Intramedullary Screw Fixation of Metacarpal Fractures Results in Excellent Functional Outcomes: A Literature Review

Complications Following Intramedullary Screw Fixation for Metacarpal Fractures: A Systematic Review

PURPOSE

There has been a recent increase in the use of intramedullary screws (IMS) for the surgical treatment of metacarpal fractures. While IMS fixation has been shown to produce excellent functional outcomes, postoperative complications have yet to be fully explored in a comprehensive way. This systematic review quantified the incidence, treatment, and results of complications following IMS fixation for metacarpal fractures.

METHODS

A systematic review was performed using PubMed, Cochrane Central, EBSCO, and EMBASE databases. All clinical studies that documented IMS complications following metacarpal fracture fixation were included. Descriptive statistics were analyzed for all available data.

RESULTS

Twenty-six studies were included: 2 randomized trials, 4 cohort studies, 19 case series, and 1 case report. Among the 1,014 fractures studied, 47 complications were reported across all studies (4.6%). Stiffness was the most common, followed by extension lag, loss of reduction, shortening, and complex regional pain syndrome. Other complications included screw fracture, bending, and migration; early-onset arthrosis; infection; tendon adhesion; hypertrophic scar; hematoma; and nickel allergy. Eighteen of the 47 (38%) patients with complications underwent revision surgery.

CONCLUSIONS

Complications following IMS fixation of metacarpal fractures are relatively uncommon.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The biomechanical evaluation of metacarpal fractures fixation methods during finger movements: a finite element study

Objective

This study used finite element analysis to simulate four commonly used fixation methods for metacarpal shaft oblique fractures during finger motion and evaluate their biomechanical performance. The aim was to provide evidence for clinically selecting the optimal fixation method, guiding early rehabilitation treatment, and reducing the risk of complications.

Methods

Finite element analysis simulated dynamic proximal phalanx motion (60° flexion, 20° extension, 20° adduction, and 20° abduction). We analysed stress, displacement, and distributions for dorsal plates, intramedullary nails, Kirschner wire, and screw fixation methods.

Results

At 60° of finger flexion and 20° of abduction, plate fixation demonstrated greater stability and minimal displacement, with a peak displacement of 0.19 mm; however, it showed higher stress levels in all motion states, increasing the risk of failure. The stability of the intramedullary nail was similar to that of the dorsal plate, with a maximum displacement difference of 0.04 mm, and it performed better than the dorsal plate during adduction of 20°. Kirschner wire showed the highest stress levels of 81.6 Mpa during finger flexion of 60°, indicating a greater risk of failure and unstable displacement. Screws had lower stress levels in all finger motion states, reducing the risk of failure, but had poorer stability. Stress and displacement distributions showed that the dorsal plate, intramedullary nail, and Kirschner wire mainly bore stress on the implants, concentrating near the fracture line and the proximal metacarpal. In contrast, the screws partially bore stress in the screw group. The anterior end of the metacarpal mainly hosted the maximum displacement.

Conclusion

This study demonstrates that under simulated finger motion states, the dorsal plate fixation method provides the best stability in most cases, especially during finger flexion and abduction. However, high stress levels also indicate a higher risk of failure. The intramedullary nail is similar to the dorsal plate in stability and performs better in certain motion states. Kirschner wire exhibits the highest risk of failure during flexion. Although screws have poorer stability in some motion states, they offer a lower risk of failure. These findings provide important reference and surgical selection strategies for treating metacarpal fractures.

Determining the Optimal Intramedullary Screw Canal Fill Ratio in Length Unstable Metacarpal Fractures: A Biomechanical Investigation

PURPOSE

Intramedullary (IM) screw fixation is gaining popularity in the treatment of metacarpal fractures. Despite its rapid adoption, there is a paucity of evidence regarding parameters to optimize effectiveness. This study aimed to quantify the relationship between stability, IM screw size, and canal fill using a cadaveric model.

METHODS

Thirty cadaveric metacarpals (14 index, 13 middle, and three ring fingers; mean age: 58.3 years, range: 48-70) were selected to allow for canal fill ratios of 0.7-1.1 for screws sized 3.0, 3.5, and 4.5 mm. Metacarpals underwent a 45° volar-dorsal osteotomy at the midpoint before fixation with an IM screw. Specimens were subjected to 100 cycles of loading at 10 N, 20 N, and 30 N before load-to-failure testing. Correlation coefficients for angular displacement on the final cycle at each load, peak load to failure, and average stiffness were assessed.

RESULTS

Correlation coefficients for the angular displacement on the 100th cycle were as follows: 10 N, R = 0.62, 20 N, R = 0.57, and 30N, R = 0.58. Correlation values for peak load to failure as a function of canal fit were as follows: 3.0 mm, R = 0.5, 3.5 mm, R = 0.17, and 4.5 mm, R = 0.44. The canal fill ratio that intersected the line-of-best fit at an angular deformity of 10° was 0.74. Average peak forces for 3.0-, 3.5-, and 4.5-mm screws were 79.5, 136.5, and 179.6 N, respectively. Average stiffness for each caliber was 14.8, 33.4, and 52.3 N/mm.

CONCLUSIONS

Increasing screw diameter and IM fill resulted in more stable fixation, but marginal gains were seen in ratios >0.9. A minimum fill ratio of 0.74 was sufficient to withstand forces of early active motion with angular deformity <10°.

CLINICAL RELEVANCE

An understanding of the relationship of IM fill ratio of metacarpal screws to fracture stability may provide a framework for clinicians to optimally size these implants.

