Study reference

Study characteristics

Patient characteristics ²

Intervention (I)

Comparison / control (C) ³

Follow-up

Outcome measures and effect size ⁴

n.s. no statistically significant difference

n.c. no clinical relevant difference

* details not reported

Comments

⁵ Cepni et al., 2016

Type of study:

Non-randomized prospective observational study

Setting:

Hospital

Country:

Turkey

Source of funding:

No funding received

Inclusion criteria:

• >18 years
• acute (0-15 days) closed and simple little finger metacarpal neck fracture
• absence of ipsilateral injury or deformity
• presence of angulation of >40^o in oblique plane imaging
• a masters’ degree or still being a student
• employee in social-professional environment with mild physical activities

Exclusion criteria:

None reported

N total at baseline:

Intervention: 12

Control: 12

Important prognostic factors²:

Important prognostic factors²:

Age (mean, range): 28 (18-46)

Sex:

I: 100% male

C: 100% male

Potential confounding factors:

Time of fracture to treatment (mean, range):

I: 3 days (0-13)

C: 2 days (0-4)

Describe intervention (treatment/procedure/test):

Surgical procedure with block anaesthesia under operating room conditions. Closed reduction was applied employing the Jahss manoeuvre under fluoroscopic guidance. Then, a simple incision of 2 cm was made right to the distal of the carpometacarpal joint, proximal to the fifth metacarpal. A cortical window was created with the sharp end of a 1.6-mm K-wire and widened cautiously. Fixation was performed with an intramedullary insertion of two pre-contoured K-wires of 1.6 mm in an antegrade fashion. Distal angulation of the first K-wire was advanced towards the palmar region and then rotated towards the dorsal upon reaching the metacarpal head in order to correct the palmar angulation. Stability of the reduction was improved with an insertion of the second K-wire. Distal ends of the K-wires were advanced to the cancellous part of the metacarpal head for adequate fixation. Proximal ends of the wires were cut off at the cortex level and left under the skin. The surgical incision site was closed with 4/0 absorbable sutures. The mean duration of surgery was 34 (20–45) min. K-wires of all patients were removed on the 30th postoperative day under local anaesthesia without any redisplacement cases. Splints applied after wound dressings were removed on the seventh day. Hygienic interactions during daily activities and use of keyboard and pens were allowed.

Describe control (treatment/procedure/test):

Gentle closed reduction with the Jahss manoeuvre . Immobilization in a U-shaped ulnar gutter spint that was applied to fix the fourth and fifth MCP, proximal and interphalangeal joints in semiflexion. Reduction was repeated in the presence of an angulation of >40^o in the obliqe plane in the follow-up radiographs. Control visits on the second and seventh days after closed reduction. Splints were removed on the fourth week.

Length of follow-up:

45 days

Loss-to-follow-up:

Intervention:

Not reported

Control:

Not reported

Incomplete outcome data:

Intervention:

Not reported

Control:

Not reported

Outcome measures and effect size (include 95%CI and p-value if available):

Palmar angulation (^o) before treatment | after treatment (mean, range):

I: 43 (40-55) | 8 (0-17)

C: 43 (27-55) | 14 (10-28)

p=0.86 | p=0.24

Metacarpal shortening (mm) before treatment | after treatment (mean, range):

I: 9.3 (6-15) | 0.5 (0-3)

C: 5.6 (5-6) | 2 (0-4)

p=0.23 (after treatment)

Total joint ROM (percentage of ROM of healthy side) after treatment (mean, range)

Flexion:

I: 84 (75-100) versus C: 91 (75-100), p=0.24

Extension:

I: 96 (90-100) versus C: 93 (80-100), p=0.20

Return to work (days) (mean, range):

I: 4 (3-5) versus C: 34 (26-41), p<0.001

QuickDASH (mean, range):

30 days:

I: 3 (0-16) versus C: 70 (59-80), p<0.05

45 days:

I:1 (0-2) versus C: 39 (23-61), p<0.05

Complications (number and type of complication):

I: 2 reduction loss

C: 2 failure of reduction during first week

Authors’ conclusions:

• Surgically treated patients gained hand functions earlier and returned to active daily living and work activities in a short period of time
• No differences were found in physical and radiological findings for both treatment groups.

Limitations:

• Limited sampling power

Authors’ recommendation:

• The authors recommend antegrade intramedullary K-wire fixation as a reliable method, which minimized the functional loss and allows for early return to daily activities in office workers who sustained a fracture of the fifth metacarpal neck.

²³ Sletten et al., 2015

Type of study:

RCT

Setting:

Hospital

Country:

Norway

Source of funding:

Sofies Mindes Ortopedi AS, Oslo, Norway

Inclusion criteria:

• >18 years
• little finger metacarpal neck fractures

Exclusion criteria:

• <30^o palmar angulation
• clinically detectable rotational deformity of the little finger
• extensor lag or pseudoclawing
• >50% lateral displacement of the metacarpal head on the anteroposterior radiographs
• extension of the fracture into the joint
• concomitant injury (e.g. multiple fractures)
• fractures older than 14 days
• patients who did not speak Norwegian or English
• patients who lived too far away from the hospitals
• patients suffering from drug abuse or dementia

N total at baseline: 85

Intervention: 42

Control: 43

Important prognostic factors²:

Age (median, range):

I: 25, 18-68

C: 29, 18-67

Sex:

I: 93% male

C: 91% male

Potential confounding:

Manual workers:

I: 43%

C: 16%

A statistically significant higher rate of manual workers in the intervention group.

Describe intervention (treatment/procedure/test):

Closed reduction and internal fixation by antegrade, intramedullary bouquet pinning. Pre-bent wires were cut below the skin to minimize risk for infection. The postoperative regime was identical to the conservative regime. Operations were standardized by a protocol detailing the surgical exposure over the base of the little finger metacarpal, reduction of the fracture, numbers and sizes of wires, wound closure, and formation of the plaster cast.

The experience level of the first surgeon was recorded as one of three levels; consultant orthopaedic surgeon, resident surgeon with more than 2 years of operative experience, and resident surgeon with less than 2 years of operative experience.

Describe control (treatment/procedure/test):

After an initial plaster-of-Paris applied for pain relief for 1 week, buddy strapping was applied over the proximal phalanges of the little and ring fingers, and the patients started active exercises.

Length of follow-up:

1 year

Loss-to-follow-up:

Intervention N (%): 5 (12%)

Reasons: not reported

Control N (%): 3 (7%)

Reasons: not reported

Incomplete outcome data:

Intervention: not reported

Control: not reported

Outcome measures and effect size (include 95%CI and p-value if available):

Primary outcome:

QuickDASH after 1 year (median, range)

I: 0, 0-41, n.s.

C: 0, 0-25, n.s.

QuickDASH (median)

6 weeks: I 25 versus C 6, p=0.07

3 months: n.s. *

Pain at rest VAS (0-100, 0 best)

6 weeks: (n.c.) *

3 months: n.c. *

1 year: n.c. *

Pain at activity VAS (0-100, 0 best)

6 weeks: n.c. *

3 months: n.c. *

1 year: n.c. *

Use of painkiller (yes/no)

6 weeks: n.c. *

3 months: n.c. *

1 year: n.c. *

Satisfaction VAS (0-100, 100 best)

6 weeks: n.s. *

3 months: n.s. *

1 year (median, range): I 100 (25-100) versus C 97 (19-100), p=0.17

Quality of life EQ-5D-3L

6 weeks: n.s. *

3 months: n.s. *

1 year: n.s. *

Self-made questions (yes/no)

Hand function as good as before injury?

3 months (no): I 13 versus C 20, p=0.06

1 year: n.s. *

Range of motion as good as before injury?

3 months (no): I 10 versus C 21, p=0.004

1 year: n.s. *

Hand as strong as before injury?

3 months: n.s. *

1 year: n.s. *

Activities no longer able able to perform due to the injury?

3 months: n.s. *

1 year: n.s. *

Content with hand appearance?

3 months: n.s. *

1 year (no): I 1/36 versus C 7/40, p=0.06

ROM in both little fingers (median degrees, range)

Active flexion MP joints

3 months: n.s. *

1 year: I 75 (50-100) versus C 75 (35-100), p=0.99

Flexion deficit MP joints

3 months: n.s. *

1 year: I 5 (-10-25) versus C 5 (-3-45), p=0.14

Active extension MP joints

3 months: n.s. *

1 year: I 25 (-30-40) versus C 20 (0-40), p=0.61

Extension deficit MP joints

3 months: n.s. *

1 year: I 2 versus C 4, p=0.85

Total active motion

3 months: n.s. *

1 year: I 260 versus C 261, p=0.68

Grip strength (kg)

Median (range)

3 months: n.s. *

1 year: I 49 (29-70) versus C 49 (28-64), p=0.78

Total number of complications at 1 year:

I 19 versus C 10, p=0.02

Intervention (number of patients and type of complication):

2 complex regional pain syndrome II

2 superficial infections

2 pin migrations

1 pin bending after further injury

1 acute post-operative Dupuytren’s contracture development

1 ulnar nerve irritation

4 rotational deformity of little fingers

1 plaster wound

5 altered sensibility at 1 year

8 altered sensibility resolved at 1 year

2 cold sensitivity at 1 year

1 cold sensitivity resolved at 1 year

Control:

1 permanent pain and tenderness

1 rotational deformity of little fingers

1 pressure wound from plaster

3 altered sensibility

3 altered sensibility resolved at 1 year

3 cold sensitivity at 1 year

5 cold sensitivity resolved at 1 year

Length of sick leave working patients (median number of days, range):

I (n=35): 42, 0-406 versus C (n=35): 8, 0-65, p=0.001

Manual workers:

I (n=17): 49, 1-84 versus C (n=7): 13, 0-65

Authors’ conclusions:

• No statistically significant differences between surgical and conservative treatment.
• Overall outcome was very good.
• Small benefit of operative treatment on hand function satisfaction at 3 months, must be weighed against the risk of complications and a longer period of work disability.
• Two cases of complex regional pain syndrome II were the only major complications. Both cases were re-operated and could be linked to suboptimal surgery.

