Surgical Treatment, Hardware Removal, and the Wide-Awake Approach for Metacarpal Fractures

S u r g i c a l Tre a t m e n t , H ardware Remo v al , an d t h e Wi d e - Awa k e A p p ro a c h f o r M e t a c a r p a l F r a c t u res Shu Guo Xing, MD, Jin Bo Tang, MD* KEYWORDS  Metacarpal fracture  Internal fixation  Hardware removal  Wide-awake surgery

KEY POINTS

The authors’ hand surgery unit handles 150 to 200 metacarpal fractures each year. Review of upper extremity fractures shows that 163 metacarpal fractures were treated by the authors in 2012. These metacarpal fractures accounted for 7.8% of the all upper extremity fractures or 21.6% of all fractures in the hand (including fractures of carpal bones) (Fig. 1). In the literature, fractures of the metacarpals are reported to account for 18% of fractures below the elbow.1 The metacarpals of the ring and small fingers are most often involved and fractures occur at the shaft most frequently (Table 1). Cause of the fractures varies greatly. The authors see that most fractures are caused by punching something hard, by machines or tools, or during fighting or sports activities. Pain

is the most common complaint. Swelling and limitation in hand motion are common. Plain radiographs are usually sufficient to confirm the diagnosis and assess displacement of the fracture. The radiographs should routinely include posteroanterior, lateral, and oblique views of the affected hand. Brewerton view dorsally places the hand down and shoots the film at an ulnar oblique angle, allowing better visualization of the metacarpal bases. In the Robert view, the hand is hyperpronated so that the dorsum of the thumb lies on the radiograph plate; this gives a true anteroposterior view of the thumb. In the Bett view, the hand is pronated approximately 20 to 30 and the imaging beam is directed obliquely at 15 in a distal

Department of Hand Surgery, The Hand Surgery Research Center, Affiliated Hospital of Nantong University, 20 West Temple Road, Nantong 226001, Jiangsu, China * Corresponding author. E-mail address: [email protected] Clin Plastic Surg 41 (2014) 463–480 http://dx.doi.org/10.1016/j.cps.2014.03.005 0094-1298/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.

plasticsurgery.theclinics.com

 Metacarpal fractures are mostly treated with cast or plaster splint immobilization for 5 to 6 weeks after closed reduction. If the reduction is unstable, percutaneous insertion of single (or double) intramedullary Kirschner wires is an easy and minimally invasive solution for most of these cases.  Only large, oblique fractures may have to be fixed with 1 or 2 screws or a plate. Multiple fractures in the shaft or oblique fractures in multiple metacarpals may need plate fixation as well. Indications for plating metacarpal fractures are very limited.  After internal fixation, the authors advocate early intermittent active motion. The patient actively moves the metacarpophalangeal joint fully, or over a limited range, with a protective plaster splint or with finger buddy taping. The Kirschner wire is removed after bone healing (ie, 4–6 weeks after surgery). Screws and plates may not be removed, but if removal is necessary, it should be done 6 months after surgery.  The wide-awake approach is applicable to internal fixation and hardware removal in fractured metacarpals.

464

Xing & Tang

Fig. 1. Incidences of metacarpal fractures in different digits in the hand are shown at the base of each digit. The data shown within the deep red outlines are at the sites with the highest occurrence (all data are based on the metacarpal fractures treated in the authors’ unit in 2012).

to proximal direction, centered over the trapeziometacarpal joint. In this view, the thumb carpometacarpal (CMC) joint is well visualized as well as the articulations of the trapezium with the trapezoid, scaphoid, and index metacarpal. Roberts and Betts views, to evaluate the thumb, may help the diagnosis of more subtle injuries. It is not usual to use advanced imaging, such as computed tomography (CT), to make a diagnosis.

CT scan or 3-dimensional (3D) CT reconstructed images, which permit multiplanar analysis of fractures, however, are useful in fractures involving the CMC joint. In the authors’ experience, CT scans and their 3D reconstructions are not necessary unless surgeons want to know details of the CMC joint involvement, displacement, intra-articular fracture, or fracture-dislocation. Because of the complex nature of the thumb CMC joint fracture, CT scans may provide better understanding for articular involvement. Magnetic resonance imaging is not indicated except with avulsion fractures of the thumb metacarpophalangeal (MCP) collateral ligaments. Clinical examination begins with an assessment of alignment, skin condition, and neurovascular status of the hand. Trauma may cause open metacarpal fractures and complex soft tissue defects. These cases require great attention in assessing the circulatory status. For the hand with open injury involving an articular surface, thorough irrigation is necessary and special attention should be directed to restoring joint surface integrity. Cases with severe trauma are often accompanied by segmental bone loss or loss of a part of the articular surface—especially at the MCP joint.2

DECISIONS ON TREATMENT OPTIONS Nonoperative Treatment with Casting or Splinting When deciding among treatment options, it must be understood that most metacarpal fractures are treated successfully with nonoperative functional cast or splint immobilization. A cast is used for stable fractures and extends from the distal forearm to the proximal phalanges. It allows for moderate MCP joint motion and free motion at the proximal interphalangeal (PIP) joints. The MCP joint is kept in 50 to 70 of flexion (intrinsic

Table 1 Total number of metacarpal fractures that the authors treated in 2012 and their locationsa Fracture Locations

Thumb

Index

Middle

Ring

Little

Total

Head Neck Shaft Base CMC joint Total

2 (1.2%) 1 (0.6%) 12 (7.4%) 8 (4.9%) 7 (4.3%) 23 (14.1%)

2 (1.2%) 5 (3.1%) 11 (6.7%) 4 (2.5%) 2 (1.2%) 22 (13.5%)

2 (1.2%) 6 (3.7%) 17 (10.4%)b 4 (2.5%) 2 (1.2%) 29 (17.8%)

1 (0.6%) 4 (2.5%) 34 (20.9%)b 3 (1.8%) 2 (1.2%) 42 (25.8%)

2 (1.2%) 15 (9.2%)b 22 (13.5%)b 8 (4.9%) 5 (3.1%) 47 (28.8%)

9 (5.5%) 31 (19.0%) 96 (58.9%) 27 (16.6%) 18 (11.0%) 163

a In the fractures that the team treated in the year 2012, upper extremity fractures were 1487 (7.8% were metacarpal fractures). Hand fractures were 537, among which 163 (21.6%) were metacarpal fractures and 374 (78.4%) were phalangeal fractures. Total patients with metacarpal fractures were 116. Below-elbow fractures were 940. The 163 metacarpal fractures accounted for17.3% of all below-elbow fractures. b The sites with the highest incidence of the fracture.

Surgical Treatment of Metacarpal Fractures plus position) by the cast or the splint. The senior author usually applies a cast from the wrist to just distal to the MCP joint for the shaft or base fracture. The MCP joint is flexed around 50 and the patient can move the MCP joint over a limited range. This joint position is comfortable and allows partial active motion of the MCP joint (for about 40 to 70 of flexion). A dorsal plaster slab is appropriate for incomplete fractures or fractures with minimal to no displacement. Ulnar gutter plaster splints are most suitable for stable fractures involving the distal part of the ulnar-most 2 metacarpals, such as the Boxer’s fracture. Almost complete return of hand function can be expected with the above fracture management.

