The Nonoperative Management of Hand Fractures in United Kingdom

The Treatment of Closed Finger and Metacarpal Fractures

BACKGROUND

Fractures of the fingers and metacarpal bones are the most common fracture type in the upper limb, with an incidence of 114 to 1483 per 100 000 persons per year. The clinical importance of closed finger and metacarpal fractures is often underestimated; inadequate diagnostic and therapeutic measures may result in serious harm. This review concerns the basic elements of the diagnosis and treatment of finger and metacarpal fractures.

METHODS

This review of the incidence, diagnosis and treatment of finger and metacarpal fractures is based on pertinent publications retrieved by a selective search of the literature.

RESULTS

The main focus of treatment lies on restoration of hand function in consideration of the requirements of the individual patient. The currently available evidence provides little guidance to optimal treatment (level II evidence). Although most closed fractures can be managed conservatively, individualized surgical treatment is advisable in comminuted fractures and fractures with a relevant degree of torsional malposition, axis deviation, or shortening, as well as in intra-articular fractures. Minimally invasive techniques are, in principle, to be performed wherever possible, yet open surgery is sometimes needed because of fracture morphology. Postsurgical complication rates are in the range of 32-36%, with joint fusion accounting for 67-76% of the complications. 15% involve delayed fracture healing and pseudarthrosis.

CONCLUSION

Individualized treatment for finger and metacarpal fractures can improve patients' outcomes, with major socioeconomic and societal benefits. Further high-quality studies evaluating the relative merits of the available treatments are needed as a guide to optimized therapy.

Outcome of functional treatment with a Lucerne Cast in patients with hand fractures: a retrospective case series

PURPOSE

The purpose of this study was to determine the clinical outcome of patients treated with a functional Lucerne Cast (LuCa) for different types of hand fractures. Static casting has traditionally been the preferred treatment for hand fractures. However, functional casting may lead to good functional outcomes, less stiffness, and earlier return to work.

METHODS

A retrospective case series of all consecutive patients with a metacarpal or proximal phalangeal fracture treated with a LuCa between 2018 and 2019 was conducted. A total of 90 patients were included. Clinical data were collected directly from the patient's medical records. Functional outcome was assessed with the Michigan Hand Outcomes Questionnaire (MHQ).

RESULTS

The median MHQ score was 95 (IQR 83-100) with a median follow-up of 23 months. Complications occurred in 7 of 90 patients (8%). Functional impairment occurred in two (2%) patients. Functional impairment was defined as stiffness, persisting rotational deformity, a boutonnière or swanneck deformity. Persisting pain or CRPS occurred in six (7%) patients.

CONCLUSION

The LuCa shows to be effective in the functional treatment of both metacarpal and proximal phalangeal fractures with excellent patient-reported outcomes but at a relatively high rate of persisting pain.

Arthroscopic Hemitrapezectomy and Suspension with Mini TightRope for the Treatment of Rhizarthrosis: Outcome in patients in stages Eaton-Littler 2 to 3

Introduction Rhizarthrosis is a common cause of pain and impaired function of the hand. Most patients present an excellent response to the conservative treatment, although a small percentage requires a surgical procedure due to the persistence of symptoms. Different surgical procedures have been described; however, there is still no consensus in the literature regarding the superiority of one technique over the others.

Objective To evaluate the clinical and radiological results of patients with a diagnosis of rhizarthrosis in stages 2 to 3 of the Eaton-Littler classification, submitted to arthroscopic hemitrapezectomy and suspension with Mini TightRope (Arthrex, Naples, FL, US).

Materials and methods We conducted a retrospective evaluation of the clinical and radiological results of patients operated on through the technique proposed in Clínica INDISA, in Santiago, Chile, between 2017 and 2019. The pre- and postsurgical assessments were performed using the visual analog scale (VAS) for pain, the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and the Kapandji score. The state of the articular cartilage was also evaluated intraoperatively according to the Badia classification.

