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Treatment of Comminuted Fractures of the Base of the Thumb Metacarpal Using a Cemented Bone-K-Wire Frame

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Treatment of Comminuted Fractures of the Base of the Thumb Metacarpal Using a Cemented Bone-K-Wire Frame Hand Surgery and Rehabilitation 38 (2019) 44–51 Available online at ScienceDirect www.sciencedirect.com Original article Treatment of comminuted fractures of the base of the thumb metacarpal using a cemented bone-K-wire frame Traitement des fractures comminutives de la base du premier me´tacarpien graˆce a` un cadre os-broches-ciment W. Duan, X. Zhang, Y. Yu, Z. Zhang *, X. Shao, W. Du Department of Hand Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, PR China ARTICLE INFO ABSTRACT Article history: We aimed to describe the treatment of comminuted fractures of the base of the thumb metacarpal using a Received 13 June 2018 cemented bone-K-wire frame. Between March 2010 and January 2016, 41 fractures of the base of the thumb Received in revised form 8 August 2018 were treated using a cemented bone-K-wire frame. The mean age of the patients was 34 years. The patients’ Accepted 7 September 2018 history included a fall onto the hand in 7 cases, direct trauma in 31 cases, and polytrauma with an unclear Available online 11 October 2018 mechanism of injury in 3 cases. At the final follow-up, hand grip and pinch strength were measured using a dynamometer. All measurements were compared with those of the opposite hand. The patients were assessed Keywords: functionally using the Smith and Cooney score.All K-wires were left in place until the bone healed. Bone healing Cemented K-wire frame was achieved in all thumbs in an average of 5.2 weeks. Follow-up averaged 27 months. The mean hand pinch External fixator Rolando fracture andgripstrengthwas8.7 kg Æ 2.4 kgand38.4 kg Æ 5.9 kg,respectively.Themeanmeasurementsontheopposite Thumb side were 9.2 kg Æ 2.5 kg and 40.2 kg Æ 6.6 kg, respectively. Based on the Smith and Cooney score,[13_TD$IF] we obtained an Range of motion averagescoreof87 Æ 9.3,with25excellent,9good,and2fairresults.Thecementedbone-K-wireframeisanexternal fixator alternative that can be used for treating comminuted intra-articular fractures of the base of the thumb metacarpal. The system is cheap, easy to apply, and provides rigid fixation, resulting in good functional recovery. C 2018 Published by Elsevier Masson SAS on behalf of SFCM. RE´ SUME´ Mots cle´s: Notre objectif e´tait d’introduire le traitement des fractures comminutives de la base du premier Cadre os-broche-ciment me´tacarpien a` l’aide d’un cadre os-broches-ciment. De mars 2010 a` janvier 2016, 41 fractures de la base du Fixateur externe pouce ont e´te´ traite´s en utilisant le cadre os-broches-ciment. L’aˆge moyen des patients e´tait de 34 ans. Fracture de Rolando L’histoire raconte´e par les patients de´crivait une chute sur la main dans 7 cas, un traumatisme direct dans Pouce 31 cas, et un polytraumatisme avec un me´canisme peu clair de la le´sion dans 3 cas. Au recul final, les forces Amplitude de mouvements de poigne et de pince ont e´te´ mesure´es a` l’aide d’un dynamome`tre. Toutes les mesures ont e´te´ compare´es avec celles de la main oppose´e. Les patients ont e´te´ e´value´s sur le plan fonctionnel graˆce au score de Smith et Cooney. Toutes les broches de Kirschner ont e´te´ laisse´es en place jusqu’a` la consolidation osseuse. Celle-ci a e´te´ obtenue dans tous les pouces en 5,2 semaines en moyenne. Le recul moyen e´tait de 27 mois. Les forces moyennes de poigne et de pince e´taient respectivement de 8,7 kg Æ 2,4 kg et de 38,4 kg Æ 5,9 kg, pour des chiffres moyens du coˆte´ oppose´ respectivement de 9,2 kg Æ 2,5 kg et de 40,2 kg Æ 6,6 kg. Sur la base du score de Smith et Cooney, nous avons obtenu un score moyen de 87 Æ 9,3, correspondant a` 25 excellents, 9 bons et 2 moyens re´sultats. Le cadre os-broches-ciment est un fixateur externe intelligent et peut eˆtre une alternative pour le traitement des fractures articulaires comminutives de la base du premier me´tacarpien. Le syste`me est bon marche´, facile a` appliquer et offre une fixation rigide, permettant une bonne re´cupe´ration fonctionnelle. C 2018 Publie´ par Elsevier Masson SAS au nom de SFCM. * Corresponding author. E-mail address: [email protected] (Z. Zhang). https://doi.org/10.1016/j.hansur.2018.09.005 2468-1229/ C 2018 Published by Elsevier Masson SAS on behalf of SFCM. W. Duan et al. / Hand Surgery and Rehabilitation 38 (2019) 44–51 45 1. Introduction skeletal immaturity (n = 1); combined tendon or neurovascular injury(n = 2); Thumb metacarpal fractures make up almost 25% of all extra-articular fracture (n = 5); metacarpal fractures [1]. Approximately 80% of thumb fractures old fractures exceeding 14 days; involve the metacarpal base and 20% of thumb basal fractures are