Low-severity metacarpal and phalangeal fractures treated with miniature plates and screws

A minimally invasive technique for correcting extra-articular malunions of metacarpal fractures

PURPOSE

This study aimed to assess the efficiency of a minimally invasive technique for correcting malunions of extra-articular metacarpal fractures, followed by percutaneous fixation using a cemented K-wire frame.

METHODS

From January 2018 to January 2022, 31 patients (31 malunions of extra-articular metacarpal fractures) were treated. The mean age of the patients was 32 years (range, 21-52 years). There were 25 fifth, 4 fourth, 1 third, and 1 second metacarpal malunion. Range of motion of the fingers was assessed based on the total active motion scoring system of American Society for Surgery of the Hand. Range of motion of the joint was graded as excellent (85-100%), good (70-84%), fair (50-69%), and poor (< 50%) by comparing to the opposite uninjured finger. The aesthetic appearance of the hand was evaluated based on the 10-cm visual analogue scale. Patient satisfaction was assessed using the Short Assessment of Patient Satisfaction (0-10, very dissatisfied; 11-18, dissatisfied; 19-26, satisfied; and 27-28, very satisfied).

RESULTS

Bone healing was achieved in all patients after a mean of 5.4 weeks (range, 4-10 weeks). The mean follow-up period was 27 months (range, 24-33 months). The mean preoperative total active motion scale was 233° (range, 185°-288°), and the postoperative scale was 263° (range, 235°-290°). There were 8 excellent, 19 good, and 1 fair result. There were 15 very satisfied and 13 satisfied with the results. The mean preoperative aesthetic appearance of the hand was 7 cm (range, 5-8 cm), and the postoperative appearance was 10 cm (range, 9-10 cm).

CONCLUSION

The minimally invasive technique is effective for correcting extra-articular malunions of metacarpal fractures. Rigid fixation allows fracture healing and early joint motion of the injured hand. The technique improves hand function, patient satisfaction, and aesthetic appearance.

LEVEL OF EVIDENCE

Therapeutic study, Level IVa.

Complications of osteosynthesis for long-finger metacarpal and phalanx fracture

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

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.

Biomechanical study on fixation methods for horizontal oblique metacarpal shaft fractures

OBJECTIVE

To investigate differences in the effectiveness of two lag screws, a regular bone plate, and locking bone plate fixation in treating horizontal oblique metacarpal shaft fractures.

MATERIALS AND METHODS

Horizontal oblique metacarpal shaft fractures were created in 21 artificial metacarpal bones and fixed using one of the three methods: (1) two lag screws, (2) a regular plate, and (3) a locking plate. All the specimens were subjected to the cantilever bending test performed using a material testing machine to enable recording of the force-displacement data of the specimens before failure. The Kruskal-Wallis test was used to compare failure force and stiffness values among the three fixation methods.

RESULTS

The mean failure force of the two lag screw group (78.5 ± 6.6 N, mean + SD) was higher than those of the regular plate group (69.3 ± 17.6 N) and locking plate group (68.2 ± 14.2 N). However, the mean failure force did not significantly differ among the three groups. The mean stiffness value of the two lag screw group (17.8 ± 2.6 N/mm) was lower than those of the regular plate group (20.2 ± 10.5 N/mm) and locking plate group (21.8 ± 3.8 N/mm). However, the mean stiffness value did not significantly differ among the three groups.

CONCLUSION

The fixation strength of two lag screw fixation did not significantly differ from that of regular and locking bone plate fixation, as indicated by the measurement of the ability to sustain force and stiffness.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

Comparison of the fixation ability between lag screw and bone plate for oblique metacarpal shaft fracture

Background

For oblique metacarpal shaft fracture, if anatomical reduction is achieved through conservative cast immobilization rather than stable fixation, bone malrotation can easily occur, resulting in severe loss in hand prehensile function. However, whether bone plate fixation or only lag screw fixation is more preferable remains unclear. Few studies have evaluated whether screw fixation can provide biomechanical fixation strength similar to bone plate fixation.

Objective

We assessed the difference in fixation strength between fixtation with two lag screws and bone plate for oblique metacarpal shaft fractures.

Materials and methods

We created oblique metacarpal shaft fractures on 21 artificial bones and fixated them using (1) double lag screw (2LS group), (2) regular plate (RP group), or (3) locked plate (LP group). To obtain the force–displacement data, a cantilever bending test was conducted for each specimen through a material testing machine. One-way analysis of variance and a Tukey test were conducted to compare the maximum fracture force and stiffness of the three fixation methods.

Results

The maximum fracture force of the 2LS group (mean + SD: 153.6 ± 26.5 N) was significantly lower than that of the RP (211.6 ± 18.5 N) and LP (227.5 ± 10.0 N) groups (p < 0.001). However, no significant differences were discovered between the RP and LP groups. The coefficient of variation for the maximum fracture force of the 2LS group (17.3%) was more than twice as high as that of the RP (8.7%) and LP (4.4%) groups. In addition, the stiffness of the three fixation methods was similar.

