"Bouquet" osteosynthesis in metacarpal neck fractures: a series of 66 patients

Neck of the 5th metacarpal head retrograde screwing with a headless screw after a recurrent fracture on osteosynthesis pins: a case report

INTRODUCTION AND IMPORTANCE

This paper reports the technique we used to treat a recurrent fracture of the neck of the 5th metacarpal with bending of the pin that was still present in the patient bone.

CASE PRESENTATION

A 26-year-old soldier presents to the emergency department following a direct trauma on the right hand. This patient had already presented a similar trauma one year ago with a fracture of the 5th metacarpal neck treated by intramedullary pins according to Foucher technique's. X-rays showed a recurrent fracture of the 5th metacarpal neck with pins bended. It was decided to remove the material with a change of osteosynthesis technique by intramedullary screwing with a headless screw. This allowed a return to work and activities without restriction 6 weeks after surgery. CLINICAL DISCUSSION: to our knowledge this is the first publication dealing with management of recurrent fracture of 5th metacarpal neck. This technique provides excellent outcome and a low risk of complication.

CONCLUSION

This simple and original technique for revision osteosynthesis of a fracture the 5th metacarpal neck gives good short-term results and is interesting from a practical and functional point of view in the military patients.

Intramedullary Fixation for Metacarpal Fractures: A Multi-Institutional Prospective Outcomes Study

Purpose

Intramedullary fixation (IMF) has emerged as an effective treatment for metacarpal fractures. Benefits include stable fixation that allows early postoperative rehabilitation and high fracture union rates, without increased complications. Both headless compression screws and intramedullary threaded noncompressive nails have been described for this purpose; however, prospective outcomes reporting are lacking. This study assessed the outcomes of metacarpal fractures treated with IMF including patient-reported outcomes, grip strength, total active motion, and complications.

Methods

A prospective multicenter trial enrolled consecutive patients with closed, extra-articular metacarpal fractures treated with IMF. Radiographic healing was assessed at each postoperative visit and patient-reported outcomes included pain scores, QuickDASH (Disabilities of the Arm, Shoulder, and Hand), and Short Form Survey scores. Grip strength, goniometric motion measurements, and complications were also obtained.

Results

One-hundred-one fractures were treated in 82 patients with an average age of 33 years and mean follow-up of 69 days. Most patients were male (70%), nonlaborers (72%), and nonsmokers (74%). QuickDASH scores improved by 40 points, with a final mean of 17 following metacarpal IMF. Short Form Survey components of physical component score and mental component score at final follow-up were 55.95 and 48.74, respectively. Final average grip strength was 15 kg and total active motion was 228º. The average total active motion of the closed reduction cohort (249°) was significantly higher than the open cohort (210°) at final follow-up (P < 0.05). Four complications (3.9%) occurred, including one hardware failure, two proximal screw migrations, and one metacarpophalangeal joint contracture, with three of these patients requiring revision surgery.

Conclusions

Intramedullary fixation is a reliable technique for treatment of extra-articular metacarpal fractures with satisfactory patient-reported outcomes, excellent strength and motion, and a low complication rate. Intramedullary fixation should be considered for closed, extra-articular metacarpal fractures.

Type of study/level of evidence

Therapeutic IV.

Complications of osteosynthesis for long-finger metacarpal and phalanx fracture

Fractures of the metacarpals and phalanges represent a significant proportion of hand fractures. Although non-operative treatment is generally effective, some fractures require surgery. Historically, osteosynthesis using K-wires was widely used, but screw plates and then cannulated intramedullary screws have emerged as therapeutic alternatives. We assessed the complications associated with the different osteosynthesis techniques: stiffness, infection, bone consolidation and hardware-related problems. Each osteosynthesis technique has advantages and disadvantages, and choice depends on several factors. An individualized approach according to patient and fracture is essential to optimize clinical results.

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 Screw Fixation of Metacarpal and Phalangeal Fractures

Metacarpal and phalangeal fractures are the second and third most common hand and wrist fractures seen in the emergency department. There are a multitude of operative fixation methods for metacarpal and phalangeal fractures, including closed reduction percutaneous pinning, open reduction internal fixation, external fixation, and intramedullary screw fixation. Although intramedullary fixation is a relatively new surgical technique, it is gaining in popularity as it allows patients to resume range of motion early in the postoperative period with excellent clinical outcomes.

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.

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.

Expanding the applications of intramedullary cannulated screw fixation in the hand

OBJECTIVES

Intramedullary cannulated headless compression screw fixation (ICHCS) is gaining popularity for managing metacarpal and phalangeal fractures, but is still relatively new to the surgical landscape. We aim to further illustrate its utility and versatility by presenting the outcomes of such fractures treated with ICHCS at two tertiary plastic surgery centres. Primary objectives were to assess functional range of motion, patient-reported outcomes, and complication rates.

