Operative treatment of metacarpal and phalangeal shaft fractures

Comparison of the radiological and functional results of a plaster splint and dynamic stabilization splint for Boxer's fractures: A prospective randomized controlled study

PURPOSE

This study compared the clinical and radiological results of fifth metacarpal neck fractures treated with a short-arm plaster splint (SAPS) versus a dynamic metacarpal stabilization splint (DMSS).

MATERIALS AND METHODS

The 119 patients were referred to our institute between 2018 and 2019 and treated with SAPS or DMSS after appropriate initial closed reduction. Follow-up examinations were conducted at days 10 and 20, and at 1, 2, and 3 months after treatment. Alignment of the fracture, range of motion (ROM), and complications were evaluated during each visit. Grip strength was evaluated using a dynamometer. Self-care, usual daily activities, pain/discomfort, and anxiety/depression were evaluated using the EuroQol 5-Dimension 5-Level (EQ-5D-5L) and a VAS.

RESULTS

Of the 119 patients, 103 completed all follow up examinations. In total, 51 patients were treated with SAPS and 52 with DMSS. Skin lesions were detected in five patients in the DMSS group, but none in the SAPS group (p = 0.008). The grip strength of patients in the DMSS group was statistically better at the 1-, 2-month and 3-month follow-up visits (p < 0.001). ROM of the interphalangeal and metacarpophalangeal joints were statistically better in the DMSS group at the 1-month visit (p < 0.001) but similar at the 3-month visit (p = 0.27). Wrist ROM was statistically higher in the DMSS group at the 3-month visit (p < 0.05). Self-care, usual daily activities, pain/discomfort, and anxiety/depression were statistically better in the DMSS group at all follow-up visits (p < 0.05), as determined by the EQ-5D-5L.

CONCLUSION

Dynamic stabilization of a stable boxer's fracture with DMSS is as effective as static stabilization with SAPS for maintaining the reduction and ensuring union. However, DMSS provides better early ROM, comfort, and muscle strength, as well as an earlier return to usual daily activities despite the occasional skin lesions happened.

Management of metacarpal shaft fractures

Aims

The aims of this study were to describe the epidemiology of metacarpal shaft fractures (MSFs), assess variation in treatment and complications following standard care, document hospital resource use, and explore factors associated with treatment modality.

Methods

A multicentre, cross-sectional retrospective study of MSFs at six centres in the UK. We collected and analyzed healthcare records, operative notes, and radiographs of adults presenting within ten days of a MSF affecting the second to fifth metacarpal between 1 August 2016 and 31 July 2017. Total emergency department (ED) attendances were used to estimate prevalence.

Results

A total of 793 patients (75% male, 25% female) with 897 MSFs were included, comprising 0.1% of 837,212 ED attendances. The annual incidence of MSF was 40 per 100,000. The median age was 27 years (IQR 21 to 41); the highest incidence was in men aged 16 to 24 years. Transverse fractures were the most common. Over 80% of all fractures were treated non-surgically, with variation across centres. Overall, 12 types of non-surgical and six types of surgical treatment were used. Fracture pattern, complexity, displacement, and age determined choice of treatment. Patients who were treated surgically required more radiographs and longer radiological and outpatient follow-up, and were more likely to be referred for therapy. Complications occurred in 5% of patients (39/793). Most patients attended planned follow-up, with 20% (160/783) failing to attend at least one or more clinic appointments.

Conclusion

MSFs are common hand injuries among young, working (economically active) men, but there is considerable heterogeneity in treatment, rehabilitation, and resource use. They are a burden on healthcare resources and society, thus further research is needed to optimize treatment.

The Volar Midline Longitudinal Groove of the Middle Phalanx: An Anatomic Study and Clinical Implications

PURPOSE

To investigate the volar anatomy of the middle phalanges of the hand; in particular, to define the presence and depth of a volar midline longitudinal groove.

METHODS

Measurements were performed at 5 equidistant points along the shafts of 60 skeletonized middle phalanges from 15 cadaveric hands. The thickness at the midline of each phalanx was subtracted from the maximal dorsovolar thickness to indicate the presence or absence of a groove at each point. The phalanges were also evaluated by computed tomography to confirm the presence of a volar groove and to rule out morphological abnormalities.

RESULTS

A volar groove was confirmed in all 60 phalanges. The groove had an average depth of 0.4 mm and was found to be deepest at the mid-phalangeal shaft. The groove reached a depth of greater than 1 mm in 23% of the phalanges. The middle phalanges of the middle and ring digits consistently revealed deeper grooves than those found in the index and little fingers. Computed tomography confirmed the presence of a volar groove and showed no morphological abnormalities.

CONCLUSIONS

A midline volar longitudinal groove is present in the middle phalanges, is most pronounced in the mid-phalangeal shaft, and is the deepest in the middle and ring fingers.

CLINICAL RELEVANCE

Surgeons should be cognizant of the volar longitudinal groove when inserting screws from dorsal to volar during the fixation of middle phalangeal fractures. Lateral intraoperative fluoroscopy may not reveal excessive screw penetration because of the presence of ridges on either side of the groove. Particular care should be taken at the mid-phalangeal level of the middle phalanges of the middle and ring fingers.

Evaluating Kirschner wire fixation versus titanium plating and screws for unstable phalangeal fractures: A systematic review and meta-analysis of postoperative outcomes

Background

Unstable phalangeal fractures represent a clinical challenge in hand surgery. The choice of fixation method, whether Kirschner wire (K-wire) fixation or titanium plating with screws, often depends on surgeon preference due to the lack of comprehensive comparative data. This article aimed to compare the postoperative outcomes of K-wire fixation versus titanium plating and screws in the treatment of unstable phalangeal fractures.

Methods

This review was conducted according to the PRISMA guidelines for reporting systematic reviews and meta-analyses. A systematic review and meta-analysis of the existing literature was done encompassing PUBMED, EMBASE, Google Scholar, and Cochrane library using the keywords: "K wire/ Kirschner wire", "titanium plate/ screws", "Miniplate/ screws", and "Unstable phalan∗ fracture/ hand fracture".

