Metacarpal Shaft Fractures Research Articles

Management of metacarpal shaft fractures: a survey of current UK practice.

Metacarpal shaft fractures (MSF) are common injuries that predominantly affect young, economically active people. However, there is limited evidence to guide their management. The aims of this study were to: evaluate the management of extra-articular MSF of the fingers; assess equipoise for surgical and nonsurgical treatments; and explore factors influencing clinician decision making to inform the design of a randomised controlled trial (RCT) comparing surgical and nonsurgical treatments. A cross-sectional, web-based survey was distributed to UK hand surgeons using membership directories of different professional networks. Practice setting, clinical experience, management strategies, willingness to participate in a RCT and factors affecting suitability for randomisation were recorded. There were 108 responses eligible for analysis. Distribution of clinical experience ranged from <5 to >20 years. A variety of treatments were used for transverse, long oblique/spiral and comminuted MSF. Rotational deformity (90%), step-off deformity (5%) and angulation (5%) were the most important indications for surgical fixation. Acceptable limits of fracture angulation and shortening varied among surgeons. Over 85% expressed interest in participating in a RCT and most showed equipoise and were willing to offer operative or nonoperative treatment as part of a research study. This survey demonstrates that UK hand surgeons have varying views on treatments, acceptable parameters of deformity and indications for surgical fixation of displaced MSF. There is equipoise for surgical and nonsurgical treatments, variability in factors influencing clinical decision making and support for RCTs to investigate best practice.

Non-operative treatment of metacarpal fractures and patient-reported outcomes: a multicentre snapshot study

Abstract Purpose This study aimed to investigate practice variation in non-operative treatment methods and immobilisation duration for metacarpal fractures, and to evaluate patient-reported outcomes. Methods Conducted in 12 Dutch hospitals over three months in 2020, this study included adult patients with non-operatively treated solitary metacarpal fractures. Fractures were classified into intra-articular base, extra-articular base, shaft, neck, and intra-articular head fractures. The treatment methods (functional treatment allowing digit mobilisation or immobilisation) and immobilisation duration were assessed. Patient-reported outcomes were evaluated using the Michigan Hand Outcomes Questionnaire (MHQ) at three months post-trauma. Results Of 389 included patients, shaft fractures were most common (n = 150, 39%), with 93% immobilised, followed by fifth metacarpal neck fractures (n = 93, 24%), with 75% immobilised. Immobilisation rates for fifth metacarpal neck fractures varied between hospitals, ranging from 29% (95% CI 0.10–0.58) to 100% (95% CI 0.78–1.00). The median immobilisation duration for all fractures was 23 days (IQR: 20–28), and hospital setting was independently associated with this duration. Patients with metacarpal shaft fractures immobilised for less than 21 days had higher MHQ scores compared to those immobilised for 21 days or more (median (IQR) 83 (76–100) versus 71 (57–89), p = 0.026). Conclusions The results showed practice variation in the treatment of metacarpal fractures, especially in the treatment of fifth MC neck fractures, with some hospitals following the Dutch guideline that advocates functional treatment while others did not. There are suggestions that prolonged immobilisation of metacarpal shaft fractures may lead to a worse MHQ score. These findings underscore the need for adherence to treatment protocols and emphasize functional treatment to potentially improve patient outcomes and cost-effectiveness.

Management of metacarpal shaft fractures.

The aims of this study were to describe the epidemiology of metacarpal shaft fractures (MSFs), assess variation in treatment and complications following standard care, document hospital resource use, and explore factors associated with treatment modality. A multicentre, cross-sectional retrospective study of MSFs at six centres in the UK. We collected and analyzed healthcare records, operative notes, and radiographs of adults presenting within ten days of a MSF affecting the second to fifth metacarpal between 1 August 2016 and 31 July 2017. Total emergency department (ED) attendances were used to estimate prevalence. A total of 793 patients (75% male, 25% female) with 897 MSFs were included, comprising 0.1% of 837,212 ED attendances. The annual incidence of MSF was 40 per 100,000. The median age was 27 years (IQR 21 to 41); the highest incidence was in men aged 16 to 24 years. Transverse fractures were the most common. Over 80% of all fractures were treated non-surgically, with variation across centres. Overall, 12 types of non-surgical and six types of surgical treatment were used. Fracture pattern, complexity, displacement, and age determined choice of treatment. Patients who were treated surgically required more radiographs and longer radiological and outpatient follow-up, and were more likely to be referred for therapy. Complications occurred in 5% of patients (39/793). Most patients attended planned follow-up, with 20% (160/783) failing to attend at least one or more clinic appointments. MSFs are common hand injuries among young, working (economically active) men, but there is considerable heterogeneity in treatment, rehabilitation, and resource use. They are a burden on healthcare resources and society, thus further research is needed to optimize treatment.

