TECHNIQUE
Application of an Antibiotic Intramedullary Nail in the Management of a Large Metacarpal Bone Defect Elliot S. Mendelsohn, MD, Tibor Warganich, MD, Evan S. Nielsen, MD, and Soheil Najibi, MD, PhD
Abstract: Contaminated wounds and infected nonunions of the hand are not amenable to primary internal fixation and grafting. Antibioticimpregnated cement intramedullary nails have been used in the lower extremity in the treatment of these fractures but have not been described in the hand. This technique combines the advantages of local antibiotic delivery with the mechanical stability afforded by an intramedullary nail. We describe an alternative technique for the management of skeletal defects in a contaminated wound bed in the hand using readily available operating room equipment. The antibiotic-impregnated cement intramedullary nail can be placed temporarily until definitive internal fixation and grafting occur. Key Words: intramedullary nail, cement, local antibiotics, bone loss, metacarpal fracture (Tech Hand Surg 2013;17: 187–191)
HISTORICAL PERSPECTIVE Comminuted fractures with segmental bone defects in the hand are typically associated with high-energy mechanisms such as gunshot wounds and open fractures. Autogenous bone grafting has been shown to be a successful technique in managing these bone defects in the hand.1–3 A contaminated and/or infected wound bed may preclude primary internal fixation and grafting. Antibiotic-impregnated cement spacers have been used for bone defects and infected nonunions of the upper extremity.4–6 The antibiotic-impregnated cement allows for local delivery of a high volume of antibiotics,7 maintains appropriate soft tissue tension, and creates a space that prevents the growth of soft tissue and can be filled with bone graft. A solid cement cylinder has been used but is not rotationally stable as it can flex and rotate out of the defect with motion. Step-bent K-wires have also been employed but mechanical stability, infection, and pin migration are potential issues. Antibiotic-impregnated cement intramedullary nails are a well-described technique for treatment of infected tibia nonunions.8 This technique combines the advantages of local antibiotic delivery with the mechanical stability afforded by an intramedullary nail. Two intramedullary metacarpal nails capable of locking have been introduced,9,10 but these nails are not impregnated with antibiotic cement. We describe an alternative method of internal fixation for a metacarpal shaft
fracture with associated bone loss using an antibioticimpregnated cement spacer in the form of an intramedullary nail. The antibiotic-impregnated cement intramedullary nail can be created using readily available operating room equipment. This is an alternative technique for the management of skeletal defects in a contaminated wound bed in the hand, particularly seen with blast injuries. The antibiotic-impregnated cement intramedullary nail can be placed until definitive soft tissue coverage occurs.
INDICATIONS The use of an antibiotic-impregnated cement intramedullary nail is indicated in skeletal defects of the metacarpal diaphysis that are not amenable to immediate bone grafting and fixation, soft tissue defects of the hand requiring temporization before definitive treatment (ie, infected wound beds), contaminated wounds with open metacarpal shaft fractures, and infected metacarpal shaft nonunions. As long as there is enough bone with intact articular surface proximally and distally to engage the metaphysis, this technique is applicable. There should be at least 1 cm of bone proximally and distally to engage the Steinman pin in the intact proximal and distal fragments, but this also depends on the quality of the bone.
CONTRAINDICATIONS This technique is contraindicated in patients with allergies to specific antibiotics such as vancomycin. Alternatively, if a patient has a documented vancomycin allergy, gentamycin can be used instead.
TECHNIQUE We describe a technique for creating an antibiotic-impregnated cement intramedullary nail for application in the hand using readily available operating room equipment, including a 28 Fr chest tube (Fig. 1), a 3-mm threaded Steinman pin (Fig. 2), cement gun or Toomey syringe, and antibiotics. This is a modification of the technique used for creation of an antibiotic tibia nail.8 The size of the bone defect in the metacarpal is measured. A 28-Fr chest tube, which has an inner diameter of 9.3 mm, approximates the midshaft diameter of the
FIGURE 1. A 28 Fr chest tube.
From the Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, Torrance, CA. Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding. Address correspondence and reprint requests to Elliot S. Mendelsohn, MD, Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 422, Torrance, CA 90509. E-mail: [email protected]. Copyright r 2013 by Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
Volume 17, Number 4, December 2013
www.techhandsurg.com |
187
Mendelsohn et al
Techniques in Hand & Upper Extremity Surgery
Volume 17, Number 4, December 2013
FIGURE 2. A 3 mm threaded Steinman pin.
