Management of fractures of the hand over the last 25 years

Clinical, Radiologic, and Functional Outcomes following Bone Grafting for Metacarpal Non-Unions: A Systematic Review

Objectives: Metacarpal non-unions are complex hand defects that can lead to severe hand impairment. Treatment may require the use of artificial or autologous bone grafts. This systematic review aims to describe the outcomes of bone grafting following metacarpal non-union in an attempt to establish an optimal therapeutic protocol for this complication. Methods: A systematic review was conducted in adherence with PRISMA guidelines. Data collection and analysis were performed in duplicate and confirmed by a third investigator. Our primary outcomes focused on radiological time to bone fusion and rates of non-union. Additionally, functional outcomes and complications were analyzed as means of central tendency. Results: Eighteen studies were included in the systematic review, accounting for a total of 47 patients. The average follow-up time was 12.4 months. Fourteen studies analyzed radiological outcomes, with atrophic non-union representing the most common type. The time to bone fusion, assessed radiologically, following bone graft was an average of 6.9 months (n = 14), with a 100% rate of union in 42 patients. Regarding patient-reported pain improvement, 76% of patients experienced pain relief. Moreover, all patients reported a complete subjective return to baseline hand function. Adverse events, limited to hematoma and seroma, were seen in three patients, representing a complication rate of 11.8% in the examined population. Conclusions: Metacarpal non-union can be treated successfully via vascularized and non-vascularized bone grafting. Based on the available evidence, bone grafts demonstrate favorable union rates, post-operative pain reduction, hand function recovery, earlier bone fusion times, and minimal complications in the context of metacarpal non-union management.

Intramedullary fixation of metacarpal and phalangeal bone fractures with bioabsorbable Mg K-wire in 20 cases

PURPOSE

The treatment of irreducible or severely displaced metacarpal and phalangeal bone fractures is still much debated. The recent development of the bioabsorbable magnesium K-wire is thought to allow effective treatment upon insertion via intramedullary fixation by minimizing articular cartilage injuries without discomfort until pin removal and drawbacks, such as pin track infection and metal plate removal. Therefore, this study investigated and reported the effects of intramedullary fixation with the bioabsorbable magnesium K-wire in unstable metacarpal and phalangeal bone fractures.

METHODS

This study included 19 patients admitted to our clinic for metacarpal or phalangeal bone fractures from May 2019 to July 2021. As a result, 20 cases were examined among these 19 patients.

RESULTS

Bone union was observed in all 20 cases, with a mean bone union time of 10.5 (SD 3.4) weeks. Reduction loss was observed in six cases, all showing dorsal angulation with a mean angle of 6.6° (SD 3.5°) at 4.6 weeks as compared with that noted in the unaffected side. The gas cavity upon H2 gas formation was first observed approximately 2 weeks postoperatively. The mean DASH score was 33.5 for instrumental activity and 9.5 for work/task performance. No patient complained of notable discomfort after surgery.

CONCLUSION

Intramedullary fixation with the bioabsorbable magnesium K-wire may be used for unstable metacarpal and phalanx bone fractures. This wire is expected to be a particularly favorable indication for shaft fractures, although care should be taken due to the possibility of complications related to rigidity and deformity.

Comparing the torsional resistance of different fixation techniques for spiral metacarpal fractures

This study aimed to compare the torsional resistance of three fixation techniques for spiral metacarpal fractures: screw-only fixation, screw plus neutralization plate fixation, and a locking plate construct. A spiral fracture was created on 18 cadaveric metacarpal bones by applying an axial and torsional loading force using an Instron 3343 mechanical tester. The failure strength was defined as the native torque strength. The fractures were divided into three groups and fixed using each of the three techniques. The repaired bones were loaded to failure to determine the post-repair strength. The neutralization plate group conferred a post-repair torque (278.6 Nmm) that was similar to the native torque (292 Nmm) with a diminution of only 4.5% and appeared to provide the best resistance to torsion.

Inter-relationships of Metacarpals 1 to 5, Regarding Their Length, Metaphyseal Midshaft Width, Articular Surface Area of Head and Base, Age, and Sex: A Cadaveric Study

