A comparative study of clinical and functional outcome between K-Wire and jess for fixation of extra articular metacarpal fractures

Background: The incidence of Hand and Forearm fractures accounts for 1.5% of all Emergency cases. They are the 3rd commonest hand fractures next to distal forearm and phalanges. Closed multiple metacarpal fractures are found to be highly unstable and are more prone for poor functional outcome when they are managed conservatively. In this study we assessed the functional and radiological outcome of Mini Implants for closed metacarpal diaphyseal fractures. Patients And Methods: In our study we had 22 patients with closed metacarpal fracture which were treated with open reduction and internal fixation with mini screws and plates. Functional outcomes were assessed clinically using TAF (Total Active Flexion) and ASSH(American Society for Surgery of Hand) Scoring system and radiologically using RUST scoring system at 6 weeks, 3rd month and 6th month. Result: Union rates of 100% were achieved in all cases. The average time period of union in our study was 13.3 weeks. Functional outcomes were excellent in all cases with an active range of movement >220 degrees. Twocases developed infection, one was superficial and the another was deep infection. Infection got resolved for both the patients with adequate antibiotics and regular dressings. Conclusion: In this study we concluded that mini screws and plates is a good option for treating closed diaphyseal metacarpal fractures as it provided a rigid fixation for early mobilization and had a good functional outcome. Keywords: Hand, Metacarpal fracture, mini implants

Intramedullary nail (IMN) fixation of metacarpal fractures is an alternative to Kirschner wire (K-wire) fixation. The goal of this study was to compare the biomechanical properties of K-wire fixation with a threaded IMN (InNate; ExsoMed, Aliso Viejo, California). The study design was based on previously described biomechanical models for evaluating metacarpal fractures. Sixteen fresh frozen small finger-matched and ring finger-matched pairs were randomized to either IMN or 0.045 in K-wire fixation after receiving a standardized neck osteotomy. Proper implant placement was confirmed with plain radiographs. Specimens then underwent loading in a 3-point bend configuration. Load to failure (LTF), stiffness, and fracture displacement were recorded. Mechanical failure was defined by a sharp change in the load-displacement curve. Age, sex, sidedness (left or right), and digit (ring or small finger) were evenly distributed between groups. The IMN had a significantly higher LTF than K-wires (546 N vs 154 N, P < .001). The K-wire fixation demonstrated plastic deformation between 75 and 150 N. Intramedullary nail stiffness was higher than that of K-wires (155.89 N/mm vs 59.28 N/mm, P < .001). When surgical fixation is indicated for metacarpal neck and shaft fractures, the threaded IMN is biomechanically superior to crossed K-wires with the application of 3-point bend.

Metacarpal fracture is the most common fracture of the hand. Many successful techniques have been developed to treat metacarpal fractures. We describe a method for the reduction and fixation of metacarpal fractures using absorbable suture and the Nice knot cerclage technique. The cerclage technique is a simple method of internal fixation and is used to tighten the bone fragments or soft tissue for repair. Westberg et al.1 reported that high-performance sutures might provide an alternative to steel wire for cerclage fixation, namely, nonmetallic cerclage, because they performed well in biomechanical tests. The Nice knot combines a doubled suture with a sliding knot that is self-stabilizing, adjustable, and easy to perform. It allows accurate control of the tension applied and provides progressive tensioning.2 In addition, the Nice knot resulted in greater stiffness and less elongation in static testing and was much more resistant to elongation in dynamic testing. After the fracture is reduced and provisional fixation is applied with a reduction clamp, a coated Vicryl Plus antibacterial (polyglactin 910) absorbable suture (size 0; Ethicon, Somerville, N.J.) is used. Two cerclage Nice knots are tied at the ends of the oblique fracture (Fig. 1). Then the sliding knot is tightened down to obtain both progressive tensioning2 and interfragmentary compression. Nice knots can be placed on either the radial or ulnar side of the metacarpal to prevent irritation of the extensor tendon.Fig. 1.: Intraoperative photograph demonstrating double cerclage Nice knot suture fixation of the fourth metacarpal oblique fracture. Lateral placement of the knots prevents tendonitis.In our case example, there was no significant interfragmentary micromotion with passive finger movement during the operation. [See Video (online), which shows an anatomic reduction and no interfragmentary micromotion of the fractures.] Both fractures healed well clinically and radiographically (Fig. 2) at postoperative follow-up. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video.","caption":"The intraoperative video revealed anatomic reduction and no interfragmentary micromotion of the fractures.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_9iqk3bdr"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Fig. 2.: Two months after the operation, an oblique radiograph shows excellent alignment and bony union.The polyglactin suture can be dissolved and absorbed by the patient’s body. It also does not irritate tendons or surrounding tissues. The degradation time is long enough to allow initial bony union of fractures. Unlike with the hemicerclage,3,4 we do not need to drill holes in the metacarpal bone, as the suture is passed circumferentially around the shaft and knotted either on the radial or ulnar side. Besides, the friction of the double-strand sutures against the bone surface is sufficient to resist slippage. Full cerclages fix the bone fragments directly to one another and produce angular and rotational stability, and they have much more sufficient stability, in contrast to nonmetallic hemicerclage.4 With the absorption of sutures, the static concentric compression of nonmetallic cerclage will decrease, and the influence on the periosteum blood supply will gradually disappear. Current existing nonmetallic materials produce a lower pretension than that seen with the metallic cerclage, and the strangulation resulting in bone necrosis is currently not found.5 Since we have been applying this technique to fix metacarpal fractures, no patients with delay union or nonunion have been found. There is also no need for a second operation to remove the internal fixation, unlike with the metal hemicerclage technique.3 We have applied this technique to fixation of clavicular, ulnar, and radial fractures, especially the butterfly fracture block, sometimes as an assistant rather than a final fixation. This method is suggested as an option for fracture fixation in some unusual circumstances, such as metal allergies and open fractures. Ideal indications for this technique are long oblique or torsion fractures of the metacarpals. ACKNOWLEDGMENTS The authors would like to thank Wen-Tao Wang for information technology support. The present study was approved by the ethics committee of Karamay Central Hospital and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki. Informed written consent was obtained from all patients. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding was received for this article.

