EXTERNAL FIXATION FOR METACARPAL FRACTURES
Author: Dr. Katnesis D.
Co-author: Dr. Koyris A., Dr. Schonochoritis N., Dr. Psilogloy N., Dr. Pogiatzis Nikolarakos P., Dr. Tselfes P.
Country: Greece
Email: katsenis@yahoo.com
Purpose The retrospective evaluation of the results of the treatment of the diaphyseal and metaphyseal fractures of the metacarpals using the <<mini orthofix>> external fixation.
Methods From 1999-2004, 55 metacarpal fractures were treated with an open or closed procedure and the application of the <<mini orthofix>> external fixation. Internal fixation was applied in 9 fractures. Fractures were located at the fifth metacarpal (42), fourth metacarpal (2) and first metacarpal (11). Fifty fractures were closed and five were Gustillo type 1 open fractures. Closed procedure was performed in 47 fractures. Intravenous block anaesthesia was applied in all patients.
Results
Solid union without a further procedure was achieved in 51 fractures. Four fractures required an additional bone grafting. All these fractures had been treated with an open procedure. Excellent functional result was recorded in 42 patients good in 12 and poor in one patient. Early loss of the reduction, re-manipulation and additional internal fixation was done in four fractures. Superficial inflammation at the pin sites was noticed in almost every fracture, all subsided with oral antibiotics. No deep infection was recorded in this series.
Conclusions
External fixation for metacarpal fractures is a safe, flexible practical effective and well tolerated treatment method for metacarpal fractures. It offers adequate stability of the fracture and is well tolerated for the patient.
The purpose of this study was to evaluate retrospectively the results of the minimal invasive treatment of the diaphyseal and metaphyseal fractures of the metacarpals bones using the <<mini orthofix>> external fixation.
Material-Methods
Fifty five metacarpal fractures were treated in our institution with minimal invasive surgery and the application of an external fixator. The average age was 25 (range, 18 to 59 years).
42 fractures were located at the fifth metacarpal, 2 fractures at the fourth metacarpal and 11 fractures at the first metacarpal. Forty six fractures were comminuted. Fifty fractures were closed whereas five fractures were Gustillo type 1 open injuries.
Surgical technique
The indications of surgical treatment are described in table 1. For fracture of the fifth metacarpal, the pins (2 on each fragment) were put with 40º to 90º angle on the ulnar dorsal side of the bone to avoid damage of the extensor mechanism. For the fourth metacarpal the pins were put on the dorsal side radially to eliminate the risk of the extensor mechanism penetration. Finally, for the first metacarpal the dorsal radial side of the bone is considered as the most suitable for the application of the pins of the external fixator.
The mean follow up was 9 months (range, 6 to 24 months). Clinical and radiographical criteria were used to evaluate the final result.
Results
Union was achieved in 51 fractures. The mean time of healing in these cases was 6 weeks (range, 5 to 8 weeks). The mean duration of the external duration was also 6 weeks (range 3 to 8 weeks).
For the fractures which did not heal with the index procedure, a second surgery for bone grafting was performed. All four fractures healed uneventfully.
Excellent functional result was recorded in 42 patients, good results in 12 patients and poor result in one patient.
Complications:
The most common minor complication was pin tract infection. In two cases, because of pin loosening, we removed the pins before the union of the fracture had completed; fortunately without compromising the final result.
Early loss of the reduction, re-manipulation and stabilization with an additional internal fixation was done in four fractures.
Discussion
Substantial evidence from several studies suggests that good final outcome can be expected in patients with metacarpal fractures even without any attempt at reduction. However, the opponents of the conservative treatment argue that even if an acceptable reduction was achieved, the prolonged time of splintage may lead to a non-correctable stiffness and to limited function of the hand.
Open reduction and internal fixation with small plates and screws disturbs the extensor tendon mechanism, the capsule and the ligaments and leads to joint contractures.
In 2000, Penning introduced his own indications for external fixation.
The main indication in our series for the surgical intervention was a non acceptable rotational deformity of the fracture and the damage of the soft tissue.
The union time in our study - average of 6 weeks compares favorably with other series. That reflects the ability of the external fixator <<mini Orthofix>> to offer adequate stability promoting the fracture healing.
98% of the patient in this series had an excellent or good final result. The worst results were recorded in patients in whom a trans-articular application of the external fixator had been performed.
The main disadvantages of any external fixation such as the patient's discomfort and the pin tract infection are not obvious in metacarpal fractures as it is in other bones. It involves fewer soft tissue problems and shorter period of application eliminating the negative impact of the external Fixator.
External fixation proved to be a suitable technique for non-reducible, unstable and open or with severe soft tissues metacarpal fractures. Is a safe, flexible, practical effective and well tolerated treatment method for these injuries.
INDICATIONS OF SURGICAL TREATMENT |
Open fractures |
5 |
Angulation > 25º |
28 |
Rotational deformity > 10º |
8 |
Shortening > 5mm |
14 |
Table 1. The indications for surgical treatment of metacarpal fractures. |
