Abstract
Purpose
To investigate the functional outcomes and complications of operatively managed carpometacarpal (CMC) fracture dislocations, excluding the thumb, in a young, active population.
Methods
A retrospective chart review of all patients undergoing surgical treatment for CMC joint injuries at a single institution over a 6-year period was performed. Patients were excluded if they had a first CMC joint injury, were under 18 years old, or had incomplete documentation. Injury radiographs were categorized as simple/extra-articular, partial articular, and complete articular. Electronic health records were searched for demographic information, mechanism, associated injuries, time to surgery, time to union, time to return to full-activity, complications, and need for revision surgery. QuickDASH (Disabilities of Arm, Shoulder, and Hand) and Patient-Reported Wrist Evaluation scores were collected at final follow-up.
Results
A total of 160 patients were included in the study, of which 89% were male. Punching was the most common mechanism of injury. Combined fourth and fifth CMC fracture dislocations and isolated fifth CMC fracture dislocations encompassed 90% of the injury patterns seen. Combined fourth and fifth CMC joint injuries had an associated distal carpal row fracture 54% of the time. There was a 29% complication rate. Complications related to K-wires made up 55% of the total complications. Final follow-up was obtained on 45/160 patients (28%). The median final QuickDASH score was 11.4 (range, 0–45.5), with 65% of patients meeting the patient acceptable symptomatic state. Median Patient-Reported Wrist Evaluation score of 18.5 (range, 0–67.5) with 76% meeting the patient acceptable symptomatic state. Among the 133 active-duty military patients included, 79/133 (59%) remained on active-duty at a median of 3.3 years after surgery.
Conclusions
Despite relatively high surgical complication rates, operative management of CMC fracture dislocations results in good-to-excellent functional outcomes.
Type of study/level of evidence
Differential diagnosis/system prevalence study III.
Key words: Carpometacarpal joint, Hamate fracture, Metacarpal base fracture
Carpometacarpal (CMC) joint fracture dislocations are uncommon, with limited published outcome data. Inadequately identified or treated CMC injuries can have considerable clinical consequences, including chronic hand pain, decreased grip strength, proximal migration of the metacarpal base, dorsal prominence, and post-traumatic arthritis.1,2 The role of nonsurgical management in these injuries is unclear. A few case series have published acceptable results with nonsurgical management when appropriate treatment is initiated within 2 weeks of injury.3, 4, 5, 6, 7
In general, surgical intervention is recommended to prevent secondary dislocation and restore grip strength.5 Although specific surgical indications are debated, prior works have reported acceptable results with a myriad of operative methods. These studies, though, are generally limited by their small cohort sizes, and limited follow-up.2,5,8, 9, 10, 11, 12, 13, 14, 15 Lee et al10 reported on 29 patients with intra-articular fifth metacarpal base fractures who underwent surgical treatment with either closed reduction and percutaneous pinning (CRPP) or open reduction and internal fixation (ORIF). They found that all patients had satisfactory Disabilities of Arm, Shoulder, and Hand (DASH) scores (6.1 [± 11.4] and 4.3 [± 8.3] [CRPP vs ORIF]), with over 90% grip strength compared to the contralateral side at a median follow-up time of 41 months (12–81 months). Gülabi et al15 reported on 15 patients with fourth and fifth CMC fracture dislocations treated with either CRPP or open reduction and percutaneous pinning (ORPP) at a mean follow-up of 20.3 and 23.8 months, respectively. They found a mean QuickDASH (Disabilities of the Arm, Shoulder, and Hand) score of 9.1 (± 2.4) and 13.6 (± 3.2) for the CRPP and ORPP groups, respectively, with a statistically significant (65.8 ± 3.7 vs 75.2 ± 6.1) decrease in grip strength in the ORPP group when compared to the CRPP group.
The purpose of this study was to describe a cohort of young, active patients who sustained operatively treated CMC joint fracture dislocations, and report functional outcome data. We hypothesized patients would report excellent hand function with few residual symptoms. The primary outcome of this study was to look at patient-reported outcome scores (QuickDASH and Patient-Reported Wrist Evaluation [PRWE]) regarding operatively treated CMC joint fracture dislocations. The secondary outcome of this study was to look at return to duty rates following operative management of CMC joint injuries.
