- Email: [email protected]
Distraction-fixation in the primary treatment of metacarpal bone loss
ORIGINAL COMMUNICATIONS
Distraction-fixation in the primary treatment of metacarpal bone loss Nine patients seen in civilian practice with severe open injuries of the hand, including loss of portions of some or all of the metacarpals, were treated by primary restoration of metacarpal length and alignment by distraction-fixation with the use of transverse intermetacarpa/ Kirschner wires. An external fixation device was added in two of the nine patients. Severe associated soft tissue injuries were present in all but one patient. Two injuries were caused by firearms, and the other seven by heavy machinery. Contractures of the joints were prevented by the use of a second set of wires to position the metacarpophalangeal joints in 70° offlexion and the first metacarpal in abduction and pronation. Staged closure of wounds by local or distant flaps and secondary reconstructions by bone, nerve, and tendon grafts or transfers were necessary in all and required an average of almost 2 years until treatment was completed. All except the one child and the one most recently injured patient have returned to employment or vocational retraining. Follow-up was 24 to 78 months from injury.
Clayton A. Peimer, M.D., Richard J. Smith, M.D., and Robert D. Leffert, M.D. Buffalo, N.Y., and Boston, Mass.
From the Hand Surgery Services, Departments of Orthopaedic Sur gery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass., and the Affiliated Hospitals of the State University of New York at Buffalo, Buffalo, N.Y.
Severe injuries which cause loss of metacarpal sub stance are more commonly seen in the military than civilian populations. Bullet and shotgun wounds, ex-
Presented in part at the 34th Annual Meeting of the American Society for Surgery of the Hand, San Francisco, Calif., Feb. 19-21, 1979. Received for publication Feb. 2, 1980; revised Aug. 4, 1980.
Reprint requests: Clayton A. Peimer, M.D., Hand Surgery Service, Department of Orthopaedic Surgery, 462 Grider St., Buffalo, NY 14215.
Fig. 1. A and B. Close-range bird shot (case 2) caused this 8 em dorsal exit wound. Except for the motor branch of the ulnar nerve, the volar neurovascular structures were intact. Fracture dislocations of the second and fifth carpometacarpal joints and loss of the midshafts of the third and fourth metacarpals and portions of the distal carpal row were found. 0363-5023/81/020111 + 14$01.40/0
© 1981 American Society for Surgery of the Hand
THE JOURNAL OF HAND SURGERY
111
112
The Journal of HAND SURGERY
Peimer, Leffert, and Smith
with secondary bone grafting and later nerve and ten don reconstruction. All patients were males who ranged in age from 6 to 61 years. The follow-up from injury was 24 to 78 months. Two injuries were caused by fire arms (cases 1 and 2), one by a leaf blower at home (case 5), and six by heavy machinery at work (Table 1). The extent and complexity of the injuries varied. In all, a loss of at least a portion of one or more metacar pals and, frequently, of additional portions of the adja cent bones or joints was found. Eight of the nine pa tients had associated injuries to skin, tendons, intrinsic muscles, and neurovascular structures. The principal goals of primary treatment were to ( 1) prevent infec tion, (2) restore bone stability, length, and alignment, (3) prevent joint contractures, and (4) provide skin cover.
Techniques
Fig. lC. The internally stabilized second and fifth metacar pals were used as pillars to support the third and fourth meta carpal heads with transverse Kirschner wires. Longitudinal wires which exit dorsal to the MP joints were added to en hance angular alignment. (Reproduced with permission from Smith, R. J., and Peimer, C. A.: Injuries to the Metacarpal Bones and Joints, in Rob, C., et a!. (eds.): Advances in Surgery, volume 11. Copyright © 1977 by Year Book Medi cal Publishers, Inc., Chicago.) plosions, and heavy machinery accidents may produce compound fractures with loss of a portion of one or more metacarpals. Infection after open injury can also result in loss of a part of a metacarpal. In order to restore function to a hand which has sustained metacar pal loss, skeletal stability and alignment must be re gained first while joint motion is preserved and infec tion is prevented. ,_ 9 Restoration of function is best achieved by unimpeded primary healing and early re mobilization.
Material and methods Nine patients who sustained loss of portions of one or several metacarpals had restoration of skeletal sta bility, length, and alignment by distraction-fixation with the use of transverse intermetacarpal wires and the addition of external fixation devices wherever neces sary. The initial treatment also included soft tissue coverage as a primary or delayed-primary procedure,
If the second or third metacarpal shaft was lost, wires were drilled transversely through the head of the in jured metacarpal into the adjacent intact metacarpal. Often, two wires were used to control rotation and an gulation of the injured bone. Distraction-fixation after partial loss of one metacarpal was achieved by trans fixing the third metacarpal to the second, or the fourth to the fifth (Fig. 1, C). With loss of portions of several finger metacarpals or of the first metacarpal, when in termetacarpal wires alone were insufficient to maintain length, the transverse wires were held by external fixa tion devices which were adjusted to achieve proper bone length (Figs. 3, C and 5, D). With loss of all four metacarpals, two sets of external fixation devices were required to prevent flattening of the transverse palmar arch. For patients who lost the metacarpal shaft and head, the distal transverse wires were placed in the proximal phalanges. If the patient was seen late, when bone and soft tissue shortening had already occurred, the external fixation device was adjusted to gradually increase distraction and restore metacarpal length prior to bone grafting (case 4, Fig. 4, A through F). Because severe swelling often accompanied these in juries, it was difficult to position the joints properly with splints or dressings alone. When a distant flap was required to cover a soft tissue defect, it was impossible to apply a cast or splint. Contractures were prevented by the use of a second set of internal wires. The metacarpophalangeal (MP) joints of the fingers were held in 70° of flexion, and the first metacarpal in maxi mum abduction and pronation with the additional wires (Fig. 2, A and B). These wires were removed 3 or 4 weeks after injury. After removal of the wires, dynamic splints were useful in several patients to speed the re covery of motion (Fig. 2, C and D). Because the
Vol. 6, No. 2 March 1981
Distraction-fixation
Fig. 1. D and E. Four months after injuries, iliac bone grafting restored skeletal continuity. Distrac tion-fixation was maintained until bony union was solid. (Part D reproduced with permission from Smith, R. J., and Peimer, C. A.: Injuries to the Metacarpal Bones and Joints, in Rob, C., et al. (eds.): Advances in Surgery, volume 11. Copyright© 1977 by Year Book Medical Publishers, Inc., Chicago.)
Fig. 1. F and G. After transfer of the indicis proprius to the extensor remnants of the middle and ring fingers, a tenolysis was required. Grip strength is 16 kg.
