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Metacarpal Fracture: Fellowship Virtual Debate Series
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Metacarpal Fracture: Fellowship Virtual Debate Series
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Segment:0 .
JEFF GREENBERG: So I'm going to introduce the topic of metacarpal fractures with two cases. The first is a 17-year-old male who was injured playing hockey. He presents with a closed small finger metacarpal fracture.
JEFF GREENBERG: No zebras here, just very typical, has fracture site tenderness, deformity, which includes the loss of a prominence of the metacarpal head, fullness on the volar aspect of his hand, loss of full extension, but a significant malrotation with a crossover deformity with flexion. And here you see he's got, you know, kind of almost a shaft fracture, a distal shaft fracture with significant amount of angular angulation as well as rotation, which can be picked up clinically.
JEFF GREENBERG: And then we'll move to the second case, a 50-year-old female who's in a high speed motor vehicle accident. We were actually asked to take care of her after she was already asleep in the operating room, because she had associated orthopedic injuries. They didn't realize she had a hand injury till they got her in the OR. She has deformity, closed injuries.
JEFF GREENBERG: We don't know anything about range of motion or sensation, has a normal vascular exam, and she has this X-ray which shows these more distal not really shaft fractures, which we're covering, but has multiple metacarpal fractures in isolated hand. And here you see significant angulation. So, so we have three teams that are going to debate metacarpals. We have metacarpal plating presented by Dr. Hess.
DANIEL HESS: OK. So hi everyone, thanks for the opportunity to provide our point of view in this virtual arena. My name is Dan Hess, one of the Fellows at Duke, and I want to thank Mike Milone and Marc Richard for their help with this presentation. So metacarpal fractures are a common problem in upper extremity trauma and most often seen on the ulnar digits. These are typically injuries of aggression, which may spell trouble when considering patient compliance with the treatment or rehab protocol.
DANIEL HESS: And these certainly aren't benign injuries without repercussions if treated improperly. It's been said that patients lose about seven degrees of flexion with every 2 millimeters of shortening of the metacarpal, and just 5 degrees of malrotation can lead to 1.5cm of digital overlap so it's important we get it right. And there are a number of surgical treatment methods and you'll hear about a few of them today
DANIEL HESS: so I won't belabor the point. So when should you use a plate? There's a lot of positives about plating. First off, plating typically done from a dorsal approach, provides stable fixation on the tension side of the fracture, which we all know is technically preferred. The stable fixation is especially important in patients that need to get back to their job or work sooner or sports sooner.
DANIEL HESS: And with all the various plate designs, I think it would be hard to argue that there is a more versatile approach and plates can be used for essentially any fracture type, including ones with bone loss or articular involvement. There's no need for a secondary procedure. There should not be any concern about placing plates and screws in the setting of an open injury, as that has not been shown to increase complications.
DANIEL HESS: And finally, I think a lot has been made about complication rate with plating, especially with extensor tendon pathology. But I would offer that much of that data is based on older plate designs, newer studies looking at currently available low profile plates really show very minimal complication rates. Here's a relatively straightforward case. 34-year-old male, punched someone in the face, par for the course and sustained this fourth metacarpal shaft fracture.
DANIEL HESS: Now possibly if you're kind of looking at the x-rays, maybe a little foreshortened on the PA, a little bit of comminution. Hard to tell if there's a separate butterfly fragment there and you get a good sense on the oblique view that maybe there's a little bit of malrotation and we have that characteristic apex dorsal deformity on the lateral view.
DANIEL HESS: So we chose to plate this fracture. We used a separate lag screw with a low profile plate placed over the top as a neutralization construct. We obtained excellent reduction with the plate, counteracting the deforming forces and was able to interpose some tissue between the plate and extensor tendons upon closure, which is certainly always helpful. It's hard to argue with the range of motion, clinical parents and outcome on this final follow up pictures.
DANIEL HESS: So what does the literature say? So traditional studies have reported higher complication rates for plating with stiffness being the primary concern but a closer look shows that many of these studies may not be entirely generalizable to metacarpal shaft fractures as we deal with them today. So all of these studies use older plating systems and a lot of them have included a substantial amount of high energy injuries, which you can certainly use plates for
DANIEL HESS: but that's not the topic of today's debate. And, you know, looking at those pictures, I doubt very much that the plates are the sole reason for those digits to be stiff. Today. plating systems for metacarpal fractures are shown here so in addition to having the use of very small screws with locking options, they're very narrow and low profile. The thickness of the plates range from 0.6 to 1.5 millimeters across these four major implant companies.
DANIEL HESS: And so, well, if that's true, you know, you may ask, why are there recent reports of bad outcomes with metacarpal fractures? So this recent study in JHS, Dr. Mclamed and JHS Asia did a meta analysis supporting pins over plate and screw constructs. But let's take a deeper look at this. It only included five studies
DANIEL HESS: and a closer look showed that two of those studies were for metacarpal neck fractures, not the topic of today's debate. And another one of those studies combined, metacarpal and phalanx fractures, and a fourth study actually included only four plates in the comparison. So the only remaining study that of Ozer, published in JHS 2008, actually supports plate fixation of metacarpal fractures.
DANIEL HESS: These authors reported good DASH reduction, good total active motion and union comparable to the nailing technique that they were studying with better maintenance of reduction and less removal of hardware. Marc Exotic's group at Duke is currently working to publish our experience with metacarpal plating and we've had good outcomes using various low profile plates and in 110 fractures we only had a 5% major complication rate as defined by Page's study, who, if you remember, reported a 20% complication rate.
DANIEL HESS: We experienced no tendon ruptures and only one patient underwent removal of hardware for permanent implants. And we're not alone. Very recently, Hutt et al also demonstrated excellent outcomes with metacarpal plating. Where at 23 months, range of motion was nearly full. So what are the secrets to success? It's important in these fractures to carefully dissect the soft tissues, to preserve periosteum such that after placement of a low profile implant, you can suture the periosteum back over the top.
