Aims. The aims of this study were to describe the epidemiology of metacarpal shaft fractures (MSFs), assess variation in treatment and complications following standard care, document hospital resource use, and explore factors associated with treatment modality. Methods. A multicentre, cross-sectional retrospective study of MSFs at six centres in the UK. We collected and analyzed healthcare records, operative notes, and radiographs of adults presenting within ten days of a MSF affecting the second to fifth metacarpal between 1 August 2016 and 31 July 2017. Total emergency department (ED) attendances were used to estimate prevalence. Results. A total of 793 patients (75% male, 25% female) with 897 MSFs were included, comprising 0.1% of 837,212 ED attendances. The annual incidence of MSF was 40 per 100,000. The median age was 27 years (IQR 21 to 41); the highest incidence was in men aged 16 to 24 years. Transverse fractures were the most common. Over 80% of all fractures were treated non-surgically, with variation across centres. Overall, 12 types of non-surgical and six types of surgical treatment were used. Fracture pattern, complexity, displacement, and age determined choice of treatment. Patients who were treated surgically required more radiographs and longer radiological and outpatient follow-up, and were more likely to be referred for therapy. Complications occurred in 5% of patients (39/793). Most patients attended planned follow-up, with 20% (160/783) failing to attend at least one or more clinic appointments. Conclusion. MSFs are common hand injuries among young, working (economically active) men, but there is considerable heterogeneity in treatment, rehabilitation, and resource use. They are a burden on healthcare resources and society, thus further research is needed to optimize treatment. Cite this article: Bone Jt Open 2024;5(8):652–661

From 1987 to 1993 we treated 33 patients with 29 phalangeal and seven metacarpal fractures by external fixation using a mini-Hoffmann device. There were 27 open and 25 comminuted fractures. In 12 patients one or more tendons was involved. The mean follow-up was 4.4 years. Complications occurred in ten fractures; two required repositioning of the fixator. All the fractures healed. The functional results after metacarpal fractures were better than those after phalangeal fractures and fractures of the middle phalanx had better recovery than those of the proximal phalanx. Twenty-eight of the 33 patients were satisfied with their result. External fixation proved to be a suitable technique for stabilising unstable, open fractures with severe soft-tissue injuries

Aim of the study: The aim of this study was to explore whether adverse reactions would occur during the material’s degradation period even at a later time point after fracture healing had been completed, in metacarpal fractures treated with third generation bioabsorbable implants. Materials and Methods: 12 unstable, displaced metacarpal fractures in 10 consecutive patients (7 males, 3 females; mean age 36.4 y, range 18–75 y) were treated with third generation absorbable plates and screws (Inion. ®. OTPSTM Biodegradable Mini Plating System), where resorption is supposed to occur within 2 to 4 years. 9 patients (10 fractures) were available for follow-up (mean 25.6 months, range 14 to 44 m) and were examined both clinically and radiologically. For patients without appearance of foreign body reaction the minimum follow-up time was 24 months. Results: Fracture healing was uneventful in all cases. A foreign body reaction was observed more than a year postoperatively in 4 patients, who were subjected to surgical debridement and implant remnants removal. Histological examination confirmed the diagnosis of aseptic inflammation and foreign body reaction. 2 further patients reported a self subsiding transient local swelling. Conclusion: Our results indicate that modern absorbable implants with longer degradation period have not eliminated the problem of foreign body reaction, but simply postponed it at a later time postoperatively. Patients treated with bioabsorbable implants should be advised of this possible late complication and should be followed for at least two years, possibly longer