113
The Journal of 114
Peimer, Leffert, and Smith
HAND SURGERY
Table I Case No. Age (yr)/hand Occupation Mechanism Injuries Primary treatment (result/revision) Secondary treatment (result/revision) Final reconstructions Result Case No. Age (yr)/hand Occupation Mechanism Injuries Primary treatment (result/revision) Secondary treatment (result/revision) Final reconstructions Result
1
2
50, D Shopkeeper Bullet Loss MC II, III
16, ND Student Shotgun Los MC III, IV; disloc CMC II, V; loss extensor communis III, IV; 8 em dorsal defect DisFix; ORIF CMC joints II, V;joint wires; ab dominal flap Iliac bone graft to MC III, IV
DisFix; joint wires Iliac bone graft to MC II, III None Regular job. Full ROM all joints
Transfer EIP to EDC Ill, IV. Tenolysis Merchant seaman. MP = 0/60. PIP= 25/100. Ulnar motor loss
3 22, ND* Woodcutter Machine pulley Fx MC Ill, IV; loss all extensor tendons and central slips II, III; 14 em dorsal defect Split skin graft (Infected: multiple debridements; DisFix; joint wires and abdominal flap)
4 40, ND* Machinist Router Loss MC II- V; Fx proximal phalanges II, III, V; loss all extensors; 12 em dorsal defect Longitudinal wire spacers MC II- V; abdominal flap (MC collapse: DisFix·-extemal; PIP joint wires II- V) Gradual distraction, iliac bone graft to MC II- V with MP fusions II- V Osteotomy proximal phalanx II, V. Extensor tenolyses II- V Light duties at original place of employment. PIP = 40/85 (all)
Iliac bone graft to MC III (MC IV defect healed) Transfer: FDS III, IV to common extensors. Trans fer: FDS II to lat. bands II, III Veterinary assistant. MP = 0175 (all); PIP II, III = 30/90; PIP IV, V = 0/95
Case No. Age (yr)/hand Occupation Mechanism Injuries
5 6, D Student Leaf blower Loss MC II- V; Fx MC I, radius, ulna; loss all ex tensors; 12 em dorsal defect
Primary treatment (result/revision) Secondary treatment (result/revision)
DisFix-extemal; ORIF MC I, radius, ulna; MP joint wires; finger fillet (V) and abdominal flaps Fibular bone grafts to MC II-IV and MP I fusion; radiocarpal fusion
Final reconstructions
Transfer: FCU to MC-III. Osteotomy: MC II
Result
Limited bimanual activity. MP = 20/65; PIP = Full
6
44, D Machinist Grinding machine Loss MC III- V; Fx proximal carpal row and radius; loss all extensors; 10 em dorsal defect; impending Volkmann's ischemia DisFix; joint wires; forearm fasciotomy; ab dominal flap Iliac bone graft to MC III- V and wrist fusion. (Late infection: refusion, lunate sequestrec tomy) Tendon rods/grafts to extensors II- V; Intrinsic tenodesis II Electrical technician/vocational rehabilitation. MP = 25/70; PIP II = 30/90; PIP III- V = Full
Legend: Roman numerals refer to rays of the hand; D = dominant, NO = nondominant. Bony injuries are loss of substance except where indicated as Fx = frac ture or Disloc = dislocation. DisFix is distraction-fixation by intermetacarpal wires alone; and the use of an external device is indicated, as DisFix-extemal. *Patient referred secondarily.
distraction-fixation wires maintain skeletal stability, the patients were able to begin active exercises early. Once motion was regained and the healed wounds had ma tured, staged reconstruction was begun, starting with bone grafting to restore skeletal continuity. The distraction-fixation was maintained until the bone graft had healed. Tendon and nerve reconstructions were performed as the final stages.
The following case reports illustrate the techniques described. Case reports Case 3. A 22-year-old male woodworker caught his non dominant hand in the pulley belt of an electric planer, avuls ing all soft tissues from the dorsum of the distal forearm and hand, including the tendon aponeuroses over the proximal
Vol. 6, No. 2 March 1981
115
Distraction-fixation
Table 1-cont'd. Case No. Age (yr)/hand Occupation Mechanism Injuries
Primary treatment (result/revision) Secondary treatment (result/revision) Final reconstructions Result Case No. Age (yr)/hand Occupation Mechanism Injuries
Primary treatment (result/revision) Secondary treatment (result/revision) Final reconstructions Result
8
7
27, D
Machinist Punch press Loss MC II, III, trapezoid, capitate; Fx trapezium, hamate; disloc CMC I, V; loss FCR, FPL, FDS/ FDP II, median nerve; 5 em dorsal/volar tissue defects DisFix; joint wires; ORIF CMC I, V; volar ab dominal and dorsal rotation flaps Iliac bone graft to MC II, III with limited inter carpal fusion Micrografts to median; transfer: FDS Ill to FPL; tendon rod/graft: FDP II; transfer: EIP oppo nensplasty Vocational rehabilitation. MP II- V = full; PIP II = 0/85; PIP III- V = full; IP I = 5/50
45, D Laborer Mechanical pulley Loss MC III, IV and extensors III, IV
DisFix; skin graft Iliac bone graft to MC Ill (MC IV defect healed) Transfer: EIP to extensors IIJ, IV refused Regular job. MP III, IV 0/65; PIP = Full
= 40/60;
MP II, V
=
9 61, D Machinist Machine press Loss MC II; Fx. radius, ulna, proximal carpal row; and laceration all tissues except dorsal skin bridge Disfix; primary wrist fusion and hand revascular ization MC II defect healed
(Planned-transfer EIP opponensplasty and flexor tenolysis) In progress
phalanges of the index and middle fingers. There were spiral fractures of the third and fourth metacarpals without loss of bone. He was initially treated by debridement and a split thickness skin graft. The skin grafts did not survive and his wound became infected (Fig. 4, A). At the time of his transfer to our hospital 1 month later, the unreduced third and fourth metacarpal shafts had shortened and were malrotated. The skin graft had sloughed and the diaphyses of the fractured metacarpals and dorsal half of the distal ulna were necrotic. These areas were excised, and the third and fourth metacarpal remnants were stabilized by distraction-fixation with the use of transverse Kirschner wires passed into the uninjured second and fifth metacarpals. After further debridements, the wound was covered with an abdom inal flap and the MP joints were fixed in 70° of flexion with Kirschner wires for 3 weeks (Fig. 4, B). Four months after injury, the patient had regained full ac tive flexion and complete passive extension of the fingers. An iliac bone graft was placed in the third metacarpal shaft de fect. (The fourth metacarpal had healed spontaneously.) The transverse distraction-fixation wires were removed 3 months later when the bone graft had healed (Fig. 4, C). Five months later, 10 months after injury, the flexor superficialis tendons of the middle and ring fingers were transferred through the interosseous membrane and attached through drill holes into
the proximal phalanges of the index and middle fingers and to the extensor tendon remnants in the ring and little fingers to restore MP extension. Active interphalangeal extension in the index and middle fingers was restored by later transfer of the index flexor superficialis to the lateral bands. Forty-two months after injury, active motion of the MP joints was 0/75, and active proximal interphalangeal (PIP) joint motion was 40/100 in the index, 45/105 in the middle, and Oil 10 in the ring and little fingers (Fig. 4, D and£). The patient is working as a veterinary assistant. Case 4. A 40-year-old machinist injured his nondominant hand with a router. All dorsal soft tissues were avulsed from the wrist to the MP joints, with loss of the distal shafts and heads of all finger metacarpals. He also sustained commi nuted fractures of the bases of the proximal phalanges of the index, middle, and little fingers. The volar neurovascular structures and tendons were intact. He was treated elsewhere initially by wound debridement. Kirschner wires were bent and placed longitudinally into the proximal phalanges and metacarpal bases in an attempt to restore length. An abdomi nal flap covered the dorsal tissue defect. At the time of our examination 2 months later, roentgeno grams showed shortening and volar displacement of the in dex, middle, and little fingers at the metacarpals. The distal 75% of the second metacarpal and the distal 50% of the three
116
The Journal of HAND SURGERY
Peimer, Leffert, and Smith
devices were removed after solid bony union was achieved 2 months after grafting (Fig. 5, £). Further reconstruction has included PIP capsulectomies, extensor tenolyses, and phalangeal osteotomies to improve grasp. The patient has regained more than 45° of active PIP flexion (40/85 average), uses his hand for assistive activities, and has returned to light duties with his original employer (Fig. 5, F through H).
