Metacarpal fractures

%h?w %nstruments METACARPAL MODIFICATION

FRACTURES

OF A NEW INSTRUMENT FOR THE MAINTENANCE AFTER REDUCTION

DAVID GOLDBERG, Springjeld,

T

HE writer has recentIy described a new instrument for the treatment of metacarpal fractures. l This instrument was devised for the simpIe transverse fractures invoIving the Iateral four metacarpa bones and uses the principIe of pressure pads to maintain position of the fragments after cIosed reduction. EssentiaIIy this method of treatment, in part, was based on the principle originaIIy advocated by Jahss2 in so far that it uses the ffexed proxima1 phaIanx to push upward on the smaI1 dista1 fragment. UnIike the principIe of Jahss the proxima1 fragment is heId down and not aIIowed to go through its fuI1 physioIogic excursion unti1 it is anchored by the carpometacarpa1 joint capsme. Thus, the amount of upward on the ffexed proxima1 interforce reduced. phaIangea1 joint is materiaIIy UnIike the method of Jahss the pressure pads are adjustabIe, aIIowing the operator to reguIate frequentIy the pressure and daiIy extend the proxima1 interphaIangea1 joint. This eIiminates its greatest difficulty, nameIy, a pressure sore or ffexion deformity at this joint. The neck of the metacarpa1 which is the smahest and weakest portion of the bone is the most common site of the fracture. The fracture is more frequentIy transverse in character. The resuIting deformity is that of a depression of the head with drosa1 anguIation of the fragments. The more dorsa1 the striking force against the head the greater is the depression of the knuckIe. The more direct the force on the head in the IongitudinaI axis of the metacarpa1

OF POSITION

M.D.

Massachusetts

the greater the degree of impaction. A tangentia1 force resuIts in depression of the head with impaction and anguIation of the fragments. NormaIIy the interosseous and Iumbrical muscIes insert into a Ioose aponeurotic sIeeve over the dorsum of the proxima1 phaIanx just dista1 to the metacarpophaIangea1 joint. (Fig. I .) Contracture of these two muscIes results in ffexion at the metacarpophaIangea1 joint. FoIIowing a fracture of the metacarpa1 with depression of the metacarpal head, the directiona puI1 of these muscIes is aItered and the proxima1 phaIanx is puIIed into hyperextension. (Fig. 2.) The greater the fIexion deformity of the metacarpal, the more wiI1 be the hyperextension puI1 of the IumbricaI and interosseous muscles, the shorter wiII be the reIative Iength of the Aexor profundus and subIimis tendons and the greater wiI1 be the ffexion deformity of the interphaIangea1 joints. This deformity in the Iaborer interferes with his grasp of an impIement. The inabiIity to ffex the affected finger compIeteIy resuIts in weakness of the ffexion power of the adjacent fingers. The prominent head of the metacarpal in the paIm of the hand may cause pain when a object such as a too1 is grasped. Depression of the knuckIe, prominence on the dorsum of the hand, hyperextension at the metacarpophaIangea1 joint and ffexion deformity at the interphaIangea1 joints are cosmeticaIIy objectionabIe to women. Unfortunately in this fracture which is so easiIy reduced it is diffrcuIt ordinariIy to 224

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maintain the corrected position. Since this type of fracture is usuaIIy first seen by the genera1 practitioner, it is invariabIy treated by him with one of the many more simpIe methods avaiIabIe. These usuaIIy include the baI1 or roI1 of bandage splinted in the Transverse

Fractures

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cated by Jahss, for a period sufficient to see caIIous on the x-ray fiIm often resuIts in a ffexion deformity. With the fracture once reduced, the operator wiII find that very IittIe upward pressure on the head of the metacarpa1 Transverse

Pibers

Journal

Fibers

Dorsa 1 Aponeuros is

Lursbri oa 1

Profundus

Tendon Sublinris

Tendon

2

FIG. I. A schematic drarwing demonstrating the norma relationship of the interosseous, lumbrical and profundus muscles. FIG. 2. A schematic drawing demonstrating the relationship of the intrinsic muscles after a ffexion deformity of the metacarpal has occurred. The force of the IumbricaI and interosseous muscles have been altered from a ventral to a dorsal pul1. Because of the hyperextension deformity at the metacarpophalangeal joint, the subhmis and profundus tendons have become relativeIy shortened, thus causing a Kexion deformity at the distal interphalangeal joints.

