arc of motion, and the secondary aim was to determine clinical union, radiographic union, and recovery time before returning to employment in the 2 groups.

RESULTS

At each follow-up visit, patients in the group treated with HCS had better metacarpophalangeal arc of motion than those treated with K-wire fixation. The HCS group showed a shorter time interval to return to work (at 3 weeks) and no complications, while the K-wire group had 1 pin track infection, which was treated with oral antibiotics and pin removal.

CONCLUSIONS

Compared with K-wire fixation, limited-open HCS fixation for metacarpal neck and shaft fractures was superior in terms of the early postoperative metacarpophalangeal arc of motion and return to work.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Fractures of the fifth metacarpal neck treated by syndactyly: functional and quality of life outcomes of a series of 39 patients

The management of the fractures of the fifth metacarpal neck is still debated between surgical, orthopedic, and functional treatments. The main objective of our study was to report the functional results at two, six, and twelve weeks of patients treated with syndactyly for fifteen days for a fracture of the neck of the fifth metacarpal and to determine if these results were compatible with a short-term medical follow-up and if they allowed for a quick return to work. Thirty-nine patients were retrospectively included. Functional results and their variations were analyzed at two, six, and twelve weeks using self-questionnaires filled out during consultation (VAS scores, QuickDASH, EuroQol-5D-5L, and EuroQol- 5D-VAS). The duration of work leave was extracted from medical records. Two weeks after the trauma, patients mostly had a very moderate impact of their fracture on their daily life with an average VAS of 4.2±1, QuickDASH of 42.2±20.9, and EuroQol-5D-VAS of 78±11. QuickDASH and EuroQol-5D-VAS scores showed significant improvement between two and twelve weeks of follow-up, decreasing from 42.2±20.9 to 2.1±6 and from 78±11 to 96±6, respectively (p<0.0001). The dimensions of common activities, pain, and autonomy had the most patients in the "moderate impairment" subgroup at two weeks. Only the dimension of common activities still had 21% of patients moderately impacted. Twenty-five patients returned to work at an average of 21.8±1.5 days. Syndactyly treatment offers good functional results at two weeks that are confirmed during follow-up, compatible with reduced medical follow-up and early return to work.

Internal Fixation of Finger Fractures: Field Sterility for Surgery and Earlier Removal of K-Wires Are Safe

Field sterility for K-wire insertion outside the main operating room is much cheaper and greener (ie, there is less waste). It permits increased access to more affordable surgery because unnecessary sedation and full sterility are eliminated. Early pain-guided protected movement of K-wired finger fractures at 3 to 5 days leads to less stiffness. It will not result in loss of reduction or infection around K-wires if patients avoid "pain" (ie, do not perform movements that hurt). Early protected movement and early removal of K-wires at 2 to 4 weeks contribute to less stiffness after operative hand/finger fracture reduction and stabilization.

The Conservative Treatment of Some Hand and Carpal Fractures

In recent decades, there has been a trend toward increased use of operative treatment of hand fractures. However, internal stabilization with wires or open reduction and internal fixation of the phalanges and the metacarpals carries a risk of surgical complications that can be avoided by using appropriate conservative treatment. In this article, some hand fractures that can be managed safely without surgery are discussed. In conclusion, when facing a fracture in the hand, the first consideration is whether the fracture can be treated nonoperatively and not which operative treatment is most appropriate. This applies to both displaced and undisplaced fractures.

Fifth metacarpal neck fracture fixation: antegrade intramedullary pinning with two K-wires or percutaneous retrograde crossed pinning

Objective: The present study aimed to compare clinical and radiological outcomes in patients with displaced fifth metacarpal neck fractures after treatment with antegrade intramedullary pinning with two K-wires or percutaneous retrograde crossed pinning. Material Method: While seventeen patients were treated with antegrade intramedullary pinning (Group ), 14 were treated with percutaneous retrograde crossed pinning (Group 2). Clinical and radiological outcomes included Quick Dash, active range of motion (ROM), VAS, and dorsal angulation loss at weeks four and twelve and in the final follow-up. Results: The findings revealed that the groups had mean ages of 29.41±8.15 years and 27.78±7.42 years, res-pectively. While ROM was better in Group 2 at weeks four and twelve, we could not find a significant difference between the groups by active ROM in the final follow-up. Moreover, Group 1 had a better Dash score in the fourth week and twelth week , but both groups had similar Dash scores in the final follow-up. Finally, the groups had no preoperative and postoperative differences radiologically. Conclusion: The present findings uncovered that treatment of a displaced fifth metacarpal neck fracture by anteg-rade intramedullary pinning yielded a better in the first three months improvement in active ROM and Quick Dash than percutaneous retrograde crossed pinning.

Headless Compression Screw for Metacarpal Nonunion: Description of a New Technique and Report of 4 Cases

Nonunion is a rare complication of metacarpal fractures and is usually associated with compound, open fractures with tissue loss and infection, or after failed surgical treatment. Repair by rigid osteosynthesis with plate and screws combined with autologous bone grafting has always been the treatment of choice for most patients. Such method allows early motion, although it has been proven that the presence of hardware may cause local soft tissue irritation. Often, hardware removal and tendon releases are necessary. We describe an original technique with a fixation method for the treatment of metacarpal nonunions, considering the excellent results attained with an intramedullary, headless screw for metacarpal fracture fixation. We report a series of three cases that evolved to bone healing with excellent clinical, functional, and radiographic outcomes.

Treatment of isolated fourth metacarpal neck fractures using the closed reduction and percutaneous intermetacarpal and external fixation

BACKGROUND

The isolated fourth metacarpal neck fracture is uncommon, and the appropriate management is still debatable. The aim of this retrospective study was to introduce a closed reduction and percutaneously intermetacarpal K-wire fixation external technique to treat the isolated fourth metacarpal neck fracture.

METHODS

From October 2013 to January 2018, 21 patients with closed-isolated fourth metacarpal neck fractures (angulation ≥35°, rotation ≥5°, or shortening ≥5 mm) were treated with the closed reduction and percutaneous intermetacarpal and external fixation technique. Total active motion, grip strength of the hand, dorsal prominence, and patient satisfaction were assessed.

