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Extraarticular Hand Fractures in Adults: A Review of New Developments

Freeland, Alan, E*; Orbay, Jorge, L

Section Editor(s): Meals, Roy A MD, Guest Editor; Harness, Neil G MD, Guest Editor

Clinical Orthopaedics and Related Research: April 2006 - Volume 445 - Issue - p 133-145
doi: 10.1097/01.blo.0000205888.04200.c5
SECTION I: SYMPOSIUM: Problem Fractures of the Hand and Wrist
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This report cites new developments in the treatment of extra-articular hand fractures in adults. Recent reports confirm that small amounts of metacarpal shortening or dorsal angulation cause minimal functional impairment. Unilateral excision of the lateral band and oblique fibers of the extensor apparatus of the metacarpophalangeal joint facilitates proximal phalangeal fracture exposure and may improve functional recovery. Results using open mini screw fixation of oblique extra-articular metacarpal and phalangeal fractures may be comparable to those of percutaneous Kirschner wire fixation. Bicortical self-tapping mini screw fixation of extra-articular oblique metacarpal and phalangeal fractures simplifies screw insertion and provides stability comparable to that of fractures fixed with lag screws. Percutaneous intramedullary wire fixation may afford suitable fixation for unstable extra-articular oblique as well as transverse metacarpal fractures. Locked intramedullary nails may offer similar advantages. Unicortical screw fixation of mini plates securing transverse extra-articular metacarpal fractures affords stability comparable to that of bicortical screw fixation while creating less bone damage. The dissection required for plate fixation and the small surface area of transverse fractures delay and occasionally impair bone healing. Primary bone grafting of diaphyseal defects in clean stable wounds may shorten and simplify treatment and decrease morbidity. As little as 1.7 mm of flexor tendon excursion during the first 4 weeks after reduction or repair may substantially diminish peritendonous adhesions at the fracture site. Synchronous wrist and digital exercises may also reduce peritendonous fracture adhesions. Early motion of adjacent joints in closed simple metacarpal fractures expedites recovery of motion and strength without adversely affecting fracture alignment and leads to earlier return to work.

Level of Evidence: Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.

*From the Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS; and †the Miami Hand Center, Miami, Florida.

One or more of the authors (AEF, JLO) have received funding from AO North America and Hand Innovations.

Correspondence to: Alan E. Freeland, MD, Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS 39216. Phone: 601-815-1220; Fax: 601-815-1223; E-mail: afreeland@orthopedics.umsmed.edu.

Since the emergence of the modern era of hand fracture treatment after World War II, there has been an accelerated, indeed exponential, advancement in the understanding of the molecular, biochemical, biologic, and biomechanical aspects of fracture healing with and without internal fixation.13,26,78,91 A previously unparalleled technological explosion of implants, instruments, operative techniques, and hand therapy advances designed to assure fracture healing and functional recovery has ensued.34,66,92 Biomedical engineers and physicians continue to improve the design, biomechanics, surfaces, material composition, and application of noncorrosive mini-implants to create more secure, reliable, and safer hand fracture fixation. We continue to learn more about the safety and efficacy of surgical approaches and wound treatment. Nevertheless, the treatment of extra-articular hand fractures remains challenging and fraught with hazards. Fibroplasia, the development of scar tissue, and the risk of stiffness remain constant obstacles to the successful operative treatment of hand fractures, especially those of the proximal phalanges of the fingers.

We are now entering a new era in clinical studies that encompasses a renaissance of the application of scientific methodology, biostatistics, and evidence-based analysis of treatment options to better define risks and benefits and study validity.5,7,11,32,61,62,69,86 We are increasingly recognizing the importance of patient outcome studies and cost effectiveness (without compromise of treatment excellence) as guidelines for our decisions and part of our responsibility to individual patients, society, and health care centers, insurers, and administrators.8,53,59,89 All parties will be better informed without sacrifice of patient and physician autonomy, values, and preferences. Study designs for future research should be enhanced.

