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PROXIMAL FRACTURES OF THE FIFTH METACARPAL: A RETROSPECTIVE ANALYSIS OF 25 OPERATED CASES
PROXIMAL FRACTURES OF THE FIFTH METACARPAL: A RETROSPECTIVE ANALYSIS OF 25 OPERATED CASES M. Y. PAPALOIZOS, PH. LE MOINE, V. PRUES-LATOUR, N. BORISCH and D. R. DELLA SANTA From The Hand Surgery Unit, Division for Reconstructive Surgery, Geneva University Hospital, Geneva, Switzerland
The clinical and radiological outcomes of 25 surgically treated fractures of the proximal third of the ®fth metacarpal were retrospectively analysed. Many dierent methods of osteosynthesis were used. At follow-up after a mean of 3.3 years, 15 of 25 patients had no pain. Most patients regained a nearly full range of motion in the adjacent joints and more than 90% of the contralateral grip strength. X-ray signs of degenerative arthritis in the metacarpohamate joint were observed in 10 of 25 patients. Pain was found to be directly correlated with the presence of degenerative changes. Journal of Hand Surgery (British and European Volume, 2000) 25B: 3: 253±257 INTRODUCTION
Pain was assessed using an analogue pain scale (0±10) and by its frequency (never, sometimes, frequent, constant). Patients were asked about satisfaction (very satis®ed, satis®ed, not satis®ed) and whether they would have the operation again. Limitations during daily living (ADL), sports and professional activities were scored as follows: no limitations; few limitations; very limited. Time o work, employment status and any changes were recorded. Clinical assessment included pain on palpation and movement of the ®fth carpometacarpal joint, stability of this joint on passive motion, rotation of the small ®nger, passive and active range of motion of the metacarpophalangeal and proximal interphalangeal joints and grip strength measured with a Jamar dynamometer. X-ray ®lms of the ®fth carpometacarpal joint were assessed for the presence of arthritic changes. If present, their severity was graded in four stages (minimal, moderate, advanced, severe).
Compared with fractures at the base of the thumb metacarpal (including Bennett's fracture), fractures involving the proximal region of the ®fth metacarpal have been little studied. We found only four reports of more than 10 cases from 1968 to 1998. Petrie and Lamb (1974) reported on 19 cases (15 treated conservatively, four treated by percutaneous pinning). Bora and Didizian (1974) advocated more agressive treatment, based on their experience with 25 patients. Of these, seven were treated operatively, depending on the fracture displacement. They also recognized that proper reduction was necessary for the power grip of the hand. Niechajev (1985) reviewed 23 operated cases, all treated with the same open technique and K-wire ®xation, and proposed a classi®cation for these intra-articular fractures, based on the fracture patterns. The largest series (Kjaer-Petersen et al., 1992) included 64 intra-articular fractures. Their treatment and outcome were analysed with respect to the fracture types as described by Niechajev (1985). Kjaer-Petersen et al. (1992) noted that this kind of fracture frequently resulted in osteoarthritis (65% of cases) and decreased power grip (49%), and concluded that surgical treatment should aim at restoration of the articular surface. The purpose of the present study was to review our experience with fractures of the proximal third of the ®fth metacarpal treated operatively, and to look at possible correlations between the fracture type, the method of osteosynthesis and the functional outcome.
Patients Twenty-®ve patients (three female, 22 male) could be followed-up for at least 6 months (range 7±77; median 32 months). Nine patients performed heavy manual tasks, eight were light workers, six had oce activities and two were retired. All were right-handed; the right hand was injured in 16 cases and the left hand in nine cases. The mean age at operation was 34 years (range 18±76; median 29). The mechanism of injury was an axial load on the ®st in 10 cases, a fall on the hand in nine cases, a dorso-palmar compression in four cases and was unknown in two cases. Eight cases had associated injuries (seven fractures or fracture-dislocations of other metacarpals and one phalangeal fracture). The mean time between injury to operation was 3 days (range, 0±7; median 3). Operations were performed by eight dierent surgeons (all registrars or consultants).
