INTRODUCTION
The fractures of the metacarpal and proximal
phalangeal bones represent about 10% of all fractures,
and more than one third of all hand fractures
[1,2]. Metacarpal fracture may affect head, neck,
shaft, and base of the metacarpal bone. The most
common causes of these fractures are road traffic
injury or machinery related trauma. In other way,
fall, crush injury especially during sports, or twist-
213
ing injuries may result in these fractures [3-6].
Fracture of distal and middle phalangeal bones
occurs less frequently than proximal phalanx [7].
The prognosis of metacarpal and proximal
phalangeal fractures is dependent on the severity
of injuries, and the perfection of the management
[8]. It's reported that every 2mm shortening of
metacarpal bones may lead to 8% loss of the power
grip, and digital overlap during fist formation may
be resulted from a trivial malrotation of metacarpals
[3,9,10].
Conservative management of the stable hand
fractures can be applied in most of these fractures.
In the reverse way, the application of non-operative
techniques can lead to unsatisfactory results in
unstable hand fractures [5,6,11-13].
The management of unstable metacarpal and
proximal phalangeal fractures varies greatly worldwide,
due to resources unavailability, geographical,
and social factors [7,14-16].
It's not uncommon for operative reduction and
internal fixation of hand fractures [17]. These indications
may be unstable fractures, displaced intraarticular
fractures, compound fractures with
tendons, nerves, vessels, ligaments injuries, fractures
with segment loss, malunion/or nonunion
with disability, during replantations, some cases
of oblique or spiral hand fractures, comminuted
hand fractures with or without segment loss of the
bone, and closed multiple metacarpal fractures [18].
A lot of procedures may be applied like intramedullary
K wires, or plate and screws, and external
fixators [3,5,6,12,19].
The targets of management of these fractures
are; 1- Maintaining of proper reduction, 2- Inhibition
of malrotation , 3- Regaining of bone length,
4- Proper soft tissue handling, 5- and early starting
of mobilization [3,7,12,19-21].
Finally, the reduction should be evaluated both
in flexion and extension with assuring reduction
stability. These will permit early movement that
keep intrinsic muscles active [6,22,23].
The aim of this study was to assess the clinical
and radiologic outcomes of patients with metacarpal,
and proximal phalangeal fractures, who underwent
open anatomic reduction and fixation with
plate and screws in group I, and intramedullary K
wire fixation in group II.
PATIENTS AND METHODS
From April 2012 to July 2016, a total number
of 25 patients with unstable metacarpal and phalangeal
fractures were treated. Group I (Plate and
screw fixation) consisted of 12 male patients with
age ranged from 18 to 52 years, and the mean age
was 32±9.37 year. The preoperative lateral angulation
was 52.5±16.15º; the shortening was 1.67
±2.42mm. The injury to surgery interval ranged
from the same day (day one) to the day 22 with
mean value of 9.58±7.72 days, ten cases with
unstable metacarpal fractures in group I, and two
cases with unstable proximal phalangeal fractures
were included in this group. Regarding group II
(Intramedullary K wire fixation) consisted of 13
male patients with age ranged from 20 to 50 years,
and the mean age was 34.9±10.65 year. The preoperative
lateral angulation was 51.15±15.96º; the
shortening was 2.15±2.19mm. The injury to surgery
interval ranged from the same day (day one) to the
day 22 with mean value of 7.54±7.43 days, eleven
cases with unstable metacarpal fractures included
in group II, and two cases with unstable fracture
proximal phalanx.
Methods:
This retrospective study design was approved
by ethical committee of institutional review board
(IRB) of Faculty of Medicine, Zagazig University.
Written consents containing the details of operative
and postoperative interventions with permission
for pre and post-operative photography were taken
from all patients included in this study.
Operative technique:
The operations were done under regional nerve
block (infraclavicular, or interscalene), some cases
were operated under general anesthesia. The use
of tourniquet on the upper arm was routinely followed.
