CASE REPORTS
Year : 2022 | Volume
: 37 | Issue : 1 | Page : 30--33
Fractures of all metacarpals of both hands: A rare case report
Atin Jaiswal1, Vineet Agarwal2, Shivendra Srivastava3, Yashwant Singh Tanwar4,
1 Avadh Hospital and Heart centre, Lucknow, Uttar Pradesh, India
2 Department of Orthopaedics, Avadh Hospital and Heart Centre, Lucknow, Uttar Pradesh, India
3 Hind Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
4 Indraprastha Appolo Hospital, New Delhi, India
Correspondence Address:
Shivendra Srivastava
Hind Institute of Medical Sciences, Sitapur, A-733, Indira Nagar, Lucknow 226016, Uttar Pradesh
India
Abstract
Metacarpal bones are key structure elements in the anatomy of hand. Fractures of all the metacarpals of both hands have not been described in the literature. Malunited metacarpal fracture in a young male may be quite disabling, compromising hand functions. We present a case of compound fracture of all metacarpals of both hands in a 30-year-old man and its management with good functional outcome.
How to cite this article:
Jaiswal A, Agarwal V, Srivastava S, Tanwar YS. Fractures of all metacarpals of both hands: A rare case report.J Bone Joint Dis 2022;37:30-33
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How to cite this URL:
Jaiswal A, Agarwal V, Srivastava S, Tanwar YS. Fractures of all metacarpals of both hands: A rare case report. J Bone Joint Dis [serial online] 2022 [cited 2023 Mar 22 ];37:30-33
Available from: http://www.jbjd.in/text.asp?2022/37/1/30/345165 |
Full Text
Introduction
Metacarpal fractures comprise between 18% and 44% of all hand fractures.[1] Among metacarpal fractures, thumb metacarpal fractures comprise 12% of all metacarpal fractures.[2] Metacarpal fractures typically occur secondary to a direct blow or fall directly onto the hand. In younger patients, most common etiology is an injury during contact sports, in middle-aged persons work or occupation related injury, and in older patients due to falls[3],[4]
Metacarpals act as a key skeletal element participating in the formation of the three arches of the hand, that is, one longitudinal and two transverse arches. Metacarpals are strongly held at their bases by strong interosseous ligaments and distally by deep transverse intermetacarpal ligaments, which help to maintain the transverse arches of hand. Multiple metacarpal fractures or crush injuries of the hand may result in flattening of the arches and compromise hand functions.
We present a case of crush injury of both hands in a 30 years male due to falling of a heavy clamp over both hands resulting in fractures of all the metacarpal bones of both hands and its management.
Case Report
A 30-year-old male plumber by occupation, presented to the emergency department of our institute with crush injury to both hands. He gave a history of falling of a heavy clamp over his both hands while working at a borewell. On clinical examination, his both hands were crushed with multiple lacerations and bleeding from both hands, radiographs were ordered which suggested fractures of all the metacarpal of both hands [Figure 1] and [Figure 2]. Right-hand radiographs suggested Fracture of base of first, second, fourth, fifth metacarpals, and shaft of third metacarpal [Figure 1]. Left-hand radiograph suggested fracture of base of first and fifth, shaft of second and fourth and neck of third metatarsal. After preliminary investigations patient was posted for surgery with a plan for debridement, lavage, and fixation of all the fractures. All the dead and devitalized tissues were debrided, and there was no tendon and neurovascular injury. Metacarpals were fixed with k wires in the same setting with a combination of intramedullary and transverse k wiring as required [Figure 5] and [Figure 6]. Left hand was more crushed as compared to the right one. Right hand was covered with primary suturing and left hand was kept open for secondary debridement at 48 h [Figure 3] and [Figure 5]. Repeat debridement of the left hand was done after 48 h and deep tissue cultures were sent and stay sutures were applied [Figure 4] and [Figure 6]. Tissue cultures were negative after 72 h of incubation. Right hand healed well with primary suturing and sutures were removed on 10th day postoperative [Figure 3]. Left-hand wound showed some signs of superficial necrosis so sutures were removed and the wound was allowed to heal by secondary intention [Figure 4]. Postoperative intravenous antibiotics in the form of Cefazolin and Amikacin were given for 72 h and tetanus prophylaxis was given. Postoperatively the patient was kept on aggressive physiotherapy and active and passive wrist and finger exercises. Some K wires developed pin side infection and were removed earlier rest of all k wires were removed at 4 weeks. At 6 months postoperatively patient regained an acceptable range of motion in both hands [Figure 7] and [Figure 8].{Figure 1} {Figure 2} {Figure 3} {Figure 4} {Figure 5} {Figure 6} {Figure 7} {Figure 8}