Fixation of Long Oblique and Spiral Metacarpal Shaft Fractures With Intramedullary Screw and Cerclage Wires

Introduction: Long oblique and spiral metacarpal shaft fractures are length-unstable fracture patterns susceptible to malrotation and shortening. We expand the use of intramedullary screw fixation for traditional length-unstable fracture patterns including long oblique and spiral with cerclage wire augmentation. Materials and Methods: Surgical technique of intramedullary screws for long oblique and spiral metacarpal shaft fractures, augmented with cerclage wires, is described. Case series of patients who underwent this technique over a 3-year period from 2 surgeons at a single institution were evaluated. The inclusion criteria included patients who underwent this technique with long oblique or spiral metacarpal shaft fractures. The exclusion criteria included open injuries, and base or neck fractures. Results: A total of 8 patients were included with an average age at surgery 42 years old (range, 25 to 70). Six of the 8 patients achieved full range of motion at the time of final follow-up. One patient had ~5 to 10-degree deficit in both flexion and extension, and the other had 20-degree loss in both flexion and extension. The follow-up averaged 62 days (range, 25 to 144 days). There were no patients with nonunion, malunion, hardware failure, or postoperative fracture subsidence or malrotation. The average time to union was 6.1 weeks (range, 3.5 to 12.4 wks). Conclusions: This hybrid technique expands the use of intramedullary screws to traditional length-unstable fractures including long oblique and spiral patterns. Patients demonstrate return to full range of motion, union approximately in 6 weeks, with minimal complications following this minimally invasive technique.

Biomechanical analysis of plate versus K-wire fixation for metacarpal shaft fractures with wedge-shaped bone defects

BackgroundMetacarpal shaft fracture is a common type of hand fracture. Numerous studies have explored fixing transverse fractures in the midshaft of the metacarpal bone. However, this section of the metacarpal bone is often susceptible to high-energy injury, resulting in comminuted fracture or bone loss. In such cases, wedge-shaped bone defects can develop in the metacarpal shaft, increasing the difficulty of performing fracture fixation. Notably, the research on this type of fracture fixation is limited. This study compared the abilities of four fixation methods to fix metacarpal shaft fractures with wedge-shaped bone defects.MethodsIn total, 28 artificial metacarpal bones were used. To create wedge-shaped bone defects, an electric saw was used to create metacarpal shaft fractures at the midshaft of each bone. The artificial metacarpal bones were then divided into four groups for fixation. The bones in the first group were fixed with a dorsal locked plate (DP group), those in the second group were fixed with a volar locked plate (VP group), and those in the third group were fixed by combining dorsal and volar locked plates (DP + VP group), and those in the fourth group were fixed with two K-wires (2 K group). Cantilever bending tests were conducted using a material testing machine to measure yielding force and stiffness. The four groups’ fixation capabilities were then assessed through analysis of variance and Tukey’s test.ResultsThe DP + VP group (164.1±44.0 N) achieved a significantly higher yielding force relative to the 2 K group (50.7 ± 8.9 N); the DP group (13.6 ± 3.0 N) and VP group (12.3 ± 1.0 N) did not differ significantly in terms of yielding force, with both achieving lower yielding forces relative to the DP + VP group and 2 K group. The DP + VP group (19.8±6.3 N/mm) achieved the highest level of stiffness, and the other three groups did not differ significantly in terms of stiffness (2 K group, 5.4 ± 1.1 N/mm; DP group, 4.0 ± 0.9 N/mm; VP group, 3.9 ± 1.9 N/mm).ConclusionsThe fixation method involving the combined use of dorsal and volar locked plates (DP + VP group) resulted in optimal outcomes with respect to fixing metacarpal shaft fractures with volar wedge bone defects.

