Metacarpal Neck Research Articles

Biomechanical analysis of new cross locking plates for metacarpal neck fracture

Biomechanical analysis of new cross locking plates for metacarpal neck fracture

Fifth metacarpal neck fracture fixation: antegrade intramedullary pinning with two K-wires or percutaneous retrograde crossed pinning

Objective: The present study aimed to compare clinical and radiological outcomes in patients with displaced fifth metacarpal neck fractures after treatment with antegrade intramedullary pinning with two K-wires or percutaneous retrograde crossed pinning. Material Method: While seventeen patients were treated with antegrade intramedullary pinning (Group ), 14 were treated with percutaneous retrograde crossed pinning (Group 2). Clinical and radiological outcomes included Quick Dash, active range of motion (ROM), VAS, and dorsal angulation loss at weeks four and twelve and in the final follow-up. Results: The findings revealed that the groups had mean ages of 29.41±8.15 years and 27.78±7.42 years, res-pectively. While ROM was better in Group 2 at weeks four and twelve, we could not find a significant difference between the groups by active ROM in the final follow-up. Moreover, Group 1 had a better Dash score in the fourth week and twelth week , but both groups had similar Dash scores in the final follow-up. Finally, the groups had no preoperative and postoperative differences radiologically. Conclusion: The present findings uncovered that treatment of a displaced fifth metacarpal neck fracture by anteg-rade intramedullary pinning yielded a better in the first three months improvement in active ROM and Quick Dash than percutaneous retrograde crossed pinning.

What's New in Orthopaedic Trauma.

What's New in Orthopaedic Trauma.

Prospective Comparison of the Early Outcomes of Headless Compression Screw and Percutaneous K-Wire Fixation in Metacarpal Fractures

The study aimed to assess early clinical outcomes achieved by headless compression screws (HCS) in fixation of metacarpal fractures, and to compare them with outcomes of percutaneous K-wire fixation. The hypothesis was that HCS would show better arc of motion and superior early clinical outcomes. This was a randomized study of nonthumb metacarpal neck and shaft fractures. To compare the 2 surgical techniques, 23 patients treated for metacarpal neck and shaft fractures were divided into 2 groups: 11 treated with K-wire fixation and the other 12 with HCS fixation. We followed the patients for 12 weeks. The primary objective was to compare metacarpophalangeal arc of motion, and the secondary aim was to determine clinical union, radiographic union, and recovery time before returning to employment in the 2 groups. At each follow-up visit, patients in the group treated with HCS had better metacarpophalangeal arc of motion than those treated with K-wire fixation. The HCS group showed a shorter time interval to return to work (at 3 weeks) and no complications, while the K-wire group had 1 pin track infection, which was treated with oral antibiotics and pin removal. Compared with K-wire fixation, limited-open HCS fixation for metacarpal neck and shaft fractures was superior in terms of the early postoperative metacarpophalangeal arc of motion and return to work. Therapeutic II.

Translated article] Prospective study about orthopaedic treatment of fifth metacarpal neck fractures

IntroductionThe fifth metacarpal neck fracture is traditionally treated with closed reduction and intrinsic plus cast immobilisation. Another alternative and more functional treatment is the syndactylia. The aim of our study is to compare both treatments searching for any differences in their functional outcomes. MethodWe did a prospective, controlled, masked, randomised cohort study with patients over 18 years old attended from May 2019 to May 2020 in Vigo's Sanitary Area with this injure and an angle below 40°. The collected data was: sex, age, fracture angle, range of motion of the metacarpophalangeal articulation (MCFA), grip strength, pain, fracture consolidation, Quick DASH and comfort 4 and 6 weeks after the injury. Results39 men and 1 woman were included in the sample. 36.1 years old as the age average. 90% of the injuries affected the right hand, being all the patients right-handed, finding statistically significant differences in MCFA flexion within 4 weeks and in grade of discomfort, both in favour of the syndactylia (p<.05). Any of the other collected data was statistically significant. Every fracture achieved consolidation at the end of the follow-up. ConclusionFollowing the results, we consider both immobilizations good treatment options of these fractures; nevertheless, syndactylia has proven an earlier MCFA flexion recovery and a better tolerance.

Intramedullary Single-Kirschner-Wire Fixation in Displaced Fractures of the Fifth Metacarpal Neck (Boxer's Fracture).

