- Email: [email protected]
Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws
G Model
HANSUR-200; No. of Pages 5 Hand Surgery and Rehabilitation xxx (2018) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original article
Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws Fixation re´trograde des fractures des me´tacarpiens avec des vis de compression canule´es sans teˆte D. Jann *, M. Calcagni, P. Giovanoli, T. Giesen Department for Plastic Surgery and Hand Surgery, University Hospital Zurich, Ra¨mistrasse 100, 8091 Zurich, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 July 2017 Received in revised form 19 November 2017 Accepted 12 December 2017 Available online xxx
We analyzed the results of 20 unstable metacarpal fractures in 15 patients treated with a cannulated compression screw and no immobilization. All fractures healed within 6 weeks. One patient with multiple fractures and a flexion deficit required arthrolysis of two metacarpophalangeal joints. Another patient had an extension lag. There were no other complications. This fast and easy technique results in good outcomes for unstable metacarpal fractures. The advantages are early active motion without immobilization and stable fixation. Surgical removal of the screw is rarely needed. Level of evidence: IV (therapeutic).
C 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved.
Keywords: Metacarpal Fracture Intramedullary Fracture fixation Headless screw Compression screw
R E´ S U M E´
Mots cle´s : Me´tacarpiens Fracture Centrome´dullaire Oste´osynthe`se Vis sans teˆte Vis a` compression
Nous avons analyse´ les re´sultats de 20 fractures instables des me´tacarpiens chez 15 patients que nous avons traite´s avec des vis de compression canule´es et sans immobilisation. La consolidation des fractures e´tait obtenue dans tous les cas. Nous avons effectue´ une arthrolyse chez un patient avec des fractures multiples et un de´ficit de mobilite´ en flexion. Un autre patient montrait un de´ficit de mobilite´ en extension. Nous n’avons pas trouve´ d’autres complications. Cette technique facile et rapide montre des re´sultats favorables. Les avantages sont la fixation stable et la mobilisation pre´coce. L’ablation de la vis est rarement ne´cessaire.
C 2018 SFCM. Publie ´ par Elsevier Masson SAS. Tous droits re´serve´s.
1. Introduction Metacarpal and phalangeal fractures are the most common fractures of the upper extremity; metacarpal fractures comprise 18% of all fractures below the elbow [1]. Traditionally, screw and plate constructs are the most stable means of fixation for metacarpal shaft fractures [2]. For fractures of the head and the neck, intramedullary wiring is the most common technique [3]. Plates require extensive dissection for them to be placed
* Corresponding author. E-mail address: [email protected] (D. Jann).
correctly and often need to be removed with or without extensor tendon tenolysis a few months after surgery. K-wire fixation is also associated with a high rate of complications [4]. Intramedullary headless screw fixation has recently been described for the treatment of various metacarpal fracture patterns [5–8]. This minimally invasive technique appears to provide sufficient stability to allow early mobilization of the hand. Furthermore, it does not leave any material exposed on the surface of the treated bone, which theoretically eliminates the need for removal and lowers the risk of tendon adhesions. We present the results of 20 metacarpal fractures with different patterns, treated with percutaneous, retrograde intramedullary headless screw fixation and early mobilization.