Limitations:

• few patients with angulation ≥50^o, no sub analyses possible
• 57/171 eligible patients declined participation and preferred conservative treatment
• 4 patients withdrew when allocated to intervention

Authors’ recommendation:

• conservative treatment with early mobilization for little finger metacarpal head fractures up to 45-50^o palmar angulation in the lateral view

²⁴ Strub et al., 2010

Type of study:

RCT

Setting:

Trauma centre

Country:

Switzerland

Source of funding:

Not reported

Inclusion criteria:

• Acute, closed fractures of the little finger metacarpal neck with a displacement of between 30^o and 70^o

Exclusion criteria:

• clinically obvious rotational deformity (>10^o)
• concomitant injuries
• open fractures
• intra-articulair fractures
• shaft fractures

N total at baseline:

Intervention: 20

Control: 20

Important prognostic factors²:

Age (mean, range):

I: 28, 20-44

C: 32, 21-70

Sex:

I: 95% male

C: 95% male

Potential confounding:

Manual workers:

I: 65%

C: 55%

Dominant hand injured:

I: 85%

C: 95%

Describe intervention (treatment/procedure/test):

Operative treatment within 5 days of injury. All surgery was performed under axillary plexus anaesthesia with a tourniquet. The base of small finger metacarpal was exposed through a small dorsolateral skin incision. An entry point for the K-wires was created with a drill directed distally to open the canal. Two to three K-wires were bent in the form a hockey stick at one end with an angle of 20^o. The fracture was reduces closed using the Jahss manoeuvre. Wires were driven through the medullary canal in divergent directions to separate in the metacarpal head as a flower bouquet. Skin was then close after cutting the wires proximally.

Patients were subsequently immobilized in a palmar two-finger splint for 5 days, followed by functional immobilization in a metacarpal brace. Wires were removed after 3 months.

Describe control (treatment/procedure/test):

Immobilization in a palmar two-finger splint for 5 days, followed by functional mobilization in a metacarpal brace for 5 weeks. No hand therapy was described.

Length of follow-up:

1 year

Loss-to-follow-up:

Intervention N (%): 0 (0%)

Control N (%): 0 (0%)

Incomplete outcome data:

Intervention: not reported

Control: not reported

Outcome measures and effect size (include 95%CI and p-value if available):

Primary outcomes:

Flexion little finger MCP-joint (degrees)

Mean (SD):

2 weeks: not reported

6 weeks: not reported

3 months: not reported

6 months: not reported

1 year: I 92 (5) versus C 93 (4), p=0.69

Extension little finger MCP-joint (degrees)

Mean (SD):

2 weeks: not reported

6 weeks: not reported

3 months: not reported

6 months:

1 year: I 6 (5) versus C 3 (5), p=0.08

Total range of motion (% of non-injured hand):

2 weeks: I 62 versus C 66

6 weeks: I 80 versus C 80

3 months: I 87 versus C 92

6 months: I 94 versus C 92

1 year: I 95 versus C 95, p=0.08

Palmar displacement (degrees):

Mean (SD)

I: preoperatively 44 (10); 1 year: 9 (11)

C: preoperatively 39 (9); 1 year: 34 (11)

Shortening small finger metacarpal (mm) Mean (SD)

I: preoperatively 2.7 (1.9); 1 year: 1.1 (1.3)

C: preoperatively 2.6 (1.5); 1 year: 2.0 (1.2)

Rotational deformities:

I: none

C: none

Pain (VAS, 0-10, 0 = no pain, 10 = maximum pain)

Mean (range)

3 months (mean): I 0.53 (0-4) versus C 0.57 (0-3)

1 year (mean): I 0.03 (0-1) versus C 0.1 (0-2)

Grip strength (kg)

Mean (SD):

1 year: I 51 (10.9) versus C 46 (8.5), p=0.22

Patient satisfaction with function:

Very satisfied: I 70% versus C 55%

Satisfied: I 25% versus C 35%

Undecided: I 5% versus C 5%

Unsatisfied: I 0% versus C 5%

Patient satisfaction with appearance:

Critique

I: complexity of treatment in relation to result (5%); scarring (5%)

C: disturbing feeling when holding a tool (25%); loss of strength during shooting (5%); loss of profile of the metacarpal head (55%)

Time off work

Mean number of weeks(range): I 6 (2-10) versus C 4.8 (1-8) (all returned to previous jobs)

Intra- and postoperative complications (number of patients and type of complication):

Intervention:

no intraoperative complications

2: presented at 3 months with K-wires almost perforating and those wires were removed.

1: delayed wound healing

1: secondary displacement of fracture

Control:

none

Authors’ conclusions:

• No statistically significant differences between surgical and conservative treatment of displaced boxer’s fractures.
• Disadvantage of surgical treatment are the higher treatment costs and the need for a secondary intervention of removal of wires. Surgery can impose complications related to surgery.

Authors’ recommendation:

• Cosmetic deformity and the difficulty of maintaining reduction after conservative treatment might be arguments for surgical treatment
• Surgical correction of fracture position seems to beneficial in manual workers with a low risk for serious complications.

^A Westbrook et al., 2008

Type of study:

Non-randomized retrospective observational study

Setting:

Medical Centre

Country:

UK

Source of funding:

Wishbone Trust of the British Orthopaedic Association

Inclusion criteria:

• Isolated closed shaft or neck fractures of the little finger metacarpal bone
• at least 2 years prior to inclusion

Exclusion criteria:

• additional fractures
• significant soft tissue injuries
• complete step-off of the two main fracture fragments

N total at baseline:

Intervention: 44

Control: 218

Important prognostic factors²:

Age at injury (mean, SD):

I: 30, 15

C: 30, 12

Sex:

I: 77% male

C: 83% male

Potential confounding:

Manual workers:

I: 43%

C: 44%

Dominant hand injured:

I: 86%

C: 79%

Neck fractures:

I: 41% (N=18)

C: 48% (N=105)

Shaft fractures:

I: 61% (N=26)

C: 52% (N=113)

Describe intervention (treatment/procedure/test):

Operative treatment with fracture reduction and fixation (plates or K-wires).

Describe control (treatment/procedure/test):

Treatment by early mobilisation or temporary immobilisation in a plaster for pain relief.

Length of follow-up:

2 years

Loss-to-follow-up:

Intervention N (%): 38 (46%)

Reasons: untraceable

Control N (%): 1062 (83%)

Reasons: untraceable

Incomplete outcome data:

Intervention:

N (%)

Reasons (describe)

Control:

N (%)

Reasons (describe)

Outcome measures and effect size (include 95%CI and p-value if available):

Fractures of the neck:

Hand grip (kg)

Mean (SD) and % of other hand (SD):

I 41 (10), 99% (12) versus C 44 (12), 102% (12)

Little finger strength

% contribution of injured little finger (SD) and % of contralateral little finger (SD)

I 16 (3) and 15 (4) versus C 14 (4) and 14 (5), n.s.

Clinical measurements of metacarpal malunion

Loss of longitudinal length

Mean (SD):

I 2.2 (1.7) v C 2.2 (1.8), n.s.

Amount of palmar shift of the metacarpal head:

Mean (SD):

I 2.6 (1.5) v C 2.8 (2.6), n.s.

DASH (0-100, 0 = no disability, 100 = complete disability)

I versus C, n.s. (no means reported)

SportsDASH:

I versus C, n.s. (no means reported)

Subject’s opinion on appearance (1=normal - 5=very unsightly)

Median (range)

I 3 (1-5) versus C 2 (1-4), ns

Fractures of the shaft:

Hand grip (kg)

Mean (SD) and % of other hand (SD):

I 41 (9), 102% (11) versus C 40 (14), 100% (15)

Little finger strength

(% contribution of injured little finger (SD) and % of contralateral little finger (SD)

I 15 (4) and 16 (5) versus C 15 (4) and 15 (4), n.s.

Clinical measurements of metacarpal malunion

Loss of longitudinal length (mm):

Mean (SD):

I 1.5 (1.8) v C 2.1 (1.9), n.s.