RESULTS

Follow-up lasted 28 months (range, 24-37 months). All patients obtained bone healing at a mean time of 5 weeks (range, 4-8 weeks). External fixation devices were removed when bone healing achieved. The mean total active motion reached 97.5% (range, 92.9%-100%) of opposite side. There were 18 excellent and 3 good results. The mean grip strength reached 98.4% (range, 96.2%-100%) of the opposite hands. Based on the 100-mm visual analogue scale, the mean dorsal prominence was 0 (range, 0 to 1). Based on the Short Assessment of Patient Satisfaction, the mean satisfaction score was 26 (range, 24 to 28).

CONCLUSIONS

The closed reduction and percutaneous intermetacarpal and external fixation technique is useful and reliable for treating the isolated fourth metacarpal neck fracture. The technique can effectively restore the fracture deformities and maintain the reduction stably, resulting in good hand function.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Intramedullary Headless Screw Fixation of Metacarpal Fractures: A Radiographic Analysis for Optimal Screw Choice

Background: The purpose of this study was to investigate variations in radiographic metacarpal anatomy as it relates to intramedullary (IM) fixation of metacarpal fractures and to compare this anatomy with available headless screw dimensions. Methods: We radiographically analyzed posteroanterior and lateral (LAT) radiographs of 120 metacarpals across 30 patients without structural abnormalities. Primary outcomes included IM isthmus diameter, isthmus location, metacarpal cascade, and head entry point collinear with IM canal. Measurements were compared with a list of commercially available headless screws used for IM fixation. Results: The average largest isthmus diameter was in the small metacarpal (3.4 mm), followed by the index (2.8 mm), long (2.7 mm), and ring (2.7 mm) metacarpals. The average cascade angle between long and index, long and ring, and long and small metacarpals was 0°, 24°, and 27°, respectively. The appropriate head entry point ranged between 25% and 35% from the dorsal surface of the metacarpal head on a LAT view. The retrograde isthmus location of the index and long finger was 39.2 and 38.1 mm, respectively. Twenty-five screws from 7 manufacturers were analyzed with sizes ranging from 1.7 to 4.5 mm. Only 8 of 17 screws between 2.3 and 3.5 mm had a length range above 35 mm. Conclusions: Metacarpal head entry point and cascade angle can help identify the appropriate reduction with the guide pin starting point in the dorsal 25% to 35% of the metacarpal head. Surgeons should be mindful to choose the appropriate fixation system in light of the variations between metacarpal isthmus size, isthmus location, and available screw lengths.

A Fourteen-year Review of Practice Patterns and Evidence-based Medicine in Operative Metacarpal Fracture Repair

The American Board of Plastic Surgery has been collecting practice data on metacarpal fracture operative repair since 2006 as part of its Continuous Certification process. These data allow plastic surgeons to compare their surgical experience to national trends. Additionally, these data present the opportunity to analyze those trends in relation to evidence-based medicine.

Fifth Metacarpal Neck Fractures: Outcome-influencing Factors

Introduction Fifth metacarpal neck fractures are extremely common, but there is still no consensus regarding the ideal course of treatment.

Volar angulation and shortening are decisive factors; however, there is still controversy about the cut-off values that translate into worse clinical results.

The present study aims to answer these questions in order to provide additional data to aid in the clinical practice and decision making.

Materials and Methods A retrospective study evaluated patients with fifth metacarpal fractures treated between 2013 and 2018. A total of 133 patients were included, with an average follow-up of 2 months. Surgery was performed in 21 patients, and 112 were treated conservatively. The radiological assessment of volar anguation and shortening was based in the first and last radiographs of the follow-up. The patients were contacted and submited to a questionnaire that included the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score and subjective evaluations of pain (Visual Analogue Scale, VAS), hand strength, stiffness and finger mobility, and cosmetic result.

Results Surgery was more successful in reducing angulation than the conservative treatment, achieving more anatomic final values for angulation and shortening (p < 0.05). On the other hand, surgery seems to be associated with a higher notion of limited finger mobility (p = 0.02).

Among patients treated conservatively, inicial angulations > 60° and final angulations > 50° were associated with worse cosmetic results (p = 0,039). Final shortening > 4 mm translated into a higher notion of stiffness and limited finger mobility (p = 0.034).

More advanced age showed a correlation with higher scores on the VAS (p = 0.023) and QuickDASH (p < 0,001). Female patients (p = 0.02) were also associated with higher VAS scores. The overall satisfaction rate was of 97%.

Conclusion Although globally the functional outcome of these fractures is very good, the present study reports several factors that should be considered when treating fifth metacarpal neck fractures.

Comparison of the fixation ability of headless compression screws and locking plate for metacarpal shaft transverse fracture

Metacarpal shaft fractures are common hand fractures. Although bone plates possess strong fixation ability, they have several limitations. The use of headless compression screws for fracture repair has been reported, but their fixation ability has not been understood clearly.This study aimed to compare the fixation ability of locked plate with that of headless compression screw for metacarpal fracture repair.A total of 14 artificial metacarpal bones (Sawbones, Vashon, WA, USA) were subjected to transverse metacarpal shaft fractures and divided into 2 groups. The first group of bones was fixed using locked plates (LP group), whereas the second group was fixed using headless compression screws (HC group). A material testing machine was used to perform cantilever bending tests, whereby maximum fracture force and stiffness were measured. The fixation methods were compared by conducting a Mann-Whitney U test.The maximum fracture force of the HC group (285.6 ± 57.3 N, median + interquartile range) was significantly higher than that of the LP group (227.8 ± 37.5 N; P < .05). The median of the HC group was 25.4% greater. However, no significant difference in stiffness (P > .05) was observed between the HC (65.2 ± 24.6 N/mm) and LP (61.7 ± 19.7 N/mm) groups.Headless compression screws exhibited greater fixability than did locked plates, particularly in its resistance to maximum fracture force.

