Vascularized Transfer of Second Metacarpal Base for Treatment of Capitate Osteonecrosis.

BACKGROUND: Capitate osteonecrosis is a rare condition that mainly presents in young patients with chronic wrist pain. Treatment aims to address pain, arthritic changes, or carpal instability. METHODS: We present the surgical technique and outcomes of using a vascularized pedicled second metacarpal base transferred on the second dorsal metacarpal artery to treat capitate osteonecrosis in a 20-year-old female secretary, former gymnast, and a 25-year-old female student with acute lymphoblastic leukemia. These patients presented with idiopathic chronic wrist pain with MRI showing capitate osteonecrosis with preserved carpal height and intact articular cartilage. RESULTS: After 2 years of follow-up, both patients endorsed pain resolution and demonstrated preservation of wrist motion and grip strength with evidence of capitate healing on plain radiographs. Case 1 demonstrated grip strength 60 lbs., pinch strength 5 lbs., and wrist flexion-extension arc of 70 to 80°. Case 2 had grip strength 31 lbs., pinch strength 9 lbs., and wrist flexion-extension arc of 40 to 30° on the left. CONCLUSION: Vascularized pedicled second metacarpal base transferred on the second dorsal metacarpal artery can be successfully used in the management of capitate osteonecrosis and offers advantages over other vascularized bone grafts for capitate osteonecrosis.

Patient-Experience of Trapeziectomy for Trapeziometacarpal Osteoarthritis in Wide-Awake Local Anesthesia no Tourniquet, 2-Year Follow-up.

PURPOSE OF THE STUDY: The purpose of this study was to assess the patient experience of trapeziectomy under WALANT for trapeziometacarpal joint (TMJ) osteoarthritis (OA) in a prospective study with 2-year follow-up. MATERIAL AND METHODS: The study included 23 patients with TMJ OA undergoing trapeziectomy with WALANT. All patients were seen by a hand therapist preoperatively and at 3, 12, and 24 months postoperatively. At each visit, VAS pain scores, thumb range of motion, grip strength, and Disabilities of the Arm, Shoulder and Hand (DASH) score were assessed. The Picker Patient Experience (PPE-15) questionnaire was administered within 2 weeks of surgery. RESULTS: All 23 patients completed the PPE-15 questionnaire. Their mean age was 64 years. The 21 patients who remained at the 24-month follow-up all said they would choose the same anaesthesia method again. At this follow-up, VAS pain scores, thumb range of motion, key pinch grip and DASH scores had improved significantly, while thumb opposition and hand grip strength remained largely unchanged. The majority of patients felt well informed before and during the procedure, and all patients rated pain relief as good or satisfactory. Nearly 40% of patients reported receiving inadequate information about the postoperative medications. DISCUSSION: Patients have a positive attitude to trapeziectomy with WALANT, and seem to prefer WALANT over other methods of anaesthesia. Trapeziectomy with WALANT for TMJ OA is a safe procedure and appears to give a functional outcome similar to trapeziectomy under general anaesthesia. CONCLUSIONS: Trapeziectomy with WALANT for TMJ OA is safe, preferred by patients and has similar clinical outcome as trapeziectomy in general anesthesia. KEY WORDS: trapeziectomy, osteoarthritis, WALANT.

Percutaneous transverse pinning for metacarpal fractures: a clinical trial.