Amount of palmar shift of the metacarpal head (mm):

Mean (SD):

I 1.6 (1.8) v C 3.6 (2.3), p=0.0001

DASH (0-100, 0 = no disability, 100 = complete disability) (median, range)

I 5 (1-44) versus C 3 (0-39), p=0.001 in favour of C

SportsDASH (median, range):

I 4 (4-20) versus C 4 (4-10), p=0.009 (authors’ own remarks on the direction are opposite)

Subject’s opinion on appearance (1=normal - 5=very unsightly) (median, range)

I 3 (1-5) versus C 2 (1-4), p=0.013 in favour of C

Complications operative group

Type of operation, number of patients and type of complication.

Plating (n=27):

2 superficial infections; 4 had plates removed, 1 of them developed reflex sympathetic dystrophy; 2 persistent loss of MCP-joint flexion.

Retrograde K-wire fixation (n=7):

All had wires removed, 4 as result of infection; 1 rotational malunion.

Authors’ comment:

Comparing fractures with ≥30^o deformation (I n=13 versus C n=26) showed no statistically significant differences.

Authors’ conclusions:

Comparison of the fractures of the little finger metacarpal neck that had been treated non-operatively with those that had been treated operatively revealed no differences in functional or aesthetic outcomes.

Shaft fractures that were treated non-operatively had better aesthetic and DASH, though worse SportsDASH scores than the comparative group that had been treated operatively.

Operative fixation can produce complications that are deleterious to the final outcome and does not necessarily improve the perceived outcome.

Authors’ recommendation:

Non-operative treatment for almost all little finger metacarpal neck fractures and the majority of little finger metacarpal shaft fractures.

Study reference

Study characteristics

Patient characteristics

Intervention (I)

Comparison / control (C)

Follow-up

Outcome measures and effect size

Comments

³² Zong et al., 2016

Individual study characteristics deduced from Strub et al., 2010 and Sletten et al., 2014). Please refer to “Evidence table for intervention studies” for details on study characteristics.

SR and meta-analysis of RCTs

Literature search up to October 2015

A: Strubben et al., 2010

B: Sletten et al., 2014

Study design: RCT

Setting and Country:

Medical University, China

Source of funding:

No funding

Inclusion criteria SR:

• Adults >18 years
• acute, closed, little finger metacarpal neck fractures
• evaluation of RCTs of at least 2 medical interventions
• reported results of postoperative complications

Exclusion criteria SR:

• pathological fracture
• concomitant hand fractures
• comparison of two different conservative treatments.

6 studies included

Please refer to “Evidence table for intervention studies” for details on study characteristics.

Describe intervention:

Please refer to “Evidence table for intervention studies” for details on the intervention.

Describe control:

Please refer to “Evidence table for intervention studies” for details on the control.

End-point of follow-up:

A: 1 year

B: 1 year

For how many participants were no complete outcome data available?

(intervention/control)

A: none

B: none

Outcome & Effect:

Please refer to “Evidence table for intervention studies” for details on outcome measures and effects of the individual studies.

Total complications rate

Pooled effect (network meta-analysis) statistically significant:

OR 0.32 (95% CI 0.13 to 0.79) favoring conservative treatment.

Brief description of author’s conclusion

The network meta-analysis supports conservative treatment with less total complication rates.

Personal remarks on study quality, conclusions, and other issues (potentially) relevant to the research question

Level of evidence: GRADE (per comparison and outcome measure) including reasons for down/upgrading

Sensitivity analyses (excluding small studies; excluding studies with short follow-up; excluding low quality studies; relevant subgroup-analyses); mention only analyses which are of potential importance to the research question

Heterogeneity: clinical and statistical heterogeneity; explained versus unexplained (subgroupanalysis)

Study reference

Study characteristics

Patient characteristics ²

Intervention (I)

Comparison / control (C) ³

Follow-up

Outcome measures and effect size ⁴

Comments

Pace, 2015

Type of study:

Retrospective analysis

Setting:

query of the

electronic medical record for all patients managed at

a single tertiary care center for fifth metacarpal neck fractures between 2004 and 2014.

Country:

USA

Source of funding:

Not mentioned

Inclusion criteria:

Exclusion criteria:

Patients were excluded

if they were younger than 18 years at the time

of their initial presentation, if they had multiple

metacarpal fractures, if the fracture was open, if there

was rotational deformity after attempted reduction, or

if the fracture was ultimately treated surgically.

Subjects were also excluded if they had incomplete

medical records regarding their care or inadequate

radiographic images.

N total at baseline:

Intervention: 23

Control: 43

Important prognostic factors²:

For example

age ± SD:

I: 36

C: 35

Sex:

I: 78% M

C: 74% M

Reductions were obtained through a Jahss maneuver

after hematoma block. An ulnar gutter orthosis in

the ‘intrinsic-plus’ position was used, unless the treating

resident determined metacarpophalangeal joint extension

with a 3-point mold was the position of greater

stability.

Patients treated without reduction were

placed in an ulnar gutter orthosis with the fingers in

the ‘intrinsic-plus’ position. Orthoses were converted

to similar casts or maintained until healing if otherwise

fitting well.

Length of follow-up:

Mean follow-up was 34 days (35 days in intervention group and 34 days in control group)

Loss-to-follow-up:

No loss to follow-up

Incomplete outcome data:

All data were complete

Outcome measures and effect size (include 95%CI and p-value if available):

Fracture angulation reduction from baseline to final follow-up

I: 4° (49° at baseline (40° at initial follow-up) and 45° at final follow-up)

C: 1° (46° at baseline and 45 at final follow-up)

P= 0,16

Study reference

(first author, year of publication)

Bias due to a non-representative or ill-defined sample of patients?¹

(unlikely/likely/unclear)

Bias due to insufficiently long, or incomplete follow-up, or differences in follow-up between treatment groups?²

(unlikely/likely/unclear)

Bias due to ill-defined or inadequately measured outcome ?³

(unlikely/likely/unclear)

Bias due to inadequate adjustment for all important prognostic factors?⁴

(unlikely/likely/unclear)

Cepni et al., 2016

Unlikely

Likely: follow-up is short

Likely / unclear: blinding not reported

Likely / unclear: no adjustment for prognostic factors

Westbrook et al., 2008

Unlikely

Likely: percentage of patients lost to follow-up is large

Likely / unclear: blinding not reported

Unlikely: results for relevant subgroups reported separately

Study reference

Study characteristics

Patient characteristics

Intervention (I)

Comparison / control (C)

Follow-up

Outcome measures and effect size

Comments

Dunn, 2015

SR of 5 RCT’s.

Literature search up to 2015

A: Braakman, 1998

B: Statius Muller, 2003

C: McMahon, 1994

D: Hansen, 1998

E: Kuokkanen, 1999

Source of funding: not reported

Inclusion criteria:(1) prospective, randomized design; (2) treatment of metacarpal neck fractures; and (3) 2 treatment groups involving splinting versus soft wrap. Soft wrap techniques in this study included buddy taping or soft wrap. Either self-adherent wrap or silk tape was used for soft wrap, and all of these techniques are referred to as “wrap” for simplicity.

Exclusion criteria:

(1) non-English-language translation22; (2) any review, technique article, biomechanical study, or case series without a control group; (3) any study with unclear methods1; (4) operative management; and (5) any study that included a fracture brace in lieu of a splint

N, mean age

A: 50 patients, 26,1 y

B: 35 patients, 29 y

C: 42 patients, NR

D: 59 patients, NR

E: 29 patients, 29 y

Splint with (E) or without reduction (A/B/C/D)

Soft wrapping

Endpoint of follow-up:

Average follow-up: 13 weeks

A: 24 weeks

B: 12 weeks

C: 3 weeks

D: 12 weeks

E: 12 weeks

For how many participants were no complete outcome data available?

Not stated

No outcome measures were stated. Only stated which treatment favored on range of motion (ROM), strength and other outome scores for the individual studies.

This study has limitations. It included a limited number of patients with inconsistent and irregular follow-up. Each study used different outcome variables, making it impossible to combine data.

Heins & Heins, 2008

SR of 4 RCT’s and 1 SR

A: Braakman, 1998

B: Statius Muller, 2003

C: Kuokkanen, 1999

D: Sorensen, 1993

E: Poolman, 2005`

Source of funding: not reported

Inclusion:

This review was confined to randomized trials and systematic reviews of randomized controlled trials that specifically compared outcomes of treatment of distal fifth metacarpal fractures, comparing splint immobilization to early mobilization in patients of all ages.

Exclusion

Any patient with a distal metacarpal fracture that needed operative management was excluded. Only studies describing fractures of the first, second, third or fourth metacarpal joint were excluded.

Number of participants:

A: 50

B: 35

C: 29

D: 133

E: 253

Splint immobilization

Early mobilization

Endpoint of follow-up:

Average follow-up: 13 weeks

A: 24 weeks

B: 12 weeks

C: not stated

D: not stated

E: not stated

For how many participants were no complete outcome data available?

Not stated

No outcome measures and effect sizes were stated.