Analysis of 3 Different Operative Techniques for Extra-articular Fractures of the Phalanges and Metacarpals

Background: Several techniques have been described for treating metacarpal and phalangeal fractures. We sought to compare the 3 techniques most frequently used for extra-articular metacarpal and phalangeal fractures: plate screw (PS), Kirschner wire (KW), and retrograde intramedullary screw (RIS) fixation. We aimed to determine whether using an RIS provides better clinical outcomes than using either a PS or a KW fixation. Methods: We conducted a retrospective review of patients who underwent surgical treatment of metacarpal and phalangeal fractures from January 2011 to December 2017 in our department. Only patients with an acutely displaced short oblique or transverse extra-articular metacarpal or phalangeal fracture were included. Patients were classified into 3 groups depending on the treatment they received: PS, KW, or RIS fixation. The duration of each procedure was recorded. Clinical assessments included measuring total active motion (TAM), grip strength, and an evaluation of plain radiographs through to ultimate healing. A Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was collected on all patients. Data were analyzed by analysis of variance or Kruskal-Wallis rank test, as indicated. Results: A total of 253 fractures (202 metacarpal and 51 phalangeal) in 230 patients were included in analysis. In all, 135 fractures (53.3%) underwent PS fixation; 53 (20.9%), KW fixation; and 65 (25.6%), RIS fixation. In the KW fixation group, Bouquet pinning was performed for metacarpal fractures and cross pinning for phalangeal fractures. When more than 1 fracture coexisted in the same patient, they were considered separate instances. No differences among the 3 groups were observed when evaluating mean time to radiological union, grip strength, TAM, or QuickDASH score. Mean surgery time was significantly shorter with KW (20 minutes) and RIS (25 minutes), than with PS (32 minutes). Mean return to work or routine activities time was significantly less in the RIS (7.8 weeks) group than in the PS and KW groups (8.3 and 9.2 weeks, respectively). Conclusions: Surgical treatment is recommended in patients with unstable metacarpal and phalangeal fractures. The use of RIS was associated with shorter mean surgery duration and return to work times than PS and KW, respectively.

The curative effect analysis of a modified Kirschner wires and locking plate internal fixation method for the fifth metacarpal neck fracture

PURPOSE

To evaluate the efficacy of a modified internal fixation method for the treatment of fifth metacarpal neck fracture.

METHODS

From March 2018 to December 2019, 12 patients with the fifth metacarpal neck fractures of the hands were treated with the Kirschner wires and locking plate internal fixation method. Each patient's gender, age, dominant hand, injured hand, trauma mechanism, preoperative and postoperative deformity (angulation and the length of the fifth metacarpal), the range of motion of the metacarpophalangeal joint and grip strength of each side, the time of return to work, and follow-up time were recorded and calculated.

RESULTS

The mean follow-up time was 16.8 months, and the angulations of preoperative and postoperative deformity were 40.0 ± 3.7°and 17.6 ± 1.7°, respectively. The length of the fifth metacarpals of preoperative and postoperative deformity were 51.5 ± 2.1 mm and 60.0 ± 1.8 mm, respectively. At the last follow-up, the range of motion of the fifth metacarpophalangeal joint of the injured side and the contralateral side were 84.3 ± 3.6°and 86.5 ± 2.0°, and the grip strength of the injured side and the contralateral side were 74.8 ± 6.1 LB and 78.6 ± 8.3 LB, respectively, without statistically significant differences. QDASH score was 2.0 ± 1.0, and the time of return to work was 6.0 ± 0.7 weeks.

CONCLUSION

The modified internal fixation method is one of the alternative treatments for the fifth metacarpal neck fracture with good curative effects.

Effect of a figure-of-eight cerclage wire with two Kirschner wires on fixation strength for transverse metacarpal shaft fractures: an in vitro study with artificial bone

BACKGROUND

Metacarpal shaft fractures are a common type of hand fracture. Despite providing strong fixation strength, plate fixation has numerous shortcomings. Concerning internal fixation with Kirschner wires (K-wires), although this approach is frequently used to treat metacarpal shaft fractures, the lack of functional stability may result in fixation failure.

OBJECTIVE

To evaluate the effect of figure-of-eight cerclage wire on fixation for transverse metacarpal shaft fractures using two K-wires.

MATERIALS AND METHODS

We used a saw blade to create transverse metacarpal shaft fractures in 14 fourth-generation artificial third metacarpal bones (Sawbones, Vashon, WA, USA), which were assigned to groups undergoing fixation with two K-wires (KP) or with two K-wires and figure-of-eight cerclage wire (KP&F8). All specimens were subjected to material testing, specifically cantilever bending tests. The maximum fracture force and stiffness of the two fixation types were determined on the basis of the force-displacement data. The Mann-Whitney U test was used to compare between-group differences in maximum fracture force and stiffness.

RESULTS

The maximum fracture force of the KP group (median ± interquartile range = 97.30 ± 29.70 N) was significantly lower than that of the KP&F8 group (153.2 ± 69.50 N, p < 0.05; Figure 5a), with the median of the KP&F8 group exceeding that of the KP group by 57.5%. Similarly, stiffness was significantly lower in the KP group (18.14 ± 9.84 N/mm) than in the KP&F8 group (38.25 ± 23.49 N/mm; p < 0.05; Figure 5b), with the median of the KP&F8 group exceeding that of the KP group by 110.9%.

CONCLUSION

The incorporation of a figure-of-eight cerclage wire increased the maximum fracture force and stiffness by 57.5 and 110.9%, respectively, compared with those achieved in standard two K-wire fixation. Therefore, hand surgeons are advised to consider the proposed approach to increase fixation strength.

[Treatment of the fifth metacarpal neck fracture with elastic intramedullary nail under the guidance of high frequency ultrasound]

OBJECTIVE

To analyze the feasibility and effectiveness of elastic intramedullary nail fixation for the fifth metacarpal neck fracture under the guidance of high frequency ultrasound.

METHODS

The clinical data of 30 patients with the fifth metacarpal neck fractures who were treated with elastic intramedullary nails fixation under the guidance of high frequency ultrasound and met the selection criteria between May 2013 and September 2017 were retrospectively analysed. There were 24 males and 6 females, the age ranged from 18 to 58 years, with an average of 31.4 years. The head-shaft angle of the fifth metacarpal was (55.6±11.3)°. The time from injury to operation was 12 hours to 8 days, with an average of 2.4 days. The operation time, number of intraoperative fluoroscopy, fracture reduction, complications, and fracture healing time were recorded. The head-shaft angle of the fifth metacarpal on the affected side after fracture healing were measured and compared with the healthy side. At last follow-up, the active range of motion of the fifth metacarpophalangeal joint of both sides were measured, and the function was evaluated by using the total active movement (TAM) evaluation standard of the Hand Surgery Association of Chinese Medical Association.