INTRODUCTION: Metacarpal fractures are a common occurrence in the United States, making up 33.3% of all hand fractures. The majority can be treated nonoperatively, but surgery is indicated when fractures cannot be reduced or fracture alignment cannot be stabilized using closed methods. In 2010, Boulton et al reported intramedullary cannulated headless screw fixation of a comminuted subcapital metacarpal fracture. This method has since been described as an operative technique for displaced, comminuted subcapital, and metacarpal neck and shaft fractures. The purpose of this review is to evaluate the recent studies reporting on the outcomes of intramedullary screw fixation of metacarpal fractures. METHODS: Pubmed, Web of Science, and Cochrane were searched. All outcome data from articles reporting on the use of intramedullary screws for the treatment of metacarpal fractures were combined. RESULTS: A total of five articles, one of which was the original case report, were identified for a total of 115 metacarpal fracture repairs performed using intramedullary screw fixation. The majority (84%) were in the small finger with fracture location in the metacarpal neck (69%). All studies used 2.4mm or 3.0mm screws ranging from 32-50mm in length for fixation. Average follow-up was 14 months with an average MCP flexion of 82 degrees (n=78). One study (n=18) did not record MCP flexion, but reported each digit to have a total active motion >240 degrees. All but one study measured radiographic union as an outcome, and all (n=78) resulted in 100% union at or before the latest follow-up. Additionally, grip strength was assessed in two studies (n=29), which showed an average of at least 98% of the contralateral hand. No serious complications were reported. Only one hardware removal was performed due to radiographic suspicion of intra-articular screw penetration. Of note this was a complication of the Y strutting technique in which two intramedullary screws are placed. CONCLUSION: Intramedullary fixation of metacarpal fractures using headless compression screws has thus far proven to be a safe and successful surgical treatment option for metacarpal fractures. Advantages of this technique over previously described methods (intramedullary nail or percutaneous K-wire fixation) include no requirement of K-wire removal and increased rotational stability, thus allowing for earlier mobilization.

Comparison of Intramedullary Nailing Versus Plate-Screw Fixation of Extra-Articular Metacarpal Fractures

