Carpal, Metacarpal, and Phalangeal Fractures

CHAPTER 28 Carpal, Metacarpal, and Phalangeal Fractures

Carpal, metacarpal, and phalangeal fractures are among the most common injuries treated by hand surgeons. Historical data suggest that 10% of all fractures occur in the metacarpals and phalanges and that 80% of all hand fractures involve the tubular bones.13 Until the early 20th century, most carpal and hand fractures were treated nonoperatively. Even today, fractures that are nondisplaced or minimally displaced may be viewed as stable and treated conservatively or with closed reduced and cast immobilization. Unstable fractures require surgical fixation to maintain length, alignment, and rotation. Other options for fixation include percutaneous pinning, external fixation, traditional open reduction and internal fixation, and arthroscopically assisted reduction and internal fixation (AARIF).


Arthroscopic surgery of the wrist and hand is a rapidly evolving discipline. Since Chen first reported on diagnostic arthroscopy of the wrist and finger joints in 1979 with the Watanabe no. 24 arthroscope, techniques for small joint arthroscopy have developed at a rapid pace.4 Current indications include the diagnosis and treatment of numerous wrist disorders, including fractures, soft tissue pathology, and arthritis. Arthroscopy of small joints, including the metacarpophalangeal (MCP) and interphalangeal (IP) joints, has lagged compared with the phenomenal interest generated by wrist arthroscopy. Badia theorized that minimal reporting in the literature and lack of direct teaching of this technique have contributed to the limited use of this potentially useful technology.5

In 1995, more than 15 years after Chen’s classic article, Ryu and Fagan described their experience treating the ulnar collateral ligament Stener lesion in eight thumbs with success.6 Arthroscopic reduction was achieved by reducing the lesion until the avulsed ligament sat juxtaposed to its insertion site on the proximal phalanx. After the reduction was performed, the ligament ends were débrided, and the joint was pinned. The results were excellent, with range of motion and strength comparable to those of the unaffected contralateral thumb.

In 1999, Rozmaryn and Wei presented a paper detailing the technical aspects of MCP arthroscopy, with general references to the potential use of this technique in treating juxta-articular and intra-articular fractures.7 In the same year, Slade and Gutow published a review article on arthroscopy of the MCP joint.8 They offered detailed technical explanations and emphasized that small joint arthroscopy requires specialized instruments and a thorough knowledge of the anatomy within these specialized joints. In 2006, Badia reported encouraging results treating bony gamekeeper’s thumb with AARIF.9



Indications and Contraindications

AARIF is an excellent choice for juxta-articular fractures of the carpometacarpal (CMC) and MCP joints of the thumb and digits, because these small joint injuries require anatomic reduction to prevent post-traumatic arthritis. As Slade and Gutow pointed out in their 1999 article describing arthroscopic techniques for MCP joint fixation, minimal surgical manipulation of the soft tissue envelope and preservation of the blood supply during operative exposure are indispensable for obtaining an optimal result.8 AARIF preserves vascular blood supply to bony fragments by minimizing dissection of the soft tissue envelope surrounding the joints of the hand. Open surgery of tissues surrounding these small joints may contribute to collateral ligament and flexor tendon scarring and shortening, which ultimately limit tendon excursion and lead to stiffness and suboptimal results.11

A example of a fracture pattern amenable to AARIF is the simple two-part fracture with displacement greater than 1 mm involving the metacarpal head or base of the proximal phalanx.10 Other excellent indications for AARIF are for reduction of an avulsion fracture with a rotated fragment from the collateral ligament insertion and for treatment of die-punch articular fractures of the proximal phalangeal base. AARIF enables the surgeon to use the arthroscope to clearly visualize articular reduction with a probe or Kirschner wire and to visualize subsequent percutaneous fixation.5 In pediatric cases, Salter-Harris type III physeal fractures may be reduced and secured without additional injury to the growth plate with the use of AARIF.

Slade and colleagues presented their results using AARIF in 1998 at the Annual Meeting of the Arthroscopy Association of North America (AANA). This study documented fewer complications and improved final range of motion when fractures were treated with AARIF compared with the results of standard open reduction.12

Contraindications to the use of AARIF for MCP and proximal IP fractures are poor soft tissue coverage, open fractures, and active cellulitis.10 Fractures with three or more fragments, comminution, or associated diaphyseal extension that cannot be easily reduced through percutaneous means are also disqualified for AARIF, because these fractures are better treated with standard open approaches.

Jun 19, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Carpal, Metacarpal, and Phalangeal Fractures

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