Low Rate of Complications Following Intramedullary Headless Compression Screw Fixation of Metacarpal Fractures

Background: There has been a recent increase in the use of headless compression screws for fixation of metacarpal neck and shaft fractures as they offer several advantages, and minimal complications have been reported. This study aimed to evaluate the clinical complications and their solutions following retrograde intramedullary headless compression screw fixation of metacarpal fractures. We describe complications and the approach to their management. Methods: We performed a multicenter case series through retrospective review of all patients treated with intramedullary headless screw fixation of metacarpal fractures by 3 fellowship-trained hand surgeons. Patient demographics, implant used, type of complication, pre- and postoperative radiographs, operative reports, and sequelae were reviewed for each case. We defined complications as infection, loss of fixation, hardware failure, malrotation, nonunion, malunion, metal allergy, and any repeat surgical intervention. Results: Four complications (2.5%) were identified through the review of 160 total metacarpal fractures. One complication was a nickel allergy, one was a broken screw after repeat trauma, and 2 patients had bent intramedullary screws. Screw removal in 3 patients was simple and without complications or persistent limitations. One bent screw with a refracture was left in place. No serious complications were seen. Conclusion: Intramedullary screw fixation of metacarpal fractures is safe with a low incidence of complications (2.5%) that can be safely and effectively managed.     

Long-term follow-up of unoperated,nonscissoring spiral metacarpal fractures

BACKGROUND:

Spiral metacarpal fractures can result in shortening of the metacarpal shaft, which may lead to extension lag at the metacarpophalangeal joint and reduced grip strength. These fractures have been surgically treated to restore metacarpal length; however, there are complications associated with surgery, postoperative management and wound healing, which further threaten power recovery in the hand.

OBJECTIVE:

To determine the effect of conservative management of un-operated, nonscissoring spiral metacarpal fractures.

METHODS:

Sixty-one consecutive patients presenting with nonscissoring spiral metacarpal fractures were treated nonoperatively and studied prospectively to determine the natural history of their power outcome. Thumb fractures and those requiring surgical intervention for scissoring were excluded.

RESULTS:

Follow-up data of a minimum of five months (mean follow-up 87 weeks) were available for 13 patients. Mean grip strength at final follow-up was 36.18 kg on the uninjured side and 36.58 kg on the injured side. The strength-difference values did not differ significantly from zero (P=0.72).

CONCLUSION:

The loss of metacarpal length associated with these fractures may not cause a power deficit sufficiently large to significantly affect grip strength and functional recovery in the hand. A prospective randomized controlled trial of operated versus unoperated, nonscissoring metacarpal fractures is warranted.     

Conservative management of difficult phalangeal fractures

Stable fractures of the metacarpal and proximal phalanges can be treated satisfactorily by closed methods. The problem in those unstable fractures is whether to treat with open or closed reduction. Stiffness of the proximal interphalangeal joint (PIP), malunion, rotation deformities, shortening, and nonunion are known complications of fractures of the proximal phalanx. Fractures at the base of the proximal phalanx. Fractures at the base of the proximal phalanx have low incidence of complications if they are treated closed. Fractures at the shaft carry a much larger risk of complications with either type of treatment. This study of 158 fractures of the proximal phalanx demonstrates that there is a place for conservative treatment in the management of unstable shaft fractures of the proximal phalanx.     

Metacarpal fractures: treatment and complications

Metacarpal fractures comprise between 18–44 % of all hand fractures. Non-thumb metacarpals account for around 88 % of all metacarpal fractures, with the fifth finger most commonly involved [19]. The majority of metacarpal fractures are isolated injuries, which are simple, closed, and stable. While many metacarpal fractures do well without surgery, there is a paucity of literature and persistent controversy to guide the treating physician on the best treatment algorithm. The purpose of this article is to review non-thumb metacarpal anatomy and treatment protocols for nonoperative management of stable fractures, and compare existing literature on surgical techniques for treatment of acute fractures and complications.     

