Metacarpal Shaft Fractures - Pretest


1. The open fracture seen in Figure 1 is associated with a clinical rotational deformity of the middle finger. Open reduction and internal fixation: 

A. Immediately is contra indicated for this injury 
B. Is associated with approximately 10% complication rate
C. With plating causes more malunion than interosseous wiring
D. Should be delayed for 2 weeks to allow wound healing
E. Increases infection rate in the presence of systemic illness

Preferred Response: E

Discussion: Fusetti et al assessed the complications after open reduction and plate fixation of 157 closed metacarpal fractures and encountered 35% one or more complications, including difficulty with fracture healing which was the most frequent (15%), stiffness (10%) and plate failure (8%). They concluded that despite technical advances in implant material, design, and instrumentation, plate fixation of closed metacarpal fractures remains fraught with complications and unsatisfactory results. Swanson, Szabo and Anderson evaluated 200 open hand fractures and encountered 97 complications including 9 wound infections, 18 malunions, 17 delayed or nonunions, and 23 fixation problems. Malunion was more common with interosseous (67%) than plate fixation (0%). Infection rate increased in the presence of wound contamination, delay in treatment greater than twenty-four hours, or systemic illness. It was not increased by presence of internal fixation, immediate wound closure, large wound size, tendon/nerve/vascular injury, or high-energy mechanism. Although the infection rate was less after plate fixation than K-wires, this finding should be interpreted with caution because most patients were treated with K-wires (#105) as compared with plate fixation (#8). These authors suggested a practical classification for open hand fractures predictive of infection: type I: clean wound and no systemic illness; type II: contaminated wound, delay in treatment greater than twenty-four hours, or significant systemic illness. Immediate wound closure is appropriate for type I injuries and delayed closure
should be reserved for type II wounds. 

1. Fusetti C, Meyer H, Borisch N, Stern R, Santa DD, Papaloïzos M. Complications of plate fixation in metacarpal fractures. J Trauma. 2002 Mar;52(3):535-9.
2. Swanson TV, Szabo RM, Anderson DD. Open hand fractures: prognosis and classification. J Hand Surg [Am]. 1991;16:101-7.