In group I: The operative approach was
through an incision on the radial edge of the first
radial two metacarpals and ulnar rim of the ulnar
(fifth) metacarpal. The third and fourth metacarpal
bones were exposed by a longitudinal dorsal inci-
214 Vol. 42, No. 2 / Plate & Screw Versus Intramedullary K Wire
sion, after that, dissection, and retraction of the
extensors was done. As regard fractures of proximal
phalanges, dorsolateral incision was used to expose
the fracture site, without aggressive dissection of
soft tissues, and minimal periosteal elevation if
needed to expose fracture site. Proper Reduction
of the fracture was achieved and maintained using
a reduction forceps or small K-wire. Next, internal
fixation was carried out using appropriate Fixation
of the fractured bones with a suitable plate according
to the configuration of the fracture. Confirmation
of the reduction and accuracy of the plate and
screw sizes were assured through image intensifier.
Skin and soft tissue closure without any drains was
done. Elevation of the hand with complete rest
with plaster of Paris splint was applied for 48 hours.
Depending on the overall state of the patient, kind
of fracture and fixation technique, active finger
and metacarpophalangeal joint mobilization was
started on the Third day postoperatively, or later.
In group II; closed reduction of the fractures
was achieved in most of cases, then fixation with
intramedullary K wires. Also Reduction of the
fracture was confirmed under Image intensifier. In
some cases of unstable metacarpal fractures, especially
in open fracture, intramedullary K wire from
the fracture site to pass through metacarpophalangeal
joint, then reduction of the fracture was done.
After that, introduction of the K wire through distal
segment of the bone to pass the fracture site, to
the proximal segment of the metacarpal bone, to
be extruded at carpometacarpal joints to appear
from the skin. This technique will preserve MP
joint; with the part of the K wire outside the skin
is at carpometacarpal junction [24].
Monitoring of the union of the fracture was
confirmed by repeated X-rays, during the visits of
follow-up. Other parameters like range of motion
recorded in degrees and occurrence of complications.
Physical therapy was carried out on an outpatient
basis. The patients were evaluated clinically
and radiologically. Active ROMs of all the joints
of each finger in the involved hand were measured.
Based on these same factors, the patients were
allowed to use their hands in daily activities after
the fourth postoperative week and in activities
requiring force after the sixth week. DASH scoring
was performed in all patients. The assessment of
functional results was made on the basis of the
criteria of the American Society for Surgery of the
Hand, in which total active movement (TAM) of
the digit (other than the thumb) is measured. TAM
is defined as the total active 3 flexion range of
metacarpophalangeal (MCP) and interphalangeal
(IP) joints. The results were graded as follows:
Egypt, J. Plast. Reconstr. Surg., July 2018 215
TAM ³210º as good, TAM of 210-180° as fair and
TAM of <180º as poor (normal TAM for fingers=
260º). The complications were noted.
Statistical analysis:
Data were represented as mean ± standard
deviation (SD). Statistical analysis was performed
using the 20.0 version of SPSS statistical software
for windows. Independent student t-test was used
in the comparison between two groups of patient.
Pearson correlation was done to detect the association
between the injury to surgery interval and
each of DASH score, total active motion and radiological
healing. Chi-Square tests were done to
detect any association between the removal of hard
ware and loss of reduction or dominant side lesion.
p-values less than 0.05 were considered significant.
RESULTS
There was a non-significant difference between
group I (Plate and screw fixation) and group II
(Intramedullary nail fixation) regarding the mean
values of follow-up period (13.33±5.28, 12.61±
4.19, p>0.05). Concerning plate and screw fixation
(group I) (Figs. 1-4), showed a significant increase
in the mean values of surgery duration (43.08±
12.60min) and total active motion "TAM"
(148.5±8.05º) when compared with that of intramedullary
nail fixation (Figs. 5-7) "group II"
(27.77±7.30, p<0.01, 137.64±12.38º p<0.05, respectively),
accompanied by a significant reduction
in the mean values of DASH score (13.25±3.11),
postoperative lateral angulation (2.58±3.34º) and
radiological healing (4.958±0.69 week) in comparison
to those of intramedullary nail fixation "group
II" (27.77±7.30, p<0.05, 9.23±8.12º; p<0.05 and
6.50±1.43; p<0.01 respectively) (Table 1).
In both groups there was no significant association
between loss of reduction and removal of
hard ware (p>0.05), or between dominant side
lesion and removal of hard ware (p>0.05). Moreover,
no significant association could be detected
between loss of reduction and dominant side lesion
(p>0.05).
