The Treatment of Closed Finger and Metacarpal Fractures

[Bony and ligamentous injuries of the thumb ray]

Fractures and ligamentous lesions of the thumb ray are frequent due to the exposed position of the thumb. A thorough anatomical understanding with respect to the joints and stabilizing ligaments is essential for a targeted examination, the selection of appropriate imaging diagnostics and the decision for a surgical or conservative treatment approach. Misdiagnoses or untreated injuries can lead to impaired functionality, pain and instability, which can substantially impair the function of the hand, particularly thumb opposition.

Subcutaneous vs. transcutaneous K-wires for proximal phalanx fractures: a prospective randomized trial on infection rates

In this randomized prospective trial, we compared K-wire osteosynthesis techniques for fractures of the proximal phalanx. Between April 2021 and February 2024, 28 patients treated at the BG Trauma Center Tuebingen were divided into two groups. Both groups underwent osteosynthesis with two K-wires: in Group A, the wire ends were left transcutaneous, while in Group B, they were buried subcutaneously. Follow-up revealed a significantly lower infection rate with subcutaneous wires (5.89%) compared to transcutaneous wires (45.46%). The postoperative infection occurred within the first 6 weeks after surgery. Two patients had to undergo surgical revision changing or removing the K-wires unexpectedly. Additionally, the total active range of motion of the PIP joint in Group A was 21.85° less than in Group B. Patients also expressed a preference for subcutaneous placement of wire ends. These findings strongly support burying K-wire ends after osteosynthesis of proximal phalanx fractures.

3D-printed prosthesis for traumatic trapezium bone defect: a case report

This case report describes a two-stage surgical approach for managing a traumatic defect of the left trapezium bone. A 51-year-old male presented following a high-impact injury caused by a heavy iron object striking his left wrist. The patient reported severe wrist pain and restricted thumb motion. The patient sustained a severe wrist injury resulting in extensive bone loss. Initial treatment involved debridement and bone cement filling, followed by a second-stage implantation of a patient-specific 3D-printed titanium prosthesis. At 24-month follow-up, the patient demonstrated excellent thumb functionality and significant clinical improvement. This case illustrates the successful use of a 3D-printed trapezium prosthesis to treat a complex comminuted fracture with bone defect. This method offers a promising alternative for managing severe carpal fractures.

Shifting trends in outpatient hand trauma care: a 16-year analysis at a major center in northern Germany

BACKGROUND

Hand injuries are a leading cause of emergency department visits. Recent trends in hand trauma management reflect a shift toward outpatient care, driven by factors such as a shortage of skilled personnel or increasing cost pressures. This study analyzed these trends to propose updated management strategies for hand injuries.

MATERIALS AND METHODS

This retrospective cohort study included 14,414 patients treated at a certified major hand surgical trauma center between 2007 and 2022. Patients were divided into two groups: the earlier cohort (EC, 2007-2014) and the current cohort (CC, 2015-2022). Trends in inpatient and outpatient care, as well as hospitalization durations, were analyzed.

RESULTS

During the study period, approximately one-third of all patients required inpatient treatment, with one-third of hospitalized patients staying at least one week, one-fifth staying two weeks, and one-tenth staying three or more weeks. Inpatient treatment rates decreased annually by 7%, while outpatient care increased by 5.3% annually. A significant shift toward outpatient management was noted for various injuries, including fractures, burns, lacerations, dislocations, complex injuries, and infections. Despite declining hospitalization rates, patients in the CC group had significantly longer hospital stays, reflecting the increasing complexity and severity of cases requiring admission (p < 0.001).

CONCLUSIONS

This study reveals a growing trend toward outpatient care for hand injuries, reflecting improved efficiency without compromising quality. Although fewer patients are hospitalized, those admitted require more intensive care, highlighting a shift toward ambulatory management for moderately severe cases. These findings emphasize the importance of initial injury management and underscore the need for expanding outpatient hand surgical care to meet growing demand in a rapidly changing healthcare landscape.

LEVEL OF EVIDENCE

III.

