European Journal of Molecular & Clinical Medicine

ISSN 2515-8260 Volume 09, Issue 02, 2022

Original research paper

Functional outcome of Antegrade Intramedullary k-wire

fixation for fifth metacarpal neck fracture
1
Dr. Devendrappa H, 2Dr. BN Pavan Kumar, 3Dr. Tamil Selvan, 4Dr. Raghavendra SB

1
Professor, Department of Orthopaedics, VIMS, Ballari, Karnataka, India
2,3,4
Senior Resident, Department of Orthopaedics, VIMS, Ballari, Karnataka, India

Corresponding Author:
Dr. BN Pavan kumar

Abstract

Background: The fracture of the fifth metacarpal neck (also called a boxer’s fracture) is the
most common fracture of the hand. Displaced fractures often end in volar angulation of the
metacarpal head, shortening, and residual malrotation. Although many fractures can be
treated conservatively, surgery is indicated in patients with excessive volar angulation,
relevant shortening, or rotational deformity.
Methods: In a prospective study conducted June 2019 to June 2021 we analysed the clinical
results of 20 patients with metacarpal neck fractures that had been treated by closed reduction
with intramedullary pre bent k-wires. Patients were followed at 2weeks, 6 weeks, 12 weeks
for functional outcome and assessed by total active motion of affected and unaffected hand.
Results: Most of the patients were young, with good bone quality and low anaesthetic risk,
and they had suffered the fractures as a result of a direct trauma. Predominantly
uncomplicated. Surgical treatment was indicated for a palmar axis dislocation of >30° or if a
rotatory deficiency >10° was present.
Metacarpophalangeal joint function and correction of rotatory displacement could be assessed
on median after a period of six months. In all 20 patients flexion and extension was normal
and comparable on both sides. All the patients have pain free range of motion, cosmetic
acceptability, without any residual deformity and complete functional restoration.
Conclusion: Intramedullary k-wire fixation is a minimally invasive method for stabilizing
metacarpal neck fractures. The excellent long-term clinical results are due to the fact that the
gliding tissue around the fractures are not affected by the surgical procedure.

Keywords: K wires, metacarpophalangeal joint, Boxer fracture

Introduction

Injuries to small bones of the hand are commonly encountered in casualty, resulting in
fracture of metacarpal and phalanges. Among all metacarpal fractures, fracture of neck of
fifth metacarpal is commonest. It’s also called “Boxer’s fracture” which account for about
36% of all metacarpal fractures [1, 2]. The incidence of boxer’s fracture is about 20% of all
hand injuries and also the prevalence is more in young, active males [3, 4]. The foremost
common mode of injury is an axial impact on a clenched fist. It is commonly observed in
young individual with aggressive behaviours. A bio mechanical study showed that a fracture
angle of more than 450 produced significant muscle restriction that can limit movement of
fifth digit but a fracture angle up to 300 is compatible with normal functions [5]. Surgery is
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usually recommended when clinical malrotation of fifth finger as noted on flexion and
longitudinal shorting more than 3mm. Several surgical techniques are used such as antegrade
intramedullary K-wire, retrograde intramedullary K-wire, retrograde cross pinning with k-
wire, transverse pinning K-wire, external fixation, intraosseous wiring and plate fixation [6, 7].
Foucher et al., suggested that antegrade intramedullary K-wire technique is reliable and safe
technique produces good fracture reduction and excellent ROM for the patient with fifth
metacarpal neck fractures [8-10]. Our aim of the study is to evaluate the functional outcome of
fixing the boxers fracture with two intramedullary pre bent K wire introduced in antegrade
fashion.

Methods

Our study was a prospective study conducted in the department of Orthopaedics,

Vijayanagara institute of medical sciences, Bellary, after obtaining ethical committee
clearance. The study duration was two years form June 2019 to June 2021.
All patients presenting with fracture neck of fifth metacarpal were managed by antegrade
intramedullary k wire fixation using a prebent K wire. Patient demographics including age,
sex, handedness and other associated medical problems were collected. The mechanism of
injury was noted and also the side involved was clinically examined for rotational deformity.
A series of 20 patients with fractures of the neck of the fifth metacarpal bone (boxer's
fracture) were included within the study.
Inclusion criteria were angulation greater than 450 versus the contralateral uninjured side
when measured on a 250 pronated (oblique view) on plain X-ray of both hands
preoperatively.
Open fracture, concomitant fractures and children younger than 18 years were excluded,
articular fractures were not included in the study.

Surgical technique

We used Dorso-ulnar approach to 5th metacarpal base. Under c arm guidance, the entry point
is made without damaging the carpo-metacarpal joint and respecting the insertion of the
extensor carpi ulnar is tendon. The dorsoulnar cortex is opened with a 2 mm drill bit.
The bore is then enlarged with a 2.7 mm or 3.2 mm, drill bit. Two K-wires of 1 mm or 1.25
mm, diameter have to be inserted with the blunt tip first, to scale back the chance of risk of
perforating the thin cortex of the metacarpal head.
The distal tip is bent upwards with pliers by about 20 degrees. About 2 cm further, the wire is
bent in the same direction by not more than 10 deg.
At a point where the wire is slightly longer than the metacarpal into which it will be inserted,
the proximal end of the wire is bent through 90 degrees in the same plane. This way, the
direction of the insertion can always be controlled.
To avoid injury, the sharp end of the wire is bent over. Two wires are inserted manually into
the medullary canal and advanced into the diaphysis without reaching the fracture zone. The
bent tip should point in a volar direction. The fracture is preliminarily reduced by flexing the
MP and PIP joints to 90 degrees and using the proximal phalanx to push up the metacarpal
head (Jahss manoeuvre) 11. The wires are now advanced manually, or with a hammer, across
the fracture zone into the head.
The correct position is checked using image intensification. The K-wires are then rotated so
that the bent tips are pointing dorsally and diverging in opposite directions (dorso -radial and
dorso-ulnar).
Ideally, the blunt tips lie underneath the dorsal cortex of the head. This enables for a 3-point
fixation which increases the stability of the construct and prevents the K-wires from backing

