Metacarpal fractures are common injuries, accounting for approximately 36% of all hand and wrist fractures, occurring at an incidence rate of 13.6 fractures per 100,000 person-years.1–3 It has been estimated that metacarpal and phalangeal fractures contribute to approximately 40% of emergency room and urgent care facility visits.4,5
Multiple factors are taken into consideration when deciding between the different treatment options available to achieve the goals of returning to normal lifestyle, work activities and ultimately restoring hand function. These factors include the patient’s physical examination, mechanism of injury, injury-to-treatment time, fracture pattern, individual comorbidities, and physical demand. There is a high degree of sophistication involved in every step of the treatment decision process. In addition, advancements in our understanding of hand biomechanics and improvements in plating technology have expanded the options available for the treatment of metacarpal fractures.
There is no consensus, evidenced-based opinion regarding the optimal treatment for many types of metacarpal fractures. Often, the choice of surgical technique and approach largely depends upon surgeon preference and comfort. However, there are significant factors associated with each technique that warrant consideration in situations where one technique would clearly be advantageous.
Percutaneous pinning with Kirschner wires (K-wires) is a widely used surgical option for extra-articular metacarpal fractures. It is less invasive, versatile, and often quicker as compared with other techniques. On the other hand, wire fixation is not truly rigid, leading to the need for prolonged immobilization and potential postoperative stiffness.5
Open reduction and internal fixation (ORIF) with plates or lag screws provides a rigid and biomechanically stable fixation, ideally allowing for early mobilization.5,6 However, the disadvantages associated with ORIF using plate or lag screw fixation are well known and described in the literature. They largely result from the invasive nature of the technique and include adhesions, scarring, infection, stiffness, and the potential need for hardware removal.7 Fractures that require an incision to obtain an anatomical reduction either due to a delayed presentation or fracture comminution potentially favor placement of internal hardware to allow early motion and possibly mitigate the risks of increased scarring and stiffness.
This study was designed to retrospectively compare the clinical outcomes of both percutaneous pinning with K-wires and ORIF with miniplates or lag screws in the treatment of isolated, closed, single-digit extra-articular metacarpal fractures. The working hypothesis was that ORIF using plates or lag screws allows for earlier mobilization without compromising the stability of the fixation leading to less stiffness, higher patient satisfaction, and better clinical outcomes.
Institutional Review Board approval was obtained for this study. A retrospective chart review was performed of all patients who underwent surgery for isolated closed metacarpal fractures from January 2009 to December 2016. Patients who underwent closed reduction and percutaneous pinning (CRPP) and ORIF with plating or lag screws were selected and analyzed. The choice of fixation was made at the discretion of the operating surgeon and was based on factors such as fracture pattern, time from injury, and surgeon preference.
The analysis was limited to patients greater than 16 years old with single-digit, closed, isolated, extra-articular metacarpal fractures. Patients were required to have a minimum of 2 postoperative clinic visits and either a discharge plan or referral to hand therapy with subsequent re-evaluation. Patients were initially seen within 1–2 weeks after surgery, again at 4–6 weeks, and then at 3–6 months postoperatively. Patients were discharged when maximum medical improvement was reached, which was determined clinically and related to return of motion, return to work, and activities of daily living. Patients with multiple fractures or fractures in multiple digits, other traumatic injuries, or intra-articular fractures were excluded from the study.
All the patients underwent surgery by a group of board-certified plastic surgeons, the majority of whom have additional hand fellowship training. Preoperatively, radiographs of the digit or hand were reviewed, and a clinical examination was performed either in the clinic or the emergency room. Postoperative immobilization was achieved via either a volar, ulnar gutter, or thumb spica splint in the intrinsic plus position.
Patient demographic characteristics were compared between the 2 groups, including, age, sex, body mass index, comorbidities, including history of diabetes and smoking, occupation, the time from injury to surgery and mechanism of injury. Injury characteristics were also compared, including the metacarpal injured, injury location (base, shaft or neck) and fracture pattern (transverse, spiral/oblique, or comminuted).
Operative outcomes were assessed via retrospective chart review and included follow-up times, postoperative visits, immobilization time, total active motion (TAM—normal range 290–310), stiffness, incidence of complications and reoperations, occupational therapy referral rates, and duration of occupational therapy. Postoperative management was individualized according to each patient’s clinical progress and the standard protocol of each hand surgeon.
Removal of the splint and K-wires was decided based on the postoperative clinical progress, with evidence of clinical healing as determined by the absence of tenderness at the fracture site and postoperative x-rays. Referral to hand therapy was based on clinical indications such as degree of stiffness at the time of hardware removal for pin fixation and on average 2 weeks after plate or screw fixation. Those patients not referred to hand therapy were given a home exercise program and were followed until subsequent discharge from the clinic.