Kirners deformity - a systematic review and surgery recommendations

BACKGROUND

Kirner deformity is a rare anomaly of the little finger in adolescents, characterized by a deformity of the distal phalanx and a radiologically L-shaped epiphysis, along with palmar and radial angulation of the distal phalanx. Due to the rarity of these pathological findings, there are no systematic literature reviews available. This work serves as an overview of the clinical presentation, frequency and age distributions, as well as possible conservative and surgical treatment options.

METHODS

We present five cases of patients with Kirner's deformity of the little finger who underwent surgical treatment. A partial tenotomy of the flexor digitorum profundus tendon from the metaphyseal/diaphyseal distal phalanx was performed. In one case, a dorsal epiphysiodesis was also carried out. Additionally, a systematic review of the literature on Kirner's deformity was conducted, summarizing the prevalence, previously used surgical treatment options, and epidemiological data.

RESULTS

In the presented cases, the detachment of the FDP tendon and dorsal epiphysiodesis resulted in a good functional and aesthetic outcome. Regarding the epidemiological distribution of Kirner deformity, it is noted that significantly more females are affected than males (63% vs. 36%). The average age at presentation in the respective clinic was 9.36 years (± 2.5). In more than half of all reported cases, the deformity was bilateral. Surgical intervention was performed in only 7.4% of cases, which included FDP detachment or corrective osteotomies. More than 90% of patients were treated conservatively.

CONCLUSION

Kirner's deformity is a rare condition affecting adolescents. In cases where functional limitations or pain symptoms are present, we recommend surgical intervention via detachment of the FDP tendon. If the deformity is an incidental finding without functional or aesthetic limitations, conservative therapy with a corrective splint can be initiated. From our perspective, early surgical treatment before the age of 12 improves both the long-term functional and aesthetic outcomes.

The vascular anatomy and harvesting of the medial femoral condyle flap in pigs

INTRODUCTION

Clinically, there has been increasing employment of the medial femoral condyle flap. Pigs have been employed as a model of the medial femoral condyle flap. However, related anatomical studies from the perspective of comparative medicine are rare. The objective of this study was to explore the vascular anatomy of the medial femoral condyle in pigs, explore the surgical procedure of the medial femoral condyle flap in pigs, and compare the medial femoral condyle flap in pigs and humans.

MATERIALS AND METHODS

20 fresh cadaveric hindlimbs of hybrid pigs were used in this study. The origination, course, and branches of the vessels nourishing the medial femoral condyle were observed in 15 specimens. The variability in the anatomy of the vessels and the length and outer diameter of the vessels were evaluated. Surgical procedures for the medial femoral condyle flap were conducted on five specimens.

RESULTS

The nourishing artery of the medial femoral condyle in pigs was the second descending geniculate artery, which was observed in all 15 pigs and had a diameter and length of 2.013 ± 0.316 mm and 1.527 ± 0.212 cm, respectively. A skin incision of approximately 10 cm was used to harvest the medial femoral condyle flap of the pig in the supine position. After the adductor muscle was cut, the whole course of the second descending geniculate artery artery and its venae comitantes were exposed.

CONCLUSIONS

The vascular anatomy of the medial femoral condyle in pigs and that of humans exhibited great similarities. The medial femoral condyle flap in pigs was as easily harvested as that in humans. Pigs could serve as a suitable animal model for the medial femoral condyle flap.

Equestrian-associated injuries of the hand: a retrospective analysis of injury mechanisms and patterns

INTRODUCTION

Hand injuries are frequently caused by sports and are associated with long periods of inability to work and high economic health costs. After ball sports and cycling, the most common cause of hand injuries is horseback riding. Therefore, measures should be taken to prevent these risks and increase safety in sports, however data characterizing equestrian sports-associated injuries are limited.

MATERIALS AND METHODS

A retrospective monocentric cohort study was performed including 39 patients (mean age: 35 ± 2.6 (range 9-65) years, female 89.7% who sustained an injury to the hand while practicing equestrian sports during 2016-2021 and presented to our hand surgery center. Data analysis was performed to characterize the trauma mechanism and injury patterns by evaluating the clinical information system and conducting telephone interviews.

RESULTS

Overall, 53.8% of the injuries occurred while leading the horse owing to traction by bridles or a lead rope on the fingers, whereas only 33.3% were caused by a fall and 12.8% by a bite injury. The majority (87.2%) of cases were injuries to the phalanges (metacarpus: 7.7%; carpus: 5.1%). Fractures were present in 51.3% of cases. The most serious injuries included avulsion amputations in 23.1% of patients (10.3% subtotal; 12.8% total amputation).

