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Intra-articular fractures at the base of the fifth metacarpal
INTRA-ARTICULAR
FRACTURES AT THE BASE OF THE FIFTH METACARPAL
A clinical and radiographical study of 64 cases K. KJbR-PETERSEN,
A. G. JURIK and L. K. PETERSEN
From the University Departments of Orthopaedic Surgery and Diagnostic Radiology, University of Aarhus, Denmark
The treatment of 64 i&a-articular fractures at the base of the fifth metacarpal was studied. 11 fractures with minimal displacement had been immobilised in a plaster cast without reduction. The position was improved in five of 25 fractures treated by closed reduction and a plaster cast, six of nine fractures after percutaneous pinning, and 12 of 19 fractures after open reduction and internal fixation. At follow-up after a median of 4.3 years, 19 of 50 patients answering a questionnaire had intermittent pain, especially on firm grip. 43 patients were re-examined clhricafly and radiographitally: 21(49%) had decreased grip power, and 28 had radiographical signs of osteoarthrosis. Journal of Hand Surgery (British Volume 1992) 17B: 144-147
Intra-articular fractures at the base of the fifth metacarpal resemble Bennett’s and Rolando’s fractures in their pattern (Dommisse and Lloyd, 1979; Niechajev, 1985) and in their tendency to instability (Ker, 1955; Bora and Didizian, 1974; Berg et al., 1986; Rawles, 1988). Because of the instability of these fractures, internal fixation has been recommended by some authors (Hazlett, 1968; Hagstrsm 1975; Niechajev, 1985; O’Brien, 1988; Rawles, 1988), whereas others prefer plaster immobilisation (Shephard and Solomon, 1960; Hsu and Curtis, 1970). Documentation of the results is sparse, because only three reports include more than ten cases (Bora and Didizian, 1974; Petrie and Lamb, 1974; Niechajev, 1985). The purpose of this study was to analyse a series of 64 intra-articular fractures at the base of the fifth metacarpal, with special emphasis on the method of treatment and the functional result. Material and methods 64 fresh intra-articular fractures at the base of the fifth metacarpal were treated at our University department in the period 197881988. These accounted for 8% of all fifth metacarpal fractures, and occurred as frequently as Bennett’s and Rolando’s fractures put together. The median age of the patients at injury was 38 years (range 9-88 years). 77% were men, and the right hand was involved in 73%. Seven patients had another fractured metacarpal in the same hand and two of these also had a fracture of the distal radius. Based on the initial radiographs, which always included P.A., lateral and oblique views, the fractures were divided into three main types. These are shown in Figure 1. Both conservative and operative methods of treatment had been used. Eleven fractures had minimal displacement and were immobilised in plaster without any attempts at reduction. Most of the fractures with pronounced displacement were held by Kirschner wires after open or closed reduction. Transfixion of the hamato-
Type 1
Type II
Type Illa
Type Ill b
Fig. 1 Types of fracture and the numbers of each type in this series.
metacarpal joint was used in type I fractures, combined with intrafragmentary fixation in type II fractures with large fragments and type IIIA fractures, whereas intermetacarpal fixation was performed in type IIIB and multifragmented type II fractures. All fractures were immobilised in a ulnar plaster cast for three or four weeks and the wires were removed after a median of 42 days (range 1449 days). At follow-up, after a median of 4.3 years (range 1.211.4 years), 43 patients consented to a clinical examination and seven more patients answered a questionnaire. The patients were questioned about symptoms and disability and the examination included measurement of grip power using a dynamometer (Vigorometer) with a large rubber ball. Radiographs of the injured and the contralateral fifth metacarpal were performed using a P.A. and a “30” pronated P.A.” projection (Bora and Didizian, 1974) as shown in Figure 2.
Results Causes of injury are shown in Table 1.
The choice of treatment and the number of fractures which improved in position after attempted reduction are shown in Table 2. Only 43% of 53 fractures
Treatment.
