Eur J Surg Sci 2013;4(2):55-61

RESEARCH ARTICLE

Management of Metacarpal and Phalangeal Fractures in Hand Injuries Serdar DÜZGÜN1, Bülent ÖZKURT2, Deniz ÇANKAYA2, Erkin ÜNLÜ1, Sinem SINGIN1, A. Yalçın TABAK2 1 2

Department of Plastic and Reconstructive Surgery, Ankara Numune Teaching and Research Hospital, Ankara, Turkey Department of Orthopedics, Ankara Numune Teaching and Research Hospital, Ankara, Turkey

ABSTRACT Introduction: Metacarpal and phalangeal fractures constitute 15-28% of all cases referring to the emergency department. Although these fractures are considered minor injuries, they may cause major disabilities. Functional outcomes depend on the severity of the injury and the treatment. The aim of the present study was to review metacarpal and phalangeal fractures and to compare the treatment options. Materials and Methods: 527 patients with metacarpal or phalangeal fractures among 2837 patients with hand injury referred between 2006 and 2012 were included in the study. The fractures in which acceptable reduction could not be achieved by closed reduction, intra-articular fractures, spiral or rotational fractures, multiple fractures, fractures associated with soft tissue injury, nerve or tendon injuries, and with bone loss, and total amputations with replantation indication were treated by the proper fixation method. Total active joint range of motion point scoring system was used to assess the functional results. Results: There were 490 male and 37 female patients. The mean age of the patients was 22.4 years (range: 1-67). The patients were operated in a mean period of 3.2 days (range: 1-16). The mean follow-up period was 15.8 weeks (range: 13-38). There were 273 distal phalanx fractures, 127 middle phalanx fractures, 172 proximal phalanx fractures, and 157 metacarpal fractures. Conclusion: Distal phalangeal tuft fractures should be treated conservatively, whereas diaphyseal fractures should be treated with K-wire fixation. Metacarpal, proximal and middle phalangeal fractures should be treated with mini-plate/screw systems. Key words: Treatment, Phalangeal, Metacarpal, Fracture, Hand injuries Received: December 18, 2012 • Accepted: May 07, 2013

ÖZET

El Yaralanmalarında Metakarpal ve Falangeal Kırıkların Tedavisi Giriş: Metakarpal ve falangeal kırıklar acil servise başvuruların %15-28’ini oluşturmaktadır. Bu kırıklar minör yaralanmalar olarak değerlendirilse de büyük sorunlara yol açabilmektedir. Fonksiyonel sonuçlar yaralanmanın ciddiyetine ve tedavinin başarısına bağlıdır. Bu çalışmanın amacı metakarpal ve falangeal kırıkların sonuçlarını incelemek ve farklı tedavi seçeneklerini karşılaştırmaktır.

* Editor's Note: Self-assessment questions for this article are found on page 87-89.

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Management of Metacarpal and Phalangeal Fractures in Hand Injuries

Materyal ve Metod: 2006-2012 yılları arasında acile başvuran 2873 hasta içinden metakarpal ve falangeal kırıkları olan 527 hasta çalışmamıza dahil edildi. Kabul edilebilir redüksiyon sağlanamayan kırıklar, eklem içi kırıklar, spiral ya da rotasyonel kırıklar, çoklu ya da yumuşak doku yaralanması eşlik eden kırıklar, tendon/sinir yaralanması olan kırıklar ve replantasyon endikasyonu olan amputasyonlar uygun tespit yöntemi kullanılarak tedavi edildi. Total aktif hareket açıklığı skorlama sistemi kullanılarak fonksiyonel sonuçlar değerlendirildi. Bulgular: Çalışmayı 490 erkek, 37 kadın hasta oluşturdu. Ortalama yaş 22.4 (aralık 1-67) yıl idi. Hastalar ortalama 3.2 (aralık 1-16) günde ameliyat edildi. Ortalama takip süresi 15.8 (aralık 13-38) hafta idi. İki yüz yetmiş üç distal falanks kırığı, 127 orta falanks kırığı, 172 proksimal falanks kırığı ve 157 metakarpal kırığı ameliyat edildi. Sonuç: Distal falanks taft kırıkları konservatif yolla tedavi edilmelidir, ancak distal falanks diyafiz kırıkları K-teli ile tespit edilmelidir. Metakarpal, proksimal ve orta falanks kırıkları mini plak vida sistemleri kullanılarak tedavi edilmelidir. Anahtar kelimeler: Tedavi, Falanks, Metakarp, Kırık, El yaralanmaları Geliş Tarihi: 18 Aralık 2012 • Kabul Ediliş Tarihi: 07 Mayıs 2013