DANIEL HESS: This allows for early mobilization with minimal risk of tendon adhesions, and one must remember that the tendons don't actually span the entirety of the metacarpals but run obliquely to them. And we should also mention that we did an exhaustive literature search and revealed that plates don't pose a risk to the articular cartilage of metacarpal head, unlike their international counterparts.
DANIEL HESS: So first, do no harm. So in summary, although complications, especially stiffness, have been reported upon, it's unlikely these older reports are truly generalizable to newer implants and techniques. Moreover, a closer look at much of the literature shows that plates are actually probably getting a bad rap, especially for metacarpal shaft fractures. The plate really has many advantages, including robust fixation, direct visualization, allowing anatomic reduction and minimal malrotation.
DANIEL HESS: It, unlike intramedullary fixation, does not penetrate the articular cartilage.
DANIEL HESS: There are no pin sites, of course, so pin site infections are not a factor. They allow for early activity in return to sport. And as with all procedures, proper technique is key. So for metacarpal plating, that involves using a low profile plate that is covered with periosteum to prevent adhesions and stiffness. Thank you.
DANIEL HESS: And actually, this is a patient, that Doctor Richardson clinic this last week and actually had to include it, but maybe, the tattoo is so pretty. Maybe we argue against the big dorsal incision here, but, but pretty nice. That's all I got.
PETER WILTON: Uh, thanks, Dr. Greenberg, and greetings from sunny LA.
PETER WILTON: I'm Peter, and my mentor is Dr. Milan Stevanovic. So I'm tasked with defending intramedullary k-wires for metacarpal fractures, but I really want to advocate just in for k-wires in general. Um, first off, it was a great presentation from Dan at Duke and I have a lot of respect for Duke. The Duke lineage has provided me with several mentors of my own, and you can see here Dr. Eric Maisel, Dr. Luke Nicholson, and of course, my mentor here, Dr. Milan Stevanovic.
PETER WILTON: So I want to start by saying that the appeal of plates, especially as an orthopedic surgeon, they're a lot like a fancy new sports car. They're flashy. They're expensive, but ultimately they're an unnecessary luxury. We all know that all you need is a wire driver and some k-wires, which is a lot like the family station wagon.
PETER WILTON: Is it luxurious and flashy? Maybe not. Is it a cost effective machine that's going to get the job done? Absolutely. So this was a patient that we were, that was referred to us. He was treated by 2 separate surgeons who were obviously interested in making a sexy X-ray. He was a 23-year-old professional motocross rider who came to our clinic after two separate failed ORIF's of a fifth metacarpal shaft fracture.
PETER WILTON: His first plate broke and he came to us six months after with continued pain. We decided to treat him after removing his plate into beginning the nonunion site with transverse k-wires to hold our length and rotation, and as you can see from his final post-op visit, healed perfectly and he had extra motion, excellent motion.
PETER WILTON: So while I am here to defend a surgical technique for fixing metacarpal fractures, I have to preface this by saying that, like most of the faculty here and most of the Fellows, we work at a busy level one trauma center that sees over 150,000 emergency visits a year, and we encounter hundreds of metacarpal fractures. OR time is certainly a hot commodity and we operate on a very, very small percentage of these.
PETER WILTON: Question, do these really need surgery? And as we know, there's not really a consensus on how to treat these injuries. We know that most uncomplicated neck and shaft fractures can have great outcomes without surgery and even without a good reduction or rigid mobilization. Follow up again, because these heal so well has led many to recommend no follow up at all, certainly for the uncomplicated fracture.
PETER WILTON: However, we know that not all metacarpal fractures are treated equal and that there are fracture characteristics that gather decision making. Currently, those factors include whether or not they're open or have concurrent soft tissue injuries, the location and pattern of the fracture, as well as the amount of angulation and shortening. And what I think, most importantly, is the rotation of the involved area. Accepted treatment options, as we heard from our colleagues at Duke, would be ORIF and we'll hear shortly IM screws and then I want to advocate for k-wires.
PETER WILTON: So why k-wires? Well, I've always tried to live by the K.I.S.S mantra. Placing k-wires is a skill that every hand surgeon should be comfortable with. It requires less time in the OR, less soft tissue stripping and thus theoretically less stiffness due to adhesions. I'm also a big proponent of not leaving any hardware in the hand. As we know, the soft tissue envelope is very thin, fairly thin and unforgiving.
PETER WILTON: Peri implant fractures can be a pretty difficult problem. Also, in the era of cost conscious medical decision making, you can't get any cheaper than a couple of k-wires and importantly, you can expect very good outcomes with k-wires and few complications. So in 1995, Foucher et al published his series. Dr. Foucher published his series utilizing a technique of flexible intramedullary pinning that he had already been doing for about 20 years.
PETER WILTON: He described making a small incision over the base of the fifth metacarpal to identify and protect any dorsal sensory branches of the ulnar nerve and using an Awl to perforator the cortex on the ulnar aspect of the base. He then used three blunt ended 0.8mm k-wires, which were pre-bent and sent through the intramedullary canal. He then reduced the fracture with the jaws maneuver, and then the pins were introduced past the fracture site in a diverging fashion
PETER WILTON: so that they resemble a flower bouquet. The wires were then cut with enough length to allow for later removal and immediate active motion is allowed. His technical pearls were just to make sure that you're using blunt ended tip, with blunt ended wires because sharp wires will inevitably catch the cortex and not progress through the diaphysis and that your starting point should be at the lateral base of the metacarpal because two dorsal of a starting point can cause extensor tendon impingement.
PETER WILTON: I want to thank Dr. Francis Sharp for this case. This is a 39-year-old female who tripped over a dog and presented with this oblique fifth metacarpal shaft fracture with a 100% displacement and malrotation noted on examination. So you can see the three k-wires which are introduced, introduced from the lateral base to the fifth metacarpal, and then the divergence of the blunt ends in the metacarpal head.