The author offers the following recommendation: in ED patients with closed, nondisplaced fractures of the fifth metacarpal bone, not angulated more than 70° and not requiring surgical treatment, the nurse practitioner should provide functional treatment with taping or compression bandage or glove.

Poolman, 2005

SR of 5 RCT’s

A: Anand, 1999

B: Braakman, 1998

C: Harding, 2001

D: Kuokkanen, 1999

E: Statius Muller, 2003

Source of funding: not reported

Inclusion:

All randomised and quasi-randomised controlled trials which compare functional treatment with immobilization for closed fifth metacarpal neck fractures. For practical reasons we decided to include children and adolescents where the original studies had done so

Exclusion

-

Number of participants:

A: 60

B: 50

C: 73

D: 29

E: 40

Immobilization (plaster cast with immobilization of the MCP and wrist joints)

Functional treatment(functional taping or compression bandage)

Endpoint of follow-up:

Average follow-up: 13 weeks

A: 3 months

B: 6 months

C: 3 weeks

D: 3 months

E: 3 months

For how many participants were no complete outcome data available?

15

Comparison 1: Functional (taping) versus immobilization (POP splinting with immobilization of MCP and wrist joint)

Comparison 2: Functional (compression bandage) versus immobilization (POP splinting with immobilization of

MCP and wrist joint)

Comparison 3: Functional (neighbour strapping) versus functional brace (bracing with free movement in MCP and

wrist joint).

Comparison 4: All functional versus all immobilization treatment

Patient satisfaction

(% not fully satisfied at follow-up)

Comparison 1: totals not selected

Comparison 2 (n=84): risk ratio (95% CI): 0,75 (0,23-2,49)

Comparison 3: totals not selected

Comparison 4 (n=132): risk ratio (95% CI): 0,89 (0,46-1,69)

Not satisfied with cosmetic appearance:

Comparison 2: totals not selected

Comparison 3: totals not selected

Comparison 4: totals not selected

Decreased range of Motion

Comparison 1:

1 week follow-up: not estimable

3-6 weeks follow-up: not estimable

Final follow-up: not estimable

Comparison 2:

3-6 weeks follow-up (n=35): risk ratio (95% CI): 0,9 (0,34 -2,40)

Final follow-up (3 months) (n=84): risk ratio (95% CI): 0,75 (0,16-3,50)

Comparison 4

1 week follow-up (n=48): risk ratio (95% CI): 0,46 (0,25-0,84)

 3-6 weeks follow-up (n=83): risk ratio (95% CI): 0,25 (0,01 -8,36)

Final follow-up (3 months) (n=132): risk ratio (95% CI): 0,65 (0,16-2,60)

Loss of grip strength

Comparison 1: 3-6 week follow-up: not estimable

Final follow-up: : not estimable

Comparison 4: 3-6 week follow-up: not estimable

Final follow-up: : not estimable

Pain

Comparison 2: totals not selected

 3-6 week follow-up: not estimable

Final follow-up: not estimable

Comparison 4: totals not selected

3-6 week follow-up: not estimable

Final follow-up: not estimable

Not returned to work

Comparison 2:

3-6 week follow-up: up (n=35): risk ratio (95% CI): 0,75 (0,05 -11,05)

Final follow-up (n=84): not estimable

Comparison 4:

3-6 week follow-up: up (n=35): risk ratio (95% CI): 0,75 (0,05 -11,05)

Final follow-up (n=84): not estimable

Radiological non union (3 months)

Comparison 2: (n=29); not estimable

the CONSORT guideline for publishing of RCTs was not followed by any author. Few studies described treatment or control groups in detail and most employed the sealed envelope method of allocation concealment, which is considered sub-optimal. Blinding of treatment providers was accepted to be impossible, but blinding of outcome assessors, which was possible, was only performed by Kuokkanen 1999 and Statius Muller 2003. No study clearly described the number or reason for patient exclusion prior to randomization, and follow-up proved a major handicap in three included studies. Patients with Boxer’s fractures are known for poor compliance with follow-up arrangements (Hall 1987). However, the data should be subject to intention to treat analysis. Of the 163 participants in the three studies mentioned, 15 participants (9%) were lost to follow-up and not analysed in the treatment group assigned. Sensitivity analysis of these studies would not have allowed conclusions of particular treatment benefits to have been drawn.

Study reference

Study characteristics

Patient characteristics ²

Intervention (I)

Comparison / control (C) ³

Follow-up

Outcome measures and effect size ⁴

Comments

Hofmeister, 2008

Prospective randomized study

Country: USA

Source of funding:

Not mentioned

Inclusion

All skeletally mature patients with an acute (less than 7 days old) isolated fracture of the fifth metacarpal neck seen in the acute fracture clinic were invited to participate.

Exclusion criteria patients who had a history of metabolic bone disease, an open fracture, concomitant tendon injury, additional fractures of the ipsilateral extremity, open physis, neurologic involvement, or inability to return for follow-up care.

N total at baseline:

Intervention: 40

Control: 41

Important prognostic factors²:

For example

age ± SD:

Mean age: 25 (range 16-49 y)

Sex

I:100% M

C: 98% M

A hematoma block using 5 mL 1%lidocaine without epinephrine (Hospira Inc., Lake Forest, IL) was performed, and 4.5 kgf of longitudinal traction on the small and ring fingers was applied via finger traps for 10 minutes followed by a closed reduction maneuver of stabilizing the proximal metacarpal segment, flexing the MCP and PIP joints in 90° of flexion to relax the deforming intrinsic muscles and tighten the collateral ligaments, and applying an upward dorsal force to the flexed PIP joint with a concurrent palmar force on the dorsal proximal metacarpal. The casts were then applied: Intervention group: Short-arm cast with volar outriggers (SAC-VOR)

Same procedure as intervention group, but different type of cast:

comparison: Short-arm cast extended to the proximal interphalangeal joint with a 3-point mold (MCP-ext).

Follow-up:

1 week, 4 weeks and 3 months after initiation of treatment.

Loss-to-follow-up:

No loss to follow-up

Incomplete outcome data:

All data were complete

Outcome measures and effect size (include 95%CI and p-value if available):

Postreduction angulation plane (postreduction AP – final AP)

I: 5° - 12°

C: 14° - 22°

P=0,636

Postreduction angulation lateral (postreduction lateral– final lateral)

I: 23° - 26°

C: 21° - 27°

P=0,372

Initial DASH

I: 36

C: 34

P=0.734

1 week DASH

I: 36

C: 36

P=0,754

4 week DASH

I:35

C: 29

P=0,341

3 month DASH

I: 8

C: 9

P=0,981

Final MCP-joint range of motion:

I:loss of 7° of extension

C: loss of 1° of extension

P=0,118

Final PIP joint range of motion

I: loss of 2° of extension

C: loss of 3° of extension

P=0,686

Final grip strength

I: loss of 3,31 kg

C: loss of 1,09 kg

P=0,291

Braakman et al., 1998

Type of study: prospective randomized trial

Setting:

Orthopaedic Casualty Department

of the Maasland Hospital, Sittard

Country: Netherlands

Source of funding:

Not mentioned

Inclusion:

Only fractures with less than four fragments

were included.

Exclusion

Two tape group patients were excluded because they

did not attend the six-month follow-up session

N total at baseline:

Intervention: 25

Control: 23

Important prognostic factors²:

Mean age:

I: 26,6 (range 14-40)

C: 25,5 (range 15-44 y)

Sex: 90% Male

Fracture location:

Proximal:

I: 2

C: 1

Midshaft

I: 3

C: 3

Distal:

I: 18

C: 17

Combination

I: 2

C: 2

Cast

ulnar gutter plaster-cast for a period of four weeks. The ulnar gutter cast was applied with the wrist in 45” dorsiflexion, the MCI’ joints in 90” flexion and the P-joints in O-10” flexion. The cast surrounding the fourth and fifth metacarpals was U-shaped.

Tape

tape for a period of four weeks. The tape was applied to splint the fourth digit against the fifth one, thus preventing rotational deformity. A broad circular strap was supporting the metacarpals

Follow-up

1 week, 4 weeks, 3 months and 6 months

Loss to follow-up

Two tape group patients were excluded because they

did not attend the six-month follow-up session

Incomplete outcome data

No incomplete outcome

Extension deficit

1 week

I (n=19): max 30°, mean 12,5°

C: (n=8): max 12°, mean 2,7°

4 weeks

I (n=11): max 36°, mean 8,2°

C: (n=0): mean 0

3 months

I (n=6): max 12°, mean 2,1°

C: (n=0): mean 0

6 months

I (n=0): - mean 0

C: (n=0): mean 0

Flexion deficit

1 week

I (n=11): max 26°, mean 4,9°

C: (n=2): max 5°, mean 0,4°

4 weeks

I (n=4): max 10°, mean 0,8°

C: (n=0): mean 0

3 months

I (n=2): max 6°, mean 0,2°

C: (n=0): mean 0

6 months

I (n=1): max 5°, mean 0,2-

C: (n=0): mean 0

The restoration of pulling strength was significantly better in the tape group after one and four weeks (P<0,001). The 50 per cent recovery limit of power-grip and pulling strength was reached within four weeks in every patient of the tape group, compared with 52 per cent of the patients treated by plaster cast. The tape group also showed better performance after three months. After one week and four weeks all torque strengths were significantly better in the tape group (P<0,01) with the exception of the one week pronation strength.