FIGURE 3. A 28 Fr chest tube cut into various sizes.
FIGURE 4. Antibiotic-impregnated cement intramedullary nails with chest tube.
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r
2013 Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
Volume 17, Number 4, December 2013
Application of an Antibiotic Intramedullary Nail
FIGURE 5. Antibiotic-impregnated cement intramedullary nail of various length.
metacarpals.11 The flare of the chest tube is cut off and is cut to the appropriate length. Chest tubes and pins of various sizes are made to allow for more accurate sizing and optimal restoration of soft tissue tension in situ (Fig. 3). One package of polymethyl methacrylate bone cement (40 g), two 1.2 g vials of tobramycin, and two 1 g vials of vancomycin are mixed. The
liquid monomer is added and mixed to the polymethyl methacrylate bone cement. While the cement is still viscous, it is transferred to a cement gun or Toomey syringe. The cement is pressurized into the precut chest tube, and the Steinman pin is passed down the center of the chest tube (Fig. 4). Once the bone cement hardens, the polyethylene chest tube is cut with a
FIGURE 6. Trialing of implants to determine appropriate size and insertion of final implant. r
2013 Lippincott Williams & Wilkins
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Techniques in Hand & Upper Extremity Surgery
Mendelsohn et al
Volume 17, Number 4, December 2013
FIGURE 7. A, Low-velocity gunshot wound. B, Segmental bone loss and shortening in a third metacarpal diaphyseal fracture. C, External fixator with antibiotic beads. D, A VAC sponge. E, Antibiotic-impregnated cement intramedullary nail. F, Fracture union with bone graft.
scalpel to peel it from the surface of the smooth hardened bone cement (Fig. 5). The implants are trialed to determine the size with the most appropriate fit. The final antibiotic-impregnated cement nail is screwed into the distal fragment and then impacted into the proximal fragment (Fig. 6). When the soft tissue envelope is ready, the antibiotic nail is removed (typically 6 to 8 wk). The cement nail is cut in situ with a large wire cutter and a segmental midportion of the nail is removed. The 2 ends of the nail are unscrewed from the proximal and distal metaphysis of the metacarpal. The cortical defect is bridged with mini-fragment implants (2.0 or 2.7 mm, locked or unlocked, plate and screws) and grafted with corticocancellous or cancellous autograft.
CASE EXAMPLE We describe an unusual case in which the antibiotic nail provided such stable fixation that it was left in place rather than be used as a temporary spacer. In this case, the nail restored the anatomic length of the metacarpal and the soft tissue tension. It was a stable fixation and it was felt that it could be used as definitive fixation with bone graft surrounding the implant. A young male sustained a low-energy gunshot wound to his nondominant left hand (Fig. 7A). There was a comminuted third metacarpal diaphyseal fracture with bone loss and shortening (Fig. 7B). There was segmental damage and tendon loss to the extensor digitorum communis slip to the middle finger. On the day of presentation, the patient was taken to the operating room for irrigation, debridement, antibiotic bead application, and temporary external fixation (Fig. 7C). The external fixator was
190 | www.techhandsurg.com
assembled from a cement tube spanning the fracture site that was later filled with cement, using a technique previously described.12 The soft tissue envelope was significantly traumatized and a negative pressure dressing was applied with a VAC sponge (Vacuum Assisted Closure System; Kinetic Concepts Inc., San Antonio, TX) (Fig. 7D). The patient was placed on broad spectrum systemic intravenous antibiotics. Serial debridements and VAC changes were performed. The patient returned to the operating room for application of an antibiotic intramedullary nail 11 days after initial presentation. The external fixator was removed. The antibiotic beads were removed. The metacarpal defect was measured to be 4 to 4.5 cm. An antibiotic-impregnated cement intramedullary nail was created and implanted using the method previously described. The extensor digitorum communis tendon laceration was repaired primarily. The wound was closed and an incisional wound VAC was applied. Metacarpal length, alignment, and rotation were restored (Fig. 7E). When the soft tissue envelope was ready, the patient returned to the operating room for bone grafting and tendon and nerve repair 2½ months after initial presentation. An autogenous tricortical iliac corticocancellous bone graft was harvested and shaped to fit the defect. Tendon and digital nerve reconstruction was performed with an extensor indicis proprius transfer and a lateral antebrachial cutaneous nerve graft. Duration of follow-up was 6 months after initial presentation. The patient recovered approximately 70% of his finger motion, had no pain, and was able to use his hand for grasp and pinch. The final outcome was skeletal union 3½ months after bone grafting. The fracture healed with r
2013 Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
Volume 17, Number 4, December 2013
restoration of normal alignment and minimal shortening (Fig. 7F). The employment and functional status is unknown as the patient was lost to follow-up because of incarceration.
