LONG-TERM EVALUATION OF BENNETT’S FRACTURE ‘A comparison between open and closed reduction E, J. F. TIMMENGA, T. J. BLOKHUIS, M. MAAS and E. L. F. B, RAALJMAKERS From the Departments of Surgery, Division of Traumatology, Plastic Reconstructive and Hand Surgery, and Radiology. University of Amsterdam, Academic Medical Centre, Amsterdarn, The Netherlands 18 patients with Bennett’s fracture were evaluated after mean follow-up period of 10.7 years. ‘Treatment consisted of closed reduction and K-wire fixation in seven cases and open reduction with osteosynthesis in 11 cases. Overall, symptoms were few and restricted mobility of the thumb could not be demonstrated. The strength of the affected hand was decreased in all patients regardless of the type of treatment. Osteoarthritis was found to correlate with the quality of reduction ofthe fracture, but had developed in almost all cases even after exact reduction. Exact reduction, either by the open or closed method, should be the aim of treatment of Bennet’s fracture. Journal of Hand Surgery (British and European Volume, 1994) 19B: 373-377 Bennett’s fracture is an intraarticular fracture dislo- cation of the base of the first metacarpal of the hand. ‘Whether it should be treated by open or closed reduction still a subject of discussion. Exact restoration of the joint surface by open reduction should prevent the development of osteoarthritis. Joint incongruity and subsequent osteoarthritis after closed reduction, on the ‘other hand, may cause few symptoms and would hardly Justify operative treatment, ‘Cannon et al (1986) report good results of closed reduction after a follow-up period of 9.6 years. Livesley (1990) reported poor results of this method but his follow-up was much longer (26.4 years). Generally, studies evaluating open reduction produce favourable results (Gedda_and Moberg, 1953; Spingberg and Thorén, 1963; Gelberman et al, 1979; Salgeback et al, 1971; Kjaer-Petersen et al, 1990). However, follow-up periods in these studies are relatively short. The aim of this paper is to evaluate the results of the ‘open treatment of Bennett's fractures over a longer period of time and also to compare them with those of closed treatment. MATERIALS AND METHODS 30 patients with Bennett's fracture were treated at our ‘department between 1975 and 1985. 18 patients (62.1%) were available for follow-up examination and are included in this study. Seven patients with comminuted fractures were treated with closed reduction and trans- metacarpal K-wire fixation (Fig 1). II patients. with fractures involving one to three fragments (including Rolando fractures), were treated with open reduction and AO-lagscrews, AO-miniplate, K-wire pinning or 4 combination of methods, according to the judgement of the surgeon and ASIF guidelines (Fig 2). Plaster immob- ilization for a period of 6 weeks was added to the treatment in all patients in whom K-wires were used, including one case of open reduction and K-wire pin ning. The male/female ratio was 16/2 and the average age 43 years (5. =13.36) ‘At review, all patients were interviewed with regard to the function of the carpometacarpal joint of the thumb, pain and occupational and sports restrictions. ‘The base of the first metacarpal bone was examined for deformities. Palmar and radial extension of the thumb and opposition were measured and compared to the contralateral side, Grip strength was measured with a Jamar Dynamometer in both hands. The ratio between the dominant and the non-dominant hand was compared with a mean value obtained in a representative control- group, consisting of 13 healthy volunteers matched for age and various activities, including sports and profession, True lateral and postero-anterior radiographs of the first carpometacarpal joint were obtained and examined by the staff of the department of radiology in our hospital. The radiographs were compared to the pre- and post-operative radiographs of each patient Post-operative reduction was graded using the class fication by Kjaer-Petersen etal (1990) and osteoarthritic changes were graded on a scale 0 to 3 (see Tables 1 and 2). RESULTS The follow-up period varied between 7 and 16 years, (mean 10.7 years). The causes of injury were motoreyele accidents (44.4%), sporting activities (44.4%) and fights (Lt). Remarkably, the patients complained of very few symptoms and then they were mild. Six patients, three from each group (open and closed reduction) noticed the influence of cold weather (slight pain and stiffness on cold days). Three patients complained of slight pain afier long periods of work or a lengthy motorbike ride. Restricted mobility of the injured thumb, as measured by palmar abduction, radial abduction and opposition was not seen in any of our patients, in comparison with the non-injured thumb. The strength of the injured hand, however, was reduced in all patients compared to the average strength of the non-injured hands in the matched control-group. Patients with a Bennett's frac- ture showed a loss of strength of 9.3% and 10.1% in them “THE JOURNAL OF HAND SURGERY VOL. 198 No. 3JUNE 1984 Fig! (a) Comminuted Bennet’s fracture. (b) Good post-operative joint congruity following closed reduction and transmetacarpal K-wice ‘ration (6) Aft 8 sear allow p alo grade etna sen (the eg shape of he hell fhe eon acre |S result ofa subsequent fracture)BENNETT'S FRACTURE as a2 () Simple oesiagmen Benne’ race (b) Ect post-operative nt conga by ope eduction and osensyatet (6) Aer years follow ap grade I radiologeal osteoarthritis is eenv6 “Table 1—The clssitation by Kjcr-Petersen ct l (1990) of the grading ‘of