MATERIALS AND METHODS

All patients with metacarpal or phalangeal fractures treated with ICHCS (n = 49) between September 2018 and December 2020 were retrospectively reviewed. Outcomes were active ranges of motion (TAM), QuickDASH scores (obtained via telephone), and complication rates. Two-tailed Student's t-tests evaluated differences between centres.

RESULTS

TAMs were available for 59% (n = 34/58) of fractures; 70.7% were metacarpal and 29.3% were phalangeal. The mean cohort metacarpal TAMs and phalangeal TAMs were 237.7° and 234.5°, respectively. QuickDASH scores were available for 69% (n = 34/49) of patients. The mean cohort score for metacarpal fractures was 8.23, and 5.13 for phalangeal. Differences between the two centres were statistically significant (p < 0.05). Two complications occurred, giving an overall complication rate of 3.45%.

CONCLUSION

Our results corroborate previous reports on ICHCS, further demonstrating its versatility and capacity to provide excellent outcomes. More prospective, comparative studies are needed to fully determine the suitability of ICHCS.

Morphological Analysis of Metacarpal Shafts With Respect to Retrograde Intramedullary Headless Screw Fixation

Background: The use of retrograde intramedullary headless compression screw fixation for metacarpal neck and shaft fractures has been described in the literature. The purpose of this study was to perform a computed tomography (CT)-based morphological analysis of metacarpal size to help surgeons anticipate expected hardware needs. Methods: In all, 108 consecutive hand CT scans were evaluated for the medullary diameter in the volar-dorsal and radial-ulnar planes at the narrowest point of the canal, as well as for the distance from the articular surface to this point. Results were then analyzed by finger and by sex. Results: The ring finger had the smallest average medullary canal diameter for both men and women (2.7 and 2.6 mm, respectively); the small finger had the largest average diameter (3.9 mm) for men and the middle finger (3.6 mm) for women. Radial-ulnar was the rate-limiting dimension in the index, middle, and ring fingers, whereas volar-dorsal was the smallest dimension in the small finger, regardless of sex. Medullary diameter tended to be larger in patients aged more than 50 years. More than 50% of fingers have diameters >3.0 mm, and at least 40% of index, middle, and small fingers have diameters >3.5 mm, which are common diameters of commercially available headless compression screws. Conclusions: When preparing to perform open reduction internal fixation of a metacarpal using retrograde intramedullary headless compression screws, the surgeon needs to be prepared with screws of larger diameters to optimize fixation. Screws of larger diameters are needed to achieve endosteal purchase, regardless of sex.

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.

L-pinning for fifth metacarpal neck fracture in adolescents

INTRODUCTION

Fifth metacarpal neck fracture is the most frequent type of hand fracture in adolescents between 13 and 16 years of age. It mainly affects males and the dominant hand. The L-pinning technique combines intramedullary anterograde pinning and transverse pinning between the 4^th and 5^th metacarpals. The present study aimed to assess L-pinning without postoperative immobilization in displaced 5^th metacarpal fracture in adolescents with low residual growth.

MATERIALS AND METHODS

Data for patients aged between 13 and 16 years, operated on for closed 5^th metacarpal neck fracture between January 2017 and June 2019, were analyzed retrospectively. Surgery was indicated for angulation with>30° palmar tilt and/or horizontal malalignment. The technique consisted in intramedullary anterograde pinning and transverse pinning between the 4^th and 5^th metacarpal heads. No postoperative immobilization was applied. Hardware was removed as of day 28. The final clinical check-up was at≥12 months.

RESULTS

Eighteen patients, all male, with a mean age of 14 years, were included. All had bone age≥14 years. Mean palmar tilt was 52°±6.8° versus 6°±2.4° postoperatively, for a mean correction of 45°±4.3°. Mean operating time was 15min, and X-ray exposure 0.36minutes for a mean radiation dose of 2.89 cGy/cm². At hardware removal, all patients showed radiologic consolidation. At 3 months, 5^th ray ranges of motion were normal, with no local complications. Functional results were maintained at last follow-up (≥12 months).

CONCLUSION

L-pinning seemed reliable in terms of feasibility and stability of reduction in 5^th metacarpal neck fracture in adolescents. Absence of postoperative immobilization facilitated self-rehabilitation and accelerated functional recovery.

LEVEL OF EVIDENCE

IV.

