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    3-2 Metacarpal Neck Fractures

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    Professeur Christian Dumontier
    A 17-year-old boy presented with a fracture of the neck of a metacarpal bone in his dominant hand. Metacarpal fractures are common injuries, accounting for about 18% of hand and forearm fractures. They often result from axial loading or twisting forces. X-rays can help evaluate the injury and measure any angulation. Minor angulation under 30 degrees for most metacarpals can often be treated non-operatively with immobilization or buddy taping. Greater angulation or injuries involving rotation may require closed reduction and percutaneous pinning for stabilization.

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    3-2 Metacarpal Neck Fractures

    Uploaded by

    Professeur Christian Dumontier
    5K views34 pages
    A 17-year-old boy presented with a fracture of the neck of a metacarpal bone in his dominant hand. Metacarpal fractures are common injuries, accounting for about 18% of hand and forearm fractures. They often result from axial loading or twisting forces. X-rays can help evaluate the injury and measure any angulation. Minor angulation under 30 degrees for most metacarpals can often be treated non-operatively with immobilization or buddy taping. Greater angulation or injuries involving rotation may require closed reduction and percutaneous pinning for stabilization.

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    metacarpal neck fracture, conservative treatment, surgery

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    A 17-year-old boy presented with a fracture of the neck of a metacarpal bone in his dominant hand. Metacarpal fractures are common injuries, accounting for about 18% of hand and forearm fractures. They often result from axial loading or twisting forces. X-rays can help evaluate the injury and measure any angulation. Minor angulation under 30 degrees for most metacarpals can often be treated non-operatively with immobilization or buddy taping. Greater angulation or injuries involving rotation may require closed reduction and percutaneous pinning for stabilization.

    Copyright:

    © All Rights Reserved
    5K views34 pages

    3-2 Metacarpal Neck Fractures

    Uploaded by

    Professeur Christian Dumontier
    A 17-year-old boy presented with a fracture of the neck of a metacarpal bone in his dominant hand. Metacarpal fractures are common injuries, accounting for about 18% of hand and forearm fractures. They often result from axial loading or twisting forces. X-rays can help evaluate the injury and measure any angulation. Minor angulation under 30 degrees for most metacarpals can often be treated non-operatively with immobilization or buddy taping. Greater angulation or injuries involving rotation may require closed reduction and percutaneous pinning for stabilization.

    Copyright:

    © All Rights Reserved
    of 34

    Fracture of the neck of the

    Metacarpal bones

    Christian Dumontier, MD, PhD


    Centre de la Main, Guadeloupe

    Figures may belong to authors quoted in the references section, thanks to them
    17 years old boy, dominant hand. What would you recommend and why ?
    Metacarpal fractures

    Frequent fractures
    18% of hand and forearm fractures,
    30% of hand fractures
    Peak incidence: 15-24 years old
    Metacarpal fractures

    Mechanism: axial loading,


    twisting or direct impact
    Due to the force of intrinsics
    and extrinsic, shaft and
    neck # tend to deform in
    flexion
    X-rays

    Same patient

    AP and lateral views + oblique


    30 pronated for index and
    middle
    30 supinated for ring and little
    X-rays
    AP and lateral views + oblique
    Angulation is measured on
    the lateral view as oblique
    views tend to overestimate
    deformity
    Brewerton view may help for
    evaluation of metacarpal head
    fractures
    Clinical healing is 4 weeks,
    radiological healing is 6-8
    weeks +++
    Metacarpal neck #

    Most common
    The Fifth finger accounting for 20% of all
    hand fractures
    Axial load during a clenched fist
    (Boxers fractures) in amateur pugilists
    and brawlers .
    Volar comminution with dorsal apex
    angulation leads to shortening and loss
    of knuckle prominence
    Clinical evaluation
    Rotational alignment:
    No scissoring during finger flexion into palm
    Pseudo-clawing:
    Both are indications for surgery
    Question :
    How much angulation can be
    tolerated ?

    Is it different from finger to finger ?


    To answer: remember the biomechanics of the carpo-metacarpal
    joints of the long fingers

    CM2 and CM3 can be


    considered as non mobile joints
    CM4 has a mobility around 10
    CM5 has a mobility around 30
    to oppose the thumb
    How much angulation can be tolerated ?

