I just wanted to thank Dr. Seiler for the opportunity to be part of the panel. So I've been charged with giving an overview, looking at complications as we manage metacarpal fractures. So, unfortunately, with complications, some are certainly expected and discussed with the patients. Some are a little bit unexpected, but we all deal with complications as part of our practice. So as Dr. Lalonde and Dr. Hammer gave a great overview looking at nonoperative and operative management of metacarpal fractures, the key thing to keep in mind is the majority of metacarpal fractures are closed, simple, and stable. And really, function follows form. So there is some tolerance for some deformities. So treat the patient, don't treat the x-rays. I think most of these could be managed with minimal splinting, early mobilization. The ones that are a little bit more unstable, closed reduction with immobilization for a short period. Or if you're looking at a surgical treatment, a really minimalist approach, a closed reduction, percutaneous pinning with a short period of immobilization. Really the learning objective is to look at some of the common complications that you may face as you treat metacarpal fractures in your practice and talk about a treatment approach or algorithm to treat each of these complications. Some of the complications are inherent to surgery, bleeding, infection, and scarring. And some are more specific to metacarpal fractures, nonunion, malunion, which could be both rotation or angulation, extensor lag, and stiffness, which are probably the most common ones that you'll face in your practice. We know with complications, we can always turn to the wisdom and the guidance of Dr. Stern. This is a study in 1998, looking at metacarpal fractures treated with plate fixation, looking at complications in their series. 76% of patients did quite well with a total arc of motion greater than 220 degrees. But they noticed that 6% of patients had a major extensor lag greater than 35 degrees, and 7.9% of patients had a flexion contracture greater than 35 degrees. They're at 1.6% nonunion, as Dr. Long mentioned, very rare. Infection in one series in one case of a tendon rupture. So I think for the most part, you're looking at really extensor lag and contractures as you're treating these fractures. So I think really it's minimal dissection to avoid these complications. Their series is a little bit more recent by Fusetti, looking at 104 metacarpal fractures in 81 patients. Again, these are all treated with plate osteosynthesis. And in their series, they actually found 15 patients with healing problems, the actual nonunion or delay union, 10% of patients with stiffness, and these are, again, patients with plate fixation, 8% that, however, have failure, and 1% with a deep infection. So looking at plating versus IMO, KYR fixation, this is a prospect of a level three series where the first 20 patients have lock plating, next 19 with IMO, KYR fixation, bouquet pinning. They found that the total arc of motion, MP flexion, in the plating group is only 60% of the contralateral side, compared with nearly 100% gain of motion when you do a bouquet pinning. Extension, you have restoration of MP extension in both groups, 89, 99%, really no difference in pain, strength, dash score, and displacement. That's the main thing you're really seeing, is having the plate on the dorsal surface of metacarpal. You are predisposed into developing a MP extension contracture. And so I think for the most part, whether it's metacarpal fractures or a P1 fracture, so then even the most severe injuries, if you get a good overall closed reduction, correct the malrotation, I think pinning is really the way to go. Less is better, for the most part. If you look at that same series, looking at plate fixation versus KYRs, secondary procedures are also a lot more common in the plating group. Three out of 18 in the plating group have hardware removal and tenolysis, and they actually have one case of a patient with severe periosteal stripping, such that there's avascular necrosis in metacarpal head. Very uncommon. You see this more in P1 fractures. But something to keep in mind, as you're trying to obtain that perfect reduction, don't overstrip the periosteum. There's also a consideration of cost. If you get the exact same outcome with simple pinning, I think it's something to consider over plate fixation, for the most part. Infections, again, thankfully these are fairly rare. In an open fracture, up to 11 percent. You can see infection. In a closed fracture, it's fairly rare, 0.5 percent. This, again, mostly a level four case series reported by the authors. It's really a direct correlation to the amount of soft tissue involvement and contamination. The literature has really shown that in most grade one and grade two fractures, really no difference with emergent treatment of these injuries, versus greater than 12 hours. In a type one fracture, these can be treated like closed injuries. So irrigation debridement, definitive fixation at the initial surgery. Type two, there's really no consensus with the guidelines by authors, Gonzalez et al. You had to do a irrigation debridement, leave the wound open, and come back in 24 to 72 hours. Make sure you have a clean wound bed and definitive fixation, versus IND and definitive fixation right off the bat, if you don't think the contamination is too severe and too significant. Looking at type three fractures, where you have a significant soft tissue injury, perhaps a need for flap coverage, I think it's important to do a very aggressive irrigation debridement right off the bat in the OR, followed by either K-wires or external fixator. Penicillin is important to administer if there's soil contamination. It's important to come back with a repeat debridement at 24 and 72 hours, with repeated debridement every two, three days, and type of entropic cultures, confirming that your bacterial count is less than 10 to the five per gram, and