Results
Fig. 2A. The wires used (Case 7) to maintain MP joint flexion and thumb abduction-pronation are seen. Several transverse distraction-fixation wires and a longitudinal radiocarpal wire are also visible.
ulnar metacarpals were missing. All bones of the hand and wrist were osteoporotic. There was no active motion in the fingers; only a few degrees of passive motion at the PIP joints was possible. (The MP joints had been destroyed.) Flexion and extension of the thumb were preserved but abduction and pronation were limited (Fig. 5, A and B). To prevent further collapse and correct the shortening which had already occurred, a heavy Kirschner wire was drilled transversely through the carpus and two others through the proximal phalanges of the fingers. These wires were attached to two external Roger-Anderson devices and distracted (Fig. 5, C). The transverse palmar arch was pre served by adjusting the position of the proximal phalangeal wires. The PIP joints were manipulated and wired into 60° of flexion. The wires through the PIP joints were removed after 3 weeks; active and passive range of motion exercises were begun. Most of the original metacarpal length was re stored over the next 2 months by gradually distracting the bony fragments with the Roger-Anderson apparatus (Fig. 5, D). After maximal metacarpal length was achieved, a large cortical-cancellous iliac bone graft was inserted to bridge the defect from the metacarpal bases to the proximal phalanges and fuse the MP joints. The transverse wires and external
In this series, all nine patients had loss of at least a portion of one or more metacarpals and parts of the contiguous skeleton. Eight had severe associated in juries to skin, muscle, tendon, nerves, and/or ves sels. The seven patients treated primarily received par enteral cephalosporins from the time of admission. After debridement, the open wounds were covered with povidone-iodine-soak ed gauze and an impermeable dressing to prevent dessication of tissues. After 3 to 5 days, the wounds were reinspected under anesthesia and debrided again if necessary. Extensive soft tissue defects required local or distant flap coverage, as did all wounds for which reconstruction of tendons or nerves was necessary. Flaps were applied to gain primary clo sure in two cases (cases 5 and 6) and delayed closure in four cases (cases 2, 3, 4, and 7). An intermediate stage of skin grafting prior to application of the flap was not required. There were two infections. One patient, referred with a metacarpal osteomyelitis (case 3), underwent multiple debridements, flap application, and, later, staged bone grafting and tendon transfers under an tibiotic prophylaxis, without further infection. One pa tient who had primary closure with a distant flap (case 6) developed a deep Proteus infection 8 weeks after the bone graft (3Vz months after injury). Subsequent re construction was delayed. Six years after injury, roent genograms showed a lytic zone in the lunate which, after debridement, proved to be the nidus of infection. Secondary autogenous bone grafts were required in eight of the nine patients. However, in three cases (cases 3, 8, and 9), one metacarpal reconstituted spon taneously within 6 months. Distraction-fixation was maintained until all bones and bone grafts had healed. When joint fusions were required (cases 2, 4, 5, 6, and 7), they were performed at the time of bone grafting. In adults, we inserted a single graft for all destroyed meta carpals, while taking care to preserve the transverse arch. In the presence of open epiphyses, individual 11 grafts may be used for each metacarpal (case 5). In the two patients in whom only splints were used initially to position the joints (cases 8 and 9), MP extension and thumb adduction contractures developed
Vol. 6, No. 2 March 1981
Distraction-fixation
Fig. 2B. Joint position is maintained with the abdominal flap still attached and all wires cut subcutaneously.
Fig. 2. C and D. The flap was detached and joint wires were removed 27 days after injury. There is full passive extension and no evidence of intrinsic muscle tightness.
117
118
Peimer, Leffert, and Smith
The Journal of HAND SURGERY
Fig. 3. A and B. This hand was mangled in a leaf blower (case 5) with fractures of the distal radius, ulna, and several phalanges and the loss of all finger metacarpals.
but were overcome by vigorous exercises. None of the patients whose joints were positioned by transfixion wires developed contractures of the MP joints or the thumb web (Table 1). Tendon transfers were performed in six patients (cases 2, 3, 5, 7, 8, and 9), tendon grafts in two (cases 6 and 7), and nerve grafts in one (case 7). Additional procedures have included flexor and ex tensor tenolyses (cases 3, 4, and 9), intrinsic tenodesis (case 6), capsulorrhaphies (case 4), and os teotomies (cases 4 and 5). The staged reconstructive procedures required, on an average, more than five operations and almost 2 years to complete. All patients except a 6-year-old child and the most recent patient have returned to work or vo cational retraining. Because of the significant variations in the complexity of injuries sustained and the nature of the reconstructions, no meaningful comparison can be made between these results and those of other pub lished series of patients with bone loss. 4 • 5 • 11 - 14 Mea surements of each patient's active joint range and func tional status are given in Table I. Discussion When metacarpal length and alignment are not main tained after injury, the intrinsic muscles, flexor and extensor tendons, and scar may ultimately cause
Fig. 3C. Multiple longitudinal and transverse wires attached to an external device (Roger-Anderson) were required to re store circulation to the collapsed hand. malalignment with secondary joint stiffness or insta bility. Early restoration of metacarpal length may also improve tissue perfusion and viability (case 5). In the patients we treated, bone length, alignment,
Vol. 6, No. 2 March 1981
Distraction-fixation
Fig. 3. D and E. Function 1 year after bone grafts and transfer of the flexor carpi ulnaris to diminish and increasing flexion deformity of this fused wrist in a growing child.
Fig. 4A. Fractures of the third and fourth metacarpals with loss of all dorsal soft tissues were caused by a pulley mechanism (case 3). The patient was referred I month later with metacarpal osteomy elitis and a necrotic skin graft.
119
120
The Journal of HAND SURGERY
Peimer, Leff'err, and Smirh
Fig. 48. After debridement, the metacarpal remnants were stabilized with transverse wires. Additional wires were used to position the MP joints.
Fig. 4C. An iliac bone graft 4 months later restored the third metacarpal; the fourth metacarpal had healed spontaneously.
Fig. 4. D and E. Two years after tendon transfers, the patient is a veterinary assistant.
Vol. 6, No. 2 March 1981
Distraction~fixation
121
Fig. 5. A and B. Two months after avulsion of the dorsal soft tissues, distal ends of the four ulnar metacarpals, and comminuted phalangeal fractures, these referral roentgenograms show collapse of all fingers but the ring (case 4). There was no active motion. (Part 8 reproduced with permission from Smith, R. J., and Peimer, C. A.: Injuries to the Metacarpal Bones and Joints, in Rob, C., et al. (eds.): Advances in Surgery, volume II. Copyright© 1977 by Year Book Medical Publishers, Inc., Chicago.)