https://doi.org/10.1016/j.hansur.2017.12.005 C 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved. 2468-1229/
Please cite this article in press as: Jann D, et al. Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws. Hand Surg Rehab (2018), https://doi.org/10.1016/j.hansur.2017.12.005
G Model
HANSUR-200; No. of Pages 5 D. Jann et al. / Hand Surgery and Rehabilitation xxx (2018) xxx–xxx
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2. Patients and methods 2.1. Patients Between September 2014 and April 2016, we treated 15 consecutive patients with 20 metacarpal fractures using an intramedullary retrograde cannulated compression screw (CCS SpeedTip, Medartis, Basel, Switzerland). The fractures were evaluated on plain X-rays in anterior-posterior (AP), oblique and lateral views [9]. Long oblique and spiral fractures in the shaft and multifragment fractures were excluded because they were considered unsuitable for fixation with an intramedullary screw. Fractures at the base of the metacarpals were also excluded. The patients were all men with an average age of 38 years (range 20–77). Six patients had multiple metacarpal fractures (13 in total); out of those 13 fractures, only 10 were eligible for intramedullary screw fixation. Twelve fractures were in the dominant hand and eight in the non-dominant hand. There were two open fractures in one patient. One patient had fractures in both hands and fracture of a proximal phalanx. The fifth metacarpal was affected 13 times, the fourth 4 times and the second 3 times. There were no third metacarpal fractures in our cohort. There were five displaced subcapital fractures, ten shaft fractures and five displaced metacarpal head fractures. In one patient, we performed surgery due to secondary displacement of an initially non-displaced subcapital fifth metacarpal fracture treated with a cast. One patient with a shaft fracture of the fifth metacarpal already had a shaft fracture of the same metacarpal 14 months earlier, which had been treated with a plate that had previously been removed. All patients were informed on arrival at our emergency department about the different treatment options and then consented to undergoing surgery with the intramedullary screw technique. 2.2. Surgical technique The mean time between injury and surgical treatment was 7 days (range 0–22 days). Eleven patients had general/regional
anesthesia and four had local anesthesia. We did not use a tourniquet in the patients undergoing local anesthesia. Closed reduction was performed under fluoroscopic control. In open fractures, reduction was performed under visual control. In one patient with a metacarpal head fracture, we had to make a small (1.5 cm) incision to achieve adequate reduction. Once anatomic reduction was achieved and verified by fluoroscopy, a guide wire was inserted under fluoroscopic control through the dorsal aspect of the metacarpal head in a retrograde manner until it reached the base of the metacarpal. The tip of the wire was intentionally left protruding 1 mm through the carpometacarpal (CMC) joint to avoid mobilization or removal of the wire following manipulations or after drilling. In one patient with hard bone and one patient with a previous shaft fracture, the medullary canal was pre-drilled. In all other patients the screw was inserted without pre-drilling. The size of the screw (2.2 mm or 3.0 mm in diameter) was decided preoperatively by measuring the isthmus of the medullary canal on the lateral view or on the oblique view, when the metacarpal isthmus was impossible to outline on the lateral view. We used a 2.2 mm diameter screw when the isthmus of the medullary canal was smaller than 3 mm. We used eight 2.2 mm diameter screws and thirteen 3.0 mm diameter screws. The screw was inserted under fluoroscopic control to avoid protrusion of the screw head in the MCP joint. In one three-fragment metacarpal head fracture, two screws were used for the same fracture (Fig. 1). The tenodesis effect was used to control rotation and scissoring of fingers. Wounds were dressed with Primapore (Smith and Nephew, London, UK) and buddy strapping applied to the affected and the adjacent finger(s) for 1 month. Operative time was recorded in all cases.
2.3. Postoperative care Patients were seen 7 days (range 6–14 days) postoperatively to check the wound and take follow-up X-rays. The patients were then seen 1 month postoperatively (range 4–6 weeks) with new X-rays to verify fracture union. The last follow-up was at a mean of
Fig. 1. Multifragmentary fracture of the head of the fifth metacarpal in a 32-year-old male (left). Open reduction had to be performed. Fixation was performed with one 3.0 mm and one 2.2 mm CCS screw (right).
Please cite this article in press as: Jann D, et al. Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws. Hand Surg Rehab (2018), https://doi.org/10.1016/j.hansur.2017.12.005
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3.5 months postoperatively (range, 1–17 months). Range of motion of the metacarpophalangeal (MCP) joints and grip strength with the Jamar dynamometer (Patterson Medical Holding, Warrenville, IL, USA) were recorded. Postoperative infection, screw migration, finger malrotation, delayed union, complex regional pain syndrome (CRPS) were also recorded. 2.4. Rehabilitation Patients began active motion immediately under the supervision of a hand therapist. The protocol consisted of immediate active mobilization; passive mobilization and build-up of force was started 4 weeks postoperatively. Full force was allowed after 6 weeks.
3. Results The mean operative time was 21 minutes (range 5–45 minutes) when only the intramedullary screw was inserted, and no other fractures or injuries had to be treated. All 20 fractures were healed after an average of 4 weeks (range 4–6) (Fig. 2). At the last followup, there were no radiographic malunions [10]. At the latest follow-up, 17 digits in 13 patients had full range of motion (ROM), except for one patient with a head fracture of the second metacarpal who had a 258 extension lag. Tenolysis was recommended for this case but the patient declined. One patient who suffered polytrauma and two concomitant metacarpal fractures and a phalanx fracture to the left hand had a severe flexion deficit in two MCP joints. Tenoarthrolysis of the MCP joints was performed. He eventually achieved good function and 808 flexion in both MCP joints. The grip strength in all patients was a mean of 93% of the contralateral hand. We did not observe any infections, malunion, non-union or rotational deformities. There were no cases of CRPS. One patient had the screw removed because of slight proximal migration of the screw. The patient had no symptoms, but we removed the screw to avoid future damage to the joint cartilage. In one patient, we removed the intramedullary screw at the same time as a metacarpal plate on the adjacent metacarpal bone was being removed.
