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CASE REPORT

Madigan Orthopaedic Surgery

I would manage it nonop: cast and close follow-up to assess a possible secondary displacement. Start exercises in 3 weeks.

Dr Schulte, great looking xrays. I think this is a case where you could make the argument either for ORIF and early motion or nonop depending on the patient factors, age, activity level, occupation, sports, etc. How early did you have this patient starting ROM?

Replying to @ReedHoyerMD assuming no rotational mal-alignment, would early return to play guide your decision at all? @sanjkakar @handsurgortho @OrthoHandWrist @orthohand any thoughts?

Dr. Schulte - excellent case, thanks for sharing! Your reduction looks excellent. I'd expect nothing less. I got the same injury playing flag football during my ortho sub-I in TX. Had it pinned the next day, pins were cut and buried and was able to scrub the next day, got them pulled a month later a...t my next sub-I,...did great, so maybe I'm a bit biased. I think given the absence of clinical deformity (angulation, rotation, or shortening) you could make an argument for nonoperative management. However, I'm generally more aggressive, because I believe that in my hands it is easier to "set it and forget it". Surgery is not without risk of complications but it is often easier, for both the surgeon and the patient, to fix it and not have to watch it potentially lose reduction over the next month and need to address the fracture in the subacute or malunited setting. In young active patients, or patients who need to get back to work more expediently, fixing this will avoid lengthy immobilization and again, issues with loss or reduction or malunion. My story being case in point. I wouldn't have been able to scrub cases or effectively do my job as a result. So it really is a discussion to be had with the patient regarding their vocation and daily demands. When it comes to fixation, in my experience, less is more. Less dissection, less metal, less scar tissue and resulting stiffness. I've rarely regretted pinning, often regretted more extensive dissection of the phalanges. Pins are undervalued. You don't need an anatomic reduction in every case, especially for extra-articular fractures, and pins can often accomplish the same result percutaneously as screws and plates do but without the dissection. I'd pin this under local, wide-awake, clamp percutaneously and place three transverse/oblique pins, cut at the skin and bury, take the patient through active motion during the case to verify no deformity/rotation, and post-op begin ROM exercises immediately. Pull the pins at 4 weeks.

PMID: 26761926

Am J Orthop (Belle Mead NJ). 2016 Jan;45(1):E35-7.

Definitive Fixation of Hand and Wrist Fractures in the Emergency Department.

Am J Orthop (Belle Mead NJ). 2016 Jan

Nicholas Kusnezov | John C Dunn

Replying to @ReedHoyerMD My big-bone surgeon brain is obviously missing something, because I was thinking a buddy-strap would do considering the small displacement.

Metacarpal Fractures

PMID: 35179136 Tech Hand Up Extrem Surg. 2021 May 11;26(1):47-50. Epub 2021 May 11.

Minimally Invasive Corrective Osteotomy for Metacarpal Malrotation.

ABSTRACT
- Metacarpal fractures can be complicated by malrotation. This can cause functional problems with overriding or underriding of the fingers with flexion. Surgical treatment consists of corrective osteotomy and derotation. This is typically performed open and different techniques for osteotomy and fixation have been described. Postoperative complications include finger stiffness and hardware irritation. We propose a technique for minimally invasive corrective osteotomy of malunited metacarpal fractures with rotational malalignement. Advantages are quick rehabilitation and no prominent hardware.