144
INTRA-ARTICULAR
Fig. 2
FRACTURES
AT THE
BASE OF THE
(a) P.A. radiograph of a type IIIB fracture. percutaneous pinning.
FIFTH
METACARPAL
(b) 30” pronate :d P .A. projection
in which reduction was attempted actually improved in position. After closed reduction, improvement in position was mainly due to abolition of the subluxation of the metacarpal shaft, whereas open reduction also diminished the step-off in the articular surface. Complications occurred only in displaced fractures and are shown in Table 3. One fracture became more Table l-Cause
of injury Number ofpatients
Fall on hand Fist fight Dorsal-palmar Unknown
34 12 9 9
compression
Total
Table 2-Correlation
145
showing
exact reduction
after closed manipulation
fragmented during attempted open internal fixation and primary arthrodesis was performed. Follow-up. The number of patients
with symptoms at follow-up is shown in Table 4. 31 patients (62%) had no symptoms or disability. 19 (38%) had intermittent dull pain during weather changes or on strenous use of the hand, especially firm grip. A patient with a conservatively treated type I fracture developed a disabling pseudoarthrosis and had secondary arthrodesis and ultimately amputation through the hamato-metacarpaljoint because of continued pain. Grip power was decreased in 21 patients by a median 25% (range 5-60x).
Radiographs showed widening
of the base of all 43 metacarpals X-rayed. A step in the articular surface was still visible (Fig. 3b) in 21 fractures. 28 patients (65%) had secondary osteoarthrosis : This was mild (Thomas et al., 1975) in 16 patients (minimal joint space narrowing,
64
between the type of fracture and method of treatment Type offracture I
II
4 (0)
4 (0)
3 (0)
6 (2) 4 (3) 7 (5)
6 (0) 1 (0) 10 (5)
21 (10)
21 (5)
IIIA
Total IIIB
Minimally displaced Plaster cast Displaced Closed reduction and plaster cast Percutaneous K wire fixation Open reduction and internal fixation Total
and
Note: In brackets, the number of fractures with improved position after reduction
0
11 (0)
10 (2) 2 (2) 2 (2)
3 (1) 2 (1) 0
25 (5) 9 (6) 19 (12)
17 (6)
5 (2)
64 (23)
THE
146
JOURNAL
OF HAND
SURGERY
VOL.
17B No. 2 APRIL
1992
Fig. 3 (a) Original radiograph of a type II fracture. (b) One year after injury, there was malunion with a step in the articular surface and secondary osteoarthrosis causing significant symptoms. (c)Ten years later, moderate osteoarthrosis was present but the patient had no symptoms.
subtle spurs, slight ebumation, one or two small cysts) and moderate (Fig. 3c) in 12 patients (obvious joint space narrowing, prominent spurs, moderate eburnation, one large or multiple small cysts). There was no significant Table 3-Complications
Number ofpatients 6
Secondary displacement Operative treatment
K wire migration without secondary displacement Superficial infection Pressure sores Primary arthrodesis
Table 4-Numbers
5 3 2 1 17
Total
between osteoarthrosis
Discussion
of patients with symptoms at follow-up related to fracture type aad methods of treatment Total
Type offracture I
II
IIIA
IIIB
1(3)
0 (2)
0 (2)
0
1 (7)
4 (6)
3 (6)
1(6)
1 (2)
9 (20)
1 (5)
0 (1)
O(1)
l(1)
2 (8)
Minimally displaced
Plaster cast Displaced
Closed reduction and plaster cast Percutaneous K wire fixation Open reduction and internal fixation Total Nofe: In brackets, the number of patients at follow-up.
and symptoms at
Intra-articular fractures occur at the base of the fifth metacarpal as often as at the base of the first metacarpal. The main mechanism of injury seems to be a force along the axis of the metacarpal, occasionally combined with hyperextension of the hamato-metacarpal joint (Domisse and Lloyd, 1979; Rawles, 1988) and less frequently a direct blow. In contrast to Dommisse and Lloyd (1979) and Niechajev (1985), we found no correlation between the mechanism of injury and the type of fracture. Reduction of these fractures is difficult; 30 did not improve in position after attempted reduction. The subluxation of the metacarpal shaft was relatively easy to eliminate, but subsequent restoration of the articular surface was much more difficult. Closed reduction failed
(occurred only in displaced fractures)
Conservative treatment
relationship follow-up.
