The MetaHUS(®) fixation system versus pinning and plating in 5th metacarpal neck fractures

Comparative Evaluation of the Efficacy of Combined Intramedullary Pinning with K-Wires Pinning in the Treatment of Fifth Metacarpal Neck Fractures versus Conventional Techniques-K-Wires Pinning and Intramedullary Pinning

Background and Objectives: Since the neck is the weakest part of the metacarpals, the most common metacarpal fracture is a neck fracture, a type which accounts for 38% of all hand fractures. Such fractures can be fixed using a variety of conventional techniques, including intramedullary pinning and K-wire pinning. However, conventional techniques involve complications, such as angulation, stiffness, and rotational deformity. The purpose of this study was to compare the usefulness of our new technique, combined intramedullary pinning with K-wire pinning (IPKP), with those of intramedullary pinning (IP) and K-wire pinning (KP). Materials and Methods: This was a single-center, randomized controlled trial conducted between January 2005 and April 2023. A total of 158 patients with acute displaced fractures of the fifth-metacarpal neck were randomly assigned to either the IPKP group (n = 48), the KP group (n = 60), or the IP group (n = 50). We radiographically evaluated angulation and shortening in three visits: pre-operatively, post-operatively, and at a 1-year follow-up. We clinically evaluated the ranges of motion and Quick-DASH scores to assess daily living performance and the cosmetic scores, using the SBSES score, to assess patients' satisfaction with their cosmetic outcomes. Results: The IPKP group was superior to the KP group and the IP group regarding radiographical and clinical assessments at the 1-year follow-up visit. The angulation was 15.7° (±7.7) in the KP group, 17.0° (±5.9) in the IP group, and 12.6° (±2.5) in the IPKP group (p < 0.001) at the 1-year follow-up visit. The shortening was 0.9 mm (±0.3) in the KP group, 1.4 mm (±0.2) in the IP group, and 0.4 mm (±0.1) in the IPKP group (m < 0.001) at the 1-year follow-up visit. The TAM was 272.6° (±17.5) in the KP group, 271.1° (±18.0) in the IP group, and 274.1° (±14.9) in the IPKP group (p = 0.42). Four patients (6.6%) in the KP group and two patients (4%) in the IP group were reported as having stiffness, while no patients were found to have stiffness in the IPKP group. The average Quick-DASH score was 2.3 (±0.5) in the KP group, 2.5 (±0.4) in the IP group, and 1.9 (±0.4) in the IPKP group (p > 0.05). The average cosmetic score was 3.7 (±1.2) in the KP group, 3.8 (±0.9) in the IP group, and 4.7 (±0.8) in the IPKP group (p < 0.001). A complication involving nonunion occurred in one case (1.6%) in the KP group, while there were three cases (6%) of rotational deformity in the IP groups. Conclusions: With the IPKP technique, accurate reduction can be achieved to improve hand function and cosmetic outcomes.

Kickstand Technique for Intraoperative Reduction of Fifth Metacarpal Neck Fractures

This article reports a novel intraoperative technique for the reduction of angulated metacarpal neck fractures undergoing retrograde headless intramedullary screw fixation. This technique is a useful reduction maneuver, especially for hand surgeons operating without a first assistant, because it eliminates the need to hold manual reduction during implant placement.

Biomechanical Modeling of Connecting Intermetacarpal K-Wires in the Treatment of Metacarpal Shaft Fractures

BACKGROUND

Clinical series have been published using the configuration of 2 intercarpal Kirschner wires (K-wires) adjacent to the fracture being connected, but biomechanical analysis is lacking. The objective of this pilot biomechanical study was to model and compare the effects of externally connecting 2 intermetacarpal K-wires for the stabilization of transverse metacarpal shaft fractures. Our research hypothesis was that the connected constructs would be stiffer than the unconnected K-wires.

METHODS

A 3-dimensional computer-based model of small finger transverse metacarpal fracture stabilization was designed with 3 transverse 1.1 mm K-wires being anchored to the adjacent metacarpal. Three arrangements were tested: all 3 K-wires in parallel, the middle K-wire angled toward the proximal wire, and the middle angled K-wire being rigidly fixed to the proximal K-wire. The proximal wire was proximal to the fracture. A finite element analysis was performed by applying a cantilever force of 100 N at the head of the metacarpal. The metacarpal was considered to be uniform in composition with parameters typical for human bone. Kirschner wire parameters for stainless steel were used. Force (N) versus displacement was measured.

