INTRODUCTION
Hand fractures are the most common fractures
presenting at accident and emergency units. Appropriate
evaluation at first presentation, as well
as during their management, can significantly
prevent both morbidity and disability to a patient
[1].
405
Increasingly sophisticated advances has been
made in operative techniques on the skeleton of
the hand, in particular the development of stable
fixation with mini screws and plates has expanded
the application of open reduction and internal
fixation in metacarpal fractures. Tension band
wiring also is a simple, predictable method for
internal fixation. Nevertheless, many single closed
fractures can be reduced by closed manipulation
and protected in a functional position with splinting,
bracing, casting or a percutaneous pinning technique
with excellent results [2].
Because of the complexity of the hand, frequency
of complications following hand fractures including
stiffness, malunion, nonunion and associated
soft tissue injury; management of hand
fractures can be very challenging. Fixation of hand
fractures can be done by multiple methods including
percutaneous K-wires fixation and internal fixation
with either interosseous wiring fixation or miniplate
and screws. The choice of fixation method
depends on the location, geometry, pattern of the
fracture, associated injuries, and the surgeon's
preference [3].
The correct diagnosis and management of hand
fractures and associated injuries are very challenging,
this comparative clinical study is designed to
review the indications and compare the long term
outcome of each method.
PATIENTS AND METHODS
This prospective, non-randomized clinical study
included thirty patients presented with metacarpal
and phalangeal hand fractures, admitted to Al-
Azhar University Hospital and Helmia Military
Hospital between September 2016 and August
2017. Patients were fully informed about the procedure.
Written consents were obtained. Patients
were divided into 3 groups. Ten patients were
treated with percutaneous K wire fixation (group
A), another ten patients were treated with open
reduction and internal fixation with interosseous
wiring (group B) and the last ten patients were
treated with open reduction and internal fixation
with mini-plate and screws (group C).
Inclusion criteria:
• Traumatic hand fractures with significant
displacement, rotation, angulation and/or instability.
• Patients aged 15-50 years.
• Both sexes.
Exclusion criteria:
• Age extremes.
• Chronic co-morbid diseases.
• Auto-immune diseases.
• Bleeding disorders.
• Pathological fractures.
• Poly-traumatized patients.
• Fractures with no significant displacement,
rotation, angulation or instability.
Preoperative evaluation:
Each patient was evaluated clinically, radiologically
and by other preoperative laboratory investigations
to confirm fitness for general anesthesia
and appropriate method of surgical intervention
was determined according to the proposed indications.
The default method of management is percutaneous
fixation of the fracture using K wires
unless there is an indication for ORIF as the following.
Indications of ORIF using interosseous wiring:
Closed oblique phalangeal or metacarpal shaft
fracture, replantation and intra-articular fracture,
replantation, failed closed reduction.
Indications of ORIF using mini-plate and
screws: Multiple fractures, condylar fracture, segmental
bone loss, multifragmentary articular and
peri-articular fracture with displacement and/or
rotation, failed closed reduction.
Operative managements:
Thirty patients were submitted to three different
fixation modalities according to the indications in
each method and divided into three groups.
406 Vol. 42, No. 2 /Management of Metacarpal & Phalangeal Bone Fractures
Operative technique:
A- Percutaneous K wiring:
Metal used: Kirschner wire with thickness
ranging from 0.8mm to 1.2mm.
After hand sterilization and hair shaving, the
fracture is held in place with a towel clamp. Rotation
is verified by checking for abnormal crossing
of the fingers with flexion of the MP and IP joints.
The first wire was inserted as a guide wire perpendicular
to the fracture line followed by insertion
of a second wire crossing or parallel to the first
wire. The reduction and K-wire placement are
verified under C-arm imaging and the finger is
taken through a ROM. For comminuted or unstable
metacarpal fractures, we also inserted K-wire
through the metacarpal head into the proximal
phalanx. K-wires were cut off just beneath the skin
or left protruding and bent 90 degree to minimize
inward migration. A sterile dressing is applied, and
the finger and adjacent neighboring finger are
splinted and placed in the safety position (wrist
30 degrees dorsiflexion, MP joint 80 degrees flexion).
Post operative: Pins are removed at six weeks
and then the finger is protected with buddy taping
for another three weeks before allowing full
ROM.
Figs. (1,2): Showing 21 years old male patient presented with
shaft fracture of the middle phalanx of the left middle
finger, managed with closed reduction and percutaneous
fixation with two crossing K wires.
B- Interosseous wiring:
Metal used: 0.5mm monofilament stainless
steel wire.
Dorsal incisions are preferred and then splitting
the extensor tendon for visualizing fracture site.
