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Rotational deformity following metacarpal fracture
ROTATIONAL
DEFORMITY FOLLOWING FRACTURE
METACARPAL
S. G. ROYLE From the Department of Orthopaedic Surgery, Wythenshawe Hospital, Manchester
Ninety-one consecutive patients with 98 metacarpal fractures were looked at prospectively for rotational deformity. Whilst a quarter had minor rotation of the fracture of less than lo”, only five had more than this. Injust two cases, was there rotational instability requiring operative intervention. Assessment of rotational deformity must include an end-on view of the finger-nail, as there is often restricted movement at the metacarpal phalangeal joint following fracture. Journal of Hand Surgery (British Volume, 1990) 15B: 124-125
Patients and methods During a six-month period, 91 patients with 98 metacarpal fractures, excluding the first ray, were seen prospectively and consecutively (Table 1). Table l-Site
Metacarpal
of fracture Head
Neck
Shaft
Base
Total
0 2 3 3 8
4 1 3 35 43
1 7 8 21 37
0 1 1 8 10
5 11 15 67 98
bone was involved. 46 patients were seen within three days of injury. At this time, the M.P. joint lacked an average of 16” of extension (range O-25”) and had an average flexion of only 50” (range 25-90”). The extension lag and loss of flexion was similar in all but the basal metacarpal fractures, which had less extension loss (Table 2). Table 2-Joint
2nd 3rd 4th 5th Total
Patients were seen as soon as possible after injury (over 50% within three days) and the active movement at the metacarpo-phalangeal joint measured. The rotational deformity was measured with the palm flat and the fingers in extension, using the plane of the nail in relation to a horizontal surface. This was then compared to the opposite (normal) side. Patients with previous injuries or deformities were excluded. This method was used because there was often restriction of flexion at the M.P. joint due to pain. This prevented the obvious manifestation of rotational deformity seen as the finger crossing over a neighbouring finger in flexion. Most patients were treated symptomatically, but those with unstable or rotated fractures were manipulated or internally fixed. The Datients were reviewed after clinical union of the fracture, usually between four and six weeks, and the above readings repeated. Results The 91 patients had an age range from 1l-75 years (average 26.8 years), 88% being male. The commonest causes of the injury were a punch in 39% and a fall in 33%. In 67 (68% of cases), the fifth metacarpal was fractured and in seven more than one 124
movement of 4th and 5th metacarpal fractures
Number ofpatients Average Average
flexion loss of extension
Head 3
Neck 22
Shaft 14
Base 1
55” 18”
54” 13”
52” 20”
55” 3”
23 patients (25%) had some rotational deformity at presentation, although this was less than 10” in all but five cases (Table 3). Those with less than 10”of deformity were treated with a wool-and-crepe support bandage and early mobilisation. In none of these did the rotation increase or the measured deformity cause any problems with finger function once the fracture had healed. Four cases required operative treatment, two because of rotational instability and two due to unacceptable angulation. In three patients with between 15 and 20” of rotation, a manipulation was performed. The reduction was thought to be stable and the injured finger was strapped to the adjacent finger. This resulted ih a satisfactory result in two cases but 15” of rotatory malunion in the other (Table 3); this last case had some impairment of grip, but declined further intervention.
Discussion Rotational deformity following fracture of the metacarpal or phalangeal bones of the hand is well-recognised as a complication of these common injuries (Barton, 1984; Watson, 1985). This problem is more often seen with phalangeal fractures (Green, 1986) but can be exaggerated in metacarpal fractures as a result of the long lever arm of THE JOURNAL OF HAND SURGERY
ROTATIONAL
DEFORMITY
FOLLOWING
METACARPAL
FRACTURE
Table 3-Patients requiringoperation Case
Bone
Site
1 2 3 4 5 6 7
5th 4th 2nd 5th 5th 4th 5th
Neck Shaft Neck Shaft Shaft Head Neck
Angulation* 70” 60” 20” 30” 20” 40” 35”
Rotation
Treatment K-wire A0 Miniplate K-wire A0 Miniplate Manip. &strap Manip. &strap Manip. &strap
Deformity None Delayed union
Function FLlll Full at IO wks Full Full Impaired (see text) Full Full
*Angular deformity into flexion as seen on lateral radiograph.