The aim of this study was to explore whether adverse reactions would occur during the material’s degradation period even at a later time point after surgery and whether these phenomena were clinically significant and would influence the final outcome. 12 unstable, displaced metacarpal fractures in 10 patients (7 males, 3 females; mean age 36.4 y, range 18–75 y) were treated with the Inion. ®. OTPSTM Biodegradable Mini Plating System. 9 patients (10 fractures) were available for follow-up (mean 25.6 months, range 14 to 44 m). For patients without appearance of foreign body reaction the minimum follow-up time was 24 months. Patients were examined both radiologically to evaluate fracture healing, and clinically by completing the DASH-score and a visual analogue scale for pain assessment. Grip strength, finger strength and range of motion of metacarpo-phalangeal and interphalangeal joints were measured. Fracture healing occurred uneventfully in all patients within six weeks. The most important complication was a foreign body reaction observed in 4 of our patients more than a year postoperatively. All were re-operated and had the materials removed. Histological examination confirmed the diagnosis of aseptic inflammation and foreign body reaction. Although internal fixation of metacarpal fractures by using bioabsorbable implants is a satisfactory alternative fixation method, patients should be advised of this possible late complication and should be followed postoperatively for at least one and a half year, possibly longer

AIM: The purpose of this prospective study was to asses the outcome of antegrade intramedullary wiring of displaced distal end of fifth metacarpal fracture in skeletally immature. Intramedullary wiring for fracture metacarpals have been well described in the literature. Retrograde wiring for neck of metacarpal fractures have been associated with limitation of extension at metacarpo-phalangeal joint due to involvement of gliding extensor mechanism. Foucher described ‘Bouguet’ osteosynthesis with multiple wires for metacarpal neck fracture which can be technically demanding in small bones of children. We describe an antegrade wiring using a single bent K-wire at the tip for reducing and stabilising displaced metacarpal neck fracture by rotating 180 degree after crossing fracture site, a method similar to Methaizeau technique for stabilisation of displaced radial neck fractures using nancy nail. METHOD: Between 2000 to 2006 we treated 9 boys with displaced distal end of fifth metacarpal fracture +/− rotational deformity of little finger using above technique. All of them had closed injuries and the indication for surgery was rotatory mal-alignment or fracture angulation more than 40 degrees. The assessment involved a clinical and radiological examination. The mean age was 13 years. The mean follow-up was 15 months. RESULTS: All fractures healed in anatomical alignment. There was no loss of active or passive movement of the little finger metacarpo-phalangeal joint or weakness of grip strength in any children. All children returned to pre-injury activity level within 4–6 weeks. There were no complications. CONCLUSION: Early results of treating displaced little finger metacarpal neck fracture in children using antegrade intramedullary wire are encouraging

The aim of the study was to assess the outcome of fractures of the fifth metacarpal neck and to develop an accurate method of assessing fracture angulation.

Forty-two patients who were available for review were assessed using a patient questionnaire, assessing range of movement, cosmesis, pain and strength. A trigonometric method of determining true fracture angulation from AP and oblique radiographs was developed. There were 36 males and 6 females with an average age of 23.4 years, with a minimum follow up of 12 months. Patients with fractures angulated more than 45 degrees in whom reduction was not performed had a significantly lower score for grip strength and function. 32 patients reported a mild cosmetic deformity. The method of reduction and the method and duration of immobilisation did not correlate with the final outcome. A phantom was constructed that confirmed the accuracy of the method of calculating true fracture angulation from the oblique radiographs.

Fractures of the fifth metacarpal neck if not reduced to a true angulation of less than 45 degrees produce an unsatisfactory outcome. A method of assessing true angulation has been developed.

We completed a retrospective case study of 66 consecutive isolated closed 5. th. metacarpal neck fractures that presented to our Hospital between September 2009 and March 2010. Their management was established by referring to outpatient letters and A&E notes. The aim of the study was to establish if it would be more efficient and cost effective for these patients to be managed in A&E review clinic without compromising patient care. Of these 66 patients, 56 were males and the mean age was 26 years (12–88 years). Four fractures were not followed up at our Trust, six did not attend their outpatient appointment, one did not require follow up. Of the remaining 55, reviewed at a fracture clinic, all but two were managed conservatively, with 47% requiring one outpatient appointment only. The cost of a new patient Orthopaedic outpatient appointment is £180 with subsequent follow up appointments costing £80 per visit, in contrast to an A&E review clinic appointment at a cost of £60. In view of the small percentage in need of surgical intervention: we highlight the possibility for these patients to be managed solely in the A&E department with a management plan made at the A&E review clinic with an option to refer patients if necessary, and the provision of management guidelines and care quality assurance measures. This, we believe, would maintain care quality for these patients, improve efficiency of fracture clinics and decrease cost. We calculate that even if only all the patients that required one follow up appointment could have been managed by A&E alone then the saving to the local health commissioning body over a six month period from within our trust alone, would have been £3000, which across all trusts providing acute trauma services within the NHS would amount to a substantial saving nationwide