PATIENTS AND METHODS Assessment methods Thirty-nine patients with 39 fractures of the proximal third of the ®fth metacarpal were treated surgically over a period of 5 years (1993±1997). In this restrospective study, data were obtained from patient ®les and a structured interview (PhL and MYP), using a follow-up questionnaire. A set of standardized radiographs were taken in posteroanterior and supination (608 oblique, as described by Niechajev (1985)) projections.
Fracture classi®cation As our study addressed not only intra-articular, but also extra-articular fractures, the current classi®cation by 253
254
Niechajev (1985) and Kjaer-Petersen et al. (1992) had to be extended. The classi®cation proposed here (Fig 1) takes into account the broad diversity of fracture patterns that was encountered in our study. The ®rst four groups (A1±A4) correspond, with slight changes, to previously described intra-articular fractures: the A1 group is an equivalent of the Bennett's fracture (with subluxation of the shaft); A2 includes fractures with one single fragment, A3 are bi-condylar, T- or Y-shaped fractures and A4 are fractures with one (or more) intermediate fragments. The three next groups (B1±B3) comprise extraarticular fractures such as transverse, oblique and comminuted fractures. The last group (C) of complex `burst' fractures was created to allow for the inclusion of otherwise unclassi®ed fractures. Initially such fractures may not appear to involve the articular surface, but longitudinal split fractures are frequent and may become apparent because of secondary displacement or arthritic changes. RESULTS General The type of fractures and surgical treatments used in each fracture type are given in Table 1. Two-thirds of all
THE JOURNAL OF HAND SURGERY VOL. 25B No. 3 JUNE 2000
fractures belonged to the A type, A3 fractures being the most frequent. The remaining fractures were equally distributed among the B and C types. Treatment choices varied, from direct interfragmentary pinning to more complex ostesyntheses using combinations of screws, K-wires, autologous graft and plates. Relatively simple lesions of the A1 and A2 types were always stabilized by K-wires, either directly or by stabilizing the ®fth onto the fourth metacarpal. A similar approach was adopted for the two A4 fractures. A3 fractures were treated by all possible methods. Because of their unstable nature, B1 and B2 fractures required plate ®xation to achieve stability. Fractures of the C type were also treated by dierent means. Almost two-thirds of all cases were treated by some kind of K-wire ®xation. Twenty-one of the 25 injuries necessitated an open approach. When pinning was chosen, one to four K-wires were needed. Postoperative immobilization was used for a mean of 38 days (range 10±85), either in a metacarpal brace or a short forearm splint. There were ®ve postoperative complications: two hypertrophic scars, one algodystrophy, one partial lesion of the dorsal branch of the ulnar nerve and one super®cial pin track infection. One patient with an A2 fracture was subsequently treated for chronic pain at the carpometacarpal joint. He was painfree after intermetacarpal arthrodesis as described by Dubert (1994).
Fig 1 Classi®cation of proximal fractures of the ®fth metacarpal. A1±A4: intra-articular fractures. B1±B3: extra-articular fractures. C: complex proximal fractures.
PROXIMAL FIFTH METCARPAL FRACTURES
255
Table 1ÐOperative treatment according to fracture type Fracture type Treatments: Direct pinning Pinning of fourth metacarpal Combined pinning Screws Screws and pinning Plate Additional graft
A1
A2
A3
A4
B1
B2
B3
C
Total
1
6
8
2
2
1
1
4
25
1
3
1 1 2 1 2 1 2
1
1 1
3
Fig 2 Pain rating (analogue pain scale 0±10).