1 (5)
5 (8)
l(2)
7 (19)
8 (17)
2(11)
0 2 (3)
7 (15) 19 (50)
INTRA-ARTICULAR
FRACTURES
AT THE
BASE OF THE
FIFTH
147
METACARPAL
to improve the fracture position in all type II fractures, which shows the incapacity of this method to control the fragments. Furthermore, small interposed fragments, ligament (Shephard and Solomon, 1960; Hsu and Curtis, 1970; Hartwig and Louis, 1979) or a distally rotated radial fragment (Petrie and Lamb, 1974) make this method inadequate. Step-offs in the articular surface are best corrected by open reduction, but this is difficult because these small fractures are often more fragmented than suggested by the radiographs. This may explain why seven of 19 fractures treated by open reduction did not achieve improved position. A plaster cast alone failed to retain reduction and allowed secondary displacement in six fractures, so fractures should be secured by internal fixation. The severity of symptoms and their frequency at follow-up were comparable to those reported after similar treatment of intra-articular fractures at the base of the first metacarpal (Kjaer-Petersen et al., 1990; Langhoff et al., 1991). Bora and Didizian (1974) reported good results following conservative treatment of 18 minimally displaced fractures, whereas one of seven displaced fractures required arthrodesis. In Niechavej’s series (1985), eight of 21 patients with displaced fractures treated by open reduction and internal fixation had persistent complaints on average of 18 months later. Petrie and Lamb (1974) treated 14 fractures by unrestricted mobilisation and reported “insignificant” symptoms in four patients and “significant” symptoms in one patient after an average of 4.5 years.
Conclusion Intra-articular fractures at the base of the fifth metacarpal are difficult to reduce and frequently result later in intermittent dull pain, osteoarthrosis and decreased power of grip. Reduction should be held by internal
fixation and our results indicate that restoration articular surface should be aimed for.
of the
References BERG, E. E. and MURPHY, D. F. (1986). Ulnopahnar dislocation of the fifth carpometacarpal joint-successful closed reduction: Review of the literature and anatomic reevaluation. Journal of Hand Surgery, 11A: 4: 521-525. BORA, F. W. and DIDIZIAN, N. H. (1974). The Treatment of Injuries to the Carpometacarpal Joint of the Little Finger. Journal of Bone and Joint Surgery, 56A: 7: 1459-1463. DOMMISSE, I. G. and LLOYD, G. J. (1979). Injuries to the Fifth Carpometacarpal Region. Canadian Journal of Surgery, 22: 3: 24&244. HAGSTROM, P. (1975). Fracture Dislocation in the Ulnar Carpometacarpal Joints. Open Reduction and Pinning-A Case Report. Scandinavian Journal of Plastic and Reconstructive Surgery, 9: 249-251. HARTWIG, R. H. and LOUIS, D. S. (1979). Multiple Carpometacarpal Dislocations: A Review of Four Cases. Journal of Bone and Joint Surgery, 61A: 6: 906908. HAZLETT, .I. W. (1968). Carpometacarpal dislocationsother than the thumb. A report of I1 cases. Canadian Journal of Surgery, 11: 315-323. HSU, J. D. and CURTIS, R. M. (1970). Carpometacarpal Dislocations on the Ulnar Side of the Hand. Journal of Bone and Joint Surgery, 52A: 1: 927930. KER, H. R. (1955). Dislocation of the fifth carp@metacarpal joint. Journal of Bone and Joint Surgery, 37B: 2: 254-256. K. (1990). KJ,ER-PETERSEN, K., LANGHOFF, 0. and ANDERSEN, Bennett’s Fracture. Journal of Hand Surgery, 158: 1: 58-61. LANGHOFF, O., ANDERSEN, K. and KJ&R-PETERSEN, K. (1991) Rolando’s Fracture. Journal of Hand Surgery, 16B: 4: 454-459. NIECHAJEV, I. (1985). Dislocated Intra-Articular Fracture of the Base of the Fifth Metacarpal: A Clinical Study of 23 Patients. Plastic and Reconstructive Surgery, 75: 3: 40&410. O’BRIEN, E. T. Fractures of the Metacarpals and Phalanges. In: Green, D. P. (Ed) Operative Hand Surgery, 2nd