Fig. 5C. Transverse wires were attached to two external de vices and distracted gradually. The palmar arch was pre served by flexion at the fourth and fifth metacarpal positions. The PIP joints were manipulated and wired into 60° of flex ion. (Reproduced with permission from Smith, R. J., and Peimer, C. A.: Injuries to the Metacarpal Bones and Joints, in Rob, C., et al. (eds.): Advances in Surgery, volume II. Copyright© 1977 by Year Book Medical Publishers, Inc., Chicago.)
and rotation were primarily restored by distraction fixation with transverse intermetacarpal wires. In two patients, these wires were attached to an external fixa tion device. These techniques are not new. The use of transverse wires to treat closed metacarpal fractures was first reported by Berkman and Miles. 10 Littler 11 and Howard 12 described the principles of secondary meta carpal reconstruction, based on their World War II ex perience. Matev 13 and Kessler et al. H have stressed the use of external devices to secondarily restore metacar pal length after trauma. However, little attention has been given to the primary restoration of metacarpal length and stability after bone loss treatment also re quires internal joint stabilization, early mobilization, and staged soft tissue reconstruction. 4 - 9 • 15 21 Longitudinal wires alone cannot maintain the length of a partially destroyed metacarpal, and multiple crossed wires are often inadequate. Bent wire "spac ers,'' if fashioned correctly, can maintain length but do not control angular and rotational alignment. However, distraction-fixation with wires passed transversely pre vents longitudinal collapse and also dependably main tains both alignment and rotation. The goals of primary treatment are to prevent infec tion, restore stable skeletal length and alignment, and provide skin coverage. These injuries are usually ac
122
Peimer, Leffert, and Smith
The Journal of HAND SURGERY
Fig. SD. Active PIP motion was begun in therapy after 3 weeks. Metacarpal length was restored over the next 2 months.
companied by severe swelling, which makes it difficult to properly position joints by splints or dressings. Many patients require the use of distant flaps to cover defects, and this further complicates the prevention of contrac tures. Position of the joints can be easily maintained with a second set of internal wires. Once bony stability is achieved and the wound covered, a therapy program is begun. Exercises and splinting are continued until maximal motion of the joints is restored. Only after full mobility is achieved and the wounds have matured is reconstruction started. This treatment program allows complete restoration of skeletal length and alignment because the bone loss is treated primarily. Wound or scar contracture and bony shortening or malrotation are prevented; stiffness or instability of the joints second ary to bony malposition is avoided.
Summary and conclusions Hand function after bone loss depends on maintain ing length and alignment of the metacarpals and pre serving joint motion. With partial loss of the metacarpals, bone length can
Fig. SE. Autogenous iliac bone graft bridged the metacarpal defects and MP joints. Distraction-fixation was maintained until bony union 2 months later. (Reproduced with permis sion from Smith, R. J., and Peimer, C. A.: Injuries to the Metacarpal Bones and Joints, in Rob, C., et al. (eds.): Ad vances in Surgery, volume II. Copyright
be restored by distraction-fixation with transverse Kirschner wires. If bone is lost from a single metacar pal or both the third and fourth metacarpals, transverse wires alone are sufficient. Bone loss in two or more adjacent border metacarpals or the thumb metacarpal may require the use of an external fixation device to the wires to maintain length. With destruction of all four metacarpals, two external devices are used to preserve the transverse arch. Joint motion is preserved and contractures are pre vented by positioning the MP joints in 70° of flexion and the first metacarpal in maximum abduction and pronation with a second set of wires.
Vol. 6, No. 2 March 1981
Distraction~fixation
123
Fig. 5. F through I. Two years after PIP capsulorrhaphies, dorsal tenolyses, and phalangeal osteotomies, the patient has more than 45" of active PIP flexion.
Bone grafts are inserted when the wounds have healed, swelling has subsided, and a maximal range of motion has been restored. The distraction-fixation wires and external devices are maintained until bony union is solid. Tendon and nerve reconstructions are performed as the final stages.
We wish to thank Drs. MichaelS. Feinberg and James W. May, Jr., for allowing us to include their cases in this review.
REFERENCES I. Kaplan EB: Functional and surgical anatomy of the hand, ed 2. Philadelphia, 1965, J B Lippincott Co, pp 25-33
124
Peimer. Leff'ert, a11d Smith
2. Flatt AE: The care of minor hand injuries, ed 4. St. Louis, 1979, The C V Mosby Co, pp 3-7 3. Bunnell S: The early treatment of hand injuries. J Bone Joint Surg (Am) 33:807-11, 1951 4. McCormack RM: Reconstructive surgery and the imme diate care of the severely injured hand. Clin Orthop 13:75-82, 1959 5. Milford L: Shotgun wounds of the hand and wrist with a report of four cases. South Med J 52:403-13, 1959 6. Orner GE, Jr: The early management of gunshot wounds of the extremities. S Dakota J Med 9:340-4, 1956 7. Smith RJ. Leffert RD: 111 Flynn JE. editor: Hand surgery, ed 2. Baltimore, 1975, Williams & Wilkins Co. pp 62-74 8. Smith RJ. Peimer CA: 111 Rob C et al. editors: Ad vances in surgery, vol II. Chicago, 1977, Year Book Medical Publishers, pp 341-74 9. Chase RA: The severely injured upper limb, to amputate or reconstruct: that is the question. Arch Surg 100:382 92, 1970 10. Berkman EF, Miles GH: Internal fixation of metacar pal fractures exclusive of the thumb. J Bone Joint Surg (Am) 25:816-21, 1943 II. Littler JW: Metacarpal reconstruction. J Bone Joint Surg (Am) 29:723-37, 1947 12. Howard LD: The problem of metacarpal fractures of the hand due to war wounds. AAOS lnstr Lectures, vol 2. St. Louis, 1944, The C V Mosby Co, pp 196-201
The Journal of HAND SURGERY
13. Matev 18: Thumb reconstruction after amputation at the metacarpophalangeal joint by bone-lengthening. A pre liminary report of three cases. J Bone Joint Surg (Am) 52:957-65. 1970 14. Kessler I, Hecht 0, Baruch A: Distraction-lengthening of digital rays in the management of the injured hand. J Bone Joint Surg (Am) 61:83-7, 1977 15. Burkhalter WE. Butler B. Metz W, Orner G: Experi ences with delayed primary closure of war wounds of the hand in Viet Nam. J Bone Joint Surg (Am) 50:945-54, 1968 16. Cleveland M. Manning JG, Steward WJ: Care of battle casualties and injuries involving bones and joints. J Bone Joint Surg (Am) 33:517-27, 1951 17. Butler B, Jr: Initial management of hand wounds. Milit Med 134:1-7, 1969 18. Jabaley ME. Peterson HD: Early treatment of war wounds of the hand and forearm in VietNam. Ann Surg 177:167-73, 1973 19. Ogelsby JE: Twenty-two months' war surgery in Viet Nam. Surgery 102:607-13, 1971 20. Boyes JN: Bunnell's surgery of the hand, ed 5. Philadel phia, 1970, J B Lippincott Co, p 278 21. Adams RW: Small caliber missile blast wounds of the hand: mechanism and early management. Am J Surg 82:219-26, 1951
Distraction-fixation in the primary treatment of metacarpal bone loss Nine patients seen in civilian practice with severe open injuries of the hand, including loss of portions of some or all of the metacarpals, were treated by primary restoration of metacarpal length and alignment by distraction-fixation with the use of transverse intermetacarpa/ Kirschner wires. An external fixation device was added in two of the nine patients. Severe associated soft tissue injuries were present in all but one patient. Two injuries were caused by firearms, and the other seven by heavy machinery. Contractures of the joints were prevented by the use of a second set of wires to position the metacarpophalangeal joints in 70° offlexion and the first metacarpal in abduction and pronation. Staged closure of wounds by local or distant flaps and secondary reconstructions by bone, nerve, and tendon grafts or transfers were necessary in all and required an average of almost 2 years until treatment was completed. All except the one child and the one most recently injured patient have returned to employment or vocational retraining. Follow-up was 24 to 78 months from injury.