Results

After screening 2374 articles, 6 final studies with a total of 414 patients were included. Operative time was significantly shorter with K-wire fixation compared to plating, by a mean difference of -27.03 ​min [95% CI -43.80, -10.26] (p ​= ​0.02). Time to radiographic union averaged 7.43 weeks with K-wires versus 8.21 weeks with titanium plates. No statistically significant differences emerged between groups for overall complications (p ​= ​0.69), infection (p ​= ​0.47), malunion (p ​= ​0.36), stiffness (p ​= ​0.11), or need for reoperation (p ​= ​0.10).

Conclusion

K-wire fixation demonstrated shorter mean operating time and faster radiographic union versus plating for unstable phalangeal fractures. These findings can guide surgical decisions and emphasize the need for individualized treatment based on fracture type and patient factors.

Management of paediatric fifth metacarpal neck fractures: a systematic review

BACKGROUND

Fifth metacarpal neck fractures (FMCNFs) are common among paediatric patients. Complications include reduced metacarpophalangeal (MCP) range of motion and grip strength, which impede the hand's functional abilities. Various management options are available, but indications are not standardised. This systematic review aims to assimilate all available evidence on the management of paediatric FMCNFs to determine appropriate treatment pathways.

METHODS

PubMed (Medline), EMBASE, Scopus and Google Scholar were used to identify evidence pertaining to the management of these fractures.

RESULTS

Ten studies were identified, involving 237 patients with a mean age of 14.4 years (Range 9-17). Ninety percent of patients were male. Sixty-one (26%) patients, with an average fracture angulation of 27° (Range 16°-33°) and no rotational deformities, were managed with immobilisation alone. These patients returned to normal metacarpophalangeal range of motion and grip strength. Fifty-four (23%) patients, with an average fracture angulation of 42.7° (Range 33°-54°), were managed with fracture reduction and immobilisation. This technique did not yield sustained reduction of fractures with significant angulation or rotation after intervention. One hundred twenty-two (51%) patients, with an average fracture angulation of 48.3° (Range 30°-58°) and including cases of malrotation, were managed with fracture reduction and surgical fixation. These patients experienced good functional outcomes.

CONCLUSIONS

This review suggests paediatric FMCNFs can be safely managed with immobilisation alone when there is an absence of rotational deformity and an angulation of < 30°. In the case of a higher fracture angulation or rotational deformity, fracture reduction and surgical fixation is an appropriate method of management.

Biomechanical analysis of plate versus K-wire fixation for metacarpal shaft fractures with wedge-shaped bone defects

BACKGROUND

Metacarpal shaft fracture is a common type of hand fracture. Numerous studies have explored fixing transverse fractures in the midshaft of the metacarpal bone. However, this section of the metacarpal bone is often susceptible to high-energy injury, resulting in comminuted fracture or bone loss. In such cases, wedge-shaped bone defects can develop in the metacarpal shaft, increasing the difficulty of performing fracture fixation. Notably, the research on this type of fracture fixation is limited. This study compared the abilities of four fixation methods to fix metacarpal shaft fractures with wedge-shaped bone defects.

METHODS

In total, 28 artificial metacarpal bones were used. To create wedge-shaped bone defects, an electric saw was used to create metacarpal shaft fractures at the midshaft of each bone. The artificial metacarpal bones were then divided into four groups for fixation. The bones in the first group were fixed with a dorsal locked plate (DP group), those in the second group were fixed with a volar locked plate (VP group), and those in the third group were fixed by combining dorsal and volar locked plates (DP + VP group), and those in the fourth group were fixed with two K-wires (2 K group). Cantilever bending tests were conducted using a material testing machine to measure yielding force and stiffness. The four groups' fixation capabilities were then assessed through analysis of variance and Tukey's test.

RESULTS

The DP + VP group (164.1±44.0 N) achieved a significantly higher yielding force relative to the 2 K group (50.7 ± 8.9 N); the DP group (13.6 ± 3.0 N) and VP group (12.3 ± 1.0 N) did not differ significantly in terms of yielding force, with both achieving lower yielding forces relative to the DP + VP group and 2 K group. The DP + VP group (19.8±6.3 N/mm) achieved the highest level of stiffness, and the other three groups did not differ significantly in terms of stiffness (2 K group, 5.4 ± 1.1 N/mm; DP group, 4.0 ± 0.9 N/mm; VP group, 3.9 ± 1.9 N/mm).

CONCLUSIONS

The fixation method involving the combined use of dorsal and volar locked plates (DP + VP group) resulted in optimal outcomes with respect to fixing metacarpal shaft fractures with volar wedge bone defects.

Functional and Radiological Outcomes of Miniature Plate Osteosynthesis in Metacarpal and Phalangeal Fractures of Hand: A Prospective Study

INTRODUCTION

 There are several operative modes to address hand fractures to gain better anatomical and functional results including external fixator, percutaneous K-wire fixation, lag screw fixation, tension band wiring, intra-medullary nails or wires, and plate-screw fixation. We evaluated the results of plate osteosynthesis in fractures of metacarpals and phalanges in a prospective manner.

MATERIAL AND METHODS

 A total 50 adults (19-60 years) of either sex having 58 fractures managed by miniature plate osteosynthesis and followed for a minimum six months (6-19), including metacarpal and phalangeal fractures (unstable or serial fractures), intra-articular fractures, fracture-dislocation of proximal interphalangeal and distal interphalangeal joints with joint incongruity or subluxation were enrolled while contaminated compound fractures, pathological fractures and cases of reimplantation were excluded from study. Clinical assessment was done using the American Society for Surgery of the Hand (ASSH), total active flexion (TAF), total active range of motion (TAM) score, and the Disabilities of the Arm, Shoulder, and Hand (quick DASH) score while sequential radiographs were done at each follow-up.

RESULT

All the fractures had perfect union clinically as well as radiologically with a mean duration of six weeks while functional outcomes in reference to clinical scores were observed excellent and fair in all cases. None of the cases had any loss of reduction, loosening of the implant, or other major complications.