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4. Discussion Unstable or displaced metacarpal shaft fractures and distal metacarpal fractures (head and subcapital) can be treated with different techniques, but they all have disadvantages. Dorsal plating requires larger surgical exposure and is associated with complications such as plate prominence, infection, tendon rupture, stiffness and need of future plate removal [3,11,12]. For subcapital fractures, intramedullary wiring is the most popular treatment [12,13], but pin track infection has been reported in 6–7% of the cases [4,14]. Two large studies found an overall complication of around 15% with K-wire fixation in hand and wrist fractures [4,15]. Boulton et al. [7] published one case of an intramedullary headless screw in a comminuted subcapital fracture of the fifth metacarpal and with excellent outcomes. Del ˜ al et al. [5], showed favorable results in a large group of patients Pin with metacarpal as well as phalangeal fractures. In our study, we replicated the good functional results obtained ˜ al et al. [5] supporting the idea that intramedullary by del Pin fixation of transverse and short oblique fractures of the metacarpals, as well as head and subcapital fractures, is an effective technique. Shaft fractures treated with a plate are typically affected by a high rate of secondary surgery for plate removal as well as for tenolysis [16]. Furthermore, implantation of a plate requires a much larger surgical incision and requires a more complex surgery, resulting in a longer operative time and higher costs when compared to an intramedullary screw. The intramedullary screw may not need to be removed, resulting in less surgery for the patient and, at the same time, lower costs for the society. The fixation material per se is also much cheaper: a metacarpal plate with five screws from the same company costs 2.4 times more than a 40 mm long, 3.0 mm diameter screw (the largest screw we used in this study). Subcapital fractures are in our opinion treated properly with the Bouquet technique initially published by Foucher [13]. The only problem left with this technique is the fairly high rate of infection, normally affecting the entry point of the wires in the skin [14,17], when the wires are left exposed. Our study found no infections, suggesting a lower rate of this complication with our technique. Furthermore, our surgical technique is easier, especially
Fig. 2. Displaced transverse fracture of the fifth metacarpal bone in a 21-year-old male (left). Closed reduction and fixation with a 3.0 mm CCS screw (right).
Please cite this article in press as: Jann D, et al. Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws. Hand Surg Rehab (2018), https://doi.org/10.1016/j.hansur.2017.12.005
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Fig. 3. Intraarticular fracture of the head of the second metacarpal in a 66-year-old male (left). Closed reduction and fixation with a 3.0-mm CCS screw (right).
when no drilling is required. The tradeoff is that the cost of the screws is consistently higher than the cost of one or two K-wires. Head fractures can also be treated with the Bouquet technique or with retrograde K-wires buried in the head. However, the Bouquet technique may be inadequate in the presence of fragmentation or very distal displaced fractures. Fixation of the head with retrograde wires does not allow early mobilization. The technique using buried wires often requires the use of more wires and the wires cannot be properly buried underneath the cartilage without opening the joint. Furthermore, the wires have the tendency to migrate proximally or distally [3,4,13,14]. In Fig. 3 we present one of the metacarpal head fractures we treated. In our opinion, the intramedullary screw technique allows for easy fixation of displaced fractures of the metacarpal head along with early mobilization and no need to open the joint. For subcapital and shaft fractures, we think the screw should always reach the metacarpal isthmus to achieve a more rigid ˜ al et al. [5] suggested using 4.0 mm diameter fixation. Del Pin screws of the maximum length possible in the 5th metacarpal. In our practice, the largest available screws are 3.0 mm in diameter. The diameter of the isthmus to the 5th metacarpal can easily be greater than 5 mm. In those cases, we observed that the bone was healing as in cases of elastic fixation (Fig. 2, with callus). Therefore, we did not feel it was necessary to order larger screws or a different set of screws. We feel that — compared to intramedullary fixation with K-wires — the problem of potential rotational