Materials and Methods
Following approval from our institutional review board, the Military Analysis and Reporting Tool was used to query the Military Health System Data Repository for all patients who underwent operative management of a CMC joint fracture-dislocation (Current Procedural Terminology codes 26608, 26615, 26746, 25645, 25635, 26670, 26675, 26676, 26685, and 26686) at our institution from October 1, 2016 to October 31, 2023. Patients were included if they sustained a second to fifth CMC joint injury (fracture, dislocation, or fracture-dislocation), were treated operatively, and had clinical and radiographic data available for review. Patients were excluded if they sustained a first CMC joint injury, underwent revision of prior fixation performed at another facility, were under 18 years old, or had incomplete documentation available for review. Investigation performed at Naval Medical Center Portsmouth, Portsmouth, VA.
The initial query yielded 354 potentially eligible patients. Following manual chart review, 194 were excluded, leaving 160 patients that met inclusion criteria (Fig. 1).
Figure 1.
Inclusion and exclusion criteria. CPT, Current Procedural Terminology.
Electronic medical records of all included patients were reviewed for age at time of injury, hand dominance, injury mechanism, nicotine/tobacco usage, active-duty status, rank at time of injury (if active-duty military), associated injuries, time from injury to operative intervention, type of surgical procedure performed, time to union, time to return to full-activity or active-duty status, and postoperative complications. Injury radiographs were evaluated for fracture characteristics (metacarpals involved, presence of comminution, associated carpal fractures, and presence of dislocation or subluxation). Fractures were categorized as simple dislocations or extra-articular fractures, partial articular fractures, or complete articular fractures.
Patients were contacted via telephone to complete a supplemental questionnaire (Supplemental Document S1, available online on the Journal’s website at https://www.jhsgo.org.), QuickDASH, and the PRWE. Patients were categorized as meeting versus not meeting published values for the patient acceptable symptomatic state (PASS) for both the QuickDASH (<15.9) and PRWE (<30).16,17 Associations between meeting the PASS for both surveys were determined using chi-square/Fisher’s exact testing and Mann-Whitney U testing, as appropriate.
Surgical technique
Following informed consent, all procedures were performed under general and/or regional anesthesia. Closed reduction was attempted, and where necessary, open reduction was performed through a direct dorsal approach to the affected CMC joint. Care was taken to protect the dorsal ulnar cutaneous nerve. A dorsal capsulotomy was used as needed to address articular displacement. Following reduction, fracture fixation typically consisted of trans-articular K-wire fixation of the involved CMC joint, augmented by transverse fixation of the unstable metacarpals to adjacent stable metacarpals (1.1 mm [0.045 in] to 1.6 mm [0.062 in] diameter wires). Supplemental subchondral K-wire fixation was used to stabilize articular impaction of metacarpal bases or carpals, most commonly of the fifth metacarpal or hamate, when needed (0.7 [0.028 in] to 1.1 mm diameter wires). Allograft bone grafting was used in the presence of considerable bone loss. After surgery, all patients were immobilized in a forearm-based splint that extended to the proximal interphalangeal joint of the second to fifth digits (Figs. 2 and 3). At the 2-week postoperative appointment patients were transitioned to a cast or custom splint until union was achieved and pins removed, typically 4–6 weeks after surgery. Union was defined as minimal tenderness to palpation at the fracture site with radiographic evidence of healing. Time to pin removal was used as surrogate for this, as it is our standard practice to remove pins once healed. Referral to hand therapy was dictated by the nature of the individual injuries and degree of postoperative stiffness.
Figure 2.
Anteroposterior, oblique, and lateral images of a simple dislocation of the fourth and fifth metacarpal base with large hamate fracture treated successfully with CRPP.
Figure 3.
Anteroposterior, oblique, and lateral radiographs of a complete articular fifth metacarpal base fracture with dorsal subluxation of the fifth CMC joint treated successfully with CRPP.
