Rev. bras. ortop. vol.49 número2

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Original

Article

Intra-focal

reduction

and

percutaneous

fixation

of

neck

fractures

of

the

fifth

metacarpal:

description

of

surgical

technique

夽

,

夽夽

Gustavo

Pacheco

Martins

Ferreira

_,

_Paulo

_Randal

_Pires

_,

_André

_Lopes

_Portugal

_,

Henrique

de

Gouvêa

Schneiter

b_{HospitalRisoletaTolentinoNeves,BeloHorizonte,MG,Brazil}

c_{HospitalEládioLasserre,Cajazeiras,Salvador,BA,Brazil}

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Articlehistory:

Received11December2012 Accepted7May2013

Availableonline27March2014

Keywords:

Metacarpal Bonefractures Upperlimb BoneWires

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Objective:to demonstrate a surgical technique for treating neck fractures of the fifth metacarpal,bymeansofreductionthroughintra-focalmanipulationandpercutaneous fix-ationusingKirschnerwires,withtheaimsofmakingiteasiertoachieveandmaintainthe reductionduringtheoperationandenablingreductionofthesefracturesevenifafibrous callushasformed.

Methods:aseriesoftenpatientswithneckfracturesofthefifthmetacarpalpresenting pal-maranglesgreaterthan30◦_{underwentthesurgicaltechniquedescribed,asexamples,and}

theirresultswereevaluatedthroughpostoperativeradiographsandclinicalexaminations.

Results:allthepatientsachievedreductionsthatwereclosetoanatomicalandevolvedto consolidationofthefractureinthepositionobtained.

Conclusion:thesurgicaltechniquedescribediseffective,easytocarryout,minimally inva-siveandlow-cost,therebyenablingadequateclinicalandradiographicreduction,evenin subacutefracturesalreadypresentingafibrouscallus.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Reduc¸ão

intrafocal

e

fixac¸ão

percutânea

das

fraturas

do

colo

do

quinto

metacarpo

–

descric¸ão

de

técnica

cirúrgica

Palavras-chave:

Metacarpo Fraturasósseas Membrosuperior Fiosortopédicos

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e

s

u

m

o

Objetivo:demonstrarumatécnicacirúrgicaparaotratamentodasfraturasdocolodoquinto metacarpopormeiodereduc¸ãopormanipulac¸ãointrafocalefixac¸ãopercutâneacomfios deKirschner,visandoafacilitaraobtenc¸ãoemanutenc¸ãodareduc¸ãonointraoperatórioe possibilitarareduc¸ãodessasfraturas,aindaquecomcalofibrosoformado.

夽

Pleasecitethisarticleas:FerreiraGPM,PiresPR,PortugalAL,Schneiter,HG.Reduc¸ãointrafocalefixac¸ãopercutâneadasfraturasdo colodoquintometacarpo–descric¸ãodetécnicacirúrgica.RevBrasOrtop.2014;49:116–120.

夽夽

WorkperformedatHospitalMariaAméliaLins,BeloHorizonte,MG,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](G.P.M.Ferreira).

2255-4971/$–seefrontmatter©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

Métodos: dezpacientesportadoresdefraturadocolodoquintometacarpocomangulac¸ão palmarsuperiora30◦_{foramsubmetidos,comoexemplos,àtécnicacirúrgicadescrita.Os}

resultadosforamavaliadospormeioderadiografiaseexameclínicopós-operatório.

Resultados: todosospacientesobtiveramreduc¸ãopróximadaanatômicaeevoluírampara consolidac¸ãodafraturanaposic¸ãoobtida.