PETER WILTON: And after hardware removal, you can see it healed very nicely. Um, I think that you can really pick and choose your literature and metacarpal fractures. This was a very recent study out of Korea comparing lock plating and bucket [?]fixation in a series of 75 patients. 36 patients were treated with antegrade k-wires. They actually left theirs exposed over the skin, and 33 patients were treated with a low grade low profile locking plate.
PETER WILTON: Both groups were actually splinted for two weeks and then allowed motion afterwards and the k-wires removed at six weeks. So they initially found no difference in pain scores. The range of motion was actually better in the k-wire group initially, however, 14 of the 33 patients with plates ultimately required a second operation to remove the hardware for a variety of reasons.
PETER WILTON: After tenolysis and hardware removal, their range of motion was better in the k-wire group. So even for just the final case, showing that even with multiple metacarpal fractures as seen in this amputation, we think k-wires are still the optimal choice. They can be placed in the amputated part before the patient goes to the OR and sent retrograde to fix the bone in less than five minutes, leaving more time to work on tendons
PETER WILTON: in the micro work. Here we used 2.062 k-wires for each metacarpal, with ultimately a pretty good result for the initial injury considering that initial injury. Thank you very much.
JEFF GREENBERG: OK, that was a nice presentation Peter. Let's wrap it up with the OrthoCarolina group from Charlotte.
JED MASLOW: All right. Are we cooking? It's on. All right. So to take a step back, the treatment of long bone fractures and orthopedic surgery is widely accepted to be intramedullary
JED MASLOW: fixation and fixation confers several advantages. It's limited soft tissue dissection, early weight bearing and easy rehab. So treatment of long bone fracture, even if the bone is small, should strongly consider intramedullary fixation. The IM screw for metacarpal fracture fixation was initially described with a 3 millimeter cannulated headless screw back in 2010, and then soon thereafter the safety of the technique was confirmed with a 3D CT analysis.
JED MASLOW: Our technique is similar utilizing a small incision over the metacarpal head and splitting or mobilizing the extensor tendons. Under fleuro, the guidewire is inserted into the dorsal third of the central metacarpal head in line with the shaft, and our typical implants are shown here, matching the diameters of most metacarpals with a relatively consistent pitch for controlled compression during insertion.
JED MASLOW: It's important to control and check for rotation during insertion as these screws can tend to get a rather substantial bite. And IM screws have several advantages over the other forms of fixation. One is the variety of fractures that we can treat with it. It's much easier to ask what can't we treat with an IM screw? We can fix simple fractures. We can fix proximal fractures, we can fix multiple fractures, and we can fix multiple of different sizes of metacarpals.
JED MASLOW: We can fix nonunion as in the case in the top left where revisions with IM screw fixation achieved union or we can use IM screws for transposition of the index array after a traumatic long array resection. Additionally, Dr. Wong just recently published integrated metacarpal fixation as a nice alternative that can be ideal for proximal third fractures. So in recent literature, IM screws have tended to outperform other fixation options with the exception of biomechanical strength.
JED MASLOW: A plate and screw fixation construct clearly offers the most biomechanical stability, but it is the most invasive and it shows, so reported infection rates in some series is as high as 24%. K-wires also carry a significant infection risk, especially if left exposed. And in contrast, infection after an IM screw placement is so rare that in the few clinical series reported, none have reported a deep infection.
JED MASLOW: IM screws have consistently shown a high total arc of motion grip strength, that is at least as strong, if not stronger than the other methods. And furthermore, hardware removal is relatively rare and has only been described after asymptomatic hardware migration or fracture after repeated trauma, i.e. the patient punched something again. Another significant advantage is their early motion allowable. This is in the pack
JED MASLOW: you immediately post op where we allow patients to do active range of motion in a bulky self dressing. The disadvantages of IM screws are few. Insertion of the screw does leave an articular surface defect but we would claim that it's not functionally limiting. The top left picture is from the initial 3D CT study showing that the ideal insertion site only contacts the proximal phalanx with MP joint hyperextension.
JED MASLOW: So these are pictures of what it looks like in real life or actually in a cadaver, but the blue mark is the ideal starting point. On the right is the MP joint flexed to 90 degrees, no contact, 20 degrees of flexion, no contact. The bottom right at 20 degrees of hyperextension, you first start to see contact but this is not only a common position that our MP joint is not in, nor is it functional.
JED MASLOW: Cost of the implant has been brought up too. I reached out to our local vendors and was quoted at the average cost for an IM screw kit is around $1,000. Take this in in contrast to the combined cost of lock plating, which is actually more and takes additional time in the OR. So the reported cost of IM screws likely fall somewhere in the middle, although there is some recent data showing promising outcomes of IM screw fixation under WALANT minimal complications and a quick return to work.
JED MASLOW: While we use this method for many different types of metacarpal fractures here, not all are amenable to screw fixation and some exceptions are shown here. In summary, while the IM screw literature is smaller and earlier than for other fixation methods, its consistently favorable. So increased stability with lost tissue, less soft tissue disruption leads to fewer complications and allows for early active motion.
JED MASLOW: As a result, it's become our preferred fixation strategy for a majority of operative metacarpal fractures. Thank you.
JEFF GREENBERG: That was three excellent presentations. So we see these metacarpal fractures all the time, we see them. They have all different personalities. They're attached to all different patients.
JEFF GREENBERG: We have to have a variety of treatment options in our bag. If I could at this time, I want the mentors to go around and just granted, you presented one technique, but just kind of maybe in, you know, a minute or two minutes kind of go through your thought process and algorithm for treating these injuries. So let's start with you, Marc.