Comparison of Closed and Open Surgical Technique for Second to Fifth Metacarpal Shaft Fractures: A Multicenter, Retrospective Study in a Dutch City Population

Comparison of Closed and Open Surgical Technique for Second to Fifth Metacarpal Shaft Fractures: A Multicenter, Retrospective Study in a Dutch City Population

Plate fixation with a single incisional approach in adjoining two metacarpal shaft fractures

Purpose: Multiple metacarpal shaft fractures are higher-energy injuries than single metacarpal shaft injuries and are considered relatively unstable because reduction is easily lost after splinting. However, few studies have been published on operative treatment because these fractures are rare. The aim of this study was to analyze the characteristics of this rare type of fracture and report the surgical outcomes. Methods: Medical records of patients with adjacent metacarpal shaft fractures who underwent surgery were retrospectively analyzed. In total, 20 cases were included in this study. A single longitudinal incision was made at the middle of the web space of affected metacarpal bones. Fractures were fixed using a plate and screws. The clinical results were evaluated by determining the metacarpophalangeal joint range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and hand grip strength at the final follow-up. Results: Among the patients included, there were fifteen male and five female patients. Their mean age was 41.2 years. The average range of motion of metacarpophalangeal joints was 78.1°. The average DASH score was 6.5. The average hand grip strength was 92.4% compared to the unaffected side. The mean time to union was 7.5 weeks. There were no cases of complications, such as soft tissue infections, joint stiffness, or extensor tendon injuries. Conclusion: Plate fixation through a single incisional approach performed for adjacent metacarpal shaft fractures showed satisfactory results. This could be a recommendable approach for two unstable adjoining metacarpal shaft fractures.

Six-Week Radiographic Follow-up Does Not Change Management for Nonoperatively Treated Extraarticular Metacarpal Shaft Fractures.

Metacarpal fractures are common and account for over 30% of all hand fractures. Previous literature has shown similar outcomes between operative and nonoperative management of metacarpal shaft fractures. There is little information regarding the natural history of conservatively managed metacarpal shaft fractures and changes in management based on follow-up radiographs. A retrospective chart review was performed on all patients who presented to a single institution with an extraarticular metacarpal shaft or base fracture between 2015 and 2019. Thirty-one patients with 37 metacarpal fractures were included for review: average age 41 years, male 48%, right hand dominant 91%, and average follow-up duration 7.3 weeks. At follow-up, a change of 2.4° in angulation (P = .0005) and a change in shortening of 0.1 mm (P = .0386) were noted over the 6-week time interval. No fractures had malrotation at presentation, and none developed malrotation during the follow-up period. Recent systematic reviews and meta-analysis have suggested that metacarpal fractures treated nonoperatively had similar outcomes to surgical fixation at 12 months of follow-up. We found that extraarticular metacarpal shaft fractures that do not meet operative indications at the initial visit should be expected to heal reliably with minimal change in angulation and shortening over time. The transition to removable brace or no brace at the 2-week follow-up is likely sufficient, and additional follow-up is not necessary and will reduce cost. Level III.

A PROSPECTIVE RANDOMIZED CONTROLLED MULTICENTRE TRIAL OF DISPLACED METACARPAL FRACTURES COMPARING NONOPERATIVE WITH OPERATIVE TREATMENT

Metacarpal fractures represent up to 33% of all hand fractures; of which the majority can be treated non-operatively. Previous research has shown excellent putcomes with non-operative treatment yet surgical stabilisation is recommended to avoid malrotation and symptomatic shortening. It is unknown whether operative is superior to non-operative treatment in oblique or spiral metacarpal shaft fractures.The aim of the study was to compare non-operative treatment of mobilisation with open surgical stabilisation.42 adults (≥ 18 years) with a single displaced oblique or spiral metacarpal shaft fractures were randomly assigned in a 1:1 pattern to either non-operative treatment with free mobilisation or operative treatment with open reduction and fixation with lag screws in a prospective study. The primary outcome measure was grip-strength in the injured hand in comparison to the uninjured hand at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Score, ranges of motion, metacarpal shortening, complications, time off work, patient satisfaction and costs were secondary outcomes.All 42 patients attended final follow-up after 1 year. The mean grip strength in the non-operative group was 104% (range 73–250%) of the contralateral hand and 96% (range 58–121%) in the operatively treated patients. Mean metacarpal shortening was 5.0 (range 0–9) mm in the non-operative group and 0.6 (range 0–7) mm in the operative group. There were five minor complications and three revision operations, all in the operative group.The costs for non-operative treatment were estimated at 1,347 USD compared to 3,834USD for operative treatment; sick leave was significantly longer in the operative group (35 days, range 0–147) than in the non-operative group (12 days, range 0–62) (p=0.008).When treated with immediate free mobilization single, patients with displaced spiral or oblique metacarpal shaft fractures have outcomes that are comparable to those after operative treatment, despite some metacarpal shortening. Complication rates, costs and sick leave are higher with operative treatment. Early mobilisation of spiral or long oblique single metacarpal fractures is the preferred treatment.Trial registration number: ClinicalTrials.gov NCT03067454

