Part III: Minimally Invasive Techniques in the Phalanges and Metacarpals

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Distal Radius Fractures

Cannulated screw technology is also applicable to distal radius fractures, particularly radial styloid fractures (Fig. 6). In these instances either limited open or arthroscopic techniques can be utilized (16). For Colles’ and Barton’s fracturesplate ﬁxation is typically employed. However,ifthere is aconcomitant radial styloid fracture this can be reinforced with alag screw using either cannulated or noncannulated technology.Ifacannulated system is employed in conjunction with plating one must be carefultoinsurethat thereisnot amismatchbetween the biomaterials.

Arthroscopically assisted reduction allows for the precise reduction of the intra-articular components of the distal radius fracture.Italso provides the additional beneﬁt of evaluation of the intercarpal ligaments. The surgeon must always have ahigh index of suspicion for additional carpal or ligamentous injuries in the face of aradial styloid fracture (31).

Technical Alternatives

Other options for skeletal ﬁxation in the hand and wrist include K-wires, small external ﬁxators, cerclage, intraosseous or tension band wiring, solid screws (with or without the use of plates), and bioabsorbable implants. With the exception of bioabsorbable implants, all of these methods are used routinely and successfully in the surgery of the hand and wrist. It is up to theindividualsurgeon to determinewhatcombination of surgical technique and implant choice best ﬁts the fracture, the patient, and his or her level of experience.

With respecttothe use of solid screws,Motleyand colleagues have described atechnique in which solid screws are used with precision similar to that of cannulated screws (32). This is done by using ahybrid system in which components of the Synthes 4.5-mm cannulated screw,7.3-mm cannulated screw, and 6.5-mm solid screw systems are utilized. They achieve their precision by ﬁrst placing a1.6-mm threaded guide wire followed

by a4.5 mm measuring device. An 8.5-mm tissue protector is then used for the remaining steps in which the guide pin is ﬁrst over drilled by a3.2-mmcannulateddrill bit. This is then followed by a4.5-mm cannulated drill bit. The guide wireis then removed and a6.5-mm solid screw is then placed via the guidance of the 8.5-mm tissue protector.They cited concern over cannulated screw strength as their main impetus for developing asystem that could accurately deliver solid screws with the precision of acannulated system.

Bioabsorbable screws are also an alternative to cannulated metallic screws. Kujala and colleagues published their results using bioabsorbable screwsinthe treatment of scaphoid fractures and nonunions (33). They reported solid union in ﬁve out of six patients. They felt that this was areasonable alternative to metallic screw ﬁxation. They did, however,point out that the screws once implanted weredifﬁcult to see and that cannulated system would allow for more accurate screw placement under ﬂuoroscopic guidance.

POTENTIAL COMPLICATIONS OF CANNULATED SCREW PLACEMENT

As with the implantation of any device for surgery of the hand or upper extremity,there existrisks and potential complications.These includeinfection,nonunion, implant failure,implant migration, and damage to surrounding structures during surgicalintervention.Additionalcomplications associated with cannulated screw systems are often related to the guide wire. Schwend and colleagues reported a series of ﬁve instances where surgery was complicated by instrument breakage (34). In four instances, the guide pin was sheared offbythe cannulated drill. In the remaining case the cannulated tap broke. In each case a3.5-mm-diameter system was being utilized. Breakage of acannulated screw at the head–neck interface, as can happen with solid screws,was reportedbyMechan andGalindo (35).Inanother report,

(A) (B)

FIGURE 6 ( A )Aposteroanterior radiographofaradial styloid fracture repaired with cannulated screw technology. The fragment was largeenoughfor placement of twoscrews thus insuring rotationalstability.(B )Lateral radiographic view of the same fracture showing screw placement within the metaphysis.

Engles

Mooney and Simmons detailed amoreunique failure of the cannulated screw (36).Inthree separate instances, during initial placement of acannulated screw in the metaphyseal bone of adolescent patients, the threads dissociated from the shaft of the screw.Ineach case, the threads literally unraveled during insertion. In all three instances there was no appreciable tactile change to alert the surgeon to the compromiseof the device.