CONCLUSIONS

Miniature plate fixation provides enough stability in metacarpal and phalanges fractures, thereby allowing immediate active movements, which leads to excellent functional outcomes and early return to normal activities.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

Dorsal Plating, Lateral Plating, and Intramedullary Screw Fixation of Extra-Articular Proximal Phalangeal Fractures: A Cadaveric Biomechanical Comparison

PURPOSE

To provide a biomechanical comparison of dorsal plating, lateral plating and intramedullary screw [IMS] fixation for extra-articular proximal phalangeal fractures.

METHODS

Midshaft osteotomies were performed on 36 cadaveric proximal phalanges. The phalanges were fixed by dorsal plating, lateral plating or IMS fixation, and subjected to a four-point bending force. Force was applied to achieve displacement of 1 mm/s, until construct failure or to a maximum of 10 mm of displacement. Clinical failure was defined as 2 mm of displacement, and force required to result in 1 mm and 2 mm of displacement was recorded, as was mode of failure.

RESULTS

Dorsal plating [127.5 N ± 52.6; 46.51-229.17] and lateral plating [77.1 N ± 25.1; 48.3-113.8] required significantly greater force to achieve 1 mm of displacement when compared to IMS [41.2 N ± 12.4; 20.6-62.3]. Dorsal plating [339.2 N ± 91.8; 158.5-538.6] required significantly greater force than lateral plating [154.5 N ± 33.8; 99.0 -204.4] and intramedullary screw fixation [110.0 ± 38.6; 51.1-189.3] to result in 2 mm of displacement. Lateral and dorsal plating constructs failed through plate bending, screw cut-out or plate failure, whilst IMS failed via implant deformity. All three constructs required greater force to result in even 1 mm of displacement than what is likely subjected through rehabilitation via active motion.

CONCLUSIONS

Lateral plating and IMS fixation offer sufficient stiffness to withstand the likely forces subjected via early active motion without displacement.

CLINICAL RELEVANCE

Dorsal plating required significantly greater force than lateral plating and intramedullary screw fixation to achieve 1 mm of displacement when used in extra-articular proximal phalangeal fractures in an in vitro setting. However, all three modalities confer enough stability to likely withstand the forces associated with active range of motion.

Risks of Reoperation in Surgically Treated Fractures of the Proximal Phalanx

Purpose

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

Methods

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

Results

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

Conclusions

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

Type of study/level of evidence

Therapeutic III.

Metacarpal Fracture Repair: Early Reoperation Rates and Characteristics

Purpose

Metacarpal fractures are common injuries of the hand that often require operative repair. However, there is a paucity of data regarding the rate of reoperation and circumstances following metacarpal repair.

Methods

A retrospective review of all metacarpal fracture cases performed at a single academic institution between 2017 and 2021 was performed. All patients with isolated, acute metacarpal fractures were included for review. Data on patient demographics, fracture morphology, surgical technique, rate of early reoperation, and reason for reoperation were collected.

Results

A total of 499 patients were identified to have undergone operative treatment for an isolated metacarpal fracture with an average follow-up of 4.2 months. The rate of unplanned early reoperation was 8.0% (n = 40), with seven patients requiring revision fracture surgery and 33 patients undergoing removal of symptomatic hardware. Mean and median time to reoperation was 2.1 and 1.5 months, respectively. The rate of reoperation for fractures of the metacarpal shaft was significantly lower than that of other fracture locations. Among the 40 revision cases, one case was following percutaneous fixation while 39 cases were following open reduction and internal fixation. Other demographic factures and fracture characteristics failed to show significant correlations to the rate of reoperation.

Conclusions

An unplanned early reoperation rate of 8.0% after operative fixation of acute metacarpal fractures was observed with the majority involving cases of removal of symptomatic hardware and an average time to reoperation of approximately 2.1 months. This information can be used to counsel patients and set expectations about the potential for metacarpal fracture surgeries.

Type of Study/Level of Evidence

Prognosis 2b.

Closed Reduction Percutaneous Pinning Versus Open Reduction With Plate and Screw Fixation in Management of Unstable Proximal Phalangeal Fractures: A Systematic Review and Meta-analysis

BACKGROUND

Proximal phalanx fractures are common, with surgical fixation indicated for unstable fractures. Traditionally, closed reduction percutaneous pinning (CRPP) resulted in decreased stiffness and tendon irritation compared to open reduction internal fixation (ORIF). We hypothesized that more recent studies would have more similar outcomes to CRPP. The purpose of this study was to compare CRPP and ORIF in terms of range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and complications.

METHODS

Four electronic databases were queried from 2010 to present. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two independent reviewers performed a two-step review process to identify relevant articles. Patient demographics, total active motion (TAM), DASH, and complications were extracted. The methodological quality of each study included was assessed independently. Meta-analysis was performed for comparative trials.

RESULTS

Fourteen studies met inclusion criteria including four comparative studies: Thirteen studies included TAM. The weighted average TAM was 228 ± 34° for CRPP and 223 ± 32° for ORIF (P = .07 with 95% confidence interval (CI), -0.5 to 10.5). Seven studies evaluated DASH scores; weighted average was 8.2 ± 8.9 for CRPP and 11.7 ± 6.5 for ORIF (P < .01 with 95% CI, 1.8-5.2). Two studies directly compared CRPP to ORIF, favoring ORIF for both TAM with d = 1.07 and DASH with d = 0.23. Rates of tenolysis or hardware removal were higher for ORIF (P < .01).

CONCLUSIONS

New literature suggests more equipoise with regard to treatment of proximal phalanx fracture with CRPP versus ORIF.

TYPE OF STUDY/LEVEL OF EVIDENCE

Meta-analysis, Level II.

Surgical Technique: Lateral Plate Osteosynthesis of Proximal Phalanx Fractures

Dorsal plate fixation of proximal phalanx (PP) fractures is a conventional approach but interferes with the extensor mechanism and results in stiffness. Biomechanical studies have shown that laterally placed plates on the proximal phalanges are equally stable and rigid. This technique obviates the issue of tendon adhesion and may result in better postoperative range of motion and lower secondary procedures such as removal of implant and tenolysis. The low adoption of this technique may be related to lack of familiarity with the surgical approach. We describe our surgical technique with lateral plating of PP fractures and present our case that lateral plate osteosynthesis is an acceptable surgical fixation option for PP fractures, which extends the hand surgeon's armamentarium for more challenging and comminuted fractures.