    M2M3 neck fracture can tolerate 10-15 of volar angulation


    M4 can tolerate 30
    M5 can tolerate between 30 to 70
    Biomechanics studies have shown that 30 angulation is a
    limit as beyond this threshold there is a loss of flexor
    tendon efficiency (excursion, load and work requirements)
    as well as loss of strength and range of motion

    AliA. et al. The biomechanical effects of angulated Boxers fractures. J Hand Surg 1999;24A:835-844
    Birndorf MS et al. Metacarpal fracture angulation decreases flexor mechanical efficiency in human hands. PRS 1997; 99:1079-1085
    However
    Prospective clinical series have shown no loss of function
    or disability beyond 30 angulation and no relationship
    between the presence of symptoms and residual
    angulation

    Braakman M, Oderwald EE, Haentjens MH. Functional taping of fractures of the 5th metacarpal results in a quicker recovery. Injury.
    1998; 29(1):59.
    Statius Muller MG, Poolman RW, von Hoogstraten MJ, Steller EP. Immediate mobilization gives good results in boxer's fractures with
    volar angulation up to 70 degrees: a prospective randomized trial comparing immediate mobilization with cast immobilization. Arch
    Orthop Trauma Surg. 2003; 123(10):534537.
    McMahon PJ, Woods DA, Burge PD. Initial treatment of closed metacarpal fractures: a controlled comparison of compression glove
    and splintage. J Hand Surg Br. 1994; 19(5):597600.
    Hansen PB, Hansen TB. The treatment of fractures of the ring and little metacarpal necks: a prospective randomized study of three
    different types of treatment. J Hand Surg Br. 1998; 23(2):245247.
    Kuokkanen HO, Mulari-Keranen SK, Niskanen RO, Haapala JK, Korkala OL. Treatment of subcapital fractures of the fifth metacarpal
    bone: a prospective randomised comparison between functional treatment and reposition and splinting. Scand J Plast Reconstr Surg
    Hand Surg. 1999; 33(3):315317.
    Lowdon IM: Fractures of the metacarpal neck of the little finger, Injury 17:189-192, 1986.
    Ozturk I, Erturer E, Sahin F, et al. Effects of fusion angle on functional results following non- operative treatment for fracture of the
    neck of the fifth metacarpal. Injury. 2008; 39(12):1464 1466
    Treatment
    1st: Avoid excessive or non-adapted immobilisation !

    Real life !
    Functional treatment
    No attempt at reduction
    Immobilization in the intrinsic position for 2 weeks is
    recommended but we disagree (a protection shell is enough)
    Buddy taping +++ for 3-4 weeks
    There is no benefit to reduction and splint immobilization of closed
    boxer's fractures with initial angulation of less than 70.
    Soft wrap without reduction was generally favored in terms of MCPJ
    ROM, strength, and swelling. Outcomes were generally equivalent in
    terms of pain and tenderness, fracture healing, patient satisfaction, and
    return to work (Dunn, literature review).
    Dunn JC et al. The Boxer's Fracture: Splint Immobilization Is Not Necessary. Orthopedics 2016; 39(3):188-192
    The protection shell we recommend
    (as many others do), molded over the
    metacarpal heads and reproducing
    the metacarpal arch

    Literature recommended
    position of immobilisation
    Reduction and nonoperative treatment
    Jahss maneuver:
    1st axial traction to displace the fracture,
    2nd flexion 90 both MCP and PIP
    (relaxation of the deforming intrinsic
    muscles and tightening of collateral
    ligaments),
    3rd simultaneous dorsally directed
    pressure of the flexed phalanx and
    downward directed pressure over the
    metacarpal.
    Should be done before D7-D10, otherwise
    less successful
    Jahss SA. Fracture of the metacarpals: a new method of reduction and immobilization. JBJS 1938; 20(1):178-186.
    Jahss Maneuver
    Reduction and non-operative treatment

    Immobilization in the intrinsic position for


    2-4 weeks + Buddy taping
    HOWEVER
    no need to immobilize the PIP joint
    Closed reduction and splint immobilization of
    fifth metacarpal neck fractures was not an effective
    means of maintaining a significant improvement
    in fracture alignment upon healing (Page).