SUMMARY

Cannulated screws are an effective tool in minimally invasive surgery of the hand and wrist. They often allow for stable ﬁxation while requiring only minimal surgical exposureand thus greater preservation of the soft tissue envelope. Biomechanical studies have shown them to be at least equivalent if not better than solid screws in many respects. Additionally,the ability to use these screws via percutaneous techniques has revolutionized the treatment of several injuries and disorders of the hand and carpus. The now widespread use of percutaneous cannulated screw ﬁxation for the treatment of scaphoid fractures is atestimony to this.

Ensuing chapters in this book highlight the use of cannulated screws in speciﬁc instances and in much greater detail. The reader is directed to the accompanying list of references for amore in depth analysis of this topic.

ACKNOWLEDGMENTS

The author would like to thank Ms Amanda Martin, Design Engineer at OrthoHelix Surgical Designs, Inc., for contributing the CAD diagrams which wereused in this manuscript.

REFERENCES

1. Laing PG. The use and care of metals. In: Bechtol CA, Ferguson AB, Laiing PG, eds. Metals and Engineering in Bone and Joint Surgery. Baltimore, MD: Williams &Wilkens, 1959:92–126.

2. Collinge CA, Stern S, CordesS,etal. Mechanicalproperties of small fragment screws. Clin Orthop 2000; 373:277–84.

3. Brown GA, McCarthy T, Bourgeault CA, et al. Mechanicalperformance of standardand cannulated4.0-mm cancellous bone screws. JOrthop Res 2000; 18(2):307–12.

4. Reese K, Litsky AS, Kaeding C, et al. Cannulated screwﬁxation of Jones fractures: aclinical and biomechanicalstudy.AmJSports Med 2004; 32(7):1736–42.

5. Shaw JA. Biomechanical comparison of cannulatedsmall bone screws: abrief follow-up study.JHand Surg 1991; 16A(6):998–1001.

6. Shaw JA. Abiomechanical comparison of scaphoid screws. JHand Surg 1987; 16A:347–53.

7. Carter FM, Zimmerman C, DiPaola DM, et al. Biomechanical comparison of ﬁxation devices in experimental scaphoid osteotomies. JHand Surg1991; 16A(5):907–12.

8. Toby EB, Butler TE, McCormackTJ, et al. Acomparison of ﬁxation screws for the scaphoid during application of cyclical bending loads. JBone Joint Surg 1997; 79A(6):1190–7.

9. Wheeler DL, McLoughlin SW.Biomechanical assessment of compression screws. Clin Orthop 1998; 350:237–45.

10. Chapman JR, Harrington RM, Lee KM, et al. Factors affected the pullout strength of cancellous bone screws. JBiomech Eng 1996; 118:391–8.

11.Shigley JE. The design of screws, fasteners and connections. In:

Shigley JE, ed. Mechanical Engineering Design. 3rd ed. New York: McGraw-Hill, 1977:227–73.

12. Lo IKY,King GJW,Patterson SD, et al. Abiomechanicalanalysis of intrascaphoid compression using the 3.00 mm Synthes cannulated

screw and threaded washer: an in vitrocadaveric study.JHand Surg2001; 26B(1):22–4.

13. Kissel CG, FriedersdorfSC, Foltz DS, et al. Comparison of pullout strength of small-diameter cannulated and solid core screws. JFoot Ankle Surg 2004; 42(6):334–8.

14. Adla DC, Kitsis C, Miles AW.Compression forces generatedby mini bone screws—a comparativestudy done on bone model. Injury 2005; 36:65–70.

15. Putnam MD. Radial styloid fractures. In: Blair WF,ed. Techniques in Hand Surgery.Baltimore, MD: Williams & Wilkens, 1996:322–9.