Clayton A. Peimer, M.D., Richard J. Smith, M.D., and Robert D. Leffert, M.D. Buffalo, N.Y., and Boston, Mass.
From the Hand Surgery Services, Departments of Orthopaedic Sur gery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass., and the Affiliated Hospitals of the State University of New York at Buffalo, Buffalo, N.Y.
Severe injuries which cause loss of metacarpal sub stance are more commonly seen in the military than civilian populations. Bullet and shotgun wounds, ex-
Presented in part at the 34th Annual Meeting of the American Society for Surgery of the Hand, San Francisco, Calif., Feb. 19-21, 1979. Received for publication Feb. 2, 1980; revised Aug. 4, 1980.
Reprint requests: Clayton A. Peimer, M.D., Hand Surgery Service, Department of Orthopaedic Surgery, 462 Grider St., Buffalo, NY 14215.
Fig. 1. A and B. Close-range bird shot (case 2) caused this 8 em dorsal exit wound. Except for the motor branch of the ulnar nerve, the volar neurovascular structures were intact. Fracture dislocations of the second and fifth carpometacarpal joints and loss of the midshafts of the third and fourth metacarpals and portions of the distal carpal row were found. 0363-5023/81/020111 + 14$01.40/0
© 1981 American Society for Surgery of the Hand
THE JOURNAL OF HAND SURGERY
111
112
The Journal of HAND SURGERY
Peimer, Leffert, and Smith
with secondary bone grafting and later nerve and ten don reconstruction. All patients were males who ranged in age from 6 to 61 years. The follow-up from injury was 24 to 78 months. Two injuries were caused by fire arms (cases 1 and 2), one by a leaf blower at home (case 5), and six by heavy machinery at work (Table 1). The extent and complexity of the injuries varied. In all, a loss of at least a portion of one or more metacar pals and, frequently, of additional portions of the adja cent bones or joints was found. Eight of the nine pa tients had associated injuries to skin, tendons, intrinsic muscles, and neurovascular structures. The principal goals of primary treatment were to ( 1) prevent infec tion, (2) restore bone stability, length, and alignment, (3) prevent joint contractures, and (4) provide skin cover.
Techniques
Fig. lC. The internally stabilized second and fifth metacar pals were used as pillars to support the third and fourth meta carpal heads with transverse Kirschner wires. Longitudinal wires which exit dorsal to the MP joints were added to en hance angular alignment. (Reproduced with permission from Smith, R. J., and Peimer, C. A.: Injuries to the Metacarpal Bones and Joints, in Rob, C., et a!. (eds.): Advances in Surgery, volume 11. Copyright © 1977 by Year Book Medi cal Publishers, Inc., Chicago.) plosions, and heavy machinery accidents may produce compound fractures with loss of a portion of one or more metacarpals. Infection after open injury can also result in loss of a part of a metacarpal. In order to restore function to a hand which has sustained metacar pal loss, skeletal stability and alignment must be re gained first while joint motion is preserved and infec tion is prevented. ,_ 9 Restoration of function is best achieved by unimpeded primary healing and early re mobilization.
Material and methods Nine patients who sustained loss of portions of one or several metacarpals had restoration of skeletal sta bility, length, and alignment by distraction-fixation with the use of transverse intermetacarpal wires and the addition of external fixation devices wherever neces sary. The initial treatment also included soft tissue coverage as a primary or delayed-primary procedure,
If the second or third metacarpal shaft was lost, wires were drilled transversely through the head of the in jured metacarpal into the adjacent intact metacarpal. Often, two wires were used to control rotation and an gulation of the injured bone. Distraction-fixation after partial loss of one metacarpal was achieved by trans fixing the third metacarpal to the second, or the fourth to the fifth (Fig. 1, C). With loss of portions of several finger metacarpals or of the first metacarpal, when in termetacarpal wires alone were insufficient to maintain length, the transverse wires were held by external fixa tion devices which were adjusted to achieve proper bone length (Figs. 3, C and 5, D). With loss of all four metacarpals, two sets of external fixation devices were required to prevent flattening of the transverse palmar arch. For patients who lost the metacarpal shaft and head, the distal transverse wires were placed in the proximal phalanges. If the patient was seen late, when bone and soft tissue shortening had already occurred, the external fixation device was adjusted to gradually increase distraction and restore metacarpal length prior to bone grafting (case 4, Fig. 4, A through F). Because severe swelling often accompanied these in juries, it was difficult to position the joints properly with splints or dressings alone. When a distant flap was required to cover a soft tissue defect, it was impossible to apply a cast or splint. Contractures were prevented by the use of a second set of internal wires. The metacarpophalangeal (MP) joints of the fingers were held in 70° of flexion, and the first metacarpal in maxi mum abduction and pronation with the additional wires (Fig. 2, A and B). These wires were removed 3 or 4 weeks after injury. After removal of the wires, dynamic splints were useful in several patients to speed the re covery of motion (Fig. 2, C and D). Because the
Vol. 6, No. 2 March 1981
Distraction-fixation
Fig. 1. D and E. Four months after injuries, iliac bone grafting restored skeletal continuity. Distrac tion-fixation was maintained until bony union was solid. (Part D reproduced with permission from Smith, R. J., and Peimer, C. A.: Injuries to the Metacarpal Bones and Joints, in Rob, C., et al. (eds.): Advances in Surgery, volume 11. Copyright© 1977 by Year Book Medical Publishers, Inc., Chicago.)
Fig. 1. F and G. After transfer of the indicis proprius to the extensor remnants of the middle and ring fingers, a tenolysis was required. Grip strength is 16 kg.