RESULTS

The operation time was 22-40 minutes, with an average of 32.4 minutes; the intraoperative fluoroscopy was performed once; ultrasound images and X-ray fluoroscopy showed that the fracture was well reduced and no adjustment was required. The incisions healed well after operation, without tendon adhesion or local numbness. All 30 patients were followed up 8-16 months, with an average of 11.7 months. The fracture healing time was 4-8 weeks, with an average of 5.6 weeks. The head-shaft angle of the fifth metacarpal was (13.2±1.4)°, which was significantly improved when compared with preoperative value ( t=-20.02, P=0.00); and there was no significant difference ( t=1.94, P=0.06) when compared with the healthy side [(12.6±1.0)°]. At last follow-up, the active range of motion of the fifth metacarpophalangeal joint on the affected side was (89.4±2.4)°, showing no significant difference ( t=-1.58, P=0.13) when compared with the healthy side [(90.3±2.0)°]. According to the TAM evaluation standard of the Hand Surgery Association of Chinese Medical Association, all patients were considered to be excellent.

CONCLUSION

The effectiveness of elastic intramedullary nail fixation for the fifth metacarpal neck fracture under the guidance of high frequency ultrasound is definite. It can dynamically observe the fracture reduction from different angles, reduce ionizing radiation and postoperative complications.

Effect of oblique headless compression screw fixation for metacarpal shaft fracture: a biomechanical in vitro study

Background

Metacarpal shaft fracture is a common fracture in hand trauma injuries. Surgical intervention is indicated when fractures are unstable or involve considerable displacement. Current fixation options include Kirschner wire, bone plates, and intramedullary headless screws. Common complications include joint stiffness, tendon irritation, implant loosening, and cartilage damage.

Objective

We propose a modified fixation approach using headless compression screws to treat transverse or short-oblique metacarpal shaft fracture.

Materials and methods

We used a saw blade to model transverse metacarpal neck fractures in 28 fresh porcine metacarpals, which were then treated with the following four fixation methods: (1) locked plate with five locked bicortical screws (LP group), (2) regular plate with five bicortical screws (RP group), (3) two Kirschner wires (K group), and (4) a headless compression screw (HC group). In the HC group, we proposed a novel fixation model in which the screw trajectory was oblique to the long axis of the metacarpal bone. The entry point of the screw was in the dorsum of the metacarpal neck, and the exit point was in the volar cortex of the supracondylar region; thus, the screw did not damage the articular cartilage. The specimens were tested using a modified three-point bending test on a material testing system. The maximum fracture forces and stiffness values of the four fixation types were determined by observing the force–displacement curves. Finally, the Kruskal–Wallis test was adopted to process the data, and the exact Wilcoxon rank sum test with Bonferroni adjustment was performed to conduct paired comparisons among the groups.

Results

The maximum fracture forces (median ± interquartile range [IQR]) of the LP, RP, HC, and K groups were 173.0 ± 81.0, 156.0 ± 117.9, 60.4 ± 21.0, and 51.8 ± 60.7 N, respectively. In addition, the stiffness values (median ± IQR) of the LP, HC, RP, and K groups were 29.6 ± 3.0, 23.1 ± 5.2, 22.6 ± 2.8, and 14.7 ± 5.6 N/mm, respectively.

Conclusion

Headless compression screw fixation provides fixation strength similar to locked and regular plates for the fixation of metacarpal shaft fractures. The headless screw was inserted obliquely to the long axis of the metacarpal bone. The entry point of the screw was in the dorsum of the metacarpal neck, and the exit point was in the volar cortex of the supracondylar region; therefore the articular cartilage iatrogenic injury can be avoidable. This modified fixation method may prevent tendon irritation and joint cartilage violation caused by plating and intramedullary headless screw fixation.

Challenging the dogma: severely angulated neck fractures of the fifth metacarpal must be treated surgically

Cadaveric studies suggest that the acceptable deformity in fifth metacarpal neck fractures is maximally 30° palmar angulation. This systematic review verifies the validity of these threshold values. Eighteen prospective comparative studies on operative and/or conservative treatment options in adults were included. None of the studies demonstrated any correlation between the residual or initial angulation and the clinical results despite accepting more severe angular deformities. Closed reduction and immobilization without internal fixation improved the palmar angle by 5° to 9° in three studies and 29° in a fourth. Operative treatments compared with non-reducing conservative treatments showed no benefit of the surgery other than aesthetic issues. The synthesis of this review indicates that 90% of fractures of the metacarpal neck with apex angulation up to 70° can be treated successfully with a functional metacarpal brace without reduction. Disability of the Arm, Shoulder and Hand questionnaire scores <10 are uniformly reported. I modified my own practice accordingly a decade ago to treating these fractures conservatively regardless of the palmar angulation, except in patients with exceptional demands or other fracture deformities.

Flexible Stable Intramedullary Nailing for the Management of Metacarpal Neck Fractures

Introduction  When dealing with metacarpal neck fractures, the aim of treatment should include clinical and radiological objectives. The aim of this study was to assess the efficacy of flexible stable intramedullary nailing for the management of metacarpal neck fractures. Materials and Methods  A total of twenty four patients (22 males and 2 females; mean age: 28.2 ± 7.7 years) with metacarpal neck fractures (second in 7 patients and fifth in 17 patients) whether isolated or associated with other body injuries and managed by percutaneous flexible stable intramedullary nailing were reviewed for a retrospective case series. Personal interviews were conducted together with clinical and radiological assessments. The final results were recorded at the time of personal interviews. Results  The mean duration of surgery was 19.3 ± 2.5 minutes. The mean time of radiological union was 5 ± 1.3 weeks. The mean postoperative active range of motion of the metacarpophalangeal joint was 102.4 ± 11 degrees. The mean supination power of the involved hand in comparison to the contralateral side was 97.8 ± 3.4%, whereas the pronation power percentage was 99.2% ± 1.6. The mean power grip percentage to the contralateral side was 96.4 ± 2.9%, whereas the mean percentage of the pinch grip was 96.1 ± 4.2%. The mean postoperative DASH (Disability of Arm, Shoulder, and Hand) score was 0.3 ± 0.5. Conclusion  Percutaneous flexible stable intramedullary nailing for the treatment of metacarpal neck fractures has expanded the armamentarium of the orthopaedic surgeons as an easy, cost-effective technique overcoming all possible deformities and allowing early and reliable active rehabilitation. Level of Evidence  This is a Type IV, therapeutic retrospective case series.

Pin vs plate fixation for metacarpal fractures: a meta-analysis

BACKGROUND

The differences in the clinical and functional outcomes of closed reduction and percutaneous pin fixation and open reduction with internal fixation (ORIF) using plate and screws have been systematically synthesized by one meta-analysis. With newer studies being published, an effort to update the earlier meta-analysis is necessary.

