EVIDENCE-BASED MEDICINE
Multiple Displaced Metacarpal Fractures Youssra Marjoua, MD,* Kyle R. Eberlin, MD,* Chaitanya S. Mudgal, MD* THE PATIENT A 25-year-old man involved in a helmeted high-speed motorcycle crash is evaluated for an isolated injury to the dominant right hand. He is hemodynamically stable and has no other injuries. On physical examination, there is no wound but he has diffuse swelling and ecchymosis on the dorsum of the hand, with tenderness to palpation and mild crepitation over the index, middle, and ring fingers. Motion is limited by pain and rotational deformity cannot be assessed. Radiographs demonstrate displaced transverse fractures of the index, middle, and ring metacarpals. THE QUESTION What is the optimal treatment of multiple closed, contiguous metacarpal fractures? CURRENT OPINION Most isolated, single metacarpal fractures are stable and treated nonsurgically. Displaced multiple metacarpal fractures are less common, and operative treatment is often recommended on the basis of the loss of the stability provided by connections to adjacent intact metacarpals, and the potential for stiffness from associated soft tissue injury.1e3 In the setting of inadequate reduction, metacarpal shortening leads to loss of the transverse arch, consequential stiffness, and altered interosseous muscle anatomy with resulting force ratios that lead to altered grasp and reduced grip strength.4e6 In addition, if manipulative closed reduction of multiple metacarpal fractures is achieved successfully, it is difficult to maintain with cast treatment. THE EVIDENCE A review of 18 patients with 42 metacarpal fractures treated by open reduction internal fixation with 2-mm From the *Hand Surgery Service, Massachusetts General Hospital, Boston, MA. Received for publication December 20, 2014; accepted in revised form April 28, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding Author: Chaitanya S. Mudgal, MD, Hand and Upper Extremity Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114; e-mail: cmudgal@ partners.org. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.04.032
plates documented an average of 230 total active motion (normal, 270 ). Two patients requested plate removal for extensor irritation.7 A 3-year prospective study included 21 patients with a total of 55 closed ipsilateral multiple metacarpal fractures (most high-energy) repaired with 2.0-mm stainless-steel plates and screws.8 All fractures healed, the mean Disabilities of the Arm, Shoulder, and Hand score was 8.5 (range, 1e26), and total active flexion was categorically rated as excellent in 18 of 21 patients, good in 2, and poor in 1. Five patients with postoperative infection were managed with antibiotics alone. There was no reported tendon irritation and no implants were removed. Fusetti et al9 retrospectively reviewed 81 patients with 104 metacarpal fractures treated by open reduction and internal plate and screw fixation evaluated an average of 14 months after surgery. Six fractures had a second surgery for nonunion. In addition, plate loosening and breakage with subsequent fracture union occurred in a different set of 7 patients (8%). Eight patients (10%) had total active flexion of less than 180 , 5 of whom requested surgery to improve range of motion. Total active motion could not be calculated in this study because of the lack of information regarding extension lag in patients’ records. Two patients had disproportionate pain and disability and one had a deep infection.10 In a retrospective review of closed reduction and intramedullary Kirchner wire fixation of rotated or angulated metacarpal fractures in 35 patients, 34 had restoration of alignment and function and 1 had a residual extension deficit of 15 and a rotational deformity of 10 .11 Balfour12 treated 11 patients with multiple metacarpal shaft fractures without associated comminution using intramedullary rods. An average of 129 days after surgery, all patients could get the fingertips to the midpalmar crease and achieve at least 80 metacarpophalangeal flexion. Manueddu and Della-Santa13 reviewed 20 patients with 23 displaced metacarpal fractures treated with multiple buried 0.8-mm Kirschner wires inserted through the proximal end of the metacarpal. An average of 5 years after surgery, 19 patients had grip strength,
Ó 2015 ASSH
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Published by Elsevier, Inc. All rights reserved.