Conclusion

Compared with bone plate fixation, double lag screw fixation yielded slightly lower maximum bearable fracture force but similar stiffness. Therefore, this technique could be used for treating oblique metacarpal shaft fractures. However, using double lag screw fixation alone is technically demanding and requires considerable surgical experiences to produce consistent results.

A comparison of intramedullary cannulated screws versus miniplates for fixation of unstable metacarpal diaphyseal fractures

We carried out a prospective randomized study to compare the clinical and radiological results of metacarpal diaphyseal fractures treated with retrograde intramedullary headless cannulated screws (IHCS) and plates. Fractures were fixed with IHCS in 34 patients (37 metacarpals) and locked miniplates in 35 patients (40 metacarpals). The mean age was 33 years (range 18-61) in the IHCS group and 32 years (range 17-68) in plate group. All patients were followed up for 1 year. All fractures in the IHCS group united but there was one nonunion in the plate group. At final follow-up, there was no significant difference between the groups in total active movement, visual analogue pain score, Disabilities of the Arm, Shoulder, and Hand score and grip strength, although the study was not sufficiently powered to exclude differences with certainty. IHCS is a safe and fast technique that is a good alternative to plate fixation in metacarpal diaphyseal fractures.Level of evidence: I.

Long-Term Functional Results of Intra- and Extra-Articular Hand Fractures Treatment With Titanium Miniature Plates and Screws With Minimum Follow-Up of 24 Months

Introduction

The purpose of this study was to evaluate the long-term outcome of an extended range of hand fractures treated with titanium, low profile plates, and screws.

Materials and methods

This retrospective study included adult patients with at least one phalangeal and/or metacarpal fracture, treated with mini titanium plates and screws, between 2004-2016, in a single trauma center, that were followed-up for at least 24 months and with complete, intact medical records.

Results

90 patients (79 men and 11 women) with 114 hand (46 phalangeal, 68 metacarpal) fractures fulfilled the inclusion criteria. Thirty-two fractures were open (28.07%), 27 were intra-articular (23.68%), and 12 were both open and intra-articular fractures. The mean age of the patients was 36.02 years (range 17-75). Mean follow-up was 95.3 months (range 24 to 138). Open fractures had a reduced mean grip strength and total active motion. No difference was observed between intra-articular and extra-articular fractures (for grip strength and total active motion). Predictors of the final outcome included the severity of the initial injury (open vs closed) and not the anatomic location (intra- or extra-articular, metacarpal, or phalangeal) of the fracture.

Conclusions

Low-profile plates and screws can successfully be used to establish union and restore the alignment of the fractured bone while achieving a satisfactory clinical outcome, even in cases of open or intra-articular fractures.

The effect of early controlled mobilization combined with target focused exercise regime in management of closed reduction K-wire fixation of proximal phalanx fracture

The phalangeal and metacarpal fractures are common fractures of the upper extremity. The most common complications of proximal phalanx fracture are the extensor lag and stiffness at the proximal interphalangeal joint, which leads to poor outcomes. Poor treatment compliance has also been identified among our patients. The target focused exercise regime with early controlled active mobilization should improve outcomes and treatment compliance among our patients. In this observational study with recruited 13 subjects, subjects age group range from 25 to 55 yrs. Baseline assessment was administrated for all the subjects. At 12 weeks the patient was re-assessed for Total Active Motion (TAM), Total Passive Motion (TPM), pain, grip strength, and Michigan Hand outcome measure. The TAM increase was statistically significant at P ≥ 0.01 within 4th, 6th, 8th, 10th, and 12th week. The TPM increase was statistically significant at P ≥ 0.01 between 8th, 10th, and 12th week. The mean satisfaction score was 91%. The mean extensor lag was 0.42°. The mean grip strength of the affected hand was 90.6% compared to that of the unaffected hand. The early controlled mobilization combined with target focused exercise regime was effective in improving the TAM and treatment compliance.

Kirschner Wires Versus Titanium Plates and Screws in Management of Unstable Phalangeal Fractures: A Randomized, Controlled Clinical Trial

PURPOSE

To compare clinical, radiological and functional outcomes of percutaneous K-wires and lateral titanium plates and screws in the management of unstable extra-articular proximal and middle phalangeal fractures.

