[MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC] So as to be able to understand metacarpal fractures better, the basic anatomical features are listed here once again. Beginning at the red carpal bones or bones of the wrist, the metacarpal bones, shown here in purple, then follow. The phalange bones are then located further distal. 18% of all fractures below the elbow are made up by metacarpal fractures. Men aged between 20 and 30 and young women between the ages f 10 and 20 are the ones frequently affected. The typical accident mechanism either consists of direct impact trauma falling a fall or a physical altercation. This slide shows the typical localisations of metacarpal fractures. These can affect either of the metacarpal head, the shaft or the base. When conducting an examination for metacarpal fractures, care should be taken to note any swelling, dislocation, peripheral blood flow, motoricity and sensitivity. For imaging purposes, an x-ray examination in either 2 or 3 planes is recommended. In all cases where there are any uncertainties, dislocations etc., particularly in cases with fractures near the base, it is recommended that a thinly layered computerised tomogram be conducted. [MUSIC] >> Hello. My name is Dr. Vester. How can I shake hands? : Oh, that is a problem, but don’t worry. Please take a seat. >> Certainly. >> What can I do for you? >> I do not want to appear hostile, but it really is unacceptable that I have had to wait for such a long time. Anyone can see that an emergency is obviously involved here. >> I am very sorry indeed you had to wait, but we’ll take at your hand now immediately. >> That would be good. And as soon as you do it, please.... I work at the Stock Exchange and have to be back in the office as soon as possible. Time is money. >> Then please tell me first of all what happened. >> I got an investment wrong and, after unfortunately becoming somewhat annoyed, I just lost it entirely and BAM! punched the wall. >> Ok. Please show me your hand. Let's see how we can help you. >> Please be careful. >> Do you have tetanus protection in place? >> Yes, I have. >> In the last ten years? - Ok. Okay. Does that hurt? >>No. And here? >> No. >> Ok. Here? >> Nothing at all. >> Ok. Okay. And here, everything OK as well? Good. Is everything OK here in the fingers as well? >> Ok. >> Good. The feeling in your fingers - is it the same everywhere? >> Yes. >> Ok. How about there? >> There, there... >> There is something not right there. - Yes, OK, OK. >> Yes. >> There, that is where it hurts. OK. You have a scar there. Did something happen to you in the past? Hmm. Ok. OK, the blood flow is also OK. OK, I’ll demonstrate with my hand - it does not hurt there. That is my fifth finger. It runs under here as a bone called the metacarpal V bone, and down here at the base, it has a tendency to break easily if you punch a wall or a person or something similar. It looks as if that can also have happened in your case. I would therefore suggest that we take an x-ray of your hand so that we can judge the bony structures more easily and then we can discuss what is to be done afterwards. >> Everything understood. Where do I need to go? >> Please go out of this room to the x-ray area and we’ll then talk again afterwards. >> Thank you. >> Don't mention it. >> The key factor for making the decision as regards the right form of treatment is the question >> as to where the injury has taken place. This can be either in the region of the head, the shaft or at the base of the bone. These x-ray images show a hand with a metacarpal V fracture following a physical altercation. The corresponding postoperative images can be seen here. It can be clearly seen how the fracture has been threaded and stabilised by means of two Kirschner wires. These x-ray images show a subcapital metacarpal V fracture. Here are the corresponding postoperative x-ray images and the treatment by means of internal fixation with a locking-compression plate can be recognised within them. This x-ray image shows a metacarpal V diaphyseal fracture. Here is the postoperative x-ray image. The fracture has been treated by means of internal fixation with a locking-compression plate. These x-ray images show a metacarpal V fracture in the vicinity of the base. The postoperative x-ray images show the treatment undertaken by means of internal fixation with a locking-compression plate. In summary, it can be stated that metacarpal fractures occur relatively frequently. They are caused either by a fall or a blow within the context of a physical altercation. The decision to be taken as regards treatment depends on the degrees of dislocation and instability. The surgical procedures available are: K-wires, screws, conventional and internal fixation with a locking-compression plate as well as fixateur externe systems. [KNOCK] >> Come in. - Please, take a seat. >> Thank