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MULTIPLE DISPLACED METACARPAL FRACTURES
motion, and radiographic alignment comparable to the uninjured side. One patient who fractured 4 metacarpals had resulting sympathetically mediated pain and slight limitation of metacarpophalangeal flexion, with residual 1-cm fingertip to palm deficit on attempted flexion.
arch, altered interosseous muscle anatomy leading to reduced grip strength, and stiffness. We favor a plate and screw construct because we think it can more reliably restore length and anatomy, particularly for the fixation of transverse metacarpal fractures. For long oblique fractures, however, a lag screw construct may be sufficient to achieve absolute stability. Active range of motion exercises are initiated within a few days of surgery. Multiple minimally displaced or undisplaced metacarpal fractures are treated with 4 weeks of orthosis immobilization in the intrinsic plus position with the interphalangeal joints free. Interphalangeal joint motion is initiated with buddy tapes to the neighboring digits as soon as the patient is comfortable, which is usually within the first 7 days after injury.
SHORTCOMINGS OF THE EVIDENCE Multiple closed contiguous metacarpal fractures are difficult to study because they are uncommon. There is often enough deformity to make surgery compelling, which makes multiple metacarpal fractures with less deformity even more uncommon and difficult to study. The available evidence is limited to several small case series that combine isolated and multiple metacarpal fractures and often advocate a particular operative or nonsurgical technique. The results of nonsurgical treatment of multiple metacarpal fractures are unclear. The threshold of displacement or deformity at which the benefits of operative treatment outweigh the risks has not been studied.
REFERENCES 1. Stern P. Fractures of the metacarpals and phalanges. In: Green DP, ed. Operative Hand Surgery. 3rd ed. New York, NY: Churchill Livingstone; 1993:711e771. 2. Amadio P. Fractures of the hand and the wrist. In: Jupiter JB, ed. Flynn’s Hand Surgery. Baltimore, MD: Williams & Wilkins; 1991: 122e186. 3. Jupiter JB, Hastings H, Capo JT. The treatment of complex fractures and fracture-dislocations of the hand. Instr Course Lect. 2010;59: 333e341. 4. Barton NJ. Fractures of the hand. J Bone Joint Surg Br. 1984;66(2): 159e167. 5. Freeland AE, Orbay JL. Extraarticular hand fractures in adults: a review of new developments. Clin Orthop Relat Res. 2006;(445): 133e145. 6. Low CK, Wong HC, Low YP, Wong HP. A cadaver study of the effects of dorsal angulation and shortening of the metacarpal shaft on the extension and flexion force ratios of the index and little fingers. J Hand Surg Br. 1995;20(5):609e613. 7. Souer JS, Mudgal CS. Plate fixation in closed ipsilateral multiple metacarpal fractures. J Hand Surg Eur Vol. 2008;33(6):740e744. 8. Soni A, Gulati A, Bassi JL, Singh D, Saini UC. Outcome of closed ipsilateral metacarpal fractures treated with mini fragment plates and screws: a prospective study. J Orthop Traumatol. 2012;13(1): 29e33. 9. Fusetti C, Meyer H, Borisch N, Stern R, Santa DD, Papaloizo M. Complications of plate fixation in metacarpal fractures. J Trauma. 2002;52(3):535e539. 10. McNemar TB, Howell JW, Chang E. Management of metacarpal fractures. J Hand Ther. 2003;16(2):143e151. 11. Kelsch G, Ulrich C. Intramedullary k-wire fixation of metacarpal fractures. Arch Orthop Trauma Surg. 2004;124(8):523e526. 12. Balfour GW. Minimally invasive intramedullary rod fixation of multiple metacarpal shaft fractures. Tech Hand Up Extrem Surg. 2008;12(1):43e45. 13. Manueddu CA, Della-Santa D. Fasciculated intramedullary pinning of metacarpal fractures. J Hand Surg Br. 1996;21(2):230e236.
DIRECTIONS FOR FUTURE RESEARCH A prospective cohort of patients with multiple metacarpal fractures and no overlapping digits from rotational malalignment, evaluated several years after nonsurgical treatment, would establish the risk of stiffness and determine whether angular deformity or shortening affects symptoms and disability. Prospective randomized trials comparing operative and nonsurgical treatment for multiple metacarpal fractures, with no overlap from malrotation, and trials comparing different types of fixation for multiple metacarpal fractures with and without malrotation would also inform treatment decisions. Although the likelihood of doing such a prospective randomized trial might be small in resource-rich environments, it might be feasible to compare operative and nonsurgical treatment of multiple closed, displaced metacarpal fractures in resource-poor environments where cast treatment is commonplace. OUR CURRENT CONCEPTS FOR THIS PATIENT We recommend open reduction internal fixation of displaced multiple metacarpal fractures based on the potential for metacarpal shortening, loss of the transverse
J Hand Surg Am.