METHODS

In a randomized controlled clinical trial, 40 patients with unstable transverse, long oblique or spiral diaphyseal fractures of the proximal and middle phalanges were divided into 2 groups: the K-wire group (20 patients), which included 12 proximal and 8 middle phalangeal fractures fixed by percutaneous K-wires; and the plate group (20 patients), which included 13 proximal and 7 middle phalangeal fractures treated with open reduction and internal fixation with a lateral titanium plate and screws. The patients were observed for at least 6 months (mean [range], 6.9 [6-8] months). Results were evaluated by total active motion (TAM), grip strength, fracture union, pain assessed by visual analog scale and the Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire, and complications.

RESULTS

Clinical and radiological union was achieved in all patients except one in the K-wire group. Mean TAM was significantly better in the plate group than in the K-wire group. Both groups were similar in terms of postoperative loss of grip strength compared with the opposite healthy hand, and as assessed by visual analog scale and the Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire. Fewer complications occurred in the plate group (2 of 20 patients) compared with the K-wire group (5 of 20 patients).

CONCLUSIONS

Fixation of unstable proximal and middle phalangeal fractures using a titanium plate and screws through a midlateral approach is a reliable and safe method for most fracture types and is associated with higher TAM and fewer complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Osteosynthesis of fractures of the metacarpals and phalanges of the hand with mini plate: about 12 cases]

Le traitement des fractures instables des métacarpes et des phalanges reste un objet de controverse. Peu de séries ont été rapportées dans la littérature, rendant leur analyse difficile. Nous rapportons une étude rétrospective comportant 12 patients, opérés par cette technique, ayant eu des fractures déplacées des métacarpes ou des phalanges, sur une période de deux ans. Les résultats globaux ont été bons dans 75% des cas, moyenne dans 16,5% des cas et mauvais dans 8,5% des cas. La stabilité du montage par mini plaques des fractures instables des métacarpiens et des phalanges ont permis une mobilisation précoce des articulations de la main, évitant ainsi la raideur.

Intramedullary Fixation of Metacarpal Fractures Using Headless Compression Screws

Introduction The purpose of this study is to examine the clinical results of retrograde intramedullary headless screw (IMHS) fixation for metacarpal fractures. Methods A retrospective review was performed on 16 patients with 18 metacarpal fractures who underwent IMHS fixation at a single institution. The average age was 32 years. The indications for surgery included rotational malalignment (five patients), multiple metacarpal fractures (five patients), angular deformity (four patients), and shortening greater than 5 mm (two patients). The average length of follow-up was 19.4 weeks (median 10.2 weeks). Results Functional outcome was considered excellent in all patients with total active motion in excess of 240 degrees. Active motion was initiated within 1 week of surgery. No secondary surgeries were performed related to a complication of IMHS fixation. Conclusion IMHS fixation of metacarpal fractures is an efficacious treatment modality for patients with comminution, multiple fractures, malrotation, and those who require rapid mobilization. It obviates the need for immobilization or more extensive plate and screw fixation techniques with excellent clinical results.

Intramedullary headless screw fixation for fractures of the proximal and middle phalanges in the digits of the hand: a review of 31 consecutive fractures

We present the results of 26 patients with 31 consecutive displaced or unstable extra-articular fractures of the base and shaft of the proximal and middle phalanges of the digits of the hand, treated over a period of 12 months with an intramedullary headless compression screw and early mobilization with no splinting. All fractures healed with no major complications. Only one patient, who had a pathological fracture through an enchondroma, required a tenolysis to improve the mobility of the finger. This technique seems to be technically simple, effective and with few drawbacks.

LEVEL OF EVIDENCE

IV.

Comparison of Clinical Outcomes of Phalangeal Fracture Treated with Dorsolateral Approach or Post-middle Approach Using AO Mini Titanium Plate

The aim of this study is to investigate the clinical outcomes of various fixation methods for proximal phalangeal fractures with Arbeitsgemeinschaft für Osteosynthesefragen (AO) mini titanium plate by dorsolateral approach or post-middle approach. Clinical results of 62 fingers of 53 patients with proximal phalangeal fracture were evaluated. For dorsolateral approach, the lateral bundle of the extensor tendon was drawn away to expose the fracture part of the bone. After reduction, the plate was located at the dorsolateral side of the bone. For post-middle approach, the extensor tendon was split to expose the fracture part of the bone. After reduction, the plate was fixed to the proximal phalangeal side of the bone, and the extensor tendon was repaired with 3-0 nonabsorbable silk sutures. We found low overall complication rates in both groups. The mean total active motion (TAM) for the dorsolateral group and post-middle group was 234.60° ± 22.63° and 221.08° ± 25.69°, respectively. There was a statistical significance between the two groups (P = 0.037 < 0.05), indicating that TAM was notably affected by various fixation methods. With AO mini titanium plate, movement in dorsolateral approach group was significantly higher than in post-middle approach group. Dorsolateral approach is an acceptable technique of incision for proximal phalangeal fractures.

