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

Surgical treatment of proximal interphalangeal joint stress fracture in a climber

Proximal interphalangeal joint stress fractures commonly occur as epiphyseal line injuries in teenage climbers; however, fractures with closed epiphyseal lines are rare. Poor outcomes are more common if treatment is delayed. We report the case of a 16-year-old climber who underwent delayed surgical treatment for a fracture with a closed epiphyseal line, with a favorable outcome. There was 20 ° extension lag at the proximal interphalangeal joint and a fracture on the dorsal aspect of the base of the metaphyseal bone, with osteosclerosis at the fracture site. The fracture site was refreshed and internal fixation was performed using the tension-band wiring technique. At 3 months postoperatively, there was no pain, extension had improved, and bone union was achieved. This case illustrates the effectiveness of surgery in achieving favorable outcomes for delayed proximal interphalangeal joint stress fractures in climbers with epiphyseal line closure. LEVEL OF EVIDENCE: V.

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.

Current Outcomes and Treatments of Complex Phalangeal and Metacarpal Fractures

Phalangeal and metacarpal fractures that require operative treatment have documented complications in around 50% of patients. The most common of these complications are stiffness and malunion. These can be highly challenging problems for the hand surgeon. In this article, we discuss complications after phalangeal and metacarpal fractures and treatment strategies for these complications.

Factors Associated With Implant Removal Following Plate-and-Screw Fixation of Isolated Metacarpal Fractures

PURPOSE

The incidence of and associated risk factors for implant removal following the plate-and-screw fixation of metacarpal shaft fractures have not been well described. The primary objective of our study was to identify implant-related radiographic parameters associated with implant removal in patients treated with the plate-and-screw fixation of isolated, displaced metacarpal fractures at 2 years of follow-up. The secondary objective of our study was to identify patient-related factors associated with implant removal.

METHODS

A retrospective study of all patients who underwent open treatment of a metacarpal fracture with a plate-and-screw construct from January 1, 2000, to April 30, 2019, at 2 level-1 trauma centers was conducted. After the application of exclusion criteria, we identified 138 patients with a single isolated metacarpal fracture of a nonthumb digit treated with open reduction and internal fixation using a plate-and-screw construct. Our study endpoint was the removal of the plate-and-screw construct or a minimum of 2 years of follow-up without the removal of the hardware. Twenty-three patients achieved our study endpoint as determined using their electronic medical records, and 58 additional patients were reached via telephone to confirm their implant removal status. A bivariate analysis was used to screen for factors associated with implant removal, and variables significant in the bivariate screen were included in a multivariable stepwise logistic regression model.

RESULTS

Twenty-three out of 81 patients (28%) in our final cohort underwent implant removal by the final follow-up visit. In the logistic regression analysis, the distance between the plate and metacarpophalangeal joint, the distance between the plate and carpometacarpal joint, and active smoking were independently associated with implant removal.

CONCLUSIONS

The proximity of metacarpal plates to adjacent joints is associated with subsequent implant removal. Patients may be counseled about the higher risk of implant removal when periarticular metacarpal plating is performed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis IV.

Minimally Invasive Intramedullary Screw Versus Plate Fixation for Proximal Phalanx Fractures: A Biomechanical Study

PURPOSE

To compare the maximum interfragmentary displacement of short oblique proximal phalanx (P1) fractures fixed with an intramedullary headless compression screw (IMHCS) versus a plate-and-screws construct in a cadaveric model that generates finger motion via the flexor and extensor tendons of the fingers.

METHODS

We created a 30° oblique cut in 24 P1s of the index, middle, ring, and little fingers for 3 matched pairs of cadaveric hands. Twelve fractures were stabilized with an IMHCS using an antegrade, dorsal articular margin technique at the P1 base. The 12 matched-pair P1 fractures were stabilized with a radially placed 2.0-mm plate with 2 bicortical nonlocking screws on each side of the fracture. Hands were mounted to a frame allowing a computer-controlled, motor-driven, linear actuator powered movement of fingers via 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.