RESULTS

The configuration with the middle angled K-wire being rigidly fixed to the proximal K-wire showed greater stiffness (12 N/mm) than nonattached constructs. The connected construct was 2.3 times more stiff than the unattached parallel construct and 2.5 times more stiff than angling the middle K-wire without attachment.

CONCLUSIONS

In a computer model simulation, our results show that attaching 2 K-wires adjacent to the fracture provides more than twice the stiffness of unconnected K-wires.

L-pinning for fifth metacarpal neck fracture in adolescents

INTRODUCTION

Fifth metacarpal neck fracture is the most frequent type of hand fracture in adolescents between 13 and 16 years of age. It mainly affects males and the dominant hand. The L-pinning technique combines intramedullary anterograde pinning and transverse pinning between the 4^th and 5^th metacarpals. The present study aimed to assess L-pinning without postoperative immobilization in displaced 5^th metacarpal fracture in adolescents with low residual growth.

MATERIALS AND METHODS

Data for patients aged between 13 and 16 years, operated on for closed 5^th metacarpal neck fracture between January 2017 and June 2019, were analyzed retrospectively. Surgery was indicated for angulation with>30° palmar tilt and/or horizontal malalignment. The technique consisted in intramedullary anterograde pinning and transverse pinning between the 4^th and 5^th metacarpal heads. No postoperative immobilization was applied. Hardware was removed as of day 28. The final clinical check-up was at≥12 months.

RESULTS

Eighteen patients, all male, with a mean age of 14 years, were included. All had bone age≥14 years. Mean palmar tilt was 52°±6.8° versus 6°±2.4° postoperatively, for a mean correction of 45°±4.3°. Mean operating time was 15min, and X-ray exposure 0.36minutes for a mean radiation dose of 2.89 cGy/cm². At hardware removal, all patients showed radiologic consolidation. At 3 months, 5^th ray ranges of motion were normal, with no local complications. Functional results were maintained at last follow-up (≥12 months).

CONCLUSION

L-pinning seemed reliable in terms of feasibility and stability of reduction in 5^th metacarpal neck fracture in adolescents. Absence of postoperative immobilization facilitated self-rehabilitation and accelerated functional recovery.

LEVEL OF EVIDENCE

IV.

The curative effect analysis of a modified Kirschner wires and locking plate internal fixation method for the fifth metacarpal neck fracture

PURPOSE

To evaluate the efficacy of a modified internal fixation method for the treatment of fifth metacarpal neck fracture.

METHODS

From March 2018 to December 2019, 12 patients with the fifth metacarpal neck fractures of the hands were treated with the Kirschner wires and locking plate internal fixation method. Each patient's gender, age, dominant hand, injured hand, trauma mechanism, preoperative and postoperative deformity (angulation and the length of the fifth metacarpal), the range of motion of the metacarpophalangeal joint and grip strength of each side, the time of return to work, and follow-up time were recorded and calculated.

RESULTS

The mean follow-up time was 16.8 months, and the angulations of preoperative and postoperative deformity were 40.0 ± 3.7°and 17.6 ± 1.7°, respectively. The length of the fifth metacarpals of preoperative and postoperative deformity were 51.5 ± 2.1 mm and 60.0 ± 1.8 mm, respectively. At the last follow-up, the range of motion of the fifth metacarpophalangeal joint of the injured side and the contralateral side were 84.3 ± 3.6°and 86.5 ± 2.0°, and the grip strength of the injured side and the contralateral side were 74.8 ± 6.1 LB and 78.6 ± 8.3 LB, respectively, without statistically significant differences. QDASH score was 2.0 ± 1.0, and the time of return to work was 6.0 ± 0.7 weeks.

CONCLUSION

The modified internal fixation method is one of the alternative treatments for the fifth metacarpal neck fracture with good curative effects.