edn. New York, Churchill Livingstone, 1988 : Vol I : 724-726. PETRIE, P. W. R. and LAMB, D. W. (1974). Fracture-subluxation of base of fifth metacarpal. The Hand, 6: I : 82-86. RAWLES, J. G. (1988). Dislocations and Fracture-Dislocations at the Carpometacarpal Joints of the Fingers. Hand Clinics, 4: 1: 103-l 1 I, SHEPHARD, E. and SOLOMON, D. J. (1960). Carpo-metacarpal Dislocation. Report of Four Cases. Journal of Bone and Joint Surgery, 42B: 4: 772-777. THOMAS, R. H., RESNICK, D., ALAZRAKI, N. P., DANIEL, D. and GREENFIELD, R. (1975). Compartmental Evaluation of Osteoarthritis of the Knee. A Comparative Study of Available Diagnostic Modalities. Radiology, 116: 585-594.
Klaus
KJm-Petersen,
M.D.,
0 1992 The British Society
Drejravanget 33, DK-8381 Mundelstrup, Denmark. for Surgery
of the Hand
FRACTURES AT THE BASE OF THE FIFTH METACARPAL
A clinical and radiographical study of 64 cases K. KJbR-PETERSEN,
A. G. JURIK and L. K. PETERSEN
From the University Departments of Orthopaedic Surgery and Diagnostic Radiology, University of Aarhus, Denmark
The treatment of 64 i&a-articular fractures at the base of the fifth metacarpal was studied. 11 fractures with minimal displacement had been immobilised in a plaster cast without reduction. The position was improved in five of 25 fractures treated by closed reduction and a plaster cast, six of nine fractures after percutaneous pinning, and 12 of 19 fractures after open reduction and internal fixation. At follow-up after a median of 4.3 years, 19 of 50 patients answering a questionnaire had intermittent pain, especially on firm grip. 43 patients were re-examined clhricafly and radiographitally: 21(49%) had decreased grip power, and 28 had radiographical signs of osteoarthrosis. Journal of Hand Surgery (British Volume 1992) 17B: 144-147
Intra-articular fractures at the base of the fifth metacarpal resemble Bennett’s and Rolando’s fractures in their pattern (Dommisse and Lloyd, 1979; Niechajev, 1985) and in their tendency to instability (Ker, 1955; Bora and Didizian, 1974; Berg et al., 1986; Rawles, 1988). Because of the instability of these fractures, internal fixation has been recommended by some authors (Hazlett, 1968; Hagstrsm 1975; Niechajev, 1985; O’Brien, 1988; Rawles, 1988), whereas others prefer plaster immobilisation (Shephard and Solomon, 1960; Hsu and Curtis, 1970). Documentation of the results is sparse, because only three reports include more than ten cases (Bora and Didizian, 1974; Petrie and Lamb, 1974; Niechajev, 1985). The purpose of this study was to analyse a series of 64 intra-articular fractures at the base of the fifth metacarpal, with special emphasis on the method of treatment and the functional result. Material and methods 64 fresh intra-articular fractures at the base of the fifth metacarpal were treated at our University department in the period 197881988. These accounted for 8% of all fifth metacarpal fractures, and occurred as frequently as Bennett’s and Rolando’s fractures put together. The median age of the patients at injury was 38 years (range 9-88 years). 77% were men, and the right hand was involved in 73%. Seven patients had another fractured metacarpal in the same hand and two of these also had a fracture of the distal radius. Based on the initial radiographs, which always included P.A., lateral and oblique views, the fractures were divided into three main types. These are shown in Figure 1. Both conservative and operative methods of treatment had been used. Eleven fractures had minimal displacement and were immobilised in plaster without any attempts at reduction. Most of the fractures with pronounced displacement were held by Kirschner wires after open or closed reduction. Transfixion of the hamato-
Type 1
Type II
Type Illa
Type Ill b
Fig. 1 Types of fracture and the numbers of each type in this series.