Subjective ®ndings Pain levels greater than 5 were not reported (Fig 2), and 14 out of 25 patients said they had no pain. Frequent pain at rest was reported twice, occasional pain during use eight times and during changes in weather three times. Two patients complained that they were very limited in ADL and one complained of a few limitations. Concerning sports activities, three had a few limitations and one was very limited. Seven patients had a few limitations and one was very limited during their occupations. Sixteen patients said they had no limitations at all. Fourteen patients were very satis®ed, nine satis®ed and two not satis®ed. In the last group, one complained of a malrotation of his small ®nger during ¯exion and the other of a painful carpometacarpal joint (with underlying arthritis). Eighteen patients declared they would choose to have the operation again, three that they would not (among them the two patients who were not satis®ed) and four were unable to answer. Clinical ®ndings Nine patients had pain on palpation of the carpometacarpal joint and two when this joint was moved
1 1 2
1
1 1
5 3 8 1 3 5 2
passively. Fifteen patients had no pain, either on palpation or on passive motion. The carpometacarpal joint was considered to be less stable than on the unaected side in seven cases. Six malrotations were observed, of which three were very slight (around 58) and were unnoticed by the patients themselves. Three were more pronounced (158), but only one was a reason for complaint. The eect of the fracture on the mobility of the MCP joint and on grip strength are shown in Figure 3. Most patients regained a nearly full range of motion of the MCP joint and around 90% of the contralateral grip strength. Secondary degenerative changes at X-ray follow-up are shown in Table 2. Fifteen out of 25 patients had no visible signs of degenerative arthritis in the metacarpohamate joint, though three of these cases had some irregularities in the articular surfaces. Except for the B3 type (one case), there were cases without degenerative changes in all types of fractures. Mild degenerative changes were observed in articular, as well as in extraarticular, fractures. Severe changes were seen mainly in fractures of the A2, A3 and C types. All patients returned to their previous work at fulltime, after a mean delay of 14 weeks (range 0±48 weeks; median 9). DISCUSSION The present study established that fractures of the proximal third of the ®fth metacarpal are most frequently seen in young active men, that they usually result from a fall on the hand or ®st and that they are often associated with other metacarpal fractures or dislocations, a fact already mentioned by others (Liaw et al., 1995). None of our cases had an injury of the deep motor branch of the ulnar nerve, as reported by Petersen and Sacks (1986) and by Murphy and Parkhill (1990). Such injuries were not reported in the series of Niechajev (1985) and Kjaer-Petersen et al. (1992) and must be considered as rare. The wide variety of fractures resulted in a wide range of surgical treatments. Similar to other published series, most fractures were dealt with by some form of K-wire ®xation, either directly into the fragments or, after axial
256
THE JOURNAL OF HAND SURGERY VOL. 25B No. 3 JUNE 2000
Fig 3 Mean passive and active mobility of the metacarpo-phalangeal joint and grip strength, expressed in percent of the unaected side (Whisker: standard deviation).
Table 2ÐDegenerative changes according to fracture type Fracture type Arthritis: Absent Mild Moderate Advanced Severe
A1
A2
A3
A4
B1
B2
1
3 1
5 1 1 1
2
1 1
1
2
traction, by transverse stabilization to the adjacent metacarpal. A combination of these two methods or additional screws were also used, when it was thought to be bene®cial. The variety of treatment might also have been due to the number of surgeons who were involved. Except for the unstable B type fractures, which were all stabilized by plates, no standard technique for a particular fracture type could be recognized. Most patients were satis®ed with their treatment and its outcome. Only two out of 25 complained of persistent problems, but only 14 patients had no pain at all, and they were found in all fracture categories. The impact on everyday life was limited to some restraints, mainly during occupational activities. Despite these slight limitations, all patients returned to their previous occupations. Pain on palpation and on passive motion correlated well with the subjective data, with 15 patients having no pain at all. Functional outcome, expressed in terms of mobility of the small ®nger and grip strength, could be considered satisfactory as most patients recovered a nearly full range of motion and more than 90% of the contralateral grip strength. Niechajev (1985) had similar
B3
1
C 2 1 1
Total 25 15 4 1 4 1
outcomes after a mean follow-up of 18 months, whereas Kjaer-Petersen et al. (1992) found that 49% of patients had a mean 25% decrease in grip power after a mean follow-up of 4 years. Our follow-up was around 3 years. The development of arthritis with time might be a plausible explanation for these dierences in the series. Malrotation of the small ®nger has not been previously reported as a possible late complication of these fractures. Six were found in our series. Three were minor, but three measured around 158 although only one was a matter for complaint. Surgeons should be aware of this complication when such fractures have to be stabilized. Various degrees of arthritic degenerative signs were observed in 10 out of the 25 patients and articular stepos or loss of joint surfaces congruity were noted in three more cases. In retrospect, surgical restoration of the articular surface was not achieved in half of all fractures, irrespective of the fracture type. Looking for correlation between articular congruence and patients symptoms, we found that in the group of eight patients reporting pain levels equal or greater than 2 (0±10 scale), six had some articular changes (step-o or arthritis) and
PROXIMAL FIFTH METCARPAL FRACTURES
two had no articular changes (one extra-articular and one intra-articular A1 fracture). It seems justi®able to attempt to restore the anatomy of the articular surface at the base of the ®fth metacarpal, in order to minimize late degenerative changes and related symptoms. References Bora FW Jr, Didizian NH (1974). The treatment of injuries to the carpometacarpal joint of the little ®nger. Journal of Bone and Joint Surgery, 56A: 1459±1463. Dubert T (1994). `Arthroplastie stabiliseÂe' du cinquieÁme meÂtacarpien. Proposition theÂrapeutique pour le traitement des fractures-luxations anciennes du 5e meÂtacarpien. Annales de Chirurgie de la Main, 13: 363±365. Kjaer-Petersen K, Jurik AG, Petersen LK (1992). Intra-articular fractures at the base of the ®fth metacarpal. A clinical and radiographical study of 64 cases. Journal of Hand Surgery, 17B: 144±147. Liaw Y, Kalnins G, Kirsh G, Meakin I (1995). Combined fourth and ®fth metacarpal fracture and ®fth carpometacarpal joint dislocation. Journal of Hand Surgery, 20B: 249±252.