failure is simply non-existent: the metacarpal bone is acting as a whole structure and the muscles and ligaments are re-aligning the bone. We normally used the longest screw possible. In our set, the longest screw is 40 mm, which has never been an issue until now. We did not treat any metacarpal base fractures, as those can often be treated conservatively if non-displaced, or require closed or open reduction in case of carpometacarpal fracture-dislocations. There was one case of screw migration into the MCP joint after healing of a very proximal shaft fracture. The migration was asymptomatic. We decided to remove the screw 6 weeks after the initial surgery. In another case, we decided to remove the screw as we were removing a plate from the adjacent metacarpal and the
patient asked us to do so. We found screw removal in the two cases to be easier than in phalangeal fractures, where Giesen et al. [18] stated that it might be more difficult. One patient with multiple fractures needed arthrolysis and eventually achieved good functional outcomes. In this case, the patient suffered severe polytrauma and was not able to perform any active mobilization or rehabilitation for more than 1 month postoperatively. This factor, of course, jeopardized the functional outcome. Another patient in our cohort with a complex metacarpal head fracture had a 208 extensor lag. This result is in line with the results ˜ al et al. [5], where two patients had more than published by Del Pin 308 extensor lag. We do not know if the distal head fracture pattern may have impaired the final functional outcome. Our study did not determine the amount of damage this technique caused to the articular surface of the metacarpal head. The impact on the metacarpal head cartilage has recently been studied. Borbas et al. [19] showed in their cadaveric study on fixation of phalangeal fractures through the metacarpal head that there is a defect in the articular surface between 4.6% and 8.5%, depending on the screw diameter. Ten Berg et al. [20] also showed that 2.4 mm and 3.0 mm HCS screws occupied an average of 4–5% of the metacarpal head. Nevertheless, even if the impact of the screw on the articular cartilage seems to be negligible, long-term arthritic changes could occur and long-term follow-up is needed. We see this as a weakness of our study, as well as the lack of control group. Ruchelsman et al. [8] prefer using a small open approach with small extensor split and dorsal arthrotomy to accurately determine the entry point of the screw. We do not think this is necessary as we find that fluoroscopy provides a good view of the entry point. Extensor tendon damage by percutaneous fixation with headless screws in this area has been shown to be negligible [19]. Funding The authors received no financial support for the research, authorship and/or publication of this article.
Please cite this article in press as: Jann D, et al. Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws. Hand Surg Rehab (2018), https://doi.org/10.1016/j.hansur.2017.12.005
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Ethical approval Local institutional review board approval from University Hospital Zurich and the Ethics Commission Zurich was obtained for the study. Patients signed informed consent (general consent of the University Hospital Zurich). Disclosure of interest The authors declare that they have no competing interest. References [1] Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 2001;26:908–15. [2] Curtis BD, Fajolu O, Ruff ME, Litsky AS. Fixation of metacarpal shaft fractures: biomechanical comparison of intramedullary nail crossed K-wires and platescrew constructs. Orthop Surg 2015;7:256–60. [3] Kamath JB, Harshvardhan, Naik DM, Bansal A. Current concepts in managing fractures of metacarpal and phalanges. Indian J Plast Surg 2011;44:203–11. [4] Hsu LP, Schwartz EG, Kalainov DM, Chen F, Makowiec RL. Complications of Kwire fixation in procedures involving the hand and wrist. J Hand Surg Am 2011;36:610–6. ˜ al F, Moraleda E, Ru´as JS, de Piero GH, Cerezal L. Minimally invasive [5] Del Pin fixation of fractures of the phalanges and metacarpals with intramedullary cannulated headless compression screws. J Hand Surg Am 2015;40:692–700. [6] Doarn MC, Nydick JA, Williams BD, Garcia MJ. Retrograde headless intramedullary screw fixation for displaced fifth metacarpal neck and shaft fractures: short term results. Hand (N Y) 2015;10:314–8. [7] Boulton CL, Salzler M, Mudgal CS. Intramedullary cannulated headless screw fixation of a comminuted subcapital metacarpal fracture: case report. J Hand Surg Am 2010;35:1260–3.
