40 Fracture after Prior Kirschner’s Wire Fixation
40.1 Patient History Leading to the Specific Problem
A 26-year-old man sustained a closed fracture of the third and fourth metacarpals due to a motorcycle accident (▶Fig. 40.1). The fourth metacarpal transverse shaft fracture was treated by intramedullary fixation with two 0.045-inch Kirschner’s wires (K-wires), while the third metacarpal articular base fracture was treated by intermetacarpal fixation with two 0.062-inch K-wires directed from the second to the third metacarpal (▶Fig. 40.2).
The K-wires and protective splint were maintained for 6 weeks. Ten weeks after the injury, the patient reported an acute onset of pain while holding a cutting board of approximately 4.5 lb with key pinch.
40.2 Anatomic Description of the Patient’s Current Status
Static inspection of the right hand demonstrated moderate edema. Surgical wounds from the previous surgery were healed. He was able to actively move his fingers with restriction of range of motion (ROM) of all metacarpophalangeal (MCP) joints, related to prior immobilization period. A visible deformity was evident with and apex dorsal angulation and radial rotation of the index finger with flexion (▶Fig. 40.3).
Radiographic images revealed a transverse fracture on the diaphysis of the second metacarpal (▶Fig. 40.4). The fracture was related with K-wire track. There were angulations of 20 degrees in the coronal plane and 5 degrees in the sagittal plane. There was evidence of consolidation of the previous third and fourth metacarpal fractures.
Fig. 40.1 Radiographs from the fracture of the third and fourth metacarpals.
Fig. 40.2 Postoperative radiographic follow-up of the fixation of the third and fourth metacarpals with K-wires.
Fig. 40.3 (a, b) Clinical appearance of the right hand with moderate swelling and rotational deformity.
Fig. 40.4 Fracture through the second metacarpal related to prior K-wire fixation.
40.3 Recommended Solution to the Problem
More common complications following metacarpal fractures may be associated, such as stiffness and pin track infection. To avoid stiffness, the fracture should be addressed with a plan of early ROM. Fracture fixation with plates and screws may provide immediate stability while granting anatomic reduction. An open reduction and internal fixation may potentially cause soft-tissue damage. This is a shortcoming of this approach. Nonetheless, the benefits from a stable construct may outweigh this disadvantage. Care must be taken with plate positioning in order to avoid potential complications, such as tenosynovitis, scar formation, tendon adhesions, and tendon ruptures. Meticulous dissection and minimal stripping of periosteum are critical to prevent delayed union or nonunion.
40.3.1 Recommended Solution to the Problem
• Take into account associated complications (stiffness or infection).
• Early ROM to avoid longer immobilization time.
• Larger implants and rigid construct for intensive hand therapy.
• Plates and screws may provide immediate stability.
40.4 Technique
After consent for the procedure, the patient was taken to the operative room and placed in the supine position with the right upper limb in a radiolucent table. A dorsal longitudinal incision over the second metacarpal was performed. Dissection was carried out with attention to retract the sensory nerve branches and the dorsal venous system. The extensor tendons were retracted ulnarly.
Anatomic reduction was accomplished with the aid of bone clamps. Fluoroscopic confirmation of the alignment was performed, as well as clinical evaluation of rotation. A two-row titanium 2.0-mm plate was used for the fixation. The plate was positioned on the dorsal aspect of the metacarpal shaft, in such a way that at least three screws could be placed in each fragment. Four screws were placed proximally and three distally, and the index finger was taken through full ROM while the fracture was observed. No movement of the plate or the fracture site was detected. The closure was conducted with monofilament sutures. A bulky dressing was applied and the hand was placed in a forearm-based plaster splint.