Kirschner Wire Fixation Versus Mini Plate Fixation in Multiple Metacarpal Shaft Fractures of Hand to Compare Early Range of Motion in Hand

Background: Metacarpal bone plays vital role in supporting motor functions of the human palm and is subjected to frequent stress. If a fracture of the metacarpal bone occurs, it can destabilize the palm, disrupt muscular-tendon tension, impair functions of palm joints, and have adverse impacts on the daily life and work of the patient. Objectives: To compare early range of motion (ROM) in hand following K-wire fixation versus mini plate fixation in patients with multiple metacarpal shaft fractures. Methods: Cross-sectional analysis of patients with multiple metacarpal shaft fractures was done at Mufti Mehmood Memorial Teaching Hospital, between 2021 and 2022, and comprised 108 patients managed with K-wire Fixation and mini plate fixation. The success rate as well as clinical outcome of both techniques was measured as early ROM in the hand, which was assessed at eight weeks post-surgery using DASH scores. Results: Majority of patients (p&lt;0.05) were males (73.14%), common fractures (p&lt;0.05) were closed type (75.03%), right sided (62.96%) and common cause of injury (p&lt;0.05) was traffic accidents (n=48), industrial accidents (n=13), fall (n=12), agriculture accidents (n=12) and assault (n=10). Our findings revealed that occurrence of complications was significantly higher among the patients of group K-wire fixation (11.11%) than mini wire fixation (6.48%) and assessment of ROM through DASH score system of mini plate fixation was better than K-wire fixation. Practical implication The surgeons will confidently apply mini plate fixation in patients with multiple shaft fractures rather than K-wire fixation after reading this article. Conclusion: Mini plate fixation may be more effective than K-wire fixation in restoring early ROM in the hand following surgery for multiple metacarpal shaft fractures. Keywords: DASH scoring; Palm fracture; Range of motion; Shaft fracture.

Wrist &amp; Hand

The April 2023 Wrist &amp; Hand Roundup360 looks at: MRI-based classification for acute scaphoid injuries: the OxSMART; Deep learning for detection of scaphoid fractures?; Ulnar shortening osteotomy in adolescents; Cost-utility analysis of thumb carpometacarpal resection arthroplasty; Arthritis of the wrist following scaphoid fracture nonunion; Extensor hood injuries in elite boxers; Risk factors for reoperation after flexor tendon repair; Nonoperative versus operative treatment for displaced finger metacarpal shaft fractures.

Intramedullary Metacarpal Fracture Fixation: A Biomechanical Study of Screw Diameter and Comparison With Intramedullary Wire Stabilization

Interest in intramedullary metacarpal fracture fixation (IMFF) with screws is increasing. However, the optimal screw diameter for fracture fixation is not yet established. In theory, larger screws should be more stable, but there is concern about long-term sequelae of larger metacarpal head defects and extensor mechanism injury created during insertion as well as implant cost. Therefore, the purpose of this study was to compare different diameter screws for IMFF to a popular and more cost-effective alternative of intramedullary wiring. Thirty-two cadaveric metacarpals were used in a transverse metacarpal shaft fracture model. Treatment groups consisted of IMFF with 3.0× 60 mm, 3.5 x 60 mm, and 4.5 x 60 mm screws as well as 4 1.1-mm intramedullary wires. Cyclic cantilever bending was performed with the metacarpals mounted at 45° to simulate physiologic loading. Cyclical loading at 10, 20, and 30 N was performed to determine fracture displacement, stiffness, and ultimate force. At 10, 20, and 30 N of cyclical loading, all screw diameters tested provided similar stability as measured by fracture displacement and were superior to the wire group. However, ultimate force under load to failure testing was similar between the 3.5- and 4.5-mm screws and superior to 3.0-mm screws and wires. For IMFF, 3.0, 3.5, and 4.5-mm diameter screws provide adequate stability for early active motion and are superior to wires. When comparing the different screw diameters, 3.5- and 4.5-mm diameter screws offer similar construct stability and strength superior to the 3.0-mm diameter screw. Therefore, to minimize metacarpal head morbidity, smaller screw diameters may be preferable. This study suggests that IMFF with screws is biomechanically superior to wires in cantilever bending strength in the transverse fracture model. However, smaller screws may be sufficient to permit early active motion while minimizing metacarpal head morbidity.