Intramedullary Fixation with Headless Screws versus Bouquet in Unstable Metacarpal Neck Fractures in Active Patients: A Randomized Study

Objeticve  To compare the range of motion (ROM), return-to-work time, visual analogue score (VAS), disability of the arm, shoulder, and hand (QuickDASH), and radiographic outcomes of two methods of definitive internal fixation in active patients with boxer's fractures, operated in the first week.

Methods  This was a prospective, randomized trial, in which 50 patients, with a mean age range of 18 to 40 years old, were randomized and treated to definitive intramedullary fixation using 2 headless screws ( n  = 20) or bouquet (2 or 3 Kirschner wires) ( n  = 20). The patients were assessed on return-to-work time, ROM, patient reported QuickDASH outcome, VAS, and radiographic evaluation at 6 months.

Results  At 6 months, there were no differences between the two groups in terms of ROM, postoperative pain (VAS), or QuickDASH score. The overall complication rate was 4.76% in the screw group, compared with 5% in the bouquet-fixation group.

Conclusions  In the treatment of the active patients with unstable boxer's fractures, headless screws and bouquet fixation proved to be a safe and reliable treatment. The outcomes were similar in both groups.

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.

A Single Intramedullary K-Wire Is Sufficient for the Management of Nonthumb Metacarpal Shaft Fractures

Objective

This study aims to evaluate the outcome after the internal fixation of diaphyseal metacarpal fractures by a single intramedullary K-wire.

Methods

In this prospective case series study, conducted from July 2017 to June 2019 in 23 adult patients with a single, unstable, diaphyseal metacarpal fracture, outcomes after internal surgical fixation using a single antegrade intramedullary K-wire were evaluated. The outcomes were evaluated by union rate, time to union, handgrip measurements at 6 and 12 months, and the modified Disabilities of the Arm, Shoulder, and Hand (DASH) score at 12 months.

Results

The study population consisted of 17 males and 6 females, with a mean patient age of 28.4 ± 8.5 years (range, 16–45 years). The median time to final follow-up was 14 ± 1.8 months (range: 12–24 months). The mean duration of the union was 7.3 ± 1.6 weeks (range: 5–11 weeks), with a union rate of 95.7% (22 cases). The mean handgrip strength was 68% ± 12.8% of the strength of the uninjured hand after 6 months and 92.7% ± 6.9% after 12 months. The mean modified DASH score was 2.6 ± 0.26 after 12 months (range: 0–5.8). There were no cases of malrotation or infection. In conclusion, using a single 1.8–2.0 mm K-wire gives excellent functional outcomes and union rate without significant complications when used to treat an unstable metacarpal shaft fracture.

Osteosynthesis of Fractures of the Metacarpal Neck with Self-Compressing Screw - Preliminary Analysis of 21 Cases

Objective  The present study aims to analyze the clinical results of the surgical treatment of metacarpal neck fractures with retrograde intramedullary fixation using cannulated headless screws (Herbert type).

Methods  Retrospective study of 21 closed fractures deviated from the metacarpal neck in 21 patients operated between April 2015 and November 2018.

Results  The sample included 19 men and 2 women. The mechanisms that caused the trauma were punching, falling to the ground and motor vehicle accident (n = 14, 5 and 2). The affected metacarpals were the 5 ^th , 3 ^rd , and 2 ^nd (n = 19, 1 and 1). Surgical indications were neck-shaft diaphysis of the metacarpal > 30° for the 2 ^nd and 3 ^rd metacarpals and > 40° for the 5 ^th metacarpal, shortening ≥ 5mm, rotational deviation, and the desire of the patient not to use plaster cast. In the immediate postoperative period, patients remained without immobilization and were instructed to mobilize their fingers according to tolerance. All patients had total active mobility > 240° and returned to their former occupations. All fractures consolidated and there were no reinterventions.

Discussion  The great advantages of the headless screw technique are its low morbidity, sufficient stability to avoid external immobilization, and reproducibility at low cost.

Conclusion  This is an easy, fast technique that has excellent results for the surgical treatment of displaced fractures of the neck of the metacarpals.