paIm of the hand or various types of pIaster of paris, wooden or Ieather spIints. Surgeons have used more compIicated methods : Bosworth3 maintains position by fixing the fragments with rigid wires into the adjacent metacarpa1, MeItzer4 empIoys the skeIeta1 wire traction through the proxima1 phaIanx, Carr5 maintains the position of the fragments by inserting speciaIIy constructed ice tongs into the proxima1 phaIanx and BunneI16 uses Iongitudina1 and transverse Kirschner wires. The baI1 or roI1 of gauze in the paIm of the hand does not counteract but rather emphasizes the anguIating puI1 of the IumbricaI and interosseous muscIes thereby increasing the deformity. SkeIetaI traction of any form or skeIeta1 fixation introduces the danger of infection. When pIaster is used, it is too difficult to determine the exact amount of pressure necessary to maintain the position of the fragments. Too much pressure wiI1 resuIt in pressure sores during the sweIIing stage which ensues within a few hours folIowing reduction. Too IittIe pressure wiI1 resuIt in reanguIation when the sweIIing subsides. Constant immobiIization of the flexed proxima1 interphaIangea1 joint, as advo-

and downward pressure over the dista1 end of the proxiina1 fragment is necessary to maintain the corrected position. However, an upward force cannot be made at this time on the pIantar surface of the metacarpa1 head since pressure of any consequence on the intervening flexor tendon sheath wouId irritate its membrane and resuIt in thickening and adhesions. In order to eIiminate pressure over the flexor tendon sheath the metacarpophaIangea1 and first interphaIangea1 joints are flexed to form right angles. This pIaces the base of the proximal phaIanx beneath the head of the metacarpa1. SIight pressure exerted upward against the head of the flexed phaIanx resuIts in eIevation of the metacarpa1 head and easiIy maintains the corrected position of the fragments.‘The amount of pressure necessary is mereIy the equivaIent of overcoming the anguIation deformity caused by the puI1 of the interosseous and Iumbrical muscIes. The instrument originaIIy described has been in use by the author and aIso by his associates since 1941 with equaIIy good resuIts. These fractures were originaIIy treated with a meta spIint using the ffexed finger throughout the entire period of im-

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FIG. 3. A and B, the entire course is then removed extended during

Goldberg-Metacarpal

Fractures

AUGUST,

1948

B the origin: and the modified splints incorporated. Both splints can now be used throughout of treatment. A is used during the first three or four days of treatment. The dista1 attachment by a simple boIt and the square attachment applied. This allows the involved finger to be the remaining period of immobilization.

mobiIization. (Fig. 3~.) At that time it was necessary to see the patient every second or third day in order to extend the proxima1 interphaIangea1 joint and thus avoid a ffexion contracture. An attempt was then made to eIiminate the necessity of seeing the patient so frequentIy. After the first three to five days the sweIIing of the soft tissues and the spasm of the traumatized interosseous and Iumbrica1 muscIes had subsided. Therefore, it was beIieved that a sIight amount of upward pressure on the ventra1 surface of the metacarpa1 head at this time wouId not irritate the Aexor tendon sheath. A square attachment (Fig. 3~) was then devised which appIied the upward pressure directIy beneath the metacarpa1 head. This proved to be satisfactory but one diffIcuIty was encountered. The splint which was constructed of meta obstructed adequate visualization of the fragments on the roentgenogram. Hence, on a subsequent case the spIint was constructed of a pIastic materia1 and proved more satisfactory since it was radioIucent. An attempt was then made to combine both instruments into one in order to

simpIify repIacement of the vertica1 arm with the square attachment. This was accompIished by using a simpIe boIt to disconnect the vertica1 arm and repIace it with the square attachment. Roentgenograms of a typica case are demonstrated. (Fig. 4~ to D.) TREATMENT

OF

A

SIMPLE

IMPACTED

FRACTURE

The hematoma at the fracture site is injected with about 5 cc. of a, I per cent soIution of procaine hydrochIoride. (Fig. 5.) Any skin gIue such as compound tincture of benzoin, gum mastic or Ace adherent is applied to the distal half of the forearm and the gIued area is now covered with a 2 or 3 inch circuIar stockinette. After ten or fifteen minutes the fracture site wiI1 have become anesthetized and the fragments are forcibly broken up to disengage the impaction. This is absolutely imperative. The fragments are easiIy aIigned by appIying upward pressure on the paImar surface of the metacarpa1 head and downward pressure over the distal portion of the proxima1 fragment. The patient now maintains the corrected position by pIacing the

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FIG. 4. A, simpIe fracture through the neck of the fifth metacarpal; R, fracture reduced and the originat splint applied.

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FIG. 4. C, the modified splint applied four days later shows the position of the fragments maintained.

