Multiple Metacarpal Fractures Research Articles

75 Intraoperative Use of Infrared Thermal Imaging Camera – a Clinical Aid for Pedicled Flaps in Hand Reconstruction

Abstract Introduction Venous insufficiency remains one of the commonest causes for flap failure. Forward-looking infrared (FLIR) thermography measures infrared emissions from dissipated heat and converts temperature values into an image. This has various advantages to the current use of indocyanine green (ICG) angiography to assess flap perfusion. Case A man in his mid-30s was involved in a road traffic accident and sustained extensive injuries to his right hand. These included multiple metacarpal fractures, degloving of the proximal aspect of the entire thumb and significant skin loss on the volar distal forearm. After several washouts and tissue debridement, a pedicled chest wall flap was performed. Five weeks later the chest wall flap was divided using an infrared thermal imaging camera (FLIR E5) intraoperatively as a clinical aid to assess perfusion. This detected a small area of venous congestion which was not detectable by clinical assessment. Discussion There are drawbacks to the current intraoperative use of ICG angiography to assess flap perfusion. These include hot flushes and skin rashes, and the technique requires an intraoperative injection, extensive equipment involving a screen and a specialised camera. In comparison FLIR cameras are handheld, easy to use and involves a one-off cost of purchasing the camera that is relatively inexpensive compared to ICG angiography. Conclusions Thermal imaging techniques such as FLIR provides an alternative intraoperative option for patients who are unable to have ICG, for centres that do not have access to ICG and for surgeons looking for more convenient alternatives.

The Effect of Steroid and Mannitol Combination Treatment on Postoperative Rehabilitation of Multiple Metacarpal Bone Fractures.

Background and Objectives: The expedient resolution of postoperative soft tissue edema is particularly important in hand surgery. Prolonged edema and pain become an obstacle to postoperative rehabilitation, delay return to daily life, and in severe cases, lead to a permanent decrease in range of motion. Based on the common physiology between postoperative hand swelling and complex regional pain syndrome (CRPS), we sought to determine if postoperative mannitol and steroid administration to multiple metacarpal bone fracture patients effectively reduces hand swelling and pain and is beneficial for hand rehabilitation. Materials and Methods: From March 2015 to February 2019, 21 patients who received closed pinning for multiple metacarpal fractures were included in a retrospective cohort study. The control group (n = 11) underwent a routine recovery, while the treatment group (n = 10) received dexamethasone and mannitol injections for five days postoperatively. Serial changes in the degree of pain and fingertip-to-palm distance (FPD) were measured in both groups. The duration from surgery to the initiation of rehabilitation and time to full grip was also compared. Results: Compared to the control, the treatment group showed a faster alleviation of pain scores from the postoperative fifth day (2.91 versus 1.80, p = 0.013), and faster recovery of FPD from postoperative two weeks (3.27 versus 1.90, p = 0.002). Time to physical therapy initiation (6.73 versus 3.80 days, p = 0.002) and full grip achievement (42.46 versus 32.70 days, p = 0.002) were also faster in the treatment group. Conclusions: The steroid-mannitol combination treatment for multiple metacarpal bone fracture patients in the acute postoperative phase promoted the reduction of hand edema and pain, leading to the earlier initiation of physical therapy, rapid improvement in joint motion, and faster achievement of full grip.

A 4-year study of the use of the short metacarpal cast in the management of metacarpal shaft fractures

We report on our experience of using a short, moulded metacarpal cast over a 4-year period in the non-surgical management of metacarpal shaft fractures. Between 6 April 2015 and 6 April 2019, 117 patients were treated using this method. The majority were male, and the mean age was 24.6 years. The most common mechanism of injury was a punch injury (73 patients, 62%). Fifteen patients (13%) were treated for multiple metacarpal fractures. Immediately after cast removal, 68% had a full range of finger movement and 68% were pain free. Few required formal hand therapy. Fifteen patients experienced minor complications, primarily soft tissue irritation from the cast and non-limiting extensor lag. The moulded short metacarpal cast is an effective non-surgical treatment for angulated extra-articular metacarpal fractures of the diaphysis and diametaphyseal junction.Level of evidence: IV.

Incidence of Loss of Reduction After Open Reduction Internal Fixation of Metacarpal Shaft Fractures.