16. Shin AY, Hofmeister EP.Volar percutaneous ﬁxation of stable scaphoid fractures. Atlas Hand Clin 2003; 8:19–28.

17. YipHSF,WuWC, Chang RYP, et al. Percutaneous cannulated screw ﬁxation of acute scaphoid waist fracture. JHand Surg 2002; 27B(1):42–6.

18. Slade JF,Gutow AP,Geissler WB. Percutaneous internal ﬁxation of scaphoid fractures via an arthroscopically assisted dorsal approach. JBone Joint Surg2002; 84A(Suppl. 2):21–36.

19. Brutus J-P,Palmer AK, Mosher JF,etal. Use of headless compressive screw for distal interphalangealjoint arthrodesis in digits: clinical outcome and review of complications. JHand Surg 2006; 31A(1):85–9.

20. Stern PJ, Fulton DB. Distal interphalangeal joint arthrodesis: an analysis of complications. JHand Surg 1992; 17A(6):1139–45.

21. Leibovic SJ, StricklandJW. Arthrodesis of the proximal interphalangeal joint of the ﬁnger: comparisonofthe use of the Herbert screw with other ﬁxationmethods. JHand Surg 1994; 19A(2):181–8.

22. Messer TM, Nagle DJ, Martinez AG. Thumb metacarpophalangeal joint arthrodesis using the AO 3.0-mm cannulated screw: surgical technique.JHand Surg 2002; 27(5):910–2.

23. SchmidtCC, Zimmer SM, Boles SD. Arthrodesis of the thumb metacarpophalangeal joint using acannulatedscrew and threaded washer.JHand Surg2004; 29A(6):1044–50.

24. Trumble TE, Gilbert M, Murray LW,etal. Displaced scaphoid fractures treated with open reduction and internal ﬁxation with a cannulatedscrew. JBone Joint Surg 2000; 82A(5):633–41.

25. Slade JF,MooreAE. Dorsal percutaneous ﬁxationofstable, unstable, and displacedscaphoid fractures and selected nonunions. Atlas Hand Clin 2003; 8:1–18.

26. Bond CD, Shin AY, McBride MT,etal. Percutaneous screwﬁxation or cast immobilization for nondisplacedscaphoid fractures. JBone Joint Surg 2001; 83A(4):483–8.

27. Capo JT,Tan V. Percutaneous ﬁxation repairs ascaphoid nonunion. Orthop Tech Rev 2004; 6(5).

28. Slade JF,MooreAE. Percutaneous treatment of transscaphoid, transcapitate fracture-dislocations with arthroscopic assistance. Atlas Hand Clin 2003; 8:77–94.

29. Calandruccio JH, Gelberman RH, Duncan SFM, et al. Capitolunate arthrodesis with scaphoid and triquetrumexcision. JHand Surg 2000; 25A(5):824–32.

30. Slade JF,Bomback DA. Percutaneous capitolunatearthrodesis using arthroscopic or limited approach. Atlas Hand Clin 2003; 8:149–62.

31. Helm RH, To nkin MA. The chauffeur’s fracture: simple or complex?JHand Surg 1992; 17B(2):156–9.

32. Motley TM, Perry MD, Manoli A. Placement of solid screws with cannulatedprecision. JSurgOrtho Adv 2004; 13(3):177–9.

33. Kujala S, Raatikainen T, Kaarela O, et al. Successful treatment of scaphoid fractures and nonunions using bioabsorbable screws: report of six cases. JHand Surg 2004; 29A(1):68–73.

34. Schwend RK, Hennrikus WL, O’Brien TJ, et al. Complications when using the cannulated 3.5 mm screwsystem. Orthopedics 1997; 20(3):221–3.

35. Mechan ECR, Galindo E. Cannulated screw breaking in arthroscopic surgery of osteochondritis dissecansofthe knee—a case report. Arthroscopy 1991; 7(1):108–10.

36. Mooney JF,Simmons TW.Apreviously unreported complication of the AO cannulated4.0- and 4.5-mm screwsystems: areview of three cases. JSouth Ortho Assoc 2003; 12(3):160–2.

