Orthopedics

Feature Article 

Complications of Low-Profile Plate Fixation in Metacarpal Fractures

Rita E. Baumgartner, MD; Andrew E. Federer, MD; Evan M. Guerrero, MD; Suhail K. Mithani, MD; David S. Ruch, MD; Marc J. Richard, MD

Abstract

High complication rates have been reported using conventional plating systems to treat metacarpal fractures. This study investigated complication rates in metacarpal fractures treated with low-profile anatomic plates. A retrospective chart review was performed of patients with metacarpal fractures who were treated with open reduction and internal fixation using low-profile anatomic plates at a single institution from January 2010 to February 2017. Patients with concomitant tendon injury, open fractures, prior same metacarpal fracture, or thumb metacarpal fracture were excluded. A total of 79 patients with 110 metacarpal fractures were included. The primary outcome was the presence of a complication, defined as superficial or deep infection, delayed wound healing, delayed union, nonunion, major or minor extensor lag or stiffness 90 days postoperatively, or return to the operating room. Eleven fractures (10%) had 1 or more complications. Complications included 6 fractures (5%) with major extensor lag or stiffness, 4 fractures (4%) with minor extensor lag or stiffness, 1 fracture (1%) with delayed radiographic union that did not require operative intervention, and 1 fracture (1%) with return to the operating room for removal of hardware. In this retrospective study, treatment of metacarpal fractures with low-profile plate fixation resulted in a 10% overall complication rate and a 1% reoperation rate; this rate is significantly less than reported in previous literature prior to the widespread use of low-profile plates. This study suggests treatment of patients with metacarpal fractures using low-profile plating systems provides a reliable solution with acceptable complication rates. [Orthopedics. 2021;44(1):e91–e94.]

Abstract

High complication rates have been reported using conventional plating systems to treat metacarpal fractures. This study investigated complication rates in metacarpal fractures treated with low-profile anatomic plates. A retrospective chart review was performed of patients with metacarpal fractures who were treated with open reduction and internal fixation using low-profile anatomic plates at a single institution from January 2010 to February 2017. Patients with concomitant tendon injury, open fractures, prior same metacarpal fracture, or thumb metacarpal fracture were excluded. A total of 79 patients with 110 metacarpal fractures were included. The primary outcome was the presence of a complication, defined as superficial or deep infection, delayed wound healing, delayed union, nonunion, major or minor extensor lag or stiffness 90 days postoperatively, or return to the operating room. Eleven fractures (10%) had 1 or more complications. Complications included 6 fractures (5%) with major extensor lag or stiffness, 4 fractures (4%) with minor extensor lag or stiffness, 1 fracture (1%) with delayed radiographic union that did not require operative intervention, and 1 fracture (1%) with return to the operating room for removal of hardware. In this retrospective study, treatment of metacarpal fractures with low-profile plate fixation resulted in a 10% overall complication rate and a 1% reoperation rate; this rate is significantly less than reported in previous literature prior to the widespread use of low-profile plates. This study suggests treatment of patients with metacarpal fractures using low-profile plating systems provides a reliable solution with acceptable complication rates. [Orthopedics. 2021;44(1):e91–e94.]

Metacarpal fractures comprise 18% of hand and forearm fractures, and nonthumb meta-carpal fractures account for 88% of all metacarpal fractures.1,2 Despite the prevalence of nonthumb metacarpal fractures, ongoing controversy exists regarding optimal treatment methods. Metacarpal fractures disrupt the intricate balance between flexor tendons and the extensor mechanism, and can lead to significant functional limitations if not treated appropriately.3 In fractures that cannot be adequately reduced and immobilized using external methods, internal fixation is indicated. Open reduction and internal fixation (ORIF) with plate and screws allows for precise reduction, rigid fracture immobilization, and early range of motion (ROM).3–7 However, unacceptably high complication rates, ranging from 32% to 36%, have been reported using conventional plating systems to treat metacarpal fractures. Common complications include stiffness, malunion, nonunion, hardware failure, persistent pain, and infection.6,8

In the past 10 years, significant improvements in implant materials and design have led to the availability of low-profile anatomic plates. Low-profile plates were designed to decrease surgical exposure and stripping of the periosteum, as well as to decrease irritation of the soft tissue caused by hardware (Figure 1). Fischer et al9 demonstrated low-profile plates have similar construct strength and stiffness to bending load compared with the conventionally used 2.7-mm dynamic compression plating system. Therefore, these plates should confer the stability and early ROM benefits of plate and screw fixation while decreasing complication rates.

Preoperative (A) and 2-week postoperative (B) anteroposterior radiographs of fourth and fifth metacarpal fractures treated with open reduction and internal fixation using low-profile anatomic plates.