MARC RICHARD: Thanks, Jeff, and great job, guys. That was a very balanced presentation of everything
MARC RICHARD: and I think really well done so hats off to you, Glenn's hat off to you. Um, the, I think what is, I'll answer the question first. All things being equal, all things available, if it was my hand, I would have the intramedullary screw. All things being equal, I've been very impressed with the results.
MARC RICHARD: And I think you're right. Personality of the fracture, personality of the patient has to be matched with all these and I think that the two learning points here are defending plates, I think the literature is not fair to plates because it's not the current plates we have available. so let's we got to be fair about was making sure everybody could hear me.
MARC RICHARD: You got to be fair about evaluating complications from plates for what we have available today. And if you do it with a thoughtful technique and plate is the right answer, I think you can get a great outcome. So don't throw that away just because it's bigger and bulkier and has some track record of some complications in the literature. K-wires are not without constant, without complications,
MARC RICHARD: but I think the important thing here is that we all know that fractures are soft tissue injuries that just happen to have a broken bone in them, and you have to pay attention to those components as well. All three of these techniques are within all of our potential for bag of tricks. We talked the first week of grafts from the rib or MFT'S, that's getting a little bit peripheral for some people.
MARC RICHARD: Everybody should be able to do all of these and apply them in the right situation, in the right clinical settings. So I think this is a much more evenhanded discussion, worth knowing all of them and thinking about the composite of the patient, the personality of them. But to answer your question, if it was all things being equal, I would take a screw for my metacarpal.
JEFF GREENBERG: Dr. Stevanovic?
MILAN STEVANOVIC: OK. I have been 27 years now at USC, and you can imagine the potential of the cases that we see there, probably 200, 300 metacarpal fractures a year, and probably 98% of them are never operated. I let them to heal, probably more united and later on debride dorsal side, the patient complained for aesthetics, but nothing else. So two reasons only to operate is 1, if you have a severe telescopic shortening
MILAN STEVANOVIC: and the second one if you have a crossing scissoring of the fingers so that's two. It will be so expensive for County to pay probably 3, 400 screws a year, which will be about half $1 million probably. And plates, I'm not telling that we cannot fix that with them, I think we do, any, for so many years I have been calling court to testify against, you know, try to support the patient.
MILAN STEVANOVIC: I never testify against the doctor so on and was only complications for the plate and screws and I agree with Marc, we have now different plates and different size of the screws. But my approach to this don't operate, especially if you have ability to put a splint and you have a compliant patients and try to see patient for six weeks and after that is tell the patient they don't need to come anymore.
JEFF GREENBERG: Great .Thank you very much. And then Glenn and Glenn, in addition to you, you kind of addressing this, I want you to justify something that Jed presented on his slide of a nearly $2,000 cost for k-wires. Where did that fake news come from?
GLENN GASTON: Hello Jed? I'm assuming that includes the anesthesiology in the room and everything else.
GLENN GASTON: The total cost of the case, not the cost of the actual K-WIRE. But yeah, so I think if the cost of the total case cost there Jeff not just the implant.
JED MASLOW: It was actually the total cost of care included post-op follow ups and rehab and OTP.
JEFF GREENBERG: OK, very good. Thank you.
GLENN GASTON: So it should have, it should have included the things Tom Fisher taught me
GLENN GASTON: Jeff, when I was at Indy that k-wires first penetrate, then they incinerate, then they irritate and then they separate. So Tom taught me that and I've remembered it to this day so with that in mind, what is my true algorithm? Really, I do think IM screws have been a game changer, but I agree with Milan. I think undeniably the majority of metacarpal fractures can be managed closed.
GLENN GASTON: I would add one to the things you described. You said telescopic shortening and scissoring. I think there's also the very real thing that a lot of people need things fixed just to get back to life sooner. I think very few of us would take six weeks out of our schedule to be in a cast. You've got athletes that try to return to sport, you've got dentists, you've got people who have lives that they don't want to be tied up in a cast
GLENN GASTON: and to mobilize for that period of time. And that is one of the reasons I do fix some of these particularly kind of the fractures that would be on the edge. IM screws has really changed my practice. I think you're looking at a single stitch for the majority of these and you put an IM screw down for metacarpal shaft fracture. The union rates are close to 100% and they rehab super fast with soft dressing,
GLENN GASTON: most of my patients are in a truly in a band aid on day three. So it's been a technique that I've really liked as opposed to plates and screws which I still do use and I agree with Marc. You have to have all of these in your arsenal. I loved bouquet pinning and that's what I did before IM screws became popular. I think now IM screws makes a lot more sense. Bouquet pinning,
GLENN GASTON: I couldn't personally mobilize them quite as fast. They'd still a percentage of those had to be removed at a second surgery whereas the IM screw you really, you put it in, you never think about it again. And most of them come back at two weeks with great motion so it's not just defending what Jed said, it's actually been one of the few things that's really changed my practice a lot in the last 10 years is the addition of IM screws for metacarpals for real.
JEFF GREENBERG: Great. Jerry, I know it's a little after seven, but let me just if you could give me a couple of minutes. Let me just go back to my screen and I can show everybody what we did with those cases and I think you'll get some of my bias. But already. So here's the isolated closed, got an intramedullary screw and this multiple, multiple metacarpal fracture.
JEFF GREENBERG: The patient already in the operating room, multiple metacarpal screws. So for me, for me personally, I mean, I was a big bouquet pinner for many, many years and Glenn, we probably did a bunch together. I did a kind of a modification of Fouchet's technique, but I think IM screw has really changed my practice as well and for shaft fractures that need operative intervention, which as Milan said, is a small percentage, that's really my go to.
JEFF GREENBERG: I haven't had any problem with MP motion from penetration there and you could actually do it from proximal through the CMC joint with no problem either so I'll turn it back over to you. Jerry, you guys, Fellows, you guys did a great job again. Jerry, these, these sessions have been awesome. Really appreciate you setting this up. It's been a great educational experience for the times that we've been down due to this COVID thing.