Intramedullary percutaneous fixation of metacarpal fractures: screw versus connected K-wires

The purpose of the present study was to determine clinical and radiographic outcomes in patients treated with limited-open retrograde intramedullary headless screw fixation for metacarpal neck and shaft fractures (group I) versus percutaneous antegrade and retrograde intramedullary double pinning linked by a connector (group II). We designed a retrospective comparative study, with the inclusion of two groups (20 patients each) of metacarpal unstable fractures. Both groups showed similar outcomes at the final follow-up, except for extension lag (significantly better in group II) and return to sport (significantly better in group I). Intramedullary screw fixation did not accelerate bone union and range of motion recovery in the early follow-up. In conclusion, limited-open retrograde intramedullary headless screw fixation and percutaneous connected antegrade and retrograde intramedullary double pinning are both reliable techniques of fixation for metacarpal neck and shaft fractures. LEVEL OF EVIDENCE: III.

The dorsal tangent line - A new approach in the radiological analysis of metacarpal fractures

Traditionally, the angle between the intersecting central axes (lateral projection intersecting central axes - LCA) of the proximal and distal fragments of metacarpal fractures is measured on radiographs. We recommend using the angle between the intersecting dorsal tangent lines instead (lateral projection intersecting dorsal tangent lines - LDT). We analyzed radiographs of 25 fractures of the fifth metacarpal bone shaft in three planes. Intraclass correlation coefficients (ICC) were used to estimate inter-rater and intra-rater reliability. Mean palmar tilt was 35.6° ± 12.5° according to LCA and 27.6° ± 12.0° according to LDT. There were no differences during repeated measurements. Intra-rater reliability was high: ICC (95% CI) for LDT was 0.82 (0.74-0.88) and for LCA it was 0.71 (0.51-0.83). Mean values of palmar tilt using LCA exceeded those using LDT by 8.0° ± 7.7° (p < 0.001). Only LDT measurements provided comparable results between all raters. In conclusion, we demonstrated the feasibility and reliability of intersecting dorsal tangent lines for measuring palmar tilt in fifth metacarpal fractures as an alternative to the commonly used angle between the intersecting central axes.

Management of Little Finger Metacarpal Fractures: A Meta-Analysis of the Current Evidence

Background: The little finger metacarpal neck fracture, also known as boxer's fracture, is a commonly encountered upper limb fracture in orthopaedics. There are multiple ways of managing this fracture, ranging from immediate mobilization to rigid internal fixation. However, there is still a lack of consensus on the best management option. The aim of this study is to review all comparative studies, either randomized trial or cohort studies, on little finger metacarpal neck fracture management, meta-analyze the radiological and functional outcome between conservative and operative management. Methods: A systematic search of the literature was conducted between year 1987 to 2018 on MEDLINE and EMBASE. To be included, studies needed to have shown comparison between conservative against operative management, assessing the radiological (palmar angulation) and the patient reported functional outcomes. The data were pooled using fixed-effect method. The methodology was adapted from the Cochrane Handbook for Systematic Review of Interventions and compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO CRD42018099168). Results: 5 full papers were included in our study. Our meta-analysis showed that compared to operative management, conservative management report worse radiological palmar angulation at follow-up; but equivalent functional outcome in terms of Quick-DASH and grip strength. Conservative studies also showed fewer mean days off in comparison to operative management. Conservative management also showed equivalent Total Active Motion (TAM) and Visual Analogue Score for Pain (VAS), but some studies had insufficient data to be pooled. Conclusions: Regardless of palmar angulation, conservative treatment of little finger metacarpal neck fracture provides an equivalent functional outcome to surgical intervention with an earlier return to work and no risk of surgical complications. Larger, randomised controlled trials are required.

Fixation of fifth metacarpal neck fractures: a comparison of medial locking plates with intramedullary K-wires

Surgical treatment for metacarpal neck fractures may be indicated for malrotation, palmar angulation exceeding 30° or metacarpal shortening exceeding 3 mm, although these thresholds have not been firmly established. In a retrospective study, we compared the clinical and radiographic results of 54 patients with displaced fifth metacarpal neck fractures who were treated with either medial locking plates (14 patients) or retrograde intramedullary K-wires (40 patients). At a mean follow-up of 26 months (range 12 to 62), metacarpal shortening and angulation were 2 mm greater and 4° greater, respectively, in the K-wire group. The plate group had an earlier return to work and greater aesthetic satisfaction, but operative time and complication incidence were higher. Range of motion, time to union, grip strength and Quick Disability of the Arm, Shoulder and Hand scores were similar. We conclude that medial plating offers no clear advantage over K-wire fixation in treating metacarpal neck fractures. Level of evidence: III.