INTRODUCTION: Metacarpal fractures account for 25%-50% of all hand fractures and may negatively impact hand function and ability to work. Percutaneous transverse pinning of non-articular metacarpal fractures allows mobilisation immediately after the procedure. METHODS: Between March 2017 and February 2022, 56 patients undergoing percutaneous transverse pinning for unstable metacarpal fractures were prospectively recruited. We investigated surgical outcomes in terms of Patient-rated Wrist/Hand Evaluation (PRWHE) and pre-and post-operative radiographic evaluation. The Student t-test was used to compare the means of PRWHE values after surgery. Statistical significance was set at p < 0.05. RESULTS: The mean age was 40.21 ± 17.9 years (range of 16 to 86 years). The average operating time was 27.96 min. The mean follow-up period was 14.3 ± 6.4 months (from 2 to 41 months). The mean PRWHE score was 6.5 ± 1.8. None of the patients had clinically observable rotational deformities, and the functional outcomes were satisfactory. CONCLUSION: Percutaneous transverse pinning for non-articular metacarpal fractures restores excellent function, and imaging results are satisfactory. Further high-quality clinical trials are required to validate these results on a larger scale. LEVEL OF EVIDENCE: II, prospective cohort study.

Metacarpal Fracture Fixation with Intramedullary Screws.

Background: Intramedullary screws (IMS) have become a viable option for metacarpal fracture fixation. To further appraise their utility, this study assessed clinical and patient-reported short- and medium-term outcomes of IMS fixation for extra-articular metacarpal fractures. Methods: A retrospective cohort study was performed in a series of 32 patients (with a total of 37 fractures) who underwent metacarpal fracture fixation over a 42-month period between January 2020 and July 2023. Results: Mean time for return to work was 39.8 days; mean time for return to full function was 88.4 days; total active motion was 250.7° (range: 204.9-270.9); Quick Disabilities of the Arm, Shoulder and Hand score was 2.3 (range: 0-22.7); mean visual analogue pain score was 0.9 out of 10 (range: 0-6) and a single complication was observed. Conclusions: The use of IMS in metacarpal fracture fixation is a practicable surgical option. IMS fixations yields a satisfactory duration for return to function, good postoperative range of movement, modest pain scores and low rates of complications. Level of Evidence: Level IV (Therapeutic).

Early Return of Motion in Patients With Intramedullary Screw Placement for Metacarpal and Phalangeal Fracture Fixation.

INTRODUCTION: Hand fractures are associated with significant morbidity. Current management standards often result in prolonged immobilization, stiffness, and delayed return to functional use. Intramedullary (IM) compression screws offer minimal soft tissue disruption and early postoperative active motion. In this study, we describe our outcomes after intraosseous fracture fixation using IM cannulated headless screws for a multitude of fracture patterns. METHODS: This study is a retrospective review of patients who underwent IM screw placement for fixation of metacarpal and phalangeal fractures by a single surgeon from 2017 to 2022. Data were collected to include patient demographics, fracture details, postoperative complications, and follow-up. Time to range of motion and return to unrestricted motion was recorded. RESULTS: There were 69 patients with 92 fractures (n = 54 metacarpal, n = 38 phalanx). The median patient age was 45 years (range, 18-89 years) with 75.4% males. Majority presented with a single fracture (n = 50, 72.5%), and 38 patients (55.1%) had open fractures. Small finger was the most affected digit (n = 35, 37.6%). The median time to allow range of motion from surgery was 8.7 days (interquartile range, 0-32) with 32 days (interquartile range, 10-62) for unrestricted use of the hand. Thirty-five patients (50.7%) were allowed controlled motion from the first postoperative day. One patient had loss of reduction requiring reintervention for hardware removal, and 1 patient had superficial skin infection managed with oral antibiotics. CONCLUSIONS: Our findings indicate that the IM screw provides reliable fixation for a wide variety of fracture patterns with a low complication rate and offers early return to functional use.

Novel Mini-Invasive Surgical Technique for Treating Fifth Metacarpal Neck Fractures: A Case Report.