We asked what is new and of value in advancing the hand surgeon's knowledge of the treatment of extra-articular hand fractures. We performed a cross-referenced Medline review of hand fractures and selected articles from 1999 foreword that we believed represented significant advances in the field of hand fracture treatment. Small increments of metacarpal shortening or dorsal angulation cause minimal functional impairment.2,73 Unilateral excision of the lateral band and oblique fibers of the extensor apparatus of the metacarpophalangeal joint facilitates proximal phalangeal fracture exposure and may improve functional recovery.57 Results using open mini screw fixation of oblique extra-articular metacarpal and phalangeal fractures may be comparable to those of percutaneous Kirschner wire fixation.19,57 Bicortical self-tapping mini screw fixation of extra-articular oblique metacarpal and phalangeal fractures simplifies screw insertion and provides stability comparable to that of similar fractures fixed with lag screws.84 Percutaneous intramedullary wire fixation may provide suitable fixation for unstable extra-articular oblique as well as transverse metacarpal fractures.27 Locked intramedullary nails may offer similar advantages.75 These findings may ultimately apply to similar extra-articular phalangeal fractures. Unicortical screw fixation of mini plates securing transverse extra-articular metacarpal fractures affords stability comparable to that of mini plates secured with bicortical screws while creating less bone damage.20 The dissection required for plate fixation and the small surface area of transverse fractures delay and occasionally impair bone healing.17,42 Primary bone grafting of diaphyseal defects in clean stable wounds may shorten and simplify treatment and decrease morbidity.90 Early motion of adjacent joints in closed simple metacarpal fractures may expedite recovery of motion and strength without adversely affecting fracture alignment and leads to earlier return to work.28

We also performed a Medline review of flexor tendon injuries owing to the similarity of rehabilitation challenges in managing flexor tendon lacerations within the tendon sheaths and proximal phalangeal fractures. Important recent contributions are cited. As little as 1.7 mm of flexor tendon excursion during the first 4 weeks after reduction or repair may substantially diminish adverse peritendonous adhesions at the fracture site.88 Synchronous wrist and digital exercises may also reduce peritendonous fracture adhesions and enhance the recovery of digital motion, especially proximal interphalangeal joint extension.101

Although our review was not comprehensive and does reflect our bias, we hope readers will find our discussion informative. This review may be distinguished from other journal reviews and chapters in textbooks or monographs by our emphasis on new developments and comments regarding study design.

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Principles

The final outcome of hand fractures correlates most highly with initial injury severity.15,16,21,45,58,63,80,81,94,96 Injury adjacent to the finger flexor tendon sheaths; articular injury; comminution; crush; soft tissue wounding, especially complex injuries; bone loss; additional operative dissection; delay of treatment; and even the implants themselves may confound treatment. The past six decades have witnessed an effort to blend and balance fracture treatment principles into relative, if not absolute, guidelines that will assist physicians in making decisions leading to optimal results. Anatomic or near anatomic hand fracture restoration; minimally traumatic treatment relative to the magnitude of the injury; hand elevation to treat edema; and adequate stability to control pain, allow reliable fracture healing, serve as a platform for soft tissue repair and reconstruction when necessary, and permit early active functional recovery are key doctrines.34,35,55,94 Even these canons may warrant challenge or further elucidation. The timing of patient presentation; individual patient needs, preferences, and compliance; and physician judgment often enter into the equation.

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Treatment Options

Nonoperative Treatment

Hand surgeons have long recognized the risks of fibroplasia and scar generation and the penalty of digital stiffness resulting from open surgical treatment of closed hand fractures, particularly in fractures adjacent to the flexor tendon sheaths (“no man's land”), and have admonished against injudicious open surgical procedures.3,14,71,92 A majority of extra-articular hand fractures are closed, simple, undisplaced or minimally displaced, and stable, and may be safely and effectively treated by minimal protective splinting and early motion.3,23,28,35,55,71,83

Alterations of bone anatomy may affect functional outcome commensurate with their severity. Shortening, angulation, and rotation are the principal elements of deformity and may be seen individually or in combination. Although a perfect reduction is of course ideal, the hand and digits have a remarkable capacity for functional adaptation to and tolerance of small and sometimes even significant degrees of fracture deformity. Previous reports have illuminated some of the correlations between deformity and functional loss and may help the physician to decide whether to accept or correct a residual deformity.1,9,18,70,97