FIG. 4. D, twenty-six days postreduction; motion of fifth finger normal.

index finger of his other hand beneath the metacarpa1 head and his thumb over the dorsum of the hand just proxima1 to the fracture site. The operator then appIies a few turns of pIaster of paris bandage about

American Journal of Surgery

fragments in good position;

the forearm over the stockinette. The Iong arm of the spIint (Fig. 3) is then applied in the line of the involved metacarpa1 and anchored to the forearm with another few turns of pIaster. In a few moments the

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FIG. 5. A schematic drawing demonstrating the various directions of the hypodermic needIe to facilitate striking the hematoma at the fracture site. At this point about 5 to 10 cc. of a I per cent solution of novocain is injected in order to produce anaIgesia.

pIaster wiI1 have set. The upper set screw is then adjusted so that the pressure pIate rests directIy over the metacarpa1 and is proxima1 to the fracture Iine. The invoIved finger is then ffexed to right angIes at the metacarpophaIangea1 and proximal interphaIangea1 joints. The patient now exerts upward pressure on the dista1 fragment by pressing upward on the flexed proxima1 interphaIangea1 joint and downward on the dorsa1 pressure pad. The vertica1 arm is now attached to the Iong horizonta1 arm by means of a bolt and nut. (Figs. 3~ and 6.) The Iower support bracket is raised so that it approximates the dorsal surface of the Aexed second and third phaIanges. The knuckIe is thus maintained in its norma prominent position. If the fifth metacarpa1 is involved, it wiII be noticed that the two termina1 phaIanges wiI1 deviate radiaIIy. Hence, a

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third set screw is pIaced at the Iower support in order to adjust it to the proper angIe. The upper pIate is supported by a universal joint in order to aIIow for sIight variations in the size and shape of the hand and stiI1 maintain an even distribution of force throughout the entire contact surface which is covered with a feIt pad. To prevent the possibiIity of rotation of the fragments it is advisabIe that the next norma finger be ffexed with the invoIved finger and then reIeased either immediately or after one or two days. The Iower pad can be pIaced transverseIy to accommodate both fIexed fingers. It can aIso be angulated to compensate for the different Iengths of the proxima1 phaIanges. First Postoperative Day. Twenty-four hours after reduction the operator’s thumb can be pIaced beneath the invoIved metacarpa head and his index linger over the upper pressure pad. With the position maintained in the aforementioned manner, the Iower pad is reIeased and the ffexed finger carried through a fuI1 range of motion at the proxima1 interphaIangea1 joint. The finger is IightIy massaged with any oi1, ffexed again and the Iower pressure pad reappIied. This procedure is carried out daiIy for three to five days to eIiminate the possibiIity of a pressure sore and flexion deformity at the proxima1 interphaIangea1 joint. Square Attachment. After three to five days the sweIIing of the hand and the spasm of the IumbricaI and interosseous muscIes, which is the deformity eIement, wiI1 have subsided. The fragments are again temporariIy heId by the patient or the operator. The vertica1 attachment is removed and the square attachment is appIied. (Fig. 3~ and B.) Pressure pads are then adjusted (Figs. 3 and 7) and in this manner the patient had practicaIIy a full range of hnger motion. It is now necessary to see the patient onIy once or twice weekIy unti1 caIIous is visibIe at the fracture site which usuaIIy takes three to five weeks. The spIint is then removed and no further treatment is necessary.

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FIG. 6. The vertical attachment applied to a simple fracture through the neck of a metacarpal. Pressure at “A” and “B” applied through the intervening extensor tendon during the variable phases of swelling and muscle spasm following reduction. FIG. 7. The square attachment applied to a simple fracture through the neck of a metacarpal. This attachment is applied three to five days after closed reduction. Pressure now at pad “B” is insufficient to cause injury to the intervening flexor tendon sheath. FIG. 8. The vertica1 attachment applied to a simpIe oblique or spiral fracture through the shaft of a metacarpal. When reduced, the “saw-tooth” edges of the fragments, the “sleeve-like” effect of the periosteum and the “anchorage” of the transverse metacarpal Iigament to the adjacent metacarpal may be sufficient to prevent over-riding while the splint maintains position. Frc. 9. The square attachment applied to a simple oblique or spiral fracture through the shaft of a metacarpal. If the fragments slip after closed reduction, a single wire Ioop can bc inserted into a smal1 drill hole under Iocal anesthesia. The wire loop tends to overcome some of the angulating puI1 of the lumbricals and interosseous muscles. FIG. IO. The square attachment applied to a comminuted fracture through the shaft of a metacarpal. The anchorage of the transverse metacarpa1 Iigament to the adjacent metacarpa1 prevents marked shortening. Good alignment in spite of littIe shortening leaves a satisfactory functiona result. Pressure at “B ” is Iessened since the slight bone shortening diminished the angulating force of the IumbricaI and interosseous muscIes. FIG. I I. The square attachment applied to a compounded war injury with a bony defect. The splint holds the fragments in good alignment until the soft tissue wounds hea1. The pressure pad at “A” may easily be reteased when change of dressing is necessary. Apparatus may be reapplied after bone graft is inserted.