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[8] Ruchelsman DE, Puri S, Feinberg-Zadek N, Leibman MI, Belsky MR. Clinical outcomes of limited-open retrograde intramedullary headless screw fixation of metacarpal fractures. J Hand Surg Am 2014;39:2390–5. [9] Totty WG, Gilula LA. Imaging the hand and wrist. In: Totty WG, editor. The traumatised hand and wrist. Philadelphia: WB Saunders; 1992. p. 1–19. [10] Pun WK, Chow SP, So YC, Luk KD, Chiu KY, Ng KH, et al. A prospective study on 284 digital fractures of the hand. J Hand Surg Am 1989;14:474–81. [11] Fambrough RA, Green DP. Tendon rupture as a complication of screw fixation in fractures in the hand: a case report. J Bone Joint Surg Am 1979; 61:781–2. [12] Henry MH. Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization. J Am Acad Orthop Surg 2008;16:586–95. [13] Foucher G. Bouquet’’ osteosynthesis in metacarpal neck fractures: a series of 66 patients. J Hand Surg Am 1995;20:S86–90. [14] Botte MJ, Davis JL, Rose BA, von Schroeder HP, Gellman H, Zinberg EM, et al. Complications of smooth pin fixation of fractures and dislocations in the hand and wrist. Clin Orthop Relat Res 1992;276:194–201. [15] Stahl S, Schwartz O. Complications of K-wire fixation of fractures and dislocations in the hand and wrist. Arch Orthop Trauma Surg 2001;121: 527–30. [16] Balaram AK, Bednar MS. Complications after the fractures of metacarpal and phalanges. Hand Clin 2010;26:169–77. [17] Hargreaves DG, Drew SJ, Eckersley R. Kirschner wire pin tract infection rates: a randomized controlled trial between percutaneous and buried wires. J Hand Surg Br 2004;29:374–6. [18] Giesen T, Gazzola R, Poggetti A, Giovanoli P, Calcagni M. Intramedullary headless screw fixation for fractures of the proximal and middle phalanges in the digits of the hand: a review of 31 consecutive fractures. J Hand Surg Eur 2016;41:688–94. [19] Borbas P, Dreu M, Poggetti A, Calcagni M, Giesen T. Treatment of proximal phalangeal fractures with an antegrade intramedullary screw: a cadaver study. J Hand Surg Eur 2016;41:683–7. [20] Ten Berg PW, Mudgal CS, Leibman MI, Belsky MR, Ruchelsman DE. Quantitative 3-dimensional CT analyses of intramedullary headless screw fixation for metacarpal neck fractures. J Hand Surg Am 2013;38:322–30.
Please cite this article in press as: Jann D, et al. Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws. Hand Surg Rehab (2018), https://doi.org/10.1016/j.hansur.2017.12.005
HANSUR-200; No. of Pages 5 Hand Surgery and Rehabilitation xxx (2018) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original article
Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws Fixation re´trograde des fractures des me´tacarpiens avec des vis de compression canule´es sans teˆte D. Jann *, M. Calcagni, P. Giovanoli, T. Giesen Department for Plastic Surgery and Hand Surgery, University Hospital Zurich, Ra¨mistrasse 100, 8091 Zurich, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 July 2017 Received in revised form 19 November 2017 Accepted 12 December 2017 Available online xxx
We analyzed the results of 20 unstable metacarpal fractures in 15 patients treated with a cannulated compression screw and no immobilization. All fractures healed within 6 weeks. One patient with multiple fractures and a flexion deficit required arthrolysis of two metacarpophalangeal joints. Another patient had an extension lag. There were no other complications. This fast and easy technique results in good outcomes for unstable metacarpal fractures. The advantages are early active motion without immobilization and stable fixation. Surgical removal of the screw is rarely needed. Level of evidence: IV (therapeutic).
C 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved.
Keywords: Metacarpal Fracture Intramedullary Fracture fixation Headless screw Compression screw
R E´ S U M E´
Mots cle´s : Me´tacarpiens Fracture Centrome´dullaire Oste´osynthe`se Vis sans teˆte Vis a` compression
Nous avons analyse´ les re´sultats de 20 fractures instables des me´tacarpiens chez 15 patients que nous avons traite´s avec des vis de compression canule´es et sans immobilisation. La consolidation des fractures e´tait obtenue dans tous les cas. Nous avons effectue´ une arthrolyse chez un patient avec des fractures multiples et un de´ficit de mobilite´ en flexion. Un autre patient montrait un de´ficit de mobilite´ en extension. Nous n’avons pas trouve´ d’autres complications. Cette technique facile et rapide montre des re´sultats favorables. Les avantages sont la fixation stable et la mobilisation pre´coce. L’ablation de la vis est rarement ne´cessaire.
C 2018 SFCM. Publie ´ par Elsevier Masson SAS. Tous droits re´serve´s.