    Pace GI et al. The Effect of Closed Reduction of Small Finger Metacarpal Neck Fractures on the Ultimate Angular Deformity. J
    Hand Surg Am 2015;40(8):1582-1585
    If fracture reduction is chosen, fixation is needed

    Percutaneous +++, many techniques


    ORIF (rare)
    Indications: Rotational deformity, pseudo
    clawing, severe comminution, multiple
    adjacent fractures, open fractures
    Distal retrograde K-wire fixation seems to be less efficient and is not recommended
    Transverse pinning with one K-wire proximal and two distal (when possible)
    Transverse pinning is easier to perform on extreme
    metacarpals (2nd and 5th)
    Axial pinning

    Designed to avoid
    complications such as infection
    (septic arthritis in the distal K-
    wire is intra-capsular)
    and to allow immediate
    mobilisation
    With three 8/100 pre-bended
    k-wires

    Foucher G. "Bouquet" osteosynthesis in metacarpal neck fractures: a series of 66 patients. J Hand Surg Am. 1995;20(3
    Pt 2):S86-90.
    Beware of the dorsal branch of the ulnar nerve !
    Variations: a single 18/100 K-wire
    Combination of techniques to correct an inadequate retrograde pinning. Reduction is
    better but the small k-wires have perforated the metacarpal head.
    Which technique of percutaneous fixation ?

    No significant difference between transverse pinning and


    intramedullary fixation in regards to post-op function, pain,
    ROM or grip strength (Wong, Sletten)
    Anterograde IM nailing tends toward better pain scores, grips
    strength and ROM (Yammine)
    Complications: metacarpal shortening, rotational malignement,
    pin migration, articular surface damage and neuritis.

    Wong TC et al.: Comparison between percutaneous transverse fixation and intramedullary K-wires in treating closed
    fractures of the metacarpal neck of the little finger. J Hand Surg 2006;31B:61-65
    Sletten IN 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 2012;37E:387-395.
    Yammine K et a;. Antegrade intramedullary nailing for fifth metacarpal neck fractures: a systematic review and meta-
    analysis. Eur J Orthop Surg Traumatol 2014;24:273-278
    ORIF
    Rare indications as there is a lack of
    bone on the epiphyseal side - functional
    results inferior to K-wire (Facca)
    Headless screws have been proposed

    Facca et al. Fifth metacarpal neck fracture fixation: locking plate versus k-Wire ?. OTSR 2010; 96:506-512.
    Boulton CL et al. Intramedullary Cannulated Headless Screw Fixation of a Comminuted Subcapital Metacarpal Fracture:
    Case Report. J Hand Surg 2010; 35A:12601263.
    ORIF with headless screws
    69 cases (48 metacarpal #)
    A 0.5- to 1-cm transverse incision and the
    extensor tendon opened longitudinally in
    the midline.
    3.0-mm-diameter screws
    100% healing. At 19 months FU, TAM was
    249
    Screw hole represents around 10-13% of
    the articular surface (compare to 1.3% for
    a K-wire).
    Contraindicated if severe comminution or
    long oblique #

    Del Pinal F et al. Minimally Invasive Fixation of Fractures of the Phalanges and Metacarpals With Intramedullary Cannulated Headless
    Compression Screws. J Hand Surg Am. 2015;40(4):692-700.
    ten Berg PWL et al. Quantitative 3-dimensional CT analyses of intramedullary headless screw fixation for metacarpal neck fractures. J
    Hand Surg 2013;38:322-330
    Rehabilitation ?

    No evidence-based rehabilitation regiments published


    Early motion is favored
    Night extension splint (Del Pinal)
    Expected follow-up ?
    Porter studied small finger metacarpal neck fractures and observed 100% attendance at
    the first follow-up for plaster removal 3 weeks after injury, 76% attendance 2 weeks
    after plaster removal, and 38% attendance at the third follow-up visit 2 months after
    cast removal.
    In a cohort of 335 patients (228 men and 107 women) with a mean age of 40 years
    (range, 18 88 y), independent factors associated with non-attendance were unmarried
    status (single or divorced), having no insurance, having an unemployed or disabled
    status, having an unknown work status, and having a small finger metacarpal neck
    fracture. All of these factors are considered measures of social deprivation, meaning
    exclusion from society via factors such as poverty or socioeconomic status, limited
    education, and mental illness (Ten Berg).
    The national figure for nonattendance at out-patient clinics in the United Kingdom is
    12%

    Porter ML, Hodgkinson JP, Hirst P, Wharton MR, Cunliffe M. The boxers fracture: a prospective study of functional recovery.
    Arch Emerg Med 1988;5:212215.
    ten Berg PWL et al. Patients Lost to Follow-Up After Metacarpal Fractures. J Hand Surg 2012;37A: 42-46
    Conclusion
    In displaced M2M3 neck fractures, surgical indications
    are frequent +++
    In (frequently) non-compliant patients indications for
    reduction and fixation of fifth metacarpal neck fractures
    should be discussed from case to case
    No technique has proven superior. Use the one you are
    familiar with
    Headless screws may help

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