Metacarpal and phalangeal fracture fixation may be conducted in ambulatory or inpatient settings. However, to date, little is known about the outcomes of the surgical treatment of metacarpal and phalangeal fractures in the two population groups. The aim of this study was to compare the surgical outcomes of patients undergoing treatment for metacarpal and phalangeal fractures in the ambulatory setting as compared to those in in-hospital settings. All patients who were surgically treated for metacarpal and phalangeal fractures at our institution were enrolled in this study. All patients treated non-surgically, as well as those who had sustained open fractures, were excluded from the study. A total of 85 patients met our inclusion criteria. Based on the length of hospital stay, patients were divided into two groups: inpatient (> 24 hours) and outpatient (< 24 hours). Fifty-three out of the eighty-five patients were available for follow-up examination. Patients were re-evaluated at a mean 17.9 months (range: 4-48 months; SD = 10 months) after surgery. Physical function in everyday life and specific hand function were compared between the groups using the DASH and Cooney outcome questionnaires. Range of motion of the affected side was measured using a standard goniometer and was evaluated as a proportion of total active motion (% TAM) relative to the contralateral uninjured side. Complication rates were calculated and compared between groups. There were no differences for the DASH outcome scores for phalangeal and metacarpal fractures on comparing both groups. There was also no statistically significant difference for the mean Cooney score for phalangeal fractures in both groups. The inpatient group had a significantly higher mean Cooney score (mean: 93.5; range, 70-100; SD 8.8; 95 % CI = 87.2, 99.8) after metacarpal fracture fixation than the outpatient group (mean: 82.5; range: 55-100; SD 14.5; 95 % CI = 75.3, 89.7) (p = 0.01). There was no statistically significant difference on comparing the mean proportion of total active motion (% TAM) relative to the contralateral uninjured side between the inpatient and outpatient groups (p > 0.05). The overall complication rate was 20.7 % (n = 11). The most common complication was postoperative infection with six cases (three inpatients; three outpatients). Outpatient surgical treatment of metacarpal and phalangeal fractures results in similar outcomes compared to inpatient treatment. Outpatient treatment of metacarpal and phalangeal fractures should be considered whenever possible.

This report cites new developments in the treatment of extra-articular hand fractures in adults. Recent reports confirm that small amounts of metacarpal shortening or dorsal angulation cause minimal functional impairment. Unilateral excision of the lateral band and oblique fibers of the extensor apparatus of the metacarpophalangeal joint facilitates proximal phalangeal fracture exposure and may improve functional recovery. Results using open mini screw fixation of oblique extra-articular metacarpal and phalangeal fractures may be comparable to those of percutaneous Kirschner wire fixation. Bicortical self-tapping mini screw fixation of extra-articular oblique metacarpal and phalangeal fractures simplifies screw insertion and provides stability comparable to that of fractures fixed with lag screws. Percutaneous intramedullary wire fixation may afford suitable fixation for unstable extra-articular oblique as well as transverse metacarpal fractures. Locked intramedullary nails may offer similar advantages. Unicortical screw fixation of mini plates securing transverse extra-articular metacarpal fractures affords stability comparable to that of bicortical screw fixation while creating less bone damage. The dissection required for plate fixation and the small surface area of transverse fractures delay and occasionally impair bone healing. Primary bone grafting of diaphyseal defects in clean stable wounds may shorten and simplify treatment and decrease morbidity. As little as 1.7 mm of flexor tendon excursion during the first 4 weeks after reduction or repair may substantially diminish peritendonous adhesions at the fracture site. Synchronous wrist and digital exercises may also reduce peritendonous fracture adhesions. Early motion of adjacent joints in closed simple metacarpal fractures expedites recovery of motion and strength without adversely affecting fracture alignment and leads to earlier return to work. Level V (expert opinion).

A comparative study of the anatomical and functional outcome between Joshi’s External Stabilization System and Kirschner wire fixation technique for Extra-articular Metacarpal fracture - IJOS- Print ISSN No: - 2395-1354 Online ISSN No:- 2395-1362 Article DOI No:- 10.18231/j.ijos.2020.002, Indian Journal of Orthopaedi

Fractures of the hand.

Background: Hand fractures can be treated conservatively or surgically, depending on the severity, location, and type of fracture, as in conservative management chance of nonunion, malunion, and stiffness is more if it is displaced or angulated fracture. Various modes of treatment have been used which include K-wire fixation, mini plates, and external fixator application. A modified form of mini-external fixator devised in India is Joshi's External Stabilization System (JESS). Aim: This prospective study was conducted to compare the functional and radiological outcomes following metacarpal/phalangeal fracture fixed with either K-wire or JESS. Materials and Methods: Forty patients with hand fractures (58 fractures – 18 metacarpal and 40 phalanges) were prospectively studied. Twenty patients underwent K-wire fixation and 20 were fixed with JESS, functional and radiological outcomes were assessed, grip strength using dynamometer, visual analog scale (VAS) score, disabilities of the arm, shoulder, and hand (DASH) score, range of motion (ROM) using the American Society for Surgery of the hand scale, tip pinch strength. Student's t-test, Wilcoxon test, Fisher's exact test, and Chi-squared test were used. Results: At 6 months' follow-up, patients fixed with either of the fixation modality showed statistically significant improvement in different outcome variables such as ROM (P &lt; 0.001), quick DASH score (P &lt; 0.001), VAS score (P &lt; 0.001), tip pinch strength (P &lt; 0.001), and hand grip (P &lt; 0.001). All the fractures united at an average 6 weeks. Functional outcomes were excellent in closed fracture fixed with either JESS or K-wire and good to moderate in open injuries. However, overall comparison between K-wire and JESS, no significant difference in these outcome measures was found. Conclusions: K-wires as well as JESS both provide adequate stability and satisfactory results in fractures of the metacarpal and phalanges. This study could not find the superiority of JESS over traditional K-wire fixation.