Single versus dual elastic nails for closed reduction and antegrade intramedullary nailing of displaced fifth metacarpal neck fractures

Closed reduction and internal fixation with antegrade intramedullary nails is a feasible and effective treatment for displaced fifth metacarpal neck fractures (FMNFs). The present study aimed to compare clinical and radiological outcomes in patients with displaced FMNFs after treatment with single or dual antegrade elastic intramedullary nails (AEIMNs). Thirty-three patients were treated with a single 2.0 mm AEIMN and 34 patients were treated with two 1.5 mm AEIMNs. Clinical and radiological outcomes included grip strength, active range of motion (ROM), active flexion and extension of the fifth metacarpophalangeal (MCP) joint, dorsal angulation loss, and metacarpal shortening of the fifth metacarpal at 12 months after treatment. No significant difference was observed between the two groups with respect to grip strength, ROM or flexion of the fifth MCP joint. The average values of dorsal angulation loss, metacarpal shortening, and extension of the fifth MCP joint of the dual nails group were better than those of the single nail group (dorsal angulation loss, 2.79 ± 1.93° vs. 4.05 ± 1.59°, P = 0.009; metacarpal shortening, 1.66 ± 0.80 mm vs. 2.12 ± 0.88 mm, P = 0.028; extension of the fifth MCP joint, 7.71 ± 4.43° vs. 4.82 ± 4.09°, P = 0.012). In conclusion, dual AEIMNs fixation provided better MCP extension and radiological outcomes than single AEIMN fixation.

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.

Percutaneous Fixation of Pediatric Fractures of the Proximal Phalanx Neck: A Novel Technique

INTRODUCTION

Proximal phalanx neck fractures occur almost exclusively in children. Fractures of the proximal phalanx neck can be difficult to treat nonoperatively given the anatomic location and associated extrinsic forces. A divergent or crossed pin configuration is often utilized for the stabilization of these fractures.

PURPOSE

We present a surgical technique with a single Kirschner (K-wire) placed axially along the affected finger, with a hyperextension reduction maneuver, to reduce and fixate proximal phalanx neck fractures in children and adolescents.

METHODS

We performed a retrospective review of all pediatric proximal phalanx neck fractures treated by a single surgeon. Demographic data, as well as clinical and radiographic outcomes were recorded. We then directly compared axial pinning [14 patients; average age 6.63 y (9 mo to 17 y)] with nonoperative treatment [28 patients; average age 8.03 y (9 mo to 16 y)], and open treatment [8 patients; average age 8.13 y (1 to 14 y)].

RESULTS

Patients who underwent closed reduction and axial pinning had significantly improved final coronal alignment compared with nonoperative treatment. Compared with fractures which required open reduction, closed reduction with axial pinning resulted in significantly shorter surgical duration and time to radiographic healing. The final range of motion showed no difference between intervention types, as all patients regained full range of motion.

CONCLUSIONS

We find this axial pinning technique to be simpler and faster than divergent pin fixation, with no significant differences in time to radiographic healing, time to full activity, final proximal interphalangeal active flexion or extension, loss of reduction, or radiographic parameters.

LEVEL OF EVIDENCE

Level III-Therapeutic.

Clinical Outcomes of Limited Open Intramedullary Headless Screw Fixation of Metacarpal Fractures in 91 Consecutive Patients

Background: The objective of the study is to evaluate clinical and radiographic outcomes in patients treated with limited-open retrograde intramedullary headless screw (IMHS) fixation for metacarpal neck and shaft fractures. Methods: Retrospective review of 91 consecutive patients (79 men; 12 women), mean age 28 (range =15-69) years, treated with IMHS fixation for acute displaced metacarpal neck (N = 56) and shaft (N = 35) fractures at a single institution. Mean follow-up was 10 (range = 1-71, median = 3) months. Preoperative mean magnitude of metacarpal neck angulation was 48° (range = 0°-90°), and mean shaft angulation was 42° (range = 0°-70°). Active motion was initiated within 5 days postoperatively. Clinical outcomes were assessed with digital goniometry, grip strength, and return to full activity. The time to radiographic union and radiographic arthrosis was assessed. Results: All 91 patients achieved full functional arc of metacarpophalangeal (MCP) motion, and all achieved full active MCP extension or hyperextension. At mean follow-up of 10 months, postoperative mean MCP joint flexion-extension arc was 88° (range = 55°-110°). Grip strength was available for 52 patients and measured 104.1% of the contralateral hand (range = 58%-230%). Radiographic union data were available for 86 patients. Seventy-six percent (65/86) achieved radiographic union by the end of week 6 (range = 2-10 weeks). Early arthrosis was noted in 1 patient at the MCP. There were 3 cases of shaft refracture after recurrent blunt trauma, following prior evidence of full osseous union. Conclusions: The IMHS fixation is safe, reliable, and durable for metacarpal neck/subcapital, axially stable shaft fractures, and select delayed unions or malunions. It allows for early postoperative motion without affecting union rates and obviates immobilization. This technique offers distinct advantages over formal open reduction and percutaneous Kirschner wire techniques.

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.

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.