metacarpal joint was used in type I fractures, combined with intrafragmentary fixation in type II fractures with large fragments and type IIIA fractures, whereas intermetacarpal fixation was performed in type IIIB and multifragmented type II fractures. All fractures were immobilised in a ulnar plaster cast for three or four weeks and the wires were removed after a median of 42 days (range 1449 days). At follow-up, after a median of 4.3 years (range 1.211.4 years), 43 patients consented to a clinical examination and seven more patients answered a questionnaire. The patients were questioned about symptoms and disability and the examination included measurement of grip power using a dynamometer (Vigorometer) with a large rubber ball. Radiographs of the injured and the contralateral fifth metacarpal were performed using a P.A. and a “30” pronated P.A.” projection (Bora and Didizian, 1974) as shown in Figure 2.
Results Causes of injury are shown in Table 1.
The choice of treatment and the number of fractures which improved in position after attempted reduction are shown in Table 2. Only 43% of 53 fractures
Treatment.
144
INTRA-ARTICULAR
Fig. 2
FRACTURES
AT THE
BASE OF THE
(a) P.A. radiograph of a type IIIB fracture. percutaneous pinning.
FIFTH
METACARPAL
(b) 30” pronate :d P .A. projection
in which reduction was attempted actually improved in position. After closed reduction, improvement in position was mainly due to abolition of the subluxation of the metacarpal shaft, whereas open reduction also diminished the step-off in the articular surface. Complications occurred only in displaced fractures and are shown in Table 3. One fracture became more Table l-Cause
of injury Number ofpatients
Fall on hand Fist fight Dorsal-palmar Unknown
34 12 9 9
compression
Total
Table 2-Correlation
145
showing
exact reduction
after closed manipulation
fragmented during attempted open internal fixation and primary arthrodesis was performed. Follow-up. The number of patients
with symptoms at follow-up is shown in Table 4. 31 patients (62%) had no symptoms or disability. 19 (38%) had intermittent dull pain during weather changes or on strenous use of the hand, especially firm grip. A patient with a conservatively treated type I fracture developed a disabling pseudoarthrosis and had secondary arthrodesis and ultimately amputation through the hamato-metacarpaljoint because of continued pain. Grip power was decreased in 21 patients by a median 25% (range 5-60x).
Radiographs showed widening
of the base of all 43 metacarpals X-rayed. A step in the articular surface was still visible (Fig. 3b) in 21 fractures. 28 patients (65%) had secondary osteoarthrosis : This was mild (Thomas et al., 1975) in 16 patients (minimal joint space narrowing,
64
between the type of fracture and method of treatment Type offracture I
II
4 (0)
4 (0)
3 (0)
6 (2) 4 (3) 7 (5)
6 (0) 1 (0) 10 (5)
21 (10)
21 (5)
IIIA
Total IIIB
Minimally displaced Plaster cast Displaced Closed reduction and plaster cast Percutaneous K wire fixation Open reduction and internal fixation Total
and
Note: In brackets, the number of fractures with improved position after reduction
0
11 (0)
10 (2) 2 (2) 2 (2)
3 (1) 2 (1) 0
25 (5) 9 (6) 19 (12)
17 (6)
5 (2)
64 (23)
THE
146
JOURNAL
OF HAND
SURGERY
VOL.