Background: Metacarpal factures are common, comprising up to 50% of hand fractures. More work is needed to further our understanding of metacarpal anatomy to improve fixation techniques and reduce postoperative complications following surgical implants. The purpose of this anatomic study was to evaluate the length, midshaft metaphyseal width, and area of the articular surface of the head (AH) and base (AB) of metacarpals 1 to 5. Methods: This prospective study assessed measures from 17 cadavers at 1 institution's anatomy lab. The anatomic dimensions of the metacarpals in both the right and left hands were measured. Epidemiological data including sex and age at death were also collected. Results: In all, 29 hands were dissected for metacarpal anatomic measurements, for a total of 145 metacarpals. The second metacarpal was longest, at 69.58 mm. Multivariate analysis of variance revealed a significant effect of sex overall, with greater metacarpal dimensions in men. Increasing age was associated with decreasing dimensions, except for AH of metacarpal 1 (F = 3.43, P = .02) and AB of metacarpal 1 (F = 11.54, P < .001) and 4 (F = 4.21, P = .01). Multiple metacarpal dimensions were also significantly correlated with each other. Conclusion: Our data reveal further information regarding metacarpal dimensions of length, midshaft width, and AH and AB. The results allow for potential to improve surgical management through improving metacarpal implants, developing an optimal plate and screw design, techniques to better accommodate anatomical differences based on age and sex, reducing postoperative complications and improving the standard of care.

Bone plate fixation ability on the dorsal and lateral sides of a metacarpal shaft transverse fracture

Background

Metacarpal shaft fractures are a common hand trauma. The current surgical fixation options for such fractures include percutaneous Kirschner wire pinning and nonlocking and locking plate fixation. Although bone plate fixation, compared with Kirschner wire pinning, has superior fixation ability, a consensus has not been reached on whether the bone plate is better placed on the dorsal or lateral side.

Objective

The purpose of this study was to evaluate the fixation of locking and regular bone plates on the dorsal and lateral sides of a metacarpal shaft fracture.

Materials and methods

Thirty-five artificial metacarpal bones were used in the experiment. Metacarpal shaft fractures were created using a saw blade, which were then treated with four types of fixation as follows: (1) a locking plate with four locking bicortical screws on the dorsal side (LP_D); (2) a locking plate with four locking bicortical screws on the lateral side (LP_L); (3) a regular plate with four regular bicortical screws on the dorsal side (RP_D); (4) a regular plate with four regular bicortical screws on the lateral side (RP_D); and (5) two K-wires (KWs). All specimens were tested through cantilever bending tests on a material testing system. The maximum fracture force and stiffness of the five fixation types were determined based on the force–displacement data. The maximum fracture force and stiffness of the specimens with metacarpal shaft fractures were first analyzed using one-way analysis of variance and Tukey’s test.

Results

The maximum fracture force results of the five types of metacarpal shaft fracture were as follows: LP_D group (230.1 ± 22.8 N, mean ± SD) ≅ RP_D group (228.2 ± 13.4 N) > KW group (94.0 ± 17.4 N) > LP_L group (59.0 ± 7.9 N) ≅ RP_L group (44.5 ± 3.4 N). In addition, the stiffness results of the five types of metacarpal shaft fracture were as follows: LP_D group (68.7 ± 14.0 N/mm) > RP_D group (54.9 ± 3.2 N/mm) > KW group (20.7 ± 5.8 N/mm) ≅ LP_L group (10.6 ± 1.7 N/mm) ≅ RP_L group (9.4 ± 1.2 N/mm).

Conclusion

According to our results, the mechanical strength offered by lateral plate fixation of a metacarpal shaft fracture is so low that even KW fixation can offer relatively superior mechanical strength; this is regardless of whether a locking or nonlocking plate is used for lateral plate fixation. Such fixation can reduce the probability of extensor tendon adhesion. Nevertheless, our results indicated that when lateral plate fixation is used for fixating a metacarpal shaft fracture in a clinical setting, whether the mechanical strength offered by such fixation would be strong enough to support bone union remains questionable.

Effect of Bicortical Interfragmentary Screw Size on the Fixation of Metacarpal Shaft Fractures: A 3-Dimensional-Printed Biomechanical Study

Purpose

Spiral metacarpal fractures fixed with 2 non-lagged, interfragmentary cortical screws were tested to failure. The effect of screw size (1.2 mm, 1.5 mm, 2.0 mm, and 2.3 mm) on construct strength was tested in 3-point bending.

Methods

Three-dimensional-printed metacarpal test models were reproduced from computed tomography scans to reduce the confounding variables of bone density and anatomy, often encountered when using cadavers.

Results

No significant difference was found between the screw sizes, and the peak failure force was similar. Drill bit fracture and deformation during the insertion of the smallest screw (1.2 mm) as well as model failure during the insertion of the largest screw (2.3 mm) were found in some cases.

Conclusions

Screws of 1.5 mm and 2.0 mm in diameter were of sufficient strength and did not have the issues encountered with smaller or larger screws. Concerns from previous authors regarding intraoperative fracture were consistent with the pre-testing failure of some 2.3-mm models.