Metacarpal Fracture Fixation with Intramedullary Screws

Background: Intramedullary screws (IMS) have become a viable option for metacarpal fracture fixation. To further appraise their utility, this study assessed clinical and patient-reported short- and medium-term outcomes of IMS fixation for extra-articular metacarpal fractures. Methods: A retrospective cohort study was performed in a series of 32 patients (with a total of 37 fractures) who underwent metacarpal fracture fixation over a 42-month period between January 2020 and July 2023. Results: Mean time for return to work was 39.8 days; mean time for return to full function was 88.4 days; total active motion was 250.7° (range: 204.9-270.9); Quick Disabilities of the Arm, Shoulder and Hand score was 2.3 (range: 0-22.7); mean visual analogue pain score was 0.9 out of 10 (range: 0-6) and a single complication was observed. Conclusions: The use of IMS in metacarpal fracture fixation is a practicable surgical option. IMS fixations yields a satisfactory duration for return to function, good postoperative range of movement, modest pain scores and low rates of complications. Level of Evidence: Level IV (Therapeutic).

Early Return of Motion in Patients With Intramedullary Screw Placement for Metacarpal and Phalangeal Fracture Fixation

INTRODUCTION

Hand fractures are associated with significant morbidity. Current management standards often result in prolonged immobilization, stiffness, and delayed return to functional use. Intramedullary (IM) compression screws offer minimal soft tissue disruption and early postoperative active motion. In this study, we describe our outcomes after intraosseous fracture fixation using IM cannulated headless screws for a multitude of fracture patterns.

METHODS

This study is a retrospective review of patients who underwent IM screw placement for fixation of metacarpal and phalangeal fractures by a single surgeon from 2017 to 2022. Data were collected to include patient demographics, fracture details, postoperative complications, and follow-up. Time to range of motion and return to unrestricted motion was recorded.

RESULTS

There were 69 patients with 92 fractures (n = 54 metacarpal, n = 38 phalanx). The median patient age was 45 years (range, 18-89 years) with 75.4% males. Majority presented with a single fracture (n = 50, 72.5%), and 38 patients (55.1%) had open fractures. Small finger was the most affected digit (n = 35, 37.6%). The median time to allow range of motion from surgery was 8.7 days (interquartile range, 0-32) with 32 days (interquartile range, 10-62) for unrestricted use of the hand. Thirty-five patients (50.7%) were allowed controlled motion from the first postoperative day. One patient had loss of reduction requiring reintervention for hardware removal, and 1 patient had superficial skin infection managed with oral antibiotics.

CONCLUSIONS

Our findings indicate that the IM screw provides reliable fixation for a wide variety of fracture patterns with a low complication rate and offers early return to functional use.

Comparison of Intramedullary Screw Fixation, Plating, and K-Wires for Metacarpal Fracture Fixation: A Meta-Analysis

BACKGROUND

Metacarpal fractures are common injuries with multiple options for fixation. Our purpose was to compare outcomes in metacarpal fractures treated with intramedullary screw fixation (IMF), Kirschner wires (K-wires), or plating.

METHODS

A systematic literature review using the MEDLINE database was performed for studies investigating metacarpal fractures treated with IMF, plating, or K-wires. We identified 34 studies (9 IMF, 8 plating, 17 K-wires). A meta-analysis using both mixed and fixed effects models was performed. Outcome measures included mean Disabilities of the Arm, Shoulder, and Hand (DASH) scores, total active motion (TAM), grip strength, time to radiographic healing, and rates of infection and reoperation.

RESULTS

Patients with IMF had significantly lower DASH scores (0.6 [95% confidence interval [CI], 0.2-1.0]) compared with K-wires (7.4 [4.8-9.9]) and plating (9.8 [5.3-14.3]). Intramedullary screw fixation also had significantly lower rates of reoperation (4%, [2%-7%]), compared with K-wires (11% [7%-16%]) and plating (11% [0.07-0.17]). Grip strength was significantly higher in IMF (104.4% [97.0-111.8]) compared with K-wires (88.5%, [88.3-88.7]) and plating (90.3%, [85.4-95.2]). Mean odds ratio time was similar between IMF (21.0 minutes [10.4-31.6]) and K-wires (20.8 minutes [14.0-27.6]), but both were shorter compared with plating (52.6 minutes [33.1-72.1]). There were no statistically significant differences in time to radiographic healing, TAM, or rates of reoperation or infection.

CONCLUSIONS

This meta-analysis compared the outcomes of metacarpal fixation with IMF, K-wires, or plating. Intramedullary screw fixation provided statistically significant lower DASH scores, higher grip strength, and lower rates of reoperation, suggesting that it is a comparable method of fixation to K-wires and plating for metacarpal fractures.

Outcomes and Complications of Intramedullary Metacarpal Fixation

BACKGROUND

Metacarpal fractures are common orthopedic injuries with potentially debilitating outcomes. Ideal surgical treatment remains a topic of debate, with intramedullary fixation becoming popular as a technique to allow for earlier mobilization with few reported complications. The aim of this study was to report observed outcomes and complications of intramedullary metacarpal fixation using the ExsoMed INnate metacarpal nail.

METHODS

A retrospective chart review of 37 patients with 44 metacarpals treated with the ExsoMed INnate between July 2020 and December 2021 by a single fellowship-trained hand surgeon at a single level 1 trauma center was performed. Variables recorded included both patient and injury demographics, surgical complications, and postoperative outcomes. We also measured metacarpal isthmus diameter of the second to fifth metacarpals on all patients to determine the intramedullary canal diameter to assist in implant size selection.