Use of Cannulated Screws in Hand and Wrist Surgery

Part III: Minimally Invasive Te chniques in the Phalanges and Metacarpals

Percutaneous Pinning of Phalangeal and Metacarpal Fractures

Yi-Meng Ye n

Steadman-Hawkins Clinic Vail, Vail, Colorado, U.S.A.

Roy A. Meals

Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California,U.S.A.

INTRODUCTION

Fractures of the metacarpals and phalanges are some of the most common injuries that are presented to the hand surgeon (1,2). Tenpercent of all fractures occur in the metacarpals or phalanges and 80% of all hand fractures involve these bones (3,4). Untilthe earlypartofthe twentieth century,these fractures weretreated nonoperatively.Albin Lambotte in 1928 pioneeredthe work of operative ﬁxation for metacarpal fractures (5). Even today the majority of metacarpal and phalangeal fractures are treated conservatively.Those fractures that are nondisplaced or minimally displaced are inherently stable and require only nonsurgical management. Other fractures can be reduced in aclosed manner and held in acast or splint.

The unstable fracture or dislocation, such as atransverse or obliquemetacarpalorphalangeal shaftfracture, requires surgicalﬁxationtomaintainalignment. Percutaneous pin ﬁxation of small bone fractures was ﬁrst pioneered by Tennant in 1924 using aphonograph needle. Kirschner described the use of small traction wires made from piano wire in 1927 (6,7). Bosworth reported using closed reduction and percutaneous pinning of ﬁfth metacarpal neck fractures with Kirschner (K) wires in 1937 (8). World WarIIcreated avast opportunity for fracture stabilization.Bunnell andothersusedK-wires for various percutaneous ﬁxations in the hand (6). VomSaal in 1953 reported his results after closed reduction and percutaneousﬁxationofavarietyofmetacarpal and phalangeal fractures (9). Twenty years later,Green and Anderson described crossed K-wire ﬁxation of phalangeal fractures(10).

Percutaneous ﬁxation can be applied to fractures of the hand because most bones have subcutaneous access for insertion of K-wires. Percutaneous techniques minimize the swelling andstiffness that may result from usingplates or screws. Although percutaneous ﬁxation is notasrigid as plate or screw ﬁxation, increased rigidity may not be necessary when the hand is immobilized. Percutaneous pinning can be used with both closed and open reduction; however,this chapter will focus on the technique of closed reduction and percutaneous pinning of metacarpal and phalangeal fractures.

INDICATIONS

Operative indications for metacarpal or phalangeal fractures are for those fractures with instability after closed reduction,

malrotation, intra-articular fragments, bone loss, open injury and severe contamination, adjacent fractures, and also those with major soft tissue injury requiring reconstructive surgery. The choice of open reduction and ﬁxation with ascrew or plate versus percutaneous ﬁxation depends upon the injury pattern and soft tissue coverage. Patients who have concomitant tendon injuries or those who require immediate motion generally beneﬁt from rigid internal ﬁxation, which allows early motion and gives better tendon gliding. Patients with fracturesthat have segmental bone loss or that are extensively comminuted also beneﬁt from rigid internal ﬁxation, althoughpercutaneousexternal ﬁxation canbeused. Inadequate closed reduction is acontraindication for percutaneous pin ﬁxation.

Metacarpal Fractures

Metacarpal head fractures are rare and generally involve the articularsurface. Theyusually require open reduction,and K-wire ﬁxation may delay mobilization of the joint. Metacarpal neck fractures are quite common and consideration for closed reduction and percutaneous pinning depends upon the degree of angulation and which metacarpal neck is fractured. If the index and middle ﬁngers are fractured, residual angulation and volar prominence of the metacarpal head may adversely alter grip patterns, so near anatomic reduction is preferred. Although there is lack of consensus for small and ring ﬁnger metacarpal neck fractures, it is generally agreed that up to 408 of apexdorsal angulation is acceptable.