Outcomes After Surgically Managed Oblique Extra-Articular Proximal Phalanx Fractures: A Comparison of Closed-Reduction Percutaneous Pinning and Open-Reduction Internal Fixation With Lag Screws

BACKGROUND

Long oblique extra-articular proximal phalanx fractures are common orthopedic injuries. When unstable and without substantial comminution, treatment options include closed-reduction percutaneous pinning (CRPP) and open-reduction internal fixation using lag screws (ORIF-screws). The aims of this study are primarily to compare the functional outcomes and complication rates between these techniques and secondarily to assess potential factors affecting outcomes after surgery.

METHODS

All patients with long oblique extra-articular proximal phalanx fractures treated surgically within a single orthopedic institution from 2010 to 2017 were identified. Outcome measures and complications were assessed at the final follow-up.

RESULTS

Sixty patients were included in the study with a mean time to the final follow-up of 41 weeks (range: 12-164 weeks). Thirty-four patients (57%) were treated with CRPP and 26 patients (43%) with ORIF-screws. The mean Disabilities of the Arm, Shoulder, and Hand score across both fixation types was 8 (range: 0-43) and did not differ significantly between the 2 groups. Mean proximal interphalangeal extension at the final follow-up was 9° short of full extension after CRPP and 13° short of full extension after ORIF-screws. The rates of flexion contracture and extensor lag were 15% and 41% in the CRPP group compared with 12% and 68% in the ORIF-screws group. Reoperation rates and complication rates did not differ significantly between fixation strategies.

CONCLUSIONS

Acceptable outcomes can be achieved after surgical fixation of long oblique extra-articular proximal phalanx fractures using both CRPP and ORIF-screws. Extensor lag may be more common after ORIF-screws.

Intramedullary Headless Screw Fixation for Phalanx Fractures: Technique and Review of Current Literature

Fractures of the phalanges can often be managed nonoperatively, but displaced phalangeal fracture patterns, including malrotation, are more amenable to operative treatment. There are several described methods for surgical management of phalanx fractures, but there remains no consensus on a clearly superior method of fixation. Percutaneous Kirschner wires, interfragmentary screws, plate and screw constructs, intramedullary nails, and cannulated intramedullary headless screws are all utilized in the treatment of these fractures. Intramedullary headless screws for phalanx fractures may provide suitable fixation allowing early motion and recovery. Here, we describe a technique for antegrade and retrograde intramedullary headless screw fixation for phalanx fractures.

A Systematic Review of Treatment Interventions for Metacarpal Shaft Fractures in Adults

Metacarpal shaft fractures are common hand injuries that predominantly affect younger patients. There is wide variability in their treatment with no consensus on best practice. We performed a systematic review to assess the breadth and quality of available evidence supporting different treatment modalities for metacarpal shaft fractures of the finger digits in adults. A comprehensive search was conducted across multiple databases, in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 1600 records were identified; 7 studies fulfilled eligibility criteria and were included. No randomized controlled trials directly comparing surgery with nonsurgical treatment were found. One retrospective study compared nonsurgical with surgical treatment, whereas 6 compared surgical or nonsurgical treatments. Considerable heterogeneity between studies along with a high or critical risk of bias restricts direct comparison and conclusions. There is a lack of high-quality evidence to guide treatment, supporting the need for well-designed, multicenter trials to identify the most effective and cost-efficient treatment for metacarpal shaft fractures in adults.

Comparison of Lag Versus Nonlag Screw Fixation for Long Oblique Proximal Phalanx Fractures: A Biomechanical Study

PURPOSE

To compare lag versus nonlag screw fixation for long oblique proximal phalanx (P1) fractures in a cadaveric model of finger motion via the flexor and extensor tendons.

METHODS

We simulated long oblique P1 fractures with a 45° oblique cut in the index, middle, and ring fingers of 4 matched pairs of cadaveric hands for a total of 24 simulated fractures. Fractures were stabilized using 1 of 3 techniques: two 1.5-mm fully threaded bicortical screws using a lag technique, two 1.5-mm fully threaded bicortical nonlag screws, or 2 crossed 1.14-mm K-wires as a separate control. The fixation method was randomized for each of the 3 fractures per matched-pair hand, with each fixation being used in each hand and 8 total P1 fractures per fixation group. Hands were mounted to a custom frame where a computer-controlled, motor-driven, linear actuator powered movement of the flexor and extensor tendons. All fingers underwent 2,000 full flexion and extension cycles. Maximum interfragmentary displacement was continuously measured using a differential variable reluctance transducer. Our primary outcome was the difference in the mean P1 fragment displacement between lag and nonlag screw fixation at 2,000 cycles.

RESULTS

The observed differences in mean displacement between lag and nonlag screw fixation were not statistically significant throughout all time points. A two one-sided test procedure for paired samples confirmed statistical equivalence in the fragment displacement between these fixation methods at all time points, including the primary end point of 2,000 cycles.

CONCLUSIONS

Nonlag screws provided equivalent biomechanical stability to lag screws for simulated long oblique P1 fractures during cyclic testing in this cadaveric model.

CLINICAL RELEVANCE

Fixation of long oblique P1 fractures with nonlag screws has the potential to simplify treatment without sacrificing fracture stability during immediate postoperative range of motion.

Treatment of hand and finger fractures with the Stryker Hand Plating System

Objectives: 10% of all fractures occur in the fingers and metacarpal region. Early mobilization with preservation of grip function is the goal of any therapy for these injuries. Osteosyntheses with plates are used in complex fractures that do not allow any other treatment. The aim of this retrospective study was to evaluate the performance and safety of the Stryker Hand System. Patients and methods: Between 2010 and 2019, 190 patients underwent surgical treatment with plates for fractures of the fingers and metacarpal region. Of these, 140 operations could be analyzed according to the inclusion criteria based on clinical and radiological parameters. Results: Three-quarters of the patients were male. The mean age at the time of surgery was 39.3±16 years. Falling was the leading cause for hand fractures, and the most common were fractures of the shaft (>52%). More than 15% were complex hand injuries with more than one fractured finger. The majority of patients were healthy non-smokers without systemic diseases and relevant medical history. Conclusion: The Stryker Finger Plates are safe implants with good results that are consistent with those reported in the literature. The trend is also toward stable-angle implants for fracture treatment of the finger, in order to enable the earliest possible functional, safe mobilization. Level of Evidence: Level: IV; outcome-study, retrospective.