RESULTS

Average follow-up was 5.84 weeks with average time to radiographic healing of 5.5 weeks, and time to full activity 6.32 weeks. The mean postsurgical active total arc of motion was 250°, while passive total arc of motion was 259.74°. A total of 10 complications (22%) were identified, including 4 bent screws which occurred as a result of a punching event postoperatively.

CONCLUSIONS

Intramedullary fixation of metacarpal fractures using the ExsoMed INnate metacarpal nail has shown to preserve range of motion and quick return to full activity, with a low rate of major complications. Our study highlights the potential major complication of the bent intramedullary screw and its association with an initial punching mechanism.

Mangled Thumb Injury Reconstruction with the Use of Definitive External Fixation and the Masquelet Technique: A Case Report

CASE

A 23-year-old right-hand dominant man presented with a high-velocity gunshot wound injury to the right thumb with severe soft-tissue damage, vascular injury, and large osseous defect of the right thumb metacarpal. The patient was successfully treated with metacarpophalangeal joint arthrodesis and metacarpal reconstruction using definitive external fixation, an intramedullary Kirschner wire, and use of the Masquelet bone grafting technique.

CONCLUSION

The authors' treatment approach for a mangled thumb injury with definitive external fixation and utilization of the Masquelet technique resulted in restoration of a large osseous defect, avoidance of infection, and limited loss of mobility.

Extensor Tendon Integrity After Percutaneous Placement of Intramedullary Metacarpal Screws: A Cadaveric Study

BACKGROUND

Intramedullary implants are an increasingly common method for fixation of metacarpal fractures. Numerous techniques for instrumentation have been described with varied consideration for the risk of extensor tendon injury. The current cadaveric study evaluates the prevalence and degree of extensor tendon injury and compares percutaneous approaches with different drilling techniques.

METHODS

Ninety-six metacarpals (thumbs excluded) from 24 fresh-frozen cadaveric upper extremities were used to compare 2 percutaneous approaches and 2 drilling techniques. This resulted in 4 subgroups available for comparison: oscillate to bone (OB), forward to bone (FB), oscillating through the skin (OS), and forward through the skin (FS). After instrumentation, the extensor tendons were dissected and disruption was characterized. The main outcome measures were tendon "hit rate" and relative extensor tendon defect width.

RESULTS

Tendon hit rate was significantly higher in the long finger (LF), that is, 79.2%, compared with other metacarpals: index finger, 20.8%; ring finger, 12.5%; and small finger 25%. The mean relative tendon disruption was significantly less in the OB group (16.05%) compared with the other groups: FB (31.84%), FS (31.50%), and OS (29.85%).

CONCLUSION

Retrograde intramedullary screw fixation of metacarpal fractures can be performed using percutaneous approaches without a significant disruption of the extensor mechanism. Instrumentation through a longitudinal stab incision down to the metacarpal head and the use of drill oscillation minimize injury to the extensor tendons. The LF extensor tendon is most at risk with retrograde intramedullary implant placement.

Single Buried Intramedullary K-Wire Fixation in Nonthumb Metacarpal Shaft Fractures with Immediate Postoperative Mobilization without Any Immobilization

Objective

This study aims to evaluate the outcomes of single intramedullary K-wire fixation in nonthumb, metacarpal shaft fractures with immediate postoperative hand mobilization without any immobilization.

Method

This is a retrospective case series conducted from January 2019 to December 2022. We included patients with closed, simple transverse, or short oblique metacarpal shaft fracture treated with single, 1.4 mm, intramedullary K-wire fixation. Gentle postoperative range of motion exercise was encouraged in every patient without any hand, finger, or wrist motion restriction material. Clinical outcomes were evaluated with total active flexion; grip strength; disability of arm, shoulder, and hand (DASH) score; and the American Society for Surgery of the Hand Total Active Flexion (ASSH TAF) score.

Results

This study included 34 patients, 25 males and 9 females with a mean age of 33.14 years (ranging 18-59). A total of 43 metacarpal shafts were treated. The mean DASH score at two and 6 weeks postoperative was 41.5 (ranging 19.16-60.34) and 9.58 (ranging 0.83-23.27). The mean final DASH score at last follow-up was 3.48 (ranging 0-8.33). Mean TAF at 2 weeks postoperative, 6 weeks postoperative, and at final follow-up was 203.8 (ranging 185-240), 238.2 (ranging 220-270), and 259.25 (ranging 240-270) degrees, respectively. The mean grip strength of the injured hand was 66.14 and 86.1% of the uninjured hand at 6 weeks and 3 months postoperative. There was no nonunion, malrotation, or infection. In conclusion, single intramedullary K-wire fixation gives excellent outcomes in the treatment of single or multiple, simple, metacarpal shaft fractures without the need of postoperative immobilization.

Intramedullary fixation of metacarpal and phalangeal bone fractures with bioabsorbable Mg K-wire in 20 cases

PURPOSE

The treatment of irreducible or severely displaced metacarpal and phalangeal bone fractures is still much debated. The recent development of the bioabsorbable magnesium K-wire is thought to allow effective treatment upon insertion via intramedullary fixation by minimizing articular cartilage injuries without discomfort until pin removal and drawbacks, such as pin track infection and metal plate removal. Therefore, this study investigated and reported the effects of intramedullary fixation with the bioabsorbable magnesium K-wire in unstable metacarpal and phalangeal bone fractures.

