Perioperative management - Intramedullary K-wire osteosynthesis of a subcapital fracture of the fifth metacarpal

• Palmar tilt of more than 45°
• Rotational error

• Local or general diseases that contraindicate elective surgery surgically or anesthesiologically, or are improvable preoperatively

• Clinical examination (rotation error!)
• X-ray examination of the hand, anteroposterior and strictly lateral, to determine the extent of angulation

• no special preparation of the patient necessary
• generally an outpatient procedure
• clarification of contraindication for bloodlessness (e.g., existing shunt in dialysis)

Information about:

• surgical method
• metal allergy (nickel)
• general surgical risks (wound healing disorder, functional deficit wrist/hand, CRPS)
• specific surgical risks:

1. Injury to R. dorsalis N. ulnaris with neuropathic pain - prolonged scar pain (usually subsides after 6 months)
2. insufficient correction
3. injury to the bone/joint by perforating wire, tendon injury
4. pseudoarthrosis

• intravenous regional anesthesia
• plexus anesthesia
• general anesthesia

• Supine positioning
• Positioning of the hand on a hand table
• Recommended application of upper arm tourniquet

• The surgeon should sit on the side where the leading hand points distally with the scissor tip
• An assistant may sit opposite
• The instrumenting nurse positions themselves at the head of the hand table

• It is recommended to apply an upper arm tourniquet
• Image intensifier
• A hand instrument set is used
• Special instruments: awl for opening the bone, bending pliers, metal cutter

Postoperative Analgesia

• Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management).
• Follow the link to the current guideline Treatment of Acute Perioperative and Posttraumatic Pain.
• Possibly apply cold packs as a local physical measure.

Medical Follow-up Treatment

• Regular wound inspection, elastic compression bandage (Caution: constriction!) for a few days
• Suture removal after 14 days
• Immobilization in a forearm-finger splint for 4 weeks
• Metal removal under local anesthesia after fracture consolidation (approximately 8-12 weeks)
• Release of load-bearing after metal removal

Thrombosis Prophylaxis

• not applicable

Mobilization

• immediate

Physical Therapy

• Active exercise therapy with possible physiotherapeutic support with full extension and fist closure of the fingers from the 1st postoperative day (prevents hand edema and finger stiffness).
• Specific hand therapeutic measures after the end of immobilization and movement restriction.

Dietary Progression

• not applicable

Bowel Regulation

• not applicable

Incapacity for Work

• Generally 14-21 days depending on manual activity (maximum 6 weeks).