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중수골 단독 골절에 대한 최소 관혈적 정복술 Mini-Open Reduction Of

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중수골 단독 골절에 대한 최소 관혈적 정복술 Mini-Open Reduction Of Arch Hand Microsurg 2019;24(4):321-329. https://doi.org/10.12790/ahm.2019.24.4.321 Archives of pISSN 2586-3290 • eISSN 2586-3533 Hand and Microsurgery Original Article 중수골 단독 골절에 대한 최소 관혈적 정복술 정연진1ㆍ오세영2ㆍ최지선2ㆍ임진수2ㆍ심형섭2 1가톨릭대학교 의과대학 은평성모병원 성형외과학교실, 2가톨릭대학교 의과대학 성빈센트병원 성형외과학교실 Mini-Open Reduction of Isolated Metacarpal Bone Fracture Yeon Jin Jeong1, Se Young Oh2, Ji Seon Choi2, Jin Soo Lim2, Hyung-Sup Shim2 1Department of Plastic and Reconstructive Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea 2Department of Plastic and Reconstructive Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea Purpose: Metacarpal bone fracture is a commonly encountered. The authors applied a minimally invasive open reduction technique that comprises only a stab incision to treat metacarpal bone fractures, thereby minimizing complications that accompany traditional open reduction methods while retaining the advantages of closed reduction techniques. Methods: A 5-year retrospective study was carried out of all patients who underwent surgical treatment performed by two separate hand surgeons. Total 37 patients were operated. Fourteen patients of conventional open reduction group and 23 patients of minimal invasive group were included in the study. Results: Mini-open reduction group had shorter operative time, comparable radiological reduction result, lower subjec- tive pain, comparable mean active range of motion of the metacarpophalangeal joint, similar complication rate and supe- rior outcome scar quality than conventional open reduction group. Conclusion: Mini-open reduction method may be an alternative to conventional open reduction in treating metacarpal fractures. Key Words: Metacarpal fracture, Open reduction, Internal fixation, Closed reduction, Kirschner wire INTRODUCTION open reduction and closed reduction using percutaneous pinning3. Metacarpal bone fracture is a commonly encountered In many cases, metacarpal fractures can be treated non- upper limb trauma, comprising one fifth of upper extrem- operatively. However, fractures with severe angulation4,5, ity fractures and one half of hand fractures1,2. Treatment rotation6, shortening7, unstable fractures such as long for metacarpal bone fractures can be either surgical or oblique fractures, fractures with bone loss, and multiple nonsurgical, and the former may further be divided into fractures3 require surgical management. Due to the lack Received July 8, 2019, Revised ‌August 4, 2019, Accepted September 4, 2019 Corresponding author: Hyung-Sup Shim Department of Plastic and Reconstructive Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu- daero, Paldal-gu, Suwon 16247, Korea TEL: +82-31-249-7206, FAX: +82-31-241-0005, E-mail: [email protected], ORCID: https://orcid.org/0000-0001-5156-2239 Copyright ⓒ 2019 by Korean Society for Surgery of the Hand, Korean Society for Microsurgery, and Korean Society for Surgery of the Peripheral Nerve. All Rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 321 Archives of Hand and Microsurgery Vol. 24, No. 4, December 2019 of high-level evidence from prospective cohorts or ran- titanium plate and screws (open reduction group, group domized controlled trials, however, debate still exists on I), and 23 patients (62.2% of total) undergoing mini-open whether closed or open reduction technique produces op- reduction (mini-open reduction group, group II). timal results5,8,9. All patients were admitted to the hospital through out- The open reduction technique may easily be applied to patient clinic or emergency room, and surgery was done stable fractures, and is also favored when dealing with under general anesthesia within two weeks from the date unstable fractures with poor maintenance of reduction. of the injury. Depending on the degree of fracture and de- Open reduction is usually indicated for transverse shaft gree of associated injury, the admission date was varied fractures that either are significantly displaced or have from pod 2 to 7. Pain control started with nonsteroidal residual angulation of more than 10 degrees in the second anti-inflammatory drugs and applied pethidine intrave- and third metacarpals, 20 to 30 degrees in the ring meta- nous (IV) when control was difficult and patients were carpal, and 30 to 40 degrees in the small finger metacar- treated with IV antibiotics until discharge. The patient pal and indicated for most spiral and oblique fractures, maintained a short arm splint for 4-6 weeks. particularly if there is evidence of a rotational deformity Results in both groups were analyzed based on opera- on physical examination, because fracture reduction is tion time, and the total sum score (ten being the highest difficult to maintain by closed techniques and the ana- score) given by two separate hand surgeons on a scale of tomical positions of