METHODS

Comprehensive searches were done systematically through PubMed, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), and Google scholar databases. Randomized controlled trials, quasi-experimental studies, prospective comparative non-randomized studies, and even studies reporting findings from retrospective chart review were eligible to be included. Statistical analysis was done using STATA version 13.0. GRADE assessment was done to assess the quality of pooled evidence.

RESULTS

A total of 9 studies were included. The pooled estimates did not suggest any significant differences in the disabilities of the arm, shoulder, and hand (DASH) score [WMD - 0.77; 95% CI, - 3.55, 2.00; I² = 75.5%], range of movement (ROM) of the metacarpophalangeal joint (^o) [WMD 4.44; 95% CI, - 4.19, 13.07; I² = 86.0%], and grip strength [WMD - 4.63; 95% CI, - 14.52, 5.26; I² = 86.9%] among the two intervention modalities. No difference was seen in the risk of complications between the two interventions (RR 0.93; 95% CI, 0.57, 1.53; I² = 31.2%). For all the outcomes, the quality of pooled evidence was judged as low to very low.

CONCLUSION

No significant long-term differences were noted in the functional outcomes suggesting that both these techniques are comparable. The choice of modality should be made based on the skills and preference of the surgeon and availability of resources.

Treatment for a Metacarpal Shaft Fracture using Locked Wire Fixator: A Case Report of New Surgical Technique

Introduction:

This article reports a case of metacarpal shaft fracture using a low-invasive simple locked wires fixator with a high degree of flexibility. A new surgical technique for this injury will also be presented.

Case Report:

A 27-year-old female with the right 3rd metacarpal shaft fracture caused by falling down while riding a bicycle. The patient was a professional ballet dancer and requested treatment enabling an early return to exercise and non-noticeable wound. Pins were percutaneously inserted antegradely and retrogradely to the metacarpal bone as intramedullary pinning, then were connected using locked wires fixator. Post-operative immobilization was not necessary. The locked wire fixator was removed 6 weeks after surgery. Postoperatively, there were no limitations of the range of motion of the finger joints and the operative scar was almost unrecognizable.

Conclusion:

This is a new breakthrough procedure facilitating. Furthermore, this surgical procedure may be selected as an esthetically useful method making a small wound because it can be percutaneously applied.

Management of Fifth Metacarpal Neck Fracture (Boxer's Fracture): A Literature Review

Boxer’s fracture is the fifth metacarpal neck fracture resulting from direct trauma to the clenched fist. Worldwide, this type of fracture is the most typical presentation to emergency departments. The management of fifth metacarpal fractures varies from one setting to another. Conservative management is the preferred option for closed, non-angulated, non-malrotated fractures while open fractures, significant angulation, rotational deformity, and intra-articular extension are recognised indications for surgical intervention. The scope of this article covers the results of a literature review examining the management strategies for such fractures.

Fixation of fifth metacarpal neck fractures: a comparison of medial locking plates with intramedullary K-wires

Surgical treatment for metacarpal neck fractures may be indicated for malrotation, palmar angulation exceeding 30° or metacarpal shortening exceeding 3 mm, although these thresholds have not been firmly established. In a retrospective study, we compared the clinical and radiographic results of 54 patients with displaced fifth metacarpal neck fractures who were treated with either medial locking plates (14 patients) or retrograde intramedullary K-wires (40 patients). At a mean follow-up of 26 months (range 12 to 62), metacarpal shortening and angulation were 2 mm greater and 4° greater, respectively, in the K-wire group. The plate group had an earlier return to work and greater aesthetic satisfaction, but operative time and complication incidence were higher. Range of motion, time to union, grip strength and Quick Disability of the Arm, Shoulder and Hand scores were similar. We conclude that medial plating offers no clear advantage over K-wire fixation in treating metacarpal neck fractures. Level of evidence: III.

Current methods, outcomes and challenges for the treatment of hand fractures

In treating hand fractures, we have to make a proper decision about conservative treatment versus surgical intervention and decide on individual surgical methods. This article reviews recent publications, technical advances, and outcome measures in treating metacarpal fractures, phalangeal fractures, complex fractures of the proximal interphalangeal joints, bony mallet fingers, and fractures of the thumb. My personal preferences and considerations are presented. At the end, the current challenges that hand surgeons are facing in treating frequent phalangeal and metacarpal fractures are discussed.

Comparing the Efficacy and Safety of Metacarpal Neck Fracture Treatments: A Systematic Review and Network Meta-Analysis

Purpose

Metacarpal neck fractures may perform well without operative intervention, but the current literature on this topic is fragmented and guidance on managing these injuries needs further refinement. We conducted a systematic review and network meta-analysis to provide a comprehensive evaluation of the various treatments available for these injuries.

Methods

We searched 3 electronic databases and included any study comparing interventions for metacarpal neck fractures. We conducted a Bayesian network meta-analysis for each outcome.

Results

We identified a total of 14 studies comparing: antegrade (AIMP) or retrograde (RIMP) intramedullary pinning, buddy strapping, transverse pinning (TP), functional bracing, plating, retrograde cross-pinning, a combination of retrograde cross-pinning and plating, and placement of an orthosis or casting. Although the results were not statistically significant, the effect estimates suggested more favorable pain reduction and functional improvement with AIMP compared with nonsurgical therapies and RIMP in the short term (3 months or less). However, differences between interventions at later follow-up were less extreme; data on short-term pain and function with surgical options outside AIMP and RIMP were unavailable. In addition, compared with both plating and TP, AIMP was associated with significantly higher risks for implant migration and neurological events. There were contrasting findings in union-related outcomes. Plating showed the earliest time to union (not statistically significant) but TP demonstrated the lowest risk for a delayed union.

Conclusions

This review demonstrated that although AIMP may be a viable surgical option for early symptomatic relief after a metacarpal neck fracture, it may also be associated with a greater likelihood of certain postoperative complications. Clinicians should consider patient preferences for the time frame of symptomatic relief when selecting the optimal treatment, and patients should weigh the advantages and disadvantages of each available option, especially when considering invasive surgery. Considering the lack of high-quality primary research investigating these interventions, future studies are needed to make more definitive conclusions.

Type of study/level of evidence

Therapeutic II.