1. Introduction Metacarpal and phalangeal fractures are the most common fractures of the upper extremity; metacarpal fractures comprise 18% of all fractures below the elbow [1]. Traditionally, screw and plate constructs are the most stable means of fixation for metacarpal shaft fractures [2]. For fractures of the head and the neck, intramedullary wiring is the most common technique [3]. Plates require extensive dissection for them to be placed
* Corresponding author. E-mail address: [email protected] (D. Jann).
correctly and often need to be removed with or without extensor tendon tenolysis a few months after surgery. K-wire fixation is also associated with a high rate of complications [4]. Intramedullary headless screw fixation has recently been described for the treatment of various metacarpal fracture patterns [5–8]. This minimally invasive technique appears to provide sufficient stability to allow early mobilization of the hand. Furthermore, it does not leave any material exposed on the surface of the treated bone, which theoretically eliminates the need for removal and lowers the risk of tendon adhesions. We present the results of 20 metacarpal fractures with different patterns, treated with percutaneous, retrograde intramedullary headless screw fixation and early mobilization.
https://doi.org/10.1016/j.hansur.2017.12.005 C 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved. 2468-1229/
Please cite this article in press as: Jann D, et al. Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws. Hand Surg Rehab (2018), https://doi.org/10.1016/j.hansur.2017.12.005
G Model
HANSUR-200; No. of Pages 5 D. Jann et al. / Hand Surgery and Rehabilitation xxx (2018) xxx–xxx
2
2. Patients and methods 2.1. Patients Between September 2014 and April 2016, we treated 15 consecutive patients with 20 metacarpal fractures using an intramedullary retrograde cannulated compression screw (CCS SpeedTip, Medartis, Basel, Switzerland). The fractures were evaluated on plain X-rays in anterior-posterior (AP), oblique and lateral views [9]. Long oblique and spiral fractures in the shaft and multifragment fractures were excluded because they were considered unsuitable for fixation with an intramedullary screw. Fractures at the base of the metacarpals were also excluded. The patients were all men with an average age of 38 years (range 20–77). Six patients had multiple metacarpal fractures (13 in total); out of those 13 fractures, only 10 were eligible for intramedullary screw fixation. Twelve fractures were in the dominant hand and eight in the non-dominant hand. There were two open fractures in one patient. One patient had fractures in both hands and fracture of a proximal phalanx. The fifth metacarpal was affected 13 times, the fourth 4 times and the second 3 times. There were no third metacarpal fractures in our cohort. There were five displaced subcapital fractures, ten shaft fractures and five displaced metacarpal head fractures. In one patient, we performed surgery due to secondary displacement of an initially non-displaced subcapital fifth metacarpal fracture treated with a cast. One patient with a shaft fracture of the fifth metacarpal already had a shaft fracture of the same metacarpal 14 months earlier, which had been treated with a plate that had previously been removed. All patients were informed on arrival at our emergency department about the different treatment options and then consented to undergoing surgery with the intramedullary screw technique. 2.2. Surgical technique The mean time between injury and surgical treatment was 7 days (range 0–22 days). Eleven patients had general/regional
anesthesia and four had local anesthesia. We did not use a tourniquet in the patients undergoing local anesthesia. Closed reduction was performed under fluoroscopic control. In open fractures, reduction was performed under visual control. In one patient with a metacarpal head fracture, we had to make a small (1.5 cm) incision to achieve adequate reduction. Once anatomic reduction was achieved and verified by fluoroscopy, a guide wire was inserted under fluoroscopic control through the dorsal aspect of the metacarpal head in a retrograde manner until it reached the base of the metacarpal. The tip of the wire was intentionally left protruding 1 mm through the carpometacarpal (CMC) joint to avoid mobilization or removal of the wire following manipulations or after drilling. In one patient with hard bone and one patient with a previous shaft fracture, the medullary canal was pre-drilled. In all other patients the screw was inserted without pre-drilling. The size of the screw (2.2 mm or 3.0 mm in diameter) was decided preoperatively by measuring the isthmus of the medullary canal on the lateral view or on the oblique view, when the metacarpal isthmus was impossible to outline on the lateral view. We used a 2.2 mm diameter screw when the isthmus of the medullary canal was smaller than 3 mm. We used eight 2.2 mm diameter screws and thirteen 3.0 mm diameter screws. The screw was inserted under fluoroscopic control to avoid protrusion of the screw head in the MCP joint. In one three-fragment metacarpal head fracture, two screws were used for the same fracture (Fig. 1). The tenodesis effect was used to control rotation and scissoring of fingers. Wounds were dressed with Primapore (Smith and Nephew, London, UK) and buddy strapping applied to the affected and the adjacent finger(s) for 1 month. Operative time was recorded in all cases.