Box 1 Authors’ general principles for treatment 1. Most cases should be treated without surgery. 2. Surgery is reserved for those with unstable reduction, or multiple fractures, or joint involvement that cannot be reduced or maintained conservatively. 3. Minimally invasive CRPP is the first choice if surgical reduction is needed and works well in almost all fractures, except those with an unstable large oblique fracture or multiple unstable fractures needing plating or screw fixation. 4. Do not overplate these fractures.

Surgical Fixation After Close or Open Reduction Only a small subset of metacarpal fractures require surgical intervention. Among the senior author’s patients, 95% of the fractures required no surgery or only close reduction with a minimally invasive surgery. More than half of metacarpal fractures are treated with cast or plaster splint fixation for 5 to 6 weeks. About one-third of the fractures required percutaneous pinning, and only 5% required open reduction followed by Kirschner (K-wire) or plate fixation, or other surgery. If surgical treatment is indicated, the surgery can be done immediately if hand condition is good and swelling is not remarkable. Alternatively, surgery can be delayed for 3 to as late as 10 days to allow swelling to subside, to treat an active wound infection, or to follow the management of other concomitant injuries. If a soft tissue defect is present, fractures and soft tissue defects can be treated simultaneously. The senior author’s general treatment principle is given in Box 1. Different treatments based on site and severity of the fracture are discussed later.

MANAGEMENT OF SECOND TO FIFTH METACARPAL FRACTURES According to the fracture site, fractures are called metacarpal head, neck, shaft, and base fracture. The highest fracture incidence is at the shaft, whereas head fracture rates are the lowest. Among metacarpal fractures treated in the authors’ department, head fractures accounted for 5.5%, neck fractures 19%, shaft fractures 58.9%, and base fractures 16.6% (see Table 1).

5. Some shortening (<5 mm) and some angulation (<20 anteriorly) are well tolerated functionally. 6. CRPP is an easy, effective, and cost-efficient method. One or 2 intramedullary K-wires (up to the base of the metacarpal) are usually sufficient. Double K-wires do not have to be crossed.

by punching a hard surface or another person. Nonoperative management is appropriate for small, avulsion fractures when the MCP joint is stable. Even when there is a small amount of joint incongruity, often open reduction is needed to restore articular congruity. Stable surgical fixation allows early motion and decreases later stiffness of the MCP joint. In the authors’ experience, insertion of 1 or 2 K-wires, or fixation with 1 or 2 screws, provides stable fixation for almost all 2-part large fragment coronal, sagittal, and oblique intra-articular fractures. Displaced fractures with ligament avulsion and osteochondral fractures can be managed similarly. However, the avulsed ligaments should be repaired or reconstructed by either direct suture repair or graft reconstruction.3 Plates have almost no application in acute metacarpal head fractures. Comminuted fractures occurring at the head pose a challenge. Multiple K-wire fixation is the authors’ preferred first choice, which works well in most cases. Sometimes, multiple screws, or screw plus pin fixation, are necessary. External fixators can be used if joint damage is severe, usually involving both the metacarpal head and the base of the proximal phalanx. Arthroplasty or fusion of the MCP joint is the late treatment options for patients with poor joint function outcomes.

Metacarpal Head Fractures Metacarpal head fractures are mostly intra-articular involving the MCP joint. These fractures, especially of the fourth and fifth metacarpals, often are caused

Metacarpal Neck Fractures Most metacarpal neck fractures involve the ring and small finger metacarpals (ie, Boxer’s fracture).

465

466

Xing & Tang Because the volar aspect of the metacarpal neck is its weak point, these fractures occur when a clenched MCP joint strikes a solid object and dorsally pushes its apex.4 Nondisplaced or stable reduced fractures are managed nonoperatively by casting for 5 to 6 weeks. Full flexion of all 3 finger joints followed by applying dorsally directly pressure over the flexed PIP joint while applying a volarly directed force to the apex of the fracture (Jahss maneuver) is helpful in reduction. A certain degree of angulation (esthetic deformity) can exist without impairment to hand function. Opinions vary regarding the allowable degrees of angulation in the metacarpal neck, but in the index, long, ring, and small fingers, 10 , 20 , 30 , and 40 of angulation are tolerated, respectively.5 Angulation in the ring and small fingers can be better compensated, because these 2 fingers have more mobility at the metacarpal level than do the index and middle fingers. Nonetheless, the authors found that greater than 30 degrees of deformity is not tolerable even for the little finger. The authors usually aim to reduce all metacarpal neck fractures to less than 20 to 30 of angulation because this improves cosmetic outcomes. That said, the authors

attempt reduction—either closed or surgical—of all fractures with more than 20 of angulation. Clinically, however, metacarpal neck and shaft fractures tolerate up to 20 of angulation, so perfecting alignment to less than 20 does not justify surgery. Surgical indications for operative metacarpal neck fracture management include unstable or severely angulated neck fractures (greater than 20 –30 ), pseudo-clawing, or significant rotational deformity. The preferred and most common approach is closed reduction with percutaneous pinning (CRPP) with K-wires (Fig. 2). Intramedullary fixation is commonly used. Reduction is usually straightforward when using a mini-C-arm machine. With CRPP, if the fixation using one intramedullary K-wire is not stable enough, the authors insert a second 0.045-inch K-wire from the MCP joint level into the medulla up to the metacarpal base (see Fig. 2). Fixation using 2 longitudinal intramedullary K-wires from or up to the base of the metacarpal usually prevents rotation; because longitudinal placement is simpler than crossing Kwires, this is the aurthors’ preferred method. Wong and colleagues6 found no difference in outcomes

Fig. 2. The index metacarpal neck fracture was reduced under a mini-C-arm machine. (A) One K-wire was inserted to immobilize the reduced fracture. (B) Another K-wire was inserted from the other side of the metacarpal head. Both K-wires went through the intramedullary cavity, anchoring at the dense bony substance at the base of the metacarpal firmly. (C) Oblique view is necessary to confirm that reduction is ideal and K-wires have been properly inserted. (D) Operative scene of K-wire insertion. (E) Completion of insertion of 2 K-wires, leaving little blood and 2 tiny pin holes, which do not need suture closure but coverage of a thin layer of gauze.

Surgical Treatment of Metacarpal Fractures between cross-pin and intramedullary pin fixation. Winter and colleagues7 found that intramedullary fixation leads to better functional outcomes than crossed pinning or transverse K-wire fixation. These findings support that simple, 2-wire intramedullary fixation is perhaps the most ideal method. Open reduction is indicated for metacarpal neck fractures when the above-detailed manipulation fails to restore an acceptable angle or rotational alignment. A mini-condylar plate provides a lowprofile, stable fixation for rigid stabilization of such fractures.8 In the authors’ practice, fixation using 2 intramedullary or 2 crossed K-wires is most often used after open reduction (Fig. 3). Alternatively, a dorsal tension band wire with a supplemental K-wire can be used in these cases.