Metacarpal fractures represent up to 33% of all hand fractures; of which the majority can be treated non-operatively. Previous research has shown excellent putcomes with non-operative treatment yet surgical stabilisation is recommended to avoid malrotation and symptomatic shortening. It is unknown whether operative is superior to non-operative treatment in oblique or spiral metacarpal shaft fractures. The aim of the study was to compare non-operative treatment of mobilisation with open surgical stabilisation. 42 adults (≥ 18 years) with a single displaced oblique or spiral metacarpal shaft fractures were randomly assigned in a 1:1 pattern to either non-operative treatment with free mobilisation or operative treatment with open reduction and fixation with lag screws in a prospective study. The primary outcome measure was grip-strength in the injured hand in comparison to the uninjured hand at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Score, ranges of motion, metacarpal shortening, complications, time off work, patient satisfaction and costs were secondary outcomes. All 42 patients attended final follow-up after 1 year. The mean grip strength in the non-operative group was 104% (range 73–250%) of the contralateral hand and 96% (range 58–121%) in the operatively treated patients. Mean metacarpal shortening was 5.0 (range 0–9) mm in the non-operative group and 0.6 (range 0–7) mm in the operative group. There were five minor complications and three revision operations, all in the operative group. The costs for non-operative treatment were estimated at 1,347 USD compared to 3,834USD for operative treatment; sick leave was significantly longer in the operative group (35 days, range 0–147) than in the non-operative group (12 days, range 0–62) (p=0.008). When treated with immediate free mobilization single, patients with displaced spiral or oblique metacarpal shaft fractures have outcomes that are comparable to those after operative treatment, despite some metacarpal shortening. Complication rates, costs and sick leave are higher with operative treatment. Early mobilisation of spiral or long oblique single metacarpal fractures is the preferred treatment. Trial registration number: ClinicalTrials.gov NCT03067454

Our aim was to explore factors associated with early post operative infection for surgically managed base of 4th/5th metacarpal fractures. We hypothesised that K-wires crossing the 4th and 5th carpometacarpal joint (CMCJ) would be associated with an increased risk of post-operative infection. Data from consecutive patients requiring surgical fixation for a base of 4th/5th metacarpal fracture from October 2016 to May 2021 were collected. Patient demographics, time to surgery, length of surgery, operator experience, use of tourniquet, intra-operative antibiotics, number and thickness of K-wire used, as well as whether or not the K-wires crossed CMCJ joints were recorded. Factors associated with post operative infection were assessed using Chi Squared test and univariable logistic regression using R studio. Of 107 patients, 10 (9.3%) suffered post operative infection. Time to surgery (p 0.006) and length of operation (p=0.005) were higher in those experiencing infection. There was a trend towards higher risk of infection seen in those who had K-wires crossed (p=0.06). On univariable analysis, patients who had wires crossed were >7 times more likely to experience infection than those who didn't (OR 7.79 (95% CI, 1.39 - 146.0, p=0.056). Age, smoking, K-wire size, number of K-wires used, intraoperative antibiotics, tourniquet use and operator experience were not associated with infection. In patients with a base of 4th/5th metacarpal fractures requiring surgical fixation, we find an increased risk of post-operative infection associated with K-wires crossing the CMCJ, which has implications for surgical technique. Larger prospective studies would be useful in further delineating these findings