Metacarpal shaftfractures aregenerally transverse, oblique, or spiral and can be simple or comminuted. Indications for closed reduction and percutaneous pinning are angulation greater than 308 for the small ﬁnger,20 8 for the ring ﬁnger,and any angulation in the middle or index ﬁnger. Any visible malrotation of the ray or shortening of 5mmare also indications for surgery.Metacarpal base fractures are rare in the second through fourth metacarpals but can be treated by percutaneous pinning. The so-called baby Bennett’s (ﬁfth metacarpal base) fracture tends to be unstable and closed reductionand percutaneous pinning canbeconsidered. Additionally,the Bennett’sfracture(ﬁrst metacarpal base) canbetreatedwithclosedreductionand percutaneous pinning.

Phalangeal Fractures

Indications for percutaneous pinning of phalangeal fractures are similar to metacarpal fractures. Shaft and condylar fractures that areunstablewithclosedreductionare amenable to percutaneous pinning. Long oblique and spiral oblique fractures that are initially in an acceptable position are relative indications for percutaneous pinning since these fractures can displace despite immobilization.

PREOPERATIVE PLANNING

Athorough history is taken paying particular attention to the mechanismofinjury. Thepreoperativeexamination should include acomplete assessment of the injured extremity noting the dominant hand. Open wounds should be noted. Examination of all ﬁnger extensors and ﬂexors should be conducted and compared with the contralateral side. Threshold sensation should be thoroughly documented. The patient should be asked to make aﬁst or the examiner should passively ﬂex the ﬁngers at the metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints in order to identify any rotational malalignment. Range of motion (ROM) should be assessed at each joint.

Standard lateraland posteroanteriororanteroposterior (AP) X-rays are required. If the fracture pattern is not clearly seen, semisupinated and semipronated views are helpful. The hand must be placed on theX-ray cassette in incomplete supination to obtain atrue AP view of the ﬁfth ray and in a hypersupinated position for the second ray.For all views, the X-ray beam shouldbecenteredproximally/distallyover the areaofconcern rather than capturing ageneric view of theentirehandordigit. SpecializedX-ray views (e.g., Brewerton for proximal phalanx base fractures) or computed tomography scans are sometimes needed to elucidate subtle fracture patterns, but such fracturesare generally not candidates for percutaneous K-wire ﬁxation.

SURGICAL TECHNIQUE

Operating room setup should include the standard radiolucent handtable, with the operating tablepositioned to facilitate access for theC-arm.Anexperienced surgicalassistant is helpful to hold the fracture reduction while the K-wires are inserted. The C-arm should be positioned to allow easy access for the surgeon to reduce the fracture. General anesthesia, Bier block, wrist block, digital block, or brachial plexus block can all be used. The choice depends on the desiresofthe patient, the speciﬁc injury,and preference of the surgeon and anesthesiologist. Atourniquet is generally applied to the upper arm or forearm but is usually not inﬂated. The fracture is manipulated and checkedunderﬂuoroscopy forreduction.Fracture reduction can sometimes be achieved and held with the use of fracture reduction forcepsoreven towel clips applied over the intact skin. If the fracture cannot be reduced, open reduction is appropriate.

K-wires are available in different diameters and lengths and canhaveone or both ends groundtoapoint. For metacarpals and proximal phalanges,a0.045- or 0.035-inch K-wire is generally used for large or average-sized adults. A

0.035- or 0.028-inch K-wirecan be used for smaller phalanges or children. The selection of K-wires is determined by bone size and surgeon preference. The high-rake angle trochar tips are preferred since they can be introduced at an oblique angle to the bone surface. K-wire tips that are cut in the operating room will not penetrate the bone easily; they cut alargediameter hole and

cannot be expected to sustain an appropriate interference ﬁt. Likewise, slow insertion speed and avoidance of repeat passes also improve the security of the K-wire ﬁt in the bone (11–13).