Results
Demographics
There were 160 operatively treated CMC joint fracture dislocations included in our study (Table 1).
Table 1.
Demographic and Mechanism of Injury Information
| Demographics | Result |
|---|---|
| Average age (y) | 27.3 y (18–60) |
| Male | 89.3% (143/160) |
| Female | 10.6% (17/160) |
| Active-duty | 90% (144/160) |
| Dependent | 10% (16/160) |
| Nicotine use | Yes 38.7% (62/160), No 52.5% (84/160), Unknown 8.7% (14/160) |
| Mechanism | No. of Patients |
| Fall | 29.4% (47/160) |
| Gunshot wound | 1.9% (3/160) |
| Crush | 15% (24/160) |
| Punch | 44.4% (71/160) |
| Motor vehicle | 5.6% (9/160) |
| Unknown | 3.1% (5/160) |
| Other | 0.6% (1/160) |
CMC injury patterns
The various injury patterns are presented in Table 2.
Table 2.
Fracture Patterns Sustained With Associated Carpal Fractures
| CMC Joint Injury | No. of Patients | No. of Patients With Associated Carpal Fracture |
|---|---|---|
| Second | 2 | 0 |
| Third | 0 | 0 |
| Fourth | 3 | 2 |
| Fifth | 69 | 7 |
| Second and third | 1 | 0 |
| Fourth and fifth | 75 | 41 |
| Second, third, and fourth | 1 | 0 |
| Third, fourth, and fifth | 8 | 6 |
| Second, fourth, and fifth | 2 | 0 |
Associated injuries
Fractures of the hamate were the most common associated injury, occurring in 33% (53/160) of patients. There were 57 associated carpal fractures in 56 patients (Table 2). Other associated injuries and their mechanisms can be found in Table 3.
Table 3.
Injuries Other Than Associated Carpal Fractures and the Associated CMC Joint Fracture Pattern
| Mechanism | CMC Joint Injury | Associated Injuries |
|---|---|---|
| MVC | Type 3 fifth | Ipsilateral trans-olecranon fracture-dislocation and radial head fracture |
| GSW | Type 3 fourth and fifth, hamate | Flexor digitorum superficialis (FDS) to ring, partial flexor digitorum profundus to ring finger (10%), common digital artery laceration to 3 and 4 web spaces and ulnar digital artery to little finger, extensor digiti minimi transection, radial digital nerve transection |
| MVC | Type 3 fifth | P1 fracture little finger, femur fracture |
| MCC | Type 2 second, type 1 fourth, type 3 fifth | Multiligamentous knee injury, contralateral distal radius, Le Fort fracture, subdural hematoma, transient brain injury |
| Punch | Type 3, fourth and fifth | Distal radius and ulnar styloid fracture |
| MCC | Type 3 third, type 3 fourth, type 1 fifth, hook of hamate fracture | Superficial soft tissue wounds, fifth metacarpal head, 2–5 tuft fractures, right posterior shoulder dislocation, L2–5 spinous process fracture, R femur fracture, R great toe fracture, Left foot 2–5 metatarsal fracture and base of P1 fracture |
| GSW | Type 3 second and third | Index finger FDS 90% laceration, Common digital nerve to second web space injury, 20% partial middle finger extensor digitorim communis injury, bone loss |
| MCC | Type 2 fourth and capitate fracture | Ring finger open tuft fracture, middle phalanx ring finger comminuted fracture, middle finger amputation at PIP, radial styloid fracture |
GSW, gunshot wound; MCC, motorcycle collision; MVC, motor vehicle collision; PIP, proximal interphalangeal.
Operative management
The mean time to surgery was 14.4 days (2 to 163 days). In total, 106 patients underwent CRPP, 51 underwent ORPP/ORIF, 10 underwent ORIF and bone grafting, and 1 underwent ORIF and osteotomy because of chronicity of injury. Associated carpal treatment can be found in Table 4. Mean time to union was 6.7 weeks (4.1–22.6 weeks). All patients went onto full union. Union was defined as minimal tenderness of the fracture site with evidence of bone healing on radiographs. All patients underwent initial fixation with K-wires. One patient received a screw into their hamate fracture in addition to trans-articular K-wire pinning.
