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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 4  |  Issue : 3  |  Page : 136-140

Comparative study of open reduction and internal fixation in fractures of metacarpal and proximal phalanx with Kirschner's wire and miniplate


1 Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
2 Department of Orthopaedics, Sports Injury Centre, Safdarjung Hospital, New Delhi, India
3 Department of Orthopaedics, Employee's State Insurance Hospital, Ludhiana, India
4 Department of Orthopaedics, Guru Nanak Dev Hospital, Amritsar, Punjab, India

Date of Web Publication8-Dec-2014

Correspondence Address:
Dr. Kavin Khatri
Room no 311, doctor's hostel, JPNATC-AIIMS, Safdarjung enclave, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.146404

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  Abstract 

Background: There is a rising trend in the use of miniplates over Kirschner's wire for treating hand fractures. The improved system of internal fixation by miniplates has many advantages over the Kirschner's wire. The purpose of this prospective study was to evaluate the differences between these two commonly used methods of internal fixation in fractures of proximal phalanges and metacarpals in terms of radiological union and functional outcome.
Patients and Methods: The study included a total of 40 patients with a mean age of 35.72 years. The patients excluded from the study included those with a compound injury, severe osteoporosis, and severe co-morbid conditions. The patients were divided into two groups (Group A - treated with Kirschner's wire and Group B - treated with miniplate) with 20 cases each. The outcomes of treatment were compared in the two groups using Student's t-test and chi-square test.
Results: The average time for radiological union in Group A (Kirschner's wire) was 8 weeks, while it was 8.7 weeks in Group B (miniplate). There was no statistically significant difference in the radiological union time between the two groups (P = 0.464, chi-square = 1.532). Stiffness was the most common associated complication in this study. It was more common in the group treated with Kirschner's wire (30%) compared to the group treated with mini fragment plating (20%). In Group A, 75% of cases had shown good to excellent results; while in Group B, 85% of the cases had similar result. There was no statistically significant difference (P = 0.737, chi-square = 1.268) in outcome in both groups.
Conclusions: Both Kirschner's wire and miniplate are good methods of internal fixation in fractures of metacarpal and proximal phalanx. Though patients who were treated with miniplating had better functional results, but the difference was not statistically significant.

Keywords: Kirschner′s wire, miniplate, metacarpal fracture, phalanx


How to cite this article:
Khatri K, Goyal D, Bansal D, Sohal HS. Comparative study of open reduction and internal fixation in fractures of metacarpal and proximal phalanx with Kirschner's wire and miniplate. Arch Int Surg 2014;4:136-40

How to cite this URL:
Khatri K, Goyal D, Bansal D, Sohal HS. Comparative study of open reduction and internal fixation in fractures of metacarpal and proximal phalanx with Kirschner's wire and miniplate. Arch Int Surg [serial online] 2014 [cited 2024 Mar 28];4:136-40. Available from: https://www.archintsurg.org/text.asp?2014/4/3/136/146404


  Introduction Top


Fractures of bones of the hand may have sequelae in the form of deformity from no treatment, stiffness from over treatment, and both deformity and stiffness from poor treatment. [1] They constitute about 14-25% of all the visits in the emergency department. [2] Hand is an important body part in terms of varied specialized work it does. It is both offensive and defensive in protecting the body and an adjuvant to speech in making it affirmative, impressive, and emphatic. The fundamental principle of fracture management is same as elsewhere in the body, apart from the fact that fracture of the metacarpal and phalanx needs to be urgently and accurately reduced to restore full function in the hand. Any untoward delay or suboptimal treatment is fraught with the danger of permanent residual disability. There are various methods of treatment ranging from cast, Kirschner's wire application, plating, external fixator, etc. There has been a surge in use of plating over the other techniques to treat the fractures of hand. The purpose of this study was to evaluate the difference between two commonly used methods of internal fixation in fractures of proximal phalanges and metacarpals in terms of radiological union and functional outcome.