Background: Intramedullary screws (IMS) have become a viable option for metacarpal fracture fixation. To further appraise their utility, this study assessed clinical and patient-reported short- and medium-term outcomes of IMS fixation for extra-articular metacarpal fractures. Methods: A retrospective cohort study was performed in a series of 32 patients (with a total of 37 fractures) who underwent metacarpal fracture fixation over a 42-month period between January 2020 and July 2023. Results: Mean time for return to work was 39.8 days; mean time for return to full function was 88.4 days; total active motion was 250.7° (range: 204.9-270.9); Quick Disabilities of the Arm, Shoulder and Hand score was 2.3 (range: 0-22.7); mean visual analogue pain score was 0.9 out of 10 (range: 0-6) and a single complication was observed. Conclusions: The use of IMS in metacarpal fracture fixation is a practicable surgical option. IMS fixations yields a satisfactory duration for return to function, good postoperative range of movement, modest pain scores and low rates of complications. Level of Evidence: Level IV (Therapeutic).

Compare two simple ways for treating boxer's fractures in active adults; conservative management by ulnar gutter slab and transverse pinning in fixation of fifth metacarpal's neck fracture regarding union, functional outcomes, and complications. Ninety patients with fifth metacarpals' neck fractures with palmar angulation (30-70°) were managed either conservatively by an ulnar gutter slab or surgically by transverse pinning technique from January 2020 to December 2021. Only 84 patients completed a 1-year follow-up. Patients with old, open, or mal-rotated fractures were excluded. The block-randomization method was used to create equal groups. Patients were evaluated clinically and radiologically every 2-3 weeks until union, then at 6 and 12 months. Functional assessment at the final visit was done using the quick DASH score, total active motion (TAM), and total Active Flexion (TAF). The mean radiological union time for the conservative group in this study was 7.76 weeks, while for the transverse pinning group, it was 7.38 weeks. There was no statistically significant difference between the two techniques regarding union rates and functional outcomes. All patients returned to their pre-injury jobs and level of activity. Both conservative management in ulnar gutter slab and percutaneous transverse pinning are considered effective methods in the treatment of simple extra-articular fifth metacarpal neck fractures with angulation between 30 and 70 degrees (AO: 77 A3.1). The functional and radiological results using both methods were satisfactory and statistically comparable.

Extra-articular distal radius fractures are common upper limb injuries, and optimal surgical intervention remains debated. While Kirschner’s wire (K-wire) fixation is traditionally used, volar locking plates such as the T-butterfly (T-butters) plate offer potentially superior outcomes. Objective: To assess the functional outcome of extra-articular distal radius fractures treated with T-butters volar locking plate compared to closed reduction and K-wire fixation. Methods: This quasi-experimental study was conducted at SKBZ/CMH Muzaffarabad after obtaining ethical approval from January to July 2023. A total of 70 patients aged 20–40 years with extra-articular distal radius fractures were randomized into two equal groups: Group T (open reduction and internal fixation with T-butters volar locking plate) and Group K (closed reduction and K-wire fixation followed by plaster immobilization). Functional outcomes were evaluated at 20 weeks postoperatively using a standardized scoring system. Results: In Group T, 12 patients (34.3%) had excellent outcomes, 20 (57.1%) had good outcomes, and 3 (8.6%) had fair outcomes, with no poor outcomes reported. In Group K, two patients (5.7%) had excellent outcomes, 18 (51.4%) had good outcomes, 12 (34.3%) had fair outcomes, and three patients (8.6%) had poor outcomes. Functional outcomes were significantly better in Group T compared to Group K (p &lt; 0.05). Conclusion: The use of T-butters volar locking plate for the fixation of extra-articular distal radius fractures provides superior functional outcomes with fewer complications compared to K-wire fixation. It should be considered a preferred method of surgical management for such fractures in young adults.