Table 4.
Surgical Management of Associated Carpal Fractures
| Carpal Fracture | ORIF/ORPP | CRPP | No Hardware |
|---|---|---|---|
| Hamate | 16 | 22 | 15 |
| Capitate | 1 | 0 | 1 |
| Triquetral | 0 | 0 | 1 |
| Scaphoid | 0 | 0 | 1 |
Complications
Overall, 47/160 (29%) patients experienced a complication totaling 54 complications. The complication information can be found in Table 5.
Table 5.
Postoperative Complications
| Complication | Quantity |
|---|---|
| Overall | 54 |
| K-wire migration | 18 |
| K-wire infection | 4 |
| K-wire eroded through skin | 6 |
| K-wire tendon entrapment | 1 |
| Early K-wire removal by patient | 1 |
| Refracture of metacarpal | 3 |
| Recurrent instability | 1 |
| DUCN paresthesia | 12 |
| SBRN paresthesia | 1 |
| Contact dermatitis | 1 |
| Persistent pain | 1 |
| Post-traumatic arthritis | 1 |
| PIP joint flexion contracture | 3 |
| Skin breakdown in cast | 1 |
PIP, proximal interphalangeal; SBRN, superficial branch of the radial nerve.
Five patients underwent unplanned reoperation related to their hand. Two patients with a proximal interphalangeal joint flexion contracture underwent manipulation under anesthesia while under local anesthesia. A patient who sustained a gunshot wound underwent planned conversion to a plate with iliac crest bone graft, followed by unplanned removal of hardware for the plate. This patient also underwent a manipulation under anesthesia for intrinsic tightness. One patient with a deep pin site infection underwent irrigation and debridement with pin removal. One patient underwent revision CRPP for K-wire migration with loss of reduction.
Return to activity
All patients were cleared for full activities regarding their hand at the completion of treatment at mean 12.6 weeks (5.4–43.1 weeks) after surgery. Patients were cleared for full-activity 2 weeks after removal of hardware, unless there was an extenuating circumstance.
Of the 133 active-duty service members with adequate documentation, 79 remained on full active-duty with a median after surgery service time of 3.3 years. Of those who separated from the military, 33 did so because of planned separation at the end of their military obligation (median of 1.3 years after surgery). Eight of these reported continued hand pain.
Eight patients separated prior to the end of their obligated period because of medical reasons, one of which was related to their hand injury.
Thirteen patients separated for other reasons (administrative or legal reasons), with four reporting continued hand pain.
Patient-reported outcomes
Of the 160 included patients, 45 (28%) were able to be contacted at a median 38 months after surgery (range, 9–84). Failure to meet the PASS for QuickDASH was associated with the need for treatment of other hand injuries at the time of CMC fixation, whereas failure to meet the PASS for PRWE was associated with tobacco use (Table 6, Table 7, Table 8). Twelve out of the 45 patients (30%) contacted deployed following their surgery.
Table 6.
Outcome Summary
| Outcome | Result |
|---|---|
| Median follow-up (range-wk) | 38 (9–84) |
| Median QuickDASH (range) | 11.4 (0–45.5) |
| Met PASS for QuickDASH | 29 (64%) |
| Median PRWE (range) | 18.5 (0–67.5) |
| Met PASS for PRWE | 34 (76%) |
| Returned to duty | 38 (97%) |
| Required medical separation because of hand/wrist | 0 (0%) |
| Deployed after surgery | 12 (30%) |
| Current military status | |
| Currently on active-duty | 27 (69%) |
| Median time since surgery (range) | 36 (12–84) |
| Retired/separated at EAS | 5 (13%) |
| Median time from surgery to retirement/separation | 24 (2–60) |
| Separated early unrelated to hand injury | 7 (18%) |
| Median time from surgery to separation | 12 (1–34) |
Outcome data regarding the final cohort of 45 patient who participated in phone interviews.
Table 7.