Clinical Relevance

Screws of 1.5 mm or 2 mm appear adequate for the fixation of spiral fracture patterns in metacarpal shafts using bicortical non-lagged technique with a low risk of fixation complications.

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.

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.

Analysis of Operative Techniques of Fractures of the First Metacarpal Base

INTRODUCTION

Over time, the operative treatment of extra-articular and intra-articular fractures of the first metacarpal base has gained significant importance, and at present, there are many operative strategies available because of the different osteosynthesis procedures in practice today.

PURPOSE

In this retrospective cohort study, we analyze the possible differences between 2 distinguished operative osteosynthesis techniques, in terms of patient outcome, operation time, duration of radiation exposure, and postoperative radiographic results.

METHODS

Fifty-two patients operated on for first metacarpal extra-articular or intra-articular base fracture were investigated retrospectively by means of records. After reduction, osteosynthesis was performed on 34 patients with K-wires (group I), and on 18 patients with plates and/or screws (group II). Of the 52 patients, 19 were available for a prospective follow-up examination.

RESULTS

After analyzing the operation time, a significant difference between the 2 operative techniques for epibasal and Bennett fractures (P = 0.0089 and P = 0.02) was recorded. Furthermore, for the time of radiation exposure, no significant difference could be detected. Also, no statistical difference was found between the 2 analyzed groups in terms of patient outcomes and postoperative radiographic results.

CONCLUSIONS

The determined data of the operated extra-articular and intra-articular first metacarpal base fractures revealed approximately equal results for patient outcome, postoperative x-ray results, and time of radiation exposure during the operation. After analyzing the operation time of epibasal and Bennett fractures, we can recommend that the K-wire fixation is superior to the plate and/or screw osteosynthesis as a treatment, because of the associated benefits of keeping costs low without harming the patient in the long term.

Interlocking K Wires Followed by Immediate Mobilization for Fractures of the Hand

We describe a technique of interlocking Kirschner wires to improve stability after fixation of fractures of the hand. This enables immediate mobilization of the injured fingers thus reducing the need for prolonged postoperative physical therapy and consequently diminishing chances of posttraumatic stiffness. This study analyzes outcomes in 83 fractures in 70 patients including 26 metacarpal and 57 phalangeal fractures. The technique has proven to be simple, versatile, and cost-effective. Patient compliance and satisfaction has been high and results have been gratifying.

Cemented K-wire fixation for the treatment of shaft fractures of middle phalanges

BACKGROUND

The objective of this report is to introduce an external-fixation technique using the combination of K-wires and cement.

METHODS

From February 2009 to January 2015, 51 patients with shaft fractures of middle phalanges were treated with cemented K-wire fixation. The mean age of patients at surgery was 41 years. The mean time interval from injury to operation was 6±5.78days. Injured digits included index (n=18), long (n=15), ring (n=7), and little (n=11) fingers. Types of fractures were transversal (n=32), short oblique or spiral (n=5), and comminuted (n=14) fractures. Active range of motion of the fingers was measured. Total active motion was scored based on the American Society for Surgery of the Hand. All measurements were compared with those on the opposite fingers. Patients also reported on their satisfaction using the 100-mm visual analogue scale.

RESULTS

At the final follow-ups of 2 years, range of motion of metacarpophalangeal joint, proximal phalangeal joint, and distal interphalangeal joint reached 97%±2.88, 93%±6.65, and 96%±3.22 of the opposite fingers, respectively. Based on Total active motion scoring system, we obtained 36 excellent and 15 good results. Based on VAS, patient satisfaction was 96±3.44.

CONCLUSIONS

The cemented K-wire fixation is a reliable technique for the treatment of shaft fractures of middle phalanges. The technique is a minimally invasive procedure with minimal complications.

LEVEL OF EVIDENCE

Therapeutic study, Level IVa.

Early unprotected return to contact sport after metacarpal fixation in professional athletes

AIMS

To determine whether an early return to sport in professional Australian Rules Football players after fixation of a non-thumb metacarpal fracture was safe and effective.

PATIENTS AND METHODS

A total of 16 patients with a mean age of 25 years (19 to 30) identified as having a non-thumb metacarpal fracture underwent open reduction and internal plate and screw fixation. We compared the players' professional performance statistics before and after the injury to determine whether there was any deterioration in their post-operative performance.

RESULTS

Of the 16, 12 sustained their fracture during the season: their mean time to return to unrestricted professional play was two weeks (1 to 5). All except two of the 48 player performance variables showed no reduction in performance post-operatively.