P values after 4 weeks (in favour of the tape group)

Power grip: 0,0001

Pulling strength: 0,0012

Pronation: 0,0001

Supination: 0,0001

Volar-flexion: 0,0008

Dorsi-flexion: 0,0029

In regards to pulling strength variables, only p-values were reported (not percentages).

Statius Muller et al., 2003

Type of study: prospective randomized trial

Setting:

Department of Surgery, Sint Lucas Andreas Hospital,

Country:

Netherlands

Source of funding:

Not mentioned

Inclusion:

All subcapital MC-V fractures

Exclusion

those angulated more than 70°, older than 3 days, re-fractures, pathologic fractures and fractures with a rotation deformity, were included.

N total at baseline:

I: 15

C: 20

Mean Age: 29 y (range 15-84)

Sex: 95% male

Ulnar gutter cast

The ulnar gutter cast was applied with the wrist in 45° dorsiflexion and the metacarpal joints in 90° flexion. The cast was U-shaped and surrounded the fourth and fifth metacarpals

Pressure bandage

The pressure bandage was applied to splint the fourth and fifth metacarpals together with a broad circular bandage from the metacarpal level to 10 cm above the wrist. The patients were encouraged to move the fingers immediately and they removed the bandages after 1 week.

Follow-up

6 and 12 weeks

Loss to follow-up

Five patients who had a plaster treatment were lost to follow-up and excluded.

Incomplete outcome data

Range of motion (ROM)

(% good (flexion limit of maximally 10°) and % moderate (flexion 10°-35°))

6 weeks follow-up:

I: 67% good, 33% moderate

C: 70% good, 30% moderate

RR 0,95, 95% CI: 0,6-1,5

12 weeks follow-up

I: 93% good, 7% moderate

C: 95% good, 5% moderate

RR 0,98, 95% CI: 0,8-1,2

Pain (%good and % moderate)

6 weeks follow-up:

I: 87% good, 13% moderate

C: 70% good, 30% moderate

RR 0,81, 95% CI: 0,6-1,1

12 weeks follow-up

I: 93% good, 7% moderate

C: 95% good, 5% moderate

RR 0,98, 95% CI: 0,8-1,2

Satisfaction (%good and % moderate)

6 weeks follow-up:

I: 60% good, 40% moderate

C: 60% good, 40% moderate

RR 1,0, 95% CI: 0,6-1,7

12 weeks follow-up

I: 80% good, 20% moderate

C: 80% good, 20% moderate

RR 1,0, 95% CI: 0,7-1,4

Return to work

6 weeks follow-up:

I: 93%

C: 95%

12 weeks follow-up:

I: 100%

C: 100%

McMahon et al., 1994

Type of study: prospective randomized controlled trial

Setting:

John Radcliffe Hospital, Oxford

Country:

United Kingdom

Source of funding:

Not mentioned

Inclusion:

Patients 18-80 years presenting with unilateral fresh closed stable fractures of the shaft of a single finger metacarpal. Stable fractures were defined as those which were displaced less than 50% of the width of the shaft, angulated less than 40° and which showed an angle of over 60° between the plane of the fracture and the axis of the shaft.

Exclusion

N total at baseline:

I: 21

C: 21

Mean Age:

I: 27 y

C: 35

Sex: 95% male

Immobilization in a plaster splint

A palmar plaster slab was applied over padding, extending form the proximal forearm to the finger tips with the PIP joints extended ant the MP joints flexed as far as pain would allow. Patients were instructed to elevate the hand. The splint was removed, and the patient given instruction on active exercises of the hand at the first clinic review, which was between 6 and 13 days after injury.

Compression glove and early mobilization

A Lycra compression glove of size 3, 4 or 5 was applied to the injured hand so that the glove was snug without compromising the circulation at the wrists or digits. Patients were advised to elevate the hand and to move the wrist and digits within the limits imposed by pain. The glove was removed, and the patient given instruction on active exercises of the hand at the first clinic review, which was between 6 and 13 days after injury.

Follow-up

2, 3 and 4 weeks

Loss to follow-up

No loss to follow-up

Incomplete outcome data

No incomplete outcome

Mean loss of flexion

Week 1

I: 84° (±33°)

C: 56° (±26°)

P=0,0036

Difference 28° (95% BI 10-46)

Week 2

I: 46° (±23°)

C: 23° (±17°)

P=0,0010

Difference 23° (95% BI 10-35)

Week 3

I: 23° (±19°)

C: 15 (±17°)

P=0,15

Difference 8° (95% BI -3-20)

Mean loss of active flexion

The difference in flexion loss during week 2 was due mainly to a smaller loss of IP joint movement in the glove group; de difference in the MP joint movement was small. During week 3, the difference between the groups was apparent in all three joints.

Patients with metacarpal shaft fractures were included, not subcapital fractures. No specific data were given on which metacarpal was fractured

Hansen & Hansen, 1998

Type of study: prospective randomized study

Setting:

Department of Orthopaedics, Odense University Hospital

Country:

Denmark

Source of funding:

Not mentioned

Inclusion:

Patients with fractures of the necks of the ring or little metacarpals

Exclusion:

Patients with palmar angulation of more than 60°, lateral deviation or rotational deformity were not included in the study.

20 patients (19%) were excluded, as they did not fulfil the inclusion criteria or did not attend follow-up visits.

N total at baseline:

I: 30

2: 26

3: 29

Mean Age:

Not reported

Sex: not reported

Group 1: plaster-of-Paris splint

Group 1 was treated with a ulnar plaster-of-Paris form proximal interphalangeal joint to elbow, with the hand in the ‘safe position’ and including the ring and little finger

Group 2: functional brace

Group 2 was treated with a functional brace made of Hexalite

Group 3: elastic bandage

Group 3 was treated with an elastic bandage alone

Follow-up:

4 weeks and 3 months

Loss-to-follow-up:

20 patients (19%)

Incomplete outcome data:

All data were complete

Pain during 4 weeks treatment (VAS (0-10))

Group 1: 1,5 (range 0-4)

Group 2: 1,8 (range 0-5)

Group 3: 2,7 (range 0-6)

P<0,05

Median restriction of MCPJ movement at 4 weeks

Group 1: 20° (range -10-60)

Group 2: 0° (range -5-20)

Group 3: 10° (range -30-50)

P<0,05

Median restriction of MCPJ movement at 3 months

Group 1: 0° (range -10-35)

Group 2: 0° (range 0-20)

Group 3: 10° (range 0-45)

P<0,05

Patient satisfaction

Group 1:

Fully satisfied: 14 (54%)

Satisfied: 10 (38%)

Dissatisfied: 2 (8%)

Group 2:

Fully satisfied: 15 (60%)

Satisfied: 9 (36%)

Dissatisfied: 1 (4%)

Group 3:

Fully satisfied:13 (46%)

Satisfied: 14 (50%)

Dissatisfied: 1 (1%)

Not significant

Describes fourth and fifth metacarpal fractures.

Sorensen, 1993

Type of study: prospective randomized study

Setting:

Odense University Hospital

Country:

Norway

Source of funding:

Not mentioned

Inclusion:

Patients with fractures of the second through the fifth metacarpal bones, presented between October 1988 and November 1989

Exclusion:

Patients with fractures that necessitated operative treatment according to the usual practice of the department.

N total at baseline:

I: 68

C: 65

Mean Age:

Not reported

Sex:

I:83,8% male

C: 84,6% male

Plaster cast

The plaster cast was applied as a dorsoulnar cast with the MCP and proximal interphalangeal (PIP) joints of the involved and the adjacent digits immobilized. The hand was bandaged in the safe position.

Metacarpal brace

The Galveston metacarpal brace is a U-shaped plastic brace with a movable crossbar and three pads, which effect a three-point fixation of the fracture, thereby freeing the wrist and fingers for a full range of motion (ROM). The bandage was available in three sizes and the strap was adjustable, which made it possible to accommodate different hand sizes and to accommodate the hand as the swelling decreased. Patients were instructed not to remove the brace but were allowed to adjust the Velcro strap so the brace was well fitting but not uncomfortable.

Follow-up:

1 week, 4 weeks and 3 months

Loss-to-follow-up:

At 3 month follow-up 95 patients were examined and 38 patients were interviewed by phone.

Incomplete outcome data:

13 patients from the plaster cast group (2 due to secondary operative treatment and 11 due to not arriving at the arranged clinical controls of removal of the cast) and 38 from the brace group (2 due to secondary operative treatment and 13 due to not arriving at the arranged clinical controls of removal of the brace, 17 due to pressure complications and 6 due to loss-fitting brace) did not complete the treatment.