17B No. 2 APRIL
1992
Fig. 3 (a) Original radiograph of a type II fracture. (b) One year after injury, there was malunion with a step in the articular surface and secondary osteoarthrosis causing significant symptoms. (c)Ten years later, moderate osteoarthrosis was present but the patient had no symptoms.
subtle spurs, slight ebumation, one or two small cysts) and moderate (Fig. 3c) in 12 patients (obvious joint space narrowing, prominent spurs, moderate eburnation, one large or multiple small cysts). There was no significant Table 3-Complications
Number ofpatients 6
Secondary displacement Operative treatment
K wire migration without secondary displacement Superficial infection Pressure sores Primary arthrodesis
Table 4-Numbers
5 3 2 1 17
Total
between osteoarthrosis
Discussion
of patients with symptoms at follow-up related to fracture type aad methods of treatment Total
Type offracture I
II
IIIA
IIIB
1(3)
0 (2)
0 (2)
0
1 (7)
4 (6)
3 (6)
1(6)
1 (2)
9 (20)
1 (5)
0 (1)
O(1)
l(1)
2 (8)
Minimally displaced
Plaster cast Displaced
Closed reduction and plaster cast Percutaneous K wire fixation Open reduction and internal fixation Total Nofe: In brackets, the number of patients at follow-up.
and symptoms at
Intra-articular fractures occur at the base of the fifth metacarpal as often as at the base of the first metacarpal. The main mechanism of injury seems to be a force along the axis of the metacarpal, occasionally combined with hyperextension of the hamato-metacarpal joint (Domisse and Lloyd, 1979; Rawles, 1988) and less frequently a direct blow. In contrast to Dommisse and Lloyd (1979) and Niechajev (1985), we found no correlation between the mechanism of injury and the type of fracture. Reduction of these fractures is difficult; 30 did not improve in position after attempted reduction. The subluxation of the metacarpal shaft was relatively easy to eliminate, but subsequent restoration of the articular surface was much more difficult. Closed reduction failed
(occurred only in displaced fractures)
Conservative treatment
relationship follow-up.
1 (5)
5 (8)
l(2)
7 (19)
8 (17)
2(11)
0 2 (3)
7 (15) 19 (50)
INTRA-ARTICULAR
FRACTURES
AT THE
BASE OF THE
FIFTH
147
METACARPAL
to improve the fracture position in all type II fractures, which shows the incapacity of this method to control the fragments. Furthermore, small interposed fragments, ligament (Shephard and Solomon, 1960; Hsu and Curtis, 1970; Hartwig and Louis, 1979) or a distally rotated radial fragment (Petrie and Lamb, 1974) make this method inadequate. Step-offs in the articular surface are best corrected by open reduction, but this is difficult because these small fractures are often more fragmented than suggested by the radiographs. This may explain why seven of 19 fractures treated by open reduction did not achieve improved position. A plaster cast alone failed to retain reduction and allowed secondary displacement in six fractures, so fractures should be secured by internal fixation. The severity of symptoms and their frequency at follow-up were comparable to those reported after similar treatment of intra-articular fractures at the base of the first metacarpal (Kjaer-Petersen et al., 1990; Langhoff et al., 1991). Bora and Didizian (1974) reported good results following conservative treatment of 18 minimally displaced fractures, whereas one of seven displaced fractures required arthrodesis. In Niechavej’s series (1985), eight of 21 patients with displaced fractures treated by open reduction and internal fixation had persistent complaints on average of 18 months later. Petrie and Lamb (1974) treated 14 fractures by unrestricted mobilisation and reported “insignificant” symptoms in four patients and “significant” symptoms in one patient after an average of 4.5 years.