Placing the K-wires perpendicular to the fracture
Egypt, J. Plast. Reconstr. Surg., July 2018 407
plane to make holes in the fractured bone. Removing
the wires and inserting 0.5mm dentate wire
through the first hole. Dragging the wire using a
clamp and twist it around the fractured bone.
Inserting the wire through the other hole. It can
be made in a figure of eight shaped tension band
or as an encircling wire. Tightening of the wire
and closure of skin after haemostasis. A sterile
dressing is applied, and the finger and adjacent
neighboring finger are splinted and placed in the
safety position (wrist 30 degrees dorsiflexion, MP
joint 80 degrees flexion).
Post operative: Splinting for 3-4 weeks before
allowing full active movements.
Post operative: Hand is kept in a splint for a
week before allowing active range of movement.
Figs. (3,4): Showing 20 years old male patient presented with
fracture base of the proximal phalanx of the left ring
finger, managed with open reduction and internal fixation
with interosseous wiring.
Figs. (5,6): 31 years old male patient presented with fracture
shaft of the right 5th metacarpal bone, managed with
open reduction and internal fixation with mini-plate
and screws.
All patients were submitted for post operative
splinting in the functional position and physiotherapy
was allowed after removal of the splint for
three months. Follow-up protocol included clinical
and radiological evaluation to assess pain, tenderness,
range of movement, return to work, complications,
clinical and radiological union. Postoperative
A-P and lateral X-ray was done every
two weeks for 1st month then every month for 6
successive months.
Patients' age in this study ranged from 15 to
45 years old with mean age 23.2 years old. 25
patients involved in this study were males and 5
patients were females. Patients involved were
twenty six dominant hand involvements and the
non-dominant hand was affected in four patients.
Direct injury (impaction, crushing) was responsible
for fractures in twenty eight patients and indirect
trauma (twisting injury) was responsible for fractures
in two patients.
RESULTS
This study consists of thirty patients presented
with metacarpal and phalangeal fractures. They
were classified into three groups according to the
method they were treated with.
The range of motion (ROM) was classified into
two types: Active and passive movement. Both
active and passive were measured in the medial 4
fingers at the metacarpophalangeal joint, proximal
C- Miniplate and screws:
Metal used: 2.0-2.4mm locking titanium miniplates
(>3 holes), 2.0-2.2 cortical and locking
screws.
Lazy S dorsal skin incision is preferred for
exposure of phalangeal and metacarpal fractures.
Care was taken to preserve the dorsal longitudinal
venous system. The extensor tendon is split longitudinally
for exposure of proximal phalangeal
fractures. The periosteum is longitudinally incised
and elevated to expose the fracture. To reduce
spiral and oblique fractures we exposed the sharp
proximal and distal fracture spikes. Reduction was
maintained with reduction clamps or towel clips.
Application of the plate and placement of the
screws, then closure of the wound. A sterile dressing
is applied, and the finger and adjacent neighboring
finger are splinted and placed in the safety position
( wrist 30 degrees dorsiflexion , MP joint 80 degrees
flexion).
interphalangeal joint and distal inter phalangeal
joint while in the thumb it was measured at metacarpophalangeal
and interphalangeal joints. Postoperative
active range of motion (ROM) for each
joint was calculated and compared according to
type of fixation as shown in Table (1). Patients
treated with K wires fixation had a better ROM
when compared to the patients treated with other
methods.
408 Vol. 42, No. 2 /Management of Metacarpal & Phalangeal Bone Fractures
antibiotics. One case had partial stiffness of MCP
joint and was treated with physiotherapy, while in
group B: Two cases were complicated with tendon
adhesions. One case of them had stiffness of MP
joint managed by physiotherapy with better results.
In group C: One case was complicated with wound
dehiscence and needed removal of plate and screws.
Two cases were complicated with adhesions and
decreased ROM.
DISCUSSION
This study was a prospective study of 30 consecutive
patients started from September 2016 till
August 2017 at Al-Azhar University Hospital and
Helmia Military Hospital to compare between three
different methods of metacarpal and phalangeal
fracture fixation: Percutaneous k wire fixation
versus open reduction and internal fixation using
interosseous wiring versus open reduction and
internal fixation using mini-plate and screws. The
choice of the method of management was according
to the fracture pattern and the indication of each
method proposed in this study.
Somboon reported 112 consecutive patients
and they had randomized study comparing percutaneous
fixation versus open reduction and internal
fixation of unstable proximal phalangeal fracture
during July 2006 to December 2008. There were
89 males and 23 females, with mean age 28.2 years,
while in our study patients were 25 males and 5
females with mean age 23.2 years.
