Articular fracture of the base of the thumb metacarpal: Comparative
Transcription
Articular fracture of the base of the thumb metacarpal: Comparative
Available online at ScienceDirect www.sciencedirect.com Chirurgie de la main 34 (2015) 122–125 Original article Articular fracture of the base of the thumb metacarpal: Comparative study between direct open fixation and extrafocal pinning Fracture articulaire de la base du premier métacarpien : étude comparative entre l’ostéosynthèse directe et l’embrochage extra-focal H. Abid *, M. Shimi, A. El Ibrahimi, A. El Mrini Service de chirurgie ostéo-articulaire B4, CHU Hassan II, immeuble 87, appartement 4, rue Sidney, Hay Ouafae 2, Narjiss, Fès, Morocco Received 27 February 2014; received in revised form 27 December 2014; accepted 5 January 2015 Available online 15 April 2015 Abstract The treatment of intra-articular fractures of the base of the first metacarpal bone should aim to anatomically reduce the articular surface, restore the initial length of the first metacarpal and preserve the opening of the first web space. These objectives appear to be achievable with a wellconducted surgical treatment. In a retrospective study, we reviewed a series of 38 cases, which compared open reduction and internal fixation (ORIF) and extrafocal pinning to determine which option provided the best reduction and functional recovery in young, manual workers. Direct fixation was better at restoring the configuration of the joint, regardless of the age and sex of the patients and the fracture type. This complete reduction is associated clinically with better function. Thumb opposition was statistically better in fractures treated by ORIF. Thumb retroposition was better in the cases treated by ORIF, but not significantly. ORIF appears the best technique for treating intra-articular fractures of the base of the first metacarpal, as it results in better functional recovery. # 2015 Elsevier Masson SAS. All rights reserved. Keywords: Articular fracture; First metacarpal; ORIF Résumé Le traitement des fractures articulaires de la base du premier métacarpien devrait comporter une réduction anatomique de la surface, la restauration de la longueur du premier métacarpien et la préservation de l’ouverture de la première commissure. Cet objectif ne semble être réalisable que par un traitement chirurgical. Nous avons souhaité, à travers une étude rétrospective, faire le point sur les données épidémiologiques et les résultats anatomo-cliniques d’une série de 38 cas traités soit par embrochage extrafocal, soit par ostéosynthèse à foyer ouvert. L’analyse statistique a montré la supériorité de l’ostéosynthèse directe, indépendamment de l’âge, du sexe des malades et du type de la fracture, dans la restauration de l’interligne articulaire qui était normal dans 15 cas traités par ostéosynthèse directe contre uniquement 6 cas pris en charge par embrochage. Cette perfection réductionnelle était associée à une meilleure fonction de la main opérée. L’opposition du pouce était statistiquement meilleure pour les fractures traitées par ostéosynthèse directe. La contre-opposition était meilleure dans les cas d’ostéosynthèse directe sans atteindre le seuil de significativité. L’ostéosynthèse directe nous paraît la meilleure technique pour le traitement des fractures articulaires de la base du premier métacarpien, permettant une récupération fonctionnelle optimale. # 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : Fracture articulaire ; Premier métacarpien ; Ostéosynthèse * Corresponding author. E-mail address: [email protected] (H. Abid). http://dx.doi.org/10.1016/j.main.2015.01.008 1297-3203/# 2015 Elsevier Masson SAS. All rights reserved. H. Abid et al. / Chirurgie de la main 34 (2015) 122–125 123 1. Introduction The trapeziometacarpal (TMC) joint acts as a pivot in the thumb column and allows for the execution of simple and complex movements. If a fracture in this area is missed or treated incorrectly, the joint profile will be compromised and the thumb’s function altered due to malunion and eventually osteoarthritis. It is imperative that surgical treatment restores the metacarpal articular surface, while maintaining the first web space opening. These two aspects ultimately determine the hand’s two primary grasping actions: power grip and precision tip grip. Several treatment options are available. The goal of this study was to compare the anatomical and clinical outcomes of a series of 38 intra-articular fractures of the base of the first metacarpal that were treated by extrafocal pinning (20 cases) or open reduction and internal fixation (ORIF) (18 cases). 2. Material and methods This was a retrospective study conducted over a three-year period that included all Bennett-type or Rolando-type intraarticular fractures of the base of the first metacarpal. Analysis of patient records revealed that mainly young males suffered these fractures. The right hand was affected in most cases. The fracture primarily occurred after a fall onto the palm of the hand with the thumb abducted. The patients underwent standard A/P and lateral radiographs of the thumb column, which was placed parallel to the antepulsion-retropulsion axis in the A/P view and the flexion-extension axis on the lateral view. There were 20 Bennett fractures and 18 Rolando fractures in the series. The patients were operated within 48 hours of the injury event. Regional anesthesia was carried out in all patients; 20 patients underwent Iselin-type extrafocal pinning under fluoroscopy control and 18 underwent ORIF through a dorsal approach. Additional immobilization with a cast or brace for 4– 6 weeks was essential in our opinion. At the last follow-up (mean of 24 months), the clinical outcomes were determined according to Obry’s criteria [1] for pain and grip strength, and then Kapandji’s protocol to determine the thumb’s mobility in opposition and counter-opposition (reposition). The radiological outcomes were based on specific views of the TMC joint to better evaluate the articular surface [2]. The data were described by their mean and standard deviations values and compared between groups with a Chi2 test. 3. Results The patients were divided into two groups, depending on if they had been treated by pinning (Fig. 1) or direct fixation (Fig. 2). The two groups were similar in terms of age, gender, occupation, involved side, fracture type and duration of postoperative immobilization (Table 1). There were no significant differences in the pain, repositioning ability or strength between the two treatment methods. The opposition movement was significantly better in the group that underwent ORIF (P = 0.03) (Table 1). All patients were able to return to their Fig. 1. Extrafocal pinning according to Iselin for a Bennett-type fracture. pre-injury level of work. Upon review, the trapeziometacarpal joint space appeared normal in more of the patients treated by an open approach. A step-off deformity of the articular surface was observed in 14 of the 20 fractures fixed by extrafocal pinning (P = 0.042) (Table 1). 