113
The Journal of 114
Peimer, Leffert, and Smith
HAND SURGERY
Table I Case No. Age (yr)/hand Occupation Mechanism Injuries Primary treatment (result/revision) Secondary treatment (result/revision) Final reconstructions Result Case No. Age (yr)/hand Occupation Mechanism Injuries Primary treatment (result/revision) Secondary treatment (result/revision) Final reconstructions Result
1
2
50, D Shopkeeper Bullet Loss MC II, III
16, ND Student Shotgun Los MC III, IV; disloc CMC II, V; loss extensor communis III, IV; 8 em dorsal defect DisFix; ORIF CMC joints II, V;joint wires; ab dominal flap Iliac bone graft to MC III, IV
DisFix; joint wires Iliac bone graft to MC II, III None Regular job. Full ROM all joints
Transfer EIP to EDC Ill, IV. Tenolysis Merchant seaman. MP = 0/60. PIP= 25/100. Ulnar motor loss
3 22, ND* Woodcutter Machine pulley Fx MC Ill, IV; loss all extensor tendons and central slips II, III; 14 em dorsal defect Split skin graft (Infected: multiple debridements; DisFix; joint wires and abdominal flap)
4 40, ND* Machinist Router Loss MC II- V; Fx proximal phalanges II, III, V; loss all extensors; 12 em dorsal defect Longitudinal wire spacers MC II- V; abdominal flap (MC collapse: DisFix·-extemal; PIP joint wires II- V) Gradual distraction, iliac bone graft to MC II- V with MP fusions II- V Osteotomy proximal phalanx II, V. Extensor tenolyses II- V Light duties at original place of employment. PIP = 40/85 (all)
Iliac bone graft to MC III (MC IV defect healed) Transfer: FDS III, IV to common extensors. Trans fer: FDS II to lat. bands II, III Veterinary assistant. MP = 0175 (all); PIP II, III = 30/90; PIP IV, V = 0/95
Case No. Age (yr)/hand Occupation Mechanism Injuries
5 6, D Student Leaf blower Loss MC II- V; Fx MC I, radius, ulna; loss all ex tensors; 12 em dorsal defect
Primary treatment (result/revision) Secondary treatment (result/revision)
DisFix-extemal; ORIF MC I, radius, ulna; MP joint wires; finger fillet (V) and abdominal flaps Fibular bone grafts to MC II-IV and MP I fusion; radiocarpal fusion
Final reconstructions
Transfer: FCU to MC-III. Osteotomy: MC II
Result
Limited bimanual activity. MP = 20/65; PIP = Full
6
44, D Machinist Grinding machine Loss MC III- V; Fx proximal carpal row and radius; loss all extensors; 10 em dorsal defect; impending Volkmann's ischemia DisFix; joint wires; forearm fasciotomy; ab dominal flap Iliac bone graft to MC III- V and wrist fusion. (Late infection: refusion, lunate sequestrec tomy) Tendon rods/grafts to extensors II- V; Intrinsic tenodesis II Electrical technician/vocational rehabilitation. MP = 25/70; PIP II = 30/90; PIP III- V = Full
Legend: Roman numerals refer to rays of the hand; D = dominant, NO = nondominant. Bony injuries are loss of substance except where indicated as Fx = frac ture or Disloc = dislocation. DisFix is distraction-fixation by intermetacarpal wires alone; and the use of an external device is indicated, as DisFix-extemal. *Patient referred secondarily.
distraction-fixation wires maintain skeletal stability, the patients were able to begin active exercises early. Once motion was regained and the healed wounds had ma tured, staged reconstruction was begun, starting with bone grafting to restore skeletal continuity. The distraction-fixation was maintained until the bone graft had healed. Tendon and nerve reconstructions were performed as the final stages.
The following case reports illustrate the techniques described. Case reports Case 3. A 22-year-old male woodworker caught his non dominant hand in the pulley belt of an electric planer, avuls ing all soft tissues from the dorsum of the distal forearm and hand, including the tendon aponeuroses over the proximal
Vol. 6, No. 2 March 1981
115
Distraction-fixation
Table 1-cont'd. Case No. Age (yr)/hand Occupation Mechanism Injuries
Primary treatment (result/revision) Secondary treatment (result/revision) Final reconstructions Result Case No. Age (yr)/hand Occupation Mechanism Injuries
Primary treatment (result/revision) Secondary treatment (result/revision) Final reconstructions Result
8
7
27, D
Machinist Punch press Loss MC II, III, trapezoid, capitate; Fx trapezium, hamate; disloc CMC I, V; loss FCR, FPL, FDS/ FDP II, median nerve; 5 em dorsal/volar tissue defects DisFix; joint wires; ORIF CMC I, V; volar ab dominal and dorsal rotation flaps Iliac bone graft to MC II, III with limited inter carpal fusion Micrografts to median; transfer: FDS Ill to FPL; tendon rod/graft: FDP II; transfer: EIP oppo nensplasty Vocational rehabilitation. MP II- V = full; PIP II = 0/85; PIP III- V = full; IP I = 5/50
45, D Laborer Mechanical pulley Loss MC III, IV and extensors III, IV
DisFix; skin graft Iliac bone graft to MC Ill (MC IV defect healed) Transfer: EIP to extensors IIJ, IV refused Regular job. MP III, IV 0/65; PIP = Full
= 40/60;
MP II, V
=
9 61, D Machinist Machine press Loss MC II; Fx. radius, ulna, proximal carpal row; and laceration all tissues except dorsal skin bridge Disfix; primary wrist fusion and hand revascular ization MC II defect healed
(Planned-transfer EIP opponensplasty and flexor tenolysis) In progress
phalanges of the index and middle fingers. There were spiral fractures of the third and fourth metacarpals without loss of bone. He was initially treated by debridement and a split thickness skin graft. The skin grafts did not survive and his wound became infected (Fig. 4, A). At the time of his transfer to our hospital 1 month later, the unreduced third and fourth metacarpal shafts had shortened and were malrotated. The skin graft had sloughed and the diaphyses of the fractured metacarpals and dorsal half of the distal ulna were necrotic. These areas were excised, and the third and fourth metacarpal remnants were stabilized by distraction-fixation with the use of transverse Kirschner wires passed into the uninjured second and fifth metacarpals. After further debridements, the wound was covered with an abdom inal flap and the MP joints were fixed in 70° of flexion with Kirschner wires for 3 weeks (Fig. 4, B). Four months after injury, the patient had regained full ac tive flexion and complete passive extension of the fingers. An iliac bone graft was placed in the third metacarpal shaft de fect. (The fourth metacarpal had healed spontaneously.) The transverse distraction-fixation wires were removed 3 months later when the bone graft had healed (Fig. 4, C). Five months later, 10 months after injury, the flexor superficialis tendons of the middle and ring fingers were transferred through the interosseous membrane and attached through drill holes into
the proximal phalanges of the index and middle fingers and to the extensor tendon remnants in the ring and little fingers to restore MP extension. Active interphalangeal extension in the index and middle fingers was restored by later transfer of the index flexor superficialis to the lateral bands. Forty-two months after injury, active motion of the MP joints was 0/75, and active proximal interphalangeal (PIP) joint motion was 40/100 in the index, 45/105 in the middle, and Oil 10 in the ring and little fingers (Fig. 4, D and£). The patient is working as a veterinary assistant. Case 4. A 40-year-old machinist injured his nondominant hand with a router. All dorsal soft tissues were avulsed from the wrist to the MP joints, with loss of the distal shafts and heads of all finger metacarpals. He also sustained commi nuted fractures of the bases of the proximal phalanges of the index, middle, and little fingers. The volar neurovascular structures and tendons were intact. He was treated elsewhere initially by wound debridement. Kirschner wires were bent and placed longitudinally into the proximal phalanges and metacarpal bases in an attempt to restore length. An abdomi nal flap covered the dorsal tissue defect. At the time of our examination 2 months later, roentgeno grams showed shortening and volar displacement of the in dex, middle, and little fingers at the metacarpals. The distal 75% of the second metacarpal and the distal 50% of the three
116
The Journal of HAND SURGERY
Peimer, Leffert, and Smith
devices were removed after solid bony union was achieved 2 months after grafting (Fig. 5, £). Further reconstruction has included PIP capsulectomies, extensor tenolyses, and phalangeal osteotomies to improve grasp. The patient has regained more than 45° of active PIP flexion (40/85 average), uses his hand for assistive activities, and has returned to light duties with his original employer (Fig. 5, F through H).