Metacarpal Shaft Fractures Metacarpal shaft fractures can be transverse, oblique, or spiral. There are several similarities among the treatments of metacarpal neck and shaft fractures. For example, reduction is indicated for angulation greater than 30 in the small finger metacarpal shaft or greater than 20 in the ring finger, and for any angulation in the index and middle metacarpals. Oblique and spiral

fractures can cause rotational malalignment. As little as 10 of malrotation can lead to 2 cm of fingertip overlap.9 Correct rotational alignment is an important factor for reduction. Another concern is metacarpal length. Controversy exists regarding the degree of acceptable shortening. Strauch and colleagues10 suggested that 2 mm of shortening would result in a 7 of extensor lag. The authors accept shortening of 2 to 5 mm for the metacarpals in their practice because such shortening does not cause functional impairment. Cast or plaster splint immobilization works well for most metacarpal shaft fractures after stable reduction. Surgical indications for operative management include open fractures, unstable fractures, and unacceptable malalignment. Closed reduction and percutaneous treatment are indicated when the fracture can be reduced but cannot be maintained, or when concomitant soft tissue injury requires dressing changes and inspection. Similar to the treatment of a neck fracture, the method of the authors is to insert 1 or 2 K-wires from the MCP joint level into the medulla of the metacarpal shaft up to the metacarpal base (Fig. 4). This method works very well in more than 90% of the cases of transverse or oblique metacarpal shaft fractures. If one K-wire keeps reduction stable, one K-wire is enough. CRPP can be used for almost all

Fig. 3. A 25-year-old man had a comminuted fracture in the neck of the fifth metacarpal caused by a clenched MCP joint striking a solid object. (A) Posteroanterior radiograph and (B) oblique radiograph. (C) Dorsal, extensorsplitting approach to the metacarpal neck. (D) Fracture reduction was maintained with K-wires. Posteroanterior (E) and oblique (F) radiographs after surgery. ([C, D] Courtesy of Dr Ren Guo Xie, Nantong University, Nantong.)

467

468

Xing & Tang

Fig. 4. (A) Transverse metacarpal shaft fracture can be reliably fixed with CRPP using one K-wire in most cases, as shown here. Oblique fracture can also be fixed with CRPP with 1 or 2 K-wires. (B) However, if the oblique fracture has spiral fracture interface, it is better to use screws to fix. Two crews are placed at different directions, offering better fixation for spiral fracture interface. If longitudinal alignment of the sprial fracture is good and the patient is willing to have a full cast from the wrist to the MCP joint level for 6 to 8 weeks (or longer), it can be treated without surgery.

metacarpal shaft fractures except in cases of multiple, oblique/spiral, unstable fractures or when associated with bone or tissue loss, which require open reduction and internal fixation (ORIF) with 2 screws (for oblique/spiral fracture, see Fig. 4) or a plate (for multiple unstable fractures, Fig. 5). Most oblique fractures can be treated by percutaneous K-wire fixation without open reduction. In the authors’ experience, K-wires may be used in nearly any fracture pattern. The authors generally reserve plate fixation for complex situations such as multiple open or spiral shaft fractures in less than 5% of the patients who have metacarpal fractures. Extra-articular metacarpal fractures treated with either intramedullary wiring or plate and screw fixation were found to have no significant difference in outcomes.11 The microplates currently available for metacarpal shaft fractures are low profile, measuring approximately 1 mm in thickness. Periosteum can often be closed over the plate to reduce tendon adhesions. Fracture stabilization, although not rigid, allows early mobilization; the incidence of hardware failure is low.12 Most implants are made of titanium. The advantages of a titanium implant include low incidence of corrosion and allergic reactions, ease of contouring, and a modulus of

elasticity that approaches that of bone. Geissler13 recommend the use of a 2-mm cage plate that may allow return to full hand mobility within 2 weeks of surgery. Absorbable poly-L-lactide implants are also available.14 Surgical procedures for a plate fixation with or without a bone defect are as follows: 1. A dorsal longitudinal incision provides access to the metacarpal shaft. In spiral and longoblique patterns (fractures are twice the length of the shaft diameter), interfragmentary fixation with 2-mm to 2.7-mm screws allows for excellent reduction and stability. 2. Ideally, longitudinal compressive (axial) forces are best counteracted by placing the screw at 90 to the bone’s long axis; torsional stresses across the fracture plane are best resisted by placing the screw 90 relative to the plane of the fracture. To resist axial and torsion loading, the screw should be placed in a plane bisecting the fracture plane and the longitudinal axis. 3. When there is segmental metacarpal bone loss, or associated soft tissue defects and contamination, application of either an external fixator or a transverse K-wire through the second through fifth metacarpal heads is necessary.15

Surgical Treatment of Metacarpal Fractures

Fig. 5. Spiral oblique shaft fractures involving ulnar 3 fingers in the left hand of a 43-year-old man caused by crush injury. (A, B) Posteroanterior and oblique radiographs, respectively. To fix these fractures, 1.5-mm titanium mini-plates and screws (Synthes) were used. (C, D) Postoperative posteroanterior and oblique views of the hand.

469

470

Xing & Tang 4. When the wound is clean, bone graft can be harvested to fill the defect; it can be stabilized with a dorsal plate or multiple pins, followed by free tendon grafts and soft tissue coverage.

after closed or open reduction.18 Again, using a dorsal approach, reduction is maintained with K-wires extending from the carpus into the metacarpals.

Surgical Points: The screws should reach beyond the opposite cortex of the bone, and screws should be placed perpendicular to the fracture line if there is a large oblique fracture. Bone graft is necessary if a defect is greater than 1 cm.

MANAGEMENT OF THUMB METACARPAL FRACTURE Fractures of the Shaft of the First Metacarpal

Metacarpal Base Fractures Extra-articular fractures of the base of the metacarpal are managed using similar principles as those for shaft fractures. Isolated intra-articular fractures of the base of the second and third metacarpals are rare. Isolated ring finger metacarpal base fractures are not common, which should raise the possibility of an associated CMC joint dislocation similar that seen with fifth metacarpal base fractures. Anterior dislocation of the CMC joint is extremely rare.16 Posterior CMC joint dislocation or fracture-dislocation is more likely, although still not common. CT scan can aid in the diagnosis and decision-making.17 When the injury is seen early, manual reduction is easy, but K-wire fixation usually is necessary to prevent re-dislocation. If closed reduction fails, surgery is indicated. Multiple CMC dislocations are high-energy injuries that nearly always require ORIF.18 Through a dorsal longitudinal incision, reduction can be maintained with K-wires extending into the carpus from the metacarpals. Intra-articular fractures of the hamate–fifth metacarpal joint are more common than the other CMC joints, are usually unstable, and are associated with proximal and dorsal subluxation of the metacarpal. The injury results from a longitudinally directed force along the fifth metacarpal resulting in proximal and dorsal subluxation of the metacarpal base. The displacement is accentuated by the pulling force of the extensor carpi ulnaris. Failure to reduce this intra-articular fracture properly may result in a malunion and weakness of grip.19 Some authors thought that restoration of the articular surface should be the goal of treatment and recommend closed reduction with K-wire fixation.18,19 However, it is rare to have arthritis following this fracture and some surgeons do not operate on it. Highly comminuted fractures require axial traction and closed reduction with percutaneous K-wires both crossing the CMC joint and extending into adjacent metacarpals. This treatment is only necessary when the articular surface is separated and displaced in a young patient. Multiple CMC dislocations are high-energy injuries that nearly always require internal fixation

The thumb tolerates greater residual deformity in its metacarpal than the fingers, because thumb joints have greater compensatory movement. Angular deformities in the frontal plane of less than 15 to 20 are functionally acceptable, although greater angulation can be a cosmetic concern. Angulation less than 20 to 30 in the lateral plane usually does not impair function. The thumb CMC joint is far more important than that of any other joints. Intra-articular fractures or persistent subluxation or dislocation of this joint can cause significant impairment of hand function—resulting in limitation of motion, pain, and weakness of pinch and of grip. Therefore, fractures involving the thumb CMC joint are functionally most relevant to the hand and should be treated with sufficient care.

