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Hand Surgery, Vol. 19, No. 3 (2014) 441–443 © World Scientific Publishing Company DOI: 10.1142/S0218810414720332

Hand Surg. 2014.19:441-443. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 02/09/15. For personal use only.

IRREDUCIBLE METACARPAL NECK FRACTURE CAUSED BY INTERPOSITION OF JUNCTURA TENDINUM Duk Hee Lee,* Jong Woong Park† and Jung Il Lee‡ *Department

of Emergency Medicine, Eulji General Hospital Eulji University, Seoul, Korea



Department of Orthopedic Surgery, Korea University Ansan Hospital Korea University, Ansan, Korea

‡Department

of Orthopedic Surgery, Hanyang University Guri Hospital Hanyang University, Guri, Korea

Received 4 December 2013; Revised 5 February 2014; Accepted 6 February 2014; Published 26 August 2014 ABSTRACT Most metacarpal neck fractures can be reduced using the close reduction technique. However, if acceptable reduction cannot be achieved by closed reduction, open reduction is indicated. A 37-year-old patient had a third metacarpal neck fracture. We tried to reduce the metacarpal neck fracture by using closed reduction methods, but failed to do so. We performed open exploration and observed that the cause of failure was interposition of the junctura tendinum (JT) connecting the third and fourth extensor digitorum tendons. The JT in the third or fourth intermetacarpal space can interpose between the fragments in cases of third, fourth, or fifth metacarpal neck fractures, because the JT in the third or fourth intermetacarpal space is thick and wide (type 2 or 3). The JT in the third or fourth intermetacarpal space should be considered as a potential obstacle to the reduction in cases of irreducible metacarpal neck fractures. Keywords: Metacarpal Neck Fracture; Irreducible Metacarpal Neck Fracture; Junctura Tendinum.

INTRODUCTION

CASE PRESENTATION

Metacarpal neck fractures are one of the most common hand injuries, and they can be reduced using a close reduction technique.1 However, if acceptable reduction cannot be achieved by closed reduction techniques, open reduction is necessary.1 Here we describe a case of a patient with irreducible third metacarpal neck fracture which required open reduction, as well as discuss the relevant aspects.

A 37-year-old man injured his left hand in the clenched state due to a fall. Plain radiographs showed a fracture of the third metacarpal neck with dorsal angulations (Fig. 1). A closed reduction was initially attempted in the emergency department on the day of injury, but it was unsuccessful. The next day, a closed reduction was re-attempted under general anesthesia, but it failed. We performed an open exploration.

Correspondence to: Dr. Jung Il Lee, Department of Orthopedic Surgery, Hanyang University Guri Hospital, 153, Gyeongchunro, Guri, 471-701, Korea. Tel: (þ82) 31560-2379, Fax: (þ82) 31-557-8781, E-mail: [email protected] 441

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D. H. Lee, J. W. Park & J. I. Lee

(A)

(B)

(C)

Fig. 1 Plain anteroposterior (A) and oblique (B) radiographs demonstrated a fracture of the third metacarpal neck with a dorsally comminuted fragment. Minimally displaced fractures of the second and fourth metacarpal bases were also observed. The sagittal computed tomographic (CT) scan (C) demonstrated that the shape of the dorsal cortical beak of the proximal fracture fragment looked like a sharp sword that could penetrate the tendons easily.

After dissection, the dorsal cortical beak of the fracture fragment and an interposed third extensor digitorum tendon were observed. After pulling the extensor digitorum tendon, we guessed that the interposed tissue was the partially split portion of the extensor tendon (Fig. 2A). However, after full disengagement of the interposed tissue, the junctura tendinum connecting the third and fourth extensor digitorum tendons was found to be trapped between the fragments (Fig. 2B). After disengagement of the trapped JT, we easily reduced and fixed the fracture fragment using a mini-plate. One year after surgery, bone union was achieved, and the MP joint showed 10 degrees of extension lag and 85 degrees of flexion.

(A)

DISCUSSION Although metacarpal neck fracture is a common hand injury, a case of irreducible metacarpal neck fracture due to soft tissue interposition has rarely been reported. The junctura tendinum ( JT) is classified into three types on the basis of the morphological features.2–4 Type 1 was described as the thinnest among the three types, and type 3 was described as the longest and thickest among the three types. Therefore, we supposed that there is a minimal chance of interposition between fracture fragments in case of type 1 JT, while there is a significant chance of interposition in case of type 3 JT. Most investigators observed that type 1 is the most common pattern of the JT in

(B)

Fig. 2 Photographs illustrating that the soft tissue was interposed between the fracture fragments; after pulling the third extensor digitorum communis (EDC) tendon, it could be seen that the interposed tissue was a partially split portion of the third EDC tendon (A); after disengagement of the interposed soft tissue, we recognised that the obstacle to the reduction was the junctura tendinum connecting the third and fourth EDC tendons (B).

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Hand Surg. 2014.19:441-443. Downloaded from www.worldscientific.com by UNIVERSITY OF AUCKLAND LIBRARY - SERIALS UNIT on 02/09/15. For personal use only.

Irreducible Metacarpal Neck Fracture

the second intermetacarpal (IMC) space, type 2 and 3 in the third IMC space, and type 3 in the fourth IMC space.2–4 Because of morphologic differences in the JT according to the anatomical location, there is a minimal chance of the JT in the second IMC space interposing between fragments of the second or third metacarpal neck fractures, while there is a significant chance of the JT in the fourth IMC space interposing between fragments of the fourth or fifth metacarpal neck fractures. In this patient, the type of JT in the third IMC space was similar to type 2, which is a well-defined connecting tissue between the third and fourth extensor digitorum tendons. In the present case report, we describe a case of an irreducible third metacarpal neck fracture caused by interposition of the JT connecting the third and fourth extensor digitorum tendons. The JT in the third or fourth IMC space should be considered as a

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potential obstacle to the reduction in cases of irreducible third, fourth, or fifth metacarpal neck fractures.

References 1. Day CS, Stern PJ, Fractures of the metacarpals and phalanges, in Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH (eds.), Green’s Operative Hand Surgery, Vol. 1, 6th ed, Elsevier Churchill Livingstone, Philadelphia, pp. 241–245, 2011. 2. von Schroeder HP, Botte MJ, Gellman H, Anatomy of the juncturae tendinum of the hand, J Hand Surg Am 15:595–602, 1990. 3. Celik S, Bilge O, Pinar Y, Govsa F, The anatomical variations of the extensor tendons to the dorsum of the hand, Clin Anat 21:652–659, 2008. 4. Pinar Y, Bilge O, Govsa F, Celik S, Aktug H, Anatomo-histological analysis of the juncturae and their relations to the extensor tendons to the dorsum of the hand, Surg Radiol Anat 31(2):77–83, 2009.

Irreducible metacarpal neck fracture caused by interposition of junctura tendinum.

Most metacarpal neck fractures can be reduced using the close reduction technique. However, if acceptable reduction cannot be achieved by closed reduc...
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