BACKGROUND Fracture of the fifth metacarpal of the hand is due to trauma to the clenched fist. The non-displaced fracture can be treated by splinting and immobilization, but fracture dislocation requires individualized management to ensure the return of function. The Jahss maneuver for reduction of volar displaced metacarpal neck fractures involves flexion of the metacarpophalangeal and proximal interphalangeal joint at 90°, with the proximal phalanx used to reduce the metacarpal head. This report is of a 25-year-old male Italian pianist with a displaced fifth metacarpal neck fracture successfully treated by reduction using the Jahss maneuver and K-wire attachment of subchondral bone to the metacarpal. CASE REPORT A pianist presented with a trauma to his right hand due to punching a wall. Radiograph images demonstrated an angulated, displaced right fifth neck fracture. A specific approach was decided, considering the complexity of the musical movements and the patient's performance needs. After fracture's reduction by the Jahss maneuver, 2 retrograde cross-pinning K-wires were inserted at the subchondral bone of the metacarpal head. Healing under splinting was uneventful, and the K-wires were removed after 45 days. At 4 months after surgery, the patient had complete recovery of both range of motion and strength. CONCLUSIONS Our technique avoided piercing the metacarpophalangeal joint capsule, preventing extensor tendon damage, dislocation, instability, and pain and retraction of the extensor cuff. This novel mini-invasive technique successfully achieved early metacarpophalangeal joint motion, joint stability, and complete recovery of movements in all planes.

Positron emission tomography assessment of metacarpal/metatarsal condylar fractures post surgical repair: Prospective study in 14 racehorses.

OBJECTIVES: To assess 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) findings associated with metacarpal/metatarsal condylar fractures at the time of fracture repair and through healing. STUDY DESIGN: Prospective descriptive study. ANIMALS: Fourteen Thoroughbred racehorses. METHODS: 18F-NaF PET was performed within 4 days of surgical metacarpal/metatarsal condylar fracture repair, on both the injured and contralateral limb. Follow-up PET scans were offered at 3- and 5-months post fracture repair. Areas of abnormal uptake were assessed using a previously validated grading system. RESULTS: Eight fractures were located in the parasagittal groove (PSG) (six lateral and two medial) and six fractures were located abaxial to the PSG (non-PSG) through the palmar/plantar condyle (all lateral). All horses in the latter group had uptake in the lateral palmar condyle of the contralateral limb suggestive of stress remodeling. Three horses with PSG fractures had uptake in a similar location in the contralateral limb. Horses with lateral condylar fracture only presented minimal or mild uptake in the medial condyle, which is considered atypical in the front limbs for horses in full training. Four horses developed periarticular uptake in the postoperative period suggestive of degenerative joint disease, three of these horses had persistent uptake at the fracture site. These four horses did not return to racing successfully. CONCLUSION: The findings of this study provide evidence of pre-existing lesions and specific uptake patterns in racehorses suffering from metacarpal/metatarsal condylar fractures. CLINICAL SIGNIFICANCE: PET has a possible role in the prevention, diagnosis, and postoperative monitoring of metacarpal/metatarsal condylar fractures in racehorses.

Intramedullary Fixation of Hand Fractures and Arthrodeses.

Intramedullary fixation has long been popular for fracture fixation in the upper extremity from the shoulder through the carpus. Recently, intramedullary fixation in the hand has gained increasing interest, specifically in the metacarpals and phalanges, corresponding with the development of improved cannulated headless screw technology. Along with the advantages of increased operative speed and less surgical dissection, which can promote rapid healing, many benefits exist, supporting their use despite some drawbacks. This article reviews the background and biomechanics of intramedullary fixation with a specific focus on cannulated headless screws, describes the application and techniques of intramedullary screw fixation in the hand, and details the associated outcomes and costs for metacarpal fractures, phalangeal fractures, and interphalangeal joint arthrodesis.

An alternative method to reconstruct grade-3 hypoplastic thumb by hemi-metacarpal transfer.

We designed a new method using hemi-longitudinal second metacarpal bone to reconstruct grade-3 hypoplastic thumbs. Seven patients were treated in two stages. In the first stage, the second metacarpal was split longitudinally and transferred to reconstruct the first metacarpal. In the second stage, opponensplasty was performed by transferring the FDS tendon. Bone union was achieved in all cases. All patients could oppose to their middle finger at least. They managed to do daily activities such as writing, eating, using smartphones and so on. This is a useful procedure to preserve a 5-digit hand with good function in treating grade-3 hypoplastic thumbs, with no harm to the foot and no need for vascular anastomosis. LEVEL OF EVIDENCE: IV.