INTRODUCTION Hand injuries are common and usually result in metacarpal and phalangeal fractures[1]. These injuries usually occur in adolescents and active young patients[2]. Metacarpal and phalangeal fractures constitute 15-28% of all cases referring to the emergency department[2,3]. Fractures of the metacarpal and phalanges constitute 10% of all fractures. Although these fractures are considered minor injuries, such injuries may cause major disabilities[4]. Functional outcomes depend on the severity of the injury and achievement of the treatment. Fractures associated with hand injuries can usually be treated conservatively, and favorable outcomes may be achieved with postoperative physiotherapy. Those fractures in which closed reduction cannot be achieved, intra-articular fractures, spiral or rotational fractures, multiple fractures, fractures associated with surrounding soft tissue, nerve or tendon injuries, and the fractures with bone loss should be treated surgically. The aim of the present study was to review metacarpal and phalangeal fractures and to compare the treatment options and lateterm results of the different treatment options. MATERIALS and METHODS The patients with hand injury who referred to the emergency department and outpatient clinic of plastic and reconstructive surgery and the orthopedics clinic between January 2006 and March 2012 were included in the study. Exclusion criteria were: pure tendon or nerve injuries, skin defects, nail and nail fold injuries without distal phalanx fractures, finger amputations without replantation indication or lack of the amputated part, and the cases in which replantation was done. The criteria defined by Kamath et al.[4] were used for operative indications. Failure to achieve

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acceptable reduction, compound fractures, rotational deformity, multiple metacarpal/phalangeal fractures, intra-articular fractures, hand fractures associated with polytrauma, fractures associated with bone loss, phalangeal neck fractures, malunion/non-union, and reimplantation were assigned as the operative treatment indications. During the study period, 2837 patients with hand injury referred to our clinics, and 527 patients with metacarpal or phalangeal fractures who met these criteria were included in the study. 2310 patients with pure tendon or nerve injuries, skin defects, nail and nail fold injuries without distal phalanx fractures, finger amputations without replantation indication or lack of the amputated part, and cases in which replantation was done were excluded from the present study. Additional soft tissue injuries were present in 492 of 527 patients (93.4%). Multiple metacarpal/phalangeal fractures were determined in 164 patients (31.1%). 179 patients had crush injury, 63 patients had finger tip crush injury, 147 patients had subtotal amputation, 26 patients had injury resulting from fist or pounding, 16 patients had gun shot or other explosion injury, and 96 patients had “other” injuries (Table 1). Non-displaced fractures and fractures with acceptable reduction after closed reduction and stable during the follow-up period were treated conservatively. The fractures in which acceptable reduction could not be achieved by closed reduction, intra-articular fractures, spiral or rotational fractures, multiple fractures, fractures associated with surrounding soft tissue or nerve or tendon injuries or with bone loss, and total amputations with replantation indication were treated by the appropriate fixation method. Patients with circulatory impairment were operated after a variable period of conservative treatment.

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Düzgün S, Özkurt B, Çankaya D, Ünlü E, Sıngın S, Tabak AY.

Table 1. Distribution of hand injuries Additional soft tissue injuries

492 (93.4%)

Multiple metacarpal/phalangeal fractures

164 (31.1%)

Crush injury

179 (33.9%)

Finger tip crush injury Subtotal amputation

63 (11.9%) 147 (27.8%)

Fist or pounding

26 (4.9%)

Gunshot or other explosion injury

16 (3.0%)

“Other” injuries

96 (18.2%)

Splint application after closed reduction under anesthesia, percutaneous K-wire fixation after closed reduction, open reduction and K-wire fixation, interosseous wiring, and mini-plate fixation were the treatment options. During the postoperative period, the patients were followed with splint or flexor splint. Physiotherapy was administered to all patients starting in various postoperative periods (1-37 days) according to the injury type and treatment option. Direct radiographs were taken during the 4th-6th weeks to evaluate bone healing. The total active joint range of motion point scoring system was used to assess the functional results[5]. Range of motion of the metacarpophalangeal joint (normal range 0°-85°), proximal interphalangeal joint (normal range 0°-110°) and distal interphalangeal joint (normal range 0°-65°) were measured, and all scores were summated. A summated score between 260°-220° was accepted as perfect, between 219°-180° as good, between 179°-130° as moderate, and below 130° as poor. RESULTS There were 490 male (93%) and 37 female (7%) patients. The mean age of the patients was 22.4 years (range: 1-67). Most of the injuries occurred as a result of an occupational accident. 492 of 527 patients (93.4%) had additional soft tissue injuries. Multiple metacarpal/phalangeal fractures were determined in 164 patients (31.1%). 179 patients had crush injury, 63 had finger tip crush injury, 147 had subtotal amputation, 26 had an injury resulting from fist or pounding, 16 had gunshot or other explosion injury, and 96 had “other” injuries. In the juvenile age group (1-14 years), the causes of hand injuries were finger tip crush injury and injury as a result of gunshot or other explosion; in the young adolescent group (15-20 years), the causes