[Osteosynthesis of metacarpal fractures with 2.0 mm LCP system and functional postoperative treatment]

BACKGROUND

Locking head systems are an additional option in the surgical treatment of metacarpal fractures. In this clinic 2.0 mm locking compression plates (LCP) are used, which provide the possibility of functional postoperative treatment even for complex and osteoporotic metacarpal fractures. For simple fractures and good bone quality the LCP system is used as a compression or neutralization plate. Depending on the type and localization of the fracture, different osteosynthesis techniques are used in order to achieve a functional postoperative treatment in as many patients as possible.

MATERIAL AND METHODS

Between July 2009 and December 2010 a total of 49 patients were enrolled in a prospective trial. All patients underwent surgical treatment with a 2.0 mm LCP system. Postoperative functionality of the hand was restored without immobilization. Clinical and radiological examinations were performed after 6 and 12 weeks and after 6 and 12 months with documentation of the range of motion (ROM), grip strength, fingertip to palm distance and the disabilities of the arm, shoulder and hand (DASH) score.

RESULTS

After 6 months a good functional result was achieved in all patients with no cases of malrotation. Radiographs showed a completely consolidated bone healing.

CONCLUSION

After osteosynthesis with 2.0 mm LCPs all types of metacarpal fractures can be treated without immobilization.

Reduction of fifth metacarpal neck fractures with a Kirschner wire

This article reports on a percutaneous joystick technique for reduction of fifth metacarpal neck fractures. The technique was performed in 76 hands. Reduction was achieved in all cases. The technique is a useful reduction maneuver in the treatment of fifth metacarpal neck fractures.

Comparison of treatment of oblique and spiral metacarpal and phalangeal fractures with mini plate plus screw or screw only

INTRODUCTION

We aimed to compare results of treatment of oblique-spiral metacarpal and phalangeal fractures with screw only or mini plate plus screw, respectively.

METHODS

A total of 43 patients who were operated with a diagnosis of displaced, irreducible, unstable, rotational oblique-spiral metacarpal and proximal phalangeal fracture between 2007 and 2010 were included in this study. The mean age of patients with a phalangeal fracture was 33.8 years (range 20-50 years; 4 females, 18 males), and the mean age of patients with a metacarpal fracture was 29.6 years (range 18-45 years; 3 females, 18 males). Mini plate plus screw or screw only was used for internal fixation of these fractures. The patients were followed up for 19.2 ± 5.4 months in the phalangeal fracture group and 20.9 ± 7.3 months in metacarpal fracture group. Of the metacarpal fractures, 14 were oblique and 10 spiral, whereas 14 of the phalangeal fractures were oblique and 8 spiral. The patients were evaluated according to total range of motion of the finger, grasping strength and Q-DASH score.

RESULTS

For patients treated with mini plate plus screw after metacarpal and phalangeal fractures, the time to return to work was significantly shorter in comparison to patients treated with screws only. There was no significant difference between patients with metacarpal fractures treated with mini plate plus screw and patients treated with screw only in terms of total range of motion and Q-DASH results at last on control examination, while results of patients with phalangeal fractures treated with screw only were significantly better. There was no significant difference between these two treatments in phalangeal fractures in terms of grasping strength of the finger in early (1st month) and late (last control examination), whereas patients with metacarpal fractures treated with mini plate plus screw reached higher grasping strength earlier.

CONCLUSION

Treatment with mini plate plus screw should be avoided in spiral and oblique phalangeal fractures, and fixation should be done with screw only with a short surgical incision and dissection. On the other hand, treatment with mini plate plus screw should be preferred in patients with spiral and oblique metacarpal fractures, especially in those who work in occupations requiring higher physical strength.

Long-term follow-up of unoperated, nonscissoring spiral metacarpal fractures

BACKGROUND

Spiral metacarpal fractures can result in shortening of the metacarpal shaft, which may lead to extension lag at the metacarpophalangeal joint and reduced grip strength. These fractures have been surgically treated to restore metacarpal length; however, there are complications associated with surgery, postoperative management and wound healing, which further threaten power recovery in the hand.

OBJECTIVE

To determine the effect of conservative management of un-operated, nonscissoring spiral metacarpal fractures.

METHODS

Sixty-one consecutive patients presenting with nonscissoring spiral metacarpal fractures were treated nonoperatively and studied prospectively to determine the natural history of their power outcome. Thumb fractures and those requiring surgical intervention for scissoring were excluded.

RESULTS

Follow-up data of a minimum of five months (mean follow-up 87 weeks) were available for 13 patients. Mean grip strength at final follow-up was 36.18 kg on the uninjured side and 36.58 kg on the injured side. The strength-difference values did not differ significantly from zero (P=0.72).

CONCLUSION

The loss of metacarpal length associated with these fractures may not cause a power deficit sufficiently large to significantly affect grip strength and functional recovery in the hand. A prospective randomized controlled trial of operated versus unoperated, nonscissoring metacarpal fractures is warranted.

