Articular fracture of the base of the thumb metacarpal: Comparative

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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.
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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.
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