Our aim was to ascertain if K-wire configuration had any influence on the infection and complication rate for base of 4th and 5th metacarpal fractures. We hypothesised that in individuals whose wires crossed the 4th and 5th carpometacarpal joint (CMCJ), the rate of complications and infection would be higher. Data was retrospectively analysed from a single centre. 106 consecutive patients with a base of 5th (with or without an associated 4th metacarpal fracture) were analysed between October 2016 and May 2021. Patients were split into two groups for comparison; those who did not have K-wires crossing the CMCJ's and those in whose fixation had wires crossing the joints. Confounding factors were accounted for and Statistical analysis was performed using SPSS version 20 software. Of 106 patients, 60 (56.6%) patients did have K-wires crossing the CMCJ. Wire size ranged from 1.2-2.0 with 65 individuals (65.7%) having size 1.6 wires inserted. The majority of patients, 66 (62.9%) underwent fixation with two wires (range 1-4). The majority of infected cases (88.9%) were in patients who had k-wires crossing the CMCJ, this trended towards clinical significance (p=0.09). Infection was associated with delay to theatre (p=0.002) and longer operative time (p=0.002). In patients with a base of 4th and 5th metacarpal fractures, we have demonstrated an increased risk of post-operative infection with a K-wire configuration that crosses the CMCJ. Biomechanical studies would be of use in determining the exact amount of movement across the CMCJ, with the different K-wire configuration in common use, and this will be part of a follow-up study

The April 2023 Wrist & Hand Roundup. 360. looks at: MRI-based classification for acute scaphoid injuries: the OxSMART; Deep learning for detection of scaphoid fractures?; Ulnar shortening osteotomy in adolescents; Cost-utility analysis of thumb carpometacarpal resection arthroplasty; Arthritis of the wrist following scaphoid fracture nonunion; Extensor hood injuries in elite boxers; Risk factors for reoperation after flexor tendon repair; Nonoperative versus operative treatment for displaced finger metacarpal shaft fractures

Introduction and Purpose. Metacarpal fractures constitute approximately one third of all hand fractures. The majority of these fractures are treated by conservative non-surgical methods. The aim of this study is to obtain the appropriate anatomical alignment of the fracture with dynamic metacarpal stabilization splint (DMSS) and to maintain the proper bone anatomy until the union is achieved. In addition, by comparing this method with short arm plaster splint (SAPS) application, it is aimed to evaluate whether patients are superior in terms of comfort, range of motion (ROM) and grip strength. Materials and Methods. In our study, SAPS or DMSS was applied to the patients with 5th metacarpal neck fracture randomly after fracture reduction and followed for 3 months. A total of 119 patients with appropriate criteria were included in the study. Radiological alignment of the fracture and amount of joint movements were evaluated during follow-up. Grip strength was evaluated with Jamar dynamometer. EQ-5D-5L and VAS scores were used for clinical evaluation. Results. 103 patients completed their follow-up. 51 patients were treated with SAPS and 52 patients were treated with DMSS. The mean age of the SAPS was 29.5 (SD ± 9.4; 16–53 years) and the mean age of the DMSS group was 27.8 (SD ± 11.6; 16–63). Pressure sores was seen in 5 patients in the DMSS group, while no pressure sore was seen in the SAPS (p = 0.008). There was no significant difference between the two groups in the VAS scores at all times. There was no significant difference between the mean dorsal cortical angulation (DCA) before the reduction, after the reduction and at the third month follow-ups. There was no statistically significant difference between the length of metacarps at first admittion before reduction, after reduction and at third month follow-ups. When the grip strength of the two groups were compared as a percentage, the grip strength of the patients in the DMSS group was found to be higher at 1st month, 2nd month and 3rd month (p <0.001). When the ROM values of the patients were evaluated, DMSS group had a higher degree of ROM in the first month compared to the SAPS group (p <0.001). No statistically significant difference was detected among groups at third month in the ROM of the IP and MP joints. However, wrist ROM was statistically higher in DMSS group at 3rd month (p <0.05). There was a statistically significant difference between EuroQol scores in favor of DMSA group (p <0.05). Discussion and Conclusion. In stable 5th metacarpal neck fractures, DMSA is as effective as SAPS to maintain bone anatomy. In addition, DMSA can be preferred for fixation plaster splint or circular plaster applications for the prevention of reduction in boxer fractures, with the advantage of having high clinical scores, which is an indication of early acquisition of grip strength, ease of use and patient comfort