CONCLUSIONS

Equestrian-associated injuries occur more frequently during horse handling than riding, resulting in severe avulsion amputations due to traction of the lunge or bridle, requiring complex microsurgical treatment. We recommend that appropriate protective gloves are worn for prevention of hand injuries. Additionally, the use of self-opening panic hooks with overload protection can prevent excessive traction.

LEVEL OF EVIDENCE

III.

The Conservative and Operative Treatment of Carpal Fractures

BACKGROUND

Carpal fractures (incidence: 30-60 per 100 000 persons per year) are one of the more commonly overlooked fracture types. They can have serious consequences, as the use of the hand is indispensable in everyday life. In the following article, we present the elements of the diagnosis and treatment of fractures of the carpal bones.

METHODS

This review is based on meta-analyses and randomized controlled trials (RCTs) published from 2013 to 2023 that were retrieved by a structured literature search, supplemented by guideline recommendations and expert consensus statements. In addition, data on the administrative prevalence of carpal fractures were obtained from the German Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung, KV) and from the German Statutory Accident Insurance (Deutsche Gesetzliche Unfallversicherung, DGUV).

RESULTS

The administrative prevalence of carpal fractures in 2022 was 44 496 outpatient cases (KV, DGUV) in one year. After clinical history-taking, physical examination and x-ray have been performed, thin-slice computed tomography is recommended as part of the diagnostic evaluation. Treatment recommendations are based on evidence of levels II to IV. Multiple RCTs have been carried out on the treatment of scaphoid fractures, and a clinical guideline exists. Proximal, dislocated and unstable scaphoid fractures should be treated surgically. Non-displaced or minimally displaced fractures of the middle third of the scaphoid bone require a shorter period of immobilization with surgical treatment (2-4 weeks) than with conservative treatment (6-8 weeks). The use of plaster casts that do not hinder elbow and thumb mobility yields healing rates similar to those obtained with the immobi - lization of both of these joints. Failure to treat an unrecognized scaphoid fracture can lead to pseudarthrosis, avascular bony necrosis, and misalignment. Other, rarer types of carpal fractures must be managed on an individual basis, as the available ev idence is limited to expert consensus.

CONCLUSION

Early recognition and appropriate treatment of carpal fractures lead to healing in more than 90% of cases. Although the available evidence on their proper treatment is growing, many questions are subject to expert consensus, and decisions about treatment must be made individually.

Management of paediatric fifth metacarpal neck fractures: a systematic review

BACKGROUND

Fifth metacarpal neck fractures (FMCNFs) are common among paediatric patients. Complications include reduced metacarpophalangeal (MCP) range of motion and grip strength, which impede the hand's functional abilities. Various management options are available, but indications are not standardised. This systematic review aims to assimilate all available evidence on the management of paediatric FMCNFs to determine appropriate treatment pathways.

METHODS

PubMed (Medline), EMBASE, Scopus and Google Scholar were used to identify evidence pertaining to the management of these fractures.

RESULTS

Ten studies were identified, involving 237 patients with a mean age of 14.4 years (Range 9-17). Ninety percent of patients were male. Sixty-one (26%) patients, with an average fracture angulation of 27° (Range 16°-33°) and no rotational deformities, were managed with immobilisation alone. These patients returned to normal metacarpophalangeal range of motion and grip strength. Fifty-four (23%) patients, with an average fracture angulation of 42.7° (Range 33°-54°), were managed with fracture reduction and immobilisation. This technique did not yield sustained reduction of fractures with significant angulation or rotation after intervention. One hundred twenty-two (51%) patients, with an average fracture angulation of 48.3° (Range 30°-58°) and including cases of malrotation, were managed with fracture reduction and surgical fixation. These patients experienced good functional outcomes.

CONCLUSIONS

This review suggests paediatric FMCNFs can be safely managed with immobilisation alone when there is an absence of rotational deformity and an angulation of < 30°. In the case of a higher fracture angulation or rotational deformity, fracture reduction and surgical fixation is an appropriate method of management.