Up to 7° of extensor lag develops for each 2 mm of residual finger metacarpal shortening.93 The intermetacarpal ligaments usually prevent greater than 3 to 4 mm of metacarpal shortening.25 Internal metacarpals (third and fourth metacarpals) have more restraint than do border metacarpals (second and fifth metacarpals) because they are anchored on both sides of the metacarpal head. A recent prospective controlled cadaver study demonstrated with good statistical validity that as much as 8% loss of grip power may result from every 2 mm of metacarpal shortening.73 Finger metacarpals may tolerate up to 3 to 4 mm of shortening, sometimes more, with only minimal clinical deformity and functional loss.

Metacarpal shaft fractures tend to angulate dorsally owing to the unbalanced pull of the interosseous muscles and extrinsic finger flexors on the distal fragment. A recent prospective controlled cadaver study has confirmed that intrinsic muscle shortening and altered muscle tension dynamics lead to measurable progressive correlative grip weakness after 30° of dorsal metacarpal angulation.2 Dorsal metacarpal angulation may be compensated to some extent by adjacent carpometacarpal and metacarpophalangeal joint motion. Consequently, dorsal angulation of approximately 10° to 15° greater than the carpometacarpal joint motion of a metacarpal may be tolerated. The ring and small finger metacarpals are more tolerant of dorsal angulation than are those of the index and middle fingers owing to their increased carpometacarpal flexibility. Satisfactory results have been reported by patients with as much as 70° of dorsal angulation of subcapital metacarpal (Boxer's) fractures.60

Physicians must weigh the risk to benefit ratio of non-operative treatment versus operative correction and stabilization for each fracture and deformity. Rotational deformity is poorly tolerated. A few degrees of malrotation may lead to finger impingement or overlap during digital flexion.74,85,87 In individual instances, however, surgeons or patients may choose to accept as much as 3 to 4 mm of metacarpal shortening and/or approximately 30° of dorsal angulation or more as an alternative to the risks accompanying surgical intervention, eg, scarring and stiffness, loss of gainful employment, and other complications. Observation of and discussion with the patient and the timing of presentation may also be critical in the decision-making process. The risk of postoperative digital stiffness may outweigh the benefit of gains in anatomical fracture restoration in instances of minor or intermediate deformities, particularly in late presenting inveterate metacarpal fractures and nascent malunions which have the early formation of callus that prevents closed manipulative fracture reduction (Fig 1).

Fig 1A

Fig 1A

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Minimally Invasive Surgery

Minimally invasive surgery with closed reduction and internal fixation (CRIF) with Kirschner wires for displaced simple extraarticular fractures is relatively atraumatic in comparison to open operative procedures. Wire fixation may be accompanied by less risk of periosteal injury, fragment devascularization, expansion of the zone of injury, and adherent scar formation.3,78 Indirect reduction may be performed by manipulating the displaced distal fragment with digital traction or an intramedullary wire inserted within the distal fragment.

Transverse and short oblique metacarpal and phalangeal fractures may be splinted with single or multiple intramedullary wires46-48,75 (Fig 2). The most technically difficult aspect of intramedullary wire application is often not the insertion of the wire, but rather its passage through the narrow intramedullary isthmus at the fracture site. Occasionally, a small incision at the fracture site is necessary to facilitate reduction and wire passage. Slightly curved flexible intramedullary wires may provide some additional stability for extraarticular hand fractures by creating friction between curved surfaces of the wire and the bone at the isthmus of the osseous canal. Splinting the distal fragment at multiple points under the subchondral bone of the metacarpal head with multiple terminally bent fasciculated intramedullary wires has achieved good results.31,72

Fig 2A

Fig 2A

Flexible bent intramedullary fascicular wires may provide sufficient stability to support oblique fractures. A recent uncontrolled retrospective consecutive case series of 22 metacarpal fractures suggests that transcutaneous intramedullary wire fixation of oblique extra-articular metacarpal shaft fractures wires achieves good results and has few complications.27 Two wires in this series bent at the fracture site resulting in angulation of 20° and one wire had to be removed owing to joint penetration. A current report of a technique for a new flexible intramedullary nail with a proximal locking pin designed to additionally stabilize oblique and comminuted extra-articular metacarpal and phalangeal fractures looks promising, but data are needed75 (Fig 3).