The stacking concept: cannulated screws for extra-articular metacarpal base fracture of the thumb.

An alternative technique to treat extra-articular fractures of the base of the first metacarpal with intramedullary canulated headless screws is presented. The principle is creating an internal fixator within the medullary canal by introducing multiple retrograde screws until they have jammed.

Basal osteotomy of the first metacarpal using patient-specific guides and instrumentation: biomechanical and 3D CT-based analysis.

INTRODUCTION: The aim of this study was to investigate the radiological outcomes of proximal closing metacarpal extension osteotomies using patient-specific guides and instruments (PSI) in early-stage trapeziometacarpal osteoarthritis to gain further insight into the joint loading surface and the benefits of the procedure. METHODS: In a prospective observational study, nine patients were included between 11/2020 and 12/2021, undergoing a total of ten proximal metacarpal extension osteotomies for basal thumb osteoarthritis. Computer-assisted surgical planning was performed using computed tomography (CT) and three-dimensional (3D) segmentation, allowing the fabrication of 3D-printed PSIs for surgical treatment. Inclusion criteria were a 1-year follow-up by CT to assess postoperative correction of the positional shift of the first metacarpal (MC1) and the location of peak loads compared with the preoperative situation. RESULTS: Radiographic analysis of the peak loading zone revealed a mean displacement on the articular surface of the trapezius of 0.4 mm ± 1.4 mm to radial and 0.1 mm ± 1.2 mm to palmar, and on the articular surface of the MC1 of 0.4 mm ± 1.4 mm to radial and 0.1 mm ± 1.2 mm to dorsal. CONCLUSION: There were trends indicating that a flatter pressure distribution and a dorsal shift of the peak loading zone may contribute to an improvement in subjective pain and patient satisfaction associated with this surgical procedure. The non-significant radiological results and the minor dorsal-radial shifts in our small study group limit a firm conclusion. LEVEL OF EVIDENCE: III.

Conservative treatment versus transverse pinning in fifth metacarpal neck fractures in active adults: a randomized controlled trial.

PURPOSE: Compare two simple ways for treating boxer's fractures in active adults; conservative management by ulnar gutter slab and transverse pinning in fixation of fifth metacarpal's neck fracture regarding union, functional outcomes, and complications. PATIENTS AND METHODS: Ninety patients with fifth metacarpals' neck fractures with palmar angulation (30-70°) were managed either conservatively by an ulnar gutter slab or surgically by transverse pinning technique from January 2020 to December 2021. Only 84 patients completed a 1-year follow-up. Patients with old, open, or mal-rotated fractures were excluded. The block-randomization method was used to create equal groups. Patients were evaluated clinically and radiologically every 2-3 weeks until union, then at 6 and 12 months. Functional assessment at the final visit was done using the quick DASH score, total active motion (TAM), and total Active Flexion (TAF). RESULTS: The mean radiological union time for the conservative group in this study was 7.76 weeks, while for the transverse pinning group, it was 7.38 weeks. There was no statistically significant difference between the two techniques regarding union rates and functional outcomes. All patients returned to their pre-injury jobs and level of activity. CONCLUSION: Both conservative management in ulnar gutter slab and percutaneous transverse pinning are considered effective methods in the treatment of simple extra-articular fifth metacarpal neck fractures with angulation between 30 and 70 degrees (AO: 77 A3.1). The functional and radiological results using both methods were satisfactory and statistically comparable.

Retro-Antegrade Technique in the Management of Severely Angulated Fourth and Fifth Metacarpal Neck Fractures: A Case Series.