most literature also supports early soft tissue flap coverage within a week after you have a clean tissue bed. Looking at osteomyelitis, very rare, but 50% of these can go on to an amputation. With diagnosis, you're really looking at clinical examination and radiographs, there's really no benefit to advanced imaging with bone scanning or MRIs, and really counting on intraoperative biopsies and cultures. If you have a hardware in place, it's important to remove all the hardware with debridement of soft tissue and bone, and placement of antibiotic-impregnated bone cement, and external or internal fixation. Again, there's really no consensus and no level one or two evidence on the preference for this or the guidelines for this. IV antibiotics before the six weeks, four weeks free of antibiotics, and you're really looking for the patient to be asymptomatic clinically, as well as normalized lab markers of ESR and CRP. In the second stage, it's important intraoperative cultures with fresh frozens, if negative bone grafting and internal fixation. Non-union, Jupiter et al. defined non-union delaying is no clinical radiographic healing at four months, but as Dr. Lon alluded to, oftentimes patients have no pain, so they're clinically healed, but you can't see radiographic evidence of a fracture line as far as 14 months, so really you're counting on clinical examination as far as defining a non-union. Oftentimes, patients actually have quite a bit of healing early on. These can be separated into hypertrophic non-unions with lack of stability, or atrophic non-unions where you have bone loss or blood supply compromise. Hypertrophic non-unions, these are patients that are inadequately mobilized, whether it's with casting or splinting, or with operative fixation, so if you have any bit of instability, or it could happen with any type of fracture where you have soft tissue interposed, or failure of fixation where you don't have rigid enough fixation in early range of motion. Treatment is generally debridement of the fibrous tissue interposed and application of rigid fixation to allow for bone instability. Atrophic non-unions, these are in the setting of an open injury or an infection where you have significant bone loss or soft tissue loss. It's important to debride interposed soft tissue. Any bone that looks like it's devitalized or infected. Bone grafting, I think for the most part, if you're going in for atrophic non-union, you debride this interposed tissue, and it's important to bone grab and stable fixation, which allows for early range of motion. So my preference for these is plate fixation, something that allows for early range of motion right off the bat for a patient to avoid stiffness. So this is a series, non-unions are rare, but this series by Fusetti in 2002 actually looked at non-unions and deli-unions and found that with a transverse fracture, deli-unions can happen as much as 30% of patients in their series. The thought is really have less bony apposition in the shaft compared to something that's more of a spiral fracture pattern. In manual workers, they attribute it to possibly compliance and doing too much too early. But deli-unions and non-unions are a lot more common in manual workers compared to the office worker. Non-union, the general guidelines are plate fixation is better than K-wire, and I think that's what's recommended. But keep in mind, we are just counseling the patient that tinolysis is oftentimes needed as a second stage procedure, and as you're looking at indications for this, there's significant soft tissue loss, so that they're just insensate, especially in a fairly complex trauma. The finger becomes a liability, so these are patients you really want to think twice as far as doing bone grafting for a non-union, and the amputation sometimes is really the best interest of the patient. Moving on to probably the most common complication, the complication that you will likely be looking at some type of operative treatment for is mal-unions. These could be from closed treatment or RIF, and the ones that you're looking at are shortening, mal-rotation, angulation, and the surgery could be performed to improve function. Sometimes it's really aesthetics, really a cosmetic complaint that the patient may have, bony prominence, loss of a knuckle contour. A look at our 1998 biomechanical studies demonstrated that if you have shortening of the metacarpal of two millimeters, it gives you a seven-degree extensor lag, and Dr. Lalonde talks about the inter-metacarpal ligaments, which prevents shortening, so shortening in central digits is fairly uncommon, so you're really looking at this as something that's more likely to happen in a border digit, but there is a compensatory aspect. The MCP joint can hyperextend approximately 20 degrees, so you can tolerate six-millimeter shortening, which theoretically gives you a 20-degree extensor lag, but with hyperextension, most patients can achieve neutral extension of the MP joint, so you can accept quite a bit of shortening in this patient population. Looking at angulation, sagittal angulation is much more common than coronal angulation, and it's important to keep in mind that I have quite a bit of mobility over the ring and small finger CMC joints, sagittal angulation, the index and middle finger, most people will not tolerate more than 10 degrees, ring finger, 20 degrees, and small finger, 30 degrees, and once you reach 30 degrees of dorsal apex angulation, it can lead to grip weakness if untreated. Moving on to metacarpal neck, looking more distally, index and metacarpal neck fractures, 10 to 15 degrees, ring finger, the general guideline is 30 degrees, small finger, I think recent literature has supported that most patients can do quite well functionally with angulation as much as 70 degrees of the metacarpal neck can do quite well. Dr. Hammer talked about the concept of pseudocline. If you have severe apex dorsal angulation, the MP joint tends to