Long-term follow-up of unoperated, nonscissoring spiral metacarpal fractures

Background

Spiral metacarpal fractures can result in shortening of the metacarpal shaft, which may lead to extension lag at the metacarpophalangeal joint and reduced grip strength. These fractures have been surgically treated to restore metacarpal length; however, there are complications associated with surgery, postoperative management and wound healing, which further threaten power recovery in the hand.

Objective

To determine the effect of conservative management of unoperated, nonscissoring spiral metacarpal fractures.

Methods

Sixty-one consecutive patients presenting with nonscissoring spiral metacarpal fractures were treated nonoperatively and studied prospectively to determine the natural history of their power outcome. Thumb fractures and those requiring surgical intervention for scissoring were excluded.

Results

Follow-up data of a minimum of five months (mean follow-up 87 weeks) were available for 13 patients. Mean grip strength at final follow-up was 36.18 kg on the uninjured side and 36.58 kg on the injured side. The strength-difference values did not differ significantly from zero (P=0.72).

Conclusion

The loss of metacarpal length associated with these fractures may not cause a power deficit sufficiently large to significantly affect grip strength and functional recovery in the hand. A prospective randomized controlled trial of operated versus unoperated, nonscissoring metacarpal fractures is warranted.

Outcomes of closed reduction and periarticular pinning of base and shaft fractures of the proximal phalanx

PURPOSE

To review the results of periarticular pinning of extra-articular fractures of the proximal phalanx base and shaft.

METHODS

A retrospective review was performed of the senior author's practice (C.S.M.) from 2006 to 2012. The inclusion criteria were patients older than 18 years of age who underwent periarticular pinning of base or shaft fractures of the proximal phalanx. Age, sex, fracture location, fracture pattern, and time to surgery were recorded. Outcome measures were range of motion, time to healing, and complication rate.

RESULTS

A total of 43 patients with 50 fractures were identified. There were 19 men and 24 women with 16 shaft and 34 base fractures. Five fractures were open. The little finger was involved in 62%, the ring finger in 30%, and the index and middle fingers in 4% each. Most fractures were transverse or oblique, and just over half had comminution and/or impaction. Average follow-up was 17 weeks, and average time to clinical union was 35 days. Nine patients (18%) were lost to follow-up. Twenty-six fingers had excellent results (63%), lacking less than 10° of total motion. Seven patients (17%) had good results, lacking less than 20° of motion; 7 patients had fair results (17%); and 1 patient had a poor result. Three patients (7%) developed stiffness requiring tenolysis. There were 2 pin-site infections, 1 of which resulted in a loss of reduction. Results for shaft and base fractures were not significantly different.

CONCLUSIONS

Percutaneous periarticular pinning is an acceptable option for unstable base and shaft fractures of the proximal phalanx. Most fractures healed within 4 weeks. The majority of patients had excellent or good results.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Evidence-based medicine: Metacarpal fractures

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Determine the need for operative treatment of metacarpal fractures. (2) Describe the position of immobilization for nonoperative treatment of fifth metacarpal fractures. (3) Assess the differences between intramedullary pinning and transverse pinning of displaced metacarpal fractures. (4) Compare the advantages of plating and pinning for treatment of displaced metacarpal fractures. (5) Recognize appropriate timing and treatment of open metacarpal fractures.

SUMMARY

The body of evidence regarding the treatment of metacarpal fractures continues to grow. Conservative management, closed reduction with percutaneous Kirschner wire fixation, intramedullary fixation, and open reduction and internal fixation with plates and/or screws are all accepted treatment modalities. The goal of this review is to highlight the most recent literature and the best evidence available for the management of metacarpal fractures.

Palmar opening wedge osteotomy for malunion of fifth metacarpal neck fractures

Malunion of fifth metacarpal neck fractures may present an aesthetic problem that needs surgical correction. This article reports palmar opening wedge osteotomy for the treatment of malunion of fifth metacarpal neck fractures in 21 hands. The length of the fifth metacarpal was increased using the technique. We also present long-term results in patients using the technique. Palmar opening wedge osteotomy is a successful surgical technique for the treatment of malunion of fifth metacarpal neck fractures.

Antegrade intramedullary nailing for fifth metacarpal neck fractures: a systematic review and meta-analysis

PURPOSE

We investigated the outcomes of the antegrade intramedullary nailing (AIMN) compared to other surgical modalities in the treatment for fifth metacarpal neck fractures via a systematic review.

METHODS

Pain, functional scores, grip strength, total active motion (TAM), the range of motion (ROM) of the fifth metacarpal joint, complications and patient satisfaction were set to be the primary outcomes. The data were evaluated using a modified version of the Cochrane Collaboration tool.