Bennett Fracture Bennett fractures accounted for 2.4% (4 of 163 metacarpal fractures) of all metacarpal fractures the authors treated in 2012. In literature, this fracture was reported to be 1.4% of all hand fractures.20 A Bennett fracture is defined as an oblique, intraarticular fracture of the base of the first metacarpal with dislocation of the CMC joint (Fig. 6). This fracture was first described by Edward Bennett in 1882. In this fracture, the volar-ulnar fracture fragment remains at its anatomic position because this fragment is attached to the anterior oblique ligament (the palmar beak ligament). This ligament prevents fragment displacement. The remaining metacarpal base subluxates radially, proximally, and dorsally by the pull of the abductor pollicis longus tendon, resulting in a fracture-dislocation of the CMC joint. This injury occurs when the thumb metacarpal is axially loaded and partially flexed. A Bennett fracture is very unstable. The size of the volar-ulnar fragment affects the degree of displacement. Almost all cases need surgical intervention. Surgical techniques include CRPP or ORIF. The authors’ clinical outcomes with the 2 techniques have been similar, as long as anatomic alignment can be achieved and maintained after surgery. Congruent joint and fracture reduction is the surgical goal. Among the different methods, mini-external fixation has been favored by some surgeons21–24 and restores joint congruity without open surgery.

Surgical Treatment of Metacarpal Fractures

Fig. 6. The radiographs of Bennett fracture (A) and Rolando fracture (B). (A) Intra-articular fracture through the base of the thumb metacarpal in which the single, volar-ulnar fracture fragment remains in anatomic position (Bennett fracture). The remaining metacarpal base subluxates radially, proximally, and dorsally. (B) A comminuted intra-articular fracture at the base of the first metacarpal (Rolando fracture).

Percutaneous fixation stabilizing the first to the second metacarpal is an effective and minimal invasive method (Fig. 7A, B), which is used as the first choice for most of the patients. The surgery takes 10 to 15 minutes and is reliable. Under a mini-C arm machine, the thumb is pulled to give traction to the fracture. The based of the first metacarpal is pushed ulnarward with the thumb in pronation. Then the first K-wire (0.045) is inserted from lateral side of the base of the first metacarpal to the trapezium and trapezoid. The base of the first metacarpal is pushed again to further reduce the fracture, as is confirmed through fluoroscopy. The second K-wire (0.045) is inserted just distal to the fracture site of the first metacarpal, passing through the second metacarpal (see Fig. 7A, B). K-wires are removed 5 weeks after surgery. Recently, arthroscopically assisted reduction using a 1.9-mm arthroscope and percutaneous fixation has been described.25 If the fracture cannot be reduced with closed manipulation, the authors have used open reduction and K-wire or screw fixation for their cases. Surgical procedure is as follows: 1. A Wagner approach is used with a small skin incision. The longitudinal limb of this incision is over the border of the thumb metacarpal (between the abductor pollicis longus tendon and the thenar muscles) and is extended proximally

2.

3.

4.

5.

6.

and ulnarly to the radial border of the flexor carpi radialis. The thenar muscles are reflected subperiosteally and the joint capsule is incised to expose the fracture. After articular congruity is restored, the fragment is held in reduction by either reduction forceps or a small bone hook. If the Bennett fragment is of adequate size, the authors insert 1 to 3 K-wires (Fig. 7C) or use internal fixation with a 1.5-mm to 2.7-mm screw to stabilize the reduced fracture fragments. Smaller fragments may not allow screw fixation. In these cases, transarticular pinning is used to supplement fixation (1 pin from the metacarpal to the fragment and a second from the metacarpal to the trapezium). A low-profile plate can be placed together with pinning. The incision is closed.

After surgery, a thumb spica cast is placed for 5 to 6 weeks. Surgical Points: Restoration of articular congruity is the key and goal of surgery. Fixation can be achieved with multiple K-wires or cannulated screws, through open approaches, or by percutaneous pinning. Some authors reported patients to have degenerative radiographic changes, but no correlation existed with symptoms.26,27 A higher

471

472

Xing & Tang

Fig. 7. (A) A Bennett fracture of a 23-year-old man before surgery; (B) after close reduction and fixation with 2 K-wires through the trapezium and through the second metacarpal. (C) Another case of a Bennett fracture of a 38-year-old man before surgery (insert) and after open reduction and multiple K-wire fixation.

incidence of symptomatic arthritis is noted when articular incongruity persisted after reduction.28 The occurrence of traumatic arthritis is closely related to the anatomic position and alignment, so exact reduction should be the treatment goal.

Rolando Fracture (Comminuted First Metacarpal Base) In 1910, Rolando29 described intra-articular Y- and T-pattern fractures of the thumb metacarpal base (see Fig. 6). Currently, the term Rolando fracture has come to include any comminuted intra-articular fracture at the base of the first metacarpal. Rolando fractures are of low incidence in the authors’ unit, representing 2.5% of all metacarpal fractures. Rolando fractures are often difficult to manage because of their articular comminution and

inherent instability in the longitudinal axis.30 Accurate reduction of the joint is important in minimizing the risk of later arthritis. Malunion of these fractures may result in long-term disability.31 The Rolando fracture can be treated with CRPP, using the same technique as for the Bennett fracture. Open reduction becomes necessary when the closed reduction is impossible. The appropriate surgical approach remains controversial.32 The following surgical procedures were used: 1. Surgical fixations options include multiple K-wires, tension banding, and plate fixation. When the fragments are large, without considerable comminution, a T-plate or L-plate can be used. K-wires or lag screws can be placed through the plate (Fig. 8). 2. For more comminuted fractures, anatomic reduction may be impossible, making distraction and external fixation more appropriate.20,33

Fig. 8. A Rolando fracture of a 41-year-old man after a fall: (A) before surgery. (B, C) Oblique and posteroanterior views after internal fixation with a 1.5-mm titanium mini-plate and screws (Synthes). (Courtesy of Dr Yan Pei Gong, Nantong University, Nantong.)

Surgical Treatment of Metacarpal Fractures 3. In the setting of significant comminution, bone graft may be necessary. Buchler and colleagues34 described a technique that combines external fixation, limited open reduction, and internal fixation with K-wires, in combination with cancellous bone grafting. This technique showed good results despite persistent joint irregularities.35,36 4. Tension band wiring and/or 8 weeks of external fixation are other options. The authors decide the treatment based on the degree of comminution. If a classic, 3-part, Rolando fracture exists, the authors prefer multiple K-wires or a plate. If it is severely comminuted, open reduction can be frustrating and unproductive; thus, the authors prefer using K-wires for articular reduction.