This study compared the incidence of loss of reduction (LOR) between metacarpal fractures fixed with screws alone and those fixed with plates and screws. Secondary aims included identifying patient or fracture characteristics associated with increased risk of LOR. We retrospectively reviewed 138 metacarpal fractures in 106 patients treated with open reduction internal fixation with screws (60 fractures) or plates and screws (78 fractures) with a mean radiographic follow-up of 50 days for evidence of LOR. We compared the incidence of LOR between the screw and plate groups using a χ2 test. We performed logistic regression analysis to determine whether patient age, sex, metacarpal location (index, long, ring, small), the presence of multiple metacarpal fractures, or fracture pattern were associated with increased incidence of LOR. Loss of reduction occurred in 19 (13.8%) of 138 fractures, with no statistically significant difference between lag screw (7 of 60, 11.6%) and plate fixation (12 of 78, 15.4%). Neither fracture pattern nor the presence of multiple metacarpal fractures was associated with an increased incidence of LOR, but patients experienced a 7% increase in the risk of LOR for each additional year of age. Loss of reduction occurred most frequently in index metacarpal fractures (4 of 12, 33%), although this did not reach statistical significance. We found no difference in LOR incidence between lag screw fixation and plate fixation. The overall incidence of LOR was higher in this study than previously reported and increased with increasing patient age.

FUNCTIONAL OUTCOME OF MINI IMPLANTS IN CLOSED 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

Antegrade Intramedullary Screw Fixation: A Novel Approach to Metacarpal Fractures

Metacarpal fractures are common upper-extremity fractures. Surgical fixation is recommended for open injuries, segmental bone loss, multiple metacarpal fractures, irreducible fractures, and unstable fracture patterns. For transverse and short oblique metacarpal shaft fracture patterns, intramedullary headless compression screws have been added most recently as a surgical option. Intramedullary headless compression screw fixation has been performed in a retrograde manner in which a guidewire and then a cannulated headless screw are placed through a skin excision, a split in the sagittal band or extensor tendon, and the dorsal central articular cartilage surface of the metacarpal head. Here, we describe a step-by-step novel approach to fixation of transverse and short oblique proximal and midshaft metacarpal fractures through an antegrade approach using intramedullary headless compression screws with a detailed 4K high-definition video demonstration and 2 clinical cases involving the middle and ring metacarpals. This surgical alternative addresses many concerns with the retrograde technique and avoids creating defects in the extensor tendon, the sagittal hood, the articular surface of the metacarpal head at the metacarpophalangeal joint, and the articulating surface of the trapezium, capitate, and hamate at the carpometacarpal articulation.

Closed Intramedullary Locking Nailing for Metacarpal Fractures: A Retrospective Study of Sixty-Six Fractures.

Introduction: Metacarpal fractures are frequent injuries in the young male working population and the majority are treated non-operatively. There is a growing trend to surgically treat these fractures, with the aim of reducing the deformity and shortening the rehabilitation period. The aim of this retrospective case series is to report on our experience and clinical outcomes of using percutaneous flexible locking nails for the management of displaced metacarpal fractures. This study is a retrospective review of 66 fractures that were managed at our centre over a 7-year period.Materials and Methods: Records of 60 patients were retrospectively reviewed. Indications for surgery were a displaced metacarpal shaft or neck fracture with associated rotational deformity, or multiple metacarpal fractures. The fracture was reduced by closed manipulation, and a flexible pre-bent locked intramedullary nail (1.6mm diameter) was inserted through a percutaneous dorsal antegrade approach, facilitated by a specially designed pre-fabricated awl. The implant was removed at union. Patients were followed-up in clinic until the fracture had united.Results: The mean union time was seven weeks (range 2 to 22 weeks) and there were nine (14%) delayed unions (>3 months) and no non-unions. The nail had migrated in three cases (5%) and caused skin impingement in two cases (3%). There was one infected case (2%). Rotational clinical deformity was evident for two (3%) cases.Conclusion: The use of a minimally-invasive locked intramedullary nailing for unstable metacarpal fractures has a significantly low complication rate, with predictable union times and good functional outcomes.

Evaluation of surgical management of metacarpal fractures – A prospective clinical study