RESULTS

We identified four studies, comprising 163 participants, which met the inclusion criteria. Meta-analyses showed that (a) AIMN demonstrated significantly better results in relation to GS at 12 months (p < 0.0001), TAM (p = 0.01) and ROM of the fifth finger (p = 0.0001); (b) AIMN technique yielded significantly lesser residual angulation at the site of fracture (p = 0.05); (c) AIMN significantly demonstrated fewer complications (p = 0.05); (d) there was a trend for better pain scores when using AIMN.

CONCLUSIONS

Though the amount of evidence was derived from just four small sample-sized studies, our findings suggested that the AIMN technique could have some advantages over the use of plates or other types of pinning in the treatment for the fifth metacarpal neck fractures. We highlighted the need for a standardization of the outcomes and their corresponding units related to this specific type of fracture. Editors and reviewers should incite authors to provide the standard deviation values for the reported means.

LEVEL OF EVIDENCE

Therapeutic II.

Ten-year results using a dynamic treatment for proximal phalangeal fractures of the hands

Fractures of the proximal phalanges of the hands can be treated by many methods. With surgical intervention, a loss in proximal interphalangeal joint movement is common. Using the stabilizing effect of the zancolli complex-metacarpophalangeal retention apparatus and an external device such as a thermoplastic metacarpophalangeal block splint, proximal phalangeal fractures can be stabilized in terms of axis, length, and rotation.This study reports the authors' 10-year results managing these fractures with dynamic treatment. All patients with closed fractures of the proximal phalanges admitted to Queen Mary Hospital, Hong Kong, China, between July 2000 and June 2010 were analyzed. Fractures with rotational deformities or displaced intra-articular configurations were excluded. A dynamic splint that kept the metacarpophalangeal joint maximally flexed while allowing free movement of the proximal and distal interphalangeal joints of the injured finger was applied for at least 4 weeks. Results were evaluated using the Belsky classification and grip strength assessment. The results of 97 patients (103 fractures) were analyzed. At a minimum 1-year follow-up, 75% of patients attained excellent or good results. Neither nonunion nor delayed fracture union was noted. The 25% of patients who attained poor results were older than those who attained excellent or good results (average age, 53.1 vs 35.1 years, respectively) and tended to comply poorly with the rehabilitation program. Using the stabilizing effect of the zancolli complex-metacarpophalangeal retention apparatus and a metacarpophalangeal block splint, bone healing and movement recovery can be achieved simultaneously.

Isolated, extra-articular neck and shaft fractures of the 4th and 5th metacarpals: a comparison of transverse and bouquet (intra-medullary) pinning in 67 patients

Although extra-articular metacarpal fractures are common, there is no consensus on the mode of treatment. We evaluated the outcome in 67 patients operated for isolated, extra-articular fractures in the neck or shaft of the ulnar two metacarpals 28 months post-operatively. There were 22 bouquet (intra-medullary) pinnings and 45 transverse pinnings; 11 were lost to follow-up. Overall, hand function was good, and no difference was detected between the two methods (QuickDASH, grip strength, range of motion, VAS pain and VAS satisfaction). Many patients suffered complications: 12% had a superficial infection (all treated with transverse pinning with wires left exposed); 39% had some impairment in skin sensation; 29% reported cold intolerance; and 10% had other complications. Due to the potential risk of a secondary fracture of the neighbouring metacarpal after transverse pinning, we recommend bouquet (intra-medullary) pinning. We also recommend burying wires beneath the skin surface to avoid infection.

Predictors of the postoperative range of finger motion for comminuted periarticular metacarpal and phalangeal fractures treated with a titanium plate

BACKGROUND

Plate and screw fixation was introduced for complex fractures of the hand. Several risk factors for a poor functional outcome have been identified, but there is a paucity of evidence regarding predictors of finger stiffness in difficult hand fractures. The purpose of this prospective cohort study was to identify independent prognostic factors of the postoperative total active motion (%TAM) in the treatment of metacarpal and phalangeal fractures.

METHODS

Seventy-two patients (62 males, 10 females; 37±15 years) with periarticular fractures involving metaphyseal comminution and displacement were evaluated at a minimum of 1 year following surgery. There were 49 phalangeal bone fractures, 30 intra-articular fractures and 20 associated soft-tissue injuries. The locations of plate placement were lateral in 42 patients and dorsal in 30. The mean duration from injury to surgery was 7.6 days (range, 0-40 days). There were eight examined variables related to patient characteristics (age, gender and hand dominance), fracture characteristics (fracture location, joint involvement and associated soft-tissue injury) and surgical variables (location of plate placement and duration from injury to surgery). Univariate and multivariate linear regression analysis were used to identify the degree to which variables affect %TAM at the final follow-up.