Results
Fig. 2A. The wires used (Case 7) to maintain MP joint flexion and thumb abduction-pronation are seen. Several transverse distraction-fixation wires and a longitudinal radiocarpal wire are also visible.
ulnar metacarpals were missing. All bones of the hand and wrist were osteoporotic. There was no active motion in the fingers; only a few degrees of passive motion at the PIP joints was possible. (The MP joints had been destroyed.) Flexion and extension of the thumb were preserved but abduction and pronation were limited (Fig. 5, A and B). To prevent further collapse and correct the shortening which had already occurred, a heavy Kirschner wire was drilled transversely through the carpus and two others through the proximal phalanges of the fingers. These wires were attached to two external Roger-Anderson devices and distracted (Fig. 5, C). The transverse palmar arch was pre served by adjusting the position of the proximal phalangeal wires. The PIP joints were manipulated and wired into 60° of flexion. The wires through the PIP joints were removed after 3 weeks; active and passive range of motion exercises were begun. Most of the original metacarpal length was re stored over the next 2 months by gradually distracting the bony fragments with the Roger-Anderson apparatus (Fig. 5, D). After maximal metacarpal length was achieved, a large cortical-cancellous iliac bone graft was inserted to bridge the defect from the metacarpal bases to the proximal phalanges and fuse the MP joints. The transverse wires and external
In this series, all nine patients had loss of at least a portion of one or more metacarpals and parts of the contiguous skeleton. Eight had severe associated in juries to skin, muscle, tendon, nerves, and/or ves sels. The seven patients treated primarily received par enteral cephalosporins from the time of admission. After debridement, the open wounds were covered with povidone-iodine-soak ed gauze and an impermeable dressing to prevent dessication of tissues. After 3 to 5 days, the wounds were reinspected under anesthesia and debrided again if necessary. Extensive soft tissue defects required local or distant flap coverage, as did all wounds for which reconstruction of tendons or nerves was necessary. Flaps were applied to gain primary clo sure in two cases (cases 5 and 6) and delayed closure in four cases (cases 2, 3, 4, and 7). An intermediate stage of skin grafting prior to application of the flap was not required. There were two infections. One patient, referred with a metacarpal osteomyelitis (case 3), underwent multiple debridements, flap application, and, later, staged bone grafting and tendon transfers under an tibiotic prophylaxis, without further infection. One pa tient who had primary closure with a distant flap (case 6) developed a deep Proteus infection 8 weeks after the bone graft (3Vz months after injury). Subsequent re construction was delayed. Six years after injury, roent genograms showed a lytic zone in the lunate which, after debridement, proved to be the nidus of infection. Secondary autogenous bone grafts were required in eight of the nine patients. However, in three cases (cases 3, 8, and 9), one metacarpal reconstituted spon taneously within 6 months. Distraction-fixation was maintained until all bones and bone grafts had healed. When joint fusions were required (cases 2, 4, 5, 6, and 7), they were performed at the time of bone grafting. In adults, we inserted a single graft for all destroyed meta carpals, while taking care to preserve the transverse arch. In the presence of open epiphyses, individual 11 grafts may be used for each metacarpal (case 5). In the two patients in whom only splints were used initially to position the joints (cases 8 and 9), MP extension and thumb adduction contractures developed
Vol. 6, No. 2 March 1981
Distraction-fixation
Fig. 2B. Joint position is maintained with the abdominal flap still attached and all wires cut subcutaneously.
Fig. 2. C and D. The flap was detached and joint wires were removed 27 days after injury. There is full passive extension and no evidence of intrinsic muscle tightness.
117
118
Peimer, Leffert, and Smith
The Journal of HAND SURGERY
Fig. 3. A and B. This hand was mangled in a leaf blower (case 5) with fractures of the distal radius, ulna, and several phalanges and the loss of all finger metacarpals.
but were overcome by vigorous exercises. None of the patients whose joints were positioned by transfixion wires developed contractures of the MP joints or the thumb web (Table 1). Tendon transfers were performed in six patients (cases 2, 3, 5, 7, 8, and 9), tendon grafts in two (cases 6 and 7), and nerve grafts in one (case 7). Additional procedures have included flexor and ex tensor tenolyses (cases 3, 4, and 9), intrinsic tenodesis (case 6), capsulorrhaphies (case 4), and os teotomies (cases 4 and 5). The staged reconstructive procedures required, on an average, more than five operations and almost 2 years to complete. All patients except a 6-year-old child and the most recent patient have returned to work or vo cational retraining. Because of the significant variations in the complexity of injuries sustained and the nature of the reconstructions, no meaningful comparison can be made between these results and those of other pub lished series of patients with bone loss. 4 • 5 • 11 - 14 Mea surements of each patient's active joint range and func tional status are given in Table I. Discussion When metacarpal length and alignment are not main tained after injury, the intrinsic muscles, flexor and extensor tendons, and scar may ultimately cause
Fig. 3C. Multiple longitudinal and transverse wires attached to an external device (Roger-Anderson) were required to re store circulation to the collapsed hand. malalignment with secondary joint stiffness or insta bility. Early restoration of metacarpal length may also improve tissue perfusion and viability (case 5). In the patients we treated, bone length, alignment,
Vol. 6, No. 2 March 1981
Distraction-fixation
Fig. 3. D and E. Function 1 year after bone grafts and transfer of the flexor carpi ulnaris to diminish and increasing flexion deformity of this fused wrist in a growing child.
Fig. 4A. Fractures of the third and fourth metacarpals with loss of all dorsal soft tissues were caused by a pulley mechanism (case 3). The patient was referred I month later with metacarpal osteomy elitis and a necrotic skin graft.
119
120
The Journal of HAND SURGERY
Peimer, Leff'err, and Smirh
Fig. 48. After debridement, the metacarpal remnants were stabilized with transverse wires. Additional wires were used to position the MP joints.
Fig. 4C. An iliac bone graft 4 months later restored the third metacarpal; the fourth metacarpal had healed spontaneously.
Fig. 4. D and E. Two years after tendon transfers, the patient is a veterinary assistant.
Vol. 6, No. 2 March 1981
Distraction~fixation
121
Fig. 5. A and B. Two months after avulsion of the dorsal soft tissues, distal ends of the four ulnar metacarpals, and comminuted phalangeal fractures, these referral roentgenograms show collapse of all fingers but the ring (case 4). There was no active motion. (Part 8 reproduced with permission from Smith, R. J., and Peimer, C. A.: Injuries to the Metacarpal Bones and Joints, in Rob, C., et al. (eds.): Advances in Surgery, volume II. Copyright© 1977 by Year Book Medical Publishers, Inc., Chicago.)