Introduction: Metacarpal fractures constitutes between 14-28% of all visits to the hospital following trauma. Too often these metacarpal fractures are neglected or treated as minor injuries and results in major disability and deformity with permanent crippling of fine movements. A stable fracture fixation helps in restoring early mobilization. Early mobilization can prevent adhesions and is the key to good clinical outcome. Materials and Methods: Thirty patients with metacarpal fractures were surgically fixed with k-wire or plate and screw in our trauma centre. 24 males and 6 female patients were part of the study. The mean age was 38 years. Radiographs of affected hand, both AP & Lateral views were obtained before surgery, post- surgery, and at follow-ups. Results: Male patients in their 3rd decade following a road traffic accident fracturing right hand 4th metacarpal shaft was the common presentation. Transverse fracture pattern was most common. 70% of cases had excellent result, 20% patients with good results and 10% had fair result. Finger stiffness was the most frequently encountered complication. Conclusion: Displaced metacarpal fractures treated surgically by plate and screw or k-wire gives good result in terms of union, functional recovery and prevent stiffness. CRIF with k-wire shows faster union, faster recovery and lesser stiffness compared to ORIF with k-wire and plates and screws. Multiple metacarpal fractures in same hand treated surgically gives better results than those treated conservatively. Metacarpal fractures fixed rigidly with plate and screw can be mobilized much earlier then those with k wire fixation.

Intramedullary Fixation of Metacarpal Fractures Using Headless Compression Screws.

Introduction The purpose of this study is to examine the clinical results of retrograde intramedullary headless screw (IMHS) fixation for metacarpal fractures. Methods A retrospective review was performed on 16 patients with 18 metacarpal fractures who underwent IMHS fixation at a single institution. The average age was 32 years. The indications for surgery included rotational malalignment (five patients), multiple metacarpal fractures (five patients), angular deformity (four patients), and shortening greater than 5 mm (two patients). The average length of follow-up was 19.4 weeks (median 10.2 weeks). Results Functional outcome was considered excellent in all patients with total active motion in excess of 240 degrees. Active motion was initiated within 1 week of surgery. No secondary surgeries were performed related to a complication of IMHS fixation. Conclusion IMHS fixation of metacarpal fractures is an efficacious treatment modality for patients with comminution, multiple fractures, malrotation, and those who require rapid mobilization. It obviates the need for immobilization or more extensive plate and screw fixation techniques with excellent clinical results.

Return to play following metacarpal fractures in football players.

Metacarpal fractures are common in football players and lead to time away from competition, but current operative treatment data is limited. The purpose of this study was to examine demographics and outcomes of football players who underwent operative fixation for metacarpal fractures. Retrospective review from 2009 to 2012 of any football player surgically treated at one institution for a metacarpal fracture. Charts were reviewed for player position, level of competition, mechanism of injury, return to play, postoperative bracing, and re-fracture event. Current information was obtained via phone interviews with the patient and their athletic trainers. Fractures were classified by radiographic analysis. Twenty injuries in ten high school players, nine college players, and one recreational player were identified. The most common injured position was wide receiver (six cases) followed by defensive back (five cases). Most injuries occurred through player-to-player contact (12 cases). The long finger (11 cases) was most commonly involved metacarpal. Two players had multiple metacarpal fractures. The most common location was mid-diaphyseal (15 cases). The mean return to play for all in-season athletes was 6.3days (range 1-21). Protective splints were used for an average of 21days (range 14-36). All athletes returned to their preinjury level of play without recurrence of fracture or wound complication. Football players who required surgical fixation of a metacarpal fracture demonstrated an efficient return to play, including in-season players with use of protective bracing. Case series, Level of evidence, IV.

Return to Play Following Metacarpal Fractures in Football Players

Objectives:Injuries involving fractures of the metacarpals are common among football players of all levels. These injuries are typically treated conservatively with casting or splinting among non-in-season athletes, a method that involves a relatively lengthy recovery time (four weeks). To our knowledge, there are no previous reports documenting return to play in elite football players after operative management of metacarpal fractures. The purpose of this study was to retrospectively review and describe the results of operative treatment of metacarpal shaft fractures in 19 high level football players with respect to return to play. We hypothesized that in-season football players with metacarpal fractures treated surgically would be able to return to play more quickly than the typical recovery time following non-operative treatment.Methods:Surgically treated metacarpal fractures in elite football players were queried over a three-year period (2009-2012) from a database maintained by American Sports Medicine Institute (ASMI) in Birmingham, AL. Over the study period, 19 football players were identified who underwent open reduction internal fixation of metacarpal fractures by one of three attending surgeons. Retrospective chart review and phone interviews with the patient and their athletic trainers were performed to identify player position, level of competition, mechanism of injury, return to play, post-operative bracing, and re-fracture event. Radiographs were used to classify the fractures, and operative reports were reviewed for implant choice. Numerical means were calculated for in-season return to play as well as for brace time.Results:Ten high school players (53%) and nine college players (47%) were injured. The most common injured positions were wide receivers and defensive backs (26% each). Most injuries occurred through player to player contact (63%) at a game (37%) or practice (47%). The long finger (58%) was the most commonly involved metacarpal. Two players (11%) had multiple metacarpal fractures. The most common location was mid-diaphyseal (74%). Twelve patients were stabilized with plates and screws, five of whom underwent lag screw augmentation. Six patients were stabilized with a metacarpal nail and one was stabilized with only lag screws. All athletes were able to return to their pre-injury level of play without recurrence of fracture. Return to play for in-season athletes (N=11) was 6.3 days. The average time to return to play for in-season high school football players (N=6) was 9.2 days and 2.8 days for in-season collegiate football players (N=5). All in-season athletes returned to play with protective equipment in the form of a padded glove, bivalve padded cast, padded club cast, or padded splint. The protective equipment was used for an average of 21 days.Conclusion:This study provides support for the surgical treatment of displaced metacarpal shaft fractures with immediate return to play as tolerated for in-season football players. No re-fractures or complications were identified with the use of a plate, nail, or with lag screws. Elite football players can return to play with or without protective bracing depending on the position played and within a week of operative fixation.