Figure 1:

Preoperative (A) and 2-week postoperative (B) anteroposterior radiographs of fourth and fifth metacarpal fractures treated with open reduction and internal fixation using low-profile anatomic plates.

Despite the theoretical advantages of low-profile plates, there is insufficient evidence to demonstrate a decreased complication rate in metacarpal fractures treated with low-profile plates compared with earlier generation plates. This study was undertaken to characterize and report complications in patients with nonthumb metacarpal fractures treated with ORIF using low-profile anatomic plates.

Materials and Methods

The authors retrospectively studied the files of all patients who underwent ORIF for a metacarpal fracture using plate and screw fixation by fellowship-trained hand surgeons at a single institution from January 2010 to February 2017. Approval from the institutional review board was obtained prior to performing the study. Cases were identified using an institutional data query tool to search hospital billing records using Current Procedural Terminology code 26615 for open fixation of metacarpal fracture.

Electronic medical records and radiographs were reviewed, and data were abstracted on patient demographics, injury characteristics, operative techniques, operative construct, postoperative clinical examination, and complications. Complication was the primary outcome. Complications included superficial or deep infection, delayed wound healing, delayed union (lack of consolidation at 3 months), nonunion (no evidence of bony union at 6 months), major extensor lag or stiffness at 90 days after surgery (lag >35° or total active flexion [TAF] <180°), minor extensor lag or stiffness at 90 days after surgery (lag >15° or total metacarpophalangeal joint [MCPJ] flexion <75°),8 and return to the operating room. Range of motion data were collected from occupational therapy (OT) notes or from clinic notes if OT notes were not available. Range of motion was measured using a standard goniometer.

Exclusion criteria were fixation other than plate and screw (143 patients), thumb metacarpal fracture (3 patients), patients with concomitant tendon injury or open fracture (11 patients), prior same meta-carpal fracture (5 patients), revision ORIF for malunion or nonunion (3 patients), or surgical treatment by a non–fellowship-trained hand surgeon (70 patients). Descriptive summary statistics were used to report complication rates. Unpaired two-tailed t tests and analysis of variance were used to compare complications between cohorts. P<.05 was considered significant.

Results

A total of 79 patients with 110 metacarpal fractures were included in the analysis. Eighty-five percent of the patients were male. Mean age at time of surgery was 35.5 years (SD, 15.8 years; range, 15.2–79.1 years). Fifty-eight patients presented with a single metacarpal fracture, and 21 patients presented with multiple metacarpal fractures. There were 18 second meta-carpal fractures, 19 third metacarpal fractures, 32 fourth metacarpal fractures, and 41 fifth metacarpal fractures included in this review. Mean follow-up was 3 months (range, 1–24 months).

Indications for plate fixation, as well as plate selection and fixation construct were determined by the attending surgeon. Low-profile anatomic plates from Acumed, KLS Martin, Medartis, Stryker, and Synthes were used. All plates were placed dorsally through a dorsal approach to the metacarpal.

One or more complications occurred in 11 fractures (10%). Stiffness was the most common complication, occurring in 10 fractures (7%). Minor extensor lag or stiffness at 90 days after surgery occurred in 4 fractures (4%). Major extensor lag or stiffness at 90 days after surgery occurred in 6 fractures (5%); 1 of these fractures (1%) required additional surgery 6 months after ORIF of a fifth metacarpal fracture for removal of hardware, extensor tenolysis, and MCPJ contracture release. At 3 months after hardware removal, this patient had major stiffness with TAF of 170° in his small finger but was able to return to work.

One fracture (1%) had delayed radiographic union with lack of consolidation at 3 months. This patient had no clinical limitations at that time. After 4 months of follow-up, abundant fracture callus was present with no evidence of hardware failure, and operative intervention was not required.

Nine of 79 patients (11.4%) experienced a postoperative complication. Two of 21 patients (9.52%) with multiple fractures experienced complications compared with 7 of 58 patients (12%) with an isolated fracture (P=.757). For patients with fracture of a single metacarpal, 2 of 8 patients (25%) with a second metacarpal fracture, 0 of 6 patients (0%) with a third metacarpal fracture, 3 of 17 patients (17.6%) with a fourth metacarpal fracture, and 2 of 27 patients (7.41%) with a fifth metacarpal fracture experienced a complication (P=.387). For patients with fracture of a single metacarpal, 2 of 14 patients (14.3%) with a metaphyseal or metadiaphyseal fracture experienced a complication and 5 of 44 patients (11.4%) with a diaphyseal fracture experienced a complication (P=.528). Five of 27 patients (18.5%) who were active smokers had a complication compared with 4 of 52 patients (7.69%) who did not actively smoke (P=.155).