JEFF GREENBERG: So thanks again.
Segment:0 .
JEFF GREENBERG: So I'm going to introduce the topic of metacarpal fractures with two cases. The first is a 17-year-old male who was injured playing hockey. He presents with a closed small finger metacarpal fracture.
JEFF GREENBERG: No zebras here, just very typical, has fracture site tenderness, deformity, which includes the loss of a prominence of the metacarpal head, fullness on the volar aspect of his hand, loss of full extension, but a significant malrotation with a crossover deformity with flexion. And here you see he's got, you know, kind of almost a shaft fracture, a distal shaft fracture with significant amount of angular angulation as well as rotation, which can be picked up clinically.
JEFF GREENBERG: And then we'll move to the second case, a 50-year-old female who's in a high speed motor vehicle accident. We were actually asked to take care of her after she was already asleep in the operating room, because she had associated orthopedic injuries. They didn't realize she had a hand injury till they got her in the OR. She has deformity, closed injuries.
JEFF GREENBERG: We don't know anything about range of motion or sensation, has a normal vascular exam, and she has this X-ray which shows these more distal not really shaft fractures, which we're covering, but has multiple metacarpal fractures in isolated hand. And here you see significant angulation. So, so we have three teams that are going to debate metacarpals. We have metacarpal plating presented by Dr. Hess.
DANIEL HESS: OK. So hi everyone, thanks for the opportunity to provide our point of view in this virtual arena. My name is Dan Hess, one of the Fellows at Duke, and I want to thank Mike Milone and Marc Richard for their help with this presentation. So metacarpal fractures are a common problem in upper extremity trauma and most often seen on the ulnar digits. These are typically injuries of aggression, which may spell trouble when considering patient compliance with the treatment or rehab protocol.
DANIEL HESS: And these certainly aren't benign injuries without repercussions if treated improperly. It's been said that patients lose about seven degrees of flexion with every 2 millimeters of shortening of the metacarpal, and just 5 degrees of malrotation can lead to 1.5cm of digital overlap so it's important we get it right. And there are a number of surgical treatment methods and you'll hear about a few of them today
DANIEL HESS: so I won't belabor the point. So when should you use a plate? There's a lot of positives about plating. First off, plating typically done from a dorsal approach, provides stable fixation on the tension side of the fracture, which we all know is technically preferred. The stable fixation is especially important in patients that need to get back to their job or work sooner or sports sooner.
DANIEL HESS: And with all the various plate designs, I think it would be hard to argue that there is a more versatile approach and plates can be used for essentially any fracture type, including ones with bone loss or articular involvement. There's no need for a secondary procedure. There should not be any concern about placing plates and screws in the setting of an open injury, as that has not been shown to increase complications.
DANIEL HESS: And finally, I think a lot has been made about complication rate with plating, especially with extensor tendon pathology. But I would offer that much of that data is based on older plate designs, newer studies looking at currently available low profile plates really show very minimal complication rates. Here's a relatively straightforward case. 34-year-old male, punched someone in the face, par for the course and sustained this fourth metacarpal shaft fracture.
DANIEL HESS: Now possibly if you're kind of looking at the x-rays, maybe a little foreshortened on the PA, a little bit of comminution. Hard to tell if there's a separate butterfly fragment there and you get a good sense on the oblique view that maybe there's a little bit of malrotation and we have that characteristic apex dorsal deformity on the lateral view.
DANIEL HESS: So we chose to plate this fracture. We used a separate lag screw with a low profile plate placed over the top as a neutralization construct. We obtained excellent reduction with the plate, counteracting the deforming forces and was able to interpose some tissue between the plate and extensor tendons upon closure, which is certainly always helpful. It's hard to argue with the range of motion, clinical parents and outcome on this final follow up pictures.
DANIEL HESS: So what does the literature say? So traditional studies have reported higher complication rates for plating with stiffness being the primary concern but a closer look shows that many of these studies may not be entirely generalizable to metacarpal shaft fractures as we deal with them today. So all of these studies use older plating systems and a lot of them have included a substantial amount of high energy injuries, which you can certainly use plates for
DANIEL HESS: but that's not the topic of today's debate. And, you know, looking at those pictures, I doubt very much that the plates are the sole reason for those digits to be stiff. Today. plating systems for metacarpal fractures are shown here so in addition to having the use of very small screws with locking options, they're very narrow and low profile. The thickness of the plates range from 0.6 to 1.5 millimeters across these four major implant companies.
DANIEL HESS: And so, well, if that's true, you know, you may ask, why are there recent reports of bad outcomes with metacarpal fractures? So this recent study in JHS, Dr. Mclamed and JHS Asia did a meta analysis supporting pins over plate and screw constructs. But let's take a deeper look at this. It only included five studies
DANIEL HESS: and a closer look showed that two of those studies were for metacarpal neck fractures, not the topic of today's debate. And another one of those studies combined, metacarpal and phalanx fractures, and a fourth study actually included only four plates in the comparison. So the only remaining study that of Ozer, published in JHS 2008, actually supports plate fixation of metacarpal fractures.
DANIEL HESS: These authors reported good DASH reduction, good total active motion and union comparable to the nailing technique that they were studying with better maintenance of reduction and less removal of hardware. Marc Exotic's group at Duke is currently working to publish our experience with metacarpal plating and we've had good outcomes using various low profile plates and in 110 fractures we only had a 5% major complication rate as defined by Page's study, who, if you remember, reported a 20% complication rate.
DANIEL HESS: We experienced no tendon ruptures and only one patient underwent removal of hardware for permanent implants. And we're not alone. Very recently, Hutt et al also demonstrated excellent outcomes with metacarpal plating. Where at 23 months, range of motion was nearly full. So what are the secrets to success? It's important in these fractures to carefully dissect the soft tissues, to preserve periosteum such that after placement of a low profile implant, you can suture the periosteum back over the top.