257 Murphy TP, Parkhill WS (1990). Fracture-dislocation of the base of the ®fth metacarpal with an ulnar motor nerve lesion: case report. Journal of Trauma, 30: 1585±1587. Niechajev I (1985). Dislocated intra-articular fracture of the base of the ®fth metacarpal: a clinical study of 23 patients. Plastic and Reconstructive Surgery, 75: 406±410. Peterson P, Sacks S (1986). Fracture-dislocation of the base of the ®fth metacarpal associated with injury to the deep motor branch of the ulnar nerve: a case report. Journal of Hand Surgery, 11A: 525±528. Petrie PWR, Lamb DW (1974). Fracture-subluxation of base of ®fth metacarpal. The Hand, 6: 82±86.
Received 30 June 1999 Accepted after revision: 10 February 2000 M.Y. PapaloõÈ zos, Hand Surgery Unit, Division for Reconstructive Surgery, Geneva University Hospital, 24, Micheli-du-Crest, 1211 Geneva 14, Switzerland. E-mail: [email protected] # 2000 The British Society for Surgery of the Hand DOI: 10.1054/jhsb.2000.0375, available online at http://www.idealibrary.com on
The clinical and radiological outcomes of 25 surgically treated fractures of the proximal third of the ®fth metacarpal were retrospectively analysed. Many dierent methods of osteosynthesis were used. At follow-up after a mean of 3.3 years, 15 of 25 patients had no pain. Most patients regained a nearly full range of motion in the adjacent joints and more than 90% of the contralateral grip strength. X-ray signs of degenerative arthritis in the metacarpohamate joint were observed in 10 of 25 patients. Pain was found to be directly correlated with the presence of degenerative changes. Journal of Hand Surgery (British and European Volume, 2000) 25B: 3: 253±257 INTRODUCTION
Pain was assessed using an analogue pain scale (0±10) and by its frequency (never, sometimes, frequent, constant). Patients were asked about satisfaction (very satis®ed, satis®ed, not satis®ed) and whether they would have the operation again. Limitations during daily living (ADL), sports and professional activities were scored as follows: no limitations; few limitations; very limited. Time o work, employment status and any changes were recorded. Clinical assessment included pain on palpation and movement of the ®fth carpometacarpal joint, stability of this joint on passive motion, rotation of the small ®nger, passive and active range of motion of the metacarpophalangeal and proximal interphalangeal joints and grip strength measured with a Jamar dynamometer. X-ray ®lms of the ®fth carpometacarpal joint were assessed for the presence of arthritic changes. If present, their severity was graded in four stages (minimal, moderate, advanced, severe).