ANATOMY, EPIDEMIOLOGY, DIAGNOSIS, MANAGEMENT AND TREATMENT OF THE METACARPAL FRACTURES

Introduction: The fracture of the neck of the fifth metacarpal, also known as boxers fracture, is one of the most frequent traumatic pathologies seen in the emergency department and is usually treated with conservative measures. The fifth metacarpal is the most frequently fractured, representing almost 25% of all metacarpal fractures and 10% of all fractures. Objective: to define and explore the anatomy, epidemiology, approach, diagnosis, management and treatment of metacarpal fractures. Methodology: a total of 40 articles were analyzed in this review, including review and original articles, as well as cases and clinical trials, of which 26 bibliographies were used because the information collected was not important enough to be included in this study. The sources of information were Cochrane, PubMed and Google Scholar, SciElo; the terms used to search for information in Spanish, Portuguese and English were: fractura del boxeador, fratura do metacarpo, fracture of the fifth metacarpal and boxers fractures. Results: About 30% of all hand fractures and 18% of all below-elbow fractures are metacarpal fractures. Small-finger neck fractures and ring-finger shaft fractures are among the most frequent metacarpal fractures.To diagnose the boxers fracture and evaluate the degree of angulation, plain radiographs are the gold standard. Fractures with significant angulation require closed reduction and splinting. Surgical management can result in hardware-related issues such as adhesions, infection, and tendon rupture, whereas a more conservative approach may result in malunion or stiffness due to immobilization. Conclusions: Uncomplicated fractures of the fifth metacarpal are usually treated with immobilization and splinting or neighboring strapping, with a comparable degree of functional outcome. In Metacarpal head fractures nonoperative treatment options include immobilization in the intrinsic plus position. Small finger metacarpal neck fractures are the most typical and are frequently referred to as boxers fractures. Metacarpal fractures that have no associated rotational deformity can typically be managed conservatively with immobilization and serial radiographs. The use of the Jahss maneuver can result in reduction of fractures with rotational deformity or pseudoclawing. The most common types of metacarpal shaft fractures are transverse fractures, oblique fractures, and comminuted fractures. Operative intervention should be taken into consideration if there is pseudoclawing, rotational deformity, significant metacarpal shortening, or a noticeable dorsal deformity. Despite being a rare injury, intra-articular base fractures of the index- through ring-finger metacarpals have been suggested to be an underreported and misdiagnosed condition. Complications related to these injuries are prevalent and may result from surgical or non-surgical treatment of the initial injury. KEYWORDS: fracture of the fifth metatarsal, Boxers Fracture, hand injury.

A Comparison of Outcomes following Plate versus Pin Fixation of Metacarpal Shaft and Neck Fractures.

Electronic medical records at two institutions were reviewed for patients who underwent surgical intervention for metacarpal fractures. Data were collected from those who underwent reduction and internal fixation with either plates or Kirschner wires (K-wires). Inclusion criteria included minimum postoperative follow-up of 60 days and age 18 years or older. Exclusion criteria included insufficient radiographic data, previously attempted closed reduction with immobilization, pathologic fracture mechanism, history of previous trauma or surgery to the affected bone, and fixation technique other than plate or K-wire. We reviewed data for patients treated over a 22-year time period. Ultimately, 81 metacarpal shaft and neck fractures in 60 patients met inclusion criteria. Among all metacarpal fractures, complications were present in 39 (48.1%) cases. There were no significant associations between complication prevalence and hardware type. Revision surgery was required in 11 (13.6%) patients; there were no significant associations between revision procedures and hardware type. Postoperatively, all patients with imaging data had radiograph follow-up to assess union status. There was no significant association between time to union and hardware type. Outcomes showed no significant difference between plate and pin fixation for metacarpal shaft and neck fractures. These findings suggest that surgeons may have flexibility to decide on the type of operative intervention while considering patient-specific factors, such as the need for early mobilization.