Application of an Antibiotic Intramedullary Nail
ACKNOWLEDGMENTS The authors thank Roger Abarca and Anida Phathayakorn, whose daily hard work and assistance helped make this project and all of our other efforts possible.
COMPLICATIONS Complications with this technique include hardware loosening or breakage, continued nonunion after bone grafting, rotational malalignment, difficulty removing the implant and fracturing native bone, and loss of native bone. Malrotation can be minimized by careful attention to the angular and rotational alignment of the fracture when using intramedullary implants. The use of fluoroscopy can be useful in judging restoration of length intraoperatively. Contralateral hand radiographs and intraoperative C-arm imaging aids in accurate templating and length measurements. Customizing the size of the spacer allows for a precise fit as it is impacted into place. This helps achieve length stability as tension is applied to the surrounding dynamic musculotendinous structures spanning the fracture. Interfragmentary compression with autogenous tricortical iliac crest graft minimizes the risk of nonunion when spanning these large bony defects. It is important to wait for a compliant soft tissue envelope before proceeding with autogenous grafting.
REHABILITATION We recommend immobilization of the fracture until union. This may involve a substantial period of time, as management of these challenging injuries requires multiple operations for debridements, provisional stabilization, definitive internal fixation, and autogenous bone grafting. Physical therapy is paramount during the skeletal reconstruction. These patients should be engaged in exercises to assist with edema control, minimize adhesion formation, and maintain flexibility of the surrounding joints. Rehab protocols and splints should be employed as dictated by the tendon and/or neurovascular repair. In this case, the patient was placed in dynamic middle finger extension splint after repair and reconstruction of his extensor apparatus.
CONCLUSIONS This article describes the use of antibiotic cement with a central Steinman pin to act as an antibacterial bone spacer until the soft tissue envelope is suitable for internal fixation and bone grafting. The construct is cost effective, easy to fashion, radiolucent, antimicrobial, and readily available in most operating rooms.
r
2013 Lippincott Williams & Wilkins
REFERENCES 1. Freeland AE, Rehm JP. Autogenous bone grafting for fractures of the hand. Tech Hand Up Extrem Surg. 2004;8:78–86. 2. Saint-Cyr M, Miranda D, Gonzalez R, et al. Immediate corticocancellous bone autografting in segmental bone defects of the hand. J Hand Surg Br. 2006;31:168–177. 3. Gonzalez MH, McKay W, Hall RF Jr. Low-velocity gunshot wounds of the metacarpal: treatment by early stable fixation and bone grafting. J Hand Surg Am. 1993;18:267–270. 4. DeSilva GL, Fritzler A, DeSilva SP. Antibiotic-impregnated cement spacer for bone defects of the forearm and hand. Tech Hand Up Extrem Surg. 2007;11:163–167. 5. Allende C. Cement spacers with antibiotics for the treatment of posttraumatic infected nonunions and bone defects of the upper extremity. Tech Hand Up Extrem Surg. 2010;14:241–247. 6. Georgiadis GM, DeSilva SP. Reconstruction of skeletal defects in the forearm after trauma: treatment with cement spacer and delayed cancellous bone grafting. J Trauma. 1995;38:910–914. 7. Eckman JB Jr, Henry SL, Mangino PD, et al. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res. 1988;237:213–215. 8. Thonse R, Conway J. Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects. J Orthop Trauma. 2007;21:258–268. 9. Bach HG, Gonzalez MH, Hall RF Jr. Locked intramedullary nailing of metacarpal fractures secondary to gunshot wounds. J Hand Surg Am. 2006;31:1083–1087. 10. Orbay JL, Touhami A. The treatment of unstable metacarpal and phalangeal shaft fractures with flexible nonlocking and locking intramedullary nails. Hand Clin. 2006;22:279–286. 11. Lazar G, Schulter-Ellis FP. Intramedullary structure of human metacarpals. J Hand Surg Am. 1980;5:477–481. 12. Walter FL, Papandrea RF. A mini external fixator for hand and finger fractures constructed from readily available materials. Tech Hand Up Extrem Surg. 2011;15:215–218.