Conclusão:atécnicacirúrgicadescritaéeficaz,desimplesexecuc¸ão,minimamenteinvasiva, debaixocustoepermitereduc¸ãoclínicaeradiográficaadequadas,mesmoem fraturas subagudascomcalofibrosoformado.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Fractures of the neck of the fifth metacarpal generally result from an axial impact mechanism on the head of the metacarpal with the fist closed. For this reason, they are known as boxer’s fractures, even though they only rarelyoccuramongprofessionalpugilists.1–4_{Thesefractures}

generallypresentpalmarangulationbecauseofthe deform-ing force of the interosseous muscles and comminution ofthe volarcortex,withconsequent instability.4 _Asagittal

angle greater than 30◦ _{or shortening of more than 5mm}

is associated with alteration of the biomechanics of the flexor system and may lead to dysfunction. Presence of rotationaldeviationgreaterthan5◦ _mayleadto

superimpo-sition ofthe affected ray, with obstruction ofthe adjacent fingers.1,2,4,5

In1938,Jahss6_{describedamaneuverforreducingfractures}

ofthemetacarpals withpalmar displacementthat became establishedboth forconservative treatment and for main-tainingthereductionduringsurgicalfixation.However,this maneuverrequiresanassistanttomaintainthereduction dur-ingtheoperation,whichalsoaddsdifficultytopercutaneous insertionoftheKirschnerwiresunderradioscopybecausethe assistant’sandthepatient’shandsoverlapandalsobecause thereductionoftenbecomeslostifthereisanymovementof thehand.Furthermore,themaneuverisincapableofreducing subacutefractureswithafibrouscallusalreadyformed,which typicallyoccursafter7–10days.

In1987,Kapandji7_{describedanewtechniqueforreduction}

andintrafocalfixationoffracturesofthedistalradius.Because ofthesuccessofthistechnique,itbecameestablishedandwas extrapolatedfortreatingseveraltypesoffracture.Thisserved asmotivationforapplicationtofracturesoftheneckofthe fifthmetacarpal.

Inthepresentstudy,atechniqueforintrafocalreduction andpercutaneousfixationwithKirschnerwiresfortreating fracturesoftheneckofthefifthmetacarpalisdescribed,the radiographicresultsobtainedarepresentedand the advan-tagesofthistechniquearediscussed.

Materials

and

methods

BetweenSeptemberandOctober2012,tenpatientswithneck fracturesofthefifthmetacarpalweretreatedsurgicallyusing thetechniquedescribed, andthe radiographicresultswere

Fig.1–Measurementoffracturedisplacementangle.

recorded todemonstratetheefficacy ofthetechnique.The othercharacteristicsofthepatientsaredescribedinTable1.

All the patients were operated by a single professional hand surgeon. Theinclusion criteria were as follows: frac-turewithvolardisplacementinthesagittalplanegreaterthan 30◦ _{and/orrotationaldisplacement greaterthan 5}◦ _on

clin-icalexamination; andlength ofevolutionafterthe trauma ofbetween1and21days.Theexclusioncriteriawere skele-tal immaturity,exposedfracture, previousfracturing ofthe fifthmetacarpal and fracturing extendingtothe joint.The preoperativeandpostoperativedisplacementsofthefracture weremeasuredonradiographsinposteroanteriorandoblique (semipronatedat30◦_{)viewsoftheaffectedhand,bymeansof}

astandardmethodfordeterminationoftheanatomicalaxis. Theangleswere measuredusingtheAdobePhotoshopCS3 Extended10.0software(Fig.1).

Descriptionofthetechnique

Table1–Patients’characteristics.

Patient Sex Age Palmarangulation Rotation Lengthofevolution(days)

1 M 27 56.9 No 15

2 M 36 32.8 No 20

3 M 18 42.1 No 10

4 M 19 55.9 No 15

5 M 19 42.8 No 17

6 M 18 64.1 No 5

7 M 30 59.6 No 21

8 M 19 49.4 No 19

9 M 19 50.2 No 14

10 M 22 49.2 No 9

Mean=22.7 Mean=50.3◦ _Mean=14.5

Fig.2–Introductionoftheintrafocalwire.Positionconfirmedbymeansofradioscopy.

Fig.3–Reductionofthefracture.

Fig.4–Mobilityofthemetacarpophalangealjointwithoutlossofreduction.

metacarpalspresentsubcutaneouslocationsonthedorsumof thehand(Fig.3).Maintainingthewireinthispositionenabled metacarpophalangealjointmobilitywithoutlossofthe reduc-tion,which facilitatedevaluation ofthe possiblerotational

Fig.5–Fixationofthefracture.

anchoredatthebaseofthemetacarpalforbetterstabilization ofthefixation(Fig.5)and wereleftprotrudingthroughthe skinwiththepointsfoldedover.