CONCLUSION

Our data suggest that professional athletes who sustained a non-thumb metacarpal fracture can safely return to professional play without restriction two weeks after internal fixation. Cite this article: Bone Joint J 2017;99-B:1343-7.

Operative treatment of metacarpal and phalangeal fractures in athletes: early return to play

BACKGROUND

Evaluating the outcomes of operative treatment for metacarpal and phalangeal fractures in athletes returning early to play and discussing the more effective methods that permit rapid early return to athletic activity.

METHODS

We retrospectively identified a total of 105 metacarpal or phalangeal fractures in 105 athletes with conservative or operative treatment in our department. Of these, 20 athletes required an early return to sport because of a pending important game in their competition within 1 month after injury. Therefore, they underwent surgical treatment with open reduction and internal fixation of metacarpal or phalangeal fractures in an attempt to achieve an early return to their chosen sport at their usual competitive level. The patients included 6 rugby football players, 2 soccer goalkeepers, 3 American football players, 3 handball players, 2 baseball players and 4 who participated in other sports. The clinical records of preoperative and postoperative radiographs were available for all patients, and clinical outcome was evaluated by total active motion (TAM).

RESULTS

The patients were followed up for a mean of 27 (24-43) months. At the latest follow-up examination, bone union was obtained in all cases. In cases with metacarpal and phalangeal fractures, the average TAM was 263° (range 240°-270°).

CONCLUSION

We consider that an early comeback to training and competition can be permitted exclusively for patients with metacarpal and phalangeal fractures. It is important for the attending physician to administer such treatment after obtaining informed consent and develop a trusting relationship with the patient and other related individuals while paying attention to their hope of quick recovery.

Non-surgical management of metacarpal fractures

Metacarpal fractures are among the most common fractures of the upper extremity. Surgical management is generally offered for unstable or significantly displaced fractures. A more conservative, nonsurgical approach, however, may provide safe, rapid recovery while maintaining normal active range of motion. This article reviews the nonsurgical approach, protocols, and outcomes of metacarpal fractures.

Metacarpal fractures: treatment and complications

Metacarpal fractures comprise between 18-44 % of all hand fractures. Non-thumb metacarpals account for around 88 % of all metacarpal fractures, with the fifth finger most commonly involved [19]. The majority of metacarpal fractures are isolated injuries, which are simple, closed, and stable. While many metacarpal fractures do well without surgery, there is a paucity of literature and persistent controversy to guide the treating physician on the best treatment algorithm. The purpose of this article is to review non-thumb metacarpal anatomy and treatment protocols for nonoperative management of stable fractures, and compare existing literature on surgical techniques for treatment of acute fractures and complications.

Treatment of phalangeal fractures

Treatment of phalangeal fractures depends on the characteristics of the fracture, condition of the soft tissue envelope, associated injuries, patient functional requirements, and surgeon familiarity and comfort with various techniques. Most phalangeal fractures can be treated successfully with nonoperative means. Surgery is considered to treat unstable injuries, articular incongruity, concomitant soft tissue damage, or other situations in which restoration of anatomy and preservation of function are achieved only via operative stabilization. Careful soft tissue handling and early mobilization are premises on which surgical phalangeal fracture treatment is based.

Percutaneous fixation of hand fractures using locked K-wires: mechanical analysis and clinical application

Closed percutaneous wire fixation of hand fractures frequently requires protection with external splintage. This splintage increases the risk of joint stiffness, prolongs recovery time, and increases therapy input. We have developed a method of linking external Kirschner wires (K-wires), using a metal clamp, after their insertion, so as to increase the security of fixation and facilitate postoperative mobilization. The mechanical properties of this method have been assessed in vitro and compared with conventionally fixed, unlinked, K-wires. We have been able to establish that the linked K-wire system is better able to resist loosening. This work proposes that linkage of K-wires permits omission of all additional external splintage, with no detriment to management. The technique has been applied in clinical cases over the past 8 years and results of treatments were evaluated mainly to detect unexpected complications. We report a low rate of complications and good results in terms of bone healing and recovery of function.

A new technique of locked, flexible intramedullary nailing of spiral and comminuted fractures of the metacarpals: a series of 21 cases

BACKGROUND

Spiral and comminuted fractures of the metacarpals are rotationally and axially unstable fractures with a tendency to shorten, which in turn causes significant extensor lag and loss of grip strength. We have designed a new, cheap and locally developed method of locked intramedullary nailing of these metacarpal fractures. We are presenting the results of our first 21 patients with 22 fractures treated by closed, fluoroscopically assisted, intramedullary K-wiring with proximal locking done by a specially designed locking pin.