2.3. Postoperative care Patients were seen 7 days (range 6–14 days) postoperatively to check the wound and take follow-up X-rays. The patients were then seen 1 month postoperatively (range 4–6 weeks) with new X-rays to verify fracture union. The last follow-up was at a mean of
Fig. 1. Multifragmentary fracture of the head of the fifth metacarpal in a 32-year-old male (left). Open reduction had to be performed. Fixation was performed with one 3.0 mm and one 2.2 mm CCS screw (right).
Please cite this article in press as: Jann D, et al. Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws. Hand Surg Rehab (2018), https://doi.org/10.1016/j.hansur.2017.12.005
G Model
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3.5 months postoperatively (range, 1–17 months). Range of motion of the metacarpophalangeal (MCP) joints and grip strength with the Jamar dynamometer (Patterson Medical Holding, Warrenville, IL, USA) were recorded. Postoperative infection, screw migration, finger malrotation, delayed union, complex regional pain syndrome (CRPS) were also recorded. 2.4. Rehabilitation Patients began active motion immediately under the supervision of a hand therapist. The protocol consisted of immediate active mobilization; passive mobilization and build-up of force was started 4 weeks postoperatively. Full force was allowed after 6 weeks.
3. Results The mean operative time was 21 minutes (range 5–45 minutes) when only the intramedullary screw was inserted, and no other fractures or injuries had to be treated. All 20 fractures were healed after an average of 4 weeks (range 4–6) (Fig. 2). At the last followup, there were no radiographic malunions [10]. At the latest follow-up, 17 digits in 13 patients had full range of motion (ROM), except for one patient with a head fracture of the second metacarpal who had a 258 extension lag. Tenolysis was recommended for this case but the patient declined. One patient who suffered polytrauma and two concomitant metacarpal fractures and a phalanx fracture to the left hand had a severe flexion deficit in two MCP joints. Tenoarthrolysis of the MCP joints was performed. He eventually achieved good function and 808 flexion in both MCP joints. The grip strength in all patients was a mean of 93% of the contralateral hand. We did not observe any infections, malunion, non-union or rotational deformities. There were no cases of CRPS. One patient had the screw removed because of slight proximal migration of the screw. The patient had no symptoms, but we removed the screw to avoid future damage to the joint cartilage. In one patient, we removed the intramedullary screw at the same time as a metacarpal plate on the adjacent metacarpal bone was being removed.
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4. Discussion Unstable or displaced metacarpal shaft fractures and distal metacarpal fractures (head and subcapital) can be treated with different techniques, but they all have disadvantages. Dorsal plating requires larger surgical exposure and is associated with complications such as plate prominence, infection, tendon rupture, stiffness and need of future plate removal [3,11,12]. For subcapital fractures, intramedullary wiring is the most popular treatment [12,13], but pin track infection has been reported in 6–7% of the cases [4,14]. Two large studies found an overall complication of around 15% with K-wire fixation in hand and wrist fractures [4,15]. Boulton et al. [7] published one case of an intramedullary headless screw in a comminuted subcapital fracture of the fifth metacarpal and with excellent outcomes. Del ˜ al et al. [5], showed favorable results in a large group of patients Pin with metacarpal as well as phalangeal fractures. In our study, we replicated the good functional results obtained ˜ al et al. [5] supporting the idea that intramedullary by del Pin fixation of transverse and short oblique fractures of the metacarpals, as well as head and subcapital fractures, is an effective technique. Shaft fractures treated with a plate are typically affected by a high rate of secondary surgery for plate removal as well as for tenolysis [16]. Furthermore, implantation of a plate requires a much larger surgical incision and requires a more complex surgery, resulting in a longer operative time and higher costs when compared to an intramedullary screw. The intramedullary screw may not need to be removed, resulting in less surgery for the patient and, at the same time, lower costs for the society. The fixation material per se is also much cheaper: a metacarpal plate with five screws from the same company costs 2.4 times more than a 40 mm long, 3.0 mm diameter screw (the largest screw we used in this study). Subcapital fractures are in our opinion treated properly with the Bouquet technique initially published by Foucher [13]. The only problem left with this technique is the fairly high rate of infection, normally affecting the entry point of the wires in the skin [14,17], when the wires are left exposed. Our study found no infections, suggesting a lower rate of this complication with our technique. Furthermore, our surgical technique is easier, especially
Fig. 2. Displaced transverse fracture of the fifth metacarpal bone in a 21-year-old male (left). Closed reduction and fixation with a 3.0 mm CCS screw (right).