diabetes, gout, ganglion, or bone tumors; intra-articular [2]. Comminuted fractures are usually treated [135_TD$IF] declined to participate in the study. surgically because it is difficult to maintain reduction with a cast [3]. The best treatment is still debated. Owing to the advantages of Thus, a total of 41 patients (41 thumbs) were analyzed for this minimally invasive procedures, closed and percutaneous reduction study (Table 1). and fixation may be a worthy strategy. Preoperative radiographs and CT images were obtained in all Fractures at the base of the thumb metacarpal are classified into patients (Fig. 1A–E). All procedures were performed by the same four types: Bennett fracture, Rolando fracture, comminuted senior hand surgeon using the same surgical technique. fracture, and extra-articular fracture [4]. The Rolando fracture was first described in 1910 by Silvio Rolando [5]. It consists of three 2.1. Surgical technique distinct fragments and is typically Y-shaped. This term now includes essentially all comminuted fractures of the base of thumb The procedure was performed under brachial plexus block metacarpal [6]. Therefore, we combined Rolando fractures and without tourniquet control. First, the intra-articular fracture of comminuted fractures into one group in our study. thumb base was reduced with axial traction in most cases (Fig. 2A). For the treatment of comminuted fractures, there are various Otherwise, adequate reduction could be achieved with the aid of surgical procedures, including open reduction and internal fixation percutaneous leveraging, hooking and joystick techniques (Fig. 2B, (ORIF) with K-wires [7], ORIF with Herbert screws, external C). Intra-articular reduction was verified under fluoroscopy as fixation, closed reduction with percutaneous K-wire fixation [8,9], needed. Second, we inserted an axial 1.0 mm K-wire into the oblique traction with a K-wire and splinting [10,11]. Although ORIF metacarpal, from the head to the base, to maintain the reduction can achieve good reduction, the major drawbacks are tendon temporarily (Fig. 2D). Third, two or three K-wires (1.0–1.5 mm) adhesions, wound infection, and decreased vascularity. were inserted into the basal fragments to maintain the intra- A mini plate-and-screw system can achieve more rigid fixation, articular reduction (Fig. 3A). Fourth, we inserted two K-wires (1.0– which allows almost full joint motion soon after surgery. However, 1.25 mm) into the distal fragment in a transverse manner. We the extensive dissection required carries a high risk of nonunion, inserted another two K-wires into the trapezium in a transverse infection, tendon excursion limitation and stiffness, as well as manner (Fig. 3B, C). During insertion, care was taken to avoid higher treatment costs and the need for secondary implant injuring the tendon and neurovascular structures (Fig. 4A). removal [12]. Longitudinal pinning is typically unable to maintain Acceptable K-wire positioning was confirmed under fluoroscopy satisfactory reduction [13]. An external fixator can be used to on Kapandji’s[136_TD$IF] six views [17]. The K-wires were bent about 1.5 cm achieve rigid fixation with the advantages of restoring the length of distal to the skin, toward the fracture site. The monomer (liquid) the metacarpal and controlling rotation [14]. However, owing to and polymer (powder) components of bone cement (Palacos1,[132_TD$IF] the inherent weakness in the design of small devices, mini-fixators Hanau, Germany) were mixed. The bone cement’s[137_TD$IF] viscosity are difficult to assemble, especially for a small thumb base and changed over time from a runny liquid into dough-like state that small bone fragments [15]. Usually, a maximum of four pins can be was applied to the K-wire ends, and then finally hardened into inserted. External fixators are expensive. To get around these solid material (Fig. 4B, C). The distance between the cement glob drawbacks, we used K-wires and bone cement to create a clever and skin was about 1 cm. The axial K-wire for temporary fixation external frame. Ebelin et al. [16] were the first to use bone cement was removed. Acceptable fracture reduction and alignment was and K-wires to build an external fixator. Ebelin’s[134_TD$IF] study encom- confirmed on radiographs. If the articular surface was still passed thumb to little finger injuries, and their surgical procedures displaced, complete reduction was achieved with the aid of included fixation of various fractures and joint fusion, as well as percutaneous techniques using a K-wire and arthroscope. compression and traction of phalanges. Their study did not specifically focus on thumb basal fractures. The purpose of this retrospective study was to report on closed Table 1 reduction and percutaneous fixation for the treatment of Demographic data for the patients.
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