METHODS

This study included 19 patients admitted to our clinic for metacarpal or phalangeal bone fractures from May 2019 to July 2021. As a result, 20 cases were examined among these 19 patients.

RESULTS

Bone union was observed in all 20 cases, with a mean bone union time of 10.5 (SD 3.4) weeks. Reduction loss was observed in six cases, all showing dorsal angulation with a mean angle of 6.6° (SD 3.5°) at 4.6 weeks as compared with that noted in the unaffected side. The gas cavity upon H2 gas formation was first observed approximately 2 weeks postoperatively. The mean DASH score was 33.5 for instrumental activity and 9.5 for work/task performance. No patient complained of notable discomfort after surgery.

CONCLUSION

Intramedullary fixation with the bioabsorbable magnesium K-wire may be used for unstable metacarpal and phalanx bone fractures. This wire is expected to be a particularly favorable indication for shaft fractures, although care should be taken due to the possibility of complications related to rigidity and deformity.

Metacarpal fractures

Metacarpal fractures are common and can be functionally disabling. The majority are managed non-operatively. When surgical intervention is indicated, various methods of fixation are available with the utility of each being based on injury pattern, patient function and surgeon preference. Early mobilization, especially in case of open reduction and internal fixation, is a critical component of treatment to prevent stiffness and restore function. When possible, a fixation construct that can withstand the applied forces of early postoperative motion is chosen. We provide an updated description for diagnosis, treatment options and operative fixation for metacarpal fractures.

Cost Comparison of Kirschner Wire Versus Intramedullary Screw Fixation of Metacarpal and Phalangeal Fractures

BACKGROUND

Intramedullary screw fixation is a relatively new technique for fixation of metacarpal and phalangeal fractures. The objective of this study was to compare health care-associated costs and outcomes for intramedullary screw versus Kirschner wire (K-wire) fixation of hand fractures.

METHODS

A retrospective review of patients undergoing intramedullary screw fixation of hand fractures at a single center during 2016-2019 inclusive was conducted. Health care-associated costs were compared with age-matched and fracture pattern-matched controls who underwent K-wire fixation.

RESULTS

Fifty patients met the study inclusion criteria, incorporating 62 fractures (29 K-wire, 33 intramedullary screw fixation). The median age was 34.6 years (18.0-90.1 years). There was no significant difference in primary operative costs (£1130.4 ± £162.7 for K-wire vs £1087.0 ± £104.2 for intramedullary screw), outpatient follow-up costs (£958.7 ± £149.4 for K-wire vs £782.4 ± £143.8 for intramedullary screw), or total health care-associated costs (£2089.1 ± £209.0 for K-wire vs £1869.4 ± £195.3 for intramedullary screw). However, follow-up costs were significantly lower for the uncomplicated intramedullary screw cohort (£847.1 ± £109.1 for K-wire vs £657.5 ± £130.8 for intramedullary screw, P = .05). Subgroup analysis also revealed that overall costs were significantly higher for buried K-wire techniques. Complication rates, time to return to active work, and Disabilities of the Arm, Shoulder, and Hand scores were similar.

CONCLUSIONS

This study identified significantly lower outpatient follow-up costs for uncomplicated intramedullary screw fixation of hand fractures compared with K-wires, along with a trend toward lower overall health care-associated costs. In addition, buried K-wire techniques were also found to carry a significantly higher financial burden. Higher powered prospective studies are required to determine indirect costs.

Intramedullary Headless Screw Fixation for Metacarpal Fractures - Technical Tips

Metacarpal fractures are a common injury in the hand. When surgical intervention is indicated, there are multiple approaches and techniques of fixation. Intramedullary fixation has become an increasingly versatile method of fixation. The limited dissection needed for its insertion, rotational stability provided by the isthmic fit and lack of requisite hardware removal are improvements over conventional K-wire or plate fixation techniques. Multiple outcome studies have confirmed its safety and effectiveness. In this technical note, we provide some tips that can help surgeons considering intramedullary headless screw fixation of metacarpal fractures. Level of Evidence: Level V (Therapeutic).

Expanding the applications of intramedullary cannulated screw fixation in the hand

OBJECTIVES

Intramedullary cannulated headless compression screw fixation (ICHCS) is gaining popularity for managing metacarpal and phalangeal fractures, but is still relatively new to the surgical landscape. We aim to further illustrate its utility and versatility by presenting the outcomes of such fractures treated with ICHCS at two tertiary plastic surgery centres. Primary objectives were to assess functional range of motion, patient-reported outcomes, and complication rates.

MATERIALS AND METHODS

All patients with metacarpal or phalangeal fractures treated with ICHCS (n = 49) between September 2018 and December 2020 were retrospectively reviewed. Outcomes were active ranges of motion (TAM), QuickDASH scores (obtained via telephone), and complication rates. Two-tailed Student's t-tests evaluated differences between centres.

RESULTS

TAMs were available for 59% (n = 34/58) of fractures; 70.7% were metacarpal and 29.3% were phalangeal. The mean cohort metacarpal TAMs and phalangeal TAMs were 237.7° and 234.5°, respectively. QuickDASH scores were available for 69% (n = 34/49) of patients. The mean cohort score for metacarpal fractures was 8.23, and 5.13 for phalangeal. Differences between the two centres were statistically significant (p < 0.05). Two complications occurred, giving an overall complication rate of 3.45%.

CONCLUSION

Our results corroborate previous reports on ICHCS, further demonstrating its versatility and capacity to provide excellent outcomes. More prospective, comparative studies are needed to fully determine the suitability of ICHCS.