Table (1): Statistical analysis of Follow-up period (weeks),
Surgery duration (min), DASH score, total active motion
(TAM), postoperative lateral angulation (POLA), and radiological
healing (weeks) in group I (Plate and screw fixation)
and group II (intramedullary K wire fixation).
Follow-up period
Surgery duration
DASH score
TAM
POLA
Radiological
healing (week)
13.33±5.28
43.08±12.60
13.25±3.11
148.5±8.05
2.58±3.34
4.958±0.69
Group I
12.61±4.19
27.77±7.30
18.15±7.65
137.64±12.38
9.23±8.12
6.50±1.43
Group II
0.709
0.001
0.049
0.017
0.015
0.003
p-value
of tt
Fig. (4): Intensifier photo, Plate and screws fixation of proximal
phalangeal fracture of the 4th figure of left hand.
Fig. (1): Preoperative, proximal phalangeal fracture of the
4th figure of left hand.
Fig. (2): Preoperative, X-ray of proximal phalangeal fracture
of the 4th figure of left hand (2 views).
Fig. (3): Intraoperative, incision with plate and screws fixation
of proximal phalangeal fracture of the 4th figure of
left hand.
DISCUSSION
Metacarpal bones and phalanges are small
bones; in spite of that the improper management
of their unstable fractures is of bad impact on the
whole patient satisfaction, quality of life, and daily
patient's activity [25]. Strauch et al. [26] declared
216 Vol. 42, No. 2 / Plate & Screw Versus Intramedullary K Wire
by cadaveric study, that lag by about 7° of extensor
tendon with each 2mm of shortening of metacarpals,
and the angulation also affects the power grip
and flexor digitorum function.
Closed reduction of the metacarpal and proximal
phalangeal bones can be applied in the majority
of cases, and then wrist and finger plaster immobilization
would be attained in the intrinsic-plus
or “clam-digger” situation (extended wrist in 30-
40º, metacarpophalangeal joints is flexed in 80-
90º, and full extension of interphalangeal joints)
[3,5,6,27]. The drawbacks of these conservative
policies are also serious, including poor stability,
long recovery time, fracture displacement, and stiff
joints [28,29].
The goal of management of fractures of metacarpal
and proximal phalangeal bones is to attain
painless range of motion in the affected finger in
the shortest possible time. As well known, any
elongation of the time of restriction of mobility of
joints next to the deal with these fractures leads to
stiffness of joints and loss of pliability of soft
tissues [30,31].
Barr et al. [32] stated functional loss in approximately
77% of fingers with unstable metacarpal
Fig. (8): Intramedullary K wire fixation of the 4th and 5th
metacarpal after anatomical reduction.
Fig. (5): Post operative view of proximal phalangeal fracture
of the 4th figure of left hand.
Fig. (6): Multiple fractures of metacarpal bone were fixed by
intramedullary K wires.
Fig. (7): K wire fixation of the 5th metacarpal bone of the
left hand.
Fig. (9): Postoperative X-ray of 2 K wires fixation of fracture
of 1st metacarpal of right hand.
Egypt, J. Plast. Reconstr. Surg., July 2018 217
and phalangeal fractures treated by closed reduction
means.
A lot of open reduction and fixation procedures
are available; nevertheless appropriate early physical
therapy is the corner stone for achieving perfect
outcomes [33]. Unfortunately, Intramedullary Kirschner
wires are used more commonly in fixation
of these fractures [6,11] due to simplicity of the
procedure, easily availability in field of the operation,
minimal time of consuming the operating
room, and the lowest association with soft tissue
trauma as it can be inserted percutaneously [5,34,35].
Percutaneous insertion of the K wire in a transverse,
cross, or insertion intramedullary can be done
easily. However, adhesions of the extensor tendons
or even tendon ruptures can be happened [27].
Moreover, K wires cannot maintain acceptable
biomechanical solidity and associated with complications
like restricted joints motion and their
stiffness [27].
Pin track infection and loosening of K wire, or
migration of the pin can occur, because the end of
the wires is kept outside the skin [36]. The delayed
beginning of movement in the affected fingers can
lead to stiff hand [6,37].