Background: This study introduces a novel method for the management of closed metacarpal neck fractures. Kirschner wires (K-wire) are introduced in a retrograde and the wires withdrawn through skin proximally at the base of the metacarpal. The fracture is reduced using traction and the reduction is maintained by antegrade advancement of the K-wires. The aim of this study is to report the outcomes of this technique. Methods: A total of 36 patients with severely angulated closed metacarpal neck fractures underwent reduction and fixation using this novel method from January 2017 to December 2020 in centres in Ireland and Saudi Arabia. We performed a retrospective review of these patients' clinical data examining their outcomes. Results: Six months postoperatively, all fractures demonstrated bony union and correction of angulation. All patients exhibited excellent range of motion (ROM) with no significant impairment of hand function. Conclusions: The method detailed here is a simple, minimally invasive and reliable technique that has not previously been described. It is suitable for use in the management of closed metacarpal neck fractures of the fourth and fifth metacarpal, with dorsal angulation greater than 60°. Level of Evidence: Level IV (Therapeutic).

The Treatment of Closed Finger and Metacarpal Fractures.

BACKGROUND: Fractures of the fingers and metacarpal bones are the most common fracture type in the upper limb, with an incidence of 114 to 1483 per 100 000 persons per year. The clinical importance of closed finger and metacarpal fractures is often underestimated; inadequate diagnostic and therapeutic measures may result in serious harm. This review concerns the basic elements of the diagnosis and treatment of finger and metacarpal fractures. METHODS: This review of the incidence, diagnosis and treatment of finger and metacarpal fractures is based on pertinent publications retrieved by a selective search of the literature. RESULTS: The main focus of treatment lies on restoration of hand function in consideration of the requirements of the individual patient. The currently available evidence provides little guidance to optimal treatment (level II evidence). Although most closed fractures can be managed conservatively, individualized surgical treatment is advisable in comminuted fractures and fractures with a relevant degree of torsional malposition, axis deviation, or shortening, as well as in intra-articular fractures. Minimally invasive techniques are, in principle, to be performed wherever possible, yet open surgery is sometimes needed because of fracture morphology. Postsurgical complication rates are in the range of 32-36%, with joint fusion accounting for 67-76% of the complications. 15% involve delayed fracture healing and pseudarthrosis. CONCLUSION: Individualized treatment for finger and metacarpal fractures can improve patients' outcomes, with major socioeconomic and societal benefits. Further high-quality studies evaluating the relative merits of the available treatments are needed as a guide to optimized therapy.

[Effectiveness on treatment of metacarpal avulsion fracture with Kirschner wire buckling combined with bone fixation].

Objective: To summarize the effectiveness of Kirschner wire buckling combined with bone fixation in the treatment of metacarpal avulsion fracture. Methods: The clinical data of 35 patients of metacarpal avulsion fracture admitted between March 2017 and June 2022 were retrospectively analyzed. There were 22 males and 13 females; the age ranged from 20 to 55 years, with an average of 31.6 years. There were 17 cases of the second metacarpal avulsion fracture, 6 cases of the fourth metacarpal avulsion fracture, and 12 cases of the fifth metacarpal avulsion fracture. The causes of injury included 21 cases of strangulation, 8 cases of sprain, and 6 cases of sports injury. X-ray film examination showed that the size of the avulsion fracture of metacarpal bone ranged from 0.30 cm×0.20 cm to 0.55 cm×0.45 cm. The total active motion (TAM) of the injured finger before operation was (154.00±17.38)°. The time from injury to operation was 3-10 days, with an average of 5.8 days. Follow-up regularly after operation, X-ray film and CT examination were performed to evaluate fracture healing and TAM of injured finger was measured. The finger function was evaluated by the trial standard of upper limb function evaluation of Hand Surgery Society of Chinese Medical Association. Results: All the incisions healed by first intention. All 35 patients were followed up 9-36 months, with an average of 28 months. All metacarpal avulsion fractures achieved bony healing, and the healing time was 4-6 weeks, with an average of 4.8 weeks. The metacarpophalangeal joint of the patient was stable, without stiffness, and the flexion and extension activities were good. At last follow-up, the TAM of the injured finger reached (261.88±6.23)°, which was significantly different from that before operation ( t=-35.351, P<0.001). The finger function was evaluated according to the trial standard of upper limb function evaluation of the Society of Hand Surgery of Chinese Medical Association, and 33 cases were excellent and 2 cases were good, with an excellent and good rate of 100%. Conclusion: The treatment of metacarpal avulsion fracture with Kirschner wire buckling combined with bone fixation has the advantages of less trauma, firm fixation, and less interference to the soft tissue around metacarpophalangeal joints, which is a good alternative method for the metacarpal avulsion fracture.