Outcomes of Unstable Extraarticular Metacarpal Fractures Treated with Low Profile Titanium Plate System

Purpose: The purpose of this study was to evaluate clinical results for open reduction and internal fixation of unstable extraarticular metacarpal fractures using low profile titanium plates. Methods: Sixty-two consecutive patients (76 metacarpals) with unstable extraarticular metacarpal fractures who prospectively underwent internal fixation with plating were enrolled. Minimum follow-up was 1 year. There were 48 males and 14 females; average age was 39 years (range, 15-71 years). The location of the fractures was shaft in 65 metacarpals and the type was transverse in 22 cases, oblique in 46 cases, and communited in 8 cases. Of the 62 patients, 11 were open; 9 of these had additional soft tissue injury. The surgical outcome was assessed by clinical and radiographic outcomes and complications. Results: Bone union was successfully achieved in all patients on the average period of 6.4 weeks. The final range of total active motion was excellent for 64 cases, good for 6 cases, fair for 5 cases, and poor for 1 case. Postoperative complications occurred in 9 patients (15 metacarpals). Statistical analysis revealed that patient age, occupation, multiple metacarpal fractures, and soft tissue injury were significantly correlated with incidence of complications at last follow-up. Conclusion: Low profile titanium plating showed the low complication rate and good results in treating unstable extraarticular metacarpal fractures.

Outcome of closed ipsilateral metacarpal fractures treated with mini fragment plates and screws: a prospective study

BackgroundClosed multiple metacarpal fractures are considered highly unstable and are more prone to poor functional outcome. The authors assess the functional outcome of mini fragment plate fixation in closed ipsilateral multiple metacarpal fractures.Patients and methodsIn 21 patients with closed ipsilateral multiple metacarpal fractures treated with open reduction and internal fixation using mini fragment plate, functional outcome was assessed using the American Society for Surgery of the Hand (ASSH) Total Active Flexion (TAF) score and the Disabilities of the Arm, Shoulder, and Hand (DASH) scoring system.ResultsUnion rate of 100% was achieved. Functional outcome was excellent in 85.71% (18 of 21) and good in 9% (2 of 21) of patients. Average DASH score was 8.47 (range 1–26). Five cases of infection (two deep, three superficial) were reported, which subsided with dressings and antibiotics.ConclusionsPlate fixation is a good option for treating closed ipsilateral multiple metacarpal fractures, providing rigid fixation for early mobilization and good functional outcome.

Plate Fixation in Closed Ipsilateral Multiple Metacarpal Fractures

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

The Triad of Multiple Metacarpal Fractures and/or Dislocations of the Fingers, Severe Hand Swelling and Clinical Evidence of Acute Median Nerve Dysfunction

Twenty-five cases of crush injury to the hand resulting in the triad of multiple finger metacarpal fractures/dislocations of the fingers, a balloon hand appearance due to severe swelling and clinical evidence of acute median nerve dysfunction were retrospectively reviewed. All were men with a mean age of 33 (range 20-45) years. All injuries occurred following industrial or major car accidents. The fracture site included metacarpal head/neck fractures, metacarpal shaft fractures and carpometacarpal joint fracture-dislocations. All patients underwent fasciotomies, open carpal tunnel release and fixation of displaced fractures, followed by immediate mobilisation of the fingers. At a mean final follow-up of 7 (range 6-8) months, full recovery of median nerve function was seen in all patients. The final mean total active motion of the fingers was 243 degrees , 230 degrees and 250 degrees in displaced distal, middle and proximal impact fractures, respectively. All patients were able to return back to work.