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

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

Outcome of Buried Versus Exposed Kirchner Wires in Terms of Infection in Fractures of Phalanges and Metacarpal Bones of Hand

Introduction and objective

The fracture of hand bones is very common among manual hand workers and a fractured hand imparts a great effect on a person’s productivity both socioeconomically and from a body image point of view. The most common method of hand fractures fixation is with the help of Kirschner wires. Kirchner wires can be inserted in exposed or in buried manner. There are a few studies that provide a comparative analysis of rate of infection between these two techniques. This study aimed to assess the rate of infection in buried versus exposed Kirschner (K)-wires for hand fractures.

Material and method

The study was designed as a randomized controlled trial with consecutive non-random sampling. It was conducted in the Department of Plastic Surgery, Holy Family Hospital, Rawalpindi, Pakistan, and lasted from June to December 2019. Blinding was not possible as both the operating surgeon and patient were aware of the procedure being done; however, the assessor was blinded and was not aware which group got which treatment. Total 122 patients with fractures of metacarpals and phalanges of hand were included in the study and were divided into two groups with 61 patients in each. Group A was treated with buried K-wires and group B with exposed K-wires. The patients were followed for one month for the outcomes in terms of infection in the patients.

Results

Group A had 24 females (39.3%) and 37 males (60.7%). Group B had 16 females (26.2%) and 45 males (73.8%). In group A, nine (14.8%) patients had ages between 10 and 20 years, 18 (29.5%) patients between 21 and 30 years, 14 (23.0%) patients between 31 and 40 years, 11 (18.0%) patients between 41 and 50 years, and nine (14.8%) were between 51 and 60 years. The mean duration of surgery was 35.16 minutes for group A and 27.30 minutes for group B. Based on modified Oppenheim scoring system for pin site infection, out of 61 patients, seven (11.5%) with buried K-wires while 14 (23%) with exposed K-wires developed pin site infection.

Conclusion

Rate of infection is low in buried K-wires as compared to exposed K-wires though not statistically significant (p>0.05) for the fractures of metacarpals and phalangeal fractures of hand.

Imaging Review of Hockey-Related Upper Extremity Injuries

Ice hockey is a fast-paced contact sport with a high incidence of injuries. Upper extremity injury is one of the most common regions of the body to be injured in hockey. This imaging review will equip the radiologist with a knowledge of the more common and severe upper extremity injuries that occur in this sport.

Intramedullary Screw Fixation Comprehensive Technique Guide for Metacarpal and Phalanx Fractures: Pearls and Pitfalls

Background:

Phalangeal and metacarpal fractures are the second and third most common upper extremity fractures after distal radius fractures with varying methods of fixation techniques. Intramedullary screw fixation is an increasingly preferred method of fixation. Benefits include early range of motion, faster recovery, limited dissection, and reduced complications. Improper technique, which is readily avoidable, can lead to suboptimal results.

Methods:

A review of recent literature on current techniques aims to summarize the biomechanics of intramedullary screw fixation and outline appropriate technique of placing headless compression screws for metacarpal and phalangeal fractures.

Results:

We discuss through images and videos the indications, preoperative workup, and technical pearls and pitfalls to encourage surgeons to add this technique to their armamentarium and improve outcomes.

Conclusions:

intrameduallry screw fixation is a powerful option for metacarpal and phalanx fixation that allows rigid stability, enabling early return of function with excellent rates of union and total active motion. With knowledge of technical pearls presented in this article, common mistakes can be avoided to improve efficiency of screw placement and optimize patient outcomes.

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

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

K-wire Made Easy by Premarking Wire Trajectory on the Skin in Management of Finger Fractures

BACKGROUND

Hand injury in general and fractures in particular are among the most common complaints of hand trauma patients presenting to our emergency department. Depending on fracture types, geometry, locations, and stability, treatment options may vary from close reduction and splinting to close reduction and K-wire fixation, and finally, to open reduction and internal fixation. The aim of the study was to prove that premarking of K-wire trajectory helps reduce procedure and fluoroscopy time, as well as the number of wire-insertion attempts, and minimize bone and soft tissue injury in the management of phalangeal finger fractures.

METHODS

This is a prospective descriptive study aimed to describe a surgical technique. Patients who underwent close reduction and K-wire fixation of phalangeal digital fractures were enrolled. A total of 20 cases were included.

RESULTS

The total number of K-wires was 37, and the total number of successful attempts was 40; average fluoroscopy time was 22.75 seconds; and average total operative time was 14.25 minutes. Surgeries of all cases were supervised by a consultant physician, but some were performed by a junior resident in the team. The inaccuracy index was measured for the group.

CONCLUSIONS

Marking of the trajectory before placing K-wires for the management of digital fractures is not described in the literature. Our study describes an innovative operative technique that, when combined with the classic K-wire fixation technique, produces beneficial outcomes in the form of reduction in operative time and number of wire introduction attempts, with overall reduction in fluoroscopy time and soft tissue and bone damage (including false passages).

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.

Comparative Analysis of Open Reduction Internal Fixation and Closed Reduction Percutaneous Pinning of Hand Fractures: Single Academic Center Retrospective Review

PURPOSE

The purpose of our study was to compare postoperative outcomes between patients receiving closed reduction percutaneous pinning (CRPP) to open reduction internal fixation (ORIF) following metacarpal and phalanx fractures.

METHODS

A retrospective chart review was performed at a single academic center for all patients suffering a metacarpal or phalanx fracture and receiving either CRPP or ORIF between 2012 and 2018. Patients were divided into fracture mechanism, high-energy mechanism of injury, low-energy mechanism of injury, or unknown, and treatment of fracture with either ORIF or CRPP. High-energy mechanism of injury included gunshot wounds, motor vehicle crash, and blast injuries, whereas low-energy mechanism of injury included all other causes. Patient demographics, postoperative complications, 30-day readmission, and return to the operating room were recorded.

