Patients outside this age range or with more than two metacarpal fractures, ipsilateral fractures in the same limb, neurovascular deficits, or compound metacarpal fractures were excluded. Upon admission, a detailed history and examination were conducted to identify any associated injuries, including vascular injuries, compartment syndrome or peripheral nerve injuries. Standard radiographs, including anteroposterior and oblique views, were taken for diagnosis and fracture pattern assessment.

Laboratory investigations, such as complete blood counts, serum electrolytes, and RA factor, were also conducted. Temporary immobilization using Charnley’s splint was provided while awaiting surgery. Thirty patients were treated using the anterograde approach of intramedullary pinning, while the remaining thirty patients underwent the retrograde approach of intramedullary pinning. The surgical procedure was carried out under regional anaesthesia (brachial or wrist block). Patients were positioned supine, and the affected limb was abducted and prepped in sterile conditions. Closed reduction was attempted under image intensifier guidance, and the procedure was performed accordingly.

Post-operatively, intravenous antibiotics were administered for three days, followed by oral antibiotics for an additional five to seven days. Patients were encouraged to engage in early finger and wrist movements to reduce oedema and promote circulation. Post-operative radiographs were taken the day after surgery to confirm reduction and pin placement. Regular follow-up visits were scheduled at two, four, six, and twelve weeks post-operatively to assess union, complications, and improvement in range of motion at the metacarpophalangeal joint. Grip strength, range of motion, and pain (measured via the VAS score) were evaluated at each follow-up visit. Clinical outcomes were measured using several parameters, including the Total Active Motion (TAM) score for the 2nd to 5th metacarpals and Gingrass criteria for the 1st metacarpal. Grip strength was assessed using a dynamometer. The final outcomes were categorized as excellent, good, fair, or poor based on these measurements.

Statistical analysis was done using SPSS 25.0 (trial version). Continuous data was expressed in mean and standard deviation. The descriptive representation of data was done in the form of frequencies and percentages. Analytical part was done using t-test. The result was considered significant at 95% level of significance and p-value<0.05.

Results

Table 1 presents the distribution of various parameters among the two groups of study participants. The mean age of patients in Group 1 was 34.60±7.35 years, while Group 2 had a slightly younger mean age of 32.53±8.80 years. Gender distribution showed that 70% of the patients in Group 1 were male, compared to 56.7% in Group 2. The majority of patients in both groups were labourers, accounting for 63.3% in Group 1 and 53.3% in Group 2. Regarding the dominant hand, 53.3% of patients in Group 1 were right-handed, compared to 73.3% in Group 2.

The mode of injury varied, with fall from two-wheelers being the most common cause in both groups (26.7% in Group 1 and 33.3% in Group 2). Fracture patterns were similar across both groups, with 50% of fractures being oblique. 56.7% of patients in Group 1 had implants removed at 6 weeks, compared to 36.7% in Group 2 who had it removed at 7 weeks. Radiological union was achieved in 43.3% of Group 2 patients by the 7th week, and in Group 1 by 5 weeks. Complications were relatively low across both groups, though Group 2 had a higher incidence of stiffness (30%) compared to Group 1 (20%). 46.7% of patients in Group 1 had TAM scores between 85-100%, while Group 2 had a higher percentage (53.3%) within the 70-84% range, indicating slightly better overall motion in Group 1. Table 2 compares the grip strength and Visual Analog Scale (VAS) scores between the two groups. At 6 weeks postoperatively, the mean grip strength in Group 1 was 19.87±4.01, significantly higher than the 14.06±4.17 in Group 2 (p-value<0.0001). At 12 weeks, Group 1 maintained higher grip strength (81.29±5.39) compared to Group 2 (74.48±6.51); (p-value <0.0001). The pre-operative VAS scores were similar between the groups, with no significant difference (p=0.053). However, at 2 weeks postoperatively, Group 1 reported significantly lower pain levels (VAS 3.98±0.94) compared to Group 2 (VAS 4.97±0.98); p-value=0.0002. This trend continued at 6 weeks, where Group 1 had a VAS score of 1.28±0.63 compared to 1.96±0.57 in Group 2 (p-value <0.0001). By 12 weeks, the VAS scores between the groups were not significantly different (p=0.197), suggesting similar pain levels at this later stage of recovery. These findings suggest that the anterograde approach might provide better grip strength and lower pain levels in the earlier postoperative period compared to the retrograde approach.