Osteosynthesis of fifth metacarpal neck fractures with a photodynamic polymer bone stabilization system

Metacarpal neck fractures with severe displacement are commonly treated surgically with intramedullary Kirschner wires. We present the results of treatment of fifth metacarpal neck fractures using a light curable intramedullary photodynamic polymer (IlluminOss™, IlluminOss Medical Inc., East Providence, RI, USA). Twenty-nine patients with isolated displaced fifth metacarpal neck fractures were included and followed up for 12-24 weeks. All fractures had radiologically healed after 3 months. In two cases, a secondary loss of reduction was seen, which did not require further correction. During the follow-up period, range of motion of the metacarpophalangeal joint was 89% after 6 weeks and increased to 100% after 3 months compared with the uninjured side. Grip strength improved over time from 61% to 85%. No implant removal was necessary. We conclude that osteosynthesis using an intramedullary photodynamic polymer is a reliable treatment option for displaced fractures of the fifth metacarpal neck. Level of evidence: IV.

Morphometric analysis of the second through fifth metacarpal through posteroanterior X-Rays

Over the past 10 years, metacarpal fractures have had an annual incidence of 13.6 per 10,000 individuals. Literature has not reviewed anatomical variations through radiographic imaging, which may play a role in reducing postoperative complications. The purpose of this study was to use radiographic imaging to provide a detailed anatomy of the second through fifth metacarpals. This retrospective study measured length, neck width, narrowest body width, and narrowest medullary canal width of the second through fifth metacarpals through the use of posteroanterior X-rays. Patients who were ≥18 years and received hand radiographs from January 2015 to July 2019 were included in this study. Those with acute injury or fracture of the metacarpal were excluded. Five hundred and seventy-two metacarpals were included in this study, with 143 metacarpals measured each for the second through fifth metacarpal. The second metacarpal had the largest measured length, neck width, and narrowest body width at 68.72, 12.34, and 8.74 mm, respectively. The fifth metacarpal had the greatest average medullary canal width at 4.15 mm. This is the largest study in literature to comprehensively examine the anatomical variation of the second through fifth metacarpals. The second metacarpal had greatest dimensions except for canal width, which was the fifth metacarpal. Men almost consistently had greater metacarpal size when compared to women, and age was associated with second and third metacarpal canal width. The increased knowledge of metacarpal anatomy may potentially lay the foundation of further improvement of metacarpal implants and potentially reduce postoperative complications. Clin. Anat., 33:1014-1018, 2020. © 2019 Wiley Periodicals, Inc.

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.

Single versus dual Kirschner wires for closed reduction and intramedullary nailing of displaced fractures of the fifth metacarpal neck (1-2 KiWi): a randomized controlled trial

AIMS

The aim of this study was to investigate whether clinical and radiological outcomes after intramedullary nailing of displaced fractures of the fifth metacarpal neck using a single thick Kirschner wire (K-wire) are noninferior to those of technically more demanding fixation with two thinner dual wires.

PATIENTS AND METHODS

This was a multicentre, parallel group, randomized controlled noninferiority trial conducted at 12 tertiary trauma centres in Germany. A total of 290 patients with acute displaced fractures of the fifth metacarpal neck were randomized to either intramedullary single-wire (n = 146) or dual-wire fixation (n = 144). The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire six months after surgery, with a third of the minimal clinically important difference (MCID) used as the noninferiority threshold. Secondary outcomes were pain, health-related quality of life (EuroQol five-dimensional questionnaire (EQ-5D)), radiological measures, functional deficits, and complications.

RESULTS

Overall, 151/290 of patients (52%) completed the six months of follow-up, leaving 83 patients in the single-wire group and 68 patients in the dual-wire group. In the modified intention-to-treat analysis set, mean DASH scores six months after surgery were 3.8 (sd 7.0) and 4.4 (sd 9.4), respectively. With multiple imputation (n = 288), mean DASH scores were estimated at 6.3 (sd 8.7) and 7.0 (sd 10.0). Upper (1 - 2α)) confidence limits consistently remained below the noninferiority margin of 3.0 points in the DASH instrument. While there was a statistically nonsignificant trend towards a higher rate of shortening and rotational malalignment in the single wire group, no statistically significant differences were observed across groups in any secondary outcome measure.

CONCLUSION

A single thick K-wire is sufficient for intramedullary fixation of acute displaced subcapital fractures of the fifth metacarpal neck. The less technically demanding single-wire technique produces noninferior clinical and radiological outcomes compared with the dual-wire approach. Cite this article: Bone Joint J 2019;101-B:1263-1271.

Plate Fixation versus Percutaneous Pinning for Unstable Metacarpal Fractures: A Meta-analysis

BACKGROUND

Whether percutaneous pinning or plate fixation is more appropriate for metacarpal fractures is still open to debate. Our study purpose was to review the current literature in an attempt to determine the optimal treatment modality for metacarpal fractures on the basis of functional outcomes, radiographic outcome and rates of complications.

METHODS

We selected Pubmed, Cochrane library, EMBASE and the relevant English orthopedic journals and pooled data from eligible trials including four comparative studies and one retrospective review. Overall, the studies contained 222 patients with 231 fractures, 143 treated with pinning and 88 treated with plates and screws. Mean follow up was 7.5 months (4-12 months). Data were analyzed and the fixed effects are assumed for meta-analysis.

RESULTS

Patients undergoing pinning for metacarpal fractures have higher motion scores when compared to open reduction and internal fixation with plate and screws. Functional scores, grip strength, radiographic parameters, time to union and complications were found not to be significantly different between the two groups.

CONCLUSIONS

There is evidence to support the use of pins over ORIF with plates and screws in the treatment of metacarpal fractures. This may have practical advantages, including minimal dissection, easier insertion and availability of the pins. The limitations of this study include the small number of eligible studies, lack of reporting of standard deviation value, and the lack of DASH score assessments at follow up. Further randomized controlled trials that include a larger patient numbers with longer follow up are needed to substantiate the superiority of one fixation method over another.

Iatrogenic Injuries in Percutaneous Pinning Techniques for Fifth Metacarpal Neck Fractures

BACKGROUND

There is little information regarding anatomic structures at risk during closed percutaneous treatment of fifth metacarpal neck fractures. This study evaluates a variety of common percutaneous techniques with the hypothesis that each approach presents unique risks to tendons and neurovascular structures.

METHODS

Seven cadaveric hands were used for this study. The senior author, a board-certified hand surgeon with more than 20 years of experience, used a mini-C arm to pass 1.6-mm Kirschner wires (K-wires). The 4 percutaneous techniques employed were anterograde, retrograde, cross-pinning, and transverse fixations. Meticulous superficial dissection was carried out, with fixation from all 4 techniques left in place, to identify any tendons or neurovascular structures penetrated by the K-wires.

