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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