you. >> Your x-ray images have also arrived as well. >> How’s it looking? >> If I can just show you here: You can see your hand here, firstly x-rayed from the front and then from the side. That is your thumb, here is the small finger and that is the metacarpal V which we were talking about before. Down here is the base. If you take a look at the bases of the other fingers, then they are always rounded off here and here - Yes? - just there - you can see a bony fragment sticking out like that. If we now take a look at the sideward view, then you can see that the small finger is here again, that is the metacarpal V bone, down here is the base and you can also see here how it has such an irregular shape and a bone fragment can be seen here. To put it clearly therefore, you have suffered a metacarpal V base fracture or a fracture of such a kind as we had already assumed before. >> That is all clear. How are you going to treat it? >> Well, as a fracture is involved which radiates out into the joint, that is to say has an intraarticular location - here at the lowest articular surface - it is the kind of fracture which we would prefer to treat surgically. >> What? >> That’s right. Because if it is not operated on, it will become so rigid that you will have a malalignment in the joint. Having a malalignment in a joint always entails an increased rate of arthrosis and that will cause you pain and particularly mean you will suffer impaired movement in the finger. >> And what does the operation involve? >> We use a small plate in this. I can use our model here to show you what will happen. This is such a plate. It is not very long when used on the small finger. Two small screws are inserted here and two small screws here and the bone fragment which is sticking out so much is effectively pushed back into its former position and then secured in place with this plate. It is only a minor operation and you will not need to undergo general anaesthetic either but will be administered plexus anaesthesia, which means just your arm will go numb. You will also need to spend at least one night here. >> Is it totally excluded for it to be done on an outpatient basis, so that I can go back home the same day? >> Yes, that can be done if you are the first person we deal with in the morning and that will mean you can perhaps go home again in the afternoon or early evening if you are up to it by then. That will depend to some extent on the wound and on the pain you are experiencing. >> OK and how long will I be off work afterwards? >> Well, after the operation, a splint will be fitted for about one week and then the physiotherapy will commence, that is to say exercising the finger outside the splint so that it is capable of moving again. You will not, however, be able to move the finger completely freely again after one week or even after two weeks, as bone healing basically takes six weeks. >> So that means I will be unable to move my finger while the splint is in place? >> No. >> As you know, I work at the Stock Exchange and it would be really good if I could use my keyboard now and again. >> You will not really be able to use your fingers while you are wearing the splint, but if you work at the Stock Exchange, then what you really need to use is your head and your secretary should take care of using the keyboard during that time. >> Ok. and how should I continue with its use in the future or in the course of the next few days until it is all over? >> The nurse in the next room will now fit a splint on your hand which will immobilise your hand and also the finger. That will help reduce the pain and also the swelling as well as ensuring the finger does not bend over even further. >> Everything understood. >> Good. My advice would be not to wait too long to undergo the operation, Sbut to get it over with as soon as convenient, or, even better, I would recommend you have it done as soon as possible. Let's have a look; ah, perhaps on Wednesday? We could fit you in then. >> Thank you. I need to check, but I think Wednesday would be OK. >> In that case, we would meet up once again on Monday in order to conduct a preparatory discussion, to explain everything and to have a talk with the anaesthetist. >> Hmm, Wednesday; I'll need to check, but I will be back on Monday in any case. OK, so that does it for now, I presume. >> Good. Then the nurse will fit the splint next door. Goodbye. >> Goodbye. [NO_AUDIO] Metacarpal I base fractures are metacarpal fractures with special features. These are designated by the name of Bennett, Rolando or Winterstein respectively. The special features of metacarpal I fractures are derived from their increased mobility. These fractures occur markedly more frequently due to the transmission of strength into the more stable metacarpal I shaft. Secondary arthrosis of the carpometacarpal joint of the thumb is to be feared as a