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were finger tip crush injury and injury resulting from fist or pounding; and in the adult group (21-67), the causes included all those described above. The patients were operated in a mean period of 3.2 days (range: 1-16), and the mean follow-up period was 15.8 weeks (range: 13-38). We were unable to assess other sociodemographic characteristics of the patients due to the retrospective analysis of the present study. 61% of the patients had left hand injury and 39% had right hand injury. Hand injuries involved the dominant hand in 38% of the patients and the non-dominant hand in 58% of the patients, and 4% of the patients had bilateral hand injury (Table 2). Among the 527 patients included in the present study, 729 bone fractures were detected. There were 273 (37.5%) distal phalanx fractures, 127 (17.4%) middle phalanx fractures, 172 (23.6%) proximal phalanx fractures, and 157 (21.5%) metacarpal fractures (Table 3). Distal phalanx fractures were seen in the patients with finger tip crush injury or crush injuries. These patients had nail and nail fold injuries, and sectional incisions on the finger tip and the pulp. Among the 273 patients with distal phalanx fractures, 158 patients (57.9%) had tuft fractures, and 115 patients (42.1%) had diaphysis fractures. The fractured segment in the tuft fractures was reduced during soft tissue reconstruction. These patients were followed with finger splint. Transverse or oblique diaphysis fractures were fixed by K-wire and mini-screw after reduction and followed with finger splint. Fifty-four patients (47%) were treated with K-wire, 38 patients (33%) with miniscrew and 23 patients (20%) with finger splint. Union was seen on orthogonal radiographs in 103 patients (89.6%) during the 4th-6th weeks. Twelve patients (10.4%) in whom union was not seen during the 4th-6th weeks had achieved union at the end of the 8th week. Active physiotherapy was started at the end of the 3rd week in all patients. Table 2. Distribution of hand injuries according to side Left hand injury

61%

Right hand injury

39%

Dominant hand

38%

Non-dominant hand

58%

Bilateral hand injury

4%

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Management of Metacarpal and Phalangeal Fractures in Hand Injuries

Table 3. Localization of the fractures Distal phalanx fractures

273

Tuft fractures 158 (57.9%)

Diaphysis fractures 115 (42.1%)

Middle phalanx fractures

127

Head fractures 47 (37%)

Diaphyseal fractures 47 (37%)

Intra-articular base fractures 33 (26%)

Proximal phalanx fractures

172

Head fractures 52 (30.2%)

Diaphyseal fractures 88 (51.2%)

Intra-articular base fractures 32 (18.6%)

Metacarpal fractures

157

Head fractures 40 (25.6%)

Diaphyseal fractures 89 (57.1%)

Intra-articular base fractures 27 (17.3%)

Middle phalanx fractures were seen in the patients with crush injuries, subtotal amputations, and the “other” injuries. Among the 127 patients with middle phalanx fractures, 47 patients (37%) had intra-articular head fractures, 47 patients (37%) had diaphyseal fractures, and 33 patients (26%) had intra-articular base fractures. Middle phalanx fractures were fixed by K-wire or mini-plate/screw after reduction and followed with finger splint. Of those with intra-articular head fractures, 24 patients (51%) were fixed with miniscrew and 23 patients (49%) were fixed with K-wire; of those with diaphyseal fractures, 29 patients (61.7%) were fixed with mini-plate/screw and 18 patients (38.3%) were fixed with K-wire; and of those with intraarticular base fractures, 26 patients (78.8%) were fixed with mini-screw and 7 patients (21.2%) were fixed with K-wire. Union was seen on orthogonal radiographs in 120 patients (94.5%) during the 4th-6th weeks. Five patients with middle phalanx diaphyseal fractures (3.9%) in whom union was not seen during the 4th-6th weeks had achieved union at the end of the 8th week. Union was not seen at the end of the 8th week in 2 patients with subtotal amputation, and it was assumed that necrosis had developed in the distal portion. Re-operation was not performed due to circulatory impairment in these 2 patients. Active physiotherapy was started at the end of the 3rd week in all patients. Functional results of the patients with middle phalanx fractures were evaluated with total active joint range of motion point scoring system during the 12th week postoperatively. Among 24 patients with intra-articular head fractures fixed with miniscrew, 1 patient (4.2%) was evaluated as excellent, 7 patients (29.2%) as good, 13 patients (54.1%) as moderate, and 3 patients (12.5%) as poor. Among 23