Conclusion Intra-articular fractures at the base of the fifth metacarpal are difficult to reduce and frequently result later in intermittent dull pain, osteoarthrosis and decreased power of grip. Reduction should be held by internal
fixation and our results indicate that restoration articular surface should be aimed for.
of the
References BERG, E. E. and MURPHY, D. F. (1986). Ulnopahnar dislocation of the fifth carpometacarpal joint-successful closed reduction: Review of the literature and anatomic reevaluation. Journal of Hand Surgery, 11A: 4: 521-525. BORA, F. W. and DIDIZIAN, N. H. (1974). The Treatment of Injuries to the Carpometacarpal Joint of the Little Finger. Journal of Bone and Joint Surgery, 56A: 7: 1459-1463. DOMMISSE, I. G. and LLOYD, G. J. (1979). Injuries to the Fifth Carpometacarpal Region. Canadian Journal of Surgery, 22: 3: 24&244. HAGSTROM, P. (1975). Fracture Dislocation in the Ulnar Carpometacarpal Joints. Open Reduction and Pinning-A Case Report. Scandinavian Journal of Plastic and Reconstructive Surgery, 9: 249-251. HARTWIG, R. H. and LOUIS, D. S. (1979). Multiple Carpometacarpal Dislocations: A Review of Four Cases. Journal of Bone and Joint Surgery, 61A: 6: 906908. HAZLETT, .I. W. (1968). Carpometacarpal dislocationsother than the thumb. A report of I1 cases. Canadian Journal of Surgery, 11: 315-323. HSU, J. D. and CURTIS, R. M. (1970). Carpometacarpal Dislocations on the Ulnar Side of the Hand. Journal of Bone and Joint Surgery, 52A: 1: 927930. KER, H. R. (1955). Dislocation of the fifth carp@metacarpal joint. Journal of Bone and Joint Surgery, 37B: 2: 254-256. K. (1990). KJ,ER-PETERSEN, K., LANGHOFF, 0. and ANDERSEN, Bennett’s Fracture. Journal of Hand Surgery, 158: 1: 58-61. LANGHOFF, O., ANDERSEN, K. and KJ&R-PETERSEN, K. (1991) Rolando’s Fracture. Journal of Hand Surgery, 16B: 4: 454-459. NIECHAJEV, I. (1985). Dislocated Intra-Articular Fracture of the Base of the Fifth Metacarpal: A Clinical Study of 23 Patients. Plastic and Reconstructive Surgery, 75: 3: 40&410. O’BRIEN, E. T. Fractures of the Metacarpals and Phalanges. In: Green, D. P. (Ed) Operative Hand Surgery, 2nd edn. New York, Churchill Livingstone, 1988 : Vol I : 724-726. PETRIE, P. W. R. and LAMB, D. W. (1974). Fracture-subluxation of base of fifth metacarpal. The Hand, 6: I : 82-86. RAWLES, J. G. (1988). Dislocations and Fracture-Dislocations at the Carpometacarpal Joints of the Fingers. Hand Clinics, 4: 1: 103-l 1 I, SHEPHARD, E. and SOLOMON, D. J. (1960). Carpo-metacarpal Dislocation. Report of Four Cases. Journal of Bone and Joint Surgery, 42B: 4: 772-777. THOMAS, R. H., RESNICK, D., ALAZRAKI, N. P., DANIEL, D. and GREENFIELD, R. (1975). Compartmental Evaluation of Osteoarthritis of the Knee. A Comparative Study of Available Diagnostic Modalities. Radiology, 116: 585-594.
Klaus
KJm-Petersen,
M.D.,
0 1992 The British Society
Drejravanget 33, DK-8381 Mundelstrup, Denmark. for Surgery
of the Hand