Other Fractures of the Thumb Metacarpal The management principles of thumb metacarpal head, neck, shaft, and extra-articular base fractures are similar to those for finger metacarpals. Extra-articular fractures are usually transverse or mildly oblique. The fracture is typically angulated dorsally with the distal fragment adducted and flexed. Angulation greater than 30 will lead

to thumb web space narrowing and compensatory MCP joint hyperextension. CRPP or immobilization in a thumb spica cast that excludes the distal phalanx is usually sufficient treatment. Open reduction uses a dorsal approach between the extensor pollicis longus and brevis tendons. If the fracture is close to the base, a low-profile plate is often used (Fig. 9). Open shaft fractures with comminution and severe tissue loss may require external fixation to prevent metacarpal shortening and allow for soft tissue healing.

POSTOPERATIVE CARE: EARLY INTERMITTENT ACTIVE MOTION The authors advocate early intermittent active motion of the hand when stable fixation has been achieved (Box 2). This protocol includes dorsal short plaster splint fixation from the distal forearm to just over the MCP joint with the wrist at 20 to 30 of extension; active or passive MCP joint motion is from about 30 to full flexion. Active MCP joint motion should happen intermittently when the patient has time during the day; also, 1 or 2 sessions of out-of-splint active motion should happen each day. The patient is asked to wear the splint throughout the day and during sleep, but is allowed to remove the splint for 2 to 3 hours

Fig. 9. A thumb metacarpal base extra-articular fracture in a 52-year-old woman. (A, B) Posteroanterior and oblique views of the fracture before surgery. (C) Dorsal, extensor-splitting approach to the thumb metacarpal. (D) Fracture reduction was maintained with a 1.5-mm titanium mini-plate and screws (Synthes). (E, F) Radiographs after reduction and internal fixation.

473

474

Xing & Tang

Box 2 Tips for postoperative motion and hardware removal 1. After surgery, relatively simple protection is encouraged. The protection may include a short palmar or dorsal slab, or soft splint, or buddy taping of 2 fingers. 2. If a slab or a soft splint is used, they should allow MCP joint motion over two-thirds of its normal range. Partial active MCP joint motion should be urged after surgery. 3. The patient should be instructed to take the slab or splint off daily to exercise MCP joint motion in a few sessions. 4. The PIP and distal interphalangeal joints should not be included in protection and should be free. 5. K-wires can be removed 4 to 6 weeks after surgery. 6. Plates or screws may not be removed; they rarely become a problem if not removed. If the patients want them removed, plan the surgery 6 months after surgery.

each day for wrist and MCP joint motion. Full extension of the MCP joint is not possible for most patients because of the pins, but recovery is easy after pin removal. Severely comminuted fractures and those treated with open reduction should be less aggressive in postoperative therapy.37,38 The rationale behind the above-described early motion therapy is to provide external protection when going outside in the day, but to allow for splint-free active motion when in a safe, home setting. While splinted, full flexion at the MCP joints prevents joint stiffness, whereas temporary

delay of full extension has no clinical consequences. The splint should be short, not extending to the PIP joints (Fig. 10). It should wrap around the hand and distal forearm and be secured by elastic bandages. The patient should be comfortable in removing and replacing his/her splint. If the surgeon explains the above exercises effectively, therapist supervision is not mandatory for this patient-directed early active motion. When stable fixation is obtained with K-wire fixation in the setting of a single metacarpal fracture, finger buddy taping can replace the use of a splint. Active motion of 2 fingers (the involved and an adjacent finger) proceeds together. Alternatively, a customized short splint made to protect from the MCP joint level to the wrist can be used from days or one to two weeks after surgery. This gives greater freedom in joint motion exercise. In general, fractures treated with screw fixation, plate-and-screw fixation, and even some forms of wiring that provide stability allow for early motion (with or without a splint) and decrease the risk of tendon adhesions. If scar formation and extensor lag develop, therapists should get involved, and more comprehensive measures should be undertaken.

COMPLICATIONS In the authors’ experience, excluding intraarticular fractures, metacarpal fractures are the least complicated fractures of the hand. In the authors’ unit, the complication rates for metacarpal fractures are about 3%. In 2012, among 163 fractures that were treated, the authors only had 3 infections and 2 malunion cases. The authors have not seen osteomyelitis or nonunion, although textbooks often cite these as possible complications. Because of the prevalent use of percutaneous

Fig. 10. Postoperative short dorsal slab protection and hand motion. The slab extends just minutely distal to the MCP joint, which permits free PIP joint motion (A) and active MCP joint flexion from 30 to 40 of flexion (A) to full fist (B). The patient can actively flex the MCP joint fully all the time. The patient is urged to take off the slab for a few sessions of multiple runs of full MCP joint extension exercise each day while at home.

Surgical Treatment of Metacarpal Fractures pinning, which decreases the need for open reduction to less than 10% of cases, very few of the authors’ patients showed sign of tendon adhesion after surgery. The authors also did not find hardware-related tendon rupture—although warning patients against overuse of the involved hand within a few months after surgery. The authors’ data indicate that osteomyelitis, nonunion, and tendon adherence are uncommon with current treatment indications and approaches. Complications such as infection and malunion often result because of the trauma itself, deformity of unstable fractures, or fracture treatment. These complications can arise after either conservative or surgical treatment modalities. Nonunion after closed reduction of metacarpal fractures is frequently associated with concurrent soft tissue injury.39 Concurrent soft tissue injury occurs after bone loss, osteomyelitis, inadequate immobilization, soft tissue interposition, or failed fixation.

Malunion Malunion is usually seen after closed treatment of unstable fractures, but can also arise after failed surgery. Extra-articular malunions may be angulatory, rotational, or shortened. Healing of second and third metacarpals with angulation is particularly bothersome cosmetically (leading to pseudo-clawing) and functionally (ie, prominent metacarpal head in the palm resulting in painful and weak grip). With the use of plates and screws, corrective osteotomies have almost 100% union rates.40 A reduction in grip strength by 8% per 2-mm shortening has been demonstrated.41 If the metacarpal is appreciably shortened because of bone loss, an opening wedge osteotomy with a bone graft is preferred. Rotational malunion of a metacarpal results in overlapping of the affected finger over an adjacent finger (scissoring). The cosmetic deformity is often marked and grip is impaired. Therefore, significant rotational deformity should be corrected operatively. Step-cut osteotomy at the base of the metacarpal can be used for correcting malunion.42 The osteotomy site is fixed with simple lag screws, thus decreasing the incidence of soft tissue adhesions associated with plate fixation.2 Metacarpal shortening of up to 5 mm gives minimal loss of finger flexion force.43

Infection Rates of infection increase in open fractures.44,45 Infection is directly related to soft tissue involvement and wound contamination. Human and animal bite wounds can produce mixed flora infections. Antibiotic treatment of open fractures should

provide broad-spectrum coverage based on the mechanism of injury. Regardless of time to surgery, prophylactic antibiotic treatment as well as copious wound irrigation must occur during initial evaluation in the emergency department. Surgical treatment of unstable fractures adds the potential for hardware-related tendon adhesions, tendon rupture, and stiffness.46 Initial treatment of these complications should consist of therapy and include dynamic MCP flexion splinting. If initial treatment fails, tenolysis with or without capsulotomy is indicated.