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patients with intra-articular head fractures fixed with K-wire, 6 patients (26.1%) were evaluated as good, 12 patients (52.2%) as moderate and 5 patients (21.7%) as poor. Among 29 patients (1 patient with non-union excluded) with diaphyseal fractures of the middle phalanx fixed with mini-plate/screw, 3 patients (10.7%) were evaluated as excellent, 10 patients (35.7%) as good, 14 patients (50%) as moderate, and 1 patient (3.6%) as poor. Among 18 patients (1 patient with non-union excluded) with diaphyseal fractures fixed with K-wire, 5 patients (29.5%) were evaluated as good, 9 patients (52.9%) as moderate and 3 patients (17.6%) as poor. Among 26 patients with intra-articular base fractures of the middle phalanx fixed with mini-screw, 1 patient (3.8%) was evaluated as excellent, 8 patients (30.8%) as good, 14 patients (53.9%) as moderate, and 3 patients (11.5%) as poor. Among 7 patients with intra-articular base fractures fixed with K-wire, 1 patient (14.2%) was evaluated as good, 3 patients (42.9%) as moderate and 3 patients (42.9%) as poor. Proximal phalanx fractures were seen in the patients with crush injuries, subtotal amputations, injury resulting from fist or pounding, gunshot or other explosion injuries, and “other” injuries. Among the 172 patients with proximal phalanx fractures, 52 patients (30.2%) had intra-articular head fractures, 88 patients (51.2%) had diaphyseal fractures and 32 patients (18.6%) had intra-articular base fractures. Proximal phalanx fractures were fixed by K-wire or mini-plate/screw after reduction and followed with finger splint. Of those with intra-articular head fractures, 28 patients (53.8%) were fixed with mini-screw and 24 patients (46.2%) were fixed with K-wire; of those with diaphyseal fractures, 57 patients (64.8%)

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Düzgün S, Özkurt B, Çankaya D, Ünlü E, Sıngın S, Tabak AY.

were fixed with mini-plate/screw and 31 patients (35.2%) were fixed with K-wire; and of those with intra-articular base fractures, 18 patients (56.3%) were fixed with mini-screw and 14 patients (43.7%) were fixed with K-wire. Union was seen on orthogonal radiographs in 135 (78.5%) patients during the 4th-6th weeks. Twelve patients with proximal phalanx fractures (6.9%) in whom union was not seen during the 4th-6th weeks had achieved union at the end of the 8th week. Union was not seen at the end of the 8th week in 25 patients (14.5%) with subtotal amputation or crush injury, and it was assumed that necrosis had developed in the proximal portion. Re-operation was not performed due to circulatory impairment in these 25 patients. Functional results of the patients with middle phalanx fractures were evaluated with total active joint range of motion point scoring system during the 12th week postoperatively. Among 24 patients with intraarticular head fractures fixed with mini-screw, 2 patients (8.3%) were evaluated as excellent, 8 patients (33.4%) as good, 12 patients (50%) as moderate, and 2 patients (8.3%) as poor. Among 21 patients with intraarticular head fractures fixed with K-wire, 5 patients (23.8%) were evaluated as good, 12 patients (57.1%) as moderate and 4 patients (19.1%) as poor. Among 57 patients with diaphyseal fractures of the proximal phalanx fixed with mini-plate/screw, 5 patients (8.7%) were evaluated as excellent, 31 patients (54.4%) as good, 17 patients (29.8%) as moderate, and 4 patients (7.1%) as poor. Among 31 patients with diaphyseal fractures fixed with K-wire, 6 patients (3.6%) were evaluated as excellent, 10 patients (29.5%) as good, 9 patients (52.9%) as moderate, and 6 patients (17.6%) as poor. Among 18 patients with intra-articular base fractures of the proximal phalanx fixed with mini-screw, 4 patients (22.2%) were evaluated as excellent, 7 patients (38.9%) as good, 4 patients (22.2%) as moderate, and 3 patients (16.7%) as poor. Among 14 patients with intra-articular base fractures fixed with K-wire, 6 patients (42.9%) were evaluated as good, 5 patients (35.7%) as moderate, and 3 patients (21.4%) as poor. Metacarpal fractures were seen in the patients with crush injuries, subtotal amputations, injury resulting from fist or pounding, gunshot or other explosion injuries, and “other” injuries. Among the 156 patients with metacarpal fractures, 40 patients (25.6%) had intra-articular head fractures, 89 patients (57.1%) had diaphyseal fractures and 27 patients (17.3%) had intra-articular base fractures. Metacarpal fractures were fixed by K-wire or miniplate/screw after reduction.