Introduction and Aim: The metacarpal fractures constitute 10% of skeletal fractures in general affecting mainly children and young adults. There is a lot of discrepancy and lack of evidence with regards to correctly managing the little finger metacarpal fractures. Our study was aimed at investigating the current practice of management little finger metacarpal fractures among upper limb surgeons in United Kingdom. Methods: We conducted an online survey between June 2006 and June 2007 consisting of 10 multiple-choice questions that was e-mailed to 278 upper limb orthopaedic specialist surgeons. The response rate was 58% (n = 158) from the upper limb surgeons. Four questionnaires had to be excluded due to multiple responses to each question or incomplete forms. Results: 43% upper limb surgeons prefer neighbour strapping alone for non-operative management of little finger metacarpal fractures. Ulnar gutter cast or splint was the next choice among 19% upper limb surgeons while 13% respondents apply neighbour strapping to ring finger along with a splint. There was mixed response regarding period of immobilisation. 40% of surgeons were in favour of 3 weeks of immobilisation, 23% for 2 weeks while 28% do not immobilise these fractures at all. With regard to considering the most important indication(s) for surgical intervention, rotational deformity was the most common indication (84%), followed by open fracture (70%), intra-articular fracture (44%), associated 4th metacarpal fracture (26%), shortening > 5mm (21%) and volar angulation – (15%). If treated non-operatively, the most preferred period of fracture clinic follow up was one visit at 3 weeks by 40% while 36% thought that no follow up is required once decision is made to treat them conservatively. Conclusion: Isolated undisplaced fractures of little metacarpal are usually managed conservatively using a plethora of methods of immobilisation. The indications for operative intervention are open fracture, rotational deformity, intra-articular fractures and shortening. Many clinical studies have demonstrated that in the conservative care of boxer’s fractures (casting, with or without reduction), between 20 degrees and 70 degrees of dorsal angulation is acceptable. We conclude that contemporary literature provides no evidence as to whether conservative or operative methods of the treatment of these fractures is superior, but rather suggests that they are equally effective. We conclude from our survey that there is no consensus even among the upper limb surgeons with regards to management of little finger metacarpal fractures in United Kingdom

Aims. To determine whether an early return to sport in professional Australian Rules Football players after fixation of a non-thumb metacarpal fracture was safe and effective. Patients and Methods. A total of 16 patients with a mean age of 25 years (19 to 30) identified as having a non-thumb metacarpal fracture underwent open reduction and internal plate and screw fixation. We compared the players’ professional performance statistics before and after the injury to determine whether there was any deterioration in their post-operative performance. Results. Of the 16, 12 sustained their fracture during the season: their mean time to return to unrestricted professional play was two weeks (1 to 5). All except two of the 48 player performance variables showed no reduction in performance post-operatively. Conclusion. Our data suggest that professional athletes who sustained a non-thumb metacarpal fracture can safely return to professional play without restriction two weeks after internal fixation. Cite this article: Bone Joint J 2017;99-B:1343–7