For this procedure, the injured arm of the patient is placed on an arm table. The incision is made 1 to 2 cm longitudinally over the ulnar base of the fifth metacarpal bone. The cortical bone is opened with an awl, and a bent 1.6-mm Kirschner wire is inserted into the medullary canal. After reaching the fracture region, the fracture is anatomically reduced. The Kirschner wire is then advanced into the head of the fifth metacarpal, securing the reduction. Malrotation can be addressed in this stage by rotating the wire under fluoroscopic control. After ensuring anatomical reduction clinically and by fluoroscopy, the wire is shortened under the skin, followed by closure of the incision. We utilize a mid-hand brace for splinting. Nonoperative treatment is common for fifth metacarpal neck fractures in the absence of malrotation, excessive angulation, and shortening. Other surgical techniques include a similar procedure that involves the use of multiple Kirschner wires, plate fixation, transverse Kirschner wire pinning, and, less commonly, retrograde headless screw fixation2,7-9. The main advantage of this technique is the preservation of the metacarpophalangeal joint and the minimal soft-tissue damage. Additionally, the use of a single Kirschner wire provides stability at low cost. With some experience, this surgery can be performed within 20 minutes1,9. This procedure provides good fracture reduction and stabilization8. The outcome is usually satisfactory, with very low Disabilities of the Arm, Shoulder, and Hand scores1. Malrotation, angulation, and shortening are sufficiently addressed, and the technique shows the same results as fixation performed with use of 2 intramedullary wires. Bending the Kirschner wire to ensure easy gliding in the medullary canal provides the opportunity to reduce the metacarpal neck once the wire is safely in the head.Aim distally as you open the cortical bone with the awl in order to facilitate the insertion of the Kirschner wire.The primary reduction should be made manually, not by the wire. Subacute fractures and substantially displaced fractures require direct force for a satisfactory reduction, which cannot be achieved by rotation of the wire only.The cortical bone on the metacarpal head is very thin. Take care not to drive the Kirschner wire through the cortical bone and into the joint.Shorten the wire under the skin approximately 1 cm above the bone surface; this ensures easy removal and prevents skin irritation. K-wire = Kirschner wire.

Trapeziectomy and Alternative Suspension Technique in Thumb Carpometacarpal Arthritis: Patient-Reported Outcome Measures

PurposeFor treatment of carpometacarpal thumb joint osteoarthritis, a trapeziectomy with an alternative suspension technique can be performed as the primary surgery or as the secondary after a failed primary surgery. This study evaluates the midterm follow-up (median, 54 months) for this technique using patient-reported outcome measures.MethodsAfter trapeziectomy, an alternative suspension technique is performed with a flexor carpi radialis tendon strip. Leaving the insertion intact, the strip is tunneled through a drill hole in the base of the first metacarpal and then through a drill hole in the second metacarpal neck and then sutured back onto itself. This suspends the first metacarpal to the shaft of the second metacarpal, creating a strong, V-shaped suspension. As the technique is performed in both the primary and secondary surgery, we analyzed both groups separately. As the primary outcome, we evaluated pain and function with the Patient-Rated Wrist and Hand Evaluation. Further, we evaluated the Disabilities of the Arm, Shoulder and Hand and Short Form 12 questionnaire scores from eligible patients. Finally, we correlated pain and function to quality of life.ResultsThe median Patient-Rated Wrist and Hand Evaluation score was 16.0 (interquartile range, 1.5–40.4) after the primary surgery and 46 (interquartile range, 34.0–75.5) after the secondary surgery. Patients after the primary surgery also scored better on the Disabilities of the Arm, Shoulder, and Hand questionnaire compared to patients after the secondary surgery. The Short Form 12 questionnaire physical scores were negatively correlated with the Disabilities of the Arm, Shoulder, and Hand questionnaire scores for the primary group (correlation coefficient, −0.468) and negatively correlated with the Patient-Rated Wrist and Hand Evaluation pain scores for the secondary group (correlation coefficient, −0.703).ConclusionsTrapeziectomy with this alternative suspension technique for treatment of carpometacarpal thumb joint osteoarthritis shows good patient-reported outcome measures for primary surgery and poor patient-reported outcome measures after the secondary surgery.Type of study/level of evidenceTherapeutic IV.

The inter-and intra-observer reliability of volar angulation measurements in a fifth metacarpal neck fracture.