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Of those with intra-articular head fractures, 22 patients (55%) were fixed with mini-screw and 18 patients (45%) were fixed with K-wire; of those with diaphyseal fractures, 64 patients (71.9%) were fixed with mini-plate/screw and 25 patients (28.1%) were fixed with K-wire; and of those with intra-articular base fractures, 12 patients (44.4%) were fixed with mini-screw and 15 patients (55.6%) were fixed with K-wire. Union was seen on orthogonal radiographs in 138 patients (88.5%) during the 4th-6th weeks. Five patients with metacarpal fractures (3.2%) in whom union was not seen during the 4th-6th weeks had achieved union at the end of the 8th week. Union was not seen at the end of the 8th week in 13 patients (8.3%) with subtotal amputation or crush injury, and it was assumed that necrosis had developed in the proximal part. Re-operation was not performed due to circulatory impairment in these 13 patients. Functional results of the patients with metacarpal fractures were evaluated with total active joint range of motion point scoring system at the 12th week postoperatively. Among 22 patients with intra-articular head fractures fixed with mini-screw, 4 patients (18.2%) were evaluated as excellent, 8 patients (36.4%) as good, 9 patients (40.9%) as moderate, and 1 patient (4.5%) as poor. Among 18 patients with intra-articular head fractures fixed with K-wire, 2 patients (11.1%) were evaluated as excellent, 4 patients (22.2%) as good, 10 patients (55.6%) as moderate, and 2 patients (11.1%) as poor. Among 64 patients with diaphyseal fractures of the metacarpal bone fixed with mini-plate/screw, 14 patients (21.9%) were evaluated as excellent, 32 patients (50%) as good, 14 patients (21.9%) as moderate, and 4 patients (6.2%) as poor. Among 25 patients with diaphyseal fractures fixed with K-wire, 7 patients (28%) were evaluated as excellent, 6 patients (24%) as good, 6 patients (24%) as moderate, and 6 patients (24%) as poor. Among 12 patients with intra-articular base fractures of the metacarpal bone fixed with mini-screw, 1 patient (8.3%) was evaluated as excellent, 5 patients (41.7%) as good, and 6 patients (50%) as moderate. Among 15 patients with intra-articular base fractures fixed with K-wire, 1 patient (6.7%) was evaluated as excellent, 6 patients (40%) as good, 5 patients (33.3%) as moderate, and 3 patients (20%) as poor (Figure 1). Malunion was not seen in any bone fractures treated operatively in the present study.

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Management of Metacarpal and Phalangeal Fractures in Hand Injuries

Figure 1. Preoperative and postoperative radiographs of a phalangeal fracture treated with mini-plate/ screw system.

DISCUSSION Fractures of the metacarpal bones and phalangeal bones constitute 10% of all fractures[4]. Nowhere in the body are form and function more closely related than in the hand. Too often these fractures are treated as minor injuries, resulting in major disabilities[2,4]. Diagnosis of skeletal injuries of the hand usually does not pose major problems if proper clinical examination is supplemented with appropriate radiological investigations. Proper preoperative planning, surgical intervention wherever needed at a center supported with the necessary equipment and implants, selection of appropriate anesthesia, and application of the principle of biological fixation, rigid enough to allow early mobilization, are all very important for a good functional outcome[4]. This article reviews the current concepts in the management of metacarpal and phalangeal fractures, incorporating tips and indications for the fixation of these fractures. The advantages and disadvantages of various approaches and modes of fixation have been discussed. Numerous studies, biomechanical and clinical, have been done in an effort to optimize the treatment of unstable metacarpal fractures[4,6]. The overall goal is to maintain sufficiently rigid fixation for bony union while allowing early motion to prevent stiffness and maximize function. Several biomechanical studies have been done to assess the relative strengths of various fixation methods of metacarpal fractures, including multiple K-wire, intramedullary and intraosseous wiring techniques, lag screws, and dorsal and lateral plating[1,6,7]. It was[6] found that 26-gauge right angle intraosseous loops and dorsal bone plates were the strongest constructs and were comparable to each

