The Iliac Crest Top Hat Bone Graft for Challenging Metacarpal Nonunion

      Metacarpal nonunion is a rare outcome of metacarpal injury, and little has been published about its management. Care typically includes open reduction and internal fixation with a possible bone graft, similar to the treatment of other nonunions. However, there is no literature guidance if traditional methods do not lead to union. To improve the treatment of these recalcitrant metacarpal diaphyseal nonunions, we proposed a new surgical technique using a “top hat” bone graft harvested from the iliac crest. The graft is carefully shaped to create a cancellous “crown,” which is inserted into the nonunion site, and cortical “brims,” which are used to secure the graft to the metacarpal. This has been successful in treating 2 cases of metacarpal nonunion that failed to heal with first-line intervention.

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        • Hammert W.C.
        Treatment of nonunion and malunion following hand fractures.
        Clin Plast Surg. 2011; 38: 683-695
        • Janowski J.
        • Coady C.
        • Catalano L.W.
        Scaphoid fractures: nonunion and malunion.
        J Hand Surg Am. 2016; 41: 1087-1092
        • Pinder R.M.
        • Brkljac M.
        • Rix L.
        • Muir L.
        • Brewster M.
        Treatment of scaphoid nonunion: a systematic review of the existing evidence.
        J Hand Surg Am. 2015; 40: 1797-1805.e3
        • Jupiter J.B.
        • Koniuch M.P.
        • Smith R.J.
        The management of delayed union and nonunion of the metacarpals and phalanges.
        J Hand Surg Am. 1985; 10: 457-466
        • Ebraheim N.A.
        • Elgafy H.
        • Xu R.
        Bone-graft harvesting from iliac and fibular donor sites: techniques and complications.
        J Am Acad Orthop Surg. 2001; 9: 210-218