Functional outcomes were self-reported using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) via telephone interview, which was conducted during the data collection process of the study. The QuickDASH is a validated, self-report questionnaire that measures symptoms and function in patients with disorders of the upper extremity. Multiple articles on the development and validation of the 11-question QuickDASH questionnaire exist in the literature.8–10 Patients who were unable to be contacted or refused to participate were not included in these calculations.
All implants were made by Synthes (Paoli, PA) and Osteomed (Glendale, CA). In the CRPP group, 0.035-, 0.045-, and 0.054-inch K-wires were used, up to 3 wires per metacarpal as dictated by the fracture pattern and surgeon preference. Most commonly, crossed intramedullary K-wires were placed percutaneously in either a retrograde or anterograde fashion according to surgeon preference. In the ORIF group, linear plates (1.5, 2.0, or 2.3 mm), T-shaped shaped (1.5 mm or 2.0 m), or Y-shaped (2.0 mm) stainless steel and titanium plates were utilized. In patients who received lag screws (1.5 or 2.0 mm), at least 2 screws per fracture site were placed.
The statistical analysis was performed using a Chi-square test to compare nominal means of continuous patient demographic characteristics and outcome characteristics. A 2-tailed Fisher’s exact test was used to compare nominal patient demographic and injury characteristics and outcome characteristics. Subgroup analyses of shaft fractures, oblique/spiral fractures, and transverse fractures were performed. Additionally, subgroup analyses based on the time from injury to treatment were conducted. Early treatment was defined as surgery less than 7 days from the time of the injury. Surgery performed 7 or more days from the time of the injury was considered late treatment. A P value of less than 0.05 was considered significant.
A total of 238 patients were treated for metacarpal injuries at our affiliated institutions in Long Island, NY, from January 2009 to December 2016, of whom 70 met our inclusion criteria for the study. Forty-four patients underwent CRPP and 26 were treated with ORIF (Table 1). Fifty-five percent of the study patients were treated at Nassau University Medical Center, an academic tertiary care county hospital. The remaining patients were treated at other university-affiliated medical centers and local community hospitals in the area by the same group of attending surgeons.
Of the 26 patients who had ORIF, plate fixation was performed in 18 (69.2%), and lag screws were utilized in 8 (30.8%). Shaft fractures constituted the majority of fractures in each treatment group (75% and 88%, respectively). In the subgroup analysis of shaft fractures, 33 patients underwent CRPP and 23 patients ORIF (Table 2). Tables 3–5 present the subgroup analyses comparing the 2 techniques with respect to transverse shaft fractures, all transverse fractures and spiral or oblique fractures.
Overall, patients who underwent ORIF were operated at a later stage than those who had CRPP, an average of 15.0 days from the time of injury, versus 7.4 days for CRPP (P = 0.001) (Table 1). This was also the case in the subgroup analyses of metacarpal shaft (P = 0.004, Table 2) and spiral/oblique fractures (P = 0.028, Table 5).
There were no statistically significant differences in the remaining demographics, mechanism of injury, and employment status between the 2 groups (Table 1). When comparing all fractures, CRPP was employed at a significantly higher rate than ORIF for fifth metacarpal and transverse fractures (P = 0.011 and 0.06, respectively), whereas ORIF was more commonly utilized in oblique and spiral fractures (P = 0.044). Focusing on metacarpal shaft fractures only (Table 2), CRPP was more commonly utilized for transverse fractures, whereas ORIF was more common for spiral/oblique fractures (P = 0.009 and 0.041, respectively).
There was no statistically significant difference in outpatient follow-up, total clinic visits, and hand therapy referral rates between the 2 groups (Table 1). In terms of immobilization, ORIF resulted in earlier splint removal and earlier referral to occupational therapy as compared with CRPP (19.7 and 30.7 days, respectively, P = 0.001). Similar results were found in the subgroup analyses of shaft fractures (20.0 and 30.9 days, respectively, P = 0.004, Table 2), transverse fractures (30.3 and 13.8 days, respectively, P = 0.004, Table 4), and spiral/oblique fractures (31.1 and 17.6 days, respectively, P = 0.001, Table 5).
Overall, comparison of TAM—actual or % of normal—revealed no statistically significant difference between the 2 techniques (Table 1). The only exception was in patients with transverse shaft fractures, where ORIF resulted in improved TAM outcomes over CRPP with similar percentage of patients requiring postoperative hand therapy (Table 3).
The outcomes of the subgroup analyses of early (less than 7 days since the injury) and late (7 or more days) postinjury treatment are presented in Tables 6–8. There were no statistically significant differences in the outcomes between early and late treatment within each group (Table 6). However, there was a trend toward shorter follow-up, less postoperative visits, enhanced TAM and less immobilization time with early ORIF when compared with ORIF performed 7 or more days following the injury (Table 6).
