1. INTRODUCTION
Fractures of metacarpals and the phalanges are approximately 10% of all the fractures of the skeletal system. Closed treatment has historically been the mainstay of treatment. However, since the late 20th century, there is an increasing trend to manage these injuries via surgical intervention.
Our aim was to compare the clinical outcomes of matched pairs of patients who had surgical fixation performed versus patients who underwent conservative management of their metacarpal or phalanges fracture. The null hypothesis was that there would be no significant difference in the outcomes.
METHODOLOGY
After obtaining approval from an Institutional Review Board/ Ethics Committee, a retrospective case control review of patients who sustained metacarpal and phalanx fractures of the hand, from 2012 to 2015 in our institution, was performed.
Demographic data including age, gender, handedness, diabetes, Workman’s compensation and affected digit were obtained from clinic visits and from sessions with the occupational therapist. Patients who have undergone surgical fixation as well as conservative management were then matched for age (to similar deciles), gender, handedness as well as the fractured bone, fracture site, geometry and angulation.
Clinic and therapy notes were queried for the final range of motion (ROM) of the involved metacarpophalangeal (MCPJ), proximal interphalangeal joint (PIPJ) and distal interphalangeal joint (DIPJ). Total active motion (TAM) was also calculated from the sum of motion of the above joints. Initial & final radiographs were retrieved from an electronic database, to record initial displacement and angulation and the eventual final angulation of the healed fracture. A total of 8 matched pairs were identified for analysis.
DISCUSSION
Most fractures are functionally stable before or after closed reduction and will fare well with protective splintage and early mobilization. Surgical treatment is only necessary when the fracture is badly displaced, when the fracture is unstable after reduction or if the articular surface is unacceptably disrupted.
Surgical treatment may bring with it its own set of complications – infection, stiffness, secondary deformity, hardware prominence, additional costs and possibly additional surgery for the removal of implants as well.
This paper shows that even in metacarpal and phalangeal fractures with initial angulation and displacement, these can be treated non-operatively with similarly equal or better outcomes with minimal morbidity. Although some have residual deformity, the function of the patient and range of motion have not shown to be affected.
There are many problems with existing literature: a lack of RCTs, bias in many studies and often incomplete reporting of outcome and data. Nonetheless, there is available data for metacarpal and phalangeal fractures that conservative management does provide equally good functional outcomes compared to surgery.
RESULTS
A total of 16 patients with 18 fractures were analyzed. All fractures regardless of whether conservatively or surgically treated, achieved bony union during follow up. There were no secondary surgeries required nor complications sustained. The mean age of the patients in this case control study was 33.4 years (17 to 46 years) and majority of the patients were males (94%). The mean duration of follow up was 4.9 months (3 to 16 months).
Out of the 8 matched pairs, 2 of the pairs had a greater total active motion in patients with fractures that were treated surgically, while 6 of the pairs had fractures with a greater total active motion after conservative treatment. There was also complaints of stiffness in 3 of the 8 patients who had undergone surgical treatment, while there was 1 patient who complained of stiffness amongst the 8 patients who had received conservative management.
CONCLUSION
In this study, the clinical & functional outcomes of matched pairs of patients who had surgical fixation performed versus patients who underwent conservative management of their metacarpal or phalanges fracture showed no difference in outcome.
Current available data suggest that for certain metacarpal and phalangeal fractures of the hand, surgery does not reliably confer benefit over good, conservative treatment.
REFERENCES
Carpenter S, Rohde RS. Treatment of Phalangeal Fractures. Hand Clin 29 (2013); 519–534
Giddins G. The Non Operative Management of Hand Fractures: A Review. Jour Trauma & Orthopaedics (2016); 4:48-51
Ahmad M, Hussain SS, et al. Management of Phalangeal Fractures of Hand. J Ayub Med Coll Abbottabad (2006); 18(4)
JK Lee, YG Jo, et al. Open Reduction and Internal Fixation for Metacarpal Fractures. Orthopäde (2017); 46:617–624
Figure 1 – Initial & post treatment radiograph of conservatively treated 5th metacarpal shaft fracture
Figure 2 – Initial & post treatment radiograph of surgically treated 5th metacarpal shaft fracture