HARDWARE REMOVAL Need of removing the hardware varies depending on the type of implant. Metacarpal fractures usually heal fully by week 5. Typically, K-wires are removed 4 to 6 weeks after fixation depending on clinical and radiographic healing. Titanium implants are less likely to require removal.47,48 If a plate is perceived as bulky or is irritating, or if there are restrictive adhesions and a tenolysis and capsulotomy procedure is indicated, it should be removed. Otherwise, the authors tend not to remove the plate. If the plate is removed, this should happen between 6 months to 1 year after the initial surgery. Currently, hardware removal secondary to tendon irritation or rupture averages 15%.49–52

WIDE-AWAKE APPROACH The wide-awake hand surgery technique was introduced by Lalonde and colleagues in 2007.53 They injected lidocaine with adrenaline into the operative field in the hand to avoid use of a tourniquet, general anesthesia, sedation, and blocks (Bier or brachial plexus). Not only is adrenaline safe in the hand and digits, it allows for adequate hemostasis without the use of a tourniquet.54,55

Patient Materials The wide-awake approach has resulted in consistently good results in cooperative patients with metacarpal fractures (Fig. 11). The authors consider metacarpal fractures to be well-suited for the wide-awake approach because they allow for effective local anesthesia. Between October 2012 and August 2013, 28 patients with metacarpal fractures were treated with the wide-awake technique in the authors’ department (Table 2). Seven patients had plate fixation and the other 21 patients had hardware removal. All the patients had pain only at injection and minimal to no pain during bone manipulation. The patients were satisfied with this approach and their medical cost was reduced. In the authors’

475

Xing & Tang

476

Fig. 11. Multiple metacarpal shaft fractures of a 20-year-old man. (A) 20 minutes after injection of 30 mL premixed 1% lidocaine with 1:100,000 epinephrine buffered with 10:1 8.4% bicarbonate to the operative fields, the skin turns pale in the field (arrow). (B) Dorsal surgical approach without bleeding. (C) During surgery, only minimal bleeding was observed; surgical plating was comfortably performed.

experience, wide-awake surgery for metacarpal fractures and hardware removal is safe, effective, and cost-efficient.

contribute to skin necrosis. Phentolamine at 1 mg per mL of saline is the antidote that reliably reverses epinephrine-induced vasoconstriction.

The Advantages of This Technique

Injection of Lidocaine and Epinephrine

This approach eliminates the risks associated with general or regional anesthesia and the discomfort associated with tourniquets. The surgeons can discuss intraoperative findings with the unsedated, awake patient as well as test the range of active motion of the hand intraoperatively. In open or closed reduction of metacarpal fractures using K-wires, the patient can comfortably move the fingers after fixation and fluoroscopy can assess the stability of the fixation to support early protected joint movement. If unstable or with significant malrotation, additional K-wires or other forms of fixation can be placed.56

Local anesthesia starts with an infiltration of 1% lidocaine at 1:100,000 concentration of epinephrine. According to Lalonde, volumes of 30 to 40 mL are recommended for hand anesthesia, staying at less than the toxic dose of 7 mg/kg of lidocaine with epinephrine. Sodium bicarbonate (8.4%) is added to comprise one-tenth of the volume, which buffers the acidic local anesthetic solution to make it work faster and causes less pain on injection.57,58 Ten to 15 mL are injected to the most proximal location that any dissection is to take place (Fig. 12). After waiting 15 to 30 minutes to allow for distal anesthesia to set in, the distal parts of the skin are injected—now pain-free—for the epinephrine-induced vasoconstriction effect. Five to 10 mL of local anesthetic is injected in the middle of the operative field and immediately after the second injection 5 to 10 mL is injected to the distal part under the skin down into the palm to

Contraindications If the skin of the operative field is dusky or blue (especially in open fractures) before the surgery, epinephrine should not be used, because it may

Table 2 Number of fractures and pain scores reported by the patients in 28 wide-awake surgeries VAS Pain Score (points)a

Number of Fractures

a

Operations

Head

Neck

Shaft

Base

Soft Tissues

Bone

Pinning Plating Removal

1 0 0

1 1 4

0 3 14

1 0 3

0 0 0

1.3  0.7 1.5  0.4 1.1  0.9

Visual analog scale (VAS) of pain reported by the patients during manipulation of soft tissues or bones.

Surgical Treatment of Metacarpal Fractures

Fig. 12. The longitudinal deep blue line indicates the incision to be made for ORIF of the fourth and fifth metacarpal fractures. The light blue area represents the area bathed by the injection of premixed 1% lidocaine with 1:100,000 epinephrine buffered with 10:1 8.4% bicarbonate. (A) The site of the first injection and infiltration area (light blue area). Ten and 15 mL of the above mixture is injected with a 27-gauge needle in the most proximal incision. The local is injected slowly just under the skin in the fat without moving the needle. (B) The second injection (the site is indicated by the needle tip in the figure) is given 15 to 30 minutes after the first injection. Five to 10 mL of mixture is injected. (C) The third injection of 5 to 10 mL is given immediately after the second injection at the site of the most distal point of surgical incision.

tumescent at least 5 mm of skin on either side of the incision. For the neck or shaft fracture, the authors inject into the medullary canal intraoperatively. For intraarticular fracture, the authors inject into the joint capsule as well as into the soft tissues around the joint.

FUTURE PERSPECTIVES OF MINIMALLY INVASIVE APPROACHES Fluoroscopic Imaging Is Reliable Fluoroscopic imaging and percutaneous pinning together provide ideal approaches to most metacarpal factures that may need surgical intervention. Recent investigations further highlight their reliability and usefulness. Greeven and colleagues59 studied the accuracy of fluoroscopic imaging of the step-off and displacement of intra-articular thumb metacarpal fractures, which was compared with digital radiographs and direct visualization after dissection. They found excellent compatibility between fluoroscopy and direct visualization and conclude that fluoroscopic visualization can adequately assess articular step-off and displacement. Sletten and colleagues60 showed that midmedullary canal measurement in the lateral view is the most reliable method to record angulation of the neck fracture.

Cost-Effective Approaches Recent reports also highlight the minimally invasive approaches as a cost-effective treatment with minimal complications and high patient satisfaction. Lee and colleagues61 reported operation time was 11 minutes (range, 6–17) for isolated single metacarpal fractures and 18 minutes (range, 13–25) for isolated simultaneous 2-metacarpal fractures in their 56 cases using retrograde percutaneous intramedullary multiple K-wire fixation for treatment of unstable displaced metacarpal neck and shaft fractures. Radiographic fracture union was achieved in all patients at a mean of 5.2 weeks. Houshian and Jing62 treated 8 displaced intra-articular fractures of the metacarpal and phalangeal heads using a Penning miniexternal fixator after an average delay for 20 days after initial injury. Closed anatomic reduction with a 2-mm overdistraction was achieved during operation. Excellent outcomes were obtained at 6 months. Lieber and colleagues63 used elastic stable intramedullary nailing in 66 metacarpal fractures. Mean operating time was 21 minutes (range 5–54). Titanium elastic nails were used with a diameter of 1.5 to 2.5 mm. A single nail was implanted in 63 cases; in 3 cases, 2 nails were implanted. All fractures healed uneventfully and the implant was removed after 1 to 3.5 months.