Afterfixation,radiographswereproducedin posteroante-rior,lateralandoblique(semipronatedat30◦_{)viewsinorderto}

measuretheanglesobtained.Thepatientswerethen immobi-lizedbymeansofashortulnarplastercastsplintthatcovered the fourthand fifthfingers inintrinsic-plus position.They weredischargedfrom hospitalafterrecoveryfrom anesthe-sia,withaprescription foranalgesicstouse athome.The Kirschnerwireswereremovedasanoutpatientprocedurein thefourthweekandthepatientswerethenreferredforhand therapy. In the sixth postoperative week, newradiographs wereproducedinordertomeasuretheanglesandassessthe radiographicconsolidation.

Results

Allthepatientsachievedangulationoflessthan30◦_onthe

oblique radiograph semipronated at 30◦ _{in the immediate}

postoperativeperiod. Noneofthe casespresentedresidual angulationinthecoronalplane,malrotationorshorteningin theclinicalorradiographicexamination.Themeanlengthof follow-upwas184.9days(minimumof169)(Table2).Innone ofthecaseswasconversiontoopensurgerynecessary.

Inallcases,theradiographobtainedinthesixth postopera-tiveweekshowedradiographicconsolidationwithouttheloss ofthereductionthatwasinitiallyobtained.Nocomplications suchashyper-reduction,translationaldisplacement,increase

inthefractureline,extensorinjuryorinfectiononthepaths oftheKirschnerwireswereobserved.

Discussion

Fracturesoftheneckofthefifthmetacarpalareamongthe onesmostcommonly treatedbytraumatologistsand hand surgeons.Althoughthereisnoconsensusregardingwhatthe acceptable volarangulation ofthese fractures is,and even thoughsomeauthorshaveacceptedangulationofupto70◦

inthesagittalplaneinsedentarypatients,thereisevidence ofvariabledegreesofdysfunctionatangulationsgreaterthan 30◦_{,albeit thatinsomecasesthe functional deficitis}

sub-jectiveandpoorlyassessedbythefunctionalquestionnaires currentlyinuse.1,2,4,5 _{Thereisnodoubtthatmanyofthese}

fractures canbe treatedconservatively.However,reduction as close as possible to the anatomical position should be sought,especiallyduringsurgicaltreatment,butminimizing theadditionaltraumatotheadjacentsofttissuesandtheir complications.

Thereisnoconsensusregardingthebestwaytomeasure theanglesonradiographs.Somestudieshaveshownlowto moderate degrees ofintra-and inter-observerconcordance formethodsofdeterminingtheanatomicalaxis(medullary canal)andthelinestangentialtothedorsalcorticalbone.1,3,8

Anatomicalobservationshaveshownthatthemetacarpalsare notrectilinear,butpresentwide-radiuscurvaturealongtheir axisinthesagittalplane,withvolarconcavity,andanormal angleofaround15◦_{betweentheneckandthediaphysis.Thus,}

Table2–Radiographicresultsobtained.

Patient Preoperativepalmar

angulation

Postoperativepalmar angulation

Degreeofcorrection obtained(%)

Lengthoffollow-up (days)

1 56.9 8.7 84.7 201

2 32.8 16.3 50.3 199

3 42.1 12.7 69.8 170

4 55.9 0 100 178

5 42.8 0 100 188

6 64.1 4.9 92.4 169

7 59.6 0 100 189

8 49.4 6.9 86 171

9 50.2 3.3 93.4 194

10 49.2 17 65.4 190

measurementbymeansoflinestangentialtothedorsal cor-ticalbonetendstooverestimatethedisplacementangleand becomesparticularlydifficultinfracturesthataremoredistal, becauseoftheellipticalshapeofthemetacarpalhead,andin lateralprojection,becauseoftheoverlappingofimagesfrom theothermetacarpals.8