手部外固定架的设计及临床应用

目的探讨手部小管状骨骨折,特别是关节附近的掌、指骨骨折,及其粉碎性骨折的更为简便有效的治疗方法,介绍一种新型实用的手部外固定架.方法自1996年10月采用自行设计的手部外固定架治疗掌、指骨骨折30例.其中掌、指骨干骨折18例,掌、指骨头骨折12例;闭合骨折25例,开放骨折5例;单纯骨折24例,粉碎骨折6例.结果平均随访4.5个月,骨折愈合时间4～8周,无骨不连及骨髓炎并发症.手功能恢复按TAM标准优22例,良4例,可4例,优良率86.7%.结论手部外固定架结构简单,方便实用,固定掌、指骨稳固,特别是对掌、指骨头骨折,以及粉碎性骨折有良好的固定作用.     

Nonunion of metacarpal extraarticular fractures in children: report of two cases and review of the literature

Extraarticular metacarpal fractures are common during childhood, and osseous healing is the rule. We have treated two patients with delayed and nonunion of three metacarpal shafts. One patient sustained closed second and third metacarpal fractures, and the other sustained an open second metacarpal fracture. Both injuries were crush-type of significant force. Although initial treatment seemed appropriate, delayed union was not appreciated. The children were referred for cosmetic deformity. One of our patients required open reduction/internal fixation with bone grafting, whereas the other was observed. All metacarpal fractures healed. Thorough clinical examination, radiographic views, reduction, and proper immobilization are factors that may help prevent this previously unreported complication in children.     

Radiographic assessment of small finger metacarpal neck fractures

Treatment recommendations for metacarpal neck fractures of the small finger are generally based on the degree of apex dorsal angulation at the fracture site. We evaluated the variability of measurement of fracture angulation and the effect this variability has on treatment recommendations for these injuries. A total of 96 radiographs (anteroposterior, lateral, oblique views) of 32 patients with fractures of the small finger metacarpal neck were evaluated independently by 3 fellowship-trained orthopedic hand surgeons. Treatment recommendations for each fracture were tabulated. This process was repeated 6 weeks later to evaluate intraobserver variability. Kappa coefficients of inter- and intraobserver reliability of fracture angulation measurement and treatment plans were generated. The mean reliability coefficient of the measurement of fracture angulation between the 3 different observers was slight. Similarly, the reproducibility of fracture angulation measurement within observers was fair. Agreement between observers for appropriate treatment recommendations for each fracture was fair and agreement within observers for treatment was only slightly better. The measurement of fracture angulation of small finger metacarpal neck fractures seems to be subject to a high degree of inter- and intraobserver variability.     

Avulsion fracture of the extensor carpi radialis longus carpal insertion due to a basketball injury: Case report and literature review

Articular fractures of the base of the 2nd metacarpal involving the extensor carpi radialis longus insertion are unusual and poorly understood. There is no consensus as to how these fractures should be treated. We report the case of a 2nd metacarpal base fracture in a professional basketball player that was treated surgically with open reduction and internal fixation using cannulated screws. The management of this case is compared to similar cases in the literature.     

铁丝夹板牵引治疗掌指骨骨折

目的：对掌指骨骨折应用铁丝夹板牵引治疗方法进行探讨。方法：对372例468个掌指骨骨折选择性地应用铁丝夹板的牵引整复固定治疗。结果：所有患指无一例感染坏死、骨折延迟愈合或不愈合，功能恢复良好，疗效满意，总优良率92.5%。结论：铁丝夹板牵引、固定治疗掌指骨骨折是一种较好的方法，操作简便，创伤小，对严重粉碎性骨折、斜形骨折及开放性骨折手术后的患进行牵引、外固定，有良好的维持复位作用。     

Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization

Treatment of fractures of the proximal phalanx and metacarpals is based on the presentation of the fracture, degree of displacement, and difficulty in maintaining fracture reduction. A wide array of treatment options exists for the variation in fracture patterns observed. Inherently stable fractures do not require surgical treatment; all other fractures should be considered for additional stabilization. In general, of the many combinations of internal fixation possible, Kirschner wires and screw-and-plate fixation predominate. Early closed reduction typically is successful for unicondylar fractures of the head of the proximal phalanx. Bicondylar proximal phalanx fractures usually are treated with plate fixation. Transverse and short oblique proximal phalanx fractures generally are treated with Kirschner wires, although a stable short oblique transverse shaft fracture can be managed with an intrinsic plus splint. Plate fixation is used in comminuted proximal phalanx as well as comminuted metacarpal fractures, and lag screws in spiral long oblique phalanx shaft fractures and metacarpal head fractures. Kirschner wire fixation is successful in metacarpal neck fractures as well as both short and long transverse oblique shaft fractures.     