Percutaneous transverse pinning for metacarpal fractures: a clinical trial

INTRODUCTION

Metacarpal fractures account for 25%-50% of all hand fractures and may negatively impact hand function and ability to work. Percutaneous transverse pinning of non-articular metacarpal fractures allows mobilisation immediately after the procedure.

METHODS

Between March 2017 and February 2022, 56 patients undergoing percutaneous transverse pinning for unstable metacarpal fractures were prospectively recruited. We investigated surgical outcomes in terms of Patient-rated Wrist/Hand Evaluation (PRWHE) and pre-and post-operative radiographic evaluation. The Student t-test was used to compare the means of PRWHE values after surgery. Statistical significance was set at p < 0.05.

RESULTS

The mean age was 40.21 ± 17.9 years (range of 16 to 86 years). The average operating time was 27.96 min. The mean follow-up period was 14.3 ± 6.4 months (from 2 to 41 months). The mean PRWHE score was 6.5 ± 1.8. None of the patients had clinically observable rotational deformities, and the functional outcomes were satisfactory.

CONCLUSION

Percutaneous transverse pinning for non-articular metacarpal fractures restores excellent function, and imaging results are satisfactory. Further high-quality clinical trials are required to validate these results on a larger scale.

LEVEL OF EVIDENCE

II, prospective cohort study.

Diagnostic power of ChatGPT 4 in distal radius fracture detection through wrist radiographs

Distal radius fractures rank among the most prevalent fractures in humans, necessitating accurate radiological imaging and interpretation for optimal diagnosis and treatment. In addition to human radiologists, artificial intelligence systems are increasingly employed for radiological assessments. Since 2023, ChatGPT 4 has offered image analysis capabilities, which can also be used for the analysis of wrist radiographs. This study evaluates the diagnostic power of ChatGPT 4 in identifying distal radius fractures, comparing it with a board-certified radiologist, a hand surgery resident, a medical student, and the well-established AI Gleamer BoneView™. Results demonstrate ChatGPT 4's good diagnostic accuracy (sensitivity 0.88, specificity 0.98, diagnostic power (AUC) 0.93), surpassing the medical student (sensitivity 0.98, specificity 0.72, diagnostic power (AUC) 0.85; p = 0.04) significantly. Nevertheless, the diagnostic power of ChatGPT 4 lags behind the hand surgery resident (sensitivity 0.99, specificity 0.98, diagnostic power (AUC) 0.985; p = 0.014) and Gleamer BoneView™(sensitivity 1.00, specificity 0.98, diagnostic power (AUC) 0.99; p = 0.006). This study highlights the utility and potential applications of artificial intelligence in modern medicine, emphasizing ChatGPT 4 as a valuable tool for enhancing diagnostic capabilities in the field of medical imaging.

Surface replacing arthroplasty of a post-traumatic stiff and deviated proximal interphalangeal joint in an adolescent

This case report describes the 4-year outcomes of proximal interphalangeal joint arthroplasty in a 14-year-old girl with a stiff joint after trauma. At follow-up, active range of motion was 35°, she was pain-free and satisfied with the outcome. Implant arthroplasty seems to be a valuable option for young patients with persistent post-traumatic stiff and deviated PIP joints to-at least temporarily-increase quality of life.

E-scooter accidents-epidemiology and injury patterns: 3-year results from a level 1 trauma center in Germany

INTRODUCTION

Since the introduction of e-scooters in Germany in 2019, they are becoming more and more popular and associated injuries have increased significantly. The aim of this study was to assess the injury patterns after e-scooter accidents.

MATERIALS AND METHODS

From May 2019 to October 2022, all consecutive patients who presented at our emergency department (ED) following e-scooter accidents were included in our study and retrospectively analyzed.

RESULTS

A total of 271 patients were included in our study. The mean age was 33 years. 38% of the patients were female and 62% were male. Most common injuries were traumatic brain injuries in 38% of the patients together with fractures affecting the upper limb (17%). An operative treatment was necessary in 40 patients. Most of the patients presented at night and about 30% were under the influence of alcohol.

CONCLUSIONS

Our study shows one of the largest cohort of patients suffering e-scooter accidents in Europe. Compulsory helmet use, stricter alcohol controls and locking periods could contribute significantly to safety.