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Application of an Antibiotic Intramedullary Nail in the Management of a Large Metacarpal Bone Defect Elliot S. Mendelsohn, MD, Tibor Warganich, MD, Evan S. Nielsen, MD, and Soheil Najibi, MD, PhD
Abstract: Contaminated wounds and infected nonunions of the hand are not amenable to primary internal fixation and grafting. Antibioticimpregnated cement intramedullary nails have been used in the lower extremity in the treatment of these fractures but have not been described in the hand. This technique combines the advantages of local antibiotic delivery with the mechanical stability afforded by an intramedullary nail. We describe an alternative technique for the management of skeletal defects in a contaminated wound bed in the hand using readily available operating room equipment. The antibiotic-impregnated cement intramedullary nail can be placed temporarily until definitive internal fixation and grafting occur. Key Words: intramedullary nail, cement, local antibiotics, bone loss, metacarpal fracture (Tech Hand Surg 2013;17: 187–191)
HISTORICAL PERSPECTIVE Comminuted fractures with segmental bone defects in the hand are typically associated with high-energy mechanisms such as gunshot wounds and open fractures. Autogenous bone grafting has been shown to be a successful technique in managing these bone defects in the hand.1–3 A contaminated and/or infected wound bed may preclude primary internal fixation and grafting. Antibiotic-impregnated cement spacers have been used for bone defects and infected nonunions of the upper extremity.4–6 The antibiotic-impregnated cement allows for local delivery of a high volume of antibiotics,7 maintains appropriate soft tissue tension, and creates a space that prevents the growth of soft tissue and can be filled with bone graft. A solid cement cylinder has been used but is not rotationally stable as it can flex and rotate out of the defect with motion. Step-bent K-wires have also been employed but mechanical stability, infection, and pin migration are potential issues. Antibiotic-impregnated cement intramedullary nails are a well-described technique for treatment of infected tibia nonunions.8 This technique combines the advantages of local antibiotic delivery with the mechanical stability afforded by an intramedullary nail. Two intramedullary metacarpal nails capable of locking have been introduced,9,10 but these nails are not impregnated with antibiotic cement. We describe an alternative method of internal fixation for a metacarpal shaft
fracture with associated bone loss using an antibioticimpregnated cement spacer in the form of an intramedullary nail. The antibiotic-impregnated cement intramedullary nail can be created using readily available operating room equipment. This is an alternative technique for the management of skeletal defects in a contaminated wound bed in the hand, particularly seen with blast injuries. The antibiotic-impregnated cement intramedullary nail can be placed until definitive soft tissue coverage occurs.
INDICATIONS The use of an antibiotic-impregnated cement intramedullary nail is indicated in skeletal defects of the metacarpal diaphysis that are not amenable to immediate bone grafting and fixation, soft tissue defects of the hand requiring temporization before definitive treatment (ie, infected wound beds), contaminated wounds with open metacarpal shaft fractures, and infected metacarpal shaft nonunions. As long as there is enough bone with intact articular surface proximally and distally to engage the metaphysis, this technique is applicable. There should be at least 1 cm of bone proximally and distally to engage the Steinman pin in the intact proximal and distal fragments, but this also depends on the quality of the bone.
CONTRAINDICATIONS This technique is contraindicated in patients with allergies to specific antibiotics such as vancomycin. Alternatively, if a patient has a documented vancomycin allergy, gentamycin can be used instead.
TECHNIQUE We describe a technique for creating an antibiotic-impregnated cement intramedullary nail for application in the hand using readily available operating room equipment, including a 28 Fr chest tube (Fig. 1), a 3-mm threaded Steinman pin (Fig. 2), cement gun or Toomey syringe, and antibiotics. This is a modification of the technique used for creation of an antibiotic tibia nail.8 The size of the bone defect in the metacarpal is measured. A 28-Fr chest tube, which has an inner diameter of 9.3 mm, approximates the midshaft diameter of the
FIGURE 1. A 28 Fr chest tube.
From the Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, Torrance, CA. Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding. Address correspondence and reprint requests to Elliot S. Mendelsohn, MD, Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 422, Torrance, CA 90509. E-mail: [email protected]. Copyright r 2013 by Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
Volume 17, Number 4, December 2013
www.techhandsurg.com |
187
Mendelsohn et al
Techniques in Hand & Upper Extremity Surgery
Volume 17, Number 4, December 2013
FIGURE 2. A 3 mm threaded Steinman pin.