Background. Isolated fractures of the distal fourth or fifth metacarpal bones, known as boxer's fractures (BF), are the most common type of metacarpal fracture. Boxer's fractures received their name from one of their most common causes — punching an object with a closed fist. This injury has been described as “a tolerable fracture in an intolerable patient” (1) It occurs commonly during fistfights or from punching a hard object such as a wall. Greer and William demonstrated that it is usually an intentional injury and these patients were at increased risk for recurrent injury (2). Further work suggested that patients with such injuries had higher features of antisocial, self-defeating personality disorders, self harm and impulsive behaviour, compared with control groups (3). It has been suggested that all patients presenting with such an injury should have psychiatric assessment. The majority of studies in the literature have concentrated on adults and little has been reported on children and adolescents who present with such fractures. This study aims to assess aggression scores in young patients discharged with metacarpal fractures due to punching using a validated questionnaire and this abstract presents the interim analysis. Methodology. Following ethical permissions patients between 11 and 18 years of age, discharged with a metacarpal fracture caused by punching diagnosis codes S622, S623 or S624 and willing to complete an anonymous quetionnairre were included. All patients recieved an information sheet and for young people under 16 parental permission was sought. The Bus and Warren validated questionnaire was completed by post, in person or over the telephone. The questionnaire included subscales of physical aggression and anger scales as well as overall aggression scoring and patients were asked to complete all sections. Results. Twenty one patients who had metacarpal fractures due to punching have. completed the study to date. All were males aged between the age of 11 and 18. The physical aggression scores ranged from 13-39 with a mean of 27.5, median 31 and mode 33. Fifteen patients demonstrated high aggression scores. Six patients demonstrated average scores. Anger scores ranged from 7-31. Median 18.5, mode 13, median 20. Thirteen patients had high anger scores compared with their peers. Eight patients were within the average range. Overall aggression scores ranged from 66-133 with a mean of 100 and median of 100. Eleven patients demonstrated high scores and 5 were in the high average range. Discussion/Conclusions. The initial interim results of this study show that over half the patients had higher overall aggression levels than the normal population. The physical aggression subscale focussed on the use of physical force and 71% had high physical aggression levels. High scores in this subscale indicate a lack of ability to control urges toward physical aggression and this is often seen in children with attention deficit disorder. Anger scores may indicate a number of conduct disorders or abusive situations and in this study 62% had raised anger scores. This may be relevant in assessing children with punch injuries as they may benefit from assessment by the CAMS team for investigation and management of their anger and aggression issues which in turn may reduce recurrence of the injuries

Background. Boxer's fractures are the most common type of metacarpal fracture. It commonly occurs during fistfights or from punching a wall. Greer et al demonstrated that it is usually an intentional injury and these patients were at increased risk for recurrent injury (2). Further work suggested that patients with such injuries had higher features of antisocial, self- harm and impulsive behavior, compared with control groups (3). There is little that has been reported on children and adolescents who present with such fractures. This study aims to assess aggression scores in young patients with metacarpal fractures due to punching using a validated questionnaire. Methodology. Following ethical permission, 11–18 year olds, with a boxers fracture and willing to complete an anonymous questionnaire were included. If they were under 16, parental permission was sought. The Buss and Warren validated questionnaire included subscales of physical aggression and anger scales as well as overall aggression scoring. Results. 48 patients who had metacarpal fractures due to punching have completed the study to date. There were 46 males and 2 females. The physical aggression scores ranged from 11–40 with a mean of 25, median 35.5 and mode 14. 24 patients demonstrated high aggression scores. Anger scores ranged from 7–33. Mean 19, mode 13, median 18.5. 18 patients demonstrated high anger scores. Overall aggression scores ranged from 43–148 with a mean of 96 and median of 92.5. Nineteen patients demonstrated high scores. Discussion. This study shows that 40% of the patients had higher overall aggression levels than the normal population. The physical aggression subscale focused on the use of physical force and 50% had high physical aggression levels. High scores in this subscale indicate a lack of ability to control urges toward physical aggression and this is often seen in children with attention deficit disorder. Anger scores may indicate a number of conduct disorders/abusive situations and in this study 38% had raised anger scores. This may be relevant in assessing children with punch injuries as they may benefit from assessment by the CAMS team for investigation and management of their anger and aggression issues, which in turn may reduce recurrence of the injuries