The fifth metacarpal neck fracture is the most common metacarpal fracture. The palmar angulation from the fracture displacement is critical for determining treatment, yet there is no consensus regarding the angulation measurement method or the surgical cut-off value. This study aimed to identify a reliable measurement method for assessing palmar angulation. We evaluated inter-observer and intra-observer validation of measuring palmar angulation in oblique plain X-ray and computed tomography (CT) sagittal cuts. We identified surgically treated patients for acute isolated fifth metacarpal neck fracture between January 1, 2008, and December 31, 2020, and obtained preoperative, opposite hand, and final follow-up oblique X-rays and sagittal computed tomography (CT) radiograms. The oblique radiograph was taken with a 45° posteroanterior pronation. The metacarpal neck palmar angulation was measured in the radiograms using the metacarpal neck-shaft center (MNSC) angle and the shaft articular surface (SAS) angle methods by three orthopedic surgeons in two sessions. For the CT radiograms, each measurer selected the sagittal slot at their discretion to measure the angle. The final palmar angulation was the average of six measurements (two sessions, three measurers per session). The study included 51 patients; the average age was 32.5 (range 18-73) years, with 46 men and 5 women. The MNSC angle inter-observer reliability was better than the SAS angle. The MNSC angle inter-observer reliability was better than that of SAS angle. Intraclass coefficients (ICCs) for the MNSC angle demonstrated an excellent inter-observer agreement among the three measurers in the first (0.93) and second (0.88) session compared to ICCs for the SAS angle in the first (0.81) and second (0.87) session. The MNSC angle intra-observer reliability was also better than the SAS angle, with higher ICCs. Preoperative CT radiograms were available for 42 patients. Using CT scans for measurements, in the two sessions, the MNSC angle inter-observer reliability was higher than that of the SAS angle [MNSC: 0.83; SAS: 0.35], second [MSNC: 0.85; SAS: 0.81]. The intra-observer reliability was also better in the MNSC angle. When comparing average value among obtained radiograms, the physiologic angulation of the opposite hand oblique X-ray had the smallest average value, followed by preoperative CT and preoperative oblique radiography. Overall, the SAS angle measurement had a slightly larger angle than the MNSC method in the fractured and non-fractured hand measurements. Finally, a serial comparison of the oblique X-rays (pre-and postoperative, final follow-up, and the opposite hand with closed reduction and internal fixation) indicated that the angulation significantly decreased, and the post-operative values did not differ from the final follow-up X-ray for either method. The palmar angulation measurement in 45° pronated oblique X-ray using the MNSC angle method had good-to-excellent reliability, with superior results to sagittal CT radiograms. Although the angle is likely overestimated, the MNSC method is reliable for judging the fracture degree and reduction adequacy after surgery compared to the non-fractured hand physiologic angulation.

Treatment of isolated fourth metacarpal neck fractures using the closed reduction and percutaneous intermetacarpal and external fixation

BackgroundThe isolated fourth metacarpal neck fracture is uncommon, and the appropriate management is still debatable. The aim of this retrospective study was to introduce a closed reduction and percutaneously intermetacarpal K-wire fixation external technique to treat the isolated fourth metacarpal neck fracture. MethodsFrom October 2013 to January 2018, 21 patients with closed-isolated fourth metacarpal neck fractures (angulation ≥35°, rotation ≥5°, or shortening ≥5 mm) were treated with the closed reduction and percutaneous intermetacarpal and external fixation technique. Total active motion, grip strength of the hand, dorsal prominence, and patient satisfaction were assessed. ResultsFollow-up lasted 28 months (range, 24–37 months). All patients obtained bone healing at a mean time of 5 weeks (range, 4–8 weeks). External fixation devices were removed when bone healing achieved. The mean total active motion reached 97.5% (range, 92.9%–100%) of opposite side. There were 18 excellent and 3 good results. The mean grip strength reached 98.4% (range, 96.2%–100%) of the opposite hands. Based on the 100-mm visual analogue scale, the mean dorsal prominence was 0 (range, 0 to 1). Based on the Short Assessment of Patient Satisfaction, the mean satisfaction score was 26 (range, 24 to 28). ConclusionsThe closed reduction and percutaneous intermetacarpal and external fixation technique is useful and reliable for treating the isolated fourth metacarpal neck fracture. The technique can effectively restore the fracture deformities and maintain the reduction stably, resulting in good hand function. Level of evidenceTherapeutic study, Level IV.