477

478

Xing & Tang At a mean follow-up of 26 months, all patients had full range of movement and cosmetic results were good or satisfactory. Rhee and colleagues64 reviewed 121 displaced metacarpal neck and shaft fractures with retrograde percutaneous intramedullary K-wire fixation and concluded it is a simple and reliable method.

A Conservative or Minimally Invasive Approach Is Generally Preferred Sahu and colleagues65 recently published their survey among 278 upper limb surgeons throughout the United Kingdom; their surgical indications are very similar to what is described above in the authors’ practice. For fifth metacarpal neck fractures, one of the most commonly seen metacarpal fractures, 43% of upper limb surgeons prefer neighbor strapping alone for nonoperative management if the fracture is not displaced. Thirty-four percent would only consider surgical intervention when the volar angulation is beyond 60 . Ninety-one percent of upper limb surgeons agreed that they would operate on metacarpal base fractures only if it was a fracture-dislocation and 72% operate on a pure dislocation. Most metacarpal fractures are treated conservatively.

GENERAL GUIDELINES IN TREATMENT: WHAT TO DO AND WHAT TO AVOID Here, 4 key points are summarized reflecting the authors’ current views and practice regarding metacarpal fractures: 1. Most fractures are treated successfully by closed reduction followed by external fixation or minimally invasive percutaneous pinning. 2. Plating should not be used unless absolutely necessary. Less than 5% of metacarpal fractures need plating. Do not overuse plating. 3. The authors advocate for early limited intermittent active motion with splinting protection and full or near-full active out-of-splint motion daily. 4. Wide-awake surgery is efficient for both plating and hardware removal.

SUMMARY Fractures of the metacarpals are relatively common, accounting for 7.8% of all upper extremity fractures in the authors’ unit last year. Most fractures are managed nonoperatively with casting or plaster splint for 5 to 6 weeks. Among surgical options, percutaneous insertion of single (or double) intramedullary K-wires is a good solution for most fractures. Only large, oblique fractures may need to be fixed with screws or a plate. Indications

for plating metacarpal fractures are very limited, including multiple shaft or oblique fractures in multiple metacarpals. In the authors’ practice, about 60% of metacarpal fractures are treated nonoperatively with success. Another 30% proceed to percutaneous K-wire fixation, and less than 5% require plate or screw fixation. The authors emphasize the importance of not overplating these fractures. After internal fixation, the patient actively moves the MCP joint over a limited range with plaster splint protection or with finger buddy taping. K-wires are removed when fractures heal. Screws and plates may not be removed, but if removal is necessary, it should be done 6 months to 1 year after surgery. Outcomes are generally very good for extra-articular fractures, but intraarticular fractures, especially Bennett or Rolando fractures, carry a less favorable prognosis. The wide-awake approach has permitted the authors to acquire consistently good results in cooperative patients.

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. Stern PJ. Management of fractures of the hand over the last 25 years. J Hand Surg Am 2000;25: 817–23. 3. Hastings H 2nd, Carroll C 4th. Treatment of closed articular fractures of the metacarpophalangeal and proximal interphalangeal joints. Hand Clin 1988;4: 503–27. 4. Henry MH. Fractures and dislocations of the hand. In: Bucholz RW, Heckman JD, Court-Brown C, editors. Rockwood and Green’s fractures in adults. 6th edition. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 772–857. 5. Baltera RM, Hastings H, Sachar K, et al. Fractures and dislocations: hand. In: Hammert WC, Calfee RP, Bozentka DJ, et al, editors. Manual of hand surgery. Philadelphia: Lippincott Williams & Wilkins; 2010. p. 186–215. 6. Wong TC, Ip FK, Yeung SH. Comparison between percutaneous transverse fixation and intramedullary K-wires in treating closed fractures of the metacarpal neck of the little finger. J Hand Surg Br 2006; 31:61–5. 7. Winter M, Balaguer T, Bessie`re C, et al. Surgical treatment of the boxer’s fracture: transverse pinning versus intramedullary pinning. J Hand Surg Eur 2007;32:709–13. 8. Bu¨chler U, Fischer T. Use of a minicondylar plate for metacarpal and phalangeal periarticular injuries. Clin Orthop Relat Res 1987;214:53–8.

Surgical Treatment of Metacarpal Fractures 9. Royle SG. Rotational deformity following metacarpal fracture. J Hand Surg Br 1990;15:124–5. 10. Strauch RJ, Rosenwasser MP, Lunt JG. Metacarpal shaft fractures: the effect of shortening on the extensor tendon mechanism. J Hand Surg Am 1998;23:519–23. 11. Ozer K, Gillani S, Williams A, et al. Comparison of intramedullary nailing versus plate-screw fixation of extra-articular metacarpal fractures. J Hand Surg Am 2008;33:1724–31. 12. Chen SH, Wei FC, Chen HC, et al. Miniature plates and screws in acute complex hand injury. J Trauma 1994;37:237–42. 13. Geissler WB. Operative fixation of metacarpal and phalangeal fractures in athletes. Hand Clin 2009; 25:409–21. 14. Dumont C, Fuchs M, Burchhardt H, et al. Clinical results of absorbable plates for displaced metacarpal fractures. J Hand Surg Am 2007;32:491–6. 15. Ashmead D 4th, Rothkopf DM, Walton RL, et al. Treatment of hand injuries by external fixation. J Hand Surg Am 1992;17:954–64. 16. Inui A, Kokubu T, Mifune Y. Volar dislocation of index and middle finger carpometacarpal joints: a case report. J Hand Surg Eur 2013 Aug 9. [Epub ahead of print]. 17. Chong AK, Chew WY. An isolated ring finger metacarpal shaft fracture?—beware an associated little finger carpometacarpal joint dislocation. J Hand Surg Br 2004;29:629–31. 18. Lawlis JF 3rd, Gunther SF. Carpometacarpal dislocations: long-term follow-up. J Bone Joint Surg Am 1991;73:52–9. 19. Bora FW Jr, Didizian NH. The treatment of injuries to the carpometacarpal joint of the little finger. J Bone Joint Surg Am 1974;56:1459–63. 20. Hove LM. Fractures of the hand. Distribution and relative incidence. Scand J Plast Reconstr Surg Hand Surg 1993;27:317–9. 21. Byrne AM, Kearns SR, Morris S, et al. “S” Quattro external fixation for complex intra-articular thumb fractures. J Orthop Surg 2008;16:170–4. 22. Huang JI, Fernandez DL. Fractures of the base of the thumb metacarpal. Instr Course Lect 2010;59: 343–56. 23. Sawaizumi T, Nanno M, Nanbu A, et al. Percutaneous leverage pinning in the treatment of Bennett’s fracture. J Orthop Sci 2005;10:27–31. 24. Meyer C, Hartmann B, Bo¨hringer G, et al. Minimal invasive cannulated screw osteosynthesis of Bennett’s fractures. Zentralbl Chir 2003;128:529–33. 25. Culp RW, Johnson JW. Arthroscopically assisted percutaneous fixation of Bennett fractures. J Hand Surg Am 2010;35:137–40. 26. Cannon SR, Dowd GS, Williams DH, et al. A longterm study following Bennett’s fracture. J Hand Surg Br 1986;11:426–31.