Clinical Outcomes of Ready-Made J-Shaped Nail Fixation for Unstable Metacarpal Fractures

Background: The purpose of this study was to report the clinical outcomes of ready-made J-shaped intramedullary nail fixation for unstable metacarpal fractures. Methods: A total of 25 unstable fractures from 24 patients were evaluated in this retrospective study, comprising 20 metacarpal neck and 5 metacarpal shaft fractures. The mean follow-up was 22 weeks. Functional outcomes were assessed based on the range of motion of the metacarpophalangeal joint. Radiographic outcomes were evaluated by four projections of the postoperative plain radiographs at the final follow-up, and then were rated as excellent if projections at the fracture site showed no correction loss or angular deformity greater than 10°. Surgery time and complications during the treatments were recorded for each case. Results: All 25 fractures obtained bony union. The mean range of motion of the metacarpophalangeal joint was 78° (range, 45°-90°). Radiographic outcomes were excellent in 24 (96%) of 25 fractures. Only one fracture had correction loss. The mean surgery time was 29 minutes (range, 14-61 minutes). Two cases had extensor tendon adhesion at the insertion site, which was easily released when the implant was removed. Conclusions: This study demonstrates that intramedullary fixation with a ready-made J-shaped nail is a reliable treatment option for unstable metacarpal fractures.

Intra-medullary, at fracture site introduction of K-wires for metacarpal fracture fixation (in-site technique). A new fixation technique and a case series

•

Metacarpal bone fractures represent one-fifth of upper extremity fractures.

•

Different technique has been described for fracture fixation with K-wires being the most described technique.

•

We present a new technique utilizing k-wires to reduce and fix metacarpal fractures in an easy less traumatic way aiming to optimize the clinical outcomes in regards of range of motion and stiffness with important remarks to learn from this technique.

Purpose

Metacarpal bone fractures represent one-fifth of upper extremity fractures. The most commonly affected bone was the fifth metacarpal also known as boxer’s fracture with a range 9.7–50%. Different techniques have been described for fracture fixation with K-wires being the most described technique. In this paper, we present a new technique utilizing k-wires to reduce and fix metacarpal fractures in an easy less traumatic way aiming to optimize the clinical outcomes in regards of range of motion and stiffness.

Methodology

Retrospective chart review including all the patients that were managed with the new technique.

Results

24 fractures were fixed with the new technique without violating the MCP joint with different fingers involvement and different presenting deformity. At the end of the splinting time, 80% of the cases had full ROM at the time of splint removal. The remaining 20% had some stiffness that improved with further physiotherapy.

Conclusion

This approach is easy to teach, fast with good clinical outcomes. However, a larger sample size study comparing this technique to the existing treatment options is needed.

Type of study

Case Series and literature review, Level IV.

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 Headless Screw Fixation for Metacarpal Fractures

Multiple techniques have been proposed for metacarpal fracture fixation, including percutaneous Kirschner-wires, interfragmentary screws, plate and screw constructs, intramedullary (IM) nails, and cannulated IM headless screws. Each of these treatment options has its proposed advantages and disadvantages, and there remains no consensus on the optimal mode of treatment. We describe a technique of retrograde IM headless screw fixation for extra-articular metacarpal fractures.

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.

Management of metacarpal fractures

The metacarpal fractures are common fractures which are treated by orthopaedic surgeons, plastic surgeons and hand surgeons equally. These are seen in young adults who have active life style. These have a major impact in life style of the patients if these are not treated adequately. The management of the fractures vary among surgeons to surgeons; two surgeons in the same centre can have a different treatment plan for a fracture. There are no standard guidelines for the treatment and it ranges from conservative management, Kirschner's wire (K-wires), plates and screws. This review article is about the management of metacarpal fractures where the commonly done procedures are reviewed.

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.

Management of extra-articular fractures of the fifth metacarpal: Operative vs. Non-opeRaTive TrEatment (FORTE) - A systematic review and meta-analysis

AIMS

Extra-articular fifth metacarpal fractures are treated operatively and non-operatively without consensus. We aim to establish whether there are differences in patient-reported outcome, objective clinical outcome and adverse events for skeletally mature patients with closed extra-articular fractures of the 5th metacarpal that are treated operatively versus non-operatively.

PATIENTS

Skeletally mature patients with closed, extra-articular 5th metacarpal fractures.

METHODS

A systematic review and meta-analysis of randomised controlled trials using methodology adapted from the Cochrane Handbook for Systematic Review of Interventions and compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. (PROSPERO CRD42018091633).

RESULTS

Two trials of 5th metacarpal neck fractures met the inclusion criteria and were included in the final pooled analysis (n = 125). There were no significant differences in patient-reported, objective clinical or radiographic outcomes between the operative and non-operative groups at 12 months. Operatively managed patients reported greater time off work and were more likely to suffer an adverse event.