Compared with fractures at the base of the thumb metacarpal (including Bennett's fracture), fractures involving the proximal region of the ®fth metacarpal have been little studied. We found only four reports of more than 10 cases from 1968 to 1998. Petrie and Lamb (1974) reported on 19 cases (15 treated conservatively, four treated by percutaneous pinning). Bora and Didizian (1974) advocated more agressive treatment, based on their experience with 25 patients. Of these, seven were treated operatively, depending on the fracture displacement. They also recognized that proper reduction was necessary for the power grip of the hand. Niechajev (1985) reviewed 23 operated cases, all treated with the same open technique and K-wire ®xation, and proposed a classi®cation for these intra-articular fractures, based on the fracture patterns. The largest series (Kjaer-Petersen et al., 1992) included 64 intra-articular fractures. Their treatment and outcome were analysed with respect to the fracture types as described by Niechajev (1985). Kjaer-Petersen et al. (1992) noted that this kind of fracture frequently resulted in osteoarthritis (65% of cases) and decreased power grip (49%), and concluded that surgical treatment should aim at restoration of the articular surface. The purpose of the present study was to review our experience with fractures of the proximal third of the ®fth metacarpal treated operatively, and to look at possible correlations between the fracture type, the method of osteosynthesis and the functional outcome.
Patients Twenty-®ve patients (three female, 22 male) could be followed-up for at least 6 months (range 7±77; median 32 months). Nine patients performed heavy manual tasks, eight were light workers, six had oce activities and two were retired. All were right-handed; the right hand was injured in 16 cases and the left hand in nine cases. The mean age at operation was 34 years (range 18±76; median 29). The mechanism of injury was an axial load on the ®st in 10 cases, a fall on the hand in nine cases, a dorso-palmar compression in four cases and was unknown in two cases. Eight cases had associated injuries (seven fractures or fracture-dislocations of other metacarpals and one phalangeal fracture). The mean time between injury to operation was 3 days (range, 0±7; median 3). Operations were performed by eight dierent surgeons (all registrars or consultants).
PATIENTS AND METHODS Assessment methods Thirty-nine patients with 39 fractures of the proximal third of the ®fth metacarpal were treated surgically over a period of 5 years (1993±1997). In this restrospective study, data were obtained from patient ®les and a structured interview (PhL and MYP), using a follow-up questionnaire. A set of standardized radiographs were taken in posteroanterior and supination (608 oblique, as described by Niechajev (1985)) projections.
Fracture classi®cation As our study addressed not only intra-articular, but also extra-articular fractures, the current classi®cation by 253
254
Niechajev (1985) and Kjaer-Petersen et al. (1992) had to be extended. The classi®cation proposed here (Fig 1) takes into account the broad diversity of fracture patterns that was encountered in our study. The ®rst four groups (A1±A4) correspond, with slight changes, to previously described intra-articular fractures: the A1 group is an equivalent of the Bennett's fracture (with subluxation of the shaft); A2 includes fractures with one single fragment, A3 are bi-condylar, T- or Y-shaped fractures and A4 are fractures with one (or more) intermediate fragments. The three next groups (B1±B3) comprise extraarticular fractures such as transverse, oblique and comminuted fractures. The last group (C) of complex `burst' fractures was created to allow for the inclusion of otherwise unclassi®ed fractures. Initially such fractures may not appear to involve the articular surface, but longitudinal split fractures are frequent and may become apparent because of secondary displacement or arthritic changes. RESULTS General The type of fractures and surgical treatments used in each fracture type are given in Table 1. Two-thirds of all
THE JOURNAL OF HAND SURGERY VOL. 25B No. 3 JUNE 2000
fractures belonged to the A type, A3 fractures being the most frequent. The remaining fractures were equally distributed among the B and C types. Treatment choices varied, from direct interfragmentary pinning to more complex ostesyntheses using combinations of screws, K-wires, autologous graft and plates. Relatively simple lesions of the A1 and A2 types were always stabilized by K-wires, either directly or by stabilizing the ®fth onto the fourth metacarpal. A similar approach was adopted for the two A4 fractures. A3 fractures were treated by all possible methods. Because of their unstable nature, B1 and B2 fractures required plate ®xation to achieve stability. Fractures of the C type were also treated by dierent means. Almost two-thirds of all cases were treated by some kind of K-wire ®xation. Twenty-one of the 25 injuries necessitated an open approach. When pinning was chosen, one to four K-wires were needed. Postoperative immobilization was used for a mean of 38 days (range 10±85), either in a metacarpal brace or a short forearm splint. There were ®ve postoperative complications: two hypertrophic scars, one algodystrophy, one partial lesion of the dorsal branch of the ulnar nerve and one super®cial pin track infection. One patient with an A2 fracture was subsequently treated for chronic pain at the carpometacarpal joint. He was painfree after intermetacarpal arthrodesis as described by Dubert (1994).