Threaded Intramedullary Nails Are Biomechanically Superior to Crossed K-wires for Metacarpal Neck Fractures

BACKGROUND

Intramedullary nail (IMN) fixation of metacarpal fractures is an alternative to Kirschner wire (K-wire) fixation. The goal of this study was to compare the biomechanical properties of K-wire fixation with a threaded IMN (InNate; ExsoMed, Aliso Viejo, California).

METHODS

The study design was based on previously described biomechanical models for evaluating metacarpal fractures. Sixteen fresh frozen small finger-matched and ring finger-matched pairs were randomized to either IMN or 0.045 in K-wire fixation after receiving a standardized neck osteotomy. Proper implant placement was confirmed with plain radiographs. Specimens then underwent loading in a 3-point bend configuration. Load to failure (LTF), stiffness, and fracture displacement were recorded. Mechanical failure was defined by a sharp change in the load-displacement curve.

RESULTS

Age, sex, sidedness (left or right), and digit (ring or small finger) were evenly distributed between groups. The IMN had a significantly higher LTF than K-wires (546 N vs 154 N, P < .001). The K-wire fixation demonstrated plastic deformation between 75 and 150 N. Intramedullary nail stiffness was higher than that of K-wires (155.89 N/mm vs 59.28 N/mm, P < .001).

CONCLUSIONS

When surgical fixation is indicated for metacarpal neck and shaft fractures, the threaded IMN is biomechanically superior to crossed K-wires with the application of 3-point bend.

[Osteosynthesis by intramedullary headless screw in digital fractures: A retrospective scannographic and anatomical study]

INTRODUCTION

Long finger skeletal fractures are common injuries. In displaced forms, surgical treatment is required. With the advent of headless cannulated screws, the technique has been simplified and allows reduction in both planes. The objective of our study was to evaluate the functional recovery of patients operated on by this technique.

MATERIAL AND METHOD

We conducted a retrospective single-center study between 2019 and 2022. Eleven patients were followed and 12 fractures analyzed. A radio-clinical follow-up was carried out at 1 month then at the last follow-up with an evaluation of the articular amplitudes and a quality of life score (QuickDash, QD). The time to return to professional and sporting activities, pain (EVA) was collected. An anatomical/scannographic evaluation was performed to assess tendon and cartilage damage.

RESULTS

At the last follow-up, the average global flexion was 266° and the extension was total. An average QD score of 15.9 and a Jamar force of 106% compared to the healthy side were observed. The return to physical and professional activities was earlier and the pain quickly tolerable. No secondary displacement was objectified and all were consolidated at the last follow-up, without malunion. No patient had been operated on secondarily.

CONCLUSION

This technique seems to be a safe and non-traumatic. It allows a faster return to sports and professional activities with fewer complications and no need to remove the material.

Temporal trends in the management of metacarpal and phalangeal fractures in the 21st century: an analysis of Australian population-based data

BACKGROUND

Fractures of the hand, specifically the metacarpals and phalanges, are a common injury. Whilst many of these fractures can be treated non-operatively, a number of advances have led to the increase in popularity of surgical intervention. The aim of this study was to assess and describe trends in management of phalangeal and metacarpal fractures in Australia over the last two decades.

METHODS

A review was conducted of the Medicare Benefits Scheme (MBS), specifically querying the item numbers pertaining to the management of metacarpal and phalanx fractures. Data was recorded as the incidence per 100 000 patients.

RESULTS

Overall, there was a statistically significant decrease in the incidence of closed reduction of metacarpal and phalanx fractures, with a converse statistically significant increase in open reduction internal fixation.

CONCLUSION

This study demonstrates that over the last 20 years, there has been a decrease in closed reduction of intra- and extra-articular phalangeal and metacarpal fractures, with a converse but smaller increase in open reduction and fixation. These trends are likely multi-factorial in aetiology, and should be monitored to guide resource allocation and health provision in the future.

Intramedullary Compression Screw Fixation of Proximal Phalangeal Fractures: A Systematic Literature Review

Proximal phalangeal fractures have traditionally been fixed via either Kirschner wires or dorsal plating. Concerns regarding lack of compression and potential for infection with wire fixation, and adhesion formation and stiffness with plating, have lead to alternative fixation methods, such as intramedullary screw fixation. However, the literature regarding this modality is limited. Methods: A systematic review was performed to review the literature regarding intramedullary screw fixation for proximal phalangeal fractures. English language studies that reported original data and commented on at least one postoperative measure of function were eligible for inclusion. 4 studies were eligible for inclusion, with a further 3 studies assessing proximal and middle phalanges analysed separately. Total active motion was greater than 240° in all proximal phalangeal studies; mean post-operative DASH was 3.62. 6% of patients sustained a major complication. Intramedullary screw fixation of proximal phalangeal fractures is safe, providing stable fixation to allow early motion.

Headless Compression Screw for Metacarpal Nonunion: Description of a New Technique and Report of 4 Cases

Nonunion is a rare complication of metacarpal fractures and is usually associated with compound, open fractures with tissue loss and infection, or after failed surgical treatment. Repair by rigid osteosynthesis with plate and screws combined with autologous bone grafting has always been the treatment of choice for most patients. Such method allows early motion, although it has been proven that the presence of hardware may cause local soft tissue irritation. Often, hardware removal and tendon releases are necessary. We describe an original technique with a fixation method for the treatment of metacarpal nonunions, considering the excellent results attained with an intramedullary, headless screw for metacarpal fracture fixation. We report a series of three cases that evolved to bone healing with excellent clinical, functional, and radiographic outcomes.