Discussion
Metacarpals fractures may be open or closed, intra- or extraarticular, and fracture lines may be spiral transverse or oblique. Goal of treatment is anatomical and functional restoration of hand. They tend to have apex dorsal angulation due to the force exerted by the intrinsic and extrinsic flexors on the distal fragment. Shortening of the metacarpals is potentially problematic as the extensor mechanism is attached at the level of the metacarpal head, through the sagittal bands, and therefore, the shortening will create a tendon imbalance resulting in an extension lag. Every 2 mm of shortening will result in 7° of extension lag. Shortening is more common at the border digits or with multiple fractures.[5] Most commonly, metacarpal fractures have apex dorsal angulation. Most authors recommend nonoperative management for up to 40°–50° of apex dorsal angulation in the small finger, 30° at the ring finger, 20° at the middle finger, and 15° at the index finger.[6] Rotational deformity is poorly tolerated in finger fractures. Malrotation may not be apparent with finger extension other than mild nail malalignment, but becomes pronounced with flexion. Each degree of rotation at the metacarpal results in 5° of rotation at the fingertip, leading to 1.5 cm of digital overlap in the closed fist[7] Symptomatic scissoring can be quite disabling. To assess rotation, the examiner should compare the affected and contralateral hands. Normally, all fingers point toward the scaphoid tubercle in cascading fashion, and deviation from this alignment may indicate a rotated fracture fragment.
Indications for operative treatment include displaced intra-articular fractures, polytrauma, severe soft tissue injury, unstable open fractures, segmental bone loss, and multiple hand or wrist fractures[8] Recommended methods of fixation of metacarpal fractures are K Wiring either intramadullary, transverse or cross-wiring, lag screw fixation, external fixators and plating depending on fracture location and morphology
K-wires have the lowest bending strength and are best for the reconstruction of the articular surface, neck, or base fracture fixation where plates or screws may be difficult to place, and to maintain reduction of dislocated metacarpals.
Facca et al.[9] prospectively compared locking plates to IM K-wire fixation of closed, isolated, displaced fifth metacarpal fractures. There was no significant difference in grip strength, pain, DASH score, or complication rates. Serial irrigation and debridement procedures are required in extensive open fracture patterns and soft tissue injuries depending on the extent of the injury rigid and stable internal fixtion is required for adequate healing of soft tissues. Intravenous antibiotic therapy needs to remain until the wound has been debrided and cleaned in the operating theater. After debridement in theater and skin closure, antibiotic therapy should terminate. Antibiotics should be broad but tailored to the mechanism of injury (particularly bites, marine, or farm contamination). The incidence of deep infection has been found in up to 11% of open fractures as compared to 0.5% in operatively treated closed fractures.[10] Complications in metacarpal fracture may include compartment syndrome, stiffness, malunion, nonunion, psudoclawing, tendon rupture, and infection.
Gonzalez et al.[11] reported a treatment algorithm for open fractures of the hand based on the modified Gustillo–Anderson classification in 1999, as summarized in [Table 1].{Table 1}
Our case was Gustilo Anderson type 2 in the right hand and type 3 in left. Therefore, right hand was debrided and primary closure was done as there was not much contamination. Left hand was debrided twice and stay sutures were applied only. Our case was managed as an algorithm given by Gonzalez et al.
Conclusion
Early aggressive debridement, fixation, and wound care along with early mobilization lead to a successful outcome in this case. Combination of intramedullary and transverse K wiring provides excellent angular and rotational stability for early mobilization with minimal chances of infection in compound injuries. To the best of our knowledge, this is the first case reported in the literature reporting fracture of all the metacarpals of both hands in a patient. This case report will add to the deficient literature regarding the management of such injuries.
Financial support and sponsorship
Not applicable.
Conflicts of interest
There are no conflicts of interest.
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