Fig 1 Classi®cation of proximal fractures of the ®fth metacarpal. A1±A4: intra-articular fractures. B1±B3: extra-articular fractures. C: complex proximal fractures.
PROXIMAL FIFTH METCARPAL FRACTURES
255
Table 1ÐOperative treatment according to fracture type Fracture type Treatments: Direct pinning Pinning of fourth metacarpal Combined pinning Screws Screws and pinning Plate Additional graft
A1
A2
A3
A4
B1
B2
B3
C
Total
1
6
8
2
2
1
1
4
25
1
3
1 1 2 1 2 1 2
1
1 1
3
Fig 2 Pain rating (analogue pain scale 0±10).
Subjective ®ndings Pain levels greater than 5 were not reported (Fig 2), and 14 out of 25 patients said they had no pain. Frequent pain at rest was reported twice, occasional pain during use eight times and during changes in weather three times. Two patients complained that they were very limited in ADL and one complained of a few limitations. Concerning sports activities, three had a few limitations and one was very limited. Seven patients had a few limitations and one was very limited during their occupations. Sixteen patients said they had no limitations at all. Fourteen patients were very satis®ed, nine satis®ed and two not satis®ed. In the last group, one complained of a malrotation of his small ®nger during ¯exion and the other of a painful carpometacarpal joint (with underlying arthritis). Eighteen patients declared they would choose to have the operation again, three that they would not (among them the two patients who were not satis®ed) and four were unable to answer. Clinical ®ndings Nine patients had pain on palpation of the carpometacarpal joint and two when this joint was moved
1 1 2
1
1 1
5 3 8 1 3 5 2
passively. Fifteen patients had no pain, either on palpation or on passive motion. The carpometacarpal joint was considered to be less stable than on the unaected side in seven cases. Six malrotations were observed, of which three were very slight (around 58) and were unnoticed by the patients themselves. Three were more pronounced (158), but only one was a reason for complaint. The eect of the fracture on the mobility of the MCP joint and on grip strength are shown in Figure 3. Most patients regained a nearly full range of motion of the MCP joint and around 90% of the contralateral grip strength. Secondary degenerative changes at X-ray follow-up are shown in Table 2. Fifteen out of 25 patients had no visible signs of degenerative arthritis in the metacarpohamate joint, though three of these cases had some irregularities in the articular surfaces. Except for the B3 type (one case), there were cases without degenerative changes in all types of fractures. Mild degenerative changes were observed in articular, as well as in extraarticular, fractures. Severe changes were seen mainly in fractures of the A2, A3 and C types. All patients returned to their previous work at fulltime, after a mean delay of 14 weeks (range 0±48 weeks; median 9). DISCUSSION The present study established that fractures of the proximal third of the ®fth metacarpal are most frequently seen in young active men, that they usually result from a fall on the hand or ®st and that they are often associated with other metacarpal fractures or dislocations, a fact already mentioned by others (Liaw et al., 1995). None of our cases had an injury of the deep motor branch of the ulnar nerve, as reported by Petersen and Sacks (1986) and by Murphy and Parkhill (1990). Such injuries were not reported in the series of Niechajev (1985) and Kjaer-Petersen et al. (1992) and must be considered as rare. The wide variety of fractures resulted in a wide range of surgical treatments. Similar to other published series, most fractures were dealt with by some form of K-wire ®xation, either directly into the fragments or, after axial
256
THE JOURNAL OF HAND SURGERY VOL. 25B No. 3 JUNE 2000
Fig 3 Mean passive and active mobility of the metacarpo-phalangeal joint and grip strength, expressed in percent of the unaected side (Whisker: standard deviation).
