Evaluation of surgical stabilization of metacarpal and phalangeal fractures of hand

Background: Optimized functional results are dif ﬁ cult to achieve following hand injuries. This prospective study was undertaken to evaluate the functional outcome after surgical stabilization of metacarpal and phalangeal fractures. Materials and Methods: Forty- ﬁ ve fractures of digits of hand in 31 patients were managed by surgical stabilization. Five fractures were ﬁ xed with closed reduction and percutaneous Kirschner wire ﬁ xation; 10 with external ﬁ xator; 26 with open reduction and Kirschner wire ﬁ xation; and four with open reduction and plate and screw or screw ﬁ xation. Results: Final evaluation of the patients was done at the end of three months. It was based on total active range of motion for digital functional assessment as suggested by the American Society for surgery of hand. Overall results were excellent to good in 87%. Better total active range of motion (excellent grade) was observed in metacarpal fractures (47%) versus phalanx fractures (31%); closed fractures (57%) versus open fractures (27%); and single digit involvement (55%) versus multiple digits (29%). Excellent total active range of motion was observed with all four plate and screw/ screw ﬁ xation technique (100%) and closed reduction and percutaneous kirschner wire ﬁ xation (60%). Twenty-two complications were observed in 10 patients with ﬁ nger stiffness being the most common. Conclusion: Surgical stabilization of metacarpal and phalangeal fractures of hand seems to give good functional outcome. Closed fractures and fractures with single digit involvement have shown a better grade of total active range of motion.

F ractures of metacarpals and phalanges constitute between 14-28% of all visits to the emergency department. 1 Functional outcome of the fractures of small bones of the hand is partly dependent upon the severity of initial injury and its management. 2 Fracture healing in the hand is not an isolated goal; rather, the functional end result is of paramount importance. 3 The purpose of this prospective study was to evaluate operative results of metacarpal and phalangeal fractures.

MATERIALS AND METHODS
Forty-five metacarpal and phalangeal fractures of the hand in 31 patients aged 14 yrs or more were included in the prospective study conducted during the period 2004-2005. Unstable metacarpal and phalangeal fractures, intraarticular fractures, avulsion fractures, fracture dislocations and open fractures with sharp and clean wounds were included in the study. An unstable fracture was defined as one in which the patient was able to move the adjacent joints by less than 30% of the expected normal range of motion. 2 Open fractures with severe soft tissue injury and fractures associated with severe osteoporosis were excluded.
The fractures were reduced and fixed using various implants including Kirschner wires, external fixators, plates or screws depending on fracture site, configuration and associated soft tissue damage. The fractures were divided into four groups depending on the type of internal fixation.
Group I (n=5): The closed reduction and percutaneous Kirschner wire fixation was done in patients with fractures of the middle phalanx, proximal phalanx and metacarpal when closed reduction was possible.
Group II (n=10): Open/closed reduction and external fixation was performed for open fractures with sharp and clean wounds.
Group III (n=26): Open reduction and Kirschner wire fixation was done in fractures where closed reduction was not possible [ . Retrograde Kirschner wire fixation, intramedullary Kirschner wire fixation avoiding the joint and cross Kirschner wire fixation was done in 16, six and four fractures respectively.

RESULTS
The mean age of the patients was 35.6 years (range 14-74 years). The most common mode of trauma was assault and roadside accidents (60%). In all, 43 digits were involved and there were a total of 45 fractures. Twenty-two patients had only a single digit involvement while two digits were involved in six patients and three digits in three patients. Fracture site and configuration in metacarpal and phalanges is shown in Table 1. Nine hands had more than one fracture and multiple metacarpal fractures were the most common combination. Twenty-three were closed and 22 were open fractures. Articular involvement was observed in nine fractures.
The functional outcome after fracture treatment was assessed by calculating total active range of motion (TAM). 4 This was done by adding the active flexion at metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints,     The hand was kept elevated and patients were encouraged to perform movements of the fingers and hand to prevent edema and stiffness. Antibiotics were given for 48h and prolonged in cases of open fractures. The Kirschner wires and external fixation devices were removed between 3 to 6 weeks. Active assisted mobilization was started after removal of Kirschner wire / external fixator usually at three to six weeks. Wax bath and contrast bath were given. Continuous passive motion (CPM) was not used. Patients were followed weekly for the first month and fortnightly for the next two months before final evaluation at three months.
after subtracting the sum of extension deficit at these three joints. Recovery is calculated as percent-regained motion compared to normal range of digital motion (260º). According to this patients with 85-100% of movement are classified as excellent; 70-84% as good; 50-69% as fair; and < 50% as poor.
A total of 22 complications were observed [ Table 2] in 10 patients out of a total of 31. Finger stiffness (15.56%) and deformity (7%) were the most commonly observed complications.
Results in various groups according to TAM are tabulated in Table 3. Best results were observed in fractures treated with open reduction with plate and / or screw fixation (Group IV) [ Figures 5-8]. The statistical difference could not be drawn between different groups, as patients in some groups were very less.

DISCUSSION
Many factors, such as delicate handling of tissues, preservation of gliding planes for tendons, prevention of infection and early and appropriate physiotherapy other than accurate reduction and fixation affect recovery of good mobility. 5 A higher incidence of excellent TAM (n=13,57%) was observed in closed fractures as compared to open fractures (n=6,27%). Pun et al. 6         two Kirschner wires. It is desirable that while using cross Kirschner wire fixation crossing point of the wires should not be located at the fracture site so as to avoid distraction.
Open reduction and plate fixation was done in two fractures and two patients were treated with screw fixation. Excellent TAM was obtained in all four fractures treated by these techniques. Bosscha  The results of the present study following surgical stabilization of fractures of metacarpals (94% excellent to good) and phalanges (54% excellent to good) were observed to be superior to those reported by Duncan et al. 19 (63% excellent to good for metacarpal fractures and 32% excellent to good for phalangeal fractures). Most of the authors have made similar observations indicating superior TAM following metacarpal fractures as compared to phalangeal fractures [ Table 4].
Limitation of the study: The sample size is very small in some groups for statistical comparison.

CONCLUSION
Surgical stabilization of metacarpal and phalangeal fractures of the hand seems to give good functional outcome. Closed fractures and fractures with single digit involvement are important determinants to achieve a better grade of total active range of motion.