FIGURE 3. A 28 Fr chest tube cut into various sizes.
FIGURE 4. Antibiotic-impregnated cement intramedullary nails with chest tube.
188 | www.techhandsurg.com
r
2013 Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
Volume 17, Number 4, December 2013
Application of an Antibiotic Intramedullary Nail
FIGURE 5. Antibiotic-impregnated cement intramedullary nail of various length.
metacarpals.11 The flare of the chest tube is cut off and is cut to the appropriate length. Chest tubes and pins of various sizes are made to allow for more accurate sizing and optimal restoration of soft tissue tension in situ (Fig. 3). One package of polymethyl methacrylate bone cement (40 g), two 1.2 g vials of tobramycin, and two 1 g vials of vancomycin are mixed. The
liquid monomer is added and mixed to the polymethyl methacrylate bone cement. While the cement is still viscous, it is transferred to a cement gun or Toomey syringe. The cement is pressurized into the precut chest tube, and the Steinman pin is passed down the center of the chest tube (Fig. 4). Once the bone cement hardens, the polyethylene chest tube is cut with a
FIGURE 6. Trialing of implants to determine appropriate size and insertion of final implant. r
2013 Lippincott Williams & Wilkins
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Techniques in Hand & Upper Extremity Surgery
Mendelsohn et al
Volume 17, Number 4, December 2013
FIGURE 7. A, Low-velocity gunshot wound. B, Segmental bone loss and shortening in a third metacarpal diaphyseal fracture. C, External fixator with antibiotic beads. D, A VAC sponge. E, Antibiotic-impregnated cement intramedullary nail. F, Fracture union with bone graft.
scalpel to peel it from the surface of the smooth hardened bone cement (Fig. 5). The implants are trialed to determine the size with the most appropriate fit. The final antibiotic-impregnated cement nail is screwed into the distal fragment and then impacted into the proximal fragment (Fig. 6). When the soft tissue envelope is ready, the antibiotic nail is removed (typically 6 to 8 wk). The cement nail is cut in situ with a large wire cutter and a segmental midportion of the nail is removed. The 2 ends of the nail are unscrewed from the proximal and distal metaphysis of the metacarpal. The cortical defect is bridged with mini-fragment implants (2.0 or 2.7 mm, locked or unlocked, plate and screws) and grafted with corticocancellous or cancellous autograft.
CASE EXAMPLE We describe an unusual case in which the antibiotic nail provided such stable fixation that it was left in place rather than be used as a temporary spacer. In this case, the nail restored the anatomic length of the metacarpal and the soft tissue tension. It was a stable fixation and it was felt that it could be used as definitive fixation with bone graft surrounding the implant. A young male sustained a low-energy gunshot wound to his nondominant left hand (Fig. 7A). There was a comminuted third metacarpal diaphyseal fracture with bone loss and shortening (Fig. 7B). There was segmental damage and tendon loss to the extensor digitorum communis slip to the middle finger. On the day of presentation, the patient was taken to the operating room for irrigation, debridement, antibiotic bead application, and temporary external fixation (Fig. 7C). The external fixator was
190 | www.techhandsurg.com
assembled from a cement tube spanning the fracture site that was later filled with cement, using a technique previously described.12 The soft tissue envelope was significantly traumatized and a negative pressure dressing was applied with a VAC sponge (Vacuum Assisted Closure System; Kinetic Concepts Inc., San Antonio, TX) (Fig. 7D). The patient was placed on broad spectrum systemic intravenous antibiotics. Serial debridements and VAC changes were performed. The patient returned to the operating room for application of an antibiotic intramedullary nail 11 days after initial presentation. The external fixator was removed. The antibiotic beads were removed. The metacarpal defect was measured to be 4 to 4.5 cm. An antibiotic-impregnated cement intramedullary nail was created and implanted using the method previously described. The extensor digitorum communis tendon laceration was repaired primarily. The wound was closed and an incisional wound VAC was applied. Metacarpal length, alignment, and rotation were restored (Fig. 7E). When the soft tissue envelope was ready, the patient returned to the operating room for bone grafting and tendon and nerve repair 2½ months after initial presentation. An autogenous tricortical iliac corticocancellous bone graft was harvested and shaped to fit the defect. Tendon and digital nerve reconstruction was performed with an extensor indicis proprius transfer and a lateral antebrachial cutaneous nerve graft. Duration of follow-up was 6 months after initial presentation. The patient recovered approximately 70% of his finger motion, had no pain, and was able to use his hand for grasp and pinch. The final outcome was skeletal union 3½ months after bone grafting. The fracture healed with r
2013 Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
Volume 17, Number 4, December 2013
restoration of normal alignment and minimal shortening (Fig. 7F). The employment and functional status is unknown as the patient was lost to follow-up because of incarceration.