CONCLUSION

Existing trial data is limited and inconclusive in terms of patient-reported outcome measures. Given that there remains wide variation in the treatment of these common injuries around the world, there is a need for further high-quality evidence to guide clinical practice.

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.

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.

Radiologic Changes by Early Motion in Neck Fractures of the Fifth Metacarpal Treated with Antegrade Intramedullary Fixation

BACKGROUND

As intramedullary (IM) fixation is one of the fixation methods used in neck fractures of the fifth metacarpal, an early motion of injured finger can be allowed. The purpose of this study is to evaluate whether immediate active motion affects the stability of antegrade IM fixation in surgical treatment of neck fractures of the fifth metacarpal bone and to assess related factors.

METHODS

Thirty one patients treated by closed reduction and antegrade IM fixation were consecutively enrolled. All patients started active motion of the little finger since 7 postoperative days and only daily activities including writing, typing or washing were allowed until the union of fracture. All fractures were healed within four to eight weeks. The changes of angulation, fifth metacarpal length and tip to head distance of K-wire were compared between immediate postoperative radiographs and radiographs at eight weeks. In addition, the effects by age, gender, initial angulation and comminution of the metacarpal neck were assessed.

RESULTS

The average change of angulation was 0.12°, 5th metacarpal length was 1.49mm and tip to head distance of K-wire was 1.31mm. There was no significant difference in the change of angulation (p = 0.137). But, there were significant differences in the change of 5th metacarpal length and tip to head distance of K-wire ([Formula: see text]). The change of angulation was related to a comminution of the metacarpal neck and that of 5th metacarpal length was related to age and sex.

CONCLUSIONS

The change of 5th metacarpal length and tip to head distance of K-wire can occur by an early mobilization in the antegrade IM fixation for neck fractures of the fifth metacarpal. However, we thought that an early active motion after surgery is important to increase the patients' satisfaction, even though careful selection of candidates is necessary.

Metacarpal Locked Intramedullary Nail: Surgical Technique and Preliminary Outcome Report

In surgically indicated metacarpal fractures, the ideal fixation should provide an ample stability for early rehabilitation. Damage to surrounding tissue should be minimized as well, to prevent stiffness which determine the outcomes. We have created the metacarpal locked intramedullary nail (MCLN) that allows immediate motion even in unstable fractures. This preliminary report is objected to demonstrate the surgical technique and outcomes of novel metacarpal fixation. Three surgical indicated metacarpal fractures were treated by MCLN. Unlimited motion was started a day after surgery without external immobilization. Clinical and radiographic control were performed up to two years after the surgery. All of patients returned to previous level of daily activities within six weeks with minimal scar. All fractures were united. The total active motions were above 260° in every patient. Complications were not observed. With this encouraged clinical results, the MCLN could be the promising alternative surgical fixation for metacarpal shaft fractures.

Technique for Intramedullary Stabilization of Ulnar Neck Fractures

BACKGROUND

Distal ulna fractures at the ulnar neck can be seen in association with distal radius fractures, and multiple techniques have been described to address the ulnar neck component of these injuries. We have found that treatment of ulnar neck fractures can be challenging in terms of anatomy and fracture fixation. We present a new percutaneous fixation technique for ulnar neck fractures commonly seen with distal radius fractures.

TECHNIQUE

Fixation of the ulnar neck fracture is performed after fixation of the distal radius fracture. Our technique uses anterograde intramedullary fixation to stabilize the fracture with a 1.6-mm (0.062 inch) Kirschner wire or a commercially available metacarpal fixation intramedullary nail. The fixation is introduced into the intramedullary space of the ulnar shaft 4 to 6 cm proximal to the fracture at a separate surgical site along the subcutaneous border of the ulna. The fixation is also supported with a sugar-tong splint for the first few weeks after surgery and requires removal of the ulnar implant approximately 10 weeks after implantation.

CONCLUSION

Our technique utilizes a percutaneous approach with minimal fracture exposure. It provides a relatively simple and reproducible method to address ulnar neck fractures commonly seen in association with distal radial fractures.

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.

Intramedullary Screws versus Kirschner Wires for Metacarpal Fixation, Functional, and Patient-Related Outcomes

Purpose  The purpose of our study is to compare the intramedullary fixation of metacarpal fractures with cannulated headless screws and antegrade Kirschner wires in terms of final total active motion, grip strength, patient-related outcomes, need for casting, and return to work times.