Comparing the Efficacy and Safety of Metacarpal Neck Fracture Treatments: A Systematic Review and Network Meta-Analysis

Purpose

Metacarpal neck fractures may perform well without operative intervention, but the current literature on this topic is fragmented and guidance on managing these injuries needs further refinement. We conducted a systematic review and network meta-analysis to provide a comprehensive evaluation of the various treatments available for these injuries.

Methods

We searched 3 electronic databases and included any study comparing interventions for metacarpal neck fractures. We conducted a Bayesian network meta-analysis for each outcome.

Results

We identified a total of 14 studies comparing: antegrade (AIMP) or retrograde (RIMP) intramedullary pinning, buddy strapping, transverse pinning (TP), functional bracing, plating, retrograde cross-pinning, a combination of retrograde cross-pinning and plating, and placement of an orthosis or casting. Although the results were not statistically significant, the effect estimates suggested more favorable pain reduction and functional improvement with AIMP compared with nonsurgical therapies and RIMP in the short term (3 months or less). However, differences between interventions at later follow-up were less extreme; data on short-term pain and function with surgical options outside AIMP and RIMP were unavailable. In addition, compared with both plating and TP, AIMP was associated with significantly higher risks for implant migration and neurological events. There were contrasting findings in union-related outcomes. Plating showed the earliest time to union (not statistically significant) but TP demonstrated the lowest risk for a delayed union.

Conclusions

This review demonstrated that although AIMP may be a viable surgical option for early symptomatic relief after a metacarpal neck fracture, it may also be associated with a greater likelihood of certain postoperative complications. Clinicians should consider patient preferences for the time frame of symptomatic relief when selecting the optimal treatment, and patients should weigh the advantages and disadvantages of each available option, especially when considering invasive surgery. Considering the lack of high-quality primary research investigating these interventions, future studies are needed to make more definitive conclusions.

Type of study/level of evidence

Therapeutic II.

Locked wires fixator for fractures of the distal third of the radius and ulna in children

BACKGROUND

Prevention of redisplacement is an issue after the treatment of fractures of the distal third of the radius in children. In this study, we used a locked wires fixator for this type of fracture and achieved favorable treatment outcomes.

METHODS

The subjects were 8 children with fractures of the distal third of the radius (male: 7, female: 1, mean age: 9.0 years old) who underwent surgery with locked wires fixators and were able to be evaluated 12 months after surgery. Immobilization was not applied after surgery. The locked wires fixator or K-wire was removed when the bridging callus was observed on plain radiography 4-6 (mean 5.5) weeks after surgery in all patients. The presence of bone union, functional outcomes, and complications were investigated postoperatively.

RESULTS

All patients achieved bone union without redisplacement excellent function. The pin site infection was observed in two patients.

CONCLUSIONS

The locked wires fixator may be a new useful treatment method for fractures likely to cause postoperative redisplacement.

Simplified internal fixation of fifth metacarpal neck fractures

BACKGROUND

Fifth metacarpal neck fractures (boxer's fractures) are common injuries that contribute 20% of all hand fractures. Divergent percutaneous pinning (bouquet fixation) as described by Foucher has gained popularity but is challenging and at times arduous, as it requires the insertion of several slender K-wires into a narrow medullary canal. Here, we report on a simplified technique in which a single thick K-wire is inserted.

TECHNIQUE

An 18/10 K-wire is bent at one end then mounted on a drill chuck. The incision is performed and the entry hole created using the K-wire, which is then advanced along the medullary canal. After reduction of the metacarpal head using the Jahss manoeuvre, the K-wire is inserted across the fracture site into the subchondral bone. Any persistent rotational malalignment is corrected by rotating the metacarpal around the K-wire. Immobilisation is by buddy taping covered by a resin guard.

METHODS

We collected follow-up data for 30 patients treated using our technique, at a mean age of 32 years.

RESULTS

90 days after surgery, the fracture was healed in all patients. No patients had rotational malalignment. Mean operative time was 14minutes. No complications were recorded.

DISCUSSION

The use of a single thick K-wire proved simple, effective, reproducible, and rapid. No rotational malalignment occurred. This technique is faster and easier to perform than divergent pinning with multiple K-wires.

CONCLUSION

This technique can be used to treat fifth metacarpal neck fractures.