RESULTS

The observed mean displacement differences between IMHCS and plate-and-screws fixation was not statistically significant throughout all time points during the 2,000 cycles. A 2 one-sided test procedure for paired samples confirmed statistical equivalence in fracture displacement between fixation methods at the final 2,000-cycle time point.

CONCLUSIONS

The IMHCS provided biomechanical stability equivalent to plate-and-screws for short oblique P1 fractures at the 2,000-cycle mark in this cadaveric model.

CLINICAL RELEVANCE

Short oblique P1 fracture fixation with an IMHCS may provide adequate stability to withstand immediate postoperative active range of motion therapy.

Clinical outcomes of unstable metacarpal and phalangeal fractures treated with a locking plate system: a prospective study

We prospectively assessed clinical and radiological outcomes of locking plate fixation in treating unstable fractures in 11 metacarpals, 15 proximal phalanges, and eight middle phalanges in 34 consecutive patients from October 2011 to December 2016. Median length of follow-up was 14 months (range 12-24). The motion of finger joints, bony union, and complication rates were recorded. The median postoperative range of motion of the two interphalangeal joints and the metacarpophalangeal joint was 82% of the contralateral hands. Fractures in the three locations had significantly different recovery of the finger motion, with the best recovery for the metacarpal fractures. Closer distance between the plate edge and joint line was associated with a more limited range of the finger motion. The clinical outcomes approached an acceptable level at final follow-up. Finger stiffness is unavoidable after locking plate fixation of metacarpal and phalangeal fractures even with early hand therapy, with stiffness occurring in 10 out of 34 cases at the time of final follow-up 1 year after surgery. Level of evidence: II.

Mini-plate versus Kirschner wire internal fixation for treatment of metacarpal and phalangeal fractures

OBJECTIVE

To conduct a meta-analysis to show the associations of perioperative and postoperative outcomes of mini-plate internal fixation (MPIF) versus Kirschner wire internal fixation (KWIF) for treating metacarpal and phalangeal fractures.

METHODS

A literature search was performed in PubMed, Web of Science, Cochrane Library, and Embase from the earliest date of data collection to April 2018. Studies that compared perioperative and postoperative outcomes of MPIF with those of KWIF in patients with metacarpal and phalangeal fractures were included.

RESULTS

Twenty-six articles met the inclusion and exclusion criteria (n = 2029 patients; 1042 with MPIF and 987 with KWIF). MPIF was related to a greater increase in length of surgery, hospital days, excellent and good rate of outcome, short-form health survey-36 score, and flexion and extension range compared with KWIF. MPIF was related to a greater decrease in intraoperative blood loss, finger visual analog scale score, functional exercise time, fracture healing time, incidence of complications, and postoperative infection rate compared with KWIF.

CONCLUSIONS

Patients with MPIF have sufficient pressure and strength, and MPIF promotes successful joint fusion and reduces complications of the operation. MPIF is ideal for reduction and stability of patients with metacarpal and phalangeal fractures.

The Effect of Extensor Tendon Adhesions on Finger Motion

PURPOSE

To quantify the amount and pattern of finger range of motion loss at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints with a simulated extensor tendon adhesion at the level of the proximal phalanx or metacarpal.

METHODS

In 10 cadaveric specimens, traction sutures were placed in the forearm extensor digitorum communis and flexor digitorum profundus tendons of the middle and ring fingers. Active motion was simulated by suspending weights from the traction sutures via pulleys. The angles of the MCP, PIP, and DIP joints were measured at the position of maximum flexion and extension. Extensor tendon adhesions were simulated alternately at the proximal phalanx and metacarpal levels of the middle and ring fingers, using suture anchors. Repeat measurements were taken using the same amount of force.

RESULTS

There was an average total loss of flexion of 38° and of extension of 6° with a proximal phalanx adhesion, with a greater contribution of flexion loss at the PIP joint. The loss of flexion was 17° and of extension was 50° with a metacarpal adhesion, with a loss of extension mostly at the MCP joint.