post-operative rediction Gapistepof tm nicl surface (rm Eves = Good i Poor >2 “Table 2—Grading of radiographic esteoarthritc changes of the first carpo-metacarpal jit Oscourthriic changes ° ‘Absent 1 ‘Slight 2 Clear 3 Severe dominant hand and the non-dominant hand, respect- ively. Patients did not notice and, therefore, did not perceive the loss of strength as a handicap. There was no difference between open and closed reduction with regard to the reduction of strength, Table 3 shows the relation between the quality of reduction and oxteoarthritic changes. Comminuted frac- tures tend to develop more severe arthritic changes (Fig 1). Note that only three patients were listed as having a “poor” reduction, but that 16 showed osteo- arthritis to sore degree. Only two patients were free ‘of degenerative changes. Five of the seven patients who had an exact post-operative reduction showed osteoarthritic changes, one of them grade 3 (Fig 1) Nevertheless, there appears to be a correlation between the quality of reduction and osteoarthritic changes. As Table 3 shows, the correlation is significant to P<0.003 (Fisher's exact test). However, there was no correlation between osteoarthritic changes and symptomatology. The six symptomatic patients did not have more serious osteoarthritis. ‘Surprisingly, in this study there is neither a correlation between the method of treatment and arthritic changes ‘Table 3—The eelaton between the quality of pustoperative reduction and the late ostecartitc changes in Bennett's fractures, Postoperative eduction is graded wuing the classification by Kjaer-Petercn et al (1990; see Table 1) and arte changes are graded 0 (03 (see Table 2) Reduction Ostcourtvite changes Total > 8 2 3 Excellent > 4 0 4 1 Good > 8 4 oo 8 Poor » 0 0 3 3 Total 28 8S patents Pann. “THE JOURNAL OF HAND SURGERY VOL. 198 No.3 JUNE 1954 (P=0.234) nor between method of treatment and joint deformity (P= 0.245). DISCUSSION Cannon et al (1986) advocated simple closed reduction and plaster immobilization as the method of choice for treatment of Bennett's fracture. Arguments that are used to support this view are that closed reduction is simple, that it lacks the morbidity of open methods and that imperfect reduction and joint incongruity do not cause symptomatic arthritis. Many have advocated open anatomical reduction and osteosynthesis (Gedda and Moberg, 1953; Spangbere and Thorén, 1963; Gelberman et al, 1979; Salgeback et al, 1971; Kjaer-Petersen et al, 1990). Two important arguments are used to support their view. First, intraart- icular fractures at the base of the first metacarpal show a tendency to dislocate and redisiocate after reduction, asa result of the pull of abductor pollicis longus, adductor pollicis and the extrinsic extensor muscles. Secondly, the joint has a complex saddle-shape that allows motion in two planes. As a result, it is exposed to intermittent high compression forces (although it is ‘non weight-bearing joint) which make it vulnerable to degenerative osteoarthritis. The saddle-shape should therefore be restored as perfectly as possible. Osteoarthritis appears to be a slowly progressive condition. Recently, the late results of closed reduction of Bennetts fracture were published. After a remarkably long period of 26 years, Livesley (1990) found poor results in terms of symptomatic osteoarthritis. These results of closed reduction, however, cannot simply be compared with the results of open reduction, because the follow-up time periods of the latter have been much shorter. Our follow-up of operative treatment over a mean period of 10.7 years is relatively long compared to other reports. Almost all patients showed first degree osteo- arthritis, including patients who had exact reduction of their Bennett’s fracture, Salgeback et al (1971) suggested that anatomical reduction would not prevent the development of joint deformity. Nevertheless, ourstudy demonstrates a corre- lation between the quality of reduction and the develop- ‘ment of osteoarthritis, although we found no correlation between the method’ of treatment and osteoarthritis This suggests that the more severe osteoarthritis follow- ing comminuted fractures is a result of the type of injury, not of the method of reduction which was used in these cases. It also supports our policy of choosing the mode of treatment according to the type of fracture. In conclusion, the choice between open and closed reduction should be made taking into account the comminution of the fracture, the ASIF guidelines and the surgeon's own specific skills.BENNETT'S FRACTURE References CANNON, $. R, DOWD. G. §. E, WILLIAMS. D. H. and SCOTT. 1. M. 186), A fag dy flowing Ben Surgery. 118": 46-131 GEDA. KO. ant MOBERG, F. (1982) Open reduction and excosnthess ofthe soiled Bennet’ esteem the carpo-metsesrpal ont of the ‘ham. Act OndopaedcaSeandnavie 22 209 256. GELBERMAN. R-H: VANCE. Mand ZAKAIB, GS. (1979). Fracture atihe bse of he hums Treatment with obi tactoe outa of Bone find out Surgery. GIA. 2 200 202 JJAER-PETERSEN, K. LANGHOFF. O. and ANDERSEN. K. (1990 Ben's fcr outal of Hae Surgery 18. 158.61 LIVESEY. Pi (1000) The sonstrvaine magomeat of Beats rte ‘ilocton: A26yeat aioap. outa of Baad Surgery. 15B:3.291 294, i” SALGEBACK,S. EIKEN.O.. CARSTAN. N. nd OHLSSON, NM (157. ‘sey of Benatar Spec leer to Haat by percutaneous Pinning. Scundinavian Joural 9 Paste and Reconstr Serger. fares, 'SPANGBERG, 0, snd THOREN, L (1963). Hemel’ facire: A method of Tretment with blige tion. Journal ef Hand Surgery. SB 4732-76 SRETE feinetba eb, mb, Dg of asc Recnsncing an Hand Susy Ul AOWSTRinre Meh paSTN AD es ie Rear