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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

1. 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.
2. Kjaer-Petersen K, Langhoff O, Andersen K. Bennett's fracture. J Hand Surg (Br) 1990;15(1):58-61.
3. Livesley PJ. The conservative management of Bennett's fracture-dislocation: a 26-year follow-up. J Hand Surg (Br) 1990;15(3):291-4.
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.
5. 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.
6. 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.