Fracture angulation

Time of injury:

I: 15° (0-45)

C: 21° (0-60)

P=0,05

After brace/cast removal

I: 10° (0-45)

C:11° (0-45)

P = not significant

Rotatory dislocation after 4 weeks

I: 0

C:0

Rotatory dislocation after 3 months

I: 2

C: 1

Superficial pressure marks after cast/brace removal (% of patients)

I: 7%

C: 15%

Not significant

Reduced mobility after cast/brace removal (% of patients)

I: 31%

C: 4%

P=0,01

Reduced mobility after 4 months

I: 0%

C: 0%

Depression of the metacarpal head after three months (n)

I: 5

C: 6

Pain after 3 months (n)

I: 3

C: 1

Patient satisfaction (% satisfied/very satisfied)

I:72%

C: 89%

P= not significant

A significant percentage of patients did not complete the treatment.

Kuokkanen, 1999

Type of study: prospective randomized study

Setting:

Department of orthopaedic surgery, Päijät-Häme Central Hospital, Lahti,

Country:

Finland

Source of funding:

Not mentioned

Inclusion

Patients with subcapital fractures of the fifth metacarpal bone.

Exclusion

Fractures angulated by more than 70° or fractures with pronounced deviation or rotation deformity or open fractures.

N total at baseline:

I: 15

C: 14

Mean Age:

I: 27 (11-60)

C: 30 (13-68)

Sex:

I: 80%

C: 100%

Median angulation of fracture

I: 35° (range 10-55)

C: 48° (range 35-60)

P=0,002

Reposition and splinting

Fracture was first anaesthetised by local infiltration before reposition. The fracture was reduced and splinted as described by O’Brien. The metacarpophalangeal (MCP) joint was immobilised in 60° of flexion and the splint reached to the level of the proximal interphalangeal joint (PIP) leaving the joint free for movement. The reduction was radiographically controlled and the fracture was repositioned if the dislocation was not corrected. The duration of the splinting was four weeks.

Functional treatment

An elastic bandage 5cm wide was applied circumferentially with slight compression from the MCP level tot 10cm above the wrist. The patients were encouraged to move the fingers immediately and they removed the bandages after one week.

Follow-up:

4 weeks and 3 months

Loss-to-follow-up:

No loss to follow-up

Incomplete outcome data:

All data were complete

Range of Movement (ROM)

MCP

4 weeks:

I: 57° (range 10-100)

C: 81° (range 45-90)

P=0,02

3 months

I: 90° (range 80-95)

C: 90° (range 80-95)

P= not significant

Range of Movement (ROM)

PIP

4 weeks:

I: 85° (range 65-100)

C: 95° (range 85-105)

P=0,01

3 months

I: 96° (range 90-100)

C: 95° (range 90-100)

P=not significant

Radiographic angulation

4 weeks

I: 30° (range 10-50)

C: 42° (range 20-60)

3 months

I: 29° (range 10-50)

C: 42° (range 20-60)

Grip force (kg, fractured hand/healthy hand)

4 weeks

I: 21 (range 10-50)/ 34 (range 18-54)

C: 37 (range 20-54)/44 (range 25-72)

P=0,002

3 months

I: 36 (range 26-54)/ 41 (range 22-59)

C: 49 (range 30-69)/51 (range 30-74)

P=0,07

Complications

No soft-tissue complications were recorded in any patient during the study

Study

First author, year

Appropriate and clearly focused question?¹

Yes/no/unclear

Comprehensive and systematic literature search?²

Yes/no/unclear

Description of included and excluded studies?³

Yes/no/unclear

Description of relevant characteristics of included studies?⁴

Yes/no/unclear

Appropriate adjustment for potential confounders in observational studies?⁵

Yes/no/unclear/not applicable

Assessment of scientific quality of included studies?⁶

Yes/no/unclear

Enough similarities between studies to make combining them reasonable?⁷

Yes/no/unclear

Potential risk of publication bias taken into account?⁸

Yes/no/unclear

Potential conflicts of interest reported?⁹

Yes/no/unclear

Dunn, 2016

No

Note: No PICO or explicit research question was formulated, the purpose was stated: ‘The purpose of this systematic review was to determine whether reduction and splint or cast immobilization is necessary for fractures of the fifth metacarpal neck.’

Yes

Yes

Yes

Not applicable

Yes

No

No

No

Poolman, 2005

Yes

Yes

Yes

Yes

Not applicable

Yes

No:

Note: different interventions were compared (brace, splint, plaster compared to tape or compression bandage). , I² = 82.7%

No

No

Heins & Heins 2008

Yes

Yes

Unclear

No

Not applicable

Yes

No

No

No

Study reference

Study characteristics

Patient characteristics

Intervention (I)

Comparison / control (C)

Follow-up

Outcome measures and effect size

Comments

Yammine and Harvey, 2013

SR and meta-analysis of 1 RCT and 3 QRTs

Literature search up to May 2013

A: Facca, 2010

B: Fujitani, 2012

C: Winter, 2007

D: Wong, 2006

Source of funding: not reported

Inclusion criteria: randomized controlled trials (RCTs) and quasi-randomised trials (QRTs) comparing the efficacy of AIMN technique to all other surgical modalities in the treatment for fifth metacarpal neck fractures. AIMN technique refers to the insertion of one or more intramedullary nails.

N, mean age

A: 38 patients, 32,1 y

B: 30 patients, 30,5 y

C: 36 patients, 31,4 y

D: 59 patients, 22,5 y

Gender (% male)

A: 89%

B: 87%

C: not reported

D: 92%

Presurgical angle

A: >45°

B: >30°

C: 30°

D: >30°

Antegrade intramedullary nail (AIMN)

Plates (A&B) or transverse pinning (C&D)

Endpoint of follow-up:

Not stated

For how many participants were no complete outcome data available?

Not stated

Effects on pain, functional scores, grip strength, total active motion, (TAM), ROM of the metacarpo-phalangeal joint (MCPJ), complications, patient satisfaction, radiological outcomes

Pain

The pooled result of 133 patients

showed better pain score with the use of AIMN but without reaching significance (-0.18, 95 % CI -0.528 to 0.154, p = 0.2, I2 = 0 %).

functional scores

Only one study reported data on functional scores after treatments. Facca et al. did not find a significant difference in the mean QuickDASH scores between AIMN and plates.

Grip strength (GS)

Two studies comparing AIMN and plates reported results on GS at 3–6 months (A/B). The pooled estimate of 68 patients yielded a difference in grip strength in

favor of plating without reaching significance (-0.28, 95 % CI -0.773 to 0.204, p = 0.2, Q: p = 0.016). Three studies reported results on GS at 12 months (B/C/D). The pooled estimate demonstrated significant differences in favor of AIMN (0.84, 95 % CI 0.468 to 1.206, p\0.0001, I2 = 54.5 %).

Total active motion (TAM)

Four studies (A/B/C/D) reported TAMvalues. Two studies (C/D) comparing AIMN and TP reported TAM values in degrees with SD values; the MA showed a significant difference where AIMN yielded better results than TP at 12 months (pooled effect size = 0.5, 95 % CI 0.087 to 0.904, p = 0.01, Q: p = 0.316).

ROM of the metacarpo-phalangeal joint (MCPJ)

One study (A) demonstrated a significant difference (p = 0.001) where the AIMN group yielded better results than the plate group at less than 6 months of follow-up. Three studies (B/C/D) reported values of the ROM of the MCPJ at 12 months. The random-effects pooled size of 1.45 was significant in favor of AIMN (95 % CI 0.787 to 2.106, p\0.0001, I2 = 55.9 %).

Complications

The MA showed that the AIMN technique yielded fewer complications (OR 0.4, 95 % CI 0.155 to 1.028, p = 0.05, I2 = 0 %).

Patient satisfaction

One study (C) investigated patient satisfaction where 15 out of 16 (94 %) of those who received AIMN were satisfied or very satisfied, whereas 13 out of 17 (76.5 %) who have been treated with TP expressed the same satisfaction levels.

Radiological outcomes

The mean residual angulation at the site of fracture was reported in three studies (A/B/C) the pooled effect size of -0.4 (95 % CI -0.779 to 0.000042, p = 0.05, I2 = 0 %) was in favor of AIMN. Only one study (B) reported the mean shortening in millimeter after interventions with no significance between AIMN and plate.

Despite the limitations of this review, we found some evidence that the AIMN technique could have advantages over the use of plates and transverse pinning in the treatment for the fifth metacarpal neck fractures. The quantitative analyses indicated probable better efficacy of AIMN particularly in relation to GS, TAM, active ROM of the fifth ray and residual angulation.

Study reference

Study characteristics

Patient characteristics

Intervention (I)

Comparison/ control (C)

Follow-up

Outcome measures and effect size

Comments

Moon et al., 2014

Type of study:

Retrospective review

Setting:

a single institution

Country:

Korea

Source of funding:

Not stated

Inclusion criteria

1) Patients of any age with closed extra-articular distal metacarpal fractures; 2) no previous fractures in the same hand; 3) rotational deformity of more than 5°; 4) lateral angulation of more than 50° for the small finger and 40° for the index, long, and ring fingers; and 5) complete displacement of the fracture with no other associated injuries.