Application of an Antibiotic Intramedullary Nail
ACKNOWLEDGMENTS The authors thank Roger Abarca and Anida Phathayakorn, whose daily hard work and assistance helped make this project and all of our other efforts possible.
COMPLICATIONS Complications with this technique include hardware loosening or breakage, continued nonunion after bone grafting, rotational malalignment, difficulty removing the implant and fracturing native bone, and loss of native bone. Malrotation can be minimized by careful attention to the angular and rotational alignment of the fracture when using intramedullary implants. The use of fluoroscopy can be useful in judging restoration of length intraoperatively. Contralateral hand radiographs and intraoperative C-arm imaging aids in accurate templating and length measurements. Customizing the size of the spacer allows for a precise fit as it is impacted into place. This helps achieve length stability as tension is applied to the surrounding dynamic musculotendinous structures spanning the fracture. Interfragmentary compression with autogenous tricortical iliac crest graft minimizes the risk of nonunion when spanning these large bony defects. It is important to wait for a compliant soft tissue envelope before proceeding with autogenous grafting.
REHABILITATION We recommend immobilization of the fracture until union. This may involve a substantial period of time, as management of these challenging injuries requires multiple operations for debridements, provisional stabilization, definitive internal fixation, and autogenous bone grafting. Physical therapy is paramount during the skeletal reconstruction. These patients should be engaged in exercises to assist with edema control, minimize adhesion formation, and maintain flexibility of the surrounding joints. Rehab protocols and splints should be employed as dictated by the tendon and/or neurovascular repair. In this case, the patient was placed in dynamic middle finger extension splint after repair and reconstruction of his extensor apparatus.
CONCLUSIONS This article describes the use of antibiotic cement with a central Steinman pin to act as an antibacterial bone spacer until the soft tissue envelope is suitable for internal fixation and bone grafting. The construct is cost effective, easy to fashion, radiolucent, antimicrobial, and readily available in most operating rooms.
r
2013 Lippincott Williams & Wilkins
REFERENCES 1. Freeland AE, Rehm JP. Autogenous bone grafting for fractures of the hand. Tech Hand Up Extrem Surg. 2004;8:78–86. 2. Saint-Cyr M, Miranda D, Gonzalez R, et al. Immediate corticocancellous bone autografting in segmental bone defects of the hand. J Hand Surg Br. 2006;31:168–177. 3. Gonzalez MH, McKay W, Hall RF Jr. Low-velocity gunshot wounds of the metacarpal: treatment by early stable fixation and bone grafting. J Hand Surg Am. 1993;18:267–270. 4. DeSilva GL, Fritzler A, DeSilva SP. Antibiotic-impregnated cement spacer for bone defects of the forearm and hand. Tech Hand Up Extrem Surg. 2007;11:163–167. 5. Allende C. Cement spacers with antibiotics for the treatment of posttraumatic infected nonunions and bone defects of the upper extremity. Tech Hand Up Extrem Surg. 2010;14:241–247. 6. Georgiadis GM, DeSilva SP. Reconstruction of skeletal defects in the forearm after trauma: treatment with cement spacer and delayed cancellous bone grafting. J Trauma. 1995;38:910–914. 7. Eckman JB Jr, Henry SL, Mangino PD, et al. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res. 1988;237:213–215. 8. Thonse R, Conway J. Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects. J Orthop Trauma. 2007;21:258–268. 9. Bach HG, Gonzalez MH, Hall RF Jr. Locked intramedullary nailing of metacarpal fractures secondary to gunshot wounds. J Hand Surg Am. 2006;31:1083–1087. 10. Orbay JL, Touhami A. The treatment of unstable metacarpal and phalangeal shaft fractures with flexible nonlocking and locking intramedullary nails. Hand Clin. 2006;22:279–286. 11. Lazar G, Schulter-Ellis FP. Intramedullary structure of human metacarpals. J Hand Surg Am. 1980;5:477–481. 12. Walter FL, Papandrea RF. A mini external fixator for hand and finger fractures constructed from readily available materials. Tech Hand Up Extrem Surg. 2011;15:215–218.
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