27. Timmenga EJ, Blokhuis TJ, Maas M, et al. Longterm evaluation of Bennett’s fracture: a comparison between open and closed reduction. J Hand Surg Br 1994;19:373–7. 28. Kjaer-Petersen K, Langhoff O, Andersen K. Bennett’s fracture. J Hand Surg Br 1990;15:58–61. 29. Rolando S. Fracture of the base of the first metacarpal and a variation that has not yet been described: 1910. Clin Orthop Relat Res 2006;445: 15–8. 30. Van Niekerk JL, Ouwens R. Fractures of the base of the first metacarpal bone: results of surgical treatment. Injury 1989;20:359–62. 31. Soyer AD. Fractures of the base of the first metacarpal: current treatment options. J Am Acad Orthop Surg 1999;7:403–12. 32. Langhoff O, Andersen K, Kjaer-Petersen K. Rolando’s fracture. J Hand Surg Br 1991;16:454–9. 33. Gelberman RH, Vance RM, Zakaib GS. Fractures at the base of the thumb. Treatment with oblique traction. J Bone Joint Surg Am 1979;61:260–2. 34. Buchler U, McCollam SM, Oppikofer C. Comminuted fractures of the basilar joint of the thumb. Combined treatment by external fixation, limited internal fixation and bone grafting. J Hand Surg Am 1991;16:556–60. 35. Marsland D, Sanghrajka AP, Goldie B. Static monolateral external fixation for the Rolando fracture: a simple solution for a complex fracture. Ann R Coll Surg Engl 2012;94:112–5. 36. Houshian S, Jing SS. Treatment of Rolando fracture by capsuloligamentotaxis using mini external fixator: a report of 16 cases. Hand Surg 2013;18: 73–8. 37. Chinchalkar SJ, Pipicelli JG. Addressing extensor digitorum communis adherence after metacarpal fracture with the use of a circumferential fracture brace. J Hand Ther 2009;22:377–81. 38. Singletary S, Freeland AE, Jarrett CA. Metacarpal fractures in athletes: treatment, rehabilitation, and safe early return to play. J Hand Ther 2003;16: 171–9. 39. Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000;8:111–21. 40. Van der Lei B, de Jonge J, Robinson PH, et al. Correction osteotomies of phalanges and metacarpals for rotational and angular malunion: a longterm follow-up and a review of the literature. J Trauma 1993;35:902–8. 41. Meunier MJ, Hentzen E, Ryan M, et al. Predicted effects of metacarpal shortening on interosseous muscle function. J Hand Surg Am 2004;29:689–93. 42. Jawa A, Zucchini M, Lauri G, et al. Modified stepcut osteotomy for metacarpal and phalangeal rotational deformity. J Hand Surg Am 2009;34: 335–40.

479

480

Xing & Tang 43. Wills BP, Crum JA, McCabe RP, et al. The effect of metacarpal shortening on digital flexion force. J Hand Surg Eur 2013;38:667–72. 44. Chow SP, Pun WK, So YC, et al. A prospective study of 245 open digital fractures of the hand. J Hand Surg Br 1991;16:137–40. 45. Swanson TV, Szabo RM, Anderson DD. Open hand fractures: prognosis and classification. J Hand Surg Am 1991;16:101–7. 46. Page SM, Stern PJ. Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg Am 1998;23: 827–32. 47. Souer JS, Ring D, Matschke S, et al. Comparison of functional outcome after volar plate fixation with 2.4-mm titanium versus 3.5-mm stainless-steel plate for extra-articular fracture of distal radius. J Hand Surg Am 2010;35:398–405. 48. Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Joint Surg Am 2003;85:1956–60. 49. Margaliot Z, Haase SC, Kotsis SV, et al. A metaanalysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am 2005;30:1185–99. 50. Faruqui S, Stern PJ, Kiefhaber TR. Percutaneous pinning of fractures in the proximal third of the proximal phalanx: complications and outcomes. J Hand Surg Am 2012;37:1342–8. 51. Sletten IN, Nordsletten L, Husby T, et al. Isolated, extra-articular neck and shaft fractures of the 4th and 5th metacarpals: a comparison of transverse and bouquet (intra-medullary) pinning in 67 patients. J Hand Surg Eur 2012;37:387–95. 52. Baldwin PC, Wolf JM. Outcomes of hand fracture treatments. Hand Clin 2013;29:621–30. 53. Bezuhly M, Sparkes GL, Higgins A, et al. Immediate thumb extension following extensor indicis proprius-to-extensor pollicis longus tendon transfer using the wide-awake approach. Plast Reconstr Surg 2007;119:1507–12. 54. McKee DE, Lalonde DH, Thoma A, et al. Optimal time delay between epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg 2013;131:811–4.

55. Thomson CJ, Lalonde DH, Denkler KA, et al. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg 2007;119:260–6. 56. Lalonde DH, Martin AL. Wide-awake flexor tendon repair and early tendon mobilization in zones 1 and 2. Hand Clin 2013;29:207–13. 57. Davies RJ. Buffering the pain of local anaesthetics: a systematic review. Emerg Med (Fremantle) 2003; 15:81–8. 58. Lalonde DH. “Hole-in-one” local anesthesia for wide-awake carpal tunnel surgery. Plast Reconstr Surg 2010;126:1642–4. 59. Greeven AP, Hammer S, Deruiter MC, et al. Accuracy of fluoroscopy in the treatment of intraarticular thumb metacarpal fractures. J Hand Surg Eur 2013;38:979–83. 60. Sletten IN, Nordsletten L, Hjorthaug GA, et al. Assessment of volar angulation and shortening in 5th metacarpal neck fractures: an inter- and intraobserver validity and reliability study. J Hand Surg Eur 2013;38:658–66. 61. Lee SK, Kim KJ, Choy WS. Modified retrograde percutaneous intramedullary multiple Kirschner wire fixation for treatment of unstable displaced metacarpal neck and shaft fractures. Eur J Orthop Surg Traumatol 2013;23:535–43. 62. Houshian S, Jing SS. A new technique for closed management of displaced intra-articular fractures of metacarpal and phalangeal head delayed on presentation: report of eight cases. J Hand Surg Eur 2014;39:232–6. 63. Lieber J, Ha¨rter B, Schmid E, et al. Elastic stable intramedullary nailing (ESIN) of pediatric metacarpal fractures: experiences with 66 cases. Eur J Pediatr Surg 2012;22:305–10. 64. Rhee SH, Lee SK, Lee SL, et al. Prospective multicenter trial of modified retrograde percutaneous intramedullary Kirschner wire fixation for displaced metacarpal neck and shaft fractures. Plast Reconstr Surg 2012;129:694–703. 65. Sahu A, Gujral SS, Batra S, et al. The current practice of the management of little finger metacarpal fractures–a review of the literature and results of a survey conducted among upper limb surgeons in the United Kingdom. Hand Surg 2012;17:55–63.