MATERIALS AND METHODS

This was a retrospective, observational cohort study of all patients with spiral and comminuted fractures of metacarpals with minimum of 1 year of follow-up and average follow-up of 14 months (range, 12 to 26 months). The patients were evaluated clinico-radiologically using range of motion, extensor lag, time to healing, amount of collapse, angulation and rotation and complications.

RESULTS

All fractures had healed uneventfully with average time to union being 8 weeks. Average metacarpal shortening was 2.04 ± 0.95 mm, while the average post-operative angulation of the fracture was 4.81° ± 1.7. The metacarpophalangeal range-of-motion recovered almost fully with the average extensor lag being only 5.22° ± 2.42. Other than extensor tendinitis in two patients, there were no other complications.

CONCLUSIONS

This method is cosmetically appealing, provides stable fixation, avoids periosteal stripping associated with open reduction and is associated with very low complication rate, and thus can be safely and effectively used for the treatment of these difficult fractures.

Stainless Steel 2.0-mm Locking Compression Plate Osteosynthesis System for the Fixation of Comminuted Hand Fractures in Asian Adults

Objective

The aim of this retrospective study was to analyse the clinical outcome of the application of stainless steel 2.0-mm locking compression plate (LCP) system for the treatment of comminuted hand fractures in Asian adults.

Methods

Six patients who had comminuted hand fractures were treated by open reduction and internal fixation with the application of stainless steel 2.0-mm LCP (AO Compact Hand System; Synthes, Oberdorf, Switzerland) from December 2009 to October 2010. The total arc of motion of fingers, grip power, complications, and additional surgery were recorded.

Results

Three out of six patients eventually restored good hand functions in terms of the total arc of finger motion (>220°) and grip power. The commonest complication was skin impingement in finger region by the implant (4 cases). Another common complication was restricted range of motion (3 cases). One patient had minimal degree of malrotation of his left little finger. Additional surgery was required in all the patients for implant removal (6 cases), tenolysis (3 cases), and capsulotomy (2 cases).

Conclusions

The stainless steel 2.0-mm LCP is useful for the fixation of unstable comminuted hand fractures, especially in metacarpal bones, because of its advantage of better stability, which allows more aggressive rehabilitation. However, its design is not very versatile and, therefore, limits its use in the finger region. Its bulkiness frequently causes implant impingement. The patients must be informed about the chance of implant removal later.

Experimental fracture model versus osteotomy model in metacarpal bone plate fixation

Introduction. Osteotomy or fracture models can be used to evaluate mechanical properties of fixation techniques of the hand skeleton in vitro. Although many studies make use of osteotomy models, fracture models simulate the clinical situation more realistically. This study investigates monocortical and bicortical plate fixation on metacarpal bones considering both aforementioned models to decide which method is best suited to test fixation techniques. Methods. Porcine metacarpal bones (n = 40) were randomized into 4 groups. In groups I and II bones were fractured with a modified 3-point bending test. The intact bones represented a further control group to which the other groups after fixation were compared. In groups III and IV a standard osteotomy was carried out. Bones were fixated with plates monocortically (group I, III) and bicortically (group II, IV) and tested for failure. Results. Bones fractured at a mean maximum load of 482.8 N ± 104.8 N with a relative standard deviation (RSD) of 21.7%, mean stiffness was 122.3 ± 35 N/mm. In the fracture model, there was a significant difference (P = 0.01) for maximum load of monocortically and bicortically fixed bones in contrast to the osteotomy model (P = 0.9). Discussion. In the fracture model, because one can use the same bone for both measurements in the intact state and the bone-plate construct states, the impact of inter-individual differences is reduced. In contrast to the osteotomy model there are differences between monocortical and bicortical fixations in the fracture model. Thus simulation of the in vivo situation is better and seems to be suitable for the evaluation of mechanical properties of fixation techniques on metacarpals.

The role of locking technology in the hand

Locked fixed-angle plating in the hand and wrist helps to optimize outcomes following surgical fixation of select acute fractures and complex reconstructions. Select indications include unstable distal ulna head/neck fractures, periarticular metacarpal and phalangeal fractures, comminuted/multifragmentary diaphyseal fractures with bone loss (ie, combined injuries of the hand), osteopenic/pathologic fractures, nonunions and corrective osteotomy fixation, and small joint arthrodesis. Locked plating techniques in the hand should not be seen as a panacea for wrist and digital acute trauma and delayed reconstructions. An understanding of the biomechanics of fixed-angle plating and proper technical application of locking constructs will optimize outcomes and minimize complications. As clinical experience with locking technology in hand trauma broadens, new indications and applications will emerge. Currently, several systems are available. The specific implants share common features in their protocols for insertion, but unique differences in their design (ie, individual locking mechanisms, uniaxial vs polyaxial locking capability, metallurgy, and plate profiles) must be appreciated and considered preoperatively.