DANIEL HESS: This allows for early mobilization with minimal risk of tendon adhesions, and one must remember that the tendons don't actually span the entirety of the metacarpals but run obliquely to them. And we should also mention that we did an exhaustive literature search and revealed that plates don't pose a risk to the articular cartilage of metacarpal head, unlike their international counterparts.
DANIEL HESS: So first, do no harm. So in summary, although complications, especially stiffness, have been reported upon, it's unlikely these older reports are truly generalizable to newer implants and techniques. Moreover, a closer look at much of the literature shows that plates are actually probably getting a bad rap, especially for metacarpal shaft fractures. The plate really has many advantages, including robust fixation, direct visualization, allowing anatomic reduction and minimal malrotation.
DANIEL HESS: It, unlike intramedullary fixation, does not penetrate the articular cartilage.
DANIEL HESS: There are no pin sites, of course, so pin site infections are not a factor. They allow for early activity in return to sport. And as with all procedures, proper technique is key. So for metacarpal plating, that involves using a low profile plate that is covered with periosteum to prevent adhesions and stiffness. Thank you.
DANIEL HESS: And actually, this is a patient, that Doctor Richardson clinic this last week and actually had to include it, but maybe, the tattoo is so pretty. Maybe we argue against the big dorsal incision here, but, but pretty nice. That's all I got.
PETER WILTON: Uh, thanks, Dr. Greenberg, and greetings from sunny LA.
PETER WILTON: I'm Peter, and my mentor is Dr. Milan Stevanovic. So I'm tasked with defending intramedullary k-wires for metacarpal fractures, but I really want to advocate just in for k-wires in general. Um, first off, it was a great presentation from Dan at Duke and I have a lot of respect for Duke. The Duke lineage has provided me with several mentors of my own, and you can see here Dr. Eric Maisel, Dr. Luke Nicholson, and of course, my mentor here, Dr. Milan Stevanovic.
PETER WILTON: So I want to start by saying that the appeal of plates, especially as an orthopedic surgeon, they're a lot like a fancy new sports car. They're flashy. They're expensive, but ultimately they're an unnecessary luxury. We all know that all you need is a wire driver and some k-wires, which is a lot like the family station wagon.
PETER WILTON: Is it luxurious and flashy? Maybe not. Is it a cost effective machine that's going to get the job done? Absolutely. So this was a patient that we were, that was referred to us. He was treated by 2 separate surgeons who were obviously interested in making a sexy X-ray. He was a 23-year-old professional motocross rider who came to our clinic after two separate failed ORIF's of a fifth metacarpal shaft fracture.
PETER WILTON: His first plate broke and he came to us six months after with continued pain. We decided to treat him after removing his plate into beginning the nonunion site with transverse k-wires to hold our length and rotation, and as you can see from his final post-op visit, healed perfectly and he had extra motion, excellent motion.
PETER WILTON: So while I am here to defend a surgical technique for fixing metacarpal fractures, I have to preface this by saying that, like most of the faculty here and most of the Fellows, we work at a busy level one trauma center that sees over 150,000 emergency visits a year, and we encounter hundreds of metacarpal fractures. OR time is certainly a hot commodity and we operate on a very, very small percentage of these.
PETER WILTON: Question, do these really need surgery? And as we know, there's not really a consensus on how to treat these injuries. We know that most uncomplicated neck and shaft fractures can have great outcomes without surgery and even without a good reduction or rigid mobilization. Follow up again, because these heal so well has led many to recommend no follow up at all, certainly for the uncomplicated fracture.
PETER WILTON: However, we know that not all metacarpal fractures are treated equal and that there are fracture characteristics that gather decision making. Currently, those factors include whether or not they're open or have concurrent soft tissue injuries, the location and pattern of the fracture, as well as the amount of angulation and shortening. And what I think, most importantly, is the rotation of the involved area. Accepted treatment options, as we heard from our colleagues at Duke, would be ORIF and we'll hear shortly IM screws and then I want to advocate for k-wires.
PETER WILTON: So why k-wires? Well, I've always tried to live by the K.I.S.S mantra. Placing k-wires is a skill that every hand surgeon should be comfortable with. It requires less time in the OR, less soft tissue stripping and thus theoretically less stiffness due to adhesions. I'm also a big proponent of not leaving any hardware in the hand. As we know, the soft tissue envelope is very thin, fairly thin and unforgiving.
PETER WILTON: Peri implant fractures can be a pretty difficult problem. Also, in the era of cost conscious medical decision making, you can't get any cheaper than a couple of k-wires and importantly, you can expect very good outcomes with k-wires and few complications. So in 1995, Foucher et al published his series. Dr. Foucher published his series utilizing a technique of flexible intramedullary pinning that he had already been doing for about 20 years.
PETER WILTON: He described making a small incision over the base of the fifth metacarpal to identify and protect any dorsal sensory branches of the ulnar nerve and using an Awl to perforator the cortex on the ulnar aspect of the base. He then used three blunt ended 0.8mm k-wires, which were pre-bent and sent through the intramedullary canal. He then reduced the fracture with the jaws maneuver, and then the pins were introduced past the fracture site in a diverging fashion
PETER WILTON: so that they resemble a flower bouquet. The wires were then cut with enough length to allow for later removal and immediate active motion is allowed. His technical pearls were just to make sure that you're using blunt ended tip, with blunt ended wires because sharp wires will inevitably catch the cortex and not progress through the diaphysis and that your starting point should be at the lateral base of the metacarpal because two dorsal of a starting point can cause extensor tendon impingement.
PETER WILTON: I want to thank Dr. Francis Sharp for this case. This is a 39-year-old female who tripped over a dog and presented with this oblique fifth metacarpal shaft fracture with a 100% displacement and malrotation noted on examination. So you can see the three k-wires which are introduced, introduced from the lateral base to the fifth metacarpal, and then the divergence of the blunt ends in the metacarpal head.