Fig 3A

Fig 3A

Oblique diaphyseal proximal phalangeal fractures may be stabilized with percutaneous transfixation wires4,52,65 (Fig 4). Wire application may be easier in uniplanar oblique fractures than in spiral fractures in which adjustments to the plane of the fracture must be made for each wire that is inserted. The cortical bone surfaces of the phalanges are hard and round. A 14-gauge needle or drill guide may control the wire, prevent slippage, and protect soft tissues at the insertion site.24 Manual or instrument compression of the fracture during wire insertion may prevent distraction at the fracture site. Percutaneous transfixation wires may also be inserted transversely through an intact adjacent metacarpal into one or more of the fragments of an unstable metacarpal fracture to provide fixation.68 Kirschner wire fixation may also be used as a contingency when technical difficulties necessitate abandonment of mini screw or plate fixation.

Fig 4A

Fig 4A

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Open Reduction and Internal Fixation

Open treatment is generally reserved for irreducible closed fractures, multiple displaced unstable hand fractures, displaced unstable hand fractures accompanied by ipsilateral extremity injuries, open fractures, and pathologic fractures29,30,34,36,38 (Figs 5, 6). These fractures constitute only a small number of all hand fractures, but may account for a much larger percentage of hand fractures in a hand specialty practice.3,70,92 Secure stabilization may be advantageous for polytraumatized patients to facilitate activities of daily living, patient handling, transfers, and ambulation. There may be advantages in using secure fixation in unreliable patients.64 Similarly, surgeons may choose to use mini screws or plates in circumstances in which they consider the fracture to be vulnerable to displacement using less stable fixation. The ease and reliable maintenance of anatomic restoration with secure fracture stability throughout the healing process and the opportunity for intensive rehabilitation are relative benefits of an open procedure. Fragment devascularization and an additional risk of stiffness are the principal disadvantages.

Fig 5A

Fig 5A

Fig 6A

Fig 6A

Although adequate fracture exposure is a necessity, the number of incisions and the amount of operative dissection should be minimized whenever possible. Open fractures may often be approached through the wound or by extending the wound.21 It may be prudent to secure the fracture with the most stable available implants that the fracture configuration and operative exposure will allow.

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Mini Screw Fixation

Two or more mini screws may be spaced at intervals to stabilize long oblique fractures whose length equals or exceeds twice the diameter of the adjacent bone34 (Figs 7,8). Mini screws may be conceptualized as small straight Kirschner wires with a head and threads. The screw head buttresses the adjacent cortex while the threads purchase the opposite cortex and enhance stability by compressing the fracture. The mini screws protect each other from shear, rotation, and bending. Mini screws are usually removed only if they become symptomatic. A recent retrospective consecutive case study suggested that bicortical self-tapping mini screw fixation was technically simpler than lag screw fixation of phalangeal and metacarpal fractures and was equally effective.84 All 37 fractures healed by an average of 7 weeks (range, 4-10 weeks) without loss of fixation or malunion.

Fig 7A

Fig 7A

Fig 8A

Fig 8A

A retrospective case study of metacarpal and phalangeal fractures reported better results with open mini screw fixation than with percutaneous Kirschner wires.19 A recent randomized controlled prospective study of 32 patients treated with percutaneous Kirschner wire or open mini screw fixation of oblique extra-articular proximal phalangeal fractures reported no difference between the two groups with regard to outcomes for fracture union, functional recovery, or residual deformity.57 An independent observer assessed the results. Results using mini screws in both of these reports compared favorably with previous reports that had used percutaneous Kirchner wires to repair similar fractures.4,29,52,65,100 Open screw fixation may be as safe and effective as percutaneous pinning for oblique extra-articular hand fractures.