Comparison between locking and non-locking plates for fixation of metacarpal fractures in an animal model

PURPOSE

The use of locking plates increases the primary load to failure, thereby reducing the rate of implant-related failure. The good clinical and biomechanical results of locking plates in long bones might be applicable to treatment of metacarpal fractures. The purpose of this study was to determine strength and stiffness of locking plates in a metacarpal fracture model with mono- and bicortical screw fixation in comparison to non-locking plate mono- and bicortical screw fixation, with both types of plates placed at the dorsal side of the bone.

METHODS

Fresh second metacarpals from domestic pigs (n=40) were randomized in 4 equal groups. Short, oblique, mid-shaft fractures were generated, using a standardized 3-point bending method. Fractures were plated with non-locking, titanium, 1-mm-thick monocortical (group 1, n=10) or bicortical (group 2, n =10) plates (Leibinger-Stryker; Stryker Corp, Freiburg, Germany). Newly designed locking titanium plates with the same width and thickness (Leibinger-Stryker) were used in the same manner for groups 3 (monocortical) and 4 (bicortical). The metacarpals were then tested to load to failure in a cantilever bending mode.

RESULTS

Bicortical, non-locking fixation (group 2, 359 +/- 90 N) had a higher load to failure than monocortical non-locking fixation (group 1, 250 +/- 56 N) in testing the maximum load to failure (p < .01). There was no significant difference in stiffness between group 1 (46 +/- 12 N/mm) and group 2 (56 +/- 21 N/mm). The difference in maximum load to failure between monocortical (group 3, 440 +/- 85N) and bicortical (group 4, 378 +/- 116 N) locking plate stabilization was not significant. Also, there was no significant difference in stiffness between monocortical (group 3, 83 +/- 35 N/mm) and bicortical locking plates (group 4, 70 +/- 31 N/mm). Comparing non-locking (group 1) and locking plates in a monocortical fixation technique (group 3) demonstrated significant differences in maximum load to failure (group 1, 250 +/- 56 N; group 3, 440 +/- 85 N) and stiffness (group 1, 46 +/- 12 N/mm; group 3, 83 +/- 35 N/mm). The stability of monocortical locking plates was stronger, although not statistically significant, than the non-locking bicortical plates (load to failure, 440 +/- 85 N vs 359 +/- 90 N; stiffness, 83 +/- 35 N/mm vs 56 +/- 21 N/mm).

CONCLUSIONS

The new generation of locking plates can be used to achieve a higher stability for fixation of metacarpal fractures. Monocortical, stable fixation can minimize flexor tendon interference and probably reduce bone and soft tissue trauma.

Operative fixation of metacarpal and phalangeal fractures in athletes

Metacarpal and phalangeal fractures are common athletic injuries that can significantly affect the athlete's career when they occur during the season and affect the athlete's training when they occur in the off season. This situation is particularly relevant if there are complications or if fixation is not stable enough to permit early range of motion and rehabilitation. This article discusses percutaneous and open reduction techniques of hand fractures as these injuries pertain to athletes. The goal is stable fixation to allow early return to competition and rehabilitation.

Minifragment screw fixation of oblique metacarpal fractures: a biomechanical analysis of screw types and techniques

The lag screw technique has historically been a successful and accepted way to treat oblique metacarpal fractures. However, it does take additional time and involve multiple steps that can increase the risk of fracture propagation or comminution in the small hand bones of the hand. An alternate fixation technique uses bicortical interfragmentary screws. Other studies support the clinical effectiveness and ease of this technique. The purpose of this study is to biomechanically assess the strength of the bicortical interfragmentary screw versus that of the traditional lag screw. Using 48 cadaver metacarpals, oblique osteotomies were created and stabilized using one of four methods: 1.5 mm bicortical interfragmentary (IF) screw, 1.5 mm lag technique screw, 2.0 mm bicortical IF screw, or 2.0 mm lag technique screw. Biomechanical testing was performed to measure post cyclic displacement and load to failure. Data was analyzed using one-way analysis of variance (ANOVA). There was no significant difference among the fixation techniques with regard to both displacement and ultimate failure strength. There was a slight trend for a higher load to failure with the 2.0 mm IF screw and 2.0 mm lag screw compared to the 1.5 mm IF and 1.5 mm lag screws, but this was not significant. Our results support previously established clinical data that bicortical interfragmentary screw fixation is an effective treatment option for oblique metacarpal fractures. This technique has clinical importance because it is an option to appropriately stabilize the often small and difficult to control fracture fragments encountered in metacarpal fractures.