the finger. This can mean that 1” of rotation at the fracture site can be magnified up to 5” at the finger tip (Opgrande and Westphal, 1983). The true incidence of this deformity has not been documented and it seems from this study that small degrees of rotation are common, but have no detrimental effect on outcome. Up to 10”of rotation seems to be welltolerated, particularly in the mobile fifth metacarpal which is the most frequently injured. Deformity greater than this can cause overlapping of the fingers in flexion and interfere with grip and hand function (Smith and Peimer, 1977). Most fractures of the metacarpals can be successfully treated by conservative means with early mobilisation (Arafa et al., 1985) rather than immobilisation by plaster or strapping (Sullivan, 1976). Only a small proportion of cases require operative treatment because of displacement, angulation or rotation at the fracture site. This can be achieved by open or percutaneous Kirschner wire fixation or open reduction using mini-plates and screws (Opgrande and Westphal, 1983). The problem of detection of this rotational deformity is highlighted by the fact that over half of our patients were unable to flex the finger enough to demonstrate overlapping in the first few days after injury. Because of this, the plane of the finger-nails, as seen end-on, must be used (Barton, 1984), though this is often overlooked by the inexperienced observer. Rotational instability can be detected by gentle manipulation, under anaesthetic if required. If greater
VOL. 15-B NO. 1
FEEUXJARY
1990
than lo”, adequate immobilisation of the .fracture is required, usually by operative means, to prevent secondary displacement. In summary, a small degree of rotational dieformity is common in patients with metacarpal fractures. Only when this is more than 10”is intervention req,uired. It is recommended that operative fixation rather than manipulation alone of the rotated fracture is performed. Manipulation and strapping is probably unsatisfactory.
References ARAFA, M., HAINES, J., NOBLE, 3. and CARDEN, D. (1986). immediate mobilisation of fractures of the neck of the fifth metacarpal. Injury, 17: 4: 217-218. BARTON, N. J. (1984). Fractures of the hand. Journalof Bone and Joint Sugery, 66B: 2: 159-167. GREEN. D. P. (1986). Comolications of Phalaneeal and Metacaroal Fractures. ., Hanh Clinik, 2: i: 307->28. OPGRANDE. J. D. and WESTPHAL, S. A. (1983). Fractures of the Hand Orthopaedic Clinics of North America, 14: 4: 779-792. SMITH, R. J. and PEIMER, C. A. (1977). Injuries to the Metacarpal Bones and Joints. Advances in Surgery, 11:341-374. SULLIVAN, M. F. Injuries of the Fingers and Hand. In: W&on, J. N. (Ed.). Watson Jones’ Fractures and Joint Injuries. 5th edn. Edinburgh, Churchill Livingstone, 1976: Vol. 2: 760-780. WATSON, F. M. (1985). Fractures in the Hand: Metacarpals and Phalanges. Emergency Medicine Clinics of North America, 3: 2: 293-310.
Accepted: 17February, 1989 Mr. S. G. Royle, Department of Orthopaedic Surgery, Hope Hospital, Stott Lane, Salford, ManchesterM6 EHD. 0 1990The
British Society for Surgery of the Hand
02667681/90/0015-0124/810.00
125
DEFORMITY FOLLOWING FRACTURE
METACARPAL
S. G. ROYLE From the Department of Orthopaedic Surgery, Wythenshawe Hospital, Manchester
Ninety-one consecutive patients with 98 metacarpal fractures were looked at prospectively for rotational deformity. Whilst a quarter had minor rotation of the fracture of less than lo”, only five had more than this. Injust two cases, was there rotational instability requiring operative intervention. Assessment of rotational deformity must include an end-on view of the finger-nail, as there is often restricted movement at the metacarpal phalangeal joint following fracture. Journal of Hand Surgery (British Volume, 1990) 15B: 124-125
Patients and methods During a six-month period, 91 patients with 98 metacarpal fractures, excluding the first ray, were seen prospectively and consecutively (Table 1). Table l-Site
Metacarpal
of fracture Head
Neck
Shaft
Base
Total
0 2 3 3 8
4 1 3 35 43
1 7 8 21 37
0 1 1 8 10
5 11 15 67 98
bone was involved. 46 patients were seen within three days of injury. At this time, the M.P. joint lacked an average of 16” of extension (range O-25”) and had an average flexion of only 50” (range 25-90”). The extension lag and loss of flexion was similar in all but the basal metacarpal fractures, which had less extension loss (Table 2). Table 2-Joint
2nd 3rd 4th 5th Total
Patients were seen as soon as possible after injury (over 50% within three days) and the active movement at the metacarpo-phalangeal joint measured. The rotational deformity was measured with the palm flat and the fingers in extension, using the plane of the nail in relation to a horizontal surface. This was then compared to the opposite (normal) side. Patients with previous injuries or deformities were excluded. This method was used because there was often restriction of flexion at the M.P. joint due to pain. This prevented the obvious manifestation of rotational deformity seen as the finger crossing over a neighbouring finger in flexion. Most patients were treated symptomatically, but those with unstable or rotated fractures were manipulated or internally fixed. The Datients were reviewed after clinical union of the fracture, usually between four and six weeks, and the above readings repeated. Results The 91 patients had an age range from 1l-75 years (average 26.8 years), 88% being male. The commonest causes of the injury were a punch in 39% and a fall in 33%. In 67 (68% of cases), the fifth metacarpal was fractured and in seven more than one 124
movement of 4th and 5th metacarpal fractures
Number ofpatients Average Average
flexion loss of extension
Head 3
Neck 22
Shaft 14
Base 1
55” 18”
54” 13”
52” 20”
55” 3”
23 patients (25%) had some rotational deformity at presentation, although this was less than 10” in all but five cases (Table 3). Those with less than 10”of deformity were treated with a wool-and-crepe support bandage and early mobilisation. In none of these did the rotation increase or the measured deformity cause any problems with finger function once the fracture had healed. Four cases required operative treatment, two because of rotational instability and two due to unacceptable angulation. In three patients with between 15 and 20” of rotation, a manipulation was performed. The reduction was thought to be stable and the injured finger was strapped to the adjacent finger. This resulted ih a satisfactory result in two cases but 15” of rotatory malunion in the other (Table 3); this last case had some impairment of grip, but declined further intervention.