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Vol. -, - 2015
Multiple Displaced Metacarpal Fractures Youssra Marjoua, MD,* Kyle R. Eberlin, MD,* Chaitanya S. Mudgal, MD* THE PATIENT A 25-year-old man involved in a helmeted high-speed motorcycle crash is evaluated for an isolated injury to the dominant right hand. He is hemodynamically stable and has no other injuries. On physical examination, there is no wound but he has diffuse swelling and ecchymosis on the dorsum of the hand, with tenderness to palpation and mild crepitation over the index, middle, and ring fingers. Motion is limited by pain and rotational deformity cannot be assessed. Radiographs demonstrate displaced transverse fractures of the index, middle, and ring metacarpals. THE QUESTION What is the optimal treatment of multiple closed, contiguous metacarpal fractures? CURRENT OPINION Most isolated, single metacarpal fractures are stable and treated nonsurgically. Displaced multiple metacarpal fractures are less common, and operative treatment is often recommended on the basis of the loss of the stability provided by connections to adjacent intact metacarpals, and the potential for stiffness from associated soft tissue injury.1e3 In the setting of inadequate reduction, metacarpal shortening leads to loss of the transverse arch, consequential stiffness, and altered interosseous muscle anatomy with resulting force ratios that lead to altered grasp and reduced grip strength.4e6 In addition, if manipulative closed reduction of multiple metacarpal fractures is achieved successfully, it is difficult to maintain with cast treatment. THE EVIDENCE A review of 18 patients with 42 metacarpal fractures treated by open reduction internal fixation with 2-mm From the *Hand Surgery Service, Massachusetts General Hospital, Boston, MA. Received for publication December 20, 2014; accepted in revised form April 28, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding Author: Chaitanya S. Mudgal, MD, Hand and Upper Extremity Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114; e-mail: cmudgal@ partners.org. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.04.032
plates documented an average of 230 total active motion (normal, 270 ). Two patients requested plate removal for extensor irritation.7 A 3-year prospective study included 21 patients with a total of 55 closed ipsilateral multiple metacarpal fractures (most high-energy) repaired with 2.0-mm stainless-steel plates and screws.8 All fractures healed, the mean Disabilities of the Arm, Shoulder, and Hand score was 8.5 (range, 1e26), and total active flexion was categorically rated as excellent in 18 of 21 patients, good in 2, and poor in 1. Five patients with postoperative infection were managed with antibiotics alone. There was no reported tendon irritation and no implants were removed. Fusetti et al9 retrospectively reviewed 81 patients with 104 metacarpal fractures treated by open reduction and internal plate and screw fixation evaluated an average of 14 months after surgery. Six fractures had a second surgery for nonunion. In addition, plate loosening and breakage with subsequent fracture union occurred in a different set of 7 patients (8%). Eight patients (10%) had total active flexion of less than 180 , 5 of whom requested surgery to improve range of motion. Total active motion could not be calculated in this study because of the lack of information regarding extension lag in patients’ records. Two patients had disproportionate pain and disability and one had a deep infection.10 In a retrospective review of closed reduction and intramedullary Kirchner wire fixation of rotated or angulated metacarpal fractures in 35 patients, 34 had restoration of alignment and function and 1 had a residual extension deficit of 15 and a rotational deformity of 10 .11 Balfour12 treated 11 patients with multiple metacarpal shaft fractures without associated comminution using intramedullary rods. An average of 129 days after surgery, all patients could get the fingertips to the midpalmar crease and achieve at least 80 metacarpophalangeal flexion. Manueddu and Della-Santa13 reviewed 20 patients with 23 displaced metacarpal fractures treated with multiple buried 0.8-mm Kirschner wires inserted through the proximal end of the metacarpal. An average of 5 years after surgery, 19 patients had grip strength,
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
MULTIPLE DISPLACED METACARPAL FRACTURES
motion, and radiographic alignment comparable to the uninjured side. One patient who fractured 4 metacarpals had resulting sympathetically mediated pain and slight limitation of metacarpophalangeal flexion, with residual 1-cm fingertip to palm deficit on attempted flexion.
arch, altered interosseous muscle anatomy leading to reduced grip strength, and stiffness. We favor a plate and screw construct because we think it can more reliably restore length and anatomy, particularly for the fixation of transverse metacarpal fractures. For long oblique fractures, however, a lag screw construct may be sufficient to achieve absolute stability. Active range of motion exercises are initiated within a few days of surgery. Multiple minimally displaced or undisplaced metacarpal fractures are treated with 4 weeks of orthosis immobilization in the intrinsic plus position with the interphalangeal joints free. Interphalangeal joint motion is initiated with buddy tapes to the neighboring digits as soon as the patient is comfortable, which is usually within the first 7 days after injury.