  Patients and Methods Top


This prospective study was performed at a teaching hospital in India. The study consisted of a total of 40 cases. Patients ≥18-years-old with fracture of metacarpal and/or proximal phalanx were included into the study. An informed written consent was obtained from the patients as well as an ethical clearance from the ethics committee of the institution. The patients excluded from the study were those who had compound injury, severe osteoporosis, and severe comorbid conditions in who risk of anesthetic complications were high. The fractures were classified according to the Orthopedic Trauma Association (OTA) classification of fractures. [3] The patients were divided into two groups. The cases of one group were treated with Kirschner's wire in proximal phalanx or metacarpal (Group A) fractures. The cases of the other group were treated with miniplate in proximal phalanx/metacarpal (Group B). The patients were given general or regional anesthesia and all the operative procedures were performed under tourniquet control.

Operative procedure for inserting Kirschner wires

Skin incision was made over the dorsal aspect centering over the fracture site. Skin and subcutaneous tissue were reflected to either side. In proximal phalangeal fractures, the extensor expansion was exposed and incised longitudinally in its center, then retracted to each side; while in case of metacarpal fractures, the extensor tendon was retracted to one side and the fracture site was exposed. Kirschner's wire was drilled into the distal fragment under direct vision and then after reducing the fracture, drilling was done retrogradely across the fracture site fixing the fracture extraarticularly. The extensor expansion was repaired in proximal phalangeal fractures supporting the finger in position of function and wrist in extension.

Operative procedure for applying miniplates

The fracture site was exposed using the technique described in the operative procedure for Kirschner wire insertion. Reduction was maintained by an assistant and the chosen plate was contoured to the dorsum of the metacarpal. The appropriate sized miniplate was centered over the fracture site and secured by insertion of mini screws on either end of the miniplate across the fracture site. In both procedures, the wound was closed in layers, tourniquet was released, and antiseptic dressing was applied over the wound.

Postoperative management

The operated limb was elevated for 48 h. Trypsin-chymotrypsin (2,00,000 armor units of enzymatic activity) was given orally thrice a day to control the inflammation. Paracetamol (1 gm intravenous (IV) qid for 3 days) was administered as analgesics. Injection tramadol (100 mg/2 ml) was given for pain relief. Radiological examination was done on the next day of the operation to document the reduction. The first postoperative dressing was done on the 5 th day. Active finger movements were commenced on the 1 st postoperative day. Alternate stitches were removed on 10 th and all remaining on 12 th postoperative day.

Follow-up

The hands were examined every three week for radiological union. Union was defined as complete obliteration of fracture gap on two perpendicular views. Nonunion was considered when a gap was present or no callus was seen on serial radiographs for 6 months. Delayed union was defined as when callus was not seen on serial radiographs at 12 weeks. On every visit, patients were examined clinically and X-rays of the hand were taken. Radiological sign of union, displacement, implant failure, or any angulation were recorded. Clinically, patients were examined for any tenderness, infection, or pain. The active assisted ranges of movements were started after 3 weeks in plating and removal of Kirschner's wire. During the period of follow-up, only active exercises at a physiotherapy center or at home were advocated. The movements of distal interphalangeal (DIP), proximal interphalangeal (PIP), and metacarpophalangeal (MCP) joints were recorded at 1 year following operative intervention.

Functional evaluation was done using total active range of motion (TAM) as suggested by American Society for the Surgery of Hand (ASSH). [4] It includes summation of active flexion at MCP, PIP, and DIP joints; after excluding the sum of extension deficits at respective joints. The movement regained was calculated as percent-regained motion compared to normal range of motion at all the three joints (270°). The results were tabulated according to Strickland's original classification. [5] The patients with 85-100% of TAM were described as excellent; 70-84% as good; 50-69% as fair, and 0-49% as poor.

Comparative evaluation of results of the two performed procedures of internal fixation in fractures of metacarpals and phalanges was done. Statistical analysis was performed using t-tests and chi-square tests; significant difference was considered when the P-value was less than 0.05.


  Results Top


The mean age of the patients was 35.72 years. 52.5% of the fractures occurred in the age group of 31-50 years. Male to female ratio is approximately 10:3. In 25 (62.5%) cases, mode of injury was road traffic accident and was the commonest cause of injury. Fourteen (35%) cases occurred because of assault and in one (2.5%) case, mode of injury was railway accident. Extraarticular diaphyseal non-comminuted fractures were observed in 68% [Figure 1] b, 29.78% had diaphyseal comminuted fractures [Figure 3] a, and 2.22% had intra-articular fractures [Figure 2] a along with diaphyseal comminution. Majority of the patients were operated within 1 week of the injury with 27 (67.5%) patients within 3 days of injury and 11 (32.5%) cases within 4-7 days of injury. One case (sustained railway track injury) was operated after 1 week due to associated abdominal injury. The average union time in Group A [Figure 2] b was 8 weeks; average union time in Group B [Figure 1]b and [Figure 3]b was 8.7 weeks; the difference is statistically not significant (chi-square = 1.532, P = 0.464).