The lateral band and oblique retinacular fibers of the metacarpophalangeal joint extensor expansion were unilaterally excised to facilitate lateral phalangeal exposure in one report.57 This technique may also minimize the risk of intrinsic tendon attrition, scarring, and tightness that may occur with lateral band incision and repair over mini implants. The efficacy of this approach was reported, but not specifically assessed.

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Mini Plate Fixation

Mini plates may provide excellent stability at the fracture site. However, the surgical approach necessary for mini plate fixation may generate additional fibroplasia.21,43,77 Miniplates may also physically restrict digital motion, especially when applied near joint margins.76 A recent prospective controlled study of a comminuted extraarticular animal fracture model also indicated that the dissection required for plate application devascularized adjacent bone and delayed healing as compared to other less invasive methods of treatment.17 Another current retrospective case study of 104 metacarpal fractures pointed out that transverse metacarpal fractures experienced more problems with consolidation than other metacarpal fracture configurations owing to the small surface area of the fracture.42

In open fractures, however; especially those with complex wounds, comminution, and bone loss, priority must often be given to stable anatomic fracture restoration and healing (Fig 9). Mini condylar plates have a fixed angle blade or locking peg that may assist in fracture reduction and support the subchondral metaphyseal bone throughout healing. These plates may be applied dorsally or laterally for juxta-articular fractures12,76 (Fig 10). Unilateral excision of the lateral band and oblique retinacular fibers of the metacarpophalangeal joint extensor expansion may decrease the risk of postoperative adhesions, tissue irritation, and intrinsic tightness when mini condylar plates are inserted on the lateral aspect of the proximal phalanx.40 One retrospective case report noted that micro plates that allowed closure of the dorsal periosteum improved results in phalangeal fractures as compared to plates that restricted periosteal repair.79 A recent prospective randomized controlled study of 18 cadaveric metacarpals noted that unicortical mini screw plate fixation was equally as effective as bicortical fixation in stabilizing metacarpal fractures while being less damaging to the bone.20

Fig 9A

Fig 9A

Fig 10A

Fig 10A

Fracture stabilization, bone grafting when necessary, wound closure or coverage, and the initiation of rehabilitation within 3 days of injury may provide the best opportunity for optimal functional recovery of open hand fractures.44,45 Successful delayed primary bone grafting of open diaphyseal defects has been reported.35,37,45,49 Primary bone grafting may safely expedite the recovery of open hand fractures with bone loss.15,45,49 A contemporary retrospective study of three patients suggests that immediate bone grafting in clean stable wounds may be equally as effective and safe as delayed primary bone grafting.90

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Rehabilitation

Functional recovery and minimizing morbidity are the fundamental goals of rehabilitation.35,55 Early digital motion and tendon gliding exercises are prioritized. Elevation augments digital motion by diminishing and resolving swelling and edema and consequently decreasing resistance to tendon gliding and joint motion.55,56 Progress is guided by soft tissue response, fracture stability, and the patient's pain tolerance; stopping short of generating additional inflammatory or fibroblastic response. Fracture stability limits pain and allows more rapid and intense implementation of exercises. A recent review of 459 patients with simple closed metacarpal shaft fractures indicated that early motion (initiated within 21 days after injury) resulted in earlier recovery of motion and strength, facilitated an earlier return to work, and did not affect fracture alignment.28 A current prospective controlled laboratory investigation in dogs indicated that synergistic wrist and digital exercises diminished adhesion formation after tendon lacerations and augmented the recovery of motion.101

Fractures treated with wire fixation may require more caution in implementing exercises during the first 4 weeks after injury than additional fractures secured with mini screws or plates.68 Rehabilitation must be modulated to initiate motion but to avoid loosening the wires and losing the fracture reduction. Previous data have indicted that the recovery of 4 to 5 mm of flexor tendon excursion during the first 4 weeks after flexor tendon repair within the flexor tendon sheath substantially decreased the formation of permanent adhesions between bone and tendon.22 Extrapolation of these findings to proximal phalangeal fractures and allowance for 4 to 5 mm of adjacent flexor and extensor tendon excursion would require a 40° to 50° partial arc of proximal interphalangeal joint motion.10,50,98,99 A recent prospective controlled laboratory study of 96 repaired flexor digitorum profundus tendons in 48 dogs suggests that as little as 1.7 mm of flexor tendon excursion during the first 4 weeks after injury may reliably diminish adhesions.88 Consequently, we believe that therapy for patients whose phalangeal fractures are treated with Kirschner wires should particularly focus on regaining at least 50° of proximal interphalangeal joint motion with as much extension as possible within these confines during the first 4 weeks after surgery.10,50,98,99 We hypothesize that this limitation in motion may be relatively safe in preventing wire and fracture displacement while minimizing the risk of adhesions and stiffness, but data are needed for confirmation.