Results A total of 12 patients (3 men and 9 women) met the inclusion criteria. Their mean age was 56 years, the mean duration of the follow-up was of 21 months. There were 7 patients in stage 2 and 5 in stage 3 according to the Eaton-Littler classification. Intraoperatively, there were 6 patients in stage II and 6 in stage III of the Badia classification. The mean preoperative score on the Kapandji index was of 3.6, and the mean postoperative score was of 9. The mean preoperative score on the VAS was of 8.8, and the mean postoperative score was of 1.2. The mean preoperative score on the DASH was of 33.3, and the mean postoperative score was of 4.7.

Conclusion Arthroscopic and suspension hemitrapezectomy with Mini TightRope for the treatment of stage 2-3 rhizarthrosis is a minimally-invasive, reproducible technique, effective in reducing pain and improving function, with sustained effects on the short and middle terms (6 to 36 months).

Minimally Invasive Procedure for Correcting Extra-Articular Malunions of Metacarpals and Phalanges

PURPOSE

Extra-articular malunions of metacarpals and phalanges may cause palmar pain, finger scissoring, and splaying, and interfere with function. Current treatment involves open osteotomy and fixation with plates and screws. We present a minimally invasive method using cannulated headless screws for correction of malunions and examine the outcomes in a series of patients.

METHODS

Twenty malunions were operated on in 17 patients. In 16 cases, the malunion involved the metacarpal and in 4 it involved the proximal phalanx. All proximal phalanx and 3 metacarpal malunions were malrotation types, while the rest of the metacarpal malunions were dorsal angulations. The operation consisted of an opening wedge osteotomy in 8 patients; closing wedge osteotomy in 5; and a transverse osteotomy and derotation in the rest. Concomitant surgery to release tendon adhesions or contracted joints or to perform adipofascial flaps was performed in 8 cases. Fixation was achieved by means of a cannulated headless screw. Immediate range of motion was permitted in all cases.

RESULTS

Correction of the malunion and osteotomy union was achieved in all cases. One patient required manipulation of a digit that was found rotated at the first follow-up visit. Eleven fingers achieved more than 280° of total active motion. In 9 digits, the total active motion was less than 280° after the operation, yet improved 76° (range, 140°-30°) from their preoperative total active motion. The mean single-assessment numeric evaluation score for the whole group was 9.1.

CONCLUSIONS

The fixation provided by the cannulated headless screw is sufficient to permit immediate range of motion. Due to the minimal tissue disruption, this approach may be a reasonable alternative to the standard approach.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Closed Metacarpal Neck Fractures: A Review of Resource Use in Operative and Nonoperative Management

BACKGROUND

Closed metacarpal neck fractures are extremely common. The authors investigated resource use among those managed operatively versus nonoperatively. They hypothesized that considerable use of services and costs are incurred with nonoperative management.

METHODS

The authors used the 2009 to 2017 Truven Marketscan Research Database to identify patients with closed metacarpal neck fractures and divided them into operative and nonoperative groups. They examined resource use, including imaging, clinic visits, surgery, and occupational therapy sessions, and performed a chi-square analysis of patient demographic data and resources used.

RESULTS

Of 125,610 patients identified, 46,845 met inclusion criteria: nonoperative, n = 45,067 (96.2 percent); and operative, n = 1778 (3.8 percent). The operative group comprised percutaneous fixation (62 percent) and open reduction and internal fixation (38 percent) patients. Nonoperative patients had the greatest mean number of clinic visits, with 1.7 per patient, compared to 1.2 for both percutaneous fixation and open reduction and internal fixation patients (p < 0.001). For nonoperative patients, one to two radiographs (beyond the index radiograph) were obtained, and they had 2.9 occupational therapy sessions; in the operative group, two to three radiographs were obtained, and they had three to four occupational therapy sessions (p < 0.001). Mean total costs were $2406 per patient for percutaneous fixation, $3092 per patient for open reduction and internal fixation, $546 per patient for closed reduction, and $261 per patient for no intervention.

CONCLUSIONS

Nonoperative management of closed metacarpal neck fracture has lower costs without the associated operating room, surgeon, and service fees; however, patient care remains resource intensive with the use of imaging, clinic visits, and occupational therapy. Shifts in the authors' treatment paradigm, including judicious use of services, will result in significant health care savings.