Methods  The authors performed a retrospective review of the hospital records. Thirty fractures were included in the study, 19 in the screw fixation group, and 11 in the Kirschner wire group. Grip strength, and total active motion, was measured at the latest follow-up for both the injured and contralateral hand. Pain was measured on the visual analog scale. Patients were requested to fill a Quick disabilities of the arm and hand score (DASH) questionnaire at the latest follow-up. Satisfaction was measured on a scale from 0 to 10. The time to return to work was quantified from the accident to the point when the patient was back to active duty. Postoperative casting time was also quantified.

Results  The authors did not find any differences between the two groups in total active motion, grip strength, pain, satisfaction, or Quick DASH scores. We did find a difference in the return to work and casting times; these appeared to be shorter in the screw group.

Conclusion  Due to the small number of cases, we have been unable to clearly conclude that there were any benefits in the application of one particular technique when compared with the other.

Radiographic and Clinical Assessment of Intramedullary Nail Fixation for the Treatment of Unstable Metacarpal Fractures

BACKGROUND

The purpose of the article was to evaluate clinical and radiographic outcomes in a case series of unstable metacarpal fractures treated with flexible intramedullary nail (IMN) fixation.

METHODS

A total of 55 patients with unstable metacarpal fractures between 2003 and 2010 were treated with IMN fixation and followed for a minimum of 1 year. The outcomes were assessed via a radiological study of longitudinal and angular collapse, Disabilities of the Arm, Shoulder, and Hand (DASH) score, total active range of motion (ROM) of the wrist, and grip strength testing.

RESULTS

In the 55 patients, metacarpal fractures were healed by clinical and radiographic assessment at an average of 12.7 weeks. IMNs were removed in all cases at an average of 13.9 weeks. Patients regained full finger ROM at the final follow-up and were capable of 72.4% of motion at 2 weeks postoperatively. The mean DASH score at the final follow-up was 6.5. Complications included 3 cases of extensor tendon irritation that resolved without functional impairment and 2 cases of "backing out" that required reoperation to replace the pin. In one case, a bony exostosis formed on the affected metacarpal that led to tendon irritation and required operative excision.

CONCLUSIONS

We found that this technique allowed for the stabilization of fractures, early ROM, resumption of usual activities, reduced immobilization, and minimal complications. A removable orthosis, instead of a cast, allowed for earlier mobilization of the wrist, metacarpophalangeal, and proximal interphalangeal joints.

The Nonoperative Management of Hand Fractures in United Kingdom

Hand fractures (excluding small avulsion fractures and scaphoid fractures) almost always unite with bone. The role of the hand surgeon is not to achieve bone union but to achieve stability in an adequate position, often with some displacement, and maintenance of good soft tissue gliding. This article establishes that many fractures treated operatively do no better and often could not realistically do better than with good nonoperative treatment. Yet many are treated surgically to satisfy surgical egos, the desire to produce excellent radiographs, or just the mistaken belief that current surgical techniques can improve on nonoperative treatment.

Elastic retrograde intramedullary percutaneous pinning for fifth metacarpal neck fractures: A series of 32 patients

The aim of our study was to evaluate an original surgical technique for the treatment of fifth metacarpal neck fractures: elastic retrograde intramedullary percutaneous pinning (ERIPP). From January 2014 to January 2016, patients with a fifth metacarpal neck fracture with greater than 30° volar displacement and/or clinodactyly were included. All patients underwent an ERIPP procedure. With this technique, K-wires are used as joysticks to assist reduction when the Jahss maneuver is insufficient. Clinical evaluation incorporated the DASH score, range of motion and grip strength at 3months. Radiographic evaluation comprised apex dorsal angulation and metacarpal shortening at 1month and 3months. Thirty-two patients were included in the study. All fractures were healed after a mean of 5 weeks (range 4-7). The DASH score was less than 30 for all patients, indicating an absence of disability. There were no differences in grip strength at 3months between the injured and the contralateral hand. There was less than 10° extension deficit in the metacarpophalangeal joint. In our experience, retrograde percutaneous pinning is a stable, compressive fixation method with effective reduction of displaced fifth metacarpal neck fractures. However, this result needs to be confirmed in comparative studies.

Headless Compression Screw Versus Kirschner Wire Fixation for Metacarpal Neck Fractures: A Biomechanical Study

PURPOSE

This study aimed to determine the biomechanical stability of headless compression screws in the fixation of metacarpal neck fractures and to compare them with another common, less invasive form of fixation, K-wires. The hypothesis was that headless compression screws would show higher stiffness and peak load to failure than K-wire fixation.