RESULTS

Univariate analysis indicated moderate correlations of %TAM with fracture location, associated soft-tissue injury and age. Multiple linear regression modelling including fracture location, age and associated soft-tissue injury resulted in formulae that could account for 46.3% of the variability in %TAM: fracture location (β=-0.388, p<0.001), age (β=-0.339, p<0.001) and associated soft-tissue injury (β=-0.296, p=0.002).

CONCLUSION

Phalangeal fracture, increasing age and associated soft-tissue injury were important risk factors to identify the postoperative %TAM in the treatment of comminuted periarticular metacarpal or phalangeal fracture with a titanium plate.

Outcome of closed ipsilateral metacarpal fractures treated with mini fragment plates and screws: a prospective study

BACKGROUND

Closed multiple metacarpal fractures are considered highly unstable and are more prone to poor functional outcome. The authors assess the functional outcome of mini fragment plate fixation in closed ipsilateral multiple metacarpal fractures.

PATIENTS AND METHODS

In 21 patients with closed ipsilateral multiple metacarpal fractures treated with open reduction and internal fixation using mini fragment plate, functional outcome was assessed using the American Society for Surgery of the Hand (ASSH) Total Active Flexion (TAF) score and the Disabilities of the Arm, Shoulder, and Hand (DASH) scoring system.

RESULTS

Union rate of 100% was achieved. Functional outcome was excellent in 85.71% (18 of 21) and good in 9% (2 of 21) of patients. Average DASH score was 8.47 (range 1-26). Five cases of infection (two deep, three superficial) were reported, which subsided with dressings and antibiotics.

CONCLUSIONS

Plate fixation is a good option for treating closed ipsilateral multiple metacarpal fractures, providing rigid fixation for early mobilization and good functional outcome.

Ten years stable internal fixation of metacarpal and phalangeal hand fractures-risk factor and outcome analysis show no increase of complications in the treatment of open compared with closed fractures

BACKGROUND

: Stable internal screw/plating systems for hand fractures have evolved during the last 20 years. The improved versatility leads to the increased use of these materials in open fractures, with the benefit of early mobilization. The aim of this retrospective study is to discern whether the broadening of the indications for these implants is accompanied by increased complication rates.

METHODS

: Data from 365 patients treated during the last 10 years at our department for metacarpal or phalangeal fractures with stable internal fixation by screw or plate were gathered and analyzed.

RESULTS

: Uneventful bony consolidation was observed in 91.2% (n = 333). The functional results were excellent to acceptable in 85.2%, whereas in 14.8% (n = 54), the result was unsatisfactory, the latter group presenting with concominant soft tissue injury. There was no statistically significant difference in infection and nonunion rates when comparing open and closed fractures.

CONCLUSION

: These results confirm that most patients with open metacarpal and phalangeal fractures can be treated by stable internal fixation.

Humane killers, human injury: functional outcome of vole captive bolt injuries

BACKGROUND

High-pressure blast injuries to the hand due to vole captive bolt devices are serious injuries that are to a great extent unknown to emergency care operators and trauma surgeons. There is no study on the functional outcome of these patients.

METHODS

We assessed the functional outcome of patients with injuries inflicted by vole captive bolt devices. Therefore, a protocol consisting of a physical examination and an assessment of static muscle power (grip and pinch strength) was performed. To capture the subjective experience of patients regarding their injury related disability and impairment, the DASH follow-up questionnaire was used. Based on clinical/radiologic findings and outcome, a classification of this unique subgroup of blast injuries was developed.

RESULTS

The functional outcome of 34 patients suffering hand injuries due to captive bolt devices between 2004 and 2007 was assessed. A significant reduction of static muscle testing parameters compared with the uninjured hand was revealed. Fourteen patients lost a digit. Average time lost from work was 5.4 weeks.

CONCLUSION

Vole captive bolt device-related hand injuries are followed by deterioration of hand function. The present observations alarmed national authorities. The manufacturers were required to take engineering and teaching measures to rule out handling errors that were identified as leading cause of injury.

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.

Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization

Treatment of fractures of the proximal phalanx and metacarpals is based on the presentation of the fracture, degree of displacement, and difficulty in maintaining fracture reduction. A wide array of treatment options exists for the variation in fracture patterns observed. Inherently stable fractures do not require surgical treatment; all other fractures should be considered for additional stabilization. In general, of the many combinations of internal fixation possible, Kirschner wires and screw-and-plate fixation predominate. Early closed reduction typically is successful for unicondylar fractures of the head of the proximal phalanx. Bicondylar proximal phalanx fractures usually are treated with plate fixation. Transverse and short oblique proximal phalanx fractures generally are treated with Kirschner wires, although a stable short oblique transverse shaft fracture can be managed with an intrinsic plus splint. Plate fixation is used in comminuted proximal phalanx as well as comminuted metacarpal fractures, and lag screws in spiral long oblique phalanx shaft fractures and metacarpal head fractures. Kirschner wire fixation is successful in metacarpal neck fractures as well as both short and long transverse oblique shaft fractures.