We reviewed our results and complications of using a pre-bent 1.6mm Kirschner wire (K-wire) for extra-articular metacarpal fractures. The surgical procedure was indicated for angulation at the fracture site in a true lateral radiograph of at least 30 degrees and/or in the presence of a rotatory deformity. A single K-wire is pre-bent in a lazy-S fashion with a sharp bend at approximately 5 millimetres and a longer smooth curve bent in the opposite direction. An initial entry point is made at the base of the metacarpal using a 2.5mm drill by hand. The K-wire is inserted blunt end first in an antegrade manner and the fracture reduced as the wire is passed across the fracture site. With the wire acting as three-point fixation, early mobilisation is commenced at the metacarpo-phalangeal joint in a Futuro hand splint. The wire is usually removed with pliers post-operatively at four weeks in the fracture clinic. We studied internal fixation of 18 little finger and 2 ring finger metacarpal fractures from November 2007 to August 2009. The average age of the cohort was 25 years with 3 women and 17 men. The predominant mechanism was a punch injury with 5 diaphyseal and 15 metacarpal neck fractures. The time to surgical intervention was a mean 13 days (range 4 to 28 days). All fractures proceeded to bony union. The wire was extracted at an average of 4.4 weeks (range three to six weeks). At an average follow up of 8 weeks, one fracture had to be revised for failed fixation and three superficial wound infections needed antibiotic treatment. With this simple and minimally invasive technique performed as day-case surgery, all patients were able to start mobilisation immediately. The general outcome was good hand function with few complications

The use of plates and screws for the treatment of certain metacarpal fractures is well established. Securing plates with bicortical screws has been considered an accepted practice. However, no study has questioned this. This study biomechanically assessed the use of bicortical versus unicortical screws in metacarpal plating. Eighteen fresh frozen cadaveric metacarpals were subject to midshaft transverse osteotomies and randomly divided into two groups. Using dorsally applied Leibinger 2.3mm 4 hole plates, one group was secured using 6mm unicortical screws, while the second group had bicortical screws. Metacarpals were tested to failure using a four point bending protocol in an apex dorsal direction on a servo-hydraulic testing machine with a 1kN load cell. Load to failure, rigidity, and mechanism of failure were all assessed. Each group had three samples that did not fail after a 900 N load was applied. Of those that failed, the mean load to failure was 596N and 541 N for the unicortical and bicortical groups respectively. These loads are well in excess of those experienced by the in-vivo metacarpal. The rigidity was 446N/mm and 458N/mm of the uni-cortical and bicortical groups respectively. Fracture at the screw/bone interface was the cause of failure in all that failed, with screw pullout not occurring in any. This study suggests that there may be no biomechanical advantage in using bicortical screws when plating metacarpal fractures. Adopting a unicortical plating method simplifies the operation, and avoids potential complications associated with overdrilling and oversized screws

Introduction: Intramedullary fixation is a recognised method of fracture fixation in fifth metacarpal fractures. We describe a new technique for fixation of fractures of the middle three metacarpals. Patients and Methods: We reviewed a single surgeon’s series of 16 male patients (mean age 27.9 years, range 18–46) with 20 displaced transverse midshaft fractures of the 2nd, 3rd and 4th metacarpals treated by antegrade intramedullary Kirschner wiring. Work related and domestic accidents constituted the mode of injury in 8 patients and in the remaining 8 as a result of an assault, fall or road traffic accident. Twelve patients were in employment at the time of injury including four heavy manual labourers. A single pre-bent 1.6 millimetre Kirschner wire was inserted into the medullary canal through a drill hole in the metacarpal base and passed across the reduced fracture into the metacarpal head. The proximal end of the wire remained protruding percutaneously. Following stabilisation of the fracture, early mobilisation was commenced. Results: All of the study group had satisfactory clinical and radiological outcomes. All of the fractures united clinically and radiologically. There was one case of delayed union, with union at 35 weeks. In the remaining patients fracture union had occurred radiologically at an average of 5.4 weeks (range 4–12 weeks). Radiologically there was a mean angular deformity of 4.05° (range 0–11°) in the coronal plane and 0.75° (range 0–9°) in the sagittal plane. Postoperatively 2 patients developed a pin tract infection requiring treatment with antibiotics and early removal of the K-wire. All patients on questioning by telephone questionnaire were satisfied with their resulting hand function and appearance. All patients had returned to normal activities of daily living by 8 weeks. Of those patients in employment all had returned to work by 6 weeks (mean 3.3. weeks). Conclusion: Antegrade intramedullary single K wiring is a useful technique for managing unstable midshaft metacarpal fractures producing excellent clinical and radiological results