PURPOSE: Metacarpal fractures are common injuries with multiple options for fixation, including plating and screws, K-wires, and intramedullary screws. Our purpose was to compare outcomes, including DASH score, total active motion (TAM), grip strength, and rates of re-operation or infection, in metacarpal fractures treated with intramedullary screw fixation (IMF), K-wires, or plates/screws. METHOD: A systematic literature review using the MEDLINE Database was performed for studies investigating metacarpal fractures treated with IMF, plates/screw, or K-wires. We identified nine studies using IMF, eight using plates/screws, and 17 using K-wires. A meta-analysis using random or fixed effects models was performed to calculate pooled effect size estimates, controlling for heterogeneity between studies. Outcome measures included mean DASH scores, mean TAM, mean grip strength (percentage to contralateral), mean time to radiographic healing, and the proportion of patients with infection and re-operation. RESULTS: Patients with IMF of metacarpal fractures had significantly lower mean DASH scores at an average of 0.6 [95% CI: 0.2, 1.0] compared to both K-wire (7.4 [4.8, 9.9]) and plates/screws (9.8 [5.3, 14.3]) (both p<0.001). IMF also had significantly lower rates of reoperation at 4% [2%, 7%], compared to K-wires 11% [7%, 16%], p= 0.001 and plate/screw fixation at 11% [0.07, 0.17] p=0.01. Grip strength was significantly higher in IMF (104.4% [97.0, 111.8]) compared to K-wires (88.5%, [88.3, 88.7]) and plate/screws (90.3, [85.4, 95.2] (both p<0.001). There were no statistically significant differences in time to radiographic healing of evidence, mean TAM, or rates of infection. Mean OR time was similar between IMF (average of 21.0 minutes [10.4, 31.6]) and K-wires (20.8 minutes [14.0, 27.6]), but both were shorter compared to plate/screw fixation (average 52.6 minutes [33.1, 72.1]) with K wires being significantly shorter (p<0.001). Summary This meta-analysis compares outcomes of metacarpal fixation with IMF, K-wires, or plates/screws. IMF provided statistically significant lower DASH scores, higher grip strength, lower rates of re-operation, when compared to K-wires and plates/screws for fixation of metacarpal fractures. There were no statistically significant differences in rates of mean TAM, time to radiographic healing, or rates of infection between the 3 groups. OR time was lower for both IMF and K wires as compared to plates and screws, but only K wires had enough data points for significance. CONCLUSION: Intramedullary screw fixation of metacarpal fractures provides lower DASH scores, higher grip strength, and lower rates of re-operation when compared to K-wires and plates/screws.

Objective To assess the clinical effects of closed reduction and intramedullary fixation with antegrade Kirschner wire plus rod rotation technique in the treatment of the fifth metacarpal neck fracture. Methods In this retrospective study, 26 patients with the fifth metacarpal neck fracture were treated by closed reduction and intramedullary fixation with antegrade Kirschner wire plus rod rotation technique at Department of Orthopaedics, Central Hospital of Karamay from August 2015 to October 2017. They were 23 males and 3 females, aged from 12 to 53 years with an average age of 25.2 years. In the intramedullary nailing, a Kirschner wire pre-bent by 10° to 15° was inserted from the base of the fifth metacarpal into the medullary canal before closed reduction. After satisfactory reduction was achieved, the Kirschner wire was inserted across the fracture site into the metacarpal head for further reduction and fixation using rod rotation technique. After operation, a plaster was applied to protect the fixation for 2 weeks. Functional exercise was started after removal of the plaster. The Kirschner wire was not removed under local anaesthesia at the outpatient department until about 10 to 16 weeks postoperation when X-ray showed fracture healing. Records of their operation time, head/shaft angle of the fifth affected metacarpal, active range of motion of the metacarpophalangeal joints and Total Active Movement (TAM) of hand function at the last follow-up were collected. Results Their operation time averaged 21 minutes (from 12 to 35 minutes). Anatomical reduction was achieved in 23 cases but not in 3 ones whose metacarpal head/shaft angle and alignment were obviously improved. Follow-ups for 6 to 29 months (average, 15.8 months) showed all the patients obtained solid fracture healing with no infection or delayed fracture healing. The head/shaft angle was improved significantly from preoperative 61.2°±11.2° to postoperative 14.7°±3.5° (P 0.05). The active range of motion of the metacarpophalangeal joint was 89.3°±4.2° after fixation removal, not significantly different from that of the healthy side (90.7°±1.5°) (P>0.05). According to TAM scores at the last follow-up, 22 cases were rated as excellent, 3 as good and one as fair. Conclusion In the treatment of the fifth metacarpal neck fracture, closed reduction and intramedullary fixation with antegrade Kirschner wire plus rod rotation technique is effective, because it is simple and limitedly invasive, and leads to limited complications, low costs and secondary reduction. Key words: Metacarpal bone; Fracture fixation, intramedullary; Bone nail; Fifth metacarpal neck fracture; Rod rotation