Intramedullary k-wire fixation of metacarpal fractures

Introduction The majority of metacarpal fractures can be treated conservatively. Nevertheless, surgical treatment is justified in certain cases. Palmar dislocation of >30° and shortening of >5 mm will significantly affect extension and flexion of the hand. Consequently, surgical treatment is indicated. The aim of our study was to evaluate the clinical results of intramedullary Kirschner-wire fixation of metacarpal fractures.Material and methods In a retrospective study we analyzed the clinical results of 35 patients with metacarpal fractures that had been treated by closed reduction and elastic fixation with at least two intramedullary k-wires.Results Most of the patients were young, with good bone quality and low anesthetic risk, and they had suffered the fractures as a result of a direct trauma. Predominantly uncomplicated, the fractures were metaphyseal, subcapital and of the fifth metacarpal bone (750.3-B1 fractures). Surgical treatment was indicated for a palmar axis dislocation of >20° or if a rotatory deficiency was present. Metacarpal joint function and correction of rotatory displacement could be assessed on median after a period of 1.1 year. In 34 patients flexion and extension was normal on both sides. In one patient we found an extension deficiency of 15° and a rotatory deficiency of 10°. In 34 out 35 patients with metacarpal fractures, minimally invasive intramedullary k-wire osteosynthesis resulted in complete restoration.Conclusions Intramedullary k-wire fixation is a minimally invasive method for stabilizing metacarpal fractures. The excellent long-term clinical results are due to the fact that the gliding tissue around the fracture will not be affected at all by the surgical procedure.The study was performed at the department of traumatology, Klinik am Eichert, Göppingen, Germany     

微型钛板内固定治疗闭合性多发掌骨骨折

目的探讨微型钛板内固定治疗闭合性多发掌骨骨折的临床疗效。方法2007年6月-2010年8月,采用手术切开复位微型钛板螺钉内固定治疗闭合性多发掌骨骨折27例,其中2处掌骨骨折12例．3处掌骨骨折15例。结果术后随访10-25个月,所有骨折骨性愈合,愈合时间平均4．6周。按中华医学会手外科学会上肢部分功能评定试用标准进行评定,各掌骨骨折对应手指功能活动：优47指,良16指,优良率91％。结论手术切开复位微型钛板内固定治疗闭合性多发掌骨骨折可取得解剖复位、固定可靠、允许关节早期功能活动的临床效果,是闭合性多发掌骨骨折理想的治疗手段。     

Plate fixation in closed ipsilateral multiple metacarpal fractures

Closed multiple metacarpal fractures are uncommon. They are usually associated with significant soft tissue swelling. Early stable fixation and functional rehabilitation optimises outcome. We present a review of 19 patients with 43 metacarpal fractures treated by early open reduction and internal fixation with 2 mm plates. Eighteen patients recovered a full range of motion, while one patient was lost to follow-up. Implant removal on account of extensor irritation was required in only two metacarpals in two patients. Plating of multiple closed metacarpal fractures is a safe, reliable and consistently reproducible treatment method.     

Metacarpal fractures

The majority of metacarpal fractures are closed injuries amenable to conservative treatment with external immobilization and subsequent rehabilitation. Internal fixation is favored for unstable fracture patterns and patients who require early motion. Percutaneous pinning usually is successful for metacarpal neck fractures and comminuted head fractures. Shaft and base fractures can be treated with pinning or open reduction and internal fixation; the latter, being more rigid, allows early rehabilitation. External fixation has a limited yet defined role for metacarpal fractures with complex soft-tissue injury and/or segmental bone loss. The recent development of bioabsorbable implants holds promise for skeletal rigidity with minimal soft-tissue morbidity, but long-term in vivo data supporting the use of these implants is not currently available. Copyright © 2002 by the American Society for Surgery of the Hand     