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other. In the present study, we compared K-wire fixation, mini-screw fixation and mini-plate/screw fixation. The decision to operate was made according to indication criteria described by Kamath et al.[4]. The fractures in which acceptable reduction could not be achieved by closed reduction, intra-articular fractures, spiral or rotational fractures, multiple bone fractures, fractures associated with surrounding soft tissue, nerve or tendon injuries, hand fractures associated with polytrauma, compound fractures, phalangeal neck fractures, fractures with bone loss, and the total amputations with replantation indication were treated by the proper fixation method. Although distal phalangeal fractures usually can be treated conservatively, operative treatment has a more favorable outcome in unstable, displaced transverse, oblique, or comminuted diaphyseal or neck fractures. Further, operative treatment prevents malunion in such fractures[7]. In the present study, K-wire fixation led to better reduction in diaphyseal distal phalangeal fractures, parallel to the literature. For the treatment of distal phalangeal neck fractures, we preferred miniscrew or K-wire fixation instead of finger splint follow-up. Metacarpal, proximal phalangeal and middle phalangeal fractures can be treated conservatively with finger splint or operatively with K-wire fixation, miniplate/screw and interosseous wiring[3,4,6,8,9]. In our study, K-wire fixation and mini-plate/screw fixation were performed for the treatment of these fractures. We determined that achievement of reduction is easier with mini-plate/screw fixation, as previously reported by several authors[8,9]. Patients treated with miniplate/screw fixation had better functional outcomes

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Düzgün S, Özkurt B, Çankaya D, Ünlü E, Sıngın S, Tabak AY.

and joint mobility. In our opinion, metacarpal, proximal phalangeal and middle phalangeal fractures should be treated by mini-plate/screw fixation. We preferred mini-plate/screw for diaphyseal fractures and mini-screw fixation for intra-articular base or head fractures. It seems that the decision regarding fixation method should be done intraoperatively during open reduction according to the fracture pattern.

5. Duncan RW, Freeland AE, Jabaley ME, Meydrech EF. Open hand fractures: an analysis of the recovery of active motion and of complications. J Hand Surg (Am) 1993; 18: 387-94.

In conclusion, late reduction and fixation may be beneficial in hand injuries with circulatory impairment. Distal phalangeal tuft fractures should be treated conservatively with finger splint, whereas distal phalangeal diaphyseal fractures should be treated with K-wire fixation. Metacarpal, proximal phalangeal and middle phalangeal fractures should be treated with mini- plate/screw systems instead of K-wire fixation or conservative treatment.

7. Chim H, Teoh LC, Yong FC. Open reduction and interfragmentary screw fixation for symptomatic nonunion of distal phalangeal fractures. J Hand Surg (Eur) 2008; 33: 71-6.

REFERENCES 1. Ashkenaze DM, Rugy LK. Metacarpal fractures and dislocations. Orthop Clin North Am 1992; 23: 19-33. 2. de Jonge JJ, Kingma J, van der Lei B. Fractures of the metacarpals. A retrospective analysis of incidence and etiology and a review of the English-language literature. Injury 1994; 25: 365-9. 3. Packer GJ, Shaheen MA. Patterns of hand fractures and dislocations in a district general hospital. J Hand Surg Br 1993; 18: 511-4.

6. Liporace FA, Kinchelow T, Gupta S, Kubiak EN, McDonnell M. Minifragment screw fixation of oblique metacarpal fractures: a biomechanical analysis of screw types and techniques. Hand 2008; 3: 311-5.

8. Trevisan C, Morganti A, Casiragi A, Marinoni EC. Lowseverity metacarpal and phalangeal fractures treated with miniature plates and screws. Ach Orthop Trauma Surg 2004; 124: 675-80. 9. Mohammed R, Farook MZ, Newman K. Percutaneous elastic intramedullary nailing of metacarpal fractures: surgical technique and clinical results study. J Orthop Surg Res 2011; 6: 37.

Address for Correspondence Bülent ÖZKURT, MD Department of Orthopedics Ankara Numune Teaching and Research Hospital Altindag, Ankara-Turkey E-mail: [email protected]

4. Kamath JB, Harshvardhan, Naik DM, Bansal A. Current concepts in managing fractures of metacarpal and phalanges. Indian J Plast Surg 2011; 44: 203-11.

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