When comparing all fractures treated in the early postinjury period, ORIF resulted in significantly fewer postoperative visits (2.6 versus 3.8, P = 0.030) and less immobilization time (12.8 versus 30.1 days, P < 0.001) than CRPP (Table 7). In the late postinjury period, ORIF allowed for less immobilization than CRPP (22.2 versus 31.3 days, P = 0.030) with a trend toward fewer patients being referred to hand therapy following ORIF (Table 7).
Focusing on shaft metacarpal fractures, ORIF results in significantly fewer postoperative visits (2.6 versus 4.2, P = 0.012) and less immobilization (23.1 versus 31.4 days, P < 0.001) than CRPP when performed in the early postinjury period (Table 8). Similarly, there is a trend toward less immobilization with ORIF in the late postinjury period too, although this did not reach statistical significance (23.1 versus 31.4, P = 0.088).
Postoperative stiffness impairing daily activities, work duties, or both was a complaint for 15 (34.1 %) patients in the CRPP group and 13 (50.0 %) patients in the ORIF group (P = 0.189) (Table 1). Among the patients with metacarpal shaft fractures, stiffness was a complaint in 10 patients following CRPP (30.3 %) and 11 patients following ORIF (47.8 %), which was not statistically significant (P = 0.183) (Table 2). Of those, one required operative treatment in the form of capsulotomy and extensor tenolysis approximately 5 months following CRPP of a fifth metacarpal shaft fracture. This was the only complication in the CRPP cohort.
In the ORIF group, there were 2 complications. One patient required hardware removal, tenolysis of the extensor pollicis longus and transfer of the extensor indicis proprius to the extensor pollicis longus approximately 6 months following ORIF of his comminuted first metacarpal shaft fracture. The second patient demonstrated clinical and radiographic signs of nonunion following ORIF using lag screws for a comminuted third metacarpal fracture and underwent revision plate fixation and bone grafting following removal of lag screws.
There were no complaints about hand or scar cosmesis, postoperative superficial or deep infections, angulation, shortening, malrotation, scissoring, or delayed union in either cohort.
We were able to contact 17 (38.6%) patients in the CRPP group and 6 (23.1 percent) patients in the ORIF group to administer the telephone QuickDASH questionnaire. The mean score for each group was satisfactory, and the difference was not statistically significant (16.3 for the CRPP and 18.7 for the ORIF group, P = 0.805). This is within 1 SD of the normal population (QuickDash 10) and indicates a mild degree of disability only.
We compared the outcomes of ORIF with closed reduction and percutaneous pinning in the management of isolated, closed metacarpal fractures. No single surgical technique has been proven superior to others when treating closed metacarpal fractures; furthermore, most studies available in the literature lack consistency with regard to endpoints, surgical techniques, and measures of clinical outcomes. Our results showed similar clinical outcomes for both techniques including TAM (except for the transverse shaft fracture population, Table 3), postoperative stiffness, patients referred to hand therapy, and QuickDASH scores.
To increase the power and statistical significance of the study, we pooled the data of all digits and extra-articular closed fracture patterns. Although certain fracture patterns like fifth metacarpal neck fractures are known to have unique characteristics, the issues that differentiate open surgery from percutaneous pinning are consistent regardless of fracture type. We then performed multiple subgroup analyses to compare and focus on more homogeneous fracture patterns. Although the numbers in this cohort were low, ORIF demonstrated significantly reduced time of immobilization and earlier postoperative motion despite most patient presenting at a later time from injury to repair. This is in line with our original hypothesis favoring ORIF for early mobilization and increased stability of fixation.
In this series, there were pretreatment delays in both cohorts, which we attribute to the fact that the vast majority of patients were treated within the County Hospital System. This presented significant challenges such as limited operating room time, lack of health insurance, poor compliance, language barrier, and hesitation to consent to surgery to avoid loss of income from time off of work. Furthermore, patients treated with ORIF were operated on an average of 7 days later than patients treated with percutaneous pinning. Logically, a delay in presentation and treatment may steer one toward open surgery if enough time has passed to allow for callus formation making closed reduction difficult or impossible. However, we were not able to determine from the records whether the decision to open was made intraoperatively or preoperatively based on other criteria such as fracture patterns or patient preference.
The specific technique of percutaneous pinning is another inconsistent variable between prior studies in the literature. Most commonly, we favored the use of retrograde crossed K-wires for the treatment in our series. The literature has focused on the use of intramedullary “bouquet” wiring or transverse pinning; however, these techniques seem to be less popular and not reflective of what is done in many practices.5 In addition, there has been disagreement on the outcomes associated with different techniques with some studies showing a preference for intramedullary wiring and others showing equivalent results.11
Fifth metacarpal fractures were treated statistically more often using percutaneous pinning (P = 0.026). This finding is consistent with the literature demonstrating better outcomes with pinning versus plating of fifth metacarpal neck fractures specifically.2,11 Fractures treated with percutaneous pinning were immobilized an average of nearly 2 weeks longer than those treated with plate or screw fixation. However, in this series, prolonged immobilization did not contribute to changes in ultimate TAM, stiffness, need for therapy, or need for revision surgery. All patients regardless of operative technique achieve outcomes that were considered good or excellent based on prior studies.