Frakturen der Mittelhand

This multicenter study analyzes data on metacarpal fractures in 1260 patients to determine optimal treatment concepts. Of the 740 patients followed up, 487 (66%) presented with fractures of a single metacarpal in one of the three most frequently observed locations (distal fractures of the 4th and 5th metacarpal, shaft fractures of the 2nd to 5th metacarpal, and fractures of the base of the first metacarpal). The overall clinical and radiological results were good to excellent. The "path" analysis used to identify baseline parameters and treatment options influencing outcome led to recommendations for metacarpal fracture treatment. Functional protocols are predominantly applied for postoperative/post-traumatic treatment. Pain and regional pain syndromes should be prevented whenever possible and early adequate treatment should be initiated due to their significant impact on outcome.     

Corrective osteotomy of malunited fractures of phalanges and metacarpals

We have retrospectively reviewed our experience of corrective osteotomies for phalangeal and metacarpal malunions in eleven patients over a 5-year period. Rotational metacarpal malunion treated by metacarpal osteotomy and AO plate fixation can be performed with confidence of achieving a good or excellent result. Phalangeal osteotomy remains a daunting undertaking for most hand surgeons. Our indifferent results are probably due to the inclusion of three intraarticular malunions treated by extraarticular osteotomy. An alternative approach to these malunions may be appropriate.     

The management of long bone fracture in the spinal cord injured patient.

Principles of management of long bone fractures in patients with spinal cord injuries vary with the type of fracture and duration of quadriplegia. Class I fractures (acute injuries) are managed by existing principles of long bone fracture management with a tendency to open reduction and internal fixation to dispense with the necessity of plaster casts on insensate skin. Class II fractures (pathologic--osteoporotic) heal well, require minimal specific treatment, and open reduction is usually contraindicated. Class III fractures (acute injuries in chronic paraplegia) are treated with methods least likely to disrupt the patient's life style in a wheelchair. Open reduction should be used whenever there are difficulties with circular casts and traction methods.     

Minimally invasive intramedullary rod fixation of multiple metacarpal shaft fractures

Metacarpal shaft fractures tend to shorten and angulate. This tendency is accentuated with the fracture of multiple metacarpals. A variety of methods for treatment have been described. The purpose of this study is to present the results of treatment in patients with multiple metacarpal shaft fractures, treated in a minimally invasive manner, with an intramedullary rod device.     

Boxer's fracture: Cost evaluation orthopaedic or surgical treatment

Many methods of treatment have been proposed for fractures of the neck of the fifth metacarpal ranging from early mobilization to various surgical techniques. The aim of this retrospective study was to evaluate the functional results and the costs of closed as opposed to open treatment (Foucher's K-Wire technique). MATERIALS AND METHODS: We conducted a retrospective study on all fractures without rotational deformity and with a palmar angulation less than 40 degrees C. Details of the patients, the fractures, functional results and the cost of management were analyzed. RESULTS: The functional results were similar between the two groups, but surgical treatment increased the cost of treatment to 1100 euros. CONCLUSIONS: We advocate the use of closed treatment for these fractures. The functional results are the same as with surgical management, but the costs are much reduced.     

Osteosynthesis for the unstable fracture of the hand

Unstable, displaced, fractures of the hand present a challenge to surgeons all over the world. Retention of the reduction using a cast, splint or even K wire fixation is difficult during the period of bone healing: also a relatively prolonged period of immobilisation after such treatment leads to stiffness of the metacarpal and finger joints. The picture gets more complicated if the hand suffers more than one fracture. The unique ability of the hand to grasp and grip objects of different size and shape depends on the intact functional anatomy of the hand articulations. Thus accurate and stable reduction of metacarpal and phalangeal fractures is essential for early active mobility with a view to early return to work even before the recovery is complete, especially in the case of an industrial worker. We recommend osteosynthesis as a method of choice for treating such displaced, unstable fractures of the hand as shown by the present retrospective study of fifty patients. We suggest a simple practical method of assessing the results of treatment for severe fractures of the hand.