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Clinical Example: Double blade plating recalcitrant metacarpal nonunion
| Metacarpal fractures are common injuries.
Metacarpal fracture nonunions are uncommon because of the support provided
by adjacent metacarpals, but can be a difficult problem following high
energy trauma. This series of pictures document the difficulty of treating
a middle metacarpal nonunion following a gunshot injury. |
| Click on each image
for a larger picture |
| The injury: point blank handgun injury,
palmar to dorsal through the middle metacarpal. Contusion of the third
web space common digital nerve. |
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| The treating surgeon debrided the wound
and maintained length with intermetacarpal pins. When the wound was stable,
the fracture was treated with bone graft, plate and screws. |
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| He did well for three months, then
broke his plate: |
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| The plate was removed, and the fracture
was replated, using more bone graft and larger screws. This plate
held for five months, then also broke. Additionally, a cross union to the
ring metacarpal can be seen: |
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| At this point, I took over his care. |
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| I believed that the nonunion was due
to the combined effects of an avascular wound bed, segmental sclerotic
bone, and the mechanical effect of cross union transferring force from
the ring metacarpal to the distal metacarpal segment. I removed the broken
plate, |
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| debrided the sclerotic fracture site,
took down the cross union, interposed a second web space interosseous
muscle flap to prevent recurrent synostosis, and used an iliac crest segmental
graft carved with intramedullary dowel extensions. |
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| I used the Synthes modular hand set,
which has screw intervals different than the small fragment set. |
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| This was the longest plate available,
not optimum, but had six cortex purchase on each side of the graft. |
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| This looked favorable initially, |
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| but began to pull out at six weeks. |
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| I removed this hardware, and used two
mini condylar blade plates at right angles to resecure the distal bone
juncture. This allowed more distal purchase while avoiding hardware placement
beneath the metacarpal head extensor hood. I replated the proximal bone
juncture although it looked clinically healed - not worth taking a chance. |
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| Final result, eight months postop,
healed: |
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| Healed. |
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| And clinically, not normal, but doing
well considering what he has been through. |
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A similar gunshot metacarpal injury can be
seen here.
|
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American
Society
for
Surgery
of the
Hand
assh.org
The Best
Resource
For Your
Hands,
Period.
|