RESULTS

A total of 408 patients, with 524 fractures, were included in the study. There were 127 fractures that resulted from high-energy mechanisms and 394 fractures that resulted from low-energy mechanisms. Open reduction internal fixation was used to treat 299 fractures, whereas CRPP was used for 225 fractures. Among fracture fixation, there was a total of 8.4% complication rate with ORIF, accounting for 10.4% of complications, and CRPP accounting for 5.8%. Among the fracture mechanism, the high-energy mechanism of injury had a 21.3% complication rate, whereas the low-energy mechanism of energy was 4.3%. When comparing the above variables, only high-energy mechanism of injury was a statistically significant predictor of complications (odds ratio, 3.2; confidence interval, 1.5-7.0; P = 0.002). The average operating room time for the ORIF group was 124.82 minutes compared with 97.6 minutes for the CRPP group.

CONCLUSION

Patients with hand fractures corrected by ORIF appeared to have a higher postoperative complication rate. When the 2 procedures, ORIF and CRPP, were controlled for mechanism of injury, there was not a statistically significant difference in postoperative complication rate (P = 0.14). However, a fracture sustained by a high-energy mechanism was a statistically significant predictor of postoperative complications (P = 0.002).

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

Complications of Low-Profile Plate Fixation in Metacarpal Fractures

High complication rates have been reported using conventional plating systems to treat metacarpal fractures. This study investigated complication rates in metacarpal fractures treated with low-profile anatomic plates. A retrospective chart review was performed of patients with metacarpal fractures who were treated with open reduction and internal fixation using low-profile anatomic plates at a single institution from January 2010 to February 2017. Patients with concomitant tendon injury, open fractures, prior same metacarpal fracture, or thumb metacarpal fracture were excluded. A total of 79 patients with 110 metacarpal fractures were included. The primary outcome was the presence of a complication, defined as superficial or deep infection, delayed wound healing, delayed union, nonunion, major or minor extensor lag or stiffness 90 days postoperatively, or return to the operating room. Eleven fractures (10%) had 1 or more complications. Complications included 6 fractures (5%) with major extensor lag or stiffness, 4 fractures (4%) with minor extensor lag or stiffness, 1 fracture (1%) with delayed radiographic union that did not require operative intervention, and 1 fracture (1%) with return to the operating room for removal of hardware. In this retrospective study, treatment of metacarpal fractures with low-profile plate fixation resulted in a 10% overall complication rate and a 1% reoperation rate; this rate is significantly less than reported in previous literature prior to the widespread use of low-profile plates. This study suggests treatment of patients with metacarpal fractures using low-profile plating systems provides a reliable solution with acceptable complication rates. [Orthopedics. 2021;44(1):e91-e94.].

Intramedullary compression screw fixation of metacarpal and phalangeal fractures

The intramedullary headless compression screw (IMCS) technique represents a reliable alternative to percutaneous Kirschner-wire and plate fixation with minimal complications.

Transverse fractures of the metacarpal shaft represent a good indication for this technique. Non-comminuted subcapital and short oblique fractures can also be treated with IMCS.

This technique should not be used in the presence of an open epiphysis, infection and, most of all, in subchondral fractures, because of the lack of purchase for the head of the screw.

A double screw construct is recommended for comminuted subcapital fractures of the metacarpal to avoid metacarpal shortening. IMCS can even be applied for peri-articular fractures of the proximal third of the phalanx and in some multi-fragmentary proximal and middle phalangeal fractures.

Usually the intramedullary screws are not removed. The main indications for screw removal are joint protrusion, infection and screw breakage after new fracture.

Cite this article: EFORT Open Rev 2020;5:624-629. DOI: 10.1302/2058-5241.5.190068

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.

Low Rate of Complications Following Intramedullary Headless Compression Screw Fixation of Metacarpal Fractures

Background: There has been a recent increase in the use of headless compression screws for fixation of metacarpal neck and shaft fractures as they offer several advantages, and minimal complications have been reported. This study aimed to evaluate the clinical complications and their solutions following retrograde intramedullary headless compression screw fixation of metacarpal fractures. We describe complications and the approach to their management. Methods: We performed a multicenter case series through retrospective review of all patients treated with intramedullary headless screw fixation of metacarpal fractures by 3 fellowship-trained hand surgeons. Patient demographics, implant used, type of complication, pre- and postoperative radiographs, operative reports, and sequelae were reviewed for each case. We defined complications as infection, loss of fixation, hardware failure, malrotation, nonunion, malunion, metal allergy, and any repeat surgical intervention. Results: Four complications (2.5%) were identified through the review of 160 total metacarpal fractures. One complication was a nickel allergy, one was a broken screw after repeat trauma, and 2 patients had bent intramedullary screws. Screw removal in 3 patients was simple and without complications or persistent limitations. One bent screw with a refracture was left in place. No serious complications were seen. Conclusion: Intramedullary screw fixation of metacarpal fractures is safe with a low incidence of complications (2.5%) that can be safely and effectively managed.

Metacarpal Bony Dimensions Related to Headless Compression Screw Sizes

Introduction  The purpose of this study is to determine the radiographic dimensions of the finger metacarpals and to compare these measurements with headless compression screws commonly used for fracture fixation. Materials and Methods  We analyzed computed tomography (CT) scans of the index, long, ring, and small metacarpal bones and measured the metacarpal length, distance from the isthmus to the metacarpal head, and intramedullary diameter of the isthmus. Metacarpals with previous fractures or hardware were excluded. We compared these dimensions with the size of several commercially available headless screws used for intramedullary fixation. Results  A total of 223 metacarpals from 57 patients were analyzed. The index metacarpal was the longest, averaging 67.6 mm in length. The mean distance from the most distal aspect of the metacarpal head to the isthmus was 40.3, 39.5, 34.4, and 31 mm for the index, long, ring, and small metacarpals, respectively. The narrowest diameter of the isthmus was a mean of 2.6, 2.7, 2.3, and 3 mm for the index, long, ring, and small metacarpals, respectively. Of 33 commercially available screws, only 27% percent reached the isthmus of the index metacarpal followed by 42, 48, and 58% in the long, ring, and small metacarpals, respectively. Conclusion  The index and long metacarpals are at a particular risk of screw mismatch given their relatively long lengths and narrow isthmus diameters.

