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Metacarpal shaft Christian Dumontier, MD

,
PhD

fractures
Centre de la main,
Guadeloupe

Presentation is available on www.diuchirurgiemain.org
Clinical case
Metacarpal fractures

❖ Frequent fractures
❖ ≈ 18% of hand and forearm
fractures,
❖ ≈ 30% of hand fractures
❖ Peak incidence: 15-24 years old
Fracture patterns depend of the mechanism of injury

❖ Transverse ➡ direct blow ➡
displace in flexion
❖ Spiral ➡ twisting injury ➡
rotational deformity
❖ Comminuted and oblique ➡
axial load with torsional or
bending forces ➡ shortening
and angular deformity
X-rays

Same patient

❖ AP and lateral views + oblique
❖ 30° pronated for index and
middle
❖ 30° supinated for ring and little
1st take home message: Most metacarpal fractures are non-
displaced and treated conservatively +++

❖ In athletes, 82% of the fractures
were minimally displaced or
nondisplaced,
❖ Average time lost from practice or
competition was 13.7 days

Rettig AC et al: Metacarpal fractures in the athlete, Am J Sports Med 1989;17:567-572.
Goals of treatment

❖ Allow healing in an anatomical
position
❖ That restores the longitudinal
and transverse concavity of the
hand
Conservative treatment ?
❖ Avoid reduction and conservative treatment as maintaining the fracture is difficult
❖ Most metacarpal shaft fractures are non or moderately displaced and inherently
stable and can be treated conservatively with acceptable functional outcomes.
❖ Khan and Giddins (in press) have shown that all spiral metacarpal fractures, even
in the presence of mal-rotation, can be treated non-operatively with very good
outcomes and minimal morbidity.
❖ Patients had to make a fist at the first outpatient visit to correct any malrotation
and ensure early mobilization.
❖ Of 30 patients, 25 were reviewed at a minimum follow-up of 6 months.
❖ They had full movement, grip strength of at least 90% of the other hand and
only minimal malrotation in one patient and mild discomfort in another.

Giddins GEB. The non-operative management of hand fractures. J Hand Surg Eur 2015; 40(1):33-41
Non-operative treatment
❖ Immobilization 3-4 weeks
(radiological healing may
take 6-8 weeks)
❖ Intrinsic position is
recommended in literature
(claw-digger cast)
❖ We recommend protection
shell and buddy taping (as
Tavassoli)
Conservative treatment

❖ Retrospective study of 263 patients comparing three
casting techniques,
❖ MP joints in flexion or extension or the IP joints free or
immobilized resulted in no difference in motion, grip
strength, or fracture alignment.
❖ They recommended immobilizing the MP joints in
extension and allowing full motion of the IP joints.

Tavassoli J et al: Three cast techniques for the treatment of extra-articular metacarpal fractures: comparison of short-term
outcomes and final fracture alignments, J Bone Joint Surg Am 2005;87:2196-2201
Surgical indications

❖ Non tolerable displaced fractures
❖ Open fractures
❖ Multiple fractures
Displaced fractures ?

❖ Rotation deformity induces
finger scissoring and cannot be
tolerated
❖ The more proximal the
fracture, the more the
angulation is amplified distally
(1° of rotation in the
metacarpal, results in 5° in the
fingertip)
Displaced fractures ?
❖ Shortening is appreciated by
drawing Chmell line on plain X-
rays
Displaced fractures: shortening
❖ Shortening can be functionally
tolerated but leaves the patient
with the disappearance of
prominence of metacarpal
head
❖ 7° of extensor lag for every 2
mm shortening
❖ Some consider a 3 mm
shortening an absolute
indication for surgery. Others
that 5 mm is not significant
Strauch RJ et al. Metacarpal shaft fractures. The effect of shortening on the extensor tendon mechanism. J Hand Surg
1998;23A:519-523.
Wills J et al. The effect of metacarpal shortening on digital flexion force. J Hand Surg Eur. 2013, 38: 667–72.
Displaced fractures : volar angulation ?

❖ Angulation < 10° is accepted
for M2M3 and up to 20° for
M4M5 for shaft fractures (≠
neck fractures)
❖ Angulation leads to loss of
flexor tendon efficiency
(excursion, load and work
requirements) as well as loss of
strength and range of motion

Birndorf MS et al. Metacarpal fracture angulation decreases flexor mechanical efficiency in human hands. PRS 1997; 99:1079-1085
Surgical treatment

❖ Per-cutaneous
❖ ORIF
❖ Metacarpals are triangular in transverse section with
a thinner flat dorsal surface and a thicker apex
pointed palmar ☞ plates will be placed dorsally

❖ Ex-Fix
Per-cutaneous fixation
❖ Complication rate ≈ 15-20%
❖ Many configurations proposed:
❖ Crossed K-wires are more rigid in transverse fracture
❖ Oblique pin configuration in oblique patterns.
❖ Intra-medullary nailing is also effective
❖ Transverse fixation on the adjacent metacarpal (1 k-wire
proximal, 2 k-Wires distal) is useful for index and little
finger
Stahl S et al. Complications of K-wire fixation of fractures and dislocations in the hand and
wrist. Arch Orthop Trauma Surg. 2001;121:527-530
Case Dr Polveche, Lille
Open surgical treatment

❖ Interfragmentary screws (at
least 2) for long oblique pattern
(screws ≥ 2 mm diameter)
❖ Dorsal plating
To avoid fragmentation, the screw hole should be a minimum of two screw diameters
from the fracture margin.
Shaft fracture of the fifth finger - use of a long plate due to multiple fracture lines
Multiple fractures should be surgically fixed
to allow for immediate mobilisation
Case Dr Polveche, Lille of
multiple fractures treated
with a combination of
techniques
Functional
outcome case Dr
Polveche
Outcomes of ORIF
❖ Major complications were encountered in 36% of fractures,
especially with phalangeal and open fractures.
❖ Complications included stiffness, nonunion, plate
prominence, infection, and tendon rupture.
❖ Forty-eight of 63 (76%) metacarpal fractures and 44 of 66
(67%) closed fractures had a final range of motion greater
than 220~240°
❖ To date, no series has proven surgery to do better than
conservative treatments
Page SM et al. Complications and range of motion following Plate Fixation of Metacarpal and
Phalangeal Fracture. J Hand Surg 1998;23A:827-832.
Conclusion

❖ Most fractures are stable or can be stabilized and
conservative treatment is the goal
❖ Multiple fractures should be treated operatively to
allow for immediate mobilisation, in order to limit the
hand swelling which is responsible for finger stiffness