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12. A, maIunited fracture near base of third metacarpal with paImar angulation of distal fragment; bullet wound first seen three months after injury. n, the deformed fifth finger was disarticulated at the proximal interphalangeat joint; the middle phalanx was used as a bone graft; open operation performed on third metacarpa which was united by fibrous union; graft. heId in situ with silver wires; fragments maintained in good position three weeks post0perativeIy. FIG.

HANDLING

OF

OTHER

FRACTURES

Transverse or Oblique Fractures. Occasionally the periosteum, the anchorage of the transverse metacarpa1 ligament‘ to the adjusted metacarpal and the “sawtooth ” shape of the fractured fragments will hold them from over-riding. In that case the fragments can be immobilized in the usua1 manner. (Fig. 8.) On the other hand, if the fragments slip, it is a simple procedure to approach the fragments through a small dorsal incision under IocaI anesthesia and insert a single wire loop through a very small drill hole in each fragment. The wire Ioop counteracts some

Fractures

AUGUST. 1948

of the angulating pulI of the spastic IumbricaI and interosseous muscles hence obviates the necessity of using the vertical attachment. Therefore, the square attachment may be applied immediately after reduction. The upper pad is placed directly over a smaI1 dressing which can be heId in pIace with any skin glue. (Fig. 9.) The wounds can Compound Fractures. be cIeaned and dressed in the usua1 man7 ner. SIight shortening of the metacarpa1 diminished the angulating puI1 of the spastic IumbricaI and interosseous muscIes. The square attachment may be directly applied. (Fig. IO.) Caused by War Injuries. Fractures When bony defects are encountered as a result of buIIet or she11 fragment injuries, the wounds can be debrided and dressed in the usual manner. The square attachment is applied over the dressing. If the wound if Ieft open, the fragments can be heId by the operator whiIe the pressure pads are removed and the wound can be redressed. The pressure pads are then reappIied. In this manner the fragments are heId in good alignment until the soft tissues have heaIed. (Fig. I I.) By this time the intervening librous tissue wiI1 hold the fragments and prevent anguIation. At some subsequent date an open operation can be performed, a smaI1 bone graft inserted, held in situ with a single wire loop at each end and the square attachment reappIied. During this entire procedure the patient has fuI1 motion of a11 his lingers. Malunited Fractures. Open operation followed by osteotomy of the fragments is simpIy performed. The square attachment is then directly appIied. If there is fear that the fragments might slip, then a single wire loop can be inserted into both fragments. Ununited Fractures. The intervening hbrous tissue is excised. The fragments are freshened and a smaI1 bone graft may be applied. The graft can be held in situ with one or two small wire loops. (Fig. I2A and B.)

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No. 2

Fractures

ofsurgery

A simpIe mechanica device has been described for use in the treatment of a11 invoIving the four types of fractures latera metacarpal bones.

of the metacarpals, a new method of reduction and immobihzation. J. Bone ev Joint Surg., 20: 178-186, 1938. 3. BOSWORTH, D. M. Internal splinting of fractures of the fifth metacarpal. J. Bone Ed Joint Surg., 19: 826-7, 1937. 4. MELTZER, H. Wire extension treatment of fractures of fingers and metacarpal bones. Surg., Cynec. Ed

Obst. i;f;: 87-9,

1932.

_

4. CARR.

REFERENCES

D. MetacarpaI fractures, a new instrument for the maintenance of position after reduction. Am. J. Surg., 5: 758-766, 1946.

GOLDBERG,

R. W. A fimzer cahoer for reduction of phaIangea1 and me;acarpaI’fractures by skeletal traction. South. M. J., 32: 543-6, 1939. 6. BUNNELL, S. Surgery of the Hand. P. 524. PhiIadeIphia, 1944. J. B. Lippincott Co.

ACCORDING to T. Horwitz, in congenita1 or deveIopmenta1 coxa vara, drilling of the femoraI neck or impIantation of a bdne graft through it as a suppIementa1 procedure to corrective osteotomy is unjustified. He tried these methods in a smaI1 series of cases but found them of no particuIar vaIue. Any chiId with a painless Iimp may have this deformity. Pain Iater appears in adoIescence or adult life as a resuIt of increasing deformity, especially of the femoral neck, and shortening of the invoIved extremity. X-rays are diagnostic, of course. SimpIe subtrochanteric osteotomy (or intertrochanteric osteotomy) is folIowed by satisfactory resuIts in most cases. Recurrence may occur especiaIIy in those with chronic cases who are operated upon too Iate, and undoubtedly secondary degenerative changes in the femora1 head and neck wiII be found by x-rays in many of these instances.

(Richard

A. Leonardo,

23 I

2. JAHSS, S. A. Fractures

CONCLUSION

I.

American Journal

M.D.)