Plate fixation in closed ipsilateral multiple metacarpal fractures

Closed multiple metacarpal fractures are uncommon. They are usually associated with significant soft tissue swelling. Early stable fixation and functional rehabilitation optimises outcome. We present a review of 19 patients with 43 metacarpal fractures treated by early open reduction and internal fixation with 2 mm plates. Eighteen patients recovered a full range of motion, while one patient was lost to follow-up. Implant removal on account of extensor irritation was required in only two metacarpals in two patients. Plating of multiple closed metacarpal fractures is a safe, reliable and consistently reproducible treatment method.

Surgical outcome of volar plate arthroplasty of the proximal interphalangeal joint using the Mitek micro GII suture anchor

BACKGROUND

The mechanism of injury in dorsal dislocation is usually a hyperextensive stress simultaneous with some degree of longitudinal compression. Operative treatment is indicated for those unstable and reduction is not achieved. We report the surgical outcome of volar plate arthroplasty of the proximal interphalangeal (PIP) joint using the Mitek Micro GII suture anchor.

METHODS

We reviewed the medical records of 20 patients with acute or chronic dorsal dislocation or subluxation of the PIP joint who were managed using the Mitek Micro GII suture anchor over the past 5 years by the same surgeon (J.T.S.). Fourteen patients had acute injuries (<4 weeks before surgery) and six patients had chronic injuries (average interval of 4.1 week from injury to surgery; range, 1-8 weeks). The patients had persistent pain and loss of range of motion after trauma, and the reductions were still unstable.

RESULTS

All patients were evaluated an average of 25 months postoperatively (range, 12-30 months). The average arc of motion of the PIP joints of the fingers was 82 degrees . There were no obvious perioperative complications, and no patient reported pain at rest or with activity.

CONCLUSION

Volar plate arthroplasty using the Mitek Micro GII suture anchor is an effective treatment choice for acute or chronic PIP joint dorsal dislocation or subluxation.

Minimally invasive intramedullary rod fixation of multiple metacarpal shaft fractures

Metacarpal shaft fractures tend to shorten and angulate. This tendency is accentuated with the fracture of multiple metacarpals. A variety of methods for treatment have been described. The purpose of this study is to present the results of treatment in patients with multiple metacarpal shaft fractures, treated in a minimally invasive manner, with an intramedullary rod device.

Simple hand fractures that aren't

Patients expect physicians to predict the future. Recognizing injuries that behave badly improves care and modulates expectations. Your antennae should deploy when you are presented with a simple fracture that isn't.

Cannulated percutaneous fixation of intra-articular hand fractures

Percutaneous fixation techniques minimize edema, scar formation, and stiffness from operative trauma when restoring position and stability of displaced and unstable hand fractures. Percutaneous Kirschner wires merely splint fractures and may migrate, disengage, or irritate soft tissues; may be associated with pin tract suppuration; and may require removal at 4 to 6 weeks after insertion. Percutaneous miniscrews may provide more secure fixation for larger articular and oblique diaphyseal fractures of the thumb and finger phalanges by means of bicortical fixation and compression, are less intrusive to adjacent tissues, retain the fracture throughout the healing process, and seldom require removal. Miniscrew canulation substantially simplifies the insertion process, and headless miniscrews are entirely unobtrusive to the adjacent tissues.

Fixation choices for closed simple unstable oblique phalangeal and metacarpal fractures

Percutaneous K-wire fixation is still a useful technique for closed oblique phalangeal and meta-carpal fractures when an adequate closed reduction can be achieved. Lag screw fixation may be the best choice for open fixation of long oblique phalangeal and metacarpal fractures. For short oblique fractures, plating or tension band wiring is recommended. Plating provide rigid fixation to allow early mobilization; however, one may encounter frequent complications such as extensor lag, stiffness, or joint contracture when plating technique is used in phalangeal fractures. Tension band wiring technique at the phalangeal location may reduce such complications. Overall, successful outcomes of treating phalangeal and metacarpal fractures require a clear appreciation of fracture anatomy and pattern. It is mandatory for the treating surgeon to be familiar with all the treatment techniques discussed in order to tailor a specific technique for a particular injury and patient type.

Closed Reduction of Hand Fractures

Stiffness is the most frequent consequence of open hand fracture treatment. Although initial injury severity and occurrence adjacent to the flexor tendon sheath are the most highly correlated determinants of hand fracture outcome, operative intervention accentuates the ultimate risk of stiffness. Closed treatment may minimize this risk. Articular fractures are at greater risk for stiffness than extra-articular fractures. Functional tolerance for small amounts of variation from perfect anatomic restoration gives us increased latitude for closed hand fracture management. Operative treatment may be justified for simple closed fractures when they are unstable, irreducible, or open, or when the surgeon believes that the risk-to-benefit ratio is favorable.