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out proximally. The K-wires are then bent at the level of the entry portal and cut. A
removable splint is applied at the end of the operation, with the hand in an intrinsic plus
(Edinburgh) position. While the patient is in bed, use pillows to keep the hand elevated above
the level of the heart to reduce swelling.

Fig 1: (A) Pre-operative x-ray with angulation at 5th metacarpal neck, (B) angulation corrected after k
wire insertion by antegrade manner, (C) complete union without any angulation

Fig 2: (A) showing MCP joint extension, (B) MCP joint flexion

Fig 3: (A) Preoperative neck shaft angle-900; (B) postoperative neck shaft angle-200

Follow up

Patient is regularly followed up. Alternate day dressing is done and check x-rays are taken to
substantiate that no secondary displacement has occurred. Active mobilization is started at
about 10-12 days, supervised by a physio therapist. The splint is continued. Additional x-rays
are taken at 6 weeks. K wires are removed at 6 week follow up.

Results

Twenty patients were included in our study and the mean follow up period was 6 months and
the total study duration was of 2 years. All the fractures involved the dominant hand (16 right
and 4 left). Out of the 20 patients operated, 18 are male and 2 females. With most typical
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mode of injury being RTA seen in 12 patients, assault (6), and fall from height (2), with age
distribution ranging in between 18-40 yrs. All the patients had good functional range of
motion, no residual deformity, and cosmetic acceptance.
The mean Total active motion (TAM) of the affected hand at the last follow-up was recorded
and was compared therewith of the unaffected hand. We found that at the last follow up the
mean TAM of the affected hand was 223.50 (Table 1). At the end of the follow-up there was
no significant difference in the Total active motion (TAM) in the affected and the unaffected
hand.

Table 1: Total Active Motion at the last follow-up and its comparison with the unaffected hand
Sl. No. Active motion (AH) Total active motion (UAH) % Improvement
1 220 225 97.7
2 215 230 93.4
3 225 230 97.8
4 210 220 95.45
5 215 225 95.5
6 225 230 97.8
7 220 225 97.7
8 230 230 100
9 230 235 97.8
10 230 240 95.8
11 235 245 95.9
12 215 225 95.5
13 230 235 97.8
14 225 230 97.8
15 230 240 95.8
16 210 220 95.4
17 220 225 97.7
18 225 235 95.7
19 225 230 97.8
20 230 240 95.8
mean value 223.25 230.75 96.74
SD 7.3 6.75 0.55

Discussion

Fifth metacarpal fracture is extremely common. Most of the fractures are simple, closed and
stable and are treated conservatively [1, 2, 4]. If the fractures aren’t stabilized properly cosmetic
and functional problems may occur.5 Closed reduction of displaced metacarpal neck fracture
is reported to be difficult to realize and impossible to retain in reduced position by non-
operative methods. By closed means using plaster slab, three- point fixation cannot be
achieved [12-14]. Green and Rowland mentioned that all the fractures of metacarpal neck are
inherently unstable due to deforming muscle forces and volar comminution at the fracture site
[15, 16]
. Indications for operative treatment include mal-rotation, longitudinal shortening and
excessive angulations of the head. Majority of surgeons agree that a shortening of the
metacarpals by more than 3 mm and any rotation deformity is poorly tolerated and needs
correction. Open reduction and internal rigid fixation using plates has been recommended for
unstable fractures [1, 2]. These may cause problems with fracture healing, soft tissue tethering,
extensor tendon adhesions, and wound breakdown. Both ante grade and retrograde
percutaneous pinning have been describe in literature. Kim et al. conducted a study within
which he compared ante grade vs retro grade pinning in displaced fractures [6]. They found
that ante grade pinning achieved better outcomes than patients in the retrograde group for all
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clinical parameters at 3 months postoperatively.

In our study we have used a pre bent k wire introduced in ante grade fashion to provide
reduction of the fragment. We found that the pre bent k wire not only provides good
reduction but also provides a stable 3-point fixation. There was no significant difference
between the affected and the unaffected hand with respect to the TAM at the end of 6 months.

Conclusion

Metacarpal neck fractures are very common fracture type in young active adults.
Conservative management is usually associated with shortening and angular deformities.
Percutaneous fixation of the fracture with pre-bent K wire placed in antegrade fashion
provides good stability at the fracture site. The bent nature of the wire helps in correction of
rotation and angular deformities. This is a relatively easy technique with good post-operative
results (cosmetic, functional) and with short learning curve.

Ethical approval

All procedures followed were following the ethical standards of the responsible committee on
human experimentation (institutional and national) and with the Helsinki Declaration of 1975,
as revised in 2008. This study was approved by our institutional review board.

Consent

Written consent has been taken from all patients to participate in the study without sharing
their personal information, signed and inserted in their medical files.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Acronyms and Abbreviations

 K-wire = Kirschner wire.

 MP = metacarpophalangeal joint.
 TAM = total active motion.
 AH = affected hand.
 UAH = unaffected hand.

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