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Metacarpal Fractures—Pins vs. Plates vs. Intramedullary Devices—When and How
Indications for Surgical Treatment
Metacarpal fractures can be treated nonoperatively or operatively depending on the fracture characteristics of angulation, displacement, rotation, and stability following reduction when applicable. The osseous and soft tissue anatomy of the metacarpals provides functional stability to many of the fractures that occur and contributes to the success of nonoperative treatment. Absolute surgical indications include open fractures, open metacarpophalangeal (MP) or carpometacarpal (CMC) joints, significant malrotation resulting in digital overlap, and those fractures with associated soft tissue injuries such as tendon or nerve injuries necessitating repair. Relative indications for surgical intervention include excessive shortening (>5 mm) especially those with pseudoclawing, extensor lag, prominence of the metacarpal head in the palm, multiple fractures, and intra-articular fractures. The decision-making between three common surgical techniques will be considered: pinning, plating, and intramedullary (IM) devices.
Pinning
Closed reduction and percutaneous pinning is the most commonly used technique when a closed reduction is easily obtained. Advantages of the technique include its low cost, universal availability, being less technically demanding, and time-proven results. Disadvantages include pin tract infections, extensor tendon irritation, and the need for supplemental immobilization. This can be performed retrograde, transversely, or antegrade with a small open approach. Transverse pinning is typically reserved for border digits especially in the case of comminution, and it requires a stable adjacent metacarpal.
Plating
Dorsal plating with locking or nonlocking plates is best suited for transverse, long oblique, or spiral fractures of the metacarpal shaft and can be used in conjunction with interfragmentary compression screws if the fracture is a spiral or long oblique pattern. Typically, plating is reserved for cases where there is diaphyseal bone loss, comminution, significant soft tissue injury, or nonunion. Advantages of plating include earlier initiation of range-of-motion exercises, lessened need for immobilization, and a lack of exposed hardware. Disadvantages include higher cost, being a more technically demanding surgery, and irritation of the overlying extensor tendons.
Intramedullary Devices
IM fixation devices such as an IM compression screw, IM rods and nails, and IM K-wires are a versatile option that can be used on most length stable metacarpal fractures that do not involve the metacarpal head or base. This technique offers some unique advantages to the other options such as no exposed hardware externally, no irritation of the hardware with the extensor mechanism, a minimally invasive approach, and the ability for early range of motion with lessened need for immobilization. Disadvantages include implant cost (depending on the selected implant), technical demand, and an application limited to certain fracture locations and patterns.
Preoperative Evaluation (Imaging, Examination, etc.)
A thorough physical examination should first be performed. This includes attention to the presence of any open wounds (especially those over the dorsum of the MP joint suggestive of a “fight bite”), any clinical rotation or coronal plane malalignment, pseudoclawing, or neurovascular injury. Initial imaging studies in the evaluation of metacarpal fractures include posteroanterior (PA), lateral, and oblique views of the hand. Lateral views of each individual metacarpal can be difficult to obtain. These basic radiographic views are usually sufficient in diagnosing the majority of metacarpal head, neck, and shaft and base fractures. The Brewerton view offers an excellent anteroposterior (AP) of the MP joint and can be specified for each digit as needed. A semipronated oblique view is helpful in better visualizing the fifth CMC joint which can have subtle dorsal subluxation that is easily missed with routine imaging.
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