Three Part Question
In [an adult patient with an undisplaced Bennetts' fracture] is [conservative management better than surgical management] at [minimising time to recovery and final disability]?
Clinical Scenario
A 32 year old man presents to the Emergency Department following a fight. He complains of pain around the base of the right thumb metacarpal. X-ray reveals an undisplaced Bennetts' fracture. You wonder whether he should be treated conservatively or surgically.
Search Strategy
Medline 1966-10/99 using the OVID interface.
[{exp fractures OR exp fractures, closed OR fracture$.mp} AND [({exp thumb OR thumb.mp OR first.mp} AND {exp metacarpus OR metacarp$.mp}) OR Bennett$] AND {exp emergency treatment OR exp treatment outcome OR treatment$.mp OR treat$.mp}] LIMIT to human AND english.
Search Outcome
98 papers found of which 92 irrelevant or of insufficient quality for inclusion. The remaining six papers are shown in the table.
Relevant Paper(s)
Author, date and country |
Patient group |
Study type (level of evidence) |
Outcomes |
Key results |
Study Weaknesses |
van Niekerk JL and Ouwens R, 1989, Netherlands | 12 of 23 patients with fractures at the base of the thumb metacarpal treated surgically | Retrospective survey | Limitation of activities of daily living | No limitations | Small numbers Uncontrolled |
Kjaer-Petersen K et al, 1990, Denmark | 41 patients with Bennett's fracture treated variously (9 closed reduction, 6 percutaneous K wires, 26 open reduction).
Followed up at a median of 7.3 years. | Retrospective survey | Residual symptoms | No symptoms in 15 of 18 with good reductions compared with 6 of 13 with residual displacement. | |
Livesley PJ, 1990, UK | 17 patients with Bennett's fracture treated conservatively
Followed up at a mean of 26 years. | Retrospective survey | Residual symptoms | 7 of 17 | Small numbers
Uncontrolled |
Range of movement and grip strength | Reduced in all patients |
Thurston AJ and Dempsey SM, 1993, New Zealand | 21 of 76 patients with Bennett's fracture
Followed up at a mean of 7 years 7 months | Retropective survey | Residual symptoms | Less if residual fracture displacement less than 1mm. Method of reduction immaterial | Small numbers |
Timmenga EJ et al, 1994, Netherlands | 18 patients with Bennett's fracture. Closed reduction with K wire fixation (7) vs open reduction and bone graft (11)
Followed up at a mean of 10.7 years | Retropective survey | Thumb mobility | Full in all cases | Small numbers |
Grip strength | Reduced in all cases |
Osteoarthritis | Degree correlated with the residual displacement |
Oosterbos CJ and de Boer HH, 1995, Netherlands | 20 of 22 patients with Bennett's fracture treated by closed reduction and plaster immobilisation. | Retrospective survey | Subjective outcome | Satisfactory in 18 of 20 | Small numbers
Uncontrolled |
Development of arthrosis | 7 of 20. in 6 of these original reduction had been nonanatomic |
Comment(s)
The evidence in this area is extremely poor. All studies are small and retrospective. A well designed PRCT is needed.
Clinical Bottom Line
Good initial reduction probably reduces the incidence of later arthrosis of the base of the thumb metacarpal. There is no evidence to help decide whether a conservative or a surgical approach is preferable.
References
- van Niekerk JL and Ouwens R. Fractures of the base of the first metacarpal bone: results of surgical treatment. Injury 1989;20(6):359-62.
- Kjaer-Petersen K, Langhoff O, Andersen K. Bennett's fracture. J Hand Surg (Br) 1990;15(1):58-61.
- Livesley PJ. The conservative management of Bennett's fracture-dislocation: a 26-year follow-up. J Hand Surg (Br) 1990;15(3):291-4.
- Thurston AJ and Dempsey SM. Bennett's fracture: a medium to long-term review. Aust New Zealand J Surg 1993;63(2):120-3.
- Timmenga EJ, Blokhuis TJ, Maas M et al. long-term evaluation of Bennett's fracture. A comparison between open and closed reduction. J Hand Surg (Br) 1994;19(3):373-7.
- Oosterbos CJ and de Boer HH. Nonoperative treatment of Bennett's fracture: a 13 year follow-up. J Orthop Trauma 1995;9(1):23-7.