Although there have been reports of similar functional and clinical outcomes of ORIF with plates or lag screws compared with CRPP in various types and patterns of metacarpal fractures, many surgeons are skeptical of this.11–13 This stems from the invasive nature of open fixation, in particular the placement of hardware in close proximity to the extensor mechanism, the extensive dissection, and overall technical demands associated with ORIF.5,14 Earlier publications have suggested that ORIF techniques are associated with higher rates of reoperation, impaired mobility, fracture healing limitations, and complications related to functional impairment.2,15–17 This is not consistent with our findings. Both groups had very few and similar complication and reoperation rates, both lower than the data published in the literature. There was also a trend toward more patients in the CRPP group requiring postoperative hand therapy (70% versus 50%), although this was not statistically significant (P = 0.201).
Interestingly, a recent meta-analysis conducted by Melamed et al.18 comparing CRPP with K-wires to ORIF with plate and screws for the treatment of unstable metacarpal fractures, focusing on functional outcomes, found statistically significant improved TAM scores with CRPP on their weighted mean analysis of the 3 studies that reported TAM scores. The authors did not find a difference in DASH scores or other functional outcome variables. The meta-analysis included only 5 studies and the authors discussed the limitations and heterogeneity of the data, which may limit the conclusions in the article. No studies in the meta-analysis looked at key variables such as the time lapse between injury and time of surgery, time of immobilization, or postoperative referral to hand therapy. In our study, there were no differences in TAM—actual or % of normal—between the 2 techniques. This important difference could be due to our study being underpowered. On the other hand, it might be attributed to higher degree of consistency in our cohort in terms of surgical technique, implant type, and postoperative care which may have led to the equivalent results in both cohorts.
We have shown that ORIF of closed metacarpal fractures allows for earlier mobilization when compared with CRPP. This reflects the stable fixation that plating and lag screw placement provides, potentially enhancing fracture healing. Spiral or oblique fractures demonstrated a trend toward ORIF, perhaps due to the favorable orientation of the fracture for the placement of internal hardware like lag screws. Earlier mobilization following ORIF may offer a significant advantage in terms of return to work, return to independent activities of daily living, and patient satisfaction versus CRPP.19–21
Based on our data, it has become our practice to favor CRPP in the cases of acute metacarpal base fractures, neck fractures, and comminuted fractures. We recommend the use of ORIF in the cases of transverse shaft fractures, delayed presentation, spiral/oblique fractures, and in the cases where early mobilization is especially advantageous to the patient.
This study is associated with several limitations. First, it is retrospective in nature with inherent response bias. Second, standardization of surgical decision-making and technique, and postoperative management was not performed. Most of the patients were treated in a county hospital clinic setting with barriers to compliance including language, insurance, and socioeconomic status. Third, average follow-up for was only 3 months for the CRPP cohort and 5 months for the ORIF cohort. Although relatively short, it should be long enough to capture most postsurgical complications including infections and those related to scarring and motion loss. Longer follow-up may capture some delayed complications such as tendon ruptures or osteomyelitis, but these numbers are expected to be low. Finally, despite our efforts, the response rate to the telephone QuickDASH questionnaire was poor for both cohorts, and this limits our ability to analyze the patient’s subjective functional outcome. Although we did not analyze cost, CRPP has lower equipment costs, shorter duration of therapy, and less overall postoperative care as compared with ORIF which could be considered an advantage to the medical system as a whole.
Despite these limitations, this is one of the few studies in the literature that focuses on the common clinical scenario of closed, isolated, extra-articular metacarpal fractures and compares the 2 most commonly used operative techniques with this sample size. In addition, we have been able to perform subgroup analyses based on fracture location and fracture patter that may help guide surgical decision-making in many common clinical scenarios. Given that postoperative outcomes were similar in both groups, and that both groups had favorable results, we recommend using ORIF in the cases of delayed presentation or when early mobilization and return to activities are advantageous for the patient.
Both percutaneous pinning and ORIF are effective techniques for the treatment of closed, extra-articular metacarpal fractures. Both techniques result in good functional outcomes with low morbidity. ORIF of closed metacarpal fractures has resulted in improved postoperative range of motion for transverse shaft fractures and allowed for faster mobilization in all fracture types without compromising fracture stability, clinical or functional short-term outcomes.
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