Metacarpal Neck (Boxer’s Fracture)

Reductionofthe fracture is most commonly done with the Jahssmaneuver(Fig. 1A)(14). TheMPand interphalangeal(IP) joints areﬂexed to 908 ,and theproximalphalanx canthenbeused to push themetacarpalheadout of itsvolarly angulatedposition.

Onemethodofﬁxationistostabilize thefractured metacarpal head to the next closest intact metacarpal head. One or two K-wires are inserted transversely from the fractured metacarpal head into the next metacarpal head (Fig. 1B). Another K-wire is inserted between the diaphysis of these metacarpals for ﬁnal stabilization. An alternative method is to use acrossed pin technique with two K-wires inserted across the fracture from opposite sides of the metacarpal head in a retrograde fashion(Fig. 1C).Other methods arenoted in Table 1. The hand is then placed in an ulnar gutter splint for 7to10days. If satisfactory alignment is maintained, protected active ROM can then be initiated. Pin removal is at three to four weeks.

Metacarpal Shaft Fractures

The fractureisreduced by ﬂexing the MP joint to 908 to tighten thecollateralligaments anduse theproximalphalanx to control the distal fragment.Atowel clamp canbeusedto assist with rotational reduction. Fractures are then ﬁxed with crossed pins introduced laterally at the retrocondylar fossa of the metacarpal head and drilled obliquely to the opposite cortex. Alternatively, K-wirescan be placed transversely from the fractured metacarpal into an adjacent intact metacarpal using the intact metacarpal as aplate of sorts. Acombination of the methods can also be used (Fig. 2). The hand is then splinted in the safety position. K-wiresare removed at three to four weeks.

Fifth Metacarpal Base Fracture (Baby Bennett’s)

Reduction is obtained by longitudinal tractionand medially and volarly directed pressure on the base of the ﬁfth metacarpal. The ﬁfth metacarpal shaft is pinned to the fourth metacarpal shaft (Fig. 3). An obliquely oriented pin can be used to ﬁx the ﬁfth metacarpal base to the hamate (15). An ulnar gutter splint is used for 7to10days. Pins are either cut and buried under the skin or left percutaneous and removed at three to four weeks.

Second to Fourth Metacarpal Base Fractures

Themiddleray is thekey to reductionand should be reducedﬁrst. Followinglongitudinal traction,palmartranslation is appliedto reduce thejoint.One pinisdrivenobliquely at 458 from the dorsoulnar surfaceofthe metacarpal crossing thecarpometacarpaljoint without interferingwith the extensor tendons (16,17). Alternatively,alongitudinal wire canbedrivendown themetacarpalthrough theMPintothe distal carpal row(18).

Bennett’s Fracture

Reductionofthe fracture is typically obtained by applying longitudinal traction, palmar abduction, and pronation of the thumb while exerting pressure over the dorsoradial aspect of the metacarpal base. Fixation requires one or two K-wires to maintain alignment of the shaft and joint surface (19).

Anearly longitudinal K-wire can secure the metacarpal base to thetrapezium(1).Another K-wire is then placed

38&Yen and Meals

transversely from the ﬁrst metacarpal base distal to the fracture into the second metacarpal base (Fig. 4A) (20). Alternatively, intermetacarpal pinning can be used alone (Fig. 4B) (21,22). A short-arm thumbspica is then applied. TheK-wires are removed at four to six weeks.

Phalangeal Fractures

Several methodsofpercutaneous pinningcan be used for phalangeal fractures(Fig. 5).Anoblique or spiralfracturecan be reducedbylongitudinal traction appliedmanuallyorwith ﬁngertraps. The fracture is held in placewithatowel clampor cannulated clamp. Rotation is veriﬁed by checkingfor abnormal crossing of theﬁngers with ﬂexion of theMPand IP joints.Multiplemid-lateral pins,placedtoavoid thelateral bands andperpendiculartothe fracture,are usedtoholdthe fracture (Fig.5D). Thereduction andpin placementare veriﬁed underﬂuoroscopy andthe ﬁngeristaken throughanROM.If extensionislimited,the pins may have transﬁxedthe extensor mechanismand shouldberepositioned.