Table 2: Comparison of grip strength and VAS score among the two groups of study participants

*p-value significant

Discussion

Various internal fixation methods for metacarpal fractures are available, but the primary goals of treatment remain the same: restoring articular anatomy, ensuring stable fracture fixation, correcting angular or rotational deformities, and rapidly restoring mobility and function.

Similarly, Gupta R et al. ^[18] and Feehan LM, Sheps SB ^[19]. reported RTA as the most frequent cause of hand fractures, accounting for 60% and 48% of cases, respectively. In contrast, Reddy PK and Javali V ^[17] observed a broader distribution, with 33.33% of injuries due to punching, 26.66% from RTAs, and 20% each from sports activities and falls. Our study demonstrated that the mean union time was 5.21 weeks in the anterograde group and 6.89 weeks in the retrograde group. These findings align with studies by Rhee SH et al ^[20] and Harris AR et al ^[21], who reported average union times of 5.6 weeks and 5 weeks, respectively. However, Roth JJ, Auerbach DM ^[22] found a slightly longer average union time of 7 weeks; Singh VJS ^[23] observed it to be 7.2 weeks and, Omokawa S et al ^[16] reported it to be 8 weeks, which corresponds more closely with our retrograde group. In terms of fracture patterns, our study found that 46.6% of fractures were oblique, and 40% were transverse, with spiral and comminuted fractures making up 11.6% and 1.6%, respectively. These results are consistent with Gupta R et al. ^[18] who found that 53.1% of fractures were transverse and 45% were oblique or spiral. The majority of fractures in our study occurred on the dominant side (53.3%=anterograde group and 73.3%=retrograde group), a finding supported by Stanton J S et al ^[13], who observed that 65% of injuries occurred in the dominant hand, and by Khan W, Fahmy N ^[24] and Anakwe RE et al ^[25] who reported a similar distribution. Regarding the TAM score, 46.7% of anterograde group had TAM scores between 85-100%, while retrograde group had a higher percentage (53.3%) within the 70-84% range, indicating slightly better overall motion in anterograde group. This result is comparable to the study by She Y, Xu Y ^[26], who found that the mean total active motion (TAM) was 270°, with excellent functional outcomes in the majority of cases. Aly T ^[27] also reported that 61.9% of patients had excellent results using the TAM for functional outcome assessment. The VAS pain score in our study decreased significantly from preoperative levels to follow-up at 6 and 12 weeks, with the anterograde group showing a more substantial reduction in pain. This is in line with the findings of Kim JK et al ^[12], who reported lower median VAS scores in the anterograde group compared to the retrograde group. In terms of complications, 76.6% of patients in the anterograde group and 70% in the retrograde group experienced no complications. Stiffness was the most common complication, affecting 16.7% of patients in the anterograde group and 23.3% in the retrograde group, consistent with findings from Aski B, Bhatnagar A ^[28] and She Y, Xu Y ^[26], who reported complications such as skin irritation, nerve injuries, and joint stiffness. Singh VJS ^[23] reported infection and stiffness, while Aly T ^[27] observed complications ranging from minor infections to significant deformities and stiffness. Conversely, Reddy PK and Javali V ^[17] reported no major complications, with patients generally satisfied with their outcomes. 46.4% of patients in the anterograde group achieved excellent results, compared to 23.4% in the retrograde group. Our findings suggest that the modified technique used in our study, particularly the single K-wire approach with early mobilization, provides favorable outcomes with fewer complications compared to traditional methods, as also noted by Singh VJS ^[23] and Aly T ^[27].