PETER WILTON: And after hardware removal, you can see it healed very nicely. Um, I think that you can really pick and choose your literature and metacarpal fractures. This was a very recent study out of Korea comparing lock plating and bucket [?]fixation in a series of 75 patients. 36 patients were treated with antegrade k-wires. They actually left theirs exposed over the skin, and 33 patients were treated with a low grade low profile locking plate.
PETER WILTON: Both groups were actually splinted for two weeks and then allowed motion afterwards and the k-wires removed at six weeks. So they initially found no difference in pain scores. The range of motion was actually better in the k-wire group initially, however, 14 of the 33 patients with plates ultimately required a second operation to remove the hardware for a variety of reasons.
PETER WILTON: After tenolysis and hardware removal, their range of motion was better in the k-wire group. So even for just the final case, showing that even with multiple metacarpal fractures as seen in this amputation, we think k-wires are still the optimal choice. They can be placed in the amputated part before the patient goes to the OR and sent retrograde to fix the bone in less than five minutes, leaving more time to work on tendons
PETER WILTON: in the micro work. Here we used 2.062 k-wires for each metacarpal, with ultimately a pretty good result for the initial injury considering that initial injury. Thank you very much.
JEFF GREENBERG: OK, that was a nice presentation Peter. Let's wrap it up with the OrthoCarolina group from Charlotte.
JED MASLOW: All right. Are we cooking? It's on. All right. So to take a step back, the treatment of long bone fractures and orthopedic surgery is widely accepted to be intramedullary
JED MASLOW: fixation and fixation confers several advantages. It's limited soft tissue dissection, early weight bearing and easy rehab. So treatment of long bone fracture, even if the bone is small, should strongly consider intramedullary fixation. The IM screw for metacarpal fracture fixation was initially described with a 3 millimeter cannulated headless screw back in 2010, and then soon thereafter the safety of the technique was confirmed with a 3D CT analysis.
JED MASLOW: Our technique is similar utilizing a small incision over the metacarpal head and splitting or mobilizing the extensor tendons. Under fleuro, the guidewire is inserted into the dorsal third of the central metacarpal head in line with the shaft, and our typical implants are shown here, matching the diameters of most metacarpals with a relatively consistent pitch for controlled compression during insertion.
JED MASLOW: It's important to control and check for rotation during insertion as these screws can tend to get a rather substantial bite. And IM screws have several advantages over the other forms of fixation. One is the variety of fractures that we can treat with it. It's much easier to ask what can't we treat with an IM screw? We can fix simple fractures. We can fix proximal fractures, we can fix multiple fractures, and we can fix multiple of different sizes of metacarpals.
JED MASLOW: We can fix nonunion as in the case in the top left where revisions with IM screw fixation achieved union or we can use IM screws for transposition of the index array after a traumatic long array resection. Additionally, Dr. Wong just recently published integrated metacarpal fixation as a nice alternative that can be ideal for proximal third fractures. So in recent literature, IM screws have tended to outperform other fixation options with the exception of biomechanical strength.
JED MASLOW: A plate and screw fixation construct clearly offers the most biomechanical stability, but it is the most invasive and it shows, so reported infection rates in some series is as high as 24%. K-wires also carry a significant infection risk, especially if left exposed. And in contrast, infection after an IM screw placement is so rare that in the few clinical series reported, none have reported a deep infection.
JED MASLOW: IM screws have consistently shown a high total arc of motion grip strength, that is at least as strong, if not stronger than the other methods. And furthermore, hardware removal is relatively rare and has only been described after asymptomatic hardware migration or fracture after repeated trauma, i.e. the patient punched something again. Another significant advantage is their early motion allowable. This is in the pack
JED MASLOW: you immediately post op where we allow patients to do active range of motion in a bulky self dressing. The disadvantages of IM screws are few. Insertion of the screw does leave an articular surface defect but we would claim that it's not functionally limiting. The top left picture is from the initial 3D CT study showing that the ideal insertion site only contacts the proximal phalanx with MP joint hyperextension.
JED MASLOW: So these are pictures of what it looks like in real life or actually in a cadaver, but the blue mark is the ideal starting point. On the right is the MP joint flexed to 90 degrees, no contact, 20 degrees of flexion, no contact. The bottom right at 20 degrees of hyperextension, you first start to see contact but this is not only a common position that our MP joint is not in, nor is it functional.
JED MASLOW: Cost of the implant has been brought up too. I reached out to our local vendors and was quoted at the average cost for an IM screw kit is around $1,000. Take this in in contrast to the combined cost of lock plating, which is actually more and takes additional time in the OR. So the reported cost of IM screws likely fall somewhere in the middle, although there is some recent data showing promising outcomes of IM screw fixation under WALANT minimal complications and a quick return to work.
JED MASLOW: While we use this method for many different types of metacarpal fractures here, not all are amenable to screw fixation and some exceptions are shown here. In summary, while the IM screw literature is smaller and earlier than for other fixation methods, its consistently favorable. So increased stability with lost tissue, less soft tissue disruption leads to fewer complications and allows for early active motion.
JED MASLOW: As a result, it's become our preferred fixation strategy for a majority of operative metacarpal fractures. Thank you.
JEFF GREENBERG: That was three excellent presentations. So we see these metacarpal fractures all the time, we see them. They have all different personalities. They're attached to all different patients.
JEFF GREENBERG: We have to have a variety of treatment options in our bag. If I could at this time, I want the mentors to go around and just granted, you presented one technique, but just kind of maybe in, you know, a minute or two minutes kind of go through your thought process and algorithm for treating these injuries. So let's start with you, Marc.
MARC RICHARD: Thanks, Jeff, and great job, guys. That was a very balanced presentation of everything
MARC RICHARD: and I think really well done so hats off to you, Glenn's hat off to you. Um, the, I think what is, I'll answer the question first. All things being equal, all things available, if it was my hand, I would have the intramedullary screw. All things being equal, I've been very impressed with the results.