Transverse fractures can be stabilized by avariety of pin placements. The fracture can be reduced with the MP and PIP joints in full ﬂexion and aK-wire inserted retrograde into the retrocondylar fossa of the proximal phalanx with aslight dorsal angulation. Asingle pin or crossed pins can be used. Alternatively,K-wires can be inserted from proximal to distal starting

(A)

(B)

(D)

(C)

FIGURE 1 ( A )Jahss maneuverfor aﬁfth metacarpalneckfracture. MP and IP joints ﬂexedto90 8 ;the prox imal phalanxcan be used to push the metacarpal head back into position. ( B )Fixation of the fractured metacarpal

head into theadjac ent metacarpal with an

additional pin in the diaphysis for stabilization. ( C )Crossed pin stabilization. ( D )Pre and post-

operative ﬁxationofaﬁfthmetacarpalneck

fracturewithasingle pin. Abbreviations:IP, interphalangeal; MP, metacarpophalangeal.

TABLE 1 Alternative Methods of Fixation for Fifth Metacarpal Neck Fractures

Fixation Method

Intramedullary Retrograde through metacarpal head

with MP ﬂexed

Bouquet osteosynthesis Multiple intramedullary K-wires pre-bent

and inserted from proximal metaphysis

External ﬁxation Span fracture with K-wires and attach

pins with polymethylmethacrylate

Abbreviations :K-wires,Kirschner wires; MP, metacarpophalangeal.

Percutaneous PinningofPhalangeal and Metacarpal Fractures&39

adjacent to the MP joint articular surface (Fig. 5B). This allows some motion at the MP joint, while permitting splinting in the safe position. For comminuted or unstable basilar fractures, a K-wire can also be inserted through the metacarpal head into the proximal phalanx (Fig. 5C). The K-wire is introduced lateral to the extensor tendon of the MP joint and advanced longitudinally across the fracture site. This violates anormal MP joint but does ensure that the MP joint remains in the favorable, fully ﬂexed position while the digit is immobilized.

K-wires can be cut offjust beneath the skin or left protruding

and bent 908 to minimize inward migration. Asterile dressing is applied, andthe ﬁngerand adjacent neighboringﬁnger are splinted and placed in the safety position. Pins are removed at three weeks and then the ﬁnger is protected with buddy taping for another three weeks before allowing full ROM. Aclinical example of an oblique distal third proximal phalanx fracture stabilized with parallel mid-lateral pins is seen in Figure 6.

COMPLICATIONS

Percutaneous pin ﬁxation can be technically demanding. The most common error when placing pins is to enter at an incorrect angle levering the fracture site open as the pin is advanced. Holding the fracture compressed and placing the pin at the correctangle preventfracturedistraction. If percutaneous

pinning does not hold the fracture reduced, conversion to an open technique is mandated. Superﬁcial pin track infection ranges from 0% to 10% (23–25). To agreat extent, pin track infections can be avoided by sharply releasing tethered skin immediately after conﬁrmation of satisfactory pin placement. Oral antibiotics with or without pin removal is usually curative. Nonunion, malunion, or delayed union may be the result from malpositioned K-wires. Loss of motion of the MP or IP joints results in poor outcomes. ROM can be maximized by ensuring an adequate reduction, ensuring excursion of thetendons perioperatively,and early active ROM. Careful pin placement and preventionofplungingthroughthe farcortexduring surgery are necessary to avoid neurovascular compromise.

OUTCOMES

Outcomefollowing ﬁxation of phalangealand metacarpal fractures is variable but is generally favorable for percutaneous pinning with K-wires (10,26,27). Green and Anderson reported that 18 of 26 unstable phalangeal fractures regained full ROM within eight weeks after percutaneous ﬁxation (10). Belsky et al. reported that 61 of 100 phalangeal fractures regained full ROM (26). Morerecently,Hornbach and Cohen have reported on 12 unstable proximal phalanx fractures, with an averagetotal

(A)

(B)

(C)

FIGURE 2 ( A )Percutaneous pinning of second and third metacarpal fractures to the adjacent metacarpal. ( B ) Preoperative fourth and ﬁfth metacarpal fractures.(C )Longitudinal single pin ﬁxation with astabilizing cross pin for rotational control.