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DISCUSSION

Hand fracture treatment should be driven by evidence-based, statistically confirmed principles and patient satisfaction and safety rather than by market forces.5,7,11,82 Although information of value may be discerned from any report, declarations of study design and evidence level help the reader gain prospective. Blinded unbiased prospective randomized controlled studies with adequate enrollments and well-defined criteria provide the highest level of validity.32,53,61,62 Information from past reports may be reviewed to establish levels of evidence, validity, confidence levels, and absolute and relative risks.86

When prospective controlled studies are not feasible, posing an appropriate research question and improving study design may enhance research quality.51 Collaborative efforts and multicenter studies do not necessarily improve study validity.61,62 Heterogeneity of study discriminators has hindered valid meta-analysis to date.6,61,62 Scientists are striving to find universally acceptable classifications for fractures, wounding, and outcomes to assist in addressing this deficiency. More patient outcome and quality of care reports are needed to assess subjective patient improvement, satisfaction, and safety.8,59,89

Investigator bias may exist and conflicts of interest must be taken into consideration.61,62,102 Look for blinded studies and unconflicted collaborative confirmation of outcomes from sources independent of manufacturers, innovators, and advocates. Marketing advertisements may contain suspect information.7,82 Product expectations have not always been fulfilled, even when based upon sound theory.

We have cited selected new reports from 1999 forward that we thought might positively impact hand fracture treatment in the future. We identified the study design to allow the reader to correlate the data with currently accepted levels of evidence.5,11,86 Concepts often need additional supporting evidence to confirm their validity.32,61,62 This review was admittedly not exhaustive and represents our bias.

Past studies suggest that hand fracture outcomes correlate most highly with initial injury severity, but may include a multiplicity of factors.30,94 Patient factors (age, chronic illness, socioeconomic factors, and patient understanding and motivation); fracture factors (location, type, displacement, stability, soft tissue injury, and soiling); and treatment factors (recognition of injury, timing of intervention, tissue treatment, fracture reduction, surgical procedures, maintenance of reduction, mobilization of joints and tendons, and treatment of complications) may individually and collectively impact outcome. The physician can control only treatment factors.

Though acceptable anatomic reduction parameters and fracture principles guide physicians, they are currently relative rather than absolute, allowing the treatment of each patient to remain an individual consideration.1,9,18,35,70,93,97 Two recent prospective controlled studies confirm that slight metacarpal shortening and angulation may be well tolerated in otherwise asymptomatic patients, often sparing them from the additional dangers and morbidity of surgery.2,73 We must continue to educate the members of the medical and legal professions, health care insurers, and the general public that the risk to benefit ratio may be reasonably best served to render optimal functional outcome in some instances by accepting some anatomic imperfection as an alternative to the surgical risks and postoperative patient morbidity that may be associated with an attempt to attain perfect anatomic restoration.

Hand fractures may be complicated by deformity from no treatment, stiffness from over-treatment, and deformity and stiffness from poor treatment.95 Stiffness is the most common complication of hand fractures and is primarily related to initial injury severity and the site of injury.16,21,63,80,94 Simple open fractures accompanied by skin laceration have only slightly greater risk of stiffness than their closed counterparts of comparable configuration, but complex injury and delay in treatment substantially increase risk. Comminuted fractures are inherently unstable; are more frequently compounded by crush, wounding, and tendon, nerve, and vascular injury; and have a higher risk of stiffness than simple fractures. The proximal interphalangeal joints of the fingers are especially susceptible to stiffness.67 Open reduction and internal fracture fixation, even when essential, may add to the risk of delayed union or digital stiffness.21,43,77 Two contemporary reports indicated that open plate fixation of diaphyseal fractures lead to fragment devascularization and delayed healing.17,42 Transverse fractures may be at greater risk for these hazards than other configurations owing to the small surface area of the fracture.42 Plate bulk may contribute to stiffness, especially when the plate is applied proximate to a joint.76,79