Three-screw versus two-screw fixation of distal fragment in fifth metacarpal neck fractures stabilized with locking plate

Fifth metacarpal neck fracture commonly requires open reduction and internal fixation. Locking plate was widely adopted in the treatment of fifth metacarpal neck fracture as first-line choice for fixation. Patients with fifth metacarpal neck fracture receiving locking plate fixation were included for analysis. Features of internal fixation including number of distal and proximal locking screws, diameter of the screws and usage of lag screws were recorded. Clinical and radiographic outcomes included final volar angulation, grip strength, Michigan Hand Outcomes Questionnaire (MHQ) and range of motion (ROM) of fifth metacarpophalangeal joint. Three-screw fixation was less frequently presented in the group with increased volar angulation (≥30 degrees). Consistently, three-screw fixation of distal fragment could improve the prognosis compared with two-screw fixation (MHQ 95.4 ± 5.1 versus 80.4 ± 12.3, ROM 83.5 ± 7.2 versus 69.6 ± 7.7). In conclusion, the metacarpal head should be fixed by three locking screws instead of two locking screws.

Locking Plate Alone versus in Combination with Two Crossed Kirschner Wires for Fifth Metacarpal Neck Fracture

Fracture of fifth metacarpal neck commonly requires open reduction and internal fixation. However, the current methods of internal fixation in fifth metacarpal neck fractures remain unsatisfactory. Patients with fractures of fifth metacarpal neck received open reduction and internal fixation with either locking plate in combination with two crossed Kirschner wires (K-wires) or locking plate alone were evaluated for the clinical outcomes. Clinical outcomes included grip strength, Michigan hand outcomes questionnaire (MHQ), final angulation and range of motion (ROM) one year after treatment. The averages of MHQ scores, final angulation and ROM of fifth metacarpophalangeal joint of plate with K-wire group were more superior to those of plate group (MHQ 96.7 versus 86.6, final angulation 11.8 versus 23.6, ROM 83.3 versus 72.2). The grip strength had no significant difference between two groups. Locking plate in combination with two crossed K-wires is a more optimal method of fixation compared with locking plate alone.

Hand Fractures: Indications, the Tried and True and New Innovations

Hand fractures are the second most common fracture of the upper extremity, and management of patients with these injuries is common for most hand surgery practices. In this article, we outline the principles of management of these injuries with a special focus on those that are common or complex. We also highlight recent innovations in the context of these injuries. From this cross-section of contemporary evidence on phalangeal and metacarpal fracture treatment, we have noted a trend toward minimally invasive surgery with immediate postoperative mobilization, the use of wide-awake anesthesia, as well as sustained investigation and innovation in the biomechanics and treatment of proximal interphalangeal joint fracture dislocations.

Fixation for metacarpal neck fracture: a biomechanical study

BACKGROUND

There is no robust evidence of the best operative treatment for displaced unstable metacarpal neck fractures. Numerous constructs are used in the fixation of metacarpal neck fractures. Currently, two common methods are dorsal locking plate and K-wire fixation. A new metacarpal sled fixation system for metacarpal neck fracture was designed to provide fracture stability but limit dissection and avoid exposed hardware. The purpose of this study was to compare the biomechanical integrity of the metacarpal sled versus standard locking plate fixation and retrograde K-wire fixation in a simulated porcine metacarpal fracture model.

METHODS

Transverse metacarpal neck fractures were created in 30 porcine second metacarpals. The specimens were randomly fixed with locking plates, metacarpal sleds, or retrograde K-wires. Constructs were then loaded to failure in three-point bending. Stiffness and peak load were measured from the load-to-failure deflection curve. Data were analyzed via ANOVA, followed by Tukey-Kramer's post hoc pairwise comparison.

RESULTS

The K-wire group had the highest initial stiffness followed by the sled group and then the plate group. Statistical difference was only found between K-wires and plate. Peak load for the K-wire group was lowest, followed by sled, and then by plate. A statistically significant difference was observed between the peak loads of the K-wires and plate, as well as the sled and plate. However, a difference in peak load was not detected between the K-wires and sled.

CONCLUSIONS

For transverse metacarpal neck fractures, a metacarpal sled construct provides similar fixation to K-wires with limited dissection and without exposed hardware or the potential for soft tissue tethering. The new low profile construct using a minimally invasive technique would be suitable for unstable metacarpal neck fractures.