Well, thank you, Don. I appreciate the opportunity to participate in this. So my role is to talk about surgical treatment of the non-thumb or the finger metacarpal fractures. I have nothing relevant to this or anything else to disclose. Maintenance of certification relies on evidence-based practice. And so what evidence-based medicine is is really the use of evidence to inform clinical decisions. And this is important for a variety of reasons. This is much different than the type of course that you typically come to at this meeting because I think we all understand what metacarpal fractures are, the basic concepts of how you treat metacarpal fractures, and we all probably get very good results. But there are certain things that I think make an evidence-based approach to this important, and we'll kind of go through some of those. At some point, reimbursement may be tied to outcomes. As we've heard in a variety of different things with the changes in the health care environment, this is going to be important in the future. There are best practice guidelines. More recently, the American Academy of Orthopedic Surgeons has developed clinical practice guidelines and appropriate use criteria. Although they don't affect finger fractures, they affect distal radius fractures, carpal tunnel syndrome, and other things that we commonly treat as hand surgeons. And then finally, for maintenance of certification, the boards require it. So as much as you may not like something like this or carpal tunnel syndrome, if you want to maintain your board certification and you became certified after 1986 or 87, this is a necessity. And so this is an easy way to get this information as you're here at the course. So to look through the finger metacarpal fractures or the non-thumb metacarpal fractures, what we did is started off with identification of the evidence. And so I looked through the databases with PubMed, OVID, and Cochrane. The timeframe that I searched for was 2005 until the present for any studies that were classified as level 1 or level 2 evidence, and then 2009 to the present to discuss level 3 and level 4 evidence. And so I'm just going to run through those. The terms that we used, the common ones that you'd think about are listed here. I don't need to read them, but really anything that could be related to metacarpal fractures and treatment. So when you look at surgical treatment, there are anatomical considerations. And as Dr. Lalonde pointed out, rotation is critical. So if they don't move and they flex and the alignment looks pretty good, you probably don't need to treat them, and so you're going to be able to manage those nonoperatively. And many of them, if not most, at least isolated metacarpal fractures can be treated nonoperatively. The malrotation of the finger flexion is what causes a problem. That's really going to be the predominant indication to operate on these. As Dr. Lalonde talked about, there is good evidence to suggest that you can splint these, particularly the fifth metacarpal neck, straight. The one thing that I find is if you flex the MP joint, it does help create more stability in a radial ulnar direction. So I still splint the fifth metacarpal neck fractures in flexion. But clearly it's whatever is easiest for you and you can get acceptable outcomes with either way. So really the indications, as we talked about, malrotation, multiple fractures because the inner metacarpal ligament has lost its ability to maintain the length and hold these in relatively good alignment. Open fractures, displaced articular fractures, and if there's residual angulation, and it becomes more problematic as you move proximal on the metacarpal. So you're going to accept a lot more angulation in the metacarpal neck region, particularly on the ulnar side of the hand, than at the metacarpal base along the radial side of the hand. So here is flexion. You can see malrotation and problem. So when you look at fixation, we decide we're going to operate on these different fixation techniques from the standpoint of being the least stable to the most stable, starting with cross-K wires, transverse wires, interosseous wires, lag screws, and then plates and screws. As has been mentioned, you don't have to have absolute rigid fixation. Functionally stable fixation is what you want with this. So you can start moving these. They're not going to fall apart. You just want to basically hold it until the body can go ahead and heal up, as opposed to, for example, in the lower extremity where you need enough stability that you can bear weight on it. As far as operative management, looking at the preoperative assessment, there's no evidence to suggest one thing is necessary or better than the other, so I have to say there's none there. From an anesthesia standpoint, there's really no evidence to suggest that one means is particularly better than the other. There's probably reasons that you would be better doing this under straight local or local incidation, from patient being able to get in and out, timing standpoint, a variety of things, but there's no evidence to suggest that any one of these methods are better than the others. Okay, and we'll go about the specific fractures here and talk about them. Interarticular fractures of the metacarpal head are fairly rare, but operative fixation is important for anatomic alignment of these joints. And so any gap greater than 25 millimeters or 25% of the articular surface is probably an indication for operative fixation. So you want to have anatomic alignment that is adequate and enough stability that you can allow early motion. In this situation, probably one or two screws countersunk below the articular surface is going to be adequate to provide stability. Another example, and sometimes in spite of your best efforts, these bones start to fragment as you try to fixate the fracture. And so what you initially planned to have one or two screws across here suddenly turns several screws, a surclodge wire and a K wire to get it out to length. And as Don mentioned, this is going to create more scarring. It's going to cause problems potentially with motion. So you really need to get these started moving as soon as you have adequate stability of your fracture. So what is the evidence for metacarpal head fractures? Well, there's not a whole lot. There's one paper published in the Journal of Hand Surgery, which is a level four evidence. They looked at 10 patients with 11 interarticular fractures, described ORIF with interfragmentary screws, countersunk below the cartilage, found that the average motion was almost 80 degrees at the MP joint. So it really doesn't tell us a whole lot other than that is something that, you know, can do reasonably well. Metacarpal neck fractures. Well, the evidence would suggest that the small and the ring are the most common and that the ulnar side of the hand tolerates more flexion secondary to the mobility at the fourth and fifth CMC joints, with the middle and ring fingers being much more stable at the CMC joints, less motion. So we can tolerate less angulation. Ring and small papers describe 40 to 70 degrees of angulation being adequate, as opposed to the index and middle finger allowing about 10 to 15 degrees. Pseudoclawing can develop, which is a situation where the metacarpal neck fractures. So you have an apex dorsal angulation and a relative shortening of the metacarpal. So you get extensor tendon pulling and it bounds down, and so you get PIP joint hyperextension because the metacarpal length has been shortened a little bit. So treatment for these, typically closed reduction and percutaneous pinning, or in some situations, ORIF. Typically, there's not enough bone distally for plate and screw fixation, so even with ORIF, you're more apt to use K-wires or bouquet osteosynthesis for your fixation. So what is the evidence regarding treatment of metacarpal neck fractures? Here's a paper that's level two evidence, published in the European Journal of Hand Surgery in 2010. It kind of had a randomized trial, but it wasn't the best randomization process. But they compared operative and nonoperative treatment of fifth metacarpal neck fractures. I think, as this was discussed, there were 20 in each arm, bouquet osteosynthesis, and then 20 managed nonoperatively. They had similar motion, grip strength, and radiographic appearance. So from an objective standpoint, the two treatments did not show any difference. But from a subjective standpoint, the operative group had higher satisfaction, secondary to higher aesthetic scores. Another level two study from the European Journal of Hand Surgery in 2007. It's a prospective randomized controlled trial comparing intramedullary fixation versus transverse pinning. In this trial, they found that the IM fixation was significantly better as far as total motion as well as active motion. Another study in the European Journal. You see a trend here. There's more of these that are looked at in the European Journal, certainly, than the American Journal. But in 2011, level three study comparing IM and transverse pinning for ring and small finger metacarpal fractures. They had 22 in the IM or bouquet pinning group and 45 in the transverse group. Demonstrated similar outcomes as far as motion, quick dash scores, and grip strength. But there's a higher complication in the transverse pinning group, which were iatrogenic fractures and pin track infections. So based on this, you conclude that the IM bouquet pinning, even though the numbers were a little bit smaller, are probably superior to transverse pinning. Another study published in the Orthopedic Trauma and Surgery Research. It's a level three IM pinning looking at 20 patients compared to locked plating for 18 patients with small finger metacarpal neck fractures. Had similar dash, grip strength, pain, and radiographic results. The IM pinning group had shorter operative times, but overall probably comparable as far as these two treatments. Another study published in the Journal Injury from 2011, level four evidence. They had 35 fifth metacarpal neck fractures treated with closed reduction pinning, 25 month follow-up. And all these patients had 90 degrees of MP motion, what they described as full IP joint motion. Two of the patients had an extensor lag less than 10 degrees. The mean dash score was five, and the angulation was corrected. These had an average of 63 degrees preoperatively. And the neutral all but three were corrected, and those averaged seven degrees. So still significant correction of the radiographic angulation. So in summary for treatment of metacarpal neck fractures, there's multiple treatment options. The literature does not support one method as clearly superior to the others. There does seem to be a higher rate of complications with transverse pinning when compared to bouquet pinning or K wires, cross K wires. Moving a little proximal to metacarpal shaft, angulation tends to be more problematic as you move proximally. So an example of this, that if everything is okay, and the other views may be acceptable being treated nonoperatively, but when you look at the oblique and you look at the lateral, this was probably a little bit too displaced just to manage nonoperatively, particularly with the overriding of the distal fragment, the lower cortex against the dorsal cortex. And so this would heal, be left with a prominence there and a depression in the metacarpal head region. And so we've seen some of the other studies, the aesthetic appearance of this can be a concern to some patients, at least those studied in the European literature. So treatment options for these, ORIF with plate and screws, certainly one example. ORIF with lag screws, depending on the obliquity of the fracture. And their example of that. So what is the evidence for treatment of metacarpal shaft fractures? Well, Con Oser had a paper published in 2008, Level 3 Evidence, so two case comparative series. There were 52 consecutive fractures. Some of them were treated with IM fixation with a plate and others with screws. So a nonrandomized trial, which is subject to all the biases of a nonrandomized trial. But in this group, or these two cohorts, they found no significant difference in dash scores, range of motion, metacarpal shortening, angulation, or healing. Another study, Level 4 Evidence, 42 metacarpal fractures and phalangeal fractures. So a little bit hard to sort through just the metacarpal fractures because they didn't classify or stratify how many were in each group. But 21 of the metacarpal fractures treated with mini plates and screws all had 100 percent union at 12 months and total active motion, so the composite of the three joints of greater than 210 degrees in 73 percent of the patients. When you look at epidemiology, paper study published in the Journal of Hand Surgery in 2010, which is a Level 4 study but really classified as a prognostic study. This is really what fractures are the most common. They looked at 67 ring and small finger metacarpals, and the small finger metacarpals found that the metacarpal neck was the most common location, and in the ring finger the metacarpal shaft was the most common location. In addition, they noted that the diameter of the ring finger metacarpal shaft is the smallest, so this has implications if you're going to treat with surgical fixation, particularly with plates and screws. Multiple fractures, this makes it a little more challenging to manage these nonoperatively, and probably one indication, as we mentioned, to almost always treat these, secondary to loss of the intermetacarpal ligaments and the ability to maintain length. So in these you're going to be more apt to stabilize these and fix these in some degree typically. If you look at the evidence, though, that's out there, there's not great evidence. A Level 4 study in the Journal of Orthopedic Trauma where they looked at 2.0 millimeter stainless steel dorsal plates, they found in total active motion 86% were excellent, and their criteria for excellent was greater than 220 degrees. Nine were classified as good, and in that range was between 120 degrees to 80 degrees, so quite a bit less. Another Level 4 paper published in the Journal of Hand Surgery 2011, multiple metacarpal fractures resulted in marked shortening due to the disruption of the intermetacarpal ligament, as discussed. Open fractures, another indication for operative treatment. These are more apt to develop infection. Closed fractures typically don't have problems with infection, even with operative treatment, but open fractures you have to at least consider. What's the evidence as far as treating them? Another Level 4 paper, so a retrospective case series published in the Journal of Trauma in 2010, comparing ORIF and open and closed metacarpal fractures. They had 365 patients with 432 fractures over 10 years, so a substantial number. And they found no higher risk of infection or postoperative complications when those were treated expeditiously, so within several hours of the presentation to the emergency department, with open reduction, internal fixation, washout, and closure of the skin, they found that the severity of the defect, the amount of comminution and soft tissue damage, were related to poor outcomes, i.e. loss of motion or stiffness, but no greater incidence of infection. Moving even more approximately, the fourth and fifth CMC fracture dislocations, much more common along the ulnar side of the hand and the radial side of the hand, so radiographic examples of what you see with that, treated with closed reduction and pinning. There's late results. So what is the evidence in managing these? Well, there's really not much. You can find anything, level one through four, demonstrating even outcomes, a retrospective case series of fourth and fifth metacarpal fractures published in the last several years. So in summary, unfortunately there's little, certainly great evidence to guide treatment and give us an idea of what to do with these. No fixation method has demonstrated to be more beneficial or functionally superior to other types. There's no good evidence for periods of immobilization or mobilization protocols, so that does leave us with some leeway to be able to do what we want from a standpoint of taking care of these patients, so relying on experience-based medicine as opposed to evidence-based medicine, which is what you have to do when there is not any evidence to guide your treatment. Stability, plates are more stable than lag screws, which are more stable than IMK wires, which are more stable than cross-K wires. If you look at pinning, IM pinning tends to result in better results than transverse pinning. When you compare pinning and plates, neither one of them has evidence to demonstrate that one is superior from an outcome standpoint, and there's no difference in types of plates or size of plates when comparing mini and micro plates, locking and non-locking plates, and absorbable plates. So that is what I have as far as fixation of non-thumb metacarpal fractures. I think next we'll move on to Dr. Wang from Seattle.

surgical treatment

non-thumb metacarpal fractures

evidence-based medicine

clinical decisions

reimbursement