24 Correction of Malunion in Metacarpal and Phalangeal Fractures Abstract We regard the technique for correction of rotational malalignment by using a special rotational plate as safe and reliable. It facilitates difficult surgery significantly. Precise surgery with premounting the plate, correct position of the osteotomy, and early rehabilitation are key points for good clinical outcome. Keywords: malunion, metacarpal fractures, phalangeal fractures, correction osteotomy, rotational plate Symptomatic malunited fractures of the metacarpals or phalanges can significantly affect hand function. Isolated fractures of metacarpals and phalanges are the commonest injuries of the upper extremity, which constitute about 10% of skeletal fractures in general and 40% of all upper extremity fractures. The failures include nonunion and malunion, which disturb hand function or are cosmetically unacceptable. Frequently, these failures are followed by reduction of finger movement, degenerative changes in neighbored joints, and algodystrophy. The management of nonunion and malunion in the metacarpals and phalanges is influenced by the multiple gliding structures and the propensity for stiffness making this kind of surgery challenging.1 Complications associated with these fractures are also prevalent, and can arise with both conservative and surgical treatment of hand fractures, making treatment of complications an essential part of caring for these injuries. Failed conservative treatment might be caused by just looking on the radiograph missing the clinical situation mostly in case of rotational malalignment. Complications of surgery are usually determined by fixing the fracture in a wrong position or with insufficient stability leading to secondary malalignment.2 Rotational and axial deformity are indications for correction osteotomy. Correction osteotomy should be performed in case of severe deformity leading to significant restriction of function. If only slight deformity is present, it depends on patients’ complaints and profile. Whereas axial deformity is obvious, rotational deformity needs precise clinical testing by examination of finger movement from extension to full flexion. Already 10 degrees of malrotation at the metacarpal site lead to 2-cm dislocation at the fingertip ( Correction of rotatory malunion of the proximal phalanx might be done either at the site of the malunion or the base of the metacarpal. An osteotomy at the site of the malunion offers the best condition for full correction of the deformity but involves an increased risk for tendon adhesions leading to contractures of the proximal interphalangeal (PIP) joint and even the metacarpophalangeal (MCP) joint.3 Osteotomy at the metacarpal side provides less risk for tendon adhesions but can lead to imbalance of the intrinsic muscles and if additionally, axial deformity is present to some kind of Z-deformity. Nowadays with the low-profile implants, we absolutely recommend performing the osteotomy at the site of the malunion as full correction of the deformity only can be achieved by that. Early recreation of the fracture or osteotomy is more likely to be rewarded with favorable results than late operation. However, if severe swelling and restriction of motion at the MCP and PIP joint are present, one should initially go for physiotherapy to improve soft tissue conditions and wait for surgery. In case of additional nonunion, early surgery of course is necessary.
24.1 Trauma Mechanism
24.2 Classification
24.3 Clinical Signs and Tests
Fig. 24.1).
24.4 Evidence
24.5 Author’s Favored Treatment Options
24.5.1 Time for Surgery
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