Intramedullary Headless Screw Fixation of Metacarpal Fractures: A Radiographic Analysis for Optimal Screw Choice

Background: The purpose of this study was to investigate variations in radiographic metacarpal anatomy as it relates to intramedullary (IM) fixation of metacarpal fractures and to compare this anatomy with available headless screw dimensions. Methods: We radiographically analyzed posteroanterior and lateral (LAT) radiographs of 120 metacarpals across 30 patients without structural abnormalities. Primary outcomes included IM isthmus diameter, isthmus location, metacarpal cascade, and head entry point collinear with IM canal. Measurements were compared with a list of commercially available headless screws used for IM fixation. Results: The average largest isthmus diameter was in the small metacarpal (3.4 mm), followed by the index (2.8 mm), long (2.7 mm), and ring (2.7 mm) metacarpals. The average cascade angle between long and index, long and ring, and long and small metacarpals was 0°, 24°, and 27°, respectively. The appropriate head entry point ranged between 25% and 35% from the dorsal surface of the metacarpal head on a LAT view. The retrograde isthmus location of the index and long finger was 39.2 and 38.1 mm, respectively. Twenty-five screws from 7 manufacturers were analyzed with sizes ranging from 1.7 to 4.5 mm. Only 8 of 17 screws between 2.3 and 3.5 mm had a length range above 35 mm. Conclusions: Metacarpal head entry point and cascade angle can help identify the appropriate reduction with the guide pin starting point in the dorsal 25% to 35% of the metacarpal head. Surgeons should be mindful to choose the appropriate fixation system in light of the variations between metacarpal isthmus size, isthmus location, and available screw lengths.

Biomechanical comparison of intramedullary screw fixation, dorsal plating and K-wire fixation for stable metacarpal shaft fractures

We compared four methods of metacarpal shaft fixation: 2.2 mm intramedullary headless compression screw; 3.0 mm intramedullary headless compression screw; intramedullary K-wire fixation; and dorsal plate fixation. Transverse mid-diaphyseal fractures were created in 64 metacarpal sawbones and were assigned into four groups. Peak load to failure and stiffness were measured in cantilever bending and torsion. We found that dorsal plating had the highest peak load to failure. However, initial bending stiffness of the 3.0 mm intramedullary headless compression screw was higher than that of the dorsal plates. In torsion testing, dorsal plating had the highest peak torque, but there was no significant difference in torsional stiffness between the plate and intramedullary headless compression screw constructs. We concluded that intramedullary headless compression screw fixation is biomechanically superior to K-wires in cantilever bending and torsion; however, it is less stable than dorsal plating. In our study, the initial stability provided by K-wire fixation was sufficient to cope with expected loads in the early rehabilitation period, whereas dorsal plates and IHCS constructs provided stability far in excess of what is required.

Intramedullary Screw Fixation Comprehensive Technique Guide for Metacarpal and Phalanx Fractures: Pearls and Pitfalls

Background:

Phalangeal and metacarpal fractures are the second and third most common upper extremity fractures after distal radius fractures with varying methods of fixation techniques. Intramedullary screw fixation is an increasingly preferred method of fixation. Benefits include early range of motion, faster recovery, limited dissection, and reduced complications. Improper technique, which is readily avoidable, can lead to suboptimal results.

Methods:

A review of recent literature on current techniques aims to summarize the biomechanics of intramedullary screw fixation and outline appropriate technique of placing headless compression screws for metacarpal and phalangeal fractures.

Results:

We discuss through images and videos the indications, preoperative workup, and technical pearls and pitfalls to encourage surgeons to add this technique to their armamentarium and improve outcomes.

Conclusions:

intrameduallry screw fixation is a powerful option for metacarpal and phalanx fixation that allows rigid stability, enabling early return of function with excellent rates of union and total active motion. With knowledge of technical pearls presented in this article, common mistakes can be avoided to improve efficiency of screw placement and optimize patient outcomes.

Analysis of 1430 hand fractures and identifying the 'Red Flags' for cases requiring surgery: Head: Hand Fracture Treatment

BACKGROUND

Hand fractures constitute 20% of hand injury patients who apply to emergency services. Conservative approaches are satisfactory in the majority of the cases. However, the minority group in need of surgery reaches a serious number of patients considering the frequency of these injuries. Retrospective questioning of the indications of the performed surgeries is a proper way of understanding the decisional process for surgery.

PATIENTS/METHODS

Patients treated for hand fractures were retrospectively reviewed. Patient gender, age, finger/fingers involved, soft tissue involvement, treatment method (conservative/surgery) and if operated, devices used for fixation were noted. Plain radiographs of the patient were evaluated. Descriptive statistics of these variables and the effect of each variable on the decision for surgery were analyzed.

RESULTS

The study involved 1430 fractures of 1303 patients (1016 male and 287 female). Fifth finger was the most commonly injured digit (31%). Comminuted fractures (29%) followed by transverse fractures (29%) and spiral/oblique fractures (22%) were commonly diagnosed fracture types. Thirteen percent (13%) of the study group needed tendon/nerve/vessel repairs. Male patients, cases with soft tissue involvement, second, third and fourth finger fractures, fractures involving multiple digits, fractures with an intra-articular component, fractures with dislocation more than 4 mm and angulation more than 15° had a significantly higher rate of surgery.