MARC RICHARD: And I think you're right. Personality of the fracture, personality of the patient has to be matched with all these and I think that the two learning points here are defending plates, I think the literature is not fair to plates because it's not the current plates we have available. so let's we got to be fair about was making sure everybody could hear me.
MARC RICHARD: You got to be fair about evaluating complications from plates for what we have available today. And if you do it with a thoughtful technique and plate is the right answer, I think you can get a great outcome. So don't throw that away just because it's bigger and bulkier and has some track record of some complications in the literature. K-wires are not without constant, without complications,
MARC RICHARD: but I think the important thing here is that we all know that fractures are soft tissue injuries that just happen to have a broken bone in them, and you have to pay attention to those components as well. All three of these techniques are within all of our potential for bag of tricks. We talked the first week of grafts from the rib or MFT'S, that's getting a little bit peripheral for some people.
MARC RICHARD: Everybody should be able to do all of these and apply them in the right situation, in the right clinical settings. So I think this is a much more evenhanded discussion, worth knowing all of them and thinking about the composite of the patient, the personality of them. But to answer your question, if it was all things being equal, I would take a screw for my metacarpal.
JEFF GREENBERG: Dr. Stevanovic?
MILAN STEVANOVIC: OK. I have been 27 years now at USC, and you can imagine the potential of the cases that we see there, probably 200, 300 metacarpal fractures a year, and probably 98% of them are never operated. I let them to heal, probably more united and later on debride dorsal side, the patient complained for aesthetics, but nothing else. So two reasons only to operate is 1, if you have a severe telescopic shortening
MILAN STEVANOVIC: and the second one if you have a crossing scissoring of the fingers so that's two. It will be so expensive for County to pay probably 3, 400 screws a year, which will be about half $1 million probably. And plates, I'm not telling that we cannot fix that with them, I think we do, any, for so many years I have been calling court to testify against, you know, try to support the patient.
MILAN STEVANOVIC: I never testify against the doctor so on and was only complications for the plate and screws and I agree with Marc, we have now different plates and different size of the screws. But my approach to this don't operate, especially if you have ability to put a splint and you have a compliant patients and try to see patient for six weeks and after that is tell the patient they don't need to come anymore.
JEFF GREENBERG: Great .Thank you very much. And then Glenn and Glenn, in addition to you, you kind of addressing this, I want you to justify something that Jed presented on his slide of a nearly $2,000 cost for k-wires. Where did that fake news come from?
GLENN GASTON: Hello Jed? I'm assuming that includes the anesthesiology in the room and everything else.
GLENN GASTON: The total cost of the case, not the cost of the actual K-WIRE. But yeah, so I think if the cost of the total case cost there Jeff not just the implant.
JED MASLOW: It was actually the total cost of care included post-op follow ups and rehab and OTP.
JEFF GREENBERG: OK, very good. Thank you.
GLENN GASTON: So it should have, it should have included the things Tom Fisher taught me
GLENN GASTON: Jeff, when I was at Indy that k-wires first penetrate, then they incinerate, then they irritate and then they separate. So Tom taught me that and I've remembered it to this day so with that in mind, what is my true algorithm? Really, I do think IM screws have been a game changer, but I agree with Milan. I think undeniably the majority of metacarpal fractures can be managed closed.
GLENN GASTON: I would add one to the things you described. You said telescopic shortening and scissoring. I think there's also the very real thing that a lot of people need things fixed just to get back to life sooner. I think very few of us would take six weeks out of our schedule to be in a cast. You've got athletes that try to return to sport, you've got dentists, you've got people who have lives that they don't want to be tied up in a cast
GLENN GASTON: and to mobilize for that period of time. And that is one of the reasons I do fix some of these particularly kind of the fractures that would be on the edge. IM screws has really changed my practice. I think you're looking at a single stitch for the majority of these and you put an IM screw down for metacarpal shaft fracture. The union rates are close to 100% and they rehab super fast with soft dressing,
GLENN GASTON: most of my patients are in a truly in a band aid on day three. So it's been a technique that I've really liked as opposed to plates and screws which I still do use and I agree with Marc. You have to have all of these in your arsenal. I loved bouquet pinning and that's what I did before IM screws became popular. I think now IM screws makes a lot more sense. Bouquet pinning,
GLENN GASTON: I couldn't personally mobilize them quite as fast. They'd still a percentage of those had to be removed at a second surgery whereas the IM screw you really, you put it in, you never think about it again. And most of them come back at two weeks with great motion so it's not just defending what Jed said, it's actually been one of the few things that's really changed my practice a lot in the last 10 years is the addition of IM screws for metacarpals for real.
JEFF GREENBERG: Great. Jerry, I know it's a little after seven, but let me just if you could give me a couple of minutes. Let me just go back to my screen and I can show everybody what we did with those cases and I think you'll get some of my bias. But already. So here's the isolated closed, got an intramedullary screw and this multiple, multiple metacarpal fracture.
JEFF GREENBERG: The patient already in the operating room, multiple metacarpal screws. So for me, for me personally, I mean, I was a big bouquet pinner for many, many years and Glenn, we probably did a bunch together. I did a kind of a modification of Fouchet's technique, but I think IM screw has really changed my practice as well and for shaft fractures that need operative intervention, which as Milan said, is a small percentage, that's really my go to.
JEFF GREENBERG: I haven't had any problem with MP motion from penetration there and you could actually do it from proximal through the CMC joint with no problem either so I'll turn it back over to you. Jerry, you guys, Fellows, you guys did a great job again. Jerry, these, these sessions have been awesome. Really appreciate you setting this up. It's been a great educational experience for the times that we've been down due to this COVID thing.
JEFF GREENBERG: So thanks again.
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