Comparison of low-profile locking plate fixation versus antegrade intramedullary nailing for unstable metacarpal shaft fractures--A prospective comparative study

BACKGROUND

The purpose of this study was to compare the effectiveness of mini-open antegrade intramedullary nailing (AIN) and open reduction and internal fixation (ORIF) using the low-profile locking plate for angulated metacarpal shaft fractures, through prospective comparative trial.

METHODS

Group 1 (mini-open AIN; 40 patients) and the other consecutive patients in group 2 (locking plate; 35 patients) who met our inclusion/exclusion criteria were investigated between January 2010 and December 2016. We compared radiological findings (e.g., union and residual angulation or shortening); clinical conditions (e.g., pain, measured on a visual analog scale (VAS), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores); active range of motion (ROM); and grip strength.

RESULTS

Union was achieved in both groups without any major complications. The final angulation measurements were not significantly different (p = 0.402). The final VAS scores were not different (p = 0.868); however, the final DASH score was better in group 1 than in group 2 (p = 0.034). The plates were removed in 14 patients at 9.6 months postoperatively for various reasons. Mean ROM at the time of hardware removal in these 14 patients was significantly lower compared with the final ROM in groups 1 and 2 (non-removal patients). Final grip strengths recovered significantly more in group 1 than in group 2 (p = 0.029). Extension lag was found in four patients in group 2, and the mean amount was 15°; however, it was resolved by tenolysis during hardware removal.

CONCLUSIONS

Both mini-open AIN and low-profile plate fixation are excellent options for metacarpal shaft fractures without significant radiological or clinical problems; however, some clinical outcomes evaluated at least 2 years postoperatively, such as DASH scores and grip strength, were better in the AIN group than in the locking plate group. Plate removal was performed under anesthesia in some patients in the plate group for various reasons, and this may have caused the small differences in the final outcomes evaluated 2 years after surgery.

A randomized comparison of bone-cement K-wire fixation vs. plate fixation of shaft fractures of proximal phalanges

BACKGROUND

The objective of this study (ClinicalTrials.gov ID: NCT03031015) is to compare the treatments of hand proximal phalanx shaft fractures with external-fixation technique using the combination of K-wires and bone-cement vs. open reduction and internal fixation technique using a miniature plate-and-screw system.

METHODS

A total of 107 patients (134 cases) were randomly allocated to group A (67 cases in 56 patients) and B (64 cases in 51 patients). Fingers in group A were treated with bone-cement K-wire fixation, and fingers in group B were treated using a plate-and-screw system.

RESULTS

Follow-ups lasted 2 years. In group A, active range of motion of proximal interphalangeal joint reached 93% ± 6.7% of the opposite fingers. In group B, the data reached 86% ± 14.4% of the opposite fingers. Based on total active motion scoring system, we obtained 21 excellent and 46 good results in group A; and 9 excellent, 50 good, and 5 fair results in group B. There was a significant difference with regards to the function of the fingers (p < 0.05).

CONCLUSIONS

The bone-cement K-wire fixation may be another option for the treatment of shaft fractures of proximal phalanges. The minimally invasive technique allows early joint motion, resulting in minimal complications and good functional recovery.

A Comparative Study of Tensile Strength of Three Operative Fixation Techniques for Metacarpal Shaft Fractures in Adults: A Cadaver Study

Background

We sought to estimate the ultimate tensile strength after metacarpal shaft fracture repair in adults using three operative fixation methods: plate fixation, Kirschner wire (K-wire) fixation, and intramedullary headless compression screw fixation. We also compared the advantages and disadvantages of each operative technique.

Methods

We acquired 30 metacarpal bones from four Korean adult cadavers without trauma, operative history, or deformities. The 30 metacarpal bones were divided into ten groups consisting of three metacarpal bones each with matching sizes and lengths. They were fractured, reduced, and fixed with plate and screws, K-wires, or headless compression screws. We performed force testing, collected ultimate tensile strength data, and created a stress-strain graph.

Results

The ultimate tensile strength of ten groups according to the fixation method was as follows: late and screw fixation, 246.1 N (range, 175.3 to 452.4 N); K-wire fixation, 134.6 N (62.7 to 175.0 N); and intramedullary headless compression screw fixation, 181.2 N (119.2 to 211.7 N). The median tensile strength of each fixation method was significantly different. In addition, the post-hoc test showed significant difference between the plate and screw fixation and K-wire fixation, between the headless compression screw fixation and K-wire fixation, and between the headless compression screw fixation and plate and screw fixation.

Conclusions

The tensile strength median values decreased in the following order showing significant differences among the fixation methods: plate and screw fixation, headless compression screw fixation, K-wire fixation. Significant differences were also observed between the plate and screw fixation and K-wire fixation, between the headless compression screw fixation and K-wire fixation, and between the headless compression screw fixation and plate and screw fixation.

Antegrade intramedullary Kirschner-wire fixation of displaced metacarpal shaft fractures

PURPOSE

The objective of this study was to analyze complications and patient-related functional outcome after antegrade intramedullary Kirschner-wire fixation of metacarpal shaft fractures.

METHODS

All consecutive patients treated from January 2010 until December 2015 were retrospectively analyzed using patient logs and radiographic images. Indications for operative fixation were angulation > 40°, shortening > 2 mm, or rotational deficit. Complications were registered from the patient logs. Functional outcome was assessed with the Patient-rated wrist/hand evaluation (PRWHE) and Disabilities of the Arm, Shoulder, and Hand score (DASH) questionnaire both ranging from 1 to 100 after a minimum follow-up of 6 months.