SHORTCOMINGS OF THE EVIDENCE Multiple closed contiguous metacarpal fractures are difficult to study because they are uncommon. There is often enough deformity to make surgery compelling, which makes multiple metacarpal fractures with less deformity even more uncommon and difficult to study. The available evidence is limited to several small case series that combine isolated and multiple metacarpal fractures and often advocate a particular operative or nonsurgical technique. The results of nonsurgical treatment of multiple metacarpal fractures are unclear. The threshold of displacement or deformity at which the benefits of operative treatment outweigh the risks has not been studied.
REFERENCES 1. Stern P. Fractures of the metacarpals and phalanges. In: Green DP, ed. Operative Hand Surgery. 3rd ed. New York, NY: Churchill Livingstone; 1993:711e771. 2. Amadio P. Fractures of the hand and the wrist. In: Jupiter JB, ed. Flynn’s Hand Surgery. Baltimore, MD: Williams & Wilkins; 1991: 122e186. 3. Jupiter JB, Hastings H, Capo JT. The treatment of complex fractures and fracture-dislocations of the hand. Instr Course Lect. 2010;59: 333e341. 4. Barton NJ. Fractures of the hand. J Bone Joint Surg Br. 1984;66(2): 159e167. 5. Freeland AE, Orbay JL. Extraarticular hand fractures in adults: a review of new developments. Clin Orthop Relat Res. 2006;(445): 133e145. 6. Low CK, Wong HC, Low YP, Wong HP. A cadaver study of the effects of dorsal angulation and shortening of the metacarpal shaft on the extension and flexion force ratios of the index and little fingers. J Hand Surg Br. 1995;20(5):609e613. 7. Souer JS, Mudgal CS. Plate fixation in closed ipsilateral multiple metacarpal fractures. J Hand Surg Eur Vol. 2008;33(6):740e744. 8. Soni A, Gulati A, Bassi JL, Singh D, Saini UC. Outcome of closed ipsilateral metacarpal fractures treated with mini fragment plates and screws: a prospective study. J Orthop Traumatol. 2012;13(1): 29e33. 9. Fusetti C, Meyer H, Borisch N, Stern R, Santa DD, Papaloizo M. Complications of plate fixation in metacarpal fractures. J Trauma. 2002;52(3):535e539. 10. McNemar TB, Howell JW, Chang E. Management of metacarpal fractures. J Hand Ther. 2003;16(2):143e151. 11. Kelsch G, Ulrich C. Intramedullary k-wire fixation of metacarpal fractures. Arch Orthop Trauma Surg. 2004;124(8):523e526. 12. Balfour GW. Minimally invasive intramedullary rod fixation of multiple metacarpal shaft fractures. Tech Hand Up Extrem Surg. 2008;12(1):43e45. 13. Manueddu CA, Della-Santa D. Fasciculated intramedullary pinning of metacarpal fractures. J Hand Surg Br. 1996;21(2):230e236.
DIRECTIONS FOR FUTURE RESEARCH A prospective cohort of patients with multiple metacarpal fractures and no overlapping digits from rotational malalignment, evaluated several years after nonsurgical treatment, would establish the risk of stiffness and determine whether angular deformity or shortening affects symptoms and disability. Prospective randomized trials comparing operative and nonsurgical treatment for multiple metacarpal fractures, with no overlap from malrotation, and trials comparing different types of fixation for multiple metacarpal fractures with and without malrotation would also inform treatment decisions. Although the likelihood of doing such a prospective randomized trial might be small in resource-rich environments, it might be feasible to compare operative and nonsurgical treatment of multiple closed, displaced metacarpal fractures in resource-poor environments where cast treatment is commonplace. OUR CURRENT CONCEPTS FOR THIS PATIENT We recommend open reduction internal fixation of displaced multiple metacarpal fractures based on the potential for metacarpal shortening, loss of the transverse
J Hand Surg Am.
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Vol. -, - 2015