When stabilization is necessary, a recent retrospective case report suggests that oblique as well as transverse metacarpal fractures may be successfully treated with multiple percutaneous fasciculated intramedullary Kirschner wires.27 More data may be needed to establish true statistical validity owing to small enrollment.61,62 Similarly, a novel percutaneous intramedullary flexible locking nail has been described that may have excellent potential for minimally traumatic stabilization of closed extra-articular metacarpal and phalangeal fractures of all configurations, however data are not yet available.75 A recent prospective controlled biomechanical study demonstrated that unicortical fixation of mini plates is of comparable stability to bicortical fixation for transverse diaphyseal metacarpal fractures while creating less damage to the bone.84

Ideally, fracture stabilization should be pursued with the least possible amount of additional soft tissue trauma necessary. A recent prospective randomized controlled study with blinded analysis implied that open mini screw fixation of simple closed oblique extra-articular proximal phalangeal fractures may be an exception to this tenet and may produce results comparable to those of percutaneous wire fixation.4,52,57,65,100 More data may be needed to establish true statistical validity.61,62 This same study describes the use of a previously reported unilateral excision of the lateral band and oblique fibers of the extensor apparatus of the metacarpophalangeal joint to approach and secure the proximal phalanx from the lateral aspect. The investigators provide an account of the procedure's efficacy, but not specific documentation.40,57 Further study is needed.

Another retrospective case study indicates that bicortical screw fixation of 37 extraarticular oblique phalangeal fractures were consistently effective in achieving union without loss of fixation or deformity. This technical modification simplifies mini screw insertion and is equally as effective as lag screw fixation.84

Open fractures should ideally be debrided within the first 24 hours after injury to prevent bacterial colonization and the establishment of pervasive deep infection.45,96 The safe timing of fracture fixation, bone grafting, and wound closure or coverage is more dependent on the wound being stable and surgically clean (fewer than 105 bacteria/cc) than upon the time since injury.64 The best results in open hand fractures may be achieved when the repair or reconstruction of complex wounds is completed within 3 days after injury.44 Primary bone grafting would implement this goal.15,45,49 A contemporary small case series indicates that bone grafting (within 24 hours after injury) may be safe in a stable clean wound.90 Additional data are needed. Mini plate fixation is especially suitable for open extra-articular hand fractures with comminution or bone loss. Stable fixation is a deterrent to infection.41

A recent prospective controlled study on dogs indicates that as little as 1.7 mm of flexor tendon excursion during the first 4 weeks after injury or surgery diminishes peritendonous adhesions.88 Another contemporary prospective controlled investigation on dogs indicates that synchronous wrist and digital motion improves tendon excursion.101 Correlation in human subjects with proximal phalangeal fractures is needed. A recent Level III review indicates that early motion lessens morbidity after closed simple metacarpal fractures without disturbing fracture alignment.28

Fixed angle-locking screws are on the horizon and will add strength to the bone-mini plate construct without requiring additional soft tissue dissection. Locking screws do not back out of the plate, afford additional stability, and may be particularly advantageous in osteopenic bone. Tissue glue may play some role in the future of hand fracture treatment. Reports of osteoconductive and osteoinductive bone graft substitutes in the treatment of hand fractures may be on the horizon. Resorbable implants have not achieved wide acceptance to date, but may play a more important role in the future. Percutaneous screw fixation has been reported, but few data are available.33,39

There is much work to be done in the future, analyzing and verifying both old and new concepts and in refining and developing hand fracture treatment strategies.

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Acknowledgments

The authors thank Igor Indriago, MD, and Amel Touhami, MD, CTBS, for their contributions to this study.

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