Clinical Outcomes of Severely Angulated Fifth Metacarpal Neck Fractures Treated Nonsurgically.

Reasonable functional outcomes for nonoperative management of isolated, closed fifth metacarpal neck fractures with up to 70° angulation have been reported; however, reported outcomes for fractures with greater than 70° angulation are limited. This study describes clinical outcomes of nonsurgically treated fifth metacarpal neck fractures with angulation of greater than 70°. A retrospective review of patients treated between May 1, 2016, and May 1, 2020, included: (1) patients aged 18 years and above with an isolated, closed, fifth metacarpal neck fracture; (2) nonsurgical treatment; (3) healed fractures with angulation greater than 70° measured on oblique radiographs; and (4) minimum 6-month follow-up after injury. Photographic hand motion and patient-rated outcomes (Functional Hand Scale, Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH], 12-item Short-Form Health Survey [SF-12]) were collected and reported. A total of 364 fractures were identified; 11% (40/364) demonstrated angulation of greater than 70° (range: 71°-82°); and 15 patients (inclusion rate: 38%, 15/40) with mean fracture angulation of 73° (range: 71°-77°) participated in the study. Mean follow-up was 32 months (range: 8-120 months), the dominant hand was injured in 87% (13/15) of patients, and 47% (7/15) of patients worked in manual labor. All patients scored the highest rating of "very good" (range: 26-30 of 30 points) on the functional hand scale. A QuickDASH score of zero (no morbidity) was reported in 80% (12/15) of patients. About 87% (13/15) of patients had average or above-average scores on the SF-12 (mean = 109, range: 84-115). Patients with healed, isolated, closed fifth metacarpal neck malunions with severe angulation greater than 70° demonstrated acceptable functional outcomes based on patient-rated outcomes scoring.

Comparison of Antegrade Percutaneous Intramedullary K-wire Fixation and Transverse Pinning for Treatment of Unstable Displaced Metacarpal Neck and Shaft Fractures: A Prospective Interventional Study

Introduction: Metacarpal fractures account for upto 10% of all body fractures and 36% of all hand fractures in adolescents, young adults, and active adults. Fractures of the metacarpal shaft and neck are common in all metacarpal fractures after direct trauma, roadside accidents, or sports injuries. The ratio of the shaft to the neck is 1:2. Closed reduction and plaster of paris cast can be used to treat the majority of these fractures conservatively. Unstable and comminuted fractures necessitate surgery. Aim: To compare the clinical, functional and radiological outcomes in antegrade intramedullary fixation and transverse pinning of metacarpal fractures in patients of unstable and displaced metacarpal shaft and neck fractures. Materials and Methods: A single-institutional prospective interventional study identified 60 cases of metacarpal fractures between November 2019 to August 2021. Each of the cases met the inclusion criteria for closed extra-articular fractures, displaced and unstable fractures of the metacarpal bone. The patients were divided into two groups having 30 subjects each, randomly allotted to two groups (Antegrade intramedullary K-wiring and Transverse Pinning). Outcomes were compared for range of movement by the American Society of Hand Surgeons Total Active Motion score (ASSH TAM), Visual Analog Scale (VAS), and radiological parameters (Angulation). Patients were followed-up for 12 weeks. Complications were listed in terms of pin site infection. Results: Most of the patients were found to be in the third decade of life. The fracture union was achieved at 8±2 weeks. Clinical evaluation done by VAS score which was found to be statistically insignificant between two groups (p-value=0.243). Radiological assessment evaluated by measuring postoperative angulation between two groups was found to be statistically insignificant (p-value=0.248). Difference in functional evaluation between the two groups done by ASSH TAM was found to statistically significant between the groups (p-value=0.036). Conclusion: Both antegrade intramedullary K-wiring and transverse pinning demonstrate good and comparable results for extra-articular neck and shaft metacarpal fractures. However, the former is superior in terms of final range of motion as per ASSH TAM score.

Factors affecting healing following percutaneous intramedullary fixation of metacarpal fractures.