Discussion Rotational deformity following fracture of the metacarpal or phalangeal bones of the hand is well-recognised as a complication of these common injuries (Barton, 1984; Watson, 1985). This problem is more often seen with phalangeal fractures (Green, 1986) but can be exaggerated in metacarpal fractures as a result of the long lever arm of THE JOURNAL OF HAND SURGERY
ROTATIONAL
DEFORMITY
FOLLOWING
METACARPAL
FRACTURE
Table 3-Patients requiringoperation Case
Bone
Site
1 2 3 4 5 6 7
5th 4th 2nd 5th 5th 4th 5th
Neck Shaft Neck Shaft Shaft Head Neck
Angulation* 70” 60” 20” 30” 20” 40” 35”
Rotation
Treatment K-wire A0 Miniplate K-wire A0 Miniplate Manip. &strap Manip. &strap Manip. &strap
Deformity None Delayed union
Function FLlll Full at IO wks Full Full Impaired (see text) Full Full
*Angular deformity into flexion as seen on lateral radiograph.
the finger. This can mean that 1” of rotation at the fracture site can be magnified up to 5” at the finger tip (Opgrande and Westphal, 1983). The true incidence of this deformity has not been documented and it seems from this study that small degrees of rotation are common, but have no detrimental effect on outcome. Up to 10”of rotation seems to be welltolerated, particularly in the mobile fifth metacarpal which is the most frequently injured. Deformity greater than this can cause overlapping of the fingers in flexion and interfere with grip and hand function (Smith and Peimer, 1977). Most fractures of the metacarpals can be successfully treated by conservative means with early mobilisation (Arafa et al., 1985) rather than immobilisation by plaster or strapping (Sullivan, 1976). Only a small proportion of cases require operative treatment because of displacement, angulation or rotation at the fracture site. This can be achieved by open or percutaneous Kirschner wire fixation or open reduction using mini-plates and screws (Opgrande and Westphal, 1983). The problem of detection of this rotational deformity is highlighted by the fact that over half of our patients were unable to flex the finger enough to demonstrate overlapping in the first few days after injury. Because of this, the plane of the finger-nails, as seen end-on, must be used (Barton, 1984), though this is often overlooked by the inexperienced observer. Rotational instability can be detected by gentle manipulation, under anaesthetic if required. If greater
VOL. 15-B NO. 1
FEEUXJARY
1990
than lo”, adequate immobilisation of the .fracture is required, usually by operative means, to prevent secondary displacement. In summary, a small degree of rotational dieformity is common in patients with metacarpal fractures. Only when this is more than 10”is intervention req,uired. It is recommended that operative fixation rather than manipulation alone of the rotated fracture is performed. Manipulation and strapping is probably unsatisfactory.
References ARAFA, M., HAINES, J., NOBLE, 3. and CARDEN, D. (1986). immediate mobilisation of fractures of the neck of the fifth metacarpal. Injury, 17: 4: 217-218. BARTON, N. J. (1984). Fractures of the hand. Journalof Bone and Joint Sugery, 66B: 2: 159-167. GREEN. D. P. (1986). Comolications of Phalaneeal and Metacaroal Fractures. ., Hanh Clinik, 2: i: 307->28. OPGRANDE. J. D. and WESTPHAL, S. A. (1983). Fractures of the Hand Orthopaedic Clinics of North America, 14: 4: 779-792. SMITH, R. J. and PEIMER, C. A. (1977). Injuries to the Metacarpal Bones and Joints. Advances in Surgery, 11:341-374. SULLIVAN, M. F. Injuries of the Fingers and Hand. In: W&on, J. N. (Ed.). Watson Jones’ Fractures and Joint Injuries. 5th edn. Edinburgh, Churchill Livingstone, 1976: Vol. 2: 760-780. WATSON, F. M. (1985). Fractures in the Hand: Metacarpals and Phalanges. Emergency Medicine Clinics of North America, 3: 2: 293-310.
Accepted: 17February, 1989 Mr. S. G. Royle, Department of Orthopaedic Surgery, Hope Hospital, Stott Lane, Salford, ManchesterM6 EHD. 0 1990The
British Society for Surgery of the Hand
02667681/90/0015-0124/810.00
125