these bones may hinder complete one to five after reviewing post-reduction radiographic reduction. images. Also, other variables including the degree of Authors applied a mini-open reduction technique that recovered range of motion of the involved metacarpopha- comprises only a stab incision to treat metacarpal bone langeal (MCP) joint six months after the surgery, subjec- fractures, thereby minimizing complications that accom- tive pain reported by the patient using the visual analogue pany traditional open reduction methods while retain- scale (VAS) postoperative two weeks, number of cases ing the advantages of closed reduction techniques, and that required secondary procedures to release postsurgi- analyzed the results. This study was approved by the cal adhesions, and postoperative complications were also Institutional Review Board of the Catholic University of evaluated. The surgical scar sites were also assessed after Korea. All data were analyzed anonymously and accord- 6 months using the Vancouver scar scale (VSS). ing to the principles in the Declaration of Helsinki (1975, We received informed consent from the patients to sub- revised in 2008). mit the imanges containing any part of the patient’s body to the paper. MATERIALS AND METHODS 2. Surgical technique: open reduction and 1. Patients internal fixation (group I) Patients with isolated second to fifth metacarpal bone Under general anesthesia, a three to five centimeter- fractures that underwent surgical treatment at our institute long dorsal incision was made depending on the location from January 2010 through December 2015 were includ- and the degree of the fracture. The periosteum of the ed and data were retrospectively reviewed in the study. metacarpal bone was exposed with careful dissection to Patients with other concomitant trauma, or those exhibit- avoid any injury to the extensor digitorum communis ing a limited range of motion from previous traumatic tendons and adjacent superficial veins and nerves. The event were excluded. A total of 37 patients were treated periosteum was elevated for subsequent reduction and as subjects, with 14 patients (37.8% of total) under go- plate fixation, with the aid of bone holding forceps to ing open reduction and internal fixation (ORIF) using maintain reduction if deemed necessary. Depending on 322 www.handmicro.org Yeon Jin Jeong, et al. New Reduction Method of Isolated Metacarpal Bone Fracture the severity of the fracture, a 4 to 6-hole plate along with 3. Surgical technique: mini-open reduction 8 to 12mm screws were used for bicortical plate fixation (group II) (Fig. 1). The periosteum was then closed using Vicryl 4-0 sutures, and anti-adhesion agent was applied before skin Under fluoroscopic guidance, a 3 mm sized longitudi- closure with 5-0 Vicryl and 5-0 Nylon sutures. Sutures nal incision was made on the dorsum above the fracture were removed 10 to 14 days after the surgery, during a site visualized, while taking care not to injure the exten- short arm splint was applied. sor digitorum communis tendons. Authors reached the fracture site with gentle dissection using the Freer eleva- tor (Fig. 2). The fractured segment was then reduced to appropriate position through simultaneous distal traction of the involved finger and direct palpation using the el- evator (Fig. 3), while any intervening tissue was pulled aside to facilitate the procedure. A 0.9-1.1 mm sized Kirschner wire (K-wire) was inserted from the proximal side of the fractured metacarpal bone toward the opposite side of the bone to avoid injury to the MCP joint. The K- wire was advanced to include the whole fractured area, while maintaining the reduction and alignment with the help of the Freer elevator (Fig. 4). In patients with unfa- vorable fractures which reduction cannot be maintained with intramedullary pinning only, transverse pining method was utilized (Fig. 5). An anti-adhesion agent was applied through the stab incision site followed by skin closure, and the tip(s) of the K-wire was buried under the Fig. 1. Depending on the severity of the fracture, a 4 to 6-hole deep skin to minimize unwarranted interference on the plate along with 8 to 12 mm screws were used for bicortical plate fixation. Fig. 3. The fractured segment was then reduced to appropriate Fig. 2. Reached the fracture site with gentle dissection using position through simultaneous distal traction of the involved the Freer elevator. finger and direct palpation using the elevator. www.handmicro.org 323 Archives of Hand and Microsurgery Vol. 24, No. 4, December 2019 Table 1. Demographics and summary of the patients enrolled in the study Group I (n=14) Group II (n=23) Age (yr) 41.2 (range, 25-57) 43.7 (range, 27-60) Sex Female/male (%) 4 (28.6)/10 (71.4) 7 (30.4)/16 (69.6) Fracture type Favorable/ 5 (35.7)/9 (64.3) 9 (39.1)/14 (60.9) unfavorable (%) Follow-up (mo) 15.4 (range, 13-21) 14.8 (range, 14-19) Values are presented as number only or number (%).
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