Please cite this article in press as: Jann D, et al. Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws. Hand Surg Rehab (2018), https://doi.org/10.1016/j.hansur.2017.12.005
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Fig. 3. Intraarticular fracture of the head of the second metacarpal in a 66-year-old male (left). Closed reduction and fixation with a 3.0-mm CCS screw (right).
when no drilling is required. The tradeoff is that the cost of the screws is consistently higher than the cost of one or two K-wires. Head fractures can also be treated with the Bouquet technique or with retrograde K-wires buried in the head. However, the Bouquet technique may be inadequate in the presence of fragmentation or very distal displaced fractures. Fixation of the head with retrograde wires does not allow early mobilization. The technique using buried wires often requires the use of more wires and the wires cannot be properly buried underneath the cartilage without opening the joint. Furthermore, the wires have the tendency to migrate proximally or distally [3,4,13,14]. In Fig. 3 we present one of the metacarpal head fractures we treated. In our opinion, the intramedullary screw technique allows for easy fixation of displaced fractures of the metacarpal head along with early mobilization and no need to open the joint. For subcapital and shaft fractures, we think the screw should always reach the metacarpal isthmus to achieve a more rigid ˜ al et al. [5] suggested using 4.0 mm diameter fixation. Del Pin screws of the maximum length possible in the 5th metacarpal. In our practice, the largest available screws are 3.0 mm in diameter. The diameter of the isthmus to the 5th metacarpal can easily be greater than 5 mm. In those cases, we observed that the bone was healing as in cases of elastic fixation (Fig. 2, with callus). Therefore, we did not feel it was necessary to order larger screws or a different set of screws. We feel that — compared to intramedullary fixation with K-wires — the problem of potential rotational failure is simply non-existent: the metacarpal bone is acting as a whole structure and the muscles and ligaments are re-aligning the bone. We normally used the longest screw possible. In our set, the longest screw is 40 mm, which has never been an issue until now. We did not treat any metacarpal base fractures, as those can often be treated conservatively if non-displaced, or require closed or open reduction in case of carpometacarpal fracture-dislocations. There was one case of screw migration into the MCP joint after healing of a very proximal shaft fracture. The migration was asymptomatic. We decided to remove the screw 6 weeks after the initial surgery. In another case, we decided to remove the screw as we were removing a plate from the adjacent metacarpal and the
patient asked us to do so. We found screw removal in the two cases to be easier than in phalangeal fractures, where Giesen et al. [18] stated that it might be more difficult. One patient with multiple fractures needed arthrolysis and eventually achieved good functional outcomes. In this case, the patient suffered severe polytrauma and was not able to perform any active mobilization or rehabilitation for more than 1 month postoperatively. This factor, of course, jeopardized the functional outcome. Another patient in our cohort with a complex metacarpal head fracture had a 208 extensor lag. This result is in line with the results ˜ al et al. [5], where two patients had more than published by Del Pin 308 extensor lag. We do not know if the distal head fracture pattern may have impaired the final functional outcome. Our study did not determine the amount of damage this technique caused to the articular surface of the metacarpal head. The impact on the metacarpal head cartilage has recently been studied. Borbas et al. [19] showed in their cadaveric study on fixation of phalangeal fractures through the metacarpal head that there is a defect in the articular surface between 4.6% and 8.5%, depending on the screw diameter. Ten Berg et al. [20] also showed that 2.4 mm and 3.0 mm HCS screws occupied an average of 4–5% of the metacarpal head. Nevertheless, even if the impact of the screw on the articular cartilage seems to be negligible, long-term arthritic changes could occur and long-term follow-up is needed. We see this as a weakness of our study, as well as the lack of control group. Ruchelsman et al. [8] prefer using a small open approach with small extensor split and dorsal arthrotomy to accurately determine the entry point of the screw. We do not think this is necessary as we find that fluoroscopy provides a good view of the entry point. Extensor tendon damage by percutaneous fixation with headless screws in this area has been shown to be negligible [19]. Funding The authors received no financial support for the research, authorship and/or publication of this article.
Please cite this article in press as: Jann D, et al. Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws. Hand Surg Rehab (2018), https://doi.org/10.1016/j.hansur.2017.12.005
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Please cite this article in press as: Jann D, et al. Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws. Hand Surg Rehab (2018), https://doi.org/10.1016/j.hansur.2017.12.005