late complication. This slide shows a Bennett fracture. What is typical in this is the medial dislocation of the metacarpal I shaft. The small diagram is meant to help you remember the proper name. This slide shows in diagrammatic form the mechanism of dislocation following metacarpal I base fractures. The abductor pollicis longus tendon pulls the metacarpal I shaft out of the joint. Bennett fractures frequently have to be treated surgically because of this tendency towards dislocation occurring. Standard access is secured by means of a Gedda-Moberg approach, while percutaneous restriction can also sometimes be possible. This slide shows a Rolando fracture. What distinguishes a Rolando fracture are T- or Y-shaped fracture lines in the region of the base of the metacarpal I. These fractures are particularly unstable. Because of this tendency towards instability, Rolando fractures are frequently treated surgically. Access is again gained by means of the Gedda-Moberg approach and the implants consist of fixed-angle plates. These x-ray images show the postoperative treatment of a Rolando fracture by means of internal fixation with a locking-compression plate. This x-ray image shows a Winterstein fracture. What distinguishes a Winterstein fracture is the fact that the articular surface is not affected. Despite this, these fractures are still very unstable due to the forces of muscular traction. The optimum treatment decision with metacarpal I fractures can be gathered from this slide. First of all, the questions have to be clarified as to whether a closed or open injury is involved, whether a torsion defect is present, a contraction, a dislocation or a malalignment with a deviation of more than 30°. If any one of these pathologies is present, then the indication is given for surgical treatment. The same indications for an operation apply for the treatment of metacarpal I diaphyseal fractures: open injury, torsion malalignment, contraction or dislocation. Metacarpal II-V base fractures are frequently unstable and are the result of high energy injuries. Treatment is administered by means of open reduction and internal restriction by means of K-wires, mini-screws or mini-plates. In the case of open injuries, the fitting of fixateur externe may be required. By way of example, this slide shows the pathomechanism and the formation of instability in metacarpal II-V base fractures. The lower slide shows restriction by means of a K-wire. These x-ray images show a metacarpal V base fracture in the right hand. These x-ray images show metacarpal diaphyseal fractures of the metacarpal bones II, III and IV. The dislocation and torsion malalignment can be clearly recognised. Identical criteria are applied when it comes to deciding about how metacarpal II-V diaphyseal fractures are to be treated. Clarification must be sought as to whether an open injury has occurred, a torsion, contraction or dislocation. If any of these pathologies is present, then treatment is to be afforded by means of Open Reduction Internal Fixation. These x-ray images show on the left a fracture of the head of a metacarpal V. On the right hand side, the injury post-stabilisation by means of Kirschner wires can be seen. Exactly the same questions need to be answered when it comes to making a decision about how fractures in the heads of metacarpal bones II-V are to be treated. Has an open or closed injury, a torsion, contraction or dislocation occurred? If any of these pathologies is present, then treatment is more likely to be afforded by means of Open Reduction Internal Fixation. Access is usually obtained from dorsal. [NO_AUDIO] The outcomes from metacarpal fractures have been published in the review work of Windolf in the journal “Unfallchirurg” (“The trauma surgeon”). Virtually no prospectively randomised studies have been published. Outcomes in the literature are essentially based on retrospective series of cases. This is most probably due to the considerable heterogeneity of the cases. In summary, it can be stated that metacarpal fractures occur relatively frequently. Typical accident mechanisms in the case of metacarpal I base fractures are patients falling directly onto their thumb. These fractures are given proper names. They are called Bennett, Winterstein or Rolando. Metacarpal V fractures are frequently the result of physical altercations. Metacarpal II-V base fractures are incurred following incidents of high speed trauma, such as motor cycling accidents. The decision as to the form of treatment to be administered depends on the answers given to the questions of: Has an open injury occurred? How stable is the situation? Is the fracture dislocated? Is the articular surface involved or is torsion malalignment present? If any of these pathologies is present, then treatment is more likely to consist of open reduction and internal fixation and osteosynthesis.