RESULTS

All techniques demonstrated penetration of at least 1 adjacent structure. The anterograde technique showed penetration of the extensor carpi ulnaris tendon in 5 out of 7 cadavers. In the retrograde approach, the K-wire impaled either the extensor digitorum communis or the extensor digitorum minimi tendons in 4 out of 7 cadavers. The transverse pinning technique exhibited injury to the dorsal cutaneous ulnar nerve in 2 of the specimens. In the retrograde cross-pin technique, there were 2 penetrations of the digital branch of the dorsal cutaneous ulnar nerve.

CONCLUSIONS

None of the described percutaneous techniques for treating fifth metacarpal neck fractures eliminate the potential for damage to surrounding tendons or nerves. Each technique has at risk structures that the treating surgeon should be aware of in order to anticipate potential complications and counsel patients accordingly.

Extra-articular Metacarpal Fractures: Closed Reduction and Percutaneous Pinning Versus Open Reduction and Internal Fixation

BACKGROUND

There is no consensus on the optimal operative treatment of isolated closed metacarpal fractures as every technique is associated with advantages and shortcomings. This retrospective study aims to compare the outcomes of single metacarpal, extra-articular fractures treated with closed reduction and percutaneous pinning (CRPP) versus open reduction and internal fixation (ORIF).

METHODS

The charts of all patients who underwent surgical repair of closed metacarpal fractures at our institutions from 2009 to 2016 were reviewed. 70 patients met the inclusion criteria, 44 had undergone CRPP and 26 ORIF with plate or lag screws. Subgroup analyses of all patients stratified by both fracture pattern and fracture location were performed. Additionally, subgroup analyses of outcomes based on the time from injury to surgery were conducted. Clinical outcomes included immobilization time, total active motion, stiffness, complication and reoperation rates, as well as occupational therapy referral rates and duration. Functional outcomes were determined using the Quick-DASH (Disabilities of the Arm, Shoulder and Hand) score via telephone questionnaire administered retrospectively.

RESULTS

Overall, there was no significant difference in functional outcome parameters including total active motion (CRPP 91% of normal vs. ORIF 87% of normal), stiffness, therapy referrals, and complications between treatment groups. Patients treated with CRPP, regardless of fracture pattern or location, were operated on earlier than those treated with ORIF (avg. 7 days vs. 15 days). The immobilization time for patients treated with ORIF was significantly less than those treated with CRPP (19.7 vs. 30.7 days; p=0.001). This difference in the immobilization time also reflected the outcomes of the subgroup analyses based on the post-injury time of surgery. When transverse shaft fractures were examined independently as a subgroup, ORIF resulted in improved post-operative range of motion vs. CRPP (100% normal vs. 91% normal). The mean DASH score for each group was satisfactory and the difference was not statistically significant (16.3 for the CRPP and 18.7 for the ORIF group, p=0.805).

CONCLUSION

Both CRPP and ORIF are viable techniques with good clinical outcomes and low complication rates. ORIF of closed metacarpal fractures allowed for earlier mobilization when compared with CRPP without compromising fracture stability, clinical or functional short-term outcomes.

Headless Screw Fixation of Metacarpal Neck Fractures: A Mechanical Comparative Analysis

BACKGROUND

The purpose of this study was to compare the mechanical properties of metacarpal neck fracture fixation by headless compression screw (HCS) with that of Kirschner wire (KW) cross-pinning and locking plate (LP) fixation.

METHODS

A metacarpal neck fracture was created in 30 fourth-generation composite Sawbones metacarpal models. A volar-based wedge was removed using a custom jig to simulate a typical apex dorsal fracture, unstable in flexion. The models were divided into 3 equal groups based on the method of fixation: retrograde cross-pinning with two 1.2-mm KWs, 2.0-mm dorsal T-plate with six 2.0-mm locking screws (LP), and a 3.0-mm retrograde HCS. Models were fixed at the proximal end, mounted in a material testing machine, and loaded through a cable tensioned over the metacarpal head, simulating grip loading. Cyclic loading from 0 to 40 N was performed, followed by loading to failure. Load, displacement, and failure mode were recorded.

RESULTS

Stiffness of the HCS (7.3 ± 0.7 N/m) was significantly greater than the KW (5.8 ± 0.5 N/m) but significantly less than the LP (9.5 ± 1.9 N/m). With cyclic loading to 40 N, the LP exhibited significantly less displacement (0.2 ± 1.3 mm) compared with the HCS (2.5 ± 2.3 mm) and KW (2.8 ± 1.0 mm). Load to failure for the HCS (215.5 ±3 9.0 N) was lower than that of the KW (279.7 ± 100.3 N) and of the LP (267.9 ± 44.1 N), but these differences were not statistically significant.

CONCLUSIONS

The HCS provided mechanical fracture fixation properties comparable with KW fixation. The LP construct allowed significantly less displacement and had the highest strength of the 3 fixation methods.

A single antegrade intramedullary k-wire for fifth metacarpal neck fractures

OBJECTIVES

Antegrade intramedullary nailing (AIMN) using 2k-wires seems to be superior to other modalities in treating displaced fractures of the fifth metacarpal neck (FFMN). Few reports demonstrated similar results retrospective with a single k-wire. The aim of the study is to describe our single k-wire technique and evaluate the related results.

METHODS

This is a retrospective study of a continuous series of patients treated with a single intramedullary k-wire for FFMN. It includes 30 patients who met the criteria for surgery: a dorsal angulation of more than 30°, malrotation, or both. The mean clinical follow-up period was 7 ± 14.9 months.

RESULTS

The mean pre-operative angle was 50° ± 11.35° and the mean immediate post-operative angle was 4.86° ± 2.8°. The mean immediate correction was 47° ± 9.3°. The mean correction at last follow-up was 45.14° ± 8.55°. Healing was obtained in all patients and bone union was achieved at a mean of 5.6 ± 1.2 weeks. The mean operative time was 8.5 min. The mean C-arm usage (number of clicks) was 7.2 times. The mean exposure radiation time was calculated at 3.6 s. The mean radiation dose was 0.08 mGy/mm². The mean satisfaction score was 1.26 ± 0.45. Quick-DASH and EQ-5D scores yielded excellent values.