Total removal of the fourth metacarpal bone in an Icelandic horse.

Fractures of the splint bones are the most common fractures in horses. Various treatment options for splint bone fractures (MC/MT II and IV), including conservative and surgical management, have been described. This report describes an acute splint bone fracture due to external trauma in a 17-year-old Icelandic mare. The fracture was diagnosed as an open multifragment fracture of the proximal third of the fourth metacarpal bone (MCIV) in the right front limb. Surgery was performed with the horse under general anaesthesia. The distal fragments were removed, and the distal part of the proximal remnant splint bone was cut with an osteotome. During the postoperative period, a routine x-ray-control two days after surgery showed a dislocated fracture of the remaining proximal part of the fourth metacarpal bone. In a second surgery, the proximal part of MCIV was entirely removed. After a reconvalescence period of 5 month, the horse reached her previous level of performance as a leisure horse. The mare is still free of lameness 6 years after the incident.

Revision of Motec Total Wrist Replacement in the Second Metacarpal.

Wrist arthroplasty is becoming more commonplace, with various implant choices available. The Motec (Swemac Orthopaedics AB, Linköping, Sweden) cementless ball-and-socket system is being increasingly utilised and is designed for the distal component to be implanted into the third metacarpal. However, distal component failure is a recognised complication. We outline our experience with the revision of this component into the second metacarpal. This technical note is presented through our experience of two patients who underwent revision arthroplasty for the management of peri-prosthetic fracture of the third metacarpal. This technique has demonstrated a safe and viable solution to this complication, achieving good anatomical centre of rotation, function, range of movement and patient satisfaction. Level of Evidence: Level V (Therapeutic).

Curative effect of external fixation combined with kirschner wire versus hollow screw in the treatment of first metacarpal bone base fracture.

PURPOSE: This study was conducted aimed at comparing the curative effect of external fixation combined with Kirschner wire fixation versus hollow screw fixation in the treatment of first metacarpal bone base fracture. METHODS: The current retrospective study included a total of 80 patients diagnosed with first metacarpal bone base fracture who were admitted in Wuxi 9th People's Hospital Affiliated to Soochow University between October 2017 and October 2020. The patients enrolled were equally divided into the combined group (40 cases, receiving external fixation combined with Kirschner wire fixation), and the control group (40 cases, receiving hollow screw fixation). Perioperative indices were collected and compared between the two groups. Pain scores before operation and three months, six months, and one year after operation were compared. Additionally, we compared the finger function in the last follow-up visit ( the follow-up period was 1 year) and rate of complications. RESULTS: Operation time, amount of bleeding, length of incision, length of hospital stay, and fracture healing time did not differ between the two groups (all P > 0.05). Pain score was comparable between the two groups before operation (P = 0.704). Despite lower results showing at 3, 6, and 12 months after operation in both groups, the pain score did not significantly differ in any time point between the two groups (all P > 0.05). Additionally, no significant differences were observed in finger function and rate of complications at the last follow-up between the two groups (both P > 0.05). CONCLUSION: External fixation combined with Kirschner wire fixation and hollow screw fixation exhibited similar curative effect in treating first metacarpal bone base fracture, indicating both surgery methods may be considered as the preferred approach.