Discussion

Metacarpal fractures are common injuries, and fixation of metacarpal fractures with traditional plate and screw constructs has resulted in complication rates ranging from 32% to 36%.6,8 This complication rate rendered plate and screw fixation a less popular option for the operative treatment of metacarpal fractures, despite numerous theoretical advantages.3–7 Plate technology has evolved in recent years to minimize common complications, but evidence of lower complication rates using low-profile anatomic plates is lacking. The results from the current study demonstrate a decreased rate of complications among patients at the authors' institution treated with low-profile anatomic plate and screw fixation for nonthumb metacarpal fractures compared with historical controls of earlier generation plate systems.

There are studies in the literature that report the results of low-profile plate fixation of metacarpal fractures; however, the methodology used in the studies makes it difficult to compare their complications with this study and previous studies of metacarpal plate complications. Takigami et al10 compared fixation using a low-profile plate and screw system with Kirschner wire fixation in phalanx and metacarpal fractures. In 39 fingers treated with the low-profile plate and screw system, they found 1 delayed union, 3 cases of screw breakage, 2 cases of screw loosening, and 5 patients with TAF less than 180°. However, they did not separate metacarpal and phalanx fractures in their analysis, and they did not differentiate between patients who received plate and screws vs screws alone.10

In a prospective study, Soni et al11 analyzed 21 patients with closed ipsi-lateral metacarpal fractures treated with mini-fragment plates and screws. They reported infection in 5 of 21 patients and poor ROM in 1 patient but otherwise had good results, with no cases of malunion, nonunion, or hardware failure.11 These results are also difficult to compare with other metacarpal plate studies, as poor ROM was defined as less than 80° of TAF, compared with less than 180° of TAF, less than 75° of MCPJ flexion, or more than 15° of extensor lag in this study and other previous studies.6,8

This study demonstrates several consistencies compared with data reported using traditional plate fixation of metacarpal fractures. In this and prior studies, infection was rare; none of the patients in the current series and 1% to 2% of patients in prior studies developed infections postoperatively.6,8 Conversely, as in prior studies, stiffness was a common complication. Page and Stern8 reported a 6% rate of major stiffness and a 15% rate of minor stiffness, and Fusetti et al6 reported a 10% rate of major stiffness. In this series, 5% of patients experienced major stiffness and 5% experienced minor stiffness. The moderate improvement in rates of stiffness in this study may be due to plate-related factors. With a thinner plate, improved approximation of the soft tissue over the plate may be possible, theoretically decreasing the risk of adhesions between the fracture and the extensor tendon. Interference to tendon gliding also may be minimized by low-profile plates.12,13

In this series, 1 patient (1%) experienced delayed radiographic union but did not require operative intervention, as the fracture had consolidated by 4 months. The most common complication reported by Fusetti et al6 was difficulty with fracture healing in 15% of patients. Page and Stern8 reported 8% of fractures with mal-union, delayed union, or nonunion. Furthermore, no patients in the current series had plate loosening or breakage compared with 6% to 8% in prior studies.6,8 These differences suggest low-profile anatomic plate materials and design provide sufficiently rigid fixation to allow for fracture healing without increased risk of screw or plate failure.

There were limitations to this study. This was a retrospective review, and results were compared with historical controls; the study was subject to the inherent limitations of this methodology. This study also relied on documentation available in the medical record, and precise documentation of ROM was typically available from OT notes. However, in some cases, patients did not see OT or were seen by outside OT, with notes not available for review. In these cases, ROM data were collected from clinic notes and may not have been recorded by an independent observer. Finally, this study reviewed complications of low-profile plate fixation of metacarpal fractures at short-term follow-up, and assumptions cannot be made regarding complications at long-term follow-up.

Conclusion

In this series, treatment of metacarpal fractures with low-profile plate fixation resulted in a 10% overall complication rate and a 1% reoperation rate. This is significantly less than reported in previous literature with the use of conventional plating systems. This study suggests treatment of patients with metacarpal fractures using low-profile plating systems provides reliable fracture fixation with acceptable complication rates.

References

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Authors

The authors are from the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina.

Drs Baumgartner, Federer, Guerrero, and Mithani have no relevant financial relationships to disclose. Dr Ruch is a paid consultant for Acumed. Dr Richard is a paid consultant for Acumed, DePuy Synthes, DJO, and Medartis.

Correspondence should be addressed to: Evan M. Guerrero, MD, Department of Orthopaedic Surgery, Duke University Medical Center, DUMC Box 3000, Durham, NC 27710 ( evan.guerrero@duke.edu).

Received: May 07, 2019
Accepted: January 28, 2020
Posted Online: October 01, 2020

10.3928/01477447-20200925-02

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