CONCLUSION

Less than half of the hand fractures require surgery, and conservative treatment is usually preferred. Certain variables that indicate surgical treatment were identified with our study. These findings may help to weigh the options and choose the right path in doubtful conditions.

LEVEL OF EVIDENCE

Level 4, Case-control study.

Intramedullary Metacarpal Screw Fracture Fixation: A Retrospective Review of the Rehabilitation Literature and an Illustrative Case Report With a Postoperative Therapy Protocol

ABSTRACT

Intramedullary metacarpal screw fixation has shown promising results and quick functional recovery with the proper postoperative rehabilitation. The rehabilitative process after this procedure has not been compared across literature. A retrospective review of literature was used to recommend a therapy timeline, activity and recommendations to allow for proper postoperative rehabilitation for optimal results. An illustrative case report is presented to explain technique and outcomes.

Minimally Invasive Intramedullary Screw Versus Plate Fixation for Proximal Phalanx Fractures: A Biomechanical Study

PURPOSE

To compare the maximum interfragmentary displacement of short oblique proximal phalanx (P1) fractures fixed with an intramedullary headless compression screw (IMHCS) versus a plate-and-screws construct in a cadaveric model that generates finger motion via the flexor and extensor tendons of the fingers.

METHODS

We created a 30° oblique cut in 24 P1s of the index, middle, ring, and little fingers for 3 matched pairs of cadaveric hands. Twelve fractures were stabilized with an IMHCS using an antegrade, dorsal articular margin technique at the P1 base. The 12 matched-pair P1 fractures were stabilized with a radially placed 2.0-mm plate with 2 bicortical nonlocking screws on each side of the fracture. Hands were mounted to a frame allowing a computer-controlled, motor-driven, linear actuator powered movement of fingers via the flexor and extensor tendons. All fingers underwent 2,000 full-flexion and extension cycles. Maximum interfragmentary displacement was continuously measured using a differential variable reluctance transducer.

RESULTS

The observed mean displacement differences between IMHCS and plate-and-screws fixation was not statistically significant throughout all time points during the 2,000 cycles. A 2 one-sided test procedure for paired samples confirmed statistical equivalence in fracture displacement between fixation methods at the final 2,000-cycle time point.

CONCLUSIONS

The IMHCS provided biomechanical stability equivalent to plate-and-screws for short oblique P1 fractures at the 2,000-cycle mark in this cadaveric model.

CLINICAL RELEVANCE

Short oblique P1 fracture fixation with an IMHCS may provide adequate stability to withstand immediate postoperative active range of motion therapy.

Intramedullary percutaneous fixation of metacarpal fractures: screw versus connected K-wires

The purpose of the present study was to determine clinical and radiographic outcomes in patients treated with limited-open retrograde intramedullary headless screw fixation for metacarpal neck and shaft fractures (group I) versus percutaneous antegrade and retrograde intramedullary double pinning linked by a connector (group II). We designed a retrospective comparative study, with the inclusion of two groups (20 patients each) of metacarpal unstable fractures. Both groups showed similar outcomes at the final follow-up, except for extension lag (significantly better in group II) and return to sport (significantly better in group I). Intramedullary screw fixation did not accelerate bone union and range of motion recovery in the early follow-up. In conclusion, limited-open retrograde intramedullary headless screw fixation and percutaneous connected antegrade and retrograde intramedullary double pinning are both reliable techniques of fixation for metacarpal neck and shaft fractures. LEVEL OF EVIDENCE: III.

Minimally Invasive Corrective Osteotomy for Metacarpal Malrotation

Metacarpal fractures can be complicated by malrotation. This can cause functional problems with overriding or underriding of the fingers with flexion. Surgical treatment consists of corrective osteotomy and derotation. This is typically performed open and different techniques for osteotomy and fixation have been described. Postoperative complications include finger stiffness and hardware irritation. We propose a technique for minimally invasive corrective osteotomy of malunited metacarpal fractures with rotational malalignement. Advantages are quick rehabilitation and no prominent hardware.

Evaluation of Antegrade Intramedullary Compression Screw Fixation of Metacarpal Shaft Fractures in a Cadaver Model

PURPOSE

Surgical options for displaced metacarpal shaft fractures include the use of Kirschner wires, plates and screws, and most recently, intramedullary headless compression screws (IMHCS), which have been reported using only retrograde insertion through the metacarpal head. We evaluated IMHCS fixation of metacarpal shaft fractures through an antegrade approach in a cadaver model.

METHODS

We performed antegrade placement of IMHCS in 10 cadaver hands including all 5 digits (total of 50). Displaced transverse proximal metacarpal shaft fractures were created and reduced with a retrograde guidewire from the metacarpal head across the shaft fracture and exiting the metacarpal base. This was retrieved through a 6-mm dorsal wrist incision and overdrilled before the placement of a 4.1-mm-diameter IMHCS in the ring finger and a 4.7-mm screw in all other metacarpals. After IMHCS placement, carpometacarpal (CMC) joint violation was measured along with the optimal starting point for the guidewire on the metacarpal head relative to the dorsal cortex.

RESULTS

In all 50 metacarpals, we achieved successful fracture reduction and fixation without violating the extensor mechanism at the wrist. Our retrograde guidewire entry point through the metacarpal head ranged from 4.2 to 4.7 mm volar to the dorsal cortex. The actual area of CMC joint violated by IMHCS placement was largest in the index CMC joint (4.9%), followed by the middle (3.7%), little (2.9%), ring (0.5%), and thumb joints (0.2%).