4. Discussion The first column of the hand allows for opposition of the thumb to the fingers thanks to the master joint, the trapeziometacarpal joint. This joint has multiple degrees of freedom that make precise thumb-finger gripping possible. Intra-articular fractures of the base of the first metacarpal, which make up 1% of all fractures in adults [1], disturb the kinetics of the first column: the displacement eliminates the TMC’s pivot action and narrows of the first interosseous space. Initially this narrowing is reducible, but later on it becomes non-reducible due to soft tissue contracture. Given that the goal of treating intra-articular fractures is to anatomically reduce the articular surfaces, conservative (non-surgical) treatment, which is said to provide insufficient reduction, stability or first web space opening, has been rejected by most teams [2–4]. Studies by Heim [5] and Iselin [6] evaluated the medium and long-term functional outcome of intra-articular fractures of the base of the thumb that were treated conservatively. With follow-up of six to 26 years, these authors reported varus angulation and TMC subluxation concomitant with movement restrictions and loss of grip strength. These findings were so common that they recommended surgical treatment, which is now the preferred approach. 124 H. Abid et al. / Chirurgie de la main 34 (2015) 122–125 Fig. 2. Open reduction and internal fixation with miniplate of a Rolando-type fracture. However, the choice between open or closed reduction continues to be debated. In studies by Wiggins et al. (33 cases) [7], Pouzou (34 cases) [8], Vichard et al. (40 cases) [9] and Dunaud et al. (70 cases) [10], where patients were treated by extrafocal pinning, the overall functional evaluation revealed 70% good or excellent results in the short and medium term. The transverse intermetarcarpal constructs described by Tubiana and Iselin were clearly superior, as they were stable Table 1 Comparison of the epidemiological data and anatomical and clinical outcomes of this study comparing extrafocal pinning to direct open fracture fixation. Gender Age Type of occupation Injured side Fracture type Postoperative immobilization Post-operative pain Level 0 Level 1 Level 2 Level 3 (NS) Opposition Fractured side Mean value (P = 0.03) Counter-opposition Fractured side Mean value (NS) Force (mean value) Pinch (kg) Grasp (kg) (NS) Joint space Normal Abnormal (P = 0.042) Iselin extrafocal pinning n = 20 Direct fixation (ORIF) n = 18 18 men/2 women 35 years [23–46] 16 manual workers (80%) Right = 17 Left = 3 12 Bennett fractures (60%) 8 Rolando fractures (40%) 4 weeks: 13 6 weeks: 7 16 men/2 women 33 years [20–43] 15 manual workers (83%) Right = 17 Left = 1 10 Bennett fractures (55%) 8 Rolando fractures (45%) 4 weeks: 12 6 weeks: 6 10 5 3 2 8 5 3 2 8.25 [6–8] 9.33 [7–10] 2.8 [1,2] 2.77 [2,3] 14 [10–16] 29 [25–32] 12.65 [10–15] 33 [23–34] 6 14 15 3 H. Abid et al. / Chirurgie de la main 34 (2015) 122–125 and able to maintain satisfactory opening of the first interosseous space. Nevertheless, these procedures did not result in anatomical reduction of the trapeziometacarpal joint surface. Vichard et al. [9] reported 10 cases of malunion in a series of 19 operated patients. The malunion rate reported by Dunaud [10] was 100% (30 cases). This joint modification leads to the development of arthritis, especially with a step-off greater than 2 mm [11]. This risk of arthritis development was lower in cases treated by direction fixation (ORIF). This observation is consistent with many previous publications, namely the one Kapandji [2] in 1953 on 39 cases, the one by Cherif [12] in 1982 on a similar number of cases. Vichard et al. [9] reported that only 12% of cases had intra-articular malunion after open surgical treatment, and observed that the reduction quality corresponded functionally to better thumb opposition. This finding was confirmed in our study: patients who underwent ORIF treatment of their fracture had better thumb opposition (Table 1) due to complete fracture reduction. More recently, arthroscopic surgery has been used to address intra-articular fractures of the base of the thumb. This demanding surgery is based on basal joint arthritis surgical procedures. It is performed through two incisions, less than 2mm long, with the posterolateral incision used for the scope and anteromedial incision used for instruments. Once synovectomy is performed, the fracture site is visible and can be fixed with screws inserted under fluoroscopy control. Although only a few publications deal with this technique, namely those of Zemirline et al. and Strugarek-Lecoanet et al. [13,14], the outcomes seem promising in experienced hands. 5. Conclusion Although the follow-up in this study is relatively short, we observed that open reduction and internal fixation was superior to extrafocal pinning in terms of the anatomical and clinical outcomes for treating Bennett and Rolando type intraarticular fractures of the base of the first metacarpal. This superiority translates to better mobility of the thumb column in opposition. Although this conclusion is consistent with published data, it is tempered by the small number of patients included in our study. 125 Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Contribution of authors All authors contributed to the treatment of patients and the writing of the manuscript. All authors have read and approved the final manuscript. References [1] Obry C. Fracture de la base du premier métacarpien. Ann Chir 1989;43:80–7. [2] Kapandji IA. Radiographie spécifique de l’articulation trapézo-métacarpienne. 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