K-wire can maintain stability of the fractures
if soft tissue is unharmed. Osteosynthesis by plates
and screws in these unstable metacarpal and proximal
phalangeal fractures provides proper anatomical
reduction and stabilization with early active
mobilization of nearby joints, and also reduction
of edema, fibrosis and scar formation [38]. A lot of
researches proved that, mini-plates and screws are
superior in biomechanical stability over other
manners of internal fixation in unstable hand fractures
[39,40]. Plate and screws fixation can be used
in comminuted metacarpal and phalangeal fractures
[5,6,34,41].
Surgical fixation by single K-wire is very simple,
however cannot avoid rotation and applies no
proper impaction between both fracture ends, thus
delaying fracture union. Besides, fixation by Kwire
requires immobilization in plaster for a while
with limitations of early mobilization [42]. In reverse
way, plate fixation can prevent malrotation and
fixation disruption with improvement of initial
beginning of functional mobilization [43,44]. Early
active and passive mobility can avoid intrinsic
muscle stiffness. Material disappointment and
irritation, nonunion, and infection also can be
avoided with the merits of plate fixation [45,46].
Fujitani et al. [47] presented another idea in a
comparative research between intramedullary nail
and plate fixation for unstable fractures neck of
metacarpals and stated according to them, that the
active range of motion of finger with intramedullary
K wire fixation group was better than those in the
plate group. They explained that results due to
more fibrosis nearby the metacarpophalangeal
joint, after a lot of soft tissue dissection during
fixation of these fractures by plate and screws.
In a comparative study done by Ozer et al. [34]
between intramedullary K wiring and fixation with
plate and screw, they stated that, in spite of the
similarity between the two groups in the clinical
consequences, the shorter operative times, and no
need for other surgery to remove the plates in the
group of intramedullary K wires are of great value.
Agarwal and Pickfoed [43] studied the fixation
of hand fractures with plate and screw of 11 metacarpal
bones, 9 phalanges. They proved satisfactory
results, with no failure of plate fixation. In
the present study, only one case from 12 patients
operated for fixation of metacarpal and proximal
phalangeal fractures by plate and screws showed
loss of reduction (success rate 91.6%). Only one
case required hard ware removal, the time of fracture
union was significantly lower than the union
with K wire fixation, mean total active motion in
affected fingers was 148.5±8.05º, with lower mean
DASH score 13.25±3.11 points, and minimal postoperative
angulation 2.58±3.34º.
As regard the management of transverse and
oblique fractures of the shaft of metacarpal bones
by percutaneous K wire intramedullary, this work
was done by Yammine and Harvey, [48] they proved
a good results, with good union power in spite of
slight malunion with mean DASH score of 5.55
points (range 0.83-11.67 points). In this present
study in 13 cases with intramedullary K wire fixation,
the achieved results were (TAM of the affected
fingers was 137.64±12.38º, DASH score
was 27.77±7.30, postoperative lateral angulation
was 9.23±8.12º, time for union in weeks was 6.50±
1.43.
Another study on forty cases of metacarpal
fractures treated with plate and screws, revealed
good stability with early permission of free mobility,
all their patients returned to their preoperative
activities, except one case required revision surgery.
Minimal irritation of fixation material with dorsal
application of the plates necessitates hard ware
removal [49].
In other words, the disadvantages of the use of
plate and screws may be tendon and other soft
tissue irritation, or tendon rupture, and if stiffness
of fingers and nonunion occurred it will be so
difficult to solve [50].
There is no agreement about the treatment of
the fractures of metacarpal bone and proximal
phalangeal bones, due to the nature of most studies
being retrospective, and mixing between these 2
fractures in the same study. The solution may be
with prospective multicenter researches with comparative
There is no agreement about the treatment of
the fractures of metacarpal bone and proximal
phalangeal bones, due to the nature of most studies
being retrospective, and mixing between these 2
fractures in the same study. The solution may be
with prospective multicenter researches with comparative
studies and wide data base [5].
Other limitations were the narrow number of
patients, without randomization, inclusion of different
fractures of the metacarpals and proximal
phalanges, the choice of the surgical procedure
was dependent on the self-preference of the surgeon
range, and finally the assessment of union radiologically
was uneasy [51].
In conclusion, although the operative duration
of plates and screws fixation was longer and being
expensive than that of K wire fixation, it had perfect
stability with early mobilization, So, it is preferred
to be the first line of choice in management of
unstable metacarpal and proximal phalangeal bone
fractures.
Conflict of interests: The authors declare no
Conflict of interests.