He used dorsal approach for ORIF and active
movement was adviced taking care not to afford
stresses at the fracture site and bulky dressing for
3 to 5 days aiming for active mobilization for all
cases as early as possible according to pain tolerance.
In our study the same approach was used but
active movement was allowed after 1 week in ORIF
and after 4-6 weeks in percutaneous fixation.
In Somboon study; Union occured in 95% of
patients and time of union ranged from 8 to 20
weeks with mean average 12 weeks, while in our
study union occurred in all patients and was classified
into clinical union which ranged from 4 to
8 weeks and radiological union which ranged from
8 to 10 weeks [4].
AlQattan reported 78 consecutive patients and
compared percutaneous fixation versus open reduction
and internal fixation of unstable proximal
phalangeal fracture during January 1994 to December
2006. There were 78 men (industrial workers),
with age ranging from 20 years to 48 years with
mean age 33 years. All of his patients had industrial
Table (1): Post operative active ROM.
MP
PIP
DIP
TAM
90
89.9
68.5
246.3
Group (A) Group (B)
85.3
74.6
52
219.3
75.3
70.2
50.1
215.2
Group (C)
Table (2): Clinical union.
4 weeks
6 weeks
8 weeks
5
4
1
Group (A) Group (B)
4
3
0
8
1
1
Clinical union Group (C)
Table (3): Radiological union.
6 weeks
8 weeks
10 weeks
8
2
Group (A) Group (B)
7
2
1
6
4
Radiological union Group (C)
Union was detected clinically starting from 4
to 8 weeks and the results in the three groups were
compared as shown in Table (2). Clinical union
was earlier in group C when 8 patients showed
clinical union at 4 weeks post operative while 7
patients and 5 patients showed clinical union at 4
weeks in group B and C respectively.
Radiological union was detected starting from
6 to 10 weeks and the results in the three groups
were compared as shown in Table (3). It was earlier
to occur in group A when 8 patients showed complete
union at 6 weeks while 7 patients and 6
patients showed radiological union at 6 weeks in
group B and C respectively.
In our study 27 patients (90%) were able to go
back to work, 3 patients (10%) were unable to go
back to work due to movement restriction. During
this study we faced a number of complications; in
group A: One case developed pin tract infection
and was treated by curettage and continuation of
Egypt, J. Plast. Reconstr. Surg., July 2018 409
injuries with no report about the exact mode of
trauma or the fracture morphology, while in our
study; the patients were 25 males and 5 females
and were classified according to the mode of trauma,
direct injury (impaction, crushing) was responsible
for fractures in twenty eight patients and
indirect trauma (twisting injury) was responsible
for fractures in two patients, the patients included
in our study were industrial and non industrial
workers.
He used k-wires in both percutaneous and open
fixation, while in our study we used k-wires only
in percutaneous fixation and interosseous dentate
wires (0.4mm) or mini-plate and screws in ORIF.
All of his patients had clinical union coming with
our results [5].
Thakur study showed dominant hand involvements
(58%). The non-dominant hand was affected
in (42%), while in our study hand dominance was
twenty six dominant hand involvements (86%),
the non-dominant hand was affected in four patients
(14%).
In Thakur study indications of surgery stated
were skeletally mature, compound fractures, multiple
fractures, angulations more than 10º in A/P
view and 20º in lateral view, multi-fragmentary
fractures, severely displaced fractures, irreduciblefractures
and intra-articular fractures. In the contrary
we stated that the default technique to be
used in hand fractures is percutaneous k-wire
fixation and stated the indications for ORIF with
mini-plate and screws or with interosseous wiring.
Hard ware used in Thakur study was K-wires
0.028 inch, 0.35 inch, 0.45 inch and 0.62 inch
while the mini DCP size was 1.5mm straight mini
DCP and screws were 1.5mm screws, while in our
study the metal used was K-wire ranging from
0.8mm to 1.2mm, 0.5mm monofilament stainless
steel wire, 2.0 -2.4mm locking titanium mini-plates
(>3 holes), 2.0-2.2 cortical and locking screws.
In our study, Postoperative active range of
motion (ROM) for each joint was calculated and
compared in each method of fixation but Thakur
didn't state post operative ROM as a follow-up
criteria [6].
Conclusion:
We found out that percutaneous fixation of
unstable metacarpal and phalangeal fractures is a
reliable and safe method for the majority of the
fracture types giving a higher ROM and less complications
in comparison with ORIF, this study
recommend usage of percutaneous K wire fixation
unless there is an indication for ORIF as in multifragmentary
articular and peri-articular fractures,
bicondylar fractures, segmental bone loss, re–plantation
or when closed reduction fails.
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