CONCLUSIONS

With potential benefits like lesser surgical time, radiation and cost, the use of a single AIMN could be safer, quicker and cheaper while reproducing similar clinical, functional and radiological outcomes to those reported with the use of 2k-wires.

A Comparison of Locking Plates and Intramedullary Pinning for Fixation of Metacarpal Shaft Fractures

BACKGROUND

Metacarpal shaft fractures that necessitate surgery are frequently fixated with either intramedullary pins or plates and screws. This study compared outcome measurements of these two techniques.

METHODS

Patients operated on for closed shaft fractures of metacarpals 2-5 were examined at least 1 year after injury. All fractures were fixated by pinning between years 2013 and 2015 and by locking plates and screws between 2016 and 2017. Evaluation included range of motion measurements for all fingers compared with the contralateral hand; comparison of grip strength; finger alignment and rotation; Disabilities of the Arm, Shoulder and Hand (DASH) score; and radiographic measurements of fracture reduction and healing.

RESULTS

Thirty patients with 39 fractured metacarpals treated by pinning were compared with 29 patients with 35 fractured metacarpals treated by locking plate and screws. Both groups had similar characteristics and preoperative fracture patterns on radiograph. Patients in the plate group were found to have significantly improved outcomes in total range of motion of the operated digits (loss of 4° extension, 10° flexion, and 14° total vs 10° extension, 19° flexion, and 29° total), grip strength (93% vs 83% of contralateral hand), rotational deformity (5 digits, 1° vs 15 digits, 6°), and DASH score (10.5 vs 15.6). Radiographic bone healing time (59 vs 50 days) and operative time (58 vs 41 minutes) were both significantly longer in fractures fixated by plates.

CONCLUSIONS

Fixation with locking plates allows earlier mobilization without need for splinting. Our study supports the use of this method over intramedullary pinning for metacarpal shaft fractures.

New fixation approach for transverse metacarpal neck fracture: a biomechanical study

Background

Fifth metacarpal neck fracture, also known as boxer’s fracture, is the most common metacarpal fracture. Percutaneous Kirschner-wire (K-wire) pinning has been shown to produce favorable clinical results. However, the fixation power of K-wires is a major concern. Plate fixation is also a surgical option, but it has the disadvantages of tendon adhesion, requirement of secondary surgery for removal of the implant, and postoperative joint stiffness. A fixation method that causes little soft tissue damage and provides high biomechanical stability is required for patients with fifth metacarpal neck fracture for whom surgical intervention is indicated. The present study proposed fixation using K-wires and a cerclage wire to treat fifth metacarpal neck fracture. The fixation power of this new method was compared with that of K-wires alone and plates.

Methods

We used a saw blade to create transverse metacarpal neck fractures in 16 artificial metacarpal bone specimens, which were then treated with four types of fixation as follows: (1) locking plate with five locking bicortical screws (LP group), (2) regular plate with five bicortical screws (RP group), (3) two K-wires (K group), and (4) two K-wires and a figure-of-eight cerclage wire (KW group). The specimens were tested by using cantilever bending testing on a material testing system. The stiffness of the four fixation types was determined by observing force–displacement curves. Finally, the Kruskal–Wallis test was adopted to process the data, and the Mann–Whitney exact test was performed to conduct paired comparison between the fixation types.

Results

The fixation strength levels of the four fixation approaches for treating fifth metacarpal neck fracture were ranked in a descending order of LP group (24.6 ± 5.1 N/mm, median ± interquartile range) > RP group (22.2 ± 5.8 N/mm) ≅ KW group (20.1 ± 3.2 N/mm) > K group (16.9 ± 3.0 N/mm).

Conclusion

The fixation strength of two K-wires was significantly higher when reinforcement was provided using a figure-of-eight cerclage wire. The strength of the proposed approach is similar to that of a regular plate with five bicortical screws but weaker than that of a locking plate with the same amount of bicortical screws. Cerclage wire-integrated K-wires can be an alternative method that avoids the excessive soft tissue dissection required for plating in open reduction internal fixation for fifth metacarpal neck fracture.

Simplified internal fixation of fifth metacarpal neck fractures

BACKGROUND

Fifth metacarpal neck fractures (boxer's fractures) are common injuries that contribute 20% of all hand fractures. Divergent percutaneous pinning (bouquet fixation) as described by Foucher has gained popularity but is challenging and at times arduous, as it requires the insertion of several slender K-wires into a narrow medullary canal. Here, we report on a simplified technique in which a single thick K-wire is inserted.

TECHNIQUE

An 18/10 K-wire is bent at one end then mounted on a drill chuck. The incision is performed and the entry hole created using the K-wire, which is then advanced along the medullary canal. After reduction of the metacarpal head using the Jahss manoeuvre, the K-wire is inserted across the fracture site into the subchondral bone. Any persistent rotational malalignment is corrected by rotating the metacarpal around the K-wire. Immobilisation is by buddy taping covered by a resin guard.

METHODS

We collected follow-up data for 30 patients treated using our technique, at a mean age of 32 years.

RESULTS

90 days after surgery, the fracture was healed in all patients. No patients had rotational malalignment. Mean operative time was 14minutes. No complications were recorded.

DISCUSSION

The use of a single thick K-wire proved simple, effective, reproducible, and rapid. No rotational malalignment occurred. This technique is faster and easier to perform than divergent pinning with multiple K-wires.

CONCLUSION

This technique can be used to treat fifth metacarpal neck fractures.

Three-screw versus two-screw fixation of distal fragment in fifth metacarpal neck fractures stabilized with locking plate

Fifth metacarpal neck fracture commonly requires open reduction and internal fixation. Locking plate was widely adopted in the treatment of fifth metacarpal neck fracture as first-line choice for fixation. Patients with fifth metacarpal neck fracture receiving locking plate fixation were included for analysis. Features of internal fixation including number of distal and proximal locking screws, diameter of the screws and usage of lag screws were recorded. Clinical and radiographic outcomes included final volar angulation, grip strength, Michigan Hand Outcomes Questionnaire (MHQ) and range of motion (ROM) of fifth metacarpophalangeal joint. Three-screw fixation was less frequently presented in the group with increased volar angulation (≥30 degrees). Consistently, three-screw fixation of distal fragment could improve the prognosis compared with two-screw fixation (MHQ 95.4 ± 5.1 versus 80.4 ± 12.3, ROM 83.5 ± 7.2 versus 69.6 ± 7.7). In conclusion, the metacarpal head should be fixed by three locking screws instead of two locking screws.