No patient in Group A had fever in comparison to one patient in Group B, which is not statistically significant (P =0.311) [Table 1]. The fever developed after 24 h of operative intervention and lasted for 2 days. There was associated wound infection in this patient. No patient in Group A had discharge from wound in comparison to one patient in Group B, which is not statistically significant (P = 0.311). The discharge was purulent due to staphylococcal infection. The patient was given injectable cefuroxime (1.5 g bd) for 3 weeks and daily antiseptic dressings were done. There was complete resolution of discharge following treatment. Six patients in Group A had shown postoperative stiffness in comparison to four patients in Group B, which was not statistically significant (P = 0.465). One patient (5%) in each Group A and B had shown delayed union [Table 2]. One patient in Group B had reported tendon rupture in comparison to none in Group A. The tendon ruptured at the metacarpal shaft level and was primarily repaired; with uneventful recovery. No patient in either group had shown nonunion, malunion, or implant failure.
Table 1: Immediate, early, and late postoperative complications

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Table 2: Time to radiological union

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Sixteen patients in Group A showed union in 6-9 weeks, three patients in 10-12 weeks, and one patient in >12 weeks in comparison to 15 patients in Group B with union in 6-9 weeks and five patients in 10-12 weeks. The average union time in Group A was 8 weeks compared to 8.7 weeks in Group B. There was no statistical significant difference in the radiological union time between two groups (P = 0.464, chi-square =1.532). Movement at DIP joint: Nine patients in Group A had flexion possible by greater than 59° at DIP, eight patients had between 49 and 58°, and three patients had less than 48°. This is in comparison to 14 patients in Group B with flexion possible at DIP by more than 59°, two patients movement at proximal interphalangeal joint ( PIP) between 49 and 58°, and four patients had less than 48°. Five patients in Group A had flexion possible by greater than 93° at PIP joint, eight patients had flexion between 77 and 92°, six patients had flexion between 55 and 76°, and one patient had less than 55°; In comparison to six patients in Group B who had shown flexion possible by greater than 89° at IP joint, eight patients had flexion between 77 and 92°, five patients had shown flexion between 55 and 76°, and one patient had flexion less than 55°.

Movement at metacarpophalangeal joint (MCP)

Ten patients in Group A had flexion possible at MCP joint by greater than 76°, eight patients had flexion between 63 and 75°, one patient had flexion between 45 and 62°, and one patient had flexion less than 45°; in comparison to six patients in Group B who had shown flexion possible at MCP joint by greater than 76°, 10 patients had flexion between 63 and 75°, four patients had shown flexion between 45 and 62°, and none had flexion less than 45°.

The evaluation of the result was done according to the Strickland's criteria [Table 3] as described earlier. In our study, seven patients (35%) in Group A had shown excellent results in comparison to eight patients (40%) in Group B, eight patients (40%) in Group A had shown good results in comparison to nine patients (45%) in Group B, four patients (20%) in Group A had shown fair results in comparison to three patients in Group B, and one patient (5%) in Group A had shown poor result in comparison to none in Group B. The poor result was due to associated infection and swelling which led to stiffness and marked decrease in range of motion. There was no statistical significant difference (P = 0.737, chi-square =1.268) in two groups in their results.
Table 3: Showing grading of results according to the Strickland's classification

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  Discussion Top


Fractures of the hand are increasing due to rapid industrialization and rise in automobile accidents. They constitute about 10% of all fractures. [6] The majority of the fractures can be managed by the nonoperative intervention, while others require operative intervention. The goal of operative intervention is to provide stable fixation for bony union and allow early range of movements to prevent stiffness. Kirschner's wire has advantages being cheap, providing only internal splintage and no compression at the fracture site and requires minimal instrumentation. Its disadvantages include lack of rotational control, pin tract infection when one end was left outside for subsequent removal, and early loosening in some cases. The miniplate has advantage of providing rotational control and compression at the fracture site in transverse fracture, while its pitfalls include fibroplasia at the fracture site due to periosteal stripping which occurs during its application. [7],[8],[9]