Although percutaneous intramedullary nailing of metacarpal fractures is a straightforward and reliable technique, it is not without complications, and patients experience different outcomes. This study analyzed factors affecting fracture healing time and complication rates in patients who underwent percutaneous intramedullary fixation of metacarpal fractures.This study was a retrospective review of the 25 patients who underwent retrograde percutaneous Kirschner wire (K-wire) nailing for fracture of the metacarpal shaft or neck at a military hospital between May 2016 and October 2018. Correlation study and multiple regression analysis were performed to evaluate variables (age, smoking history in pack-years, body-mass index, fracture site, number of K-wires used) that affect time to bone union. Clinical features of patients with metacarpal neck fractures and those with metacarpal shaft fractures were also compared.The metacarpal shaft fractures (as opposed to metacarpal neck fractures) and higher number of K-wire used were associated with longer time to bone union. Mean union time was significantly longer for metacarpal shaft fracture (8.6 weeks) than for metacarpal neck fracture (6.1 weeks) and for patients who received more K-wires than for those who received less (regression coefficient 1.307). One patient suffered fixation failure and required revision operation, and another experienced superficial infection which was treated with intravenous antibiotics.Percutaneous intramedullary nailing is an effective technique for metacarpal fractures, but fracture site and number of K-wire used affect time to achieve bone union.

Estudio prospectivo sobre el tratamiento conservador de las fracturas de cuello de quinto metacarpiano

IntroductionThe fifth metacarpal neck fracture is traditionally treated with closed reduction and intrinsic plus cast immobilization. Another alternative and more functional treatment is the syndactylia. The aim of our study is to compare both treatments searching for any differences in their functional outcomes. MethodWe did a prospective, controlled, masked, randomized cohort study with patients over 18 years old attended from May 2019 to May 2020 in Vigo's Sanitary Area with this injure and an angle below 40°. The collected data was: sex, age, fracture angle, range of motion of the metacarpophalangeal articulation (MCFA), grip strength, pain, fracture consolidation, Quick DASH and comfort 4 and 6 weeks after the injury. Results39 men and 1 woman were included in the sample. 36.1 years old as the age average. 90% of the injuries affected the right hand, being all the patients right-handed, finding statistically significant differences in MCFA flexion within 4 weeks and in grade of discomfort, both in favour of the syndactylia (p<0.05). Any of the other collected data was statistically significant. Every fracture achieved consolidation at the end of the follow-up. ConclusionFollowing the results, we consider both immobilizations good treatment options of these fractures; nevertheless, syndactylia has proven an earlier MCFA flexion recovery and a better tolerance.

Low-value injury care in the adult orthopaedic trauma population: A systematic review.

Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the evidence on these practices. We searched four databases for systematic reviews, randomised controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomised studies of interventions tool for observational studies. We summarised findings with measures of frequency and association for primary outcomes. Of the 30,670 records screened, 70studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients <60years of age, cast or splint immobilisation for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias. In this review, we identified clinical practices in orthopaedic injury care which are not supported by current evidence and whose use may be questioned. In future research, we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.

Carpometacarpal Dislocation with Third Metacarpal Fracture.

Case PresentationA 17-year-old male presented to the emergency department (ED) due to trauma to the right hand and wrist after punching a locker at school. He had significant soft tissue swelling. Radiographs demonstrated intra-articular metacarpal fractures with associated carpometacarpal dislocations. The dislocation was reduced bedside in the ED and ultimately underwent closed reduction surgical management with orthopedic surgery.DiscussionMetacarpal fractures result from high-force impact injuries and account for 30–40% of all hand injuries. The most common sites of second through fifth metacarpal fractures are at the neck and the shaft, with the majority involving the fifth metacarpal neck (commonly coined “boxer’s fractures”). Carpometacarpal (CMC) dislocations are a rare injury associated with high-force impact trauma to the wrist. These injuries account for as little as 1% of all acute hand and wrist injuries.1,2 Carpometacarpal dislocations are often difficult to diagnose on physical examination due to significant soft tissue swelling, and they can easily be missed on anterior-posterior views of the hand. Lateral and oblique plain radiograph views are essential in the diagnosis as they are more likely to show dislocations. Despite appropriate plain radiographic views, subtle CMC dislocations may be difficult to discern dependent on the level of dislocation or subluxation and overlapping of joints. These injuries are rare due to otherwise highly stable ligamentous and muscular attachments within the wrist. Because of these attachments, dislocations are often associated with concomitant metacarpal fractures.3