Table 2ÐDegenerative changes according to fracture type Fracture type Arthritis: Absent Mild Moderate Advanced Severe
A1
A2
A3
A4
B1
B2
1
3 1
5 1 1 1
2
1 1
1
2
traction, by transverse stabilization to the adjacent metacarpal. A combination of these two methods or additional screws were also used, when it was thought to be bene®cial. The variety of treatment might also have been due to the number of surgeons who were involved. Except for the unstable B type fractures, which were all stabilized by plates, no standard technique for a particular fracture type could be recognized. Most patients were satis®ed with their treatment and its outcome. Only two out of 25 complained of persistent problems, but only 14 patients had no pain at all, and they were found in all fracture categories. The impact on everyday life was limited to some restraints, mainly during occupational activities. Despite these slight limitations, all patients returned to their previous occupations. Pain on palpation and on passive motion correlated well with the subjective data, with 15 patients having no pain at all. Functional outcome, expressed in terms of mobility of the small ®nger and grip strength, could be considered satisfactory as most patients recovered a nearly full range of motion and more than 90% of the contralateral grip strength. Niechajev (1985) had similar
B3
1
C 2 1 1
Total 25 15 4 1 4 1
outcomes after a mean follow-up of 18 months, whereas Kjaer-Petersen et al. (1992) found that 49% of patients had a mean 25% decrease in grip power after a mean follow-up of 4 years. Our follow-up was around 3 years. The development of arthritis with time might be a plausible explanation for these dierences in the series. Malrotation of the small ®nger has not been previously reported as a possible late complication of these fractures. Six were found in our series. Three were minor, but three measured around 158 although only one was a matter for complaint. Surgeons should be aware of this complication when such fractures have to be stabilized. Various degrees of arthritic degenerative signs were observed in 10 out of the 25 patients and articular stepos or loss of joint surfaces congruity were noted in three more cases. In retrospect, surgical restoration of the articular surface was not achieved in half of all fractures, irrespective of the fracture type. Looking for correlation between articular congruence and patients symptoms, we found that in the group of eight patients reporting pain levels equal or greater than 2 (0±10 scale), six had some articular changes (step-o or arthritis) and
PROXIMAL FIFTH METCARPAL FRACTURES
two had no articular changes (one extra-articular and one intra-articular A1 fracture). It seems justi®able to attempt to restore the anatomy of the articular surface at the base of the ®fth metacarpal, in order to minimize late degenerative changes and related symptoms. References Bora FW Jr, Didizian NH (1974). The treatment of injuries to the carpometacarpal joint of the little ®nger. Journal of Bone and Joint Surgery, 56A: 1459±1463. Dubert T (1994). `Arthroplastie stabiliseÂe' du cinquieÁme meÂtacarpien. Proposition theÂrapeutique pour le traitement des fractures-luxations anciennes du 5e meÂtacarpien. Annales de Chirurgie de la Main, 13: 363±365. Kjaer-Petersen K, Jurik AG, Petersen LK (1992). Intra-articular fractures at the base of the ®fth metacarpal. A clinical and radiographical study of 64 cases. Journal of Hand Surgery, 17B: 144±147. Liaw Y, Kalnins G, Kirsh G, Meakin I (1995). Combined fourth and ®fth metacarpal fracture and ®fth carpometacarpal joint dislocation. Journal of Hand Surgery, 20B: 249±252.
257 Murphy TP, Parkhill WS (1990). Fracture-dislocation of the base of the ®fth metacarpal with an ulnar motor nerve lesion: case report. Journal of Trauma, 30: 1585±1587. Niechajev I (1985). Dislocated intra-articular fracture of the base of the ®fth metacarpal: a clinical study of 23 patients. Plastic and Reconstructive Surgery, 75: 406±410. Peterson P, Sacks S (1986). Fracture-dislocation of the base of the ®fth metacarpal associated with injury to the deep motor branch of the ulnar nerve: a case report. Journal of Hand Surgery, 11A: 525±528. Petrie PWR, Lamb DW (1974). Fracture-subluxation of base of ®fth metacarpal. The Hand, 6: 82±86.
Received 30 June 1999 Accepted after revision: 10 February 2000 M.Y. PapaloõÈ zos, Hand Surgery Unit, Division for Reconstructive Surgery, Geneva University Hospital, 24, Micheli-du-Crest, 1211 Geneva 14, Switzerland. E-mail: [email protected] # 2000 The British Society for Surgery of the Hand DOI: 10.1054/jhsb.2000.0375, available online at http://www.idealibrary.com on