Yen and Meals

(A)

(B)

FIGURE 3 ( A )Fractureﬁxation of a“baby Bennett’s” fracture. Obliquely orientated pin to ﬁx the ﬁfth metacarpal base into the hamate and an additional pin stabilizing the fourth andﬁfthmetacarpal. ( B )Pre andpost-operative radiographs of afourth metacarpal fracture with adislocation of the ﬁfth metacarpal.

(A) (B)

(C)

(D)

FIGURE 4 ( A )Longitudinal K-wire securingmetacarpal base to trapezium.Anadditional K-wire is used to secure the ﬁrst metacarpal to the second metacarpal base. ( B ) Intermetacarpal pinning of aBennett’sfracture. ( C )Preoperative radiographs of aBennett’s fracture. ( D )After closed reduction and pinning with asingle pin. Fracture wasstable underﬂuoroscopy. Abbreviation:K-wire, Kirschner wire.

Percutaneous PinningofPhalangeal and Metacarpal Fractures

ROM of 2658 .There was one ﬂexion contracture, one tendon adhesion, and one rotational deformity,but 10 of 12 patients obtained excellent results (24).

Metacarpalfractureﬁxationin24patients yieldedan

average of 0 8 to 3 8 of dorsal angulation having no metacarpal shortening with complete healing by six weeks (28). Anonrandomizedcomparisonoftransverseand intramedullary percutaneous pinningofthe ﬁfthmetacarpalneckshowed excellent results with both methods and no difference in grip strength, ROM, pain, and angulation (29).

Dartee et al. achieved full motion and complete pain relief in 32 of 33 patientswith Bennett’sfractures treatedwith intermetacarpal pinning (21). In acomparison of open versus percutaneous pinning of the Bennett’s fracture by Lutz et al., the typeoftreatment did notinﬂuence the clinical outcome or the prevalence of radiological posttraumatic arthritis. But the percutaneous group hadahigher incidenceofadduction deformity of the ﬁrst metacarpal (30).

SUMMARY

Percutaneous pinning of metacarpal and phalangeal fractures is auseful technique for injuries that are unsuitable for closed reduction and cast immobilization and that do not demand open reduction.Soft tissue dissection and swelling is minimized with percutaneouspinning. Onelimitationisthat motion exercises are often delayed due to immobilization and sometimes cannot be started until the K-wiresare removed. However, formanypatients,percutaneous pinning can minimize complications and provide excellent results.

SUMMATION POINTS

Indications

Unstable fractures of the metacarpals and phalanges

Outcomes

Good to excellent outcomes in O 90% of cases

Complications

Limited ROM, pin track infections, malunion, nonunion, and delayed union

(A) (C)

(B) (D)

FIGURE 5 ( A )Fixation of atransverse phalangeal fracture, ﬁrst, with reduction of the MP and IP joints in full ﬂexion. AK-wire is then inserted into the retrocondylarfossa with aslight dorsal angulation.(B )Crossed K-wire ﬁxation from proximal to distal starting adjacent to the MP articular surface. ( C )Fixation through the metacarpalheadintothe proximal phalanx. ( D )Oblique or spiral fracture is reducedand multiple midlateralpinsplacedperpendicular to thefractureavoidingthe lateral bands and extensor mechanism. Abbreviations:IP, interphalangeal; K-wire, Kirschner wire; MP, metacarpophalangeal.

FIGURE6 Post-operative radiograph of oblique distal thirdphalangeal fracture ﬁxed with two K-wires. Abbreviation:K-wires, Kirschner wires.

Yen and Meals

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Percutaneous PinningofPhalangeal and Metacarpal Fractures

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