Ideal Length and Diameter for Intramedullary Screw Fixation of Metacarpal Fractures: A Biomechanical Study

This biomechanical study evaluated the effect of intramedullary screw diameter and length relative to 3-point bending force and torsional force when used to stabilize metacarpal shaft fractures. Transverse osteotomies were made in the proximal metacarpal shaft in 36 middle finger metacarpal fourth-generation composite Sawbones. To compare screw diameters, antegrade intramedullary screws of 30-mm length were placed in 6 metacarpals, which included 4.7-mm Acutrak 2, Standard Acutrak 2 (4.0 mm), and Mini-Acutrak 2 (3.5 mm) screws. To compare screw lengths, metacarpals were fixated with Standard Acutrak 2 screws of 26, 30, or 34 mm in length, with screw tips bypassing the osteotomy by 6, 10, or 14 mm, respectively. A 6 degrees of freedom robot was used for torsional and 3-point bending testing. Increasing screw diameter demonstrated significant differences in both 3-point bending and torsional strengths. Maximum torsional loads were 69 Ncm (4.7-mm Acutrak 2), 45 Ncm (Standard Acutrak 2), and 27 Ncm (Mini-Acutrak 2) (P < .05). Loads to failure in the 3-point bending tests were 916 N (4.7-mm Acutrak 2), 713 N (Standard Acutrak 2), and 284 N (Mini-Acutrak 2) (P < .05). Differing screw lengths demonstrated significant differences with maximum torsional loads when comparing the 26-mm screws (22 Ncm) with 30- and 34-mm screws (45 and 55 Ncm, respectively) (P < .05). The 3-point dorsal bending strengths were significantly different between the 26-mm screws (320 N) and 30- and 34-mm screws (713 N and 702 N, respectively) (P < .05). The results demonstrated significantly higher torsional strength and resistance to 3-point bending with larger intramedullary screw diameters. Further, when selecting the intramedullary screw length, the screw tip should pass at least 10 mm beyond the fracture. This study provided biomechanical evidence to guide surgeons in selecting intramedullary screw diameter and length for treating metacarpal fractures.

Single Buried Intramedullary K-Wire Fixation in Nonthumb Metacarpal Shaft Fractures with Immediate Postoperative Mobilization without Any Immobilization.

This study aims to evaluate the outcomes of single intramedullary K-wire fixation in nonthumb, metacarpal shaft fractures with immediate postoperative hand mobilization without any immobilization. This is a retrospective case series conducted from January 2019 to December 2022. We included patients with closed, simple transverse, or short oblique metacarpal shaft fracture treated with single, 1.4 mm, intramedullary K-wire fixation. Gentle postoperative range of motion exercise was encouraged in every patient without any hand, finger, or wrist motion restriction material. Clinical outcomes were evaluated with total active flexion; grip strength; disability of arm, shoulder, and hand (DASH) score; and the American Society for Surgery of the Hand Total Active Flexion (ASSH TAF) score. This study included 34 patients, 25 males and 9 females with a mean age of 33.14 years (ranging 18-59). A total of 43 metacarpal shafts were treated. The mean DASH score at two and 6 weeks postoperative was 41.5 (ranging 19.16-60.34) and 9.58 (ranging 0.83-23.27). The mean final DASH score at last follow-up was 3.48 (ranging 0-8.33). Mean TAF at 2 weeks postoperative, 6 weeks postoperative, and at final follow-up was 203.8 (ranging 185-240), 238.2 (ranging 220-270), and 259.25 (ranging 240-270) degrees, respectively. The mean grip strength of the injured hand was 66.14 and 86.1% of the uninjured hand at 6 weeks and 3 months postoperative. There was no nonunion, malrotation, or infection. In conclusion, single intramedullary K-wire fixation gives excellent outcomes in the treatment of single or multiple, simple, metacarpal shaft fractures without the need of postoperative immobilization.

Intramedullary K-wires versus Alternate Techniques for Metacarpal Shaft and Neck Fractures: A Systematic Review and Meta-analysis