METHODS

Eight matched-paired hands (n = 31), using the ring and little finger metacarpals, had metacarpal fractures simulated at the physeal scar. Each group was stabilized with either a 3.5-mm headless compression screw or 2 0.045-in (1.1-mm) K-wires. Nineteen metacarpals were tested in 3-point bending and 12 in axial loading. Peak load to failure and stiffness were calculated from the load displacement curve. Bone mineral density was recorded for each specimen.

RESULTS

Bone mineral density was similar in the 2 groups tested for 3-point bending and axial loading. Stiffness was not significantly different in 3-point bending for headless compression screws and K-wires (means, 141.3 vs 194.5 N/mm) but it was significant in axial loading (means, 178.0 vs 111.6 N/mm). Peak load to failure was significantly higher in headless compression screws in 3-point bending (means, 401.2 vs 205.3 N) and axial loading (means, 467.5 vs 198.3 N).

CONCLUSIONS

Compared with K-wires, headless compression screws for metacarpal neck fractures are biomechanically superior in load to failure, 3-point bending, and axial loading.

CLINICAL RELEVANCE

Headless compression screws demonstrate excellent biomechanical stability in metacarpal neck fractures. In conjunction with promising clinical studies, these data suggest that headless compression screws may be an option for treating metacarpal neck fractures.

Fifth metacarpal neck fractures: fixation with antegrade locked flexible intramedullary nailing

Background: Fifth metacarpal neck fractures (commonly named “boxer’s fractures”) are the most common metacarpal injuries and usually affect young active people. These lesions are mainly treated conservatively. Their surgical management, if indicated, is still a matter of debate. Different procedures have been described. The aim of this study was to evaluate the outcomes of 18 boxer’s fractures which were synthesized with antegrade locked flexible intramedullary nailing. Materials and methods: All patients, at a mean follow-up of 45 months, were clinically evaluated using the Disabilities of the Arm, Shoulder and Hand (DASH) score and the Patient Rated Wrist/Hand Evaluation (PRWHE). Active and passive range of motion (ROM) of metacarpo-phalangeal (MP), proximal and distal interphalangeal (PIP and DIP) joints and Total Active Motion (TAM), and grip strength were also analyzed. Apex dorsal angulation and axial shortening were radiologically measured preoperatively and at final follow-up. Results: Clinical and radiological results which were observed were satisfactory. No TAM and grip strength differences were recorded between the operated and healthy contralateral hand. Conclusions: According to the positive outcomes and the low rate of complications of this study, antegrade locked flexible intramedullary nailing can be considered a valid treatment option in boxer’s fractures. (www.actabiomedica.it)

Comparison of AO Titanium Locking Plate and Screw Fixation versus Anterograde Intramedullary Fixation for Isolated Unstable Metacarpal and Phalangeal Fractures

OBJECTIVE

This study aimed to compare the clinical and radiologic outcomes of AO titanium locking plate and screw (ATLPS) and anterograde intramedullary (AIM) fixation for treating unstable metacarpal and phalangeal fractures.

METHODS

Adult patients with isolated fresh unstable metacarpal and phalangeal fractures who met the inclusion criteria were enrolled into this prospective study from July 2013. Patients were divided into ATLPS or AIM groups when they were admitted to our department after considering their work requirement, fracture complexity, and surgeon's experience and were then treated accordingly. Relevant demographic, clinical and preoperative clinical data were collected and analyzed. Clinical examination and radiograph evaluation were performed 1 week and 1, 3, and 6 months postoperatively. Outcome measures were visual analog scale (VAS) scores for pain, total range of motion (ROM) of the injured digit, Quick Disabilities of the Arm, Shoulder, and Hand scores (Quick-DASH) and grip strength (percentage of the contralateral corresponding digit).

RESULTS

From July 2013 to September 2014, 76 patients were treated by AIM and 71 by ATLPS. Age, sex, time from injury to operation, dominant hand, injury mechanism, fracture location, fracture type and participant occupation were similar in both groups (P > 0.05). Operations were all performed well and followed by uneventful postoperative functional recoveries. At 3-month follow-up, all clinical outcomes were significantly better in the AIM than ATLPS group ( P < 0.05) except for VAS pain scores. However, at 6-month follow-up, the differences were no longer significant, indicating similar results for both types of fixation. Patients in the AIM group developed significantly more complications ( P = 0.037). Sick leave was significantly longer in the AIM group ( P = 0.02).

CONCLUSIONS

AIM outperforms ATLPS in the treatment of unstable metacarpal and phalangeal fractures in the early, but not the later, postoperative period; the latter is associated with significantly more complications. Patients treated by ATLPS require shorter sick leave, which is of particular benefit to workers with specialized manual skills.