Fifth Metacarpal Neck Fractures: Outcome-influencing Factors

Abstract Introduction Fifth metacarpal neck fractures are extremely common, but there is still no consensus regarding the ideal course of treatment.Volar angulation and shortening are decisive factors; however, there is still controversy about the cut-off values that translate into worse clinical results.The present study aims to answer these questions in order to provide additional data to aid in the clinical practice and decision making. Materials and Methods A retrospective study evaluated patients with fifth metacarpal fractures treated between 2013 and 2018. A total of 133 patients were included, with an average follow-up of 2 months. Surgery was performed in 21 patients, and 112 were treated conservatively. The radiological assessment of volar anguation and shortening was based in the first and last radiographs of the follow-up. The patients were contacted and submited to a questionnaire that included the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score and subjective evaluations of pain (Visual Analogue Scale, VAS), hand strength, stiffness and finger mobility, and cosmetic result. Results Surgery was more successful in reducing angulation than the conservative treatment, achieving more anatomic final values for angulation and shortening (p &lt; 0.05). On the other hand, surgery seems to be associated with a higher notion of limited finger mobility (p = 0.02).Among patients treated conservatively, inicial angulations &gt; 60° and final angulations &gt; 50° were associated with worse cosmetic results (p = 0,039). Final shortening &gt; 4 mm translated into a higher notion of stiffness and limited finger mobility (p = 0.034).More advanced age showed a correlation with higher scores on the VAS (p = 0.023) and QuickDASH (p &lt; 0,001). Female patients (p = 0.02) were also associated with higher VAS scores. The overall satisfaction rate was of 97%. Conclusion Although globally the functional outcome of these fractures is very good, the present study reports several factors that should be considered when treating fifth metacarpal neck fractures.

1254 Virtual Fracture Clinic Management of Little (5th) Metacarpal Neck Fractures; a Safe and Feasible Option?

AimTo determine the safety and efficacy of a Virtual Fracture Clinic (VFC) in managing little metacarpal neck fractures.MethodRetrospective review of consecutive little MC neck fractures presenting to the ED June-December 2020 and subsequently referred on to VFC. Patient demographics and clinic outcomes were reviewed using electronic patient records and radiographs.ResultsFifty patients were identified (Male:Female 37:13; mean age 26 years, range 3-89 years). Of these, 41/50 were discharged directly following VFC advice, with no adverse event. The remaining 9/50 had a face-to-face Fracture Clinic review due to safeguarding concerns (2), concurrent neck of fourth MC fracture (2), concerns regarding fracture pattern (4), and an unclear indication (1). These 9/50 were discharged after single review, with no adverse events to date.ConclusionsOur data suggest that VFC review of patients with little MC neck fractures is a safe and feasible means of patient care which has the potential to reduce the requirement of face-to-face patient contact during the Covid-19 pandemic and reduce fracture clinic attendance. We suggest the routine incorporation of a Virtual Fracture Clinic for these hand injuries. Further work is needed to formally investigate associated patient satisfaction and the application of this approach to other trauma presentations.

Comparison of Results Based on the Number of Kirschner Wires of Different Diameters in Antegrade Intramedullary Fixation of Fifth Metacarpal Neck Fractures

Purpose: The purpose of this study was to compare the clinical and radiological results of patients with fifth metacarpal neck fractures using different sizes and numbers of Kirschner wires (K-wire).Methods: A single institutional retrospective review identified 67 patients with a fifth metacarpal neck fracture between January 2015 and July 2020. The minimum follow-up time was 6 months and they were all treated within 6.4 days of the initial injury. Either one K-wire (1.6 mm), two K-wires (1.1 mm), or three K-wires (0.9 mm) was used. We analyzed the bone union period, and K-wire removal period, duration of surgery, total active motion, intramedullary diameter, pre/postoperative shortening, and pre/postoperative angulation clinically. We used a Method of Shortening Stipulated to measure shortening and the Medullary Canal-lateral view method for angulation. The intramedullary diameter was measured in the mid-shaft of the fifth metacarpal bone in the coronal view. Total active motion was measured at the time of follow-up in our outpatient department.Results: Clinical and radiological parameters showed no statistically significant differences. Even though it did not present a statistical significance, the absolute mean duration of surgery was the shortest in a single K-wire group. Conclusion: The clinical and radiological outcomes of surgery were comparable regardless of the number of K-wires inserted. However, we could look forward to gaining potential benefit from shortened operation time in a single K-wire group. Since stable fixation can be obtained even if one K-wire is used, inserting one thick K-wire into the intramedullary canal can be an alternative according to the surgeon’s preference.