Radiological union was achieved in almost all the cases in about 12 weeks. There was a case of delayed union in one of the metacarpal fracture case treated by Kirschner's wire. The time to union was comparable in both the methods of internal fixation. The mean time to achieve union in cases treated with Kirschner's wire was 8 weeks, while it was 8.7 weeks in cases treated with metacarpal plating. Omokawa et al., [10] reported union in all the cases of fractures of hand treated with miniplates within 10 weeks, while Liew et al., [11] had reported union in Kirschner's wire group in mean time of 5.7 weeks. The time to union was comparable in miniplate and not in Kirschner's wire group with other studies due to the fact that miniplates are applied by open technique, while the Kirschner's wire can be advanced percutaneuosly.

The functional results in Kirschner's wire and miniplating group were good to excellent in majority of the cases according to Strickland's criteria. [5] The good to excellent results were obtained in 75% of the cases treated with Kirschner's wire, while the number was 85% in the other group. Gupta et al., [12] had reported 60% good to excellent results in cases treated by open reduction and internal fixation with Kirschner's wire of fractures of hand and Nalbantoglu et al., [13] had reported good to excellent in 86% of the cases treated with miniplates in metacarpal and phalangeal fractures. Stiffness was the most common complication observed in both groups. The incidence was more common in the patients treated with Kirschner's wire group; however, the difference was not statistically significant. Gupta et al., [12] had also reported stiffness as a major complication in their case series. Various other complications like tendon rupture and infection were also noted in isolated cases and were managed appropriately. The limitations of the study were nonrandomized groups, small number of patients in both groups, and short-term follow-up.

Thus, we conclude that there is a trend towards the use of miniplates over Kirschner's wire in the treatment of fractures of hand. Both Kirschner's wire and miniplating were good methods of internal fixation in fractures of metacarpal and phalanges; though patients who were treated with miniplating had marginally better results, but the difference was not statistically significant.

 
  References Top

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Swanson AB. Fractures involving the digits of the hand. Orthop Clin North Am 1970;1:261-74.  Back to cited text no. 1
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Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21:S1-133.  Back to cited text no. 3
    
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American Society for Surgery of the Hand (ASSH). Clinical assessment committee report. Rosemont: Churchill Livingstone; 1992.  Back to cited text no. 4
    
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Strickland JW. Results of flexor tendon surgery in zone II. Hand Clin 1985;1:167-79.   Back to cited text no. 5
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Emmett JE, Breck LW. A review of analysis of 11,000 fractures seen in a private practice of orthopaedic surgery 1937-1956. J Bone Joint Surg Am 1958;40-A:1169-75.  Back to cited text no. 6
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Corley FG, Schenk RC Jr. Fracture of hand. Clin Plast Surg 1996;23:447-62.  Back to cited text no. 7
    
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Ip WY, Ng KH, Chow SP. A prospective study of 924 digital fractures of the hand. Injury 1996;27:279-85.  Back to cited text no. 8
    
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Kozin SH, Thoder JJ, Liberman G. Operative treatment of metacarpal and phalangeal shaft fracture. J Am Acad Orthop Surg 2008;8:111-21.  Back to cited text no. 9
    
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Omokawa S, Fujitani R, Dohi Y, Okawa T, Yajima H. Prospective outcomes of comminuted periarticular metacarpal and phalangeal fractures treated using a titanium plate system. J Hand Surg 2008;33:857-63.   Back to cited text no. 10
    
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Liew KH, Chan BK, Low CO. Metacarpal and proximal phalangeal fractures--fixation with multiple intramedullary Kirschner wires. Hand Surg 2000;5:125-30.  Back to cited text no. 11
    
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Gupta R, Singh R, Siwach RC, Sangwan SS, Magu NK, Diwan R. Evaluation of surgical stabilization of metacarpal and phalangeal fractures of hand. Indian J Orthop 2007;41:224-9.  Back to cited text no. 12
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Nalbantoglu U, Gereli A, Ucar BY, Kocaoglu B, Dogan T. Treatment of metacarpal fractures with open reduction and low-profile plate and screw fixation. Acta Orthop Traumatol Turc 2008;42:303-9.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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