Embrochage à foyer fermé antérograde pour les fractures des métacarpiens – étude prospective sur 150 cas

Abstract

The aim of the study was to asses the results of antegrade percutaneous intramedullary K-wire fixation, for unstable displaced metacarpal fractures in a large number of cases in order to support the usage of this mini invasive technique in the largest variety of fractures as possible. One hundred and fifty patients with 165 metacarpal fractures were evaluated. Average follow-up 10 weeks. TAM of the digit, rotational deformity, Q-DASH score and PRWHE score were recorded. The radiographic outcome was assessed by evaluating the dorsal angulation and shortening of the metacarpal. Regional anesthesia, fluoroscopic guidance and upper arm tourniquet were always used. Once the metacarpal fracture was reduced, a hole at the proximal epiphiseal dorsal corner was performed percutaneously with a pointed tip K-wire (2 mm of diameter) with an incidence of about 40°. Then, a blunt tip K-wire, was inserted through the hole in the metacarpal bone in the anterograde direction along the whole intramedullary canal until the internal cortical bone of the metacarpal head, in order to obtain a stable fixation. Number and diameter of the K-wire depend on the fracture morphotype and on the size of medullary canal. They were selected to fit in the intramedullary space well to supply maximum fracture stability, verified with dynamic test. The wires were bent approximately of 90° to be perpendicular to the dorsal skin and then cut to about 2 cm outside of it to prevent tendon impingement, which is possible with subcutaneous wire cutting. A soft dressing was applied for all the patients, encouraged to begin full motion exercises. At 5 weeks the wires were removed. Few precautions distinguish our technique over others described in the literature, but they are crucial in our opinion. Percutaneous antegrade approach without joint transfixation and tendon exposition joined to an immediate finger motion is able to avoid stiffness and tendon adhesions. The thickness of K-wires is always the largest possible to ensure rotational and length stability. Do not cut the wire under the skin, prevents tendon irritations and this leads to a very low incidence of complications such as infection, algodystrophy and need for second operations. This technique represents a valid solution for the treatment of many kind of displaced and unstable fractures of the metacarpals, being of fast running, of low cost and offering excellent results both in terms clinical and radiographic.