Irreducible Metacarpal Neck Fracture due to Interposition of the Extensor Tendons.

A 15-year-old male presented with multiple right-hand fractures, including a severely angulated small finger metacarpal neck fracture. Multiple closed attempts failed, and open reduction was performed. At surgery, the extensor tendon was found to be interposed within the fracture, thereby preventing closed reduction. The tendon was extricated from the fracture site, adequate reduction was obtained, and the fracture was stabilized using K-wires. The fracture united well, with good return of motion and strength. Extensor tendon interposition is a rare scenario associated with metacarpal neck fractures and should be suspected when there is complete loss of contact between the fracture ends and multiple attempts at closed reduction have failed.

AN ATYPICAL PRESENTATION OF LEMIERRE'S SYNDROME

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lemierre's syndrome involves recent oropharyngeal infection, clinical or radiological evidence of internal jugular vein thrombosis, and isolation of anaerobic pathogens, most commonly Fusobacterium necrophorum. We present an atypical presentation of Lemierre's syndrome. CASE PRESENTATION: A 28-year-old male with a history of left second metacarpal neck fracture status post open internal reduction and pin removal one month prior presented with malaise, chills, and hand pain. His review of systems were significant for fever, headache, sore throat, productive cough, pleuritic chest pain, and dyspnea. He was febrile, tachycardic, and hypoxic. Examination revealed edema and erythema of the left hand and wrist, tenderness to palpation, and a bounding radial pulse. Laboratory investigations revealed a white cell count of 7.7 Thou/mcL, C-reactive protein 28.65 mg/dL, lactic acid 5.1 mmol/L, and procalcitonin 74.64 ng/mL. Chest X-ray showed bibasilar infiltrates. Computed tomography (CT) of the left hand showed soft tissue edema and emphysema of the wrist, hand, and forearm. He was diagnosed with sepsis due to left upper extremity necrotizing fasciitis and underwent fasciotomy with debridement. Wound cultures had no growth. Blood cultures grew Fusobacterium necrophorum. CT angiography of the pulmonary arteries revealed septic emboli. Venous duplex of the upper extremities revealed a chronic complete thrombus of the right internal jugular vein. Transthoracic echocardiogram showed no evidence of endocarditis. The diagnosis of Lemierre's Syndrome was made. The patient was discharged on enoxaparin and metronidazole for treatment. DISCUSSION: Lemierre's syndrome was first characterized by Dr. Andre Lemierre in 1936.1 The incidence decreased significantly with widespread usage of beta-lactam antibiotics in pharyngiitis.1 Due to antibiotic stewardship, the incidence has increased.1 Our patient presented with fever, left hand pain, and concern for necrotizing fasciitis with low suspicion of Lemierre's syndrome. Upon review, he did have elements consistent with the typical presentation of Lemierre's. Fever and sore throat are predominant symptoms; late sequelae involve septic emboli to the lungs resulting in chest pain and shortness of breath.3 Despite the increase in incidence of Lemierre's syndrome since physicians began practicing antibiotic stewardship, it is still rare. It is important to keep this as a differential as the mortality is around 5% if left untreated.1 CONCLUSIONS: The incidence of Lemierre's Syndrome continues to rise with the practice of antibiotic stewardship. It is crucial to consider this potentially fatal diagnosis when the clinical picture is consistent with Lemierre's syndrome. REFERENCE #1: Karkos PD, Asrani S, Karkos CD, et al. Lemierre's syndrome: A systematic review. Laryngoscope. 2009;119(8):1552-1559. doi:10.1002/lary.20542 REFERENCE #2: Lee WS, Jean SS, Chen FL, Hsieh SM, Hsueh PR. Lemierre's syndrome: A forgotten and re-emerging infection. J Microbiol Immunol Infect. 2020;53(4):513-517. doi:10.1016/j.jmii.2020.03.027 REFERENCE #3: Olivier JB, Al-Hourani K, Bolland B. Lemierre's syndrome; a rare cause of septic arthritis. BMJ Case Rep. 2017;2017:bcr2017220110. Published 2017 May 12. doi:10.1136/bcr-2017-220110 DISCLOSURES: No relevant relationships by Mikhail de Jesus, source=Web Response no disclosure on file for Jason Jacob; No relevant relationships by Rafae Shaikh, source=Web Response No relevant relationships by Asiya Tafader, source=Web Response