Non-operative vs Surgical Treatment of Isolated Non-Thumb Metacarpal Shaft Fractures

Description

Research Objectives:

The goal of this study is to compare the treatment of outcomes for the nonoperative vs. surgical treatment of isolated closed acute non-thumb metacarpal shaft fracture.

1. Primary Measure: i. Functional outcome: Patient Reported Outcomes, including VAS, PROMIS, DASH (Pre-Op, 2 weeks, 6 weeks, 3 months, 6 months) b. Secondary Measures: i. Grip Strength (6 weeks, 3 months, 6 months) ii. Extensor Lag (degrees) (Pre-Op, 2 weeks, 6 weeks, 3 months, 6 months) iii. Composite range of motion (pulp to palm distance) (Pre-Op, 2 weeks, 6 weeks, 3 months, 6 months) iv. Radiographic metacarpal shortening (at each visit) v. Malrotation (scissoring/gapping) (Pre-Op, 2 weeks, 6 weeks, 3 months, 6 months) vi. Timing of clinical union (lack of tenderness on palpation or stress) vii. Timing of radiographic union (bony bridging across fracture site)

Study Design:

1. Patients will be identified in clinic after x-rays are positive for a non-thumb metacarpal fracture. If they consent to participate in the study, they will be put into either the non-operative or surgical group. This decision will be done through randomization, and the physician will not select which group the patient is in.
2. Pre-operatively, the patient will have the following standard of care procedures:
3. Patient reported outcomes, including the PROMIS forms and Visual Analog Scale (VAS),
4. Radiographic measurement of metacarpal shortening
5. Range of Motion Measurements
6. Malrotation (scissoring/gapping) measurement
7. Pre-operatively, the patient will have the following procedures as research only:
8. Disabilities of the Arm, Shoulder and Hand survey (DASH)
9. Surgical Treatment vs. Non-Surgical Treatment Groups
10. For non-operatively addressed scissoring injuries: Closed reduction in clinic/ER and placement of short-arm cast; immediate full range active range of motion (AROM) with buddy taping to adjacent digit. Focus on achieving pulp-to palm distance of <2cm at first visit. Transition to removable short arm splint at week 2 (discontinue at 6 weeks or when non-tender). Strengthening after clinical union.
11. For non-operatively addressed non-scissoring injuries: Placement of short-arm cast; immediate active range of motion (AROM) with buddy taping to adjacent digit. Focus on achieving pulp-to palm distance of <2cm at first visit. Transition to removable short arm splint at week 2 (discontinue at 6 weeks or when non-tender). Strengthening after clinical union.
12. For surgical fixation: The surgeon will utilize either pinning, dorsal plate, or lag screws. This will be determined by surgeon expertise while intra-op. Postoperative volar short arm splint, immediate active range of motion (AROM) at full range with buddy taping to adjacent digit. Transition to removable short arm splint at week 2 after suture removal. No strengthening until clinical union.
13. Post-operatively, the patient will have the following standard of care procedures at the 2 week, 6 week, 3 month and 6 month time points:
14. Patient reported outcomes, including the PROMIS forms and Visual Analog Scale (VAS)
15. Radiographic measurement of metacarpal shortening
16. Range of Motion Measurements
17. Malrotation (scissoring/gapping) measurement
18. Grip Strength (at 6 week, 3 month, and 6 month follow-ups only)
19. Notation of timing of clinical union based upon the lack of tenderness on palpation or stress
20. Notation of the timing of radiographic union, based on bony bridging across the fracture site
21. Post-operatively, the patient will have the following research only procedures at the 2 week, 6 week, 3 month and 6 month time points:
22. Disabilities of the Arm, Shoulder and Hand survey (DASH)
23. Treatment failure is defined as non-union. Patients may be removed from the study if they are unable to comply with post-operative requirements, or if their injuries are found to be more complex than the study allows for.
24. If patients are removed from the study prematurely, their treatment will continue as standard of care with their attending physician.

Potential Risks:

A potential risk of this treatment is that a patient will experience a non-union or malunion. This is a normal risk of non-thumb metacarpal fracture.

Details