Procedure 54 Metacarpal Neck Fractures
Examination/Imaging
Clinical Examination
Note swelling and bruising over the dorsum of the hand.
Look carefully for any wounds—may indicate an open fracture (Fig. 54-1).
Look carefully for rotational deformity with fingers flexed and compared with opposite hand (Fig. 54-2).
Ensure circulation is adequate by checking capillary refill.
Surgical Anatomy
Exposures
For open plating, a longitudinal incision is centered over the metacarpal neck. The incision is on the dorsum for the long and ring fingers. For the border digits—index and small fingers—the incision is on the midlateral line and then curves dorsally at the metacarpophalangeal joint (Fig. 54-6).
For intramedullary pinning, the incision is placed at the metacarpal base (Fig. 54-7).
Pearls
For plating of adjacent metacarpals, a single skin incision between the metacarpals will allow access to both fractures.
Careful spreading dissection is necessary after skin incision to preserve subcutaneous nerves and veins.
Paratenon around extensor tendons must be preserved to minimize postoperative tendon adhesions.
With exposure for intramedullary pinning of the small finger, particular care must be taken to identify and preserve the dorsal branch of the ulnar nerve.
In case of excessive comminution, the periosteum around the fracture is left intact, and the implant is secured distally and proximally (bridge plating).
Procedure
Step 1: Preparation of Plate and Insertion of Blade
Achieve provisional reduction and stabilize with a K-wire (Fig. 54-8).
Select the appropriate-sized condylar plate.
The plate is held against the fracture, and the required length of plate is determined. The plate is cut to appropriate length (Fig. 54-9).
The blade hole is drilled first in the metacarpal head. The plate is rotated such that the blade is pointing away from the bone, and the plate hole adjacent to the blade is drilled with the drill directed parallel to the blade (Fig. 54-10).
The hole is measured, and the blade is cut to the appropriate length.
The blade is inserted into the hole, and the plate is approximated with the shaft using a bone clamp (Fig. 54-11).