PASS for the QuickDASH Score
| QuickDASH PASS Associations | P Value | Comments |
|---|---|---|
| Tobacco use | .49 | |
| Active-duty | .08 | |
| MOI | .3 | |
| Other UE injuries | .54 | |
| Hamate fx | .03∗ | (all hamate fractures met PASS) |
| Dominant side affected | .71 | |
| CRPP versus ORPP | 1 | |
| Concurrent surgical treatment of other UE injuries | .05∗ | (only 1/5 met PASS for those with other procedures) |
| Postoperative finger stiffness | .73 | |
| Any complication | .75 | |
| Age | .79 | |
| Time from injury to surgery | .78 | |
| Number of metacarpals fractured | .78 | |
| Number of metacarpals dislocated | .69 | |
| Time to union | .18 |
AD, active duty military; Fx, fracture; MOI, mechanism of injury; UE, upper extremity.
Statistically significant P ≤ .05.
Table 8.
PASS for the Patient-Reported Wrist Evaluation
| PRWE PASS Associations | P Value | Comments |
|---|---|---|
| Tobacco use | .03∗ | (Tobacco use less likely to meet PASS) |
| Active-duty | .31 | |
| MOI | .36 | |
| Other UE injuries | .49 | |
| Hamate fx | .24 | |
| Dominant side affected | .67 | |
| CRPP versus ORPP | .28 | |
| Concurrent surgical treatment of other UE injuries | .58 | |
| Postoperative finger stiffness | .41 | |
| Any complication | .29 | |
| Age | .74 | |
| Time from injury to surgery | .19 | |
| Number of metacarpals fractured | .75 | |
| Number of metacarpals dislocated | .28 | |
| Time to union | .12 |
Fx, fracture; MOI, mechanism of injury; UE, upper extremity.
Statistically significant P ≤ .05.
Discussion
The most important finding from our study is that patients can return to a high level of function, despite a relatively high complication rate, following operative management of their CMC joint fracture-dislocation. Even in a cohort where most patients were active-duty military personnel, return to unrestricted activity (including military duties) was the norm. Additionally, the majority met the PASS for both the QuickDASH and PRWE. This is consistent with previous reports in the literature.11,12,18
The majority of studies related to CMC joint injuries have focused on the ulnar-sided fourth and fifth CMCs.2, 3, 4, 5, 6,8, 9, 10, 11, 12, 13,15,18, 19, 20, 21, 22, 23 In general, the papers conclude that early operative intervention allows for anatomic reduction and favorable clinical and radiographic outcomes.1,15,22, 23, 24 In 2022, Fuller et al11 performed a systematic review of surgical management of ulnar metacarpal base fracture dislocations. Delayed treatment of the CMC joint injuries decreased the effectiveness of nonsurgical management, and increased likelihood of postoperative pain, chronic deformity, malunion, and CMC osteoarthritis. Decreased grip strength compared to the contralateral side was common. Zhang et al5 reviewed 20 patients with acute fourth and fifth CMC joint injuries, and six patients with subacute (>2 weeks) injuries treated nonoperatively. All patients returned to their previous level of work with normal range of motion compared to the contralateral side. At 1-year follow-up, all patients with acute injuries reported full function, and the mean Michigan Hand Outcomes Questionnaire was 98 ± 2. However, in the subacute/chronic group, 50% of patients noted visible deformity, limited range of motion, and decreased grip strength. The authors recommended ORIF for chronic presentations of CMC joint injuries. Similar to this study, early reduction of joint alignment and fracture fragments seems to be associated with optimal treatment outcomes. Lee et al10 retrospectively reviewed 29 patients who underwent either CRPP or open reduction and locked plate fixation of isolated fifth metacarpal base fractures at 1 year after surgery. In their cohort, the mean DASH score was 6.1 and 4.3 in the CRPP and locked plating group, respectively. These results are comparable to our mid-term outcomes, though our findings of decreased PASS rates with smoking and associated hamate fractures has not been previously reported.