Important characteristics:

N (mean age)

I: N= 19, 28 y (range 15-49)

C: N= 22, 34 y (range 19-71)

Sex

I: 74% M

C: 86% M

Fracture locations (n)

2^nd metacarpal:

I: 0

C: 1

3^rd metacarpal

I: 2

C: 2

4^th metacarpal

I: 3

C: 2

5^th metacarpal

I: 13

C: 17

Intramedullary nail (IMN) fixation

Percutaneous K-wire fixation

Length of follow-up:

Mean:

I: 11 weeks

C: 15 weeks

Loss-to-follow-up:

No loss to follow-up

Preoperative angulation (°)

I: 48° (20°-74°)

C: 41° (0°-82°)

P= not significant

Postoperative angulation (°)

I: 4.2° (0°-6°)

C: 5.6° (0°-8°)

P= not significant

Preoperative shortening (mm)

I: 8.1 mm (0-19)

C: 7.7 mm (0-17)

P= not significant

Postoperative shortening (mm)

I: 0.9 mm (0-4)

C: 0.5 mm (0-3)

P= not significant

Radiographic healing (weeks)

I: 5.4 weeks

C: 5.2 weeks

P= not significant

Loss of reduction (n)

I: 0

C:0

P= not significant

Early (5 wk) Total Active Motion (TAM) of the digit (°)

I: 225°

C: 135°

P=<0,001

Late (10 wk) TAM of the digit (°)

I: 250°

C: 245°

P= not significant

Period to return to work (wk)

I: 5.5 weeks

C: 7.9 weeks

P=0,024

Complications:

Pin site infection (n)

I: 0

C: 3

Mean Visual analog scale score

I: 9

C: 21

Discomfort by K-wire exposure (n)

I: 0

C: 11

Hand dorsum swelling (n)

I: 0

C: 9

Wong et al., 2006

Type of study:

Non-randomized controlled clinical trial

Setting:

Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital

Country:

Hongkong, China

Source of funding:

Not stated

Inclusion criteria:

all patients with

closed fractures of the metacarpal neck of the little finger, the so-called ‘Boxer’s fracture. All fractures with more than 30° angulation

Exclusion criteria:

Patients with an angular deformity less than 30°, a rotational deformity less than 15°, an open fracture, a pathological fracture, concomitant hand fractures and patients who refused surgery.

Important characteristics:

N (mean age)

I: N= 30, 22 y (range 15-35)

C: N= 29, 23 y (range 14-30)

Sex

I: 90% M

C: 93% M

Intramedullary K-wires

For intramedullary K-wire insertion, a small transverse incision was made over the dorsoulnar aspect of the metacarpal base, the medullary cavity was entered through a small drill hole and pre-bent K-wires were hammered gently to extend as far as the subchondral bone of the metacarpal head. The K-wires were cut beneath the skin.

Postoperatively, all patients followed a standard rehabilitation programme. They were put in a metacarpal brace, or flexor wrist POP, for 2 weeks. All patients started gentle mobilization exercise, with the help of hand physiotherapists, 2 days after surgery. Heavy exertion was avoided for at least 2 months after the surgery. Transverse K-wires were removed at 4 to 6 weeks under local anaesthesia. Bouquet technique wires were not removed.

Percutaneous transverse fixation

For percutaneous transverse fixation, two K-wires were inserted distal to the fracture site from the ulnar side of the little finger metacarpal into the ring finger metacarpal, with or without a third transverse K-wire inserted proximal to the fracture. The K-wires were either left protruding through the skin or buried under the skin.

The postoperative process was the same as the intervention group.

Length of follow-up:

Mean:

I: 24 months (range 12-36)

C: 24 months (range 12-36)

Loss-to-follow-up:

No loss to follow-up

Total active motion (TAM),

I: 257 (± 9,7) (range 240-270)

C: 250 (±22,2) (range 150-270)

P=0,1

Grip strength (% of normal side)

I: 97 (±3,6) (range 90-100)

C: 95 (±4,9) (range 80-100)

P=0,1

Visual analogue scale (VAS) score

I: 1,3 (±0,6) (range1-3)

C: 1,4 (±0,7) (range1-3)

P=0,6

Complications (N)

I: 1 (3,3%) (K-wire migration)

C: 1 (3,3%) (Stiffness)

Radiological union (N)

I: 30 (100%)

C: 29 (100%)

Radiological union time (weeks)

I: 10 (±3,4) (range 6-16)

C: 10 (±3,2) (range 6-16)

P=0,8

Winter et al., 2007

Type of study:

Prospective comparative randomised study

Setting:

Not reported

Country:

France

Source of funding:

Not stated

Inclusion criteria:

recent, isolated, closed and simple fracture of the neck of the little finger metacarpal bone.

Exclusion criteria:

Open fractures and fractures extending to the metacarpal shaft, or to the articular surface, were excluded from the study. Patients presenting with multiple injuries, fifth metacarpal malunion and selfinflicted

injuries were not included in the study.

Important characteristics:

N (mean age)

I: N= 18, 30,8 y (range 18-65)

C: N= 18, 32 y (range 20-49)

Sex

I: 100% M

C: 100% M

Intramedullary pinning (the ‘Bouquet’ technique)

Three K-wires, of diameter 1mm were used. These wires were contoured in order to obtain a 201 distal angulation. A small incision was made at the level of the carpometacarpal joint. After drilling a hole in the base of the little finger metacarpal, the wires were introduced into the metacarpal shaft. The distal angulation of the first wire was oriented dorsally. The two other wires were oriented in a radial and an ulnar direction, respectively. Clinical and X-rays checks of the adequacy of fracture fixation and the rotational position of the finger were carried out. The K-wires were then bent, cut and buried subcutaneously.

The postoperative procedures were equal in both groups.

Transverse pinning

Two K-wires of diameter 1.5mm were used. The first K-wire was introduced through the ulnar border of the hand and passed from the little to the ring metacarpal shaft, approximately 10mm proximal to the fracture. After reduction, the second K-wire was introduced through the ulnar border of the hand and passed from the little to the ring metacarpal head, avoiding the articular surfaces. This second wire was passed parallel to the first. The position of the finger in extension and flexion was then examined to check the rotation. Final clinical and X-ray checks of the adequacy of fracture fixation and the rotational position of the finger were carried out. The K-wires were then cut and buried subcutaneously

Length of follow-up

Mean follow-up was 2.7 (range 2–3) months.

The two groups were comparable in terms of follow-up duration.

Loss-to-follow-up:

No loss to follow-up

Total active motion (TAM)

I: 279° (±11,9)

C: 261° (±36,5)

P=0,02

Active ROM of the metacarpophalangeal (MCP) joint

I: 94° (±5,9)

C: 81,5° (±19,4)

P=0,0037

Percentage of contralateral grip strength

I: 92%

C: 83%

P=0,06

Pain (VAS)

I: 0

C: 0,3

P= not significant

Malrotation of the little finger:

I: 0

C: 0

P= not significant

Residual palmar angulation (N, mean)
I: 7 (8°, range 5-15°)

C: 5 (10°, range 5-20°)

Fujitani et al., 2012

Type of study:

Prospective review

Setting:

Not reported

Country:

Japan

Source of funding:

Not stated

Inclusion criteria:

The primary indication for surgical treatment in this study was unstable fractures with a dorsal angulation of more than 30

Exclusion criteria:

We excluded patients with open fractures associated with soft tissue injury. Patients younger than 14 years were excluded.

Important characteristics:

N (mean age)

I: N= 15, 28 y (±13, range 16-59)

C: N= 15, 33 y (±8, range 17-53)

Sex

I: 87% M

C: 87% M

Intramedullary nail:

Under Bier’s block and pneumonic tourniquet, fractures were reduced by the Jahss technique, which applies dorsal force to the distal fragment with the metacarpophalangeal and proximal interphalangeal joints fully flexed. Two Kirschner wires with a diameter of 1.2 mm were then inserted through a small incision at the metacarpal base, resembling ‘‘flower bouquets’’ of divergent wire tips. Kirschner wires were bent and cut off beneath the skin. Postoperatively, a protective splint was applied for 3 weeks, and wires were removed in all patients after the bone union

Low profile plate

A lazy dorsal curved incision at the metacarpal head was made, and the extensor tendon was retracted to the radial side. The low profile plate was placed on either the dorsal or the lateral surface of the metacarpus. After the plate fixation, the periosteum was sutured to allow tendon gliding. Passive and active finger motion was allowed 3 days after the surgery. No brace was used during a postoperative course

Length of follow-up

Follow-up was 12 months

Loss-to-follow-up:

Not stated

Average period to bone union:

I: 2.3 months

C: 2.0 months

P= not significant

Average palmar tilt angle

I: 16°

C: 16°

P= not significant

Average lateral tilt angle

I: 10°

C: 10°

P= not significant

Average shortening

I: 1,5 mm

C: 0,7 mm

P= not significant

Complications

I: n=2 (extensor tendon rupture, and transient neuritis of the dorsal ulnar nerve)

C: n=1 (transient neuritis of the dorsal ulnar nerve)

Grip strength:

3 months:

I: 67%

C: 86%

P=0,02

6 months

P=0,30

12 months

P=0,74

Total active motion (TAM)

% TAM at the 3 months follow-up in the patients with intramedullary nails showed a significant increase compared to the plate fixation group (p = 0.01). No significant differences between the two groups were found at 6 and 12 months postoperatively (p = 0.28, p = 0.17, respectively)

% metacarpophalangeal joint

motion

at 6 and 12 months of postoperative periods showed a significant increase in the patients with intramedullary nail compared to those with plate fixation (p = 0.03, p = 0.01, respectively). No significant differences between the two groups were found at 3 months (p = 0.13)

Facca et al., 2010

Type of study:

Continuous prospective comparative study

Setting:

Orthopedic and Hand Surgery Dept, SOS Hand Group Practice, Strasbourg University Hospitals

Country:

France

Source of funding:

Not stated

Inclusion criteria:

Only closed, isolated, displaced fifth metacarpal neck fractures were included. Surgery was indicated for > 45◦ metacarpal head displacement and/or impaired distal fragment rotation on long-digit flexion.