RESULTS

During the study period, 34 fractures of 27 patients could be included. Mean outpatient follow-up was 11 weeks (range 4-24 weeks). The mean interval for functional assessment was 30 months (range 8-62 months) and 19 patients (70%) responded to the questionnaires. During outpatient follow-up, all fractures proceeded to union with no signs of secondary fracture dislocation or implant migration. One re-fracture after a new adequate trauma was seen and one patient underwent tenolysis due to persistent pain and impaired function. In 26 cases (81%), the K-wires were removed of which 23 (68%) were planned removals. Functional outcome was excellent with mean PRWHE and DASH scores of 7 and 5 points, respectively.

CONCLUSIONS

If surgical treatment for metacarpal shaft fractures is considered, we recommend antegrade intramedullary K-wire fixation. This technique results in low complication rates and excellent functional outcome.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Proximal Phalanx Fracture Management

BACKGROUND

The goal of proximal phalangeal fracture management is to allow for fracture healing to occur in acceptable alignment while maintaining gliding motion of the extensor and flexor tendons.

METHODS

We reviewed the most current literature on various treatment methods of proximal phalanx fractures, focusing on the indications and outcomes of nonoperative as well as operative interventions.

RESULTS

Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. Regardless of the surgical intervention employed, the overriding goal is to restore anatomy and impart enough stability to allow for early motion. The surgical dissection contributes to soft tissue scarring and should be minimized.

CONCLUSIONS

Clinical success is achieved when acceptable fracture alignment and stability occur in the setting of unobstructed tendon gliding and early active range of motion.

Are We Over Treating Hand Fractures? Current Practice of Single Metacarpal Fractures

Purpose

We conducted a national survey of Canadian plastic surgeons to assess if inconsistencies in management strategies exist for single metacarpal fractures.

Methods

A cross-sectional study of Canadian plastic surgeons who perform hand surgeries was conducted. A 15-question survey was distributed to all members of the Canadian Society of Plastic Surgeons. Participants' demographics, practice settings, and current treatment strategies for patients presenting with single metacarpal fractures were evaluated.

Results

A total of 113 Canadian plastic surgeons met inclusion criteria. The majority of respondents were male (76%), with 50% in practice for more than 15 years. Canadian surgeons used a wide variety of surgical techniques for the management of single metacarpal fractures, with close reduction (94%), Kirshner wires (94%), and splinting and immobilization (89%) being the most common. The majority of plastic surgeons stated that rotational deformity (81%) was the most important indication for surgery. Surgeons demonstrated a trend toward immobilization after splinting (48%), instead of early mobilization after splinting (21%). When results were stratified by years in practice, no differences in surgical and non-surgical management were found, although surgeons in practice for less than 15 years were more likely to suggest hand therapy.

Conclusion

These findings demonstrate inconsistencies in management of single metacarpal fractures among Canadian plastic surgeons. Surprisingly, surgeons in the survey tended to favor immobilization, as oppose to the literature that favors mobilization. The study highlights the lack of clear guidelines dictating treatment, possibly leading to these inconsistencies.

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.

A biomechanical analysis of plate fixation using unicortical and bicortical screws in transverse metacarpal fracture models subjected to 4-point bending and dynamical bending test

In the published literature there are controversial data to the biomechanical stability of monocortical comparing to the bicortical fixation of metacarpal fractures. The aim of this study was to compare the biomechanical stability of monocortical and bicortical locking osteosynthesis in quasi-static and dynamic 4-point bending tests of composite third metacarpal bone (4th Gen third metacarpal, Sawbones, Malmö, Sweden) fixed with 7-hole locking plate (XXS System, Biotech-Ortho, Wright, Memphis, TN). The tests to determine quasi-static yield and bending strength as well as fatigue strength were conducted in 4 groups of 10 samples after creating standardized mid-shaft transverse osteotomies using a diamont belt grinder (0.3 mm saw blade). The force applied was the dorsal apex loading, similar to the forces applied to metacarpals during normal finger flexion and extension.In the quasi-static testing, no plate breakage was observed in each group. All metacarpals broke at their thinnest part. The average bending strength of the bicortical samples (10.54 ± 0.998 Nm) was significantly higher comparing to the monocortical samples (8.57 ± 0.894 Nm) (P < .001).In the dynamic loading test, all constructs (8 monocortical samples and 7 bicortical) that failed broke at the osteotomy site and the average fatigue strength did not differ in both groups.Consequently, a unicortical plating method may provide adequate strength and stability to metacarpal fractures based on the results of the cyclical loading representative of in vivo loading.

Dorsal versus lateral plate fixation of finger proximal phalangeal fractures: a retrospective study

INTRODUCTION

Unstable proximal phalanx fractures are relatively common injuries but consensus of standard treatment is lacking. Outcomes following plate fixation are highly variable, and it remains unclear which factors are predictive for poorer results. The purpose of this study was to compare dorsal and lateral plate fixation of finger proximal phalangeal fractures with regard to factors that influence the outcome.

MATERIALS AND METHODS

A retrospective chart review of proximal phalanx fractures treated with dorsal and lateral plating over a 6-year study interval was performed. Demographic data and injury-specific factors were obtained from review of clinic and therapy notes of 42 patients. Fractures were classified based on the OTA classification using preoperative radiographs. Outcomes investigated included final range of motion (ROM) and total active motion (TAM) of all finger joints. Complications and revision surgeries were also analyzed.

RESULTS

Fracture comminution, dorsal and a lateral plate position, occupational therapy, and demographic factors did not significantly influence the outcome, complication, and revision rate after plate fixation of finger proximal phalangeal fractures.

CONCLUSIONS

Based on the results of this study, no differences in the outcome of finger proximal phalangeal fractures treated by both dorsal and lateral plate fixation were observed.

LEVEL OF EVIDENCE

Therapeutic, retrospective comparative, level III.

The Use of Minilocked Plate for Management of Unstable Metacarpal Fractures

Objective This study aims to evaluate the use of minilocked plates in the treatment of the metacarpal fractures. Method A total of 30 patients of metacarpal fractures were treated by minilocked plates. Results Union was achieved in all patients. There were 27 (90%) patients having satisfactory results (excellent and good results) and 3 patients (10%) had poor results. Conclusion The use of minilocked plate is recommended for fixation of periarticular, comminuted, and osteoporotic metacarpal fractures that offer rigid fixation early mobilization, decreases the incidence of joints stiffness, and tendon adherence which maximized the hand function.