CONCLUSIONS

Placement of IMHCS through an antegrade approach from the CMC joint can be performed effectively for all transverse metacarpal fractures, including the thumb, using a limited incision. There is minimal violation of the articular surfaces of the trapezium, capitate, and hamate for the thumb, middle, ring, and little metacarpals.

CLINICAL RELEVANCE

Antegrade IMHCS fixation successfully avoids the potential morbidity of creating a metacarpal head articular surface or extensor mechanism defect at the metacarpophalangeal joint seen with the retrograde approaches.

Metacarpal shaft fixation: a biomechanical comparison of dorsal plating, lag screws, and headless compression screws

Background

Metacarpal shaft fractures are common and can be treated nonoperatively. Shortening, angulation, and rotational deformity are indications for surgical treatment. Various forms of treatment with advantages and disadvantages have been documented. The purpose of the study was to determine the stability of fracture fixation with intramedullary headless compression screws in two types of metacarpal shaft fractures and compare them to other common forms of rigid fixation: dorsal plating and lag screw fixation. It was hypothesized that headless compression screws would demonstrate a biomechanical stronger construct.

Methods

Five matched paired hands (age 60.9 ± 4.6 years), utilizing non-thumb metacarpals, were used for comparative fixation in two fracture types created by an osteotomy. In transverse diaphyseal fractures, fixation by headless compression screws (n = 7) and plating (n = 8) were compared. In long oblique diaphyseal fractures, headless compression screws (n = 8) were compared with plating (n = 8) and lag screws (n = 7). Testing was performed using an MTS frame producing an apex dorsal, three point bending force. Peak load to failure and stiffness were calculated from the load-displacement curve generated.

Results

For transverse fractures, headless compression screws had a significantly higher stiffness and peak load to failure, means 249.4 N/mm and 584.8 N, than plates, means 129.02 N/mm and 303.9 N (both p < 0.001). For long oblique fractures, stiffness and peak load to failure for headless compression screws were means 209 N/mm and 758.4 N, for plates 258.7 N/mm and 518.5 N, and for lag screws 172.18 N/mm and 234.11 N. There was significance in peak load to failure for headless compression screws vs plates (p = 0.023), headless compression screws vs lag screws (p < 0.001), and plates vs lag screws (p = 0.009). There was no significant difference in stiffness between groups.

Conclusion

Intramedullary fixation of diaphyseal metacarpal fractures with a headless compression screw provides excellent biomechanical stability. Coupled with lower risks for adverse effects, headless compression screws may be a preferable option for those requiring rapid return to sport or work.

Level of evidence

Basic Science Study, Biomechanics.

Osteosynthesis of Fractures of the Metacarpal Neck with Self-Compressing Screw - Preliminary Analysis of 21 Cases

Objective  The present study aims to analyze the clinical results of the surgical treatment of metacarpal neck fractures with retrograde intramedullary fixation using cannulated headless screws (Herbert type).

Methods  Retrospective study of 21 closed fractures deviated from the metacarpal neck in 21 patients operated between April 2015 and November 2018.

Results  The sample included 19 men and 2 women. The mechanisms that caused the trauma were punching, falling to the ground and motor vehicle accident (n = 14, 5 and 2). The affected metacarpals were the 5 ^th , 3 ^rd , and 2 ^nd (n = 19, 1 and 1). Surgical indications were neck-shaft diaphysis of the metacarpal > 30° for the 2 ^nd and 3 ^rd metacarpals and > 40° for the 5 ^th metacarpal, shortening ≥ 5mm, rotational deviation, and the desire of the patient not to use plaster cast. In the immediate postoperative period, patients remained without immobilization and were instructed to mobilize their fingers according to tolerance. All patients had total active mobility > 240° and returned to their former occupations. All fractures consolidated and there were no reinterventions.

Discussion  The great advantages of the headless screw technique are its low morbidity, sufficient stability to avoid external immobilization, and reproducibility at low cost.

Conclusion  This is an easy, fast technique that has excellent results for the surgical treatment of displaced fractures of the neck of the metacarpals.

An Anatomical Study of Metacarpal Morphology Utilizing CT Scans: Evaluating Parameters for Antegrade Intramedullary Compression Screw Fixation of Metacarpal Fractures

PURPOSE

This study evaluated metacarpal morphology for antegrade placement of intramedullary headless compression screws (IMHCS) for metacarpal fracture fixation.

METHODS

We analyzed 100 hand computed tomography scans to quantify cortical thickness, intramedullary diameter, and metacarpal lengths. In addition, dorsal or ulnar overhang of the metacarpals over their respective carpal bones was measured. We also predicted optimal entry points for guidewire placement at the metacarpal head.

RESULTS

The ring finger metacarpal had the narrowest medullary canal width (coronal, 2.8 mm; sagittal, 3.5 mm). Not counting the thumb, the little finger metacarpal had the widest midshaft medullary width of 4.1 mm in the coronal plane and the middle metacarpal was widest in the sagittal plane with canal width of 3.9 mm. On average, there was maximal dorsal overhang at the base of the middle metacarpal (4.2 mm) and maximal ulnar overhang at the base of the small metacarpal (3.9 mm). The optimal entry point for guidewire placement over each metacarpal head was approximately 3.5 to 3.8 mm volar to the dorsal cortex.

CONCLUSIONS

Minimum IMHCS diameters of 3.5 mm for the ring and 4.0 mm for the index, middle and little fingers are necessary to achieve interference fit within the medullary canal. Minimum screw lