I'm Don Lalonde, and my job is to talk about the non-operative management of metacarpal fractures, and so that part is probably a little more boring for surgeons, but I've tried to pepper it with as much evidence as I can find in this topic, and also to put in some clinical pearls of how we manage these problems. We teach our residents six main principles of hand fractures. One, early controlled movement in hand fractures is as important as early controlled movement in flexor tendon injuries for the same reason, stiff fingers are useless fingers. Number two, do as little dissection as possible to solve the problem so that when you can use percutaneous K-wires, it's good if you can do it. Number three, try to get congruous non-subluxated joint surfaces. Number four, treat to get great movement, not to get great x-rays. Number five, get off pain medicine as soon as possible and listen to your body. Don't baby it, but don't do what hurts is what we tell our patients. And number six is probably the cardinal rule of treating hand fractures. When they come in looking like this, don't screw it up with surgery unless the joints look bad. You know, if you've got bad PIP joints and they're looking like that, then you've got to do something. But if the joints look good and they have shaft fractures and their hand function looks like this, don't screw it up with surgery. So those are the main things that we teach our residents for what it's worth from a clinical Perl's perspective. There's level three evidence comparing surgery and no surgery for Boxer's fracture from this 2008 paper. And their bottom line is that non-operative treatment of Boxer's fracture has resulted in better long-term DASH and aesthetic scores than operative treatment of this injury, at least in this group. The operative group was small, though, and like all studies, it had issues. But it is level three evidence, and it was just interesting. A young woman presents with a Boxer's fracture. Which of the following outcomes has been found to be superior with bouquet osteosynthesis – that's the intramedullary splints with K-wires – versus conservative treatment for her injury? And the answer was patient satisfaction. And Dr. Warren Hammert, who's just walked in, has written a great paper on the evidence of metacarpal fractures, and a lot of these questions are taken from his paper. There's level two evidence where 20 Boxer's got no surgery, 20 Boxer's got bouquet osteosynthesis, and there was no differences in flexion, extension, grip strength. Both groups had similar radiographic angulation and shortening. But the patients in the operative group reported higher overall satisfaction and better aesthetic results. So not much difference, but the patients were happier. Most would say that more than 30 to 40 degrees should be opened, but some accept as much as 70 degrees. This paper is level two evidence from Amsterdam in a paper written in 2003. They had 40 patients with up to 70 degrees angulation randomly allocated to either ulnar gutter plaster splint for three weeks, so casted for three weeks, or a pressure bandage for one week and then move and don't do what hurts. The bottom line, no difference with respect to range of motion, satisfaction, pain perception, return to work, and hobby, or the need for physiotherapy. And that was up to 70 degrees angulation. In the 1970s and before, hands were often immobilized for four to six weeks, waiting for healed on x-ray. The problem is that radiological union of hand fractures is way behind clinical union. It's not like long bones. And many of us have operated on fractures at three weeks where the bones are solidly united like concrete, even though the radiologist interprets the x-rays as not united. And the point is that you're going to get stiff fingers if you wait for radiological union. And the pearl is that the fracture's healed when you press on it, and there's no pain there. In general, and you know this yourself, when you operate on people, if they're getting a malunion, if you press on the fracture, when you get in there, you're going to need a freer elevator to take the callus off and get the fracture apart. This was a game-changer for my practice. In 2008, Eric Hoffmeister and Alex Shin, who are both at this meeting, published a level one evidence study where they had half of the patient's prospective randomized control trial immobilized with the MP in flexion, and the other half immobilized with the MP in extension. And guess what? No difference. The theoretical argument that collateral ligament shortening is going to lead to stiff MP joints in fact did not happen with three weeks of splinting. It may be because most of our boxers are younger people, and it's hard to get younger people stiff. But there was no difference in grip strength, range of motion, or dash scores. And in my practice, it's easier to put on a cast and keep the reduction with the MP joint in extension. So ever since 2008, when this paper came out, because it was level two evidence, it's changed my practice. And that's what I've been doing for the last five years, and I got to tell you, there's no difference except for it's easier for me to keep my reductions. And I've not seen any stiffness. This paper by Beckenbaugh and colleagues from the Mayo Clinic, which barely immobilizes the MP joint, so pretty much not at all, but does it very carefully with finger trap and so on. That's level four evidence, but they had 59 patients with a minimum x-ray follow-up of three months, and they changed their angulation with this technique from 32 degrees to 6 degrees, so an 81% improvement. And they lost less than one degree from the initial clinical correction at their follow-up at three months. And so they really got quite good results, and that thing was barely immobilized. There's level two evidence in this 2007 study that follow-up after boxer fracture might not be necessary after we see them in hand clinic. They had 40 patients where they put them in a plaster or cast for three weeks and followed them up, and they had 38 patients where they just buddy taped them, gave them information sheets and said, come back if you have a problem. And the bottom line was that the patients were more satisfied with the buddy taping and come back if you have a problem than with the regular follow-up visits. The time for return to work and the come back if you have a problem group was 2.7 weeks and in the casted group was five weeks. And there was no significant difference in the 12-week dash score. So they're getting better in spite of us maybe, not because of us sometimes. The only Cochran's study that I could find on metacarpal fractures is this old one from seven years ago. They said that there were five poorly, poor quality randomized control trials to compare functional results of the different types of conservative treatment, non-surgical treatment. And the bottom line was that they all seemed to yield pretty good results and no method was better than the other. In our practice, if I have a reasonable adult like anybody in this room for this fracture, we'll put them in a removable splint. Your hand is on strike for the first two or three days. You can take Tylenol or Advil if your hand is up higher than your heart and you're not using it. When you're totally off Advil-Tylenol, then you can start to use your hand and listen to your body and don't do what hurts. You can take the splint off to get in the shower in the morning and you can take it off in the evening to move your hand as long as you're not on Advil-Tylenol so that you know what hurts. And this is pretty much what they look like at 10 days and four weeks for most reasonable adult patients. And we say to all our patients, there's two kinds of any pain after any broken bone or any operation. There's the pain of the cut or the break. And that's if your hand is sitting up here after your break and it hurts, well, you go ahead and take something for pain. Not a problem. We tell them that we don't want them to move it at all until they're off all pain medicine because then they get into the second kind of pain, which is the pain of, gee, doctor, now it only hurts when I move or when I put my hand down. Perfect. That's when you quit taking painkillers and you can start putting your hand down and start moving, but listen to your body and don't do what hurts. We tell them we didn't spend two billion years evolving pain because it's bad for us, contrary to popular opinion and certainly the makers of Advil, our pain is our body's only way to say to us, hey, stop that. I'm trying to heal in here and you're screwing it up. And a lot of patients get it. And they listen to that and they get better faster in our experience. There's a great book called The Gift of Pain that John Agee gave everybody in this society as a gift last year. I would highly recommend that you read it. And I'd also be happy to send you our pain-guided hand therapy for hand fractures, the St. John Protocol. So early protected movement for hand fractures, 30 degrees of IP joint movement is five millimeters of tendon glide. You only need to move your fingers a little bit so they don't get stiff. And early protected movement for me doesn't mean immediately. It means three or four days after surgery or fracture because collagen formation doesn't even start until day three. And if you move somebody the afternoon that you put a plate on or that you do their flexor tendon repair, what's going to happen? It's going to bleed inside the wound. That blood turns to scar and callus and that's just going to create more stiffness in the long run. And that's why we tell people to not move until they're off painkillers and listen to their body. You don't need rigid internal fixation. Functionally stable fixation is what we aim for. And functionally stable fixation is enough fixation that the bone will heal in a good position of function and get a good range of motion. And so in this case, it's a finger fracture, but we do the same thing with our metacarpal fractures. We start movement four days after the surgery as long as they're off Advil and Tylenol. When the fracture site is no longer tender, we take out the pins and we check their range of motion because we do them all wide awake, of course, and we check the range of motion after we put the K wires in and that's what we do in our practice. The problem with K wires, of course, is infection where the K wires are sticking out and that infection is totally related to movement. We all know that when we have hardware coming out of patient's skin, if there's no movement there, there's no infection. And so if the patients are allowed to move with K wires sticking out, they frequently get infected. If the patient is only allowed to move with a K wire sticking out and told that they can only move if it doesn't hurt and if they're totally off painkillers, guess what happens? They don't get infection. And the reason is that the K wire hurts if they move it too much. And if they move it too much, they stop hurting. And in this way, you can do early protected movement with K wired finger and metacarpal fractures and you're not going to have problems with infection. And so once again, it's a pain-related function and we spend a lot of time explaining and educating to our patients about pain. Why do we immobilize hand fractures too long at the risk of them going to concrete? Because we don't want to lose our pretty post-reduction x-ray. And we're also concerned about legal issues if we do that. But the fact is that non-union and metacarpal fractures pretty much doesn't happen. What does happen frequently is that they get stiff. And so it's something for you to consider. There is a fracture. I need to fix it. These spiral metacarpal fractures are very tempting. And I used to operate on them all. But what I do now is I look at their range of motion when they come in. And if they're not scissoring, then we put a splint on them and we have them come back in a week, 10 days when the bones are sticky. We then check them again to make sure they're still not scissoring. If they are scissoring, we'll go ahead and operate on them. If they're not scissoring, then we give them a removable splint, do the don't do what hurts thing, let them take it off. And with that, I've got a lot of people that I have not operated on over the years. And here they are post-op, and they've done quite well. We actually got our cases together. We will be publishing it. There's 61 of these cases where the patients did well. Unfortunately, it's hard to get long-term follow-up because a lot of these are Saturday night warriors, as you know, and never come back, especially if they have a good result. But the 13 cases that we did manage to follow with a mean of 86 weeks, there was no difference in grip strength between the two sides and no difference in power. In Al-Qahtan, level 4 evidence, he had 42 patients with the same thing, spiral metacarpal fractures, no scissoring, immediate finger mobilization. They followed them and made sure that they got sticky and continued to not scissor and got good results. So why do we operate on spiral metacarpal fractures? We do it to bring them out to length and prevent shortening to maintain power. The theory is that we maintain power. In my practice, it doesn't make any difference. And I think the reason is that the interosseous ligaments prevent the metacarpal from shortening more than 5 millimeters. And so it doesn't shorten all that much, and you don't lose all that much power. But when I used to operate on them, I used to do quite a lot of tearing of interosseous muscles as I stripped the periosteum off of the bone. And I kept thinking, what am I doing to MP flexion power by doing that? It just can't be that good for them. And that's why I try to do them closed with K wires when I can. This particular individual had talked me into operating on him. He had a minimal scissoring spiral metacarpal fracture. And he had great function with no scissoring. And I told him, look, I don't think I should operate on this because you're really not having any scissoring, and I don't think you're going to have a problem. And he didn't like his X-ray, and he said, look, I really don't like that. I want you to fix it. Can you fix it? And I said, yes, I can fix it. Even though it's not my best advice. Unfortunately, he got severe CRPS, lost his job, his income, and his marriage. Now, it might not have been my operation that did that. Maybe it would have happened anyway just because of his fracture. But I got to tell you, when stuff like this happens, it turns your hair white. Oh, maybe that's what happened. Anyway, question one, a 22-year-old presents with a boxer's fracture with 15 degrees of angulation. What's the most appropriate next step in management and probably non-operative management of some kind? I don't think most people would operate on that. A 35-year-old presents with a boxer's fracture of 40 degrees. What's the most important advantage of treating this fracture with open reduction plates and screws? And the answer is initiation of early active motion. By the way, in the course handouts by tomorrow or the next day, all of the discussions and references that Dr. Hammert and his group so nicely created are going to be online in your handouts. And that's why I'm not going through all the discussions and so on, because you want to hear about surgery. You've had enough of this stuff already. The dorsal apex angulation seen commonly in boxers' fractures is most significantly caused by unopposed forces of what group of muscles? And the answer is the interosseous muscles. Now, thumbs in kids can immobilize longer for closed reduction because kids don't get stiff and thumbs are best stable. They don't need to be as mobile as they do need to be stable. And thumb metacarpal fractures, 30 to 40 degrees of angulation can be accepted as long as there's bony apposition of 75% of the thumb metacarpal shaft diameter. But once you get past 30 degrees, the MP joint compensates and the volar plate stretches and you get hyperextension. This is a Bennett's fracture, which in my practice gets 40 cc's of 1% lidocaine with epinephrine and a closed reduction wide awake. And distraction is important, adducting the base is important. But the most important move in my view is this number three move right here, which is pronation. Because when you pronate the thumb, the dorsal ligament complex just forces that baby into a beautiful reduction and you really rarely have to open these. Most of the time, if you beautifully pronate that thing, you get a perfect reduction and a K wire and there's the fellow that I just showed you. And here he is after wide awake K wiring in the clinic. A 50-year-old mechanic presents after a crush injury to his thumb. He's got a superficial laceration and a Rolando fracture with a four millimeter articular step off, which of the following is the most important in telling you that you ought to operate? And that's getting the articular surface together. And certainly we would all operate on those. After a fall from a bicycle, a 45-year-old woman presents with metacarpal fractures of the index, long, and ring. So multiple metacarpal fractures are best managed by rigid plate fixation. And I would totally agree with this. This is a situation where I would not use K wires. I open them up and plate them. Because if you have multiple metacarpals, I just don't know any other way. But there are problems with plates and screws. And the biggest problem in my experience is not the plate. It's the darn scar over top of the plate, which makes the bow stringing of the tendons over that. And I'm sure we've all had the experience of going in and taking out a plate on Thursday. And by Monday, they already have a better range of motion, just because you're getting that scar and the plate out of there. And in Canada, I've often ended up taking plates out because of cold problems. I know it's less of a problem in southern Florida. But my biggest problem with plates and screws is the dissection. Because everywhere that you dissect, you create callus and scar that seizes tendons and joints. Because you get blood in there, and blood turns to callus and scar. And so I try to never open a fracture that I can treat closed. And whenever I can do them with K wires, I do. I think percutaneous screw fixation is probably the way of the future. It's still technically very difficult. And I'm certainly no good at it. And I bow my head to those of you who are. Because I think it's the right thing to do as much as possible. A 20-year-old woman presents with an intra-articular fracture of the index finger with a 2-millimeter bony gap after striking the wall. The most important advantage of open reduction and internal fixation is decreased post-traumatic arthrosis. And a 75-year-old suffers a bad fracture with 50 degrees. And the answer here is, why should you operate? And it's the degree of angulation. And a little pearl here, when somebody comes in with a barnyard injury with a fractured metacarpal like this person does, they get their hand totally numbed up in the emergency department. And they get a serious shower. You know, there's nothing. If you think of the concentration of bacteria in tap water, it's less than 10 to the 1. And the difference between that and sterile saline is clinically insignificant. And squirting a few cc's of holy saline on something in an operating room, to me, is not as effective as this. This patient actually never went to the operating room. We just did that, put a vac on it, and he healed. The fracture was minimally displaced, and we got no infections. For baby Bennett's, we numb up the other side of the hand and go ahead and K-wire those. Metacarpal base interarticular fractures are generally well-tolerated in the fingers, not so much in the thumb. In the thumb, Dr. Seiler's going to talk about that. And I'm just going to finish off by saying that in a 78-year-old person, which I've just turned 60, so I keep thinking about these things. When people are getting older, you want to be less and less aggressive about operating on them. And so this fellow has two spiral metacarpal fractures, and he's got a dislocated PIP joint. I want to operate on him like a hole in the head. And so we do all the usual things. We built him a little splint to remind him that he couldn't pile as much wood as he normally does. And it moves at three days, and here he is at 20 days after injury, because he wasn't scissoring at all. And if they come in looking like this, don't screw it up with surgery. That's my last take-home message about not operating metacarpal fractures. And so I think next we're going to have, who's going to go next, Dr. Warren, do you want to go next? Yeah. So can you escape me, and thank you.

non-operative management

metacarpal fractures

hand fractures

controlled movement

surgical vs non-operative treatment

thumb and spiral metacarpal fractures