Few studies have evaluated CMC joint injuries involving the second and third CMC joints.14,22,25, 26, 27, 28, 29, 30, 31, 32 Bushnell et al27 reviewed the management of intra-articular metacarpal base fractures and found only 22 previously reported cases of second and third metacarpal injuries. Although data on these injuries are extremely limited, a handful of prior works have reported good short-term results with operative management, though decreased grip strength may be present.24, 25, 26, 27, 28, 29, 30, 31 In our cohort, there were 11 total patients with an injury involving the second or third CMC joint. Unfortunately, only four could be contacted for final follow-up assessment and this study did not assess grip strength, so it remains unclear whether injuries to the second and third CMC joints differ substantially from fourth and fifth CMC injuries.
In our cohort of 45 patients who could be contacted for QuickDASH and PRWE, patients met the PASS 64% and 76% of the time with a mean score of 11.4 and 18.5, respectively. Lawlis and Gunther14 reported on the long-term follow-up of CMC joint injuries and found that the presence of pain, ulnar nerve injury, and those who had isolated injury to CMC joints of the index and middle finger had inferior outcomes in their cohort. Ulnar nerve neurapraxia and injury have been reported as potential complications of surgery at the base of the fourth and fifth metacarpal.19 Naik et al20 reported an average distance of 2.3 mm between K-wires placed at the fifth metacarpal base and the dorsal ulnar carpometacarpal nerve (DUCN) and recommended identifying and protecting the DUCN when performing ulnar-sided pinning. To avoid injury to the DUCN, Mozaffarian et al21 proposed a safe corridor for pinning on the ulnar side of the hand. Other authors have suggested avoiding penetration of the volar cortex to avoid iatrogenic injury to the deep motor branch of the ulnar nerve.19 There were no cases of ulnar nerve palsy in our study, whereas 7.5% of patients (12/160) experienced DUCN paresthesias after surgery, with all cases resolved by final follow-up. Interestingly, despite only one-third of our cases requiring open reduction, 50% of our patients who had DUCN paresthesias after surgery were treated with an open approach, which seems to contradict the recommendation that performing an open approach mitigates this risk. There are several possible explanations for this finding. Dorsal ulnar carpometacarpal nerve paresthesias from an open approach could be secondary to traction on the nerve during approach. Additionally, more challenging fracture patterns may have initially failed closed reduction attempts and secondarily converted to an open procedure.
This study does have multiple limitations. This is a single institution retrospective review, without a comparison group, which relies on the accuracy of coding diagnoses and procedures. Patient participation in the follow-up assessment at final follow-up was low, and the current symptomatology and function of the remaining patients in the cohort is unknown. The authors did try to mitigate this by examining return to active-duty military service among applicable patients as a surrogate for functional outcome. However, we recognize that this is an imperfect method, as multiple factors beyond injury recovery may play a role in the decision or ability to continue active-duty military service. Additionally, surgical indications were surgeon dependent and may have differed between surgeons, thus creating the opportunity for selection bias to impact patient outcomes and complications. The surgery performed and final pin construct/implant choice was not standardized between surgeons, which could provide a variation in quality of reduction between patients. Quality of reduction was not assessed after surgery and therefore the final outcomes were pooled together regardless of the quality of the final articular reduction. This study did not compare operative intervention to nonsurgical intervention, which the authors believe certainly has a role in the treatment of some select CMC injuries.
Despite these limitations, our data shows that operative management of these injuries, regardless of approach, number of metacarpals involved, or associated distal carpal row injuries, can achieve a good functional result. Patients can be counseled that following surgical treatment of these injuries; they can expect generally excellent function though residual symptoms are common at mid-term follow-up.
Disclaimer
The study protocol was approved by the Naval Medical Center Portsmouth Institutional Review Board in compliance with all applicable Federal regulations governing the protection of human subjects. The views expressed in this article reflect the results of research conducted by the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
I am a military service member. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.
Conflicts of Interest
No benefits in any form have been received or will be received related directly to this article.
Supplementary Data
(S1) Supplemental Document S1 is the supplemental questionnaire used to interview patients in addition to the QuickDASH and PRWE (available online on the Journal’s website at https://www.jhsgo.org).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
(S1) Supplemental Document S1 is the supplemental questionnaire used to interview patients in addition to the QuickDASH and PRWE (available online on the Journal’s website at https://www.jhsgo.org).