Measurement ofthe anglefrom the anatomical axis in obliqueprojection,semipronatedat30◦_{,waschosenbecause}

oftheease ofidentifyingthemedullarycanalofthe proxi-malfragmentofthemetacarpalandbetterevaluationofthe fractureline,withoutoverlappingofimagesfromtheother metacarpals, which enables measurements that are more reproducible. Oblique view tend to underestimate the real angleofthefracture,butitisknownthatthemaximum dif-ferenceis4◦_{intheobliqueprojectionat30}◦_{inrelationtothe}

absoluteprofile.9

ThemaneuverdescribedbyJahssin1938wasdestinedfor conservative treatmentof thesefractures but, despite pro-motingsatisfactoryreductioninacutecases,theseunstable fracturesalmostinvariablyconsolidatewithsomedegreeof lossofthereductionthatwasinitiallyobtained.1,4,6,8_During

thesurgicalprocedure, wealsoobservedthatthereduction obtained through the maneuver was difficult to maintain becauseittendedtobecomelostthroughmovementofthe patient’shandintheoperatingfield.Anassistantwasneeded inordertoperformthemaneuverandmaintaintheposition throughoutthefixation,withtheinconvenienceof overlap-pingoftheimagesofthepatient’shandandtheassistant’s handintheradioscopy,aswellastheexposureofthe assis-tant’shandstoradiation.Lastly,incasesthathaveevolvedfor morethan7–10days,eitherinpatientswhohaveundergone anattempttoprovideconservativetreatmentandmayhave evolvedtolossofthereduction,orincasesofdelayed sur-gicaltreatment,themaneuverisnotcapableofreducingthe fracture.Insuchcases,openreductionandfixationwith mini-platesandscrewsorwithKirschnerwireswillbenecessary, i.e.surgeryoflargerscale,highercostandgreater potential forcomplications,particularlyadherencesoftheextensor ten-donsandjointcontracturesthatleadtolossofmovement.

Thetechniquedescribedinthe presentstudy iseasy to performandcanevenbedonewithoutanassistant.Itenables adequatefracturereduction,independentofthedegreeof dis-placementinthesagittal andcoronalplanes.In casesthat haveevolvedfor7–21days,reductionisstillpossiblebecause oftheleverageforcethatisapplieddirectlytothedistal frag-ment, and the principles and advantages ofpercutaneous surgeryaremaintained.Thesurgeon’shandscanbekeptout oftheirradiationbandwhileobtainingintraoperative radio-scopicimages,withoutlossofreduction,therebyminimizing theexposuretoradiation.

WeonlyusedKirschnerwiresasthe implant:theseare widelyavailableand havealowcost.Wechosetoperform fixationusingcrossedwiresinaretrogrademanner,withan entrypointintheextra-articularpartofthemetacarpalhead, soasnottoblockmovement.However,thesamereduction techniquecan beused forfixation withlongitudinal wires (intramedullary)ortransversewires(anchoredinthefourth metacarpal),asdescribedbyGallanakisetal.10_{Sofar,thereis}

nodefinitiveevidencetoshowthatonemethodisbetterthan theothers.1–4

Theaimofthisstudywastogiveexamplesand demon-stratethesurgicaltechnique,andforthisreason,thesample was limited toten patients.We believethat thelong-term results would be equivalent to those from traditional sur-gical treatmentinacutecases,sincetheadditionaltrauma is negligible and the postoperative approach is the same. Subacutecaseswithoutthepossibilityofreductionthrough a closed maneuver may benefit from intrafocal reduction because of the lower aggressiveness and morbidity of the procedure, inrelation to open reduction. New studies will be necessary to verify possible changes in the functional results.

Conclusion

Thesurgicaltechniqueofintrafocalmanipulationand percu-taneousfixationdescribedherefortreatingneckfracturesof thefifthmetacarpaliseasytoperformandenablesclinical sat-isfactoryclinicalandradiographicreductionevenforsubacute fractureswithafibrouscallusalreadyformed.Itisminimally invasive,hasalowcostandbecomesanoptionfortreating thesefractures.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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