Metacarpal and Phalangeal Nonunions

Assessment of Union Rates in Ballistic Hand Fractures

BACKGROUND

Ballistic hand fractures (BHFs) are complex, multistructure injuries, unique from other hand fractures. We sought to determine BHF union rates and assess factors contributing to nonunion.

METHODS

Metacarpal or phalangeal BHFs sustained from 2016 to 2023 were identified from an institutional database. Charts and radiographs were reviewed for fracture characteristics and union by 90 days. Fractures without union by 90 days or without minimum 90-day follow-up were excluded. Comminuted fractures were categorized by severity: (1) complete bone loss (NC); (2) partial bony contact (PC); or (3) full (>80%) bony contact (FC). Univariate and multivariate analysis was performed to determine factors associated with nonunion.

RESULTS

Ninety-seven BHFs were included. Most were comminuted (78.4%, N = 76). Greater fracture severity was associated with larger bony gap (FC: 2.2 vs PC: 10.2 vs NC: 24.0 mm; P < .001). The overall union rate was 48.5% (N = 47); however, less severe BHF (ie, noncomminuted, FC) had higher rates of union than more severe BHF (ie, PC and NC; 93% and 60.5% vs 36% and 7.7%; P = .003). On multivariate regression, bony gap was an independent predictor of nonunion (P = .02). Thirteen BHFs underwent additional surgery with 90% achieving union within 90 days.

CONCLUSIONS

Ballistic hand fractures treated with a single surgery demonstrate low union rates (48.5%). Two-stage reconstruction should be considered in all BHFs to improve union rates, particularly when severe comminution or large bony gaps are present. Following stabilization and soft tissue coverage, a second stage with conversion to internal fixation, debridement of devitalized bone, and secondary bone grafting should be performed.

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

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