The patient presents with mutliple injuries including a subtalar dislocation (Figure A), femoral shaft fracture (Figure B), tibia shaft fracture (Figure C) and multiple metacarpal shaft fractures (Figure D). Multiple metacarpal shaft fractures are best managed with open reduction and internal fixation as non-operative management is associated with loss of motion, asynchronous grasp and decreased grip strength.
Souer and Mudgal retrospectively reviewed their experience treating patients with multiple metacarpal fractures utilizing hand-specific implants. They argue that rigid internal fixation of multiple metacarpal fractures allows for early mobilisation and tendon excursion, and found excellent results in 18 of 19 patients with a 230 degree total arc of motion.
Kawamura and Chung review fixation options for treating unstable oblique phalangeal and metacarpal fractures. They found low complication rates regarding tendon adhesion and stiffness with published studies examing dorsal plating of oblique metacarpal fractures as the extensor tendons are less adherent to bone at the level of the metacarpal.
Answer 2. Closed reduction and casting would lead to stiffness due to immobilization
Answer 3. External fixation would bind the extensor mechanism and would not allow for early motion
Answer 4. Immediate therapy, although beneficial, would be difficult to accomplish without rigid fixation
Answer 5. Removeable splinting would not facilitate early motion and and would likely lead to loss of metacarpal length and deformity as the stabilizing effect of the adjacent metacarpals is lost with multiple fractures
Souer JS, Mudgal CS. Plate fixation in closed ipsilateral multiple metacarpal fractures. J Hand Surg Eur Vol. 2008 Dec;33(6):740-4.
PMID:18694922 (Link to Abstract)
Kawamura K, Chung KC. Fixation choices for closed simple unstable oblique phalangeal and metacarpal fractures. Hand Clin. 2006 Aug;22(3):287-95.
PMID:16843795 (Link to Abstract)