Soft tissue sleeve approach to open reduction and internal fixation of proximal phalangeal fractures

Proximal phalangeal fractures often lead to motion loss at the proximal interphalangeal joint primarily because of adhesions between the zone 4 extensor tendon and the fracture site. This most commonly manifests as an extensor lag at the proximal interphalangeal joint, but can also include incomplete recovery of flexion range. The occurrence of the fracture alone likely generates some degree of insurmountable motion loss. Additional motion loss may be iatrogenic based on the specific surgical technique and rehabilitation strategy. It has been promoted that percutaneous pinning methods, as opposed to open fixation methods, produce less of a motion deficit. Although percutaneous pinning solves many fractures of the proximal phalanx, some fracture patterns will not be adequately treated by percutaneous pinning and will benefit from direct open reduction and internal fixation. Spiral fractures with a significant rotational deformity are well treated by lag screws. Comminuted fractures are well treated by plate fixation. When performing such fixations, the soft tissue approach to the fracture site plays a substantial role in determining the ultimate functional recovery. This article covers the specific technical details of optimizing soft tissue management when performing open fixation for proximal phalanx fractures.

Prospective outcomes of comminuted periarticular metacarpal and phalangeal fractures treated using a titanium plate system

PURPOSE

The purpose of this study was to prospectively evaluate clinical results for open reduction and internal fixation of unstable metaphyseal fractures of the metacarpal and phalangeal bones using a miniature titanium plate.

METHODS

Fifty-one consecutive patients with periarticular fractures with metaphyseal comminution and displacement were enrolled. Intra-articular involvement with a split or depression fracture was identified in 22 hands. Minimum follow-up was 1 year. There were 37 male and 14 female patients; average age was 38 years (range, 14-63). Of the 51 fractures, 15 were open; 8 of these had additional soft tissue injury, involving neurovascular injury in 4 and extensor tendon injury in 6. The average duration from injury to surgery was 6 days (range, 2-40 days).

RESULTS

Bone union was successfully achieved in all patients over an average period of 2.6 months. The final range of total active motion (%TAM) was excellent (>85%) for 26, good (70%-84%) for 17, fair (50%-69%) for 5, and poor (<49%) for 3. Postoperative complications occurred in 5 patients, including fracture redisplacement in 2, a collapse or absorption of the condylar head in 2, and superficial infection due to hardware exposure in one. Subsequently, 2 of these patients had malrotation deformities or osteoarthritic changes in the injured finger. Plates were removed in 30 cases, and additional surgery was required in 20 cases. Postoperative grip strength averaged 87% of the contralateral side. Statistical analysis revealed that patient age was significantly correlated with %TAM of the injured finger at 1-year follow-up (p < .01), and intra-articular (p < .05) and phalangeal bone (p < .01) involvement, as well as associated soft tissue injury (p < .05), significantly affected the range of finger motion.

CONCLUSIONS

Despite the technical demands of plating for comminuted metacarpal and phalangeal fractures, the low-profile titanium plate system was highly effective in maintaining anatomic reduction. The postoperative complication rate was relatively low, and the objective outcomes approached a reasonable level at 1-year follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Hand fractures and their management: an international view

Fractures of the bones of the hand are among the commonest fractures in humans, but their management varies widely in the different regions of the world. This variability is due to many reasons, including availability of resources, social factors, geographic constraints, surgeon preference and experience, and local practice patterns. Developing countries are more likely to apply less expensive methods of managing hand fractures. The treatment of these injuries will fall somewhere along a continuum that parallels the historical development of hand fracture management. This paper will review the history of phalangeal and metacarpal fracture management to infer global differences in the treatment of hand fractures. An overview of how different health care systems are likely to manage these injuries will assist health care providers in choosing the most appropriate treatment method.

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.

Experience with a new ultralow-profile osteosynthesis system for fractures of the metacarpals and phalanges

Current osteosynthesis systems for the hand generally recommend thicker plates for metacarpal than for phalangeal fractures. We report a prospective review of 20 hand fractures treated with a new plating system in which 0.6-mm-profile-height plates are used for both metacarpals (11 cases) and phalanges (9 cases). After a follow-up period ranging from 6 to 24 months, there were 8 excellent, 7 good, and 2 poor results (American Society for Surgery of the Hand criteria), with no incidence of plate failure. These outcomes were compared with a matched cohort of 20 similar fractures treated with the widely used Stryker-Leibinger system. We found no significant differences in ranges of motion or complications between the 2 groups. The new plating system was technically straightforward to use and equally effective. Use of the thinner microplates for metacarpal fractures was not associated with any untoward outcomes.