Intramedullary K-wire (IMKW) fixation is one of the mainstays for surgically treating metacarpal shaft and neck fractures. However, there remains a lack of literature comparing outcomes of the various available surgical repair techniques in all indicated metacarpals. Therefore, we conducted a systematic review and meta-analysis to investigate the clinical advantages and drawbacks of IMKW compared with alternate fracture repair techniques. A comprehensive systematic literature review was performed to identify studies that compared clinical outcomes of IMKW to alternate metacarpal fixation modalities. Outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH/quickDASH) scores, grip strength, union rate, visual analog scale pain, operative time, and complications. A random-effects model was used to compare IMKW to the pooled effect of other fixation techniques. A total of 10 studies were included in our analysis, comprising 497 metacarpal fractures (220 shafts and 277 necks). IMKW fixation was identified as the control group in all studies. The pooled experimental group included plates, transverse K-wires (TKWs), interfragmentary screws (IFSs), and K-wire cross-pinning (CP). In treating metacarpal shaft fractures, IMKW showed significantly shorter operative time (p = 0.04; mean difference = − 13; 95% confidence interval = −26 to −0.64). No significant differences were observed in treating metacarpal neck fractures for disability, grip strength, healing rate, pain, operative time, or complication rate. This systematic review and meta-analysis found no difference in clinical outcomes among various surgical techniques for treating metacarpal shaft and neck fractures. Further high evidence studies are required that investigate the efficacy and safety of IFS, CP, TKW, and intramedullary screws versus IMKW for treating closed, unstable metacarpal fractures.

Three-Dimensional Analysis of Metacarpal Head Articular Defects Created by Headless Screws.

Headless screw fixation used to treat metacarpal neck and metacarpal shaft fractures is gaining popularity. The aim of the study is to determine the proportion of the metacarpal head articular surface that is compromised during retrograde insertion of headless screws. Metacarpal screw fixation through a metacarpal head starting point was performed using fluoroscopic guidance on 14 metacarpals. Headless compression screws, with a tail diameter of 3.6mm, were used. The specimens were subsequently skeletonized and digitized using a 3-dimensional surface scanner. The articular surface defects created by the screws were then determined using computer software. Screw position in the dorsal aspect of the metacarpal head was expressed as a percentage of the total volar-to-dorsal distance. The 14 metacarpals studied consisted of 2 index, 4 long, 4 ring and 4 small metacarpals, taken from 4 hands. The average total metacarpal head surface area was 284.6 mm2 (range, 151.0-462.2 mm2); the average screw footprint in the metacarpal head was 13.3 mm2 (range, 10.3-17.4 mm2), which compromised a mean of 5.0% (3.0-7.8%) of the total cartilaginous metacarpal head surface area. In the sagittal plane, screw placement was found to lie in the dorsal 37.4% of the metacarpal head (range, 20.7-58.6%). The proportion of the articular surface area injured with retrograde insertion of headless compression screws into the metacarpal head is 5.0%. Screw placement is generally in the dorsal 37% of the metacarpal head.

Reliability of Routine Radiographs for Conservatively Treated Metacarpal Shaft and Neck Fractures.

To investigate the reliability of orthopedic hand surgeons to evaluate radiographic healing in initial and follow-up radiographs of the conservatively treated metacarpal shaft and neck fractures. The rationale for this study was to reduce the rate of unnecessary, routine radiographs when treating metacarpal fractures. Forty sets of digital x-rays,twenty at the initial visit and twenty at the 4-week follow-up,were randomly selected and reviewed. Three hand surgeons evaluated the x-rays for (1) fracture location, (2) radiograph timing, (3) healing status, (4) percentage healed, (5) angulation, and (6) confidence in healing status. Observers reviewed studies in random order and evaluated the same set of radiographs one month after the initial review. Intra- and interobserver agreements were analyzed using Fleiss' kappa (κ) for all parameters and all possible observer pairings. Interobserver and intraobserver reliability was highest when evaluating fracture location and lowest when assessing the percentage healed. The interobserver reliability was fair for radiograph timing and healing status and fair-to-moderate for angulation. The intraobserver reliability was moderate for radiograph timing and healing status and moderate-to-substantial for angulation. Observers correctly differentiated initial vs. follow-up images 62% of the time and reported to feel somewhat certain in their evaluation of healing status. When evaluating initial and 4-week follow-up radiographs, hand surgeons were somewhat confident in their assessment of healing but had less than substantial intra- and interobserver reliability following radiographic evaluation. Due to their poor reproducibility, routine radiographs may be unnecessary when evaluating conservatively treated metacarpal fractures. Further studies and guidelines that identify clear indications for the use of routine imaging in metacarpal fracture care are warranted.

The Role of Mini-Plate and Screws in Metacarpal Shaft Fracture Fixation: A Clinical and Functional Study

The Role of Mini-Plate and Screws in Metacarpal Shaft Fracture Fixation: A Clinical and Functional Study