Exclusion criteria:

Recurrent, open and/or multiple metacarpal fractures were excluded, as were cases of multiple fracture or multiple trauma.

Important characteristics:

N

I: N= 20

C: N= 18

Mean age: 32.1 y

Sex

I: 85% M

C: 94% M

Preoperative metacarpal head displacement

I: 53°

C: 48,9°

P=0,022

Intramedullary K-wires

a point approach was made facing the base of the fifth metacarpal bone and a thin square pick was used to prepare the entry for the pre-shaped osteosynthesis wire. A K-wire of 1.6mm or 2mm diameter was introduced exactly up to the fracture site, using a hand-drill, and reduction was performed by the Jahss maneuver. The intramedullary wire was then inserted under visual control up to the cancellous bone of the metacarpal head, to stabilize the osteosynthesis. Postoperative immobilization was maintained by splint for 6 weeks in the ‘intrinsic-plus’ position, leaving the wrist free. Patients were seen at weeks 1 and 3 for control X-ray. The wire was ablated in ambulatory surgery under local or locoregional anesthesia at around week 7, followed by rehabilitation if necessary, and patients were regularly followed up thereafter.

Locking plate

a longitudinal dorsal approach was performed facing the fifth metacarpal axis. The dorsal cutaneous branch of the ulnar nerve and the fifth ray extensor apparatus were drawn aside, and the periosteum was incised to access the fracture site. Screws were positioned in the distal fragment of the metacarpal bone, and reduction was performed, using the plate as lever. The proximal screws were then positioned to stabilize osteosynthesis. The titanium plates (Aptus Hand®, MédartisTM) were fixed with 2 mm-diameter locked screws. The same distal T plate design was used in all 18 fractures. There was no postoperative immobilization, and active mobilization was encouraged as soon as the locoregional anesthesia was stopped during the evening following surgery. Patients were seen again 2 weeks postoperatively for suture ablation, control X-ray and prescription of rehabilitation if necessary, and then regularly followed up.

Length of follow-up

Mean follow-up differed:

I: 3.3 months

C: 4.8 months

Loss-to-follow-up:

No loss to follow-up

Pain (VAS)

I: 0,9/10

C: 0,94/10

P=1,00

QuickDASH

I: 9,8/55

C: 15,9/55

P=0,109

Relative wrist strength

I: 92,9%

C: 88,4%

P=0,782

fifth ray metacarpophalangeal active flexion mobility

I: 97,7%

C: 58,7%

P=0,001

fifth ray metacarpophalangeal extension flexion mobility

I: 99%

C: 89,3%

P=0,05

Time off work (29 working patients)

I: 8,1 weeks

C: 7,4 weeks

P=not significant

Fifth metacarpal head flexion displacement on 3/4 view

Preoperatively

I:34,6°

C: 48,9°

P=-0,022

immediate postoperative

I:10°

C: 11,3°

P=0,342

Final follow-up

I:24,8°

C: 28,1°

0,306

Mean difference between immediate postoperative and last follow-up

I: 14,2°

C:16,7°

P=0,484

Complications

I: 7

C: 6

Wong et al., (2015)

Type of study:

retrospective comparative study

Setting:

Department of Hand Surgery, Singapore General Hospital

Country:

Singapore

Source of funding:

Not stated

Inclusion criteria:

All patients who underwent

either DP or TB wiring for 5th MC neck fractures.

Exclusion criteria:

Patients with concomitant

fractures and open fractures.

Important characteristics:

I: N= 41

C: N= 43

Mean age: 33.5 y (range 16-74)

Sex: 85% MALE

Tensionband wiring

Dorsal plating with low profile titanium plate

Length of follow-up

Mean follow-up 6,2 months (range 0,4-27,6)

Loss-to-follow-up:

Not stated

Fracture angulation

Preop

I: 40,8°

C: 38,3°

p=0,5

Post-op

I: 14,9°

C: 11,4°

p=0,06

Improvement (preop-postop)

I: 25°

C: 26,5°

P=0,8

Radial Unlar displacement

Preop

I:0,90 cm

C:1,26 cm

p=0,9

Post-op

I: 0,45 cm

C: 0,36 cm

p=0,3

Improvement (preop-postop)

I: 0,53 cm

C: 0,89 cm

P=0,2

MC Height ratio

Preop

I:0,77

C:0,73

p=0,5

Post-op

I: 0,77

C: 0,80

p=0,2

Improvement (preop-postop)

I: 0,003

C: 0,067

P=0,0003

Range of Motion

Preop

I: 50,7°

C: 32,7°

p=0,001

Post-op

I: 70,6°

C: 69,9°

p=0,8

Improvement (preop-postop)

I: 16,1°

C: 41,7°

P=0,006

Pain score

Preop

I: 1,5

C: 1,2

p=0,2

Post-op

I: 0,6

C: 0,4

p=0,7

Improvement (preop-postop)

I: 0,56

C: 0,51

P=0,7

Study reference

(first author, year of publication)

Bias due to a non-representative or ill-defined sample of patients?¹

(unlikely/likely/unclear)

Bias due to insufficiently long, or incomplete follow-up, or differences in follow-up between treatment groups?²

(unlikely/likely/unclear)

Bias due to ill-defined or inadequately measured outcome ?³

(unlikely/likely/unclear)

Bias due to inadequate adjustment for all important prognostic factors?⁴

(unlikely/likely/unclear)

Moon et al., 2014

Likely

The fixation type was based on surgeon preference.

Unclear

Mean follow-up:

I: 11 weeks

C: 15 weeks

Unclear

Note: outcome measures were not defined

Unclear

Facca et al., 2010

Unlikely

Note: The first 18 patients were managed by locked plate (group I), and the next 20 by intramedullary K-wire (group II). As the study was continuous, group-I patients were operated on 6 months before group II.

Likely

Note: Mean follow-up differed, at 4.8 months in group I and 3.3 months in group II.

Unlikely

Unclear

Fujitani et al., 2012

Unlikely

Note: Since 1996–2002, 15 consecutive patients underwent intramedullary nail fixations, and 15 consecutive patients from 2002 to 2006 had low-profile plate fixations.

Unclear

Note: loss to follow-up not stated

Unclear:

Note: it is not stated if the persons who evaluated the x-ray of the hand were blinded.

Unclear

Winter et al., 2007

Unclear

Note: the study was of a consecutive series of patients.

Unlikely

Note: Mean follow-up was 2.7 (range 2 to 3) months. The two groups were comparable in terms of follow-up duration.

Unclear:

Note: it is not stated if the persons who evaluated the x-ray of the hand were blinded.

Unclear

Wong et al., 2006

Likely

Note: The decision as to which operative procedure was carried out depended on the on-call schedule, with one surgeon always

performing one operation and the second surgeon always carrying out the other operation.

Unclear:

Note: only those patients with at least 1 year follow-up were included in the study

Unclear:

Note: it is not stated if the persons who evaluated the radiographs of the hand were blinded.

Unclear

Wong et al., 2015

Likley

Note: Choice of surgical treatment depended on surgeon predilection

Unclear

Note: Mean follow-up was 6,2 months (range 0,4-27,6 months). It was not stated if follow-up differed between groups.

Unclear:

Note: it is not stated if the persons who evaluated the radiographs of the hand were blinded.

Unclear

Study

First author, year

Appropriate and clearly focused question?¹

Yes/no/unclear

Comprehensive and systematic literature search?²

Yes/no/unclear

Description of included and excluded studies?³

Yes/no/unclear

Description of relevant characteristics of included studies?⁴

Yes/no/unclear

Appropriate adjustment for potential confounders in observational studies?⁵

Yes/no/unclear/not applicable

Assessment of scientific quality of included studies?⁶

Yes/no/unclear

Enough similarities between studies to make combining them reasonable?⁷

Yes/no/unclear

Potential risk of publication bias taken into account?⁸

Yes/no/unclear

Potential conflicts of interest reported?⁹

Yes/no/unclear

Yammine,

2013

Yes

Yes

No

Note: no reasons for excluded studies

Yes

Not applicable

Yes

Yes

No

No