Evidence in the Treatment of Hand Fractures

2 Evidence in the Treatment of Hand Fractures

János Rupnik

Abstract

In this chapter, we reviewed the hand fracture management in relation with the concept of evidence and the recent literature from the following aspects: distribution of studies regarding anatomical localization on the hand, according to the research topic, the level of evidence of the study and from the point of view of practical effectiveness of the research. We do not make any conclusions about the treatment of fractures of different bones of the hand, since these are detailed in other chapters. Our inquiry focused on what questions can we get answer and whether this has a practical effect in the management of hand fractures.

Keywords: hand fractures, evidence level, role of evidence, fracture treatment

2.1 Introduction

Evidence-based medicine (EBM)—as an interdisciplinary science—has been a determining concept in medical science and research over the past two decades. The widespread expansion of medical knowledge, the multiplication of scientific articles led to the need to develop a method which helps to properly evaluate the unmanageable amount of data. Evaluating the quality of articles has become fundamental in scientific work. In addition to fully restructure the expectations of scientific publications, EBM became an independent science. We found 74,989 articles in the PubMed database by searching for “evidence-based medicine.” In 1996, the number of articles containing the term was 241; in 2017, this number was 4,605. The increase in search results starts in 1996, and we can expect EBM to be introduced from that time. In relation to the EBM, it should also be mentioned that in addition to its clear positive effect, it may also have some potentially negative or real negative consequences, such as devaluating the basic knowledge and the accumulated clinical experience, and may not provide useful guidance in a specific case.1

The human hand consists of both long and short bones, which basically have different functions, biomechanical and healing properties. Partly because of this, there is a large number of conservative and operative treatment options and it is often difficult to find the best treatment method. There are management principles and guidelines, protocols that should be used. The question is how the scientific evidence relates to clinical practice. In a recent study, the level of evidence of hand surgery articles has been reviewed.² In the study, 993 original publications published between 1993 and 2013 were evaluated. The results show a continuous increase in the evidence level of articles, but, according to the authors, high level of evidence work is still uncommon. When developing a guideline, beyond the textbooks, we have to use the current studies with strongest recommendations. The grade A recommendations are directly based on level 1 evidence, grade B to level 2, and so on.³ Nevertheless, in clinical use, we must pay attention to the fact, that not all randomized controlled trials are conducted properly and the results should be carefully evaluated.⁴

It does not occur in everyday practice that a treatment is based on a new prospective randomized trial. The decision making during the management of a fracture basically depends on the surgeon’s knowledge, training, and experience. The basic principles of the fracture treatment provide a precise guideline. However, very often there are no scientifically proven answers to simple questions to decide, such as operative or conservative treatment, choice between different implants (K-wire, screw, compression screw, plate, fixateur externe), bone graft versus vascularized bone graft, and last but not least the question of cost benefit. The research was performed according to these considerations. The following terms were searched for in the Cochrane database: “phalangeal, metacarpal, thumb, carpal, scaphoid, and fracture, cost benefit, and treatment” in different combination. Only the articles from 2012 to 2016 were included. Through this sample, we tried to conclude the usefulness of the data obtained here in direct clinical practice.

2.2 Quality and Distribution of the Studies

2.2.1 Phalangeal Fractures

The search resulted 16 articles, among them there was no systemic review. In the period of 2012 to 2016, there were five articles, four were prospective randomized trials and one was biomechanical cadaver study. The topics of clinical studies were as follows: (1) Extra-articular fractures of the proximal phalanges of the fingers; comparison of functional, conservative treatment.5 (2) Comparison of conservative and operative treatment, distal phalanx.⁶ (3) Two different physiotherapeutic methods after proximal phalanx fracture fixation.⁷ (4) The use of denatured cellulose barrier after plate osteosynthesis of the proximal phalanx.⁸ (5) The stability of four different fixation methods was analyzed on a proximal phalanx distal intra-articular fracture cadaver model.⁹

2.2.2 Metacarpal Fractures

Only the articles published in the last 5 years have been studied. The search in the Cochrane database resulted in one systematic review and meta-analysis, six clinical trials and one biomechanical study. The systematic review investigated the outcomes of the antegrade intramedullary nailing compared to other surgical interventions in the treatment for fifth metacarpal neck fractures.10 In five of the six clinical trials, the subject was the fractures of fifth metacarpal neck fracture. One prospective study compared the intramedullary nail and low-profile plate for unstable metacarpal neck fractures.¹¹ Two prospective studies analyzed the antegrade intramedullary technique.^12,13 Two compared the conventional conservative (plaster cast) treatment and splinting of the fifth metacarpal neck fracture.^14,15 One multicenter randomized control study focused on the conservative versus operative management of the fifth metacarpal neck fracture.¹⁶ The biomechanical cadaver study compares plate fixation using mono and bicortical screws in transverse metacarpal fracture model.¹⁷