hyperextend, then you end up losing, you have slack over the PIP joints, so you end up with an extensor lag because you lose excursion of the extensor mechanism, so although these patients may do quite well functionally, you may notice an extensor lag of the PIP joint. If that happens, this is a patient that may benefit from a correction of the metacarpal neck angulation. Malrotation, perhaps the most common reason that we treat these patients operatively as far as from a functional standpoint, and you're really looking at malrotation and metacarpal transfer into digits, so you have overlap of digits over the nail bed. The angulation is well tolerated in most patients, especially metacarpal necks, tolerate angulation up to 70 degrees, but malrotation, even by a couple degrees, transmits distally, affect the entire digit. It's important to check the contralateral hand. As you see in your practice, a lot of patients have some small amount of caesarean, that's baseline, that's their anatomic variant. It's something that they've adapted to over time, but in general, with finger flexion, the digits and nails should point towards the scaphoid tubercle, and as little as five degrees of malrotation at your metacarpal shaft could transfer to 1.5 centimeter of digital overlap. So as you're looking at these patients, it's important to assess in both extension and flexion a finger that looks like it's well aligned on extension with flexion. You really get really exacerbation of the amount of digital overlap, so it's important to really check for a patient's finger cascade in full flexion. Looking at derotational osteotomy, I think you really have a choice of osteotomy through the original fracture site versus something that's more of a chronic malunion, you could do an osteotomy at the base of the metacarpal. The concept is you're doing an osteotomy to a cancellous bone, better healing than metaphyseal bone. K-wire fixation versus plate fixation, plate fixation potentially has the benefits of earlier range of motion, and osteotomy of the proximal metaphyses, you could derotate actually as much as 18 or 20 degrees distally just by doing a derotational osteotomy right at the base of the metacarpal, so you could achieve quite a bit of correction by doing this. Step cut osteotomy was a concept that was advocated by Mantelow in 1981, and Jawa and Jupiter really described the modification of this. The concept is you do a step cut osteotomy, allows for more bony apposition as opposed to transverse osteotomy, and just by removing about a millimeter of dorsal cortex and derotating the metacarpal, allows for correction of one centimeter of overlap at the fingertips. So this is a nice technique to keep in mind. And by doing a step cut osteotomy, obviates the need for plate fixation, so you could do two or three lag screws, less hardware, less adhesions, and perhaps less stiffness, and you could still do early range of motion with this patient population. And if you're looking at multi-planar deformity with angulation and rotation, in this case you have to do the osteotomy at the original fracture site. If you're looking at a chronic angulation malunion, looking at a closing or opening wedge osteotomy, a closing wedge osteotomy may allow for better healing, but you really want to be careful with over-shortening, especially with severe angulation. Stiffness, very, very common, especially with plate fixation. This is a 1979 looking at dorsal capsulotomy of the MCP joint versus PIP, dorsal or volar capsulotomy, and most of the gains were quite modest. The overall increase in total arc of motion was 13 to 18 degrees, but really giving the patient is really a change in the function of arc of motion, so most patients are quite happy that they might have not, you might change them for somebody who has a severe extension contracture to more flexion arc, but overall gains are modest, but perhaps you're giving them a better functional range of motion. But again, really important to keep in mind as we counsel these patients that the gains are quite modest in a large number of cases. Creighton and Steichen in 1994, again looked at a very large series of patients with fractures of metacarpal and phalangeal fractures, looking at extensor kineolysis only versus capsulotomy, and patients that needed a capsulotomy, these are cases where they have limited passive flexion at the MP or PIP joints, kineolysis only, the results are much better and more predictable, total arc of motion improvement from 173 to 227, so 54 degree improvement or 31%. The extensor lac could also be improved from 16, mean of 16 to 8 degrees, so 50% improvement extensor lac. However, in cases where you have limited active and passive motion, where you end up doing a kineolysis and a capsulotomy, you're improving the total arc of motion from 164 to 190 for fairly modest improvement, 20%. The extensor lac could be actually, you could actually have no improvement and perhaps worse extensor lac. So again, you're giving them more functional arc of motion, but limited improvement as far as extensor lac. And going back to the Peter Stern series with Page and Stern, 15 digits kineolysis, 7 metacarpals, 8 P1 fractures, and really a variety of kineolysis and capsulotomy. And out of the 15 patients who underwent kineolysis, only 3 had improvement in range of motion. Again, very modest gains. And 2 of the 3 were in metacarpal fractures. I think in summary, as the other two speakers have really gone to great discussion on, is majority of hand fractures are amenable to conservative management. Mild malunion, especially angulation, is well tolerated, except for rotation deformity. For the most part, less is more. If you get away with closed reduction or KOR fixation, complications are a lot more common than plate fixation. And you really have limited success with kineolysis and capsulotomy. Thank you.

panel discussion

metacarpal fractures

complications

treatment approaches

surgical interventions