CONCLUSIONS

The results of this study identified clear patterns of motion loss that are associated with isolated simulated adhesions in different locations along the extensor mechanism. The greatest motion loss occurred at the joint immediately distal to the simulated adhesion.

CLINICAL RELEVANCE

Although extrapolation of these findings to clinical relevance remains unclear, the ability to predict the level of adhesion by the pattern of motion restriction may allow for a targeted tenolysis procedure. This would reduce the amount of soft tissue dissection required, which in turn, could be expected to reduce the degree of repeat adhesion formation.

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.

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.

Predictors of Proximal Interphalangeal Joint Flexion Contracture After Homodigital Island Flap

PURPOSE

To identify independent predictors of postoperative proximal interphalangeal (PIP) joint contracture after direct-flow homodigital island flap transfer.

METHODS

Forty-four fingertip amputations in 39 patients treated with oblique triangular flaps were evaluated at a minimum of 1 year after surgery. Five variables were examined: patient age, injured finger, mechanism of injury, flap advancement distance, and time required for wound healing. Univariate and multivariate linear regression analyses were performed to identify the extent to which these variables affected the flexion contracture of the PIP joint.

RESULTS

The average reduction in the passive extension angle of the PIP joint was 16° at final follow-up. Univariate analysis indicated significant correlations of PIP joint flexion contracture with age, injured finger, and time for wound healing, but no significant correlation with the distance the flap was advanced. Multivariate analysis indicated that the age and duration of wound healing were independent predictors of the flexion contracture of the PIP joint.

CONCLUSIONS

Elderly people and cases with delayed wound healing are at risk for postoperative PIP joint contracture after homodigital flap transfer. Intervention with early hand therapy and orthotics may be useful in elderly patients with delayed wound healing.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Predictors of Postoperative Finger Stiffness in Unstable Proximal Phalangeal Fractures

BACKGROUND

The purpose of this study was to determine the risk factors for postoperative finger stiffness after open reduction and internal fixation of unstable proximal phalangeal fractures using a low-profile plate and/or screw system. We hypothesized that dorsal plate placement is a risk factor for postoperative finger stiffness.

METHODS

Seventy consecutive patients (50 men, 20 women; average age, 40 years) with 75 unstable proximal phalangeal fractures were treated with titanium plates and/or screws and evaluated at a minimum follow-up of 1 year. Thirty-six comminuted fractures and 24 intra-articular fractures were included, and 16 fractures had associated soft-tissue injuries. Plate fixation was performed in 59 fractures, and the remaining 16 were fixed with screws only. The implants were placed in a dorsal location in 33 fractures and in a lateral or volar location in 42 fractures. Finger stiffness was defined as a total active range of finger motion <80% for the treated finger. Univariate and multivariate analyses were performed on 8 variables: patient characteristics (age and sex), fracture characteristics (fracture comminution, joint involvement, and associated soft-tissue injury), and surgical characteristics (type and location of implants and removal of the implants).

RESULTS

Postoperative finger stiffness occurred in 38 fractures. The multivariate analysis indicated that plate fixation (odds ratio, 5.9; 95% confidence interval, 1.5-24.0; P = 0.01) and dorsal placement (odds ratio, 3.0; 95% confidence interval, 1.1-8.3; P = 0.03) were independent risk factors for finger stiffness.

CONCLUSION

We recommend the use of screw fixation as much as possible for unstable proximal phalangeal fractures using a midlateral approach.

Outcomes of hand fracture treatments

There is no outcome measure designated as the gold standard when assessing the treatment results following fractures of the hand. Numerous measures have been described in the literature, but only a limited number have been validated to specifically evaluate functional recovery with respect to hand fractures. Of the outcome measures validated for use with hand fractures, few have been studied in comparative trials designed to analyze their ability to predict functional recovery. This review article provides an evidence-based description of the validated scales and scores frequently used in assessing the functional outcomes and their ability to predict recovery.