Fig. 5C. Transverse wires were attached to two external de vices and distracted gradually. The palmar arch was pre served by flexion at the fourth and fifth metacarpal positions. The PIP joints were manipulated and wired into 60° of flex ion. (Reproduced with permission from Smith, R. J., and Peimer, C. A.: Injuries to the Metacarpal Bones and Joints, in Rob, C., et al. (eds.): Advances in Surgery, volume II. Copyright© 1977 by Year Book Medical Publishers, Inc., Chicago.)
and rotation were primarily restored by distraction fixation with transverse intermetacarpal wires. In two patients, these wires were attached to an external fixa tion device. These techniques are not new. The use of transverse wires to treat closed metacarpal fractures was first reported by Berkman and Miles. 10 Littler 11 and Howard 12 described the principles of secondary meta carpal reconstruction, based on their World War II ex perience. Matev 13 and Kessler et al. H have stressed the use of external devices to secondarily restore metacar pal length after trauma. However, little attention has been given to the primary restoration of metacarpal length and stability after bone loss treatment also re quires internal joint stabilization, early mobilization, and staged soft tissue reconstruction. 4 - 9 • 15 21 Longitudinal wires alone cannot maintain the length of a partially destroyed metacarpal, and multiple crossed wires are often inadequate. Bent wire "spac ers,'' if fashioned correctly, can maintain length but do not control angular and rotational alignment. However, distraction-fixation with wires passed transversely pre vents longitudinal collapse and also dependably main tains both alignment and rotation. The goals of primary treatment are to prevent infec tion, restore stable skeletal length and alignment, and provide skin coverage. These injuries are usually ac
122
Peimer, Leffert, and Smith
The Journal of HAND SURGERY
Fig. SD. Active PIP motion was begun in therapy after 3 weeks. Metacarpal length was restored over the next 2 months.
companied by severe swelling, which makes it difficult to properly position joints by splints or dressings. Many patients require the use of distant flaps to cover defects, and this further complicates the prevention of contrac tures. Position of the joints can be easily maintained with a second set of internal wires. Once bony stability is achieved and the wound covered, a therapy program is begun. Exercises and splinting are continued until maximal motion of the joints is restored. Only after full mobility is achieved and the wounds have matured is reconstruction started. This treatment program allows complete restoration of skeletal length and alignment because the bone loss is treated primarily. Wound or scar contracture and bony shortening or malrotation are prevented; stiffness or instability of the joints second ary to bony malposition is avoided.
Summary and conclusions Hand function after bone loss depends on maintain ing length and alignment of the metacarpals and pre serving joint motion. With partial loss of the metacarpals, bone length can
Fig. SE. Autogenous iliac bone graft bridged the metacarpal defects and MP joints. Distraction-fixation was maintained until bony union 2 months later. (Reproduced with permis sion from Smith, R. J., and Peimer, C. A.: Injuries to the Metacarpal Bones and Joints, in Rob, C., et al. (eds.): Ad vances in Surgery, volume II. Copyright
be restored by distraction-fixation with transverse Kirschner wires. If bone is lost from a single metacar pal or both the third and fourth metacarpals, transverse wires alone are sufficient. Bone loss in two or more adjacent border metacarpals or the thumb metacarpal may require the use of an external fixation device to the wires to maintain length. With destruction of all four metacarpals, two external devices are used to preserve the transverse arch. Joint motion is preserved and contractures are pre vented by positioning the MP joints in 70° of flexion and the first metacarpal in maximum abduction and pronation with a second set of wires.
Vol. 6, No. 2 March 1981
Distraction~fixation
123
Fig. 5. F through I. Two years after PIP capsulorrhaphies, dorsal tenolyses, and phalangeal osteotomies, the patient has more than 45" of active PIP flexion.
Bone grafts are inserted when the wounds have healed, swelling has subsided, and a maximal range of motion has been restored. The distraction-fixation wires and external devices are maintained until bony union is solid. Tendon and nerve reconstructions are performed as the final stages.
We wish to thank Drs. MichaelS. Feinberg and James W. May, Jr., for allowing us to include their cases in this review.
REFERENCES I. Kaplan EB: Functional and surgical anatomy of the hand, ed 2. Philadelphia, 1965, J B Lippincott Co, pp 25-33
124
Peimer. Leff'ert, a11d Smith
2. Flatt AE: The care of minor hand injuries, ed 4. St. Louis, 1979, The C V Mosby Co, pp 3-7 3. Bunnell S: The early treatment of hand injuries. J Bone Joint Surg (Am) 33:807-11, 1951 4. McCormack RM: Reconstructive surgery and the imme diate care of the severely injured hand. Clin Orthop 13:75-82, 1959 5. Milford L: Shotgun wounds of the hand and wrist with a report of four cases. South Med J 52:403-13, 1959 6. Orner GE, Jr: The early management of gunshot wounds of the extremities. S Dakota J Med 9:340-4, 1956 7. Smith RJ. Leffert RD: 111 Flynn JE. editor: Hand surgery, ed 2. Baltimore, 1975, Williams & Wilkins Co. pp 62-74 8. Smith RJ. Peimer CA: 111 Rob C et al. editors: Ad vances in surgery, vol II. Chicago, 1977, Year Book Medical Publishers, pp 341-74 9. Chase RA: The severely injured upper limb, to amputate or reconstruct: that is the question. Arch Surg 100:382 92, 1970 10. Berkman EF, Miles GH: Internal fixation of metacar pal fractures exclusive of the thumb. J Bone Joint Surg (Am) 25:816-21, 1943 II. Littler JW: Metacarpal reconstruction. J Bone Joint Surg (Am) 29:723-37, 1947 12. Howard LD: The problem of metacarpal fractures of the hand due to war wounds. AAOS lnstr Lectures, vol 2. St. Louis, 1944, The C V Mosby Co, pp 196-201
The Journal of HAND SURGERY
13. Matev 18: Thumb reconstruction after amputation at the metacarpophalangeal joint by bone-lengthening. A pre liminary report of three cases. J Bone Joint Surg (Am) 52:957-65. 1970 14. Kessler I, Hecht 0, Baruch A: Distraction-lengthening of digital rays in the management of the injured hand. J Bone Joint Surg (Am) 61:83-7, 1977 15. Burkhalter WE. Butler B. Metz W, Orner G: Experi ences with delayed primary closure of war wounds of the hand in Viet Nam. J Bone Joint Surg (Am) 50:945-54, 1968 16. Cleveland M. Manning JG, Steward WJ: Care of battle casualties and injuries involving bones and joints. J Bone Joint Surg (Am) 33:517-27, 1951 17. Butler B, Jr: Initial management of hand wounds. Milit Med 134:1-7, 1969 18. Jabaley ME. Peterson HD: Early treatment of war wounds of the hand and forearm in VietNam. Ann Surg 177:167-73, 1973 19. Ogelsby JE: Twenty-two months' war surgery in Viet Nam. Surgery 102:607-13, 1971 20. Boyes JN: Bunnell's surgery of the hand, ed 5. Philadel phia, 1970, J B Lippincott Co, p 278 21. Adams RW: Small caliber missile blast wounds of the hand: mechanism and early management. Am J Surg 82:219-26, 1951