Fixation of hand fractures with bicortical screws

PURPOSE

Traditionally a compression lag screw technique has been described when screw fixation alone is used to fix phalangeal or metacarpal fractures. The purpose of this retrospective case review was to determine whether there is any disadvantage to using a bicortical screw technique instead of the compression screw technique.

METHODS

Thirty-seven fractures of the phalanges and metacarpals in 36 patients had open reduction and internal fixation. Fixation was achieved with minifragment, self-tapping screws only, which were applied with bicortical fixation rather than a lag technique. Data were obtained through medical record and radiographic review. Intraoperative and immediate postoperative x-rays were compared with final x-rays. Fracture healing, confirmed radiographically, was used to determine whether the bicortical screw technique was adequate for fixation.

RESULTS

All fractures healed by an average of 7 weeks (range, 4-10 wk) without loss of fixation or malunion.

CONCLUSIONS

Based on this experience we believe bicortical fixation is a straightforward technique and provides adequate fracture stability and healing.

Rehabilitation for proximal phalangeal fractures

Proximal phalangeal fracture stability is crucial for the initiation of early and effective exercises designed to recover digital and especially proximal interphalangeal joint motion. Active digital flexion and extension exercises are implemented by synergistic wrist motion. Joint blocking exercises and active tendon gliding exercises in protective blocking splints are instrumental elements of early treatment. Dynamic splinting and serial finger casting are used in recalcitrant, severe, and late presenting cases. Surgical release is a last resort in regaining proximal interphalangeal joint motion. This measure is reserved for a failure of treatment when residual proximal interphalangeal joint contracture is persistent and severe enough to cause serious impairment of digital motion and hand function.

Metacarpal fractures in athletes: treatment, rehabilitation, and safe early return to play

Specialty gloves and buddy taping of adjacent fingers may cushion impact and dissipate twisting forces so that hands, thumbs, and fingers are protected during play. When fractures occur, athletes must be protected from contact until healing has progressed to a point where reinjury or complications are unlikely and performance standards and expectations can be met. This article outlines a program of fracture management principles and progressive graduated rehabilitation that phase the hand-injured athlete first into general conditioning and non-ball-handling drills, then into return to hand impact activities, body contact, ball handling, and catching with the use of protective hand gear. At this point, specialized playing orthoses, gloves, or taping may be added to the treatment regimen. Batting, the use of golf clubs, and racquet handling occur later, and finally throwing with precision, distance, velocity, and frequency is initiated. The importance of the particular sport, the position played, and hand dominance are factored into the decision-making processes. Safety of the patient and opponents is paramount. Extra-articular metacarpal fractures are discussed as a prototype for treatment, rehabilitation, and early safe return to play because of their frequent occurrence in athletes.

[The VB system: a new modular osteosynthesis material involving both screws and wires]

VB is an osteosynthesis system for the stabilisation of small fragments, which combines the benefits of both wires and screws. It is a modular system comprising a threaded pin and a ring. The threaded pin is first positioned. Then a ring is grasped and opened by the progressive angulation of a screwdriver. Still anchored on the screwdriver, the ring slides easily on the pin. It is clamped on the pin by simply removing the screwdriver and the pin is then cut. This modular system includes 1.8 and 1.1 mm pins and different types of rings (threaded or non threaded, with or without collars). The system is easy to handle and can be introduced using an open or percutaneous technique, allowing compression or distraction. Our preliminary series, performed in accordance with National clinical trial protocol (Huriet) consisted of 50 cases in 24 patients (five women and 19 men) with an average age of 48 years, and a follow-up of more than six months. Fourteen cases of fractures (28 implants) were treated as emergencies (two radial heads, one capitellum, one trochlea of the humerus, seven distal radius fractures, one trapezium, two metacarpals) and 12 cases (22 implants) were elective cases: arthrodesis (one trapezo-metacarpal, one intermetacarpal, two interphalangeal, two carpal), non-union (six scaphoids, one phalangeal) and one phalangeal malunion. Hardware removal was performed in 16 cases. No implant failure has been detected. One case, a DIP arthrodesis, had a suspicion of sepsis which led to the removal of the implants at six weeks. The results of this study have convinced us of the merits of the system, which combines the advantages of both wires and screws. The system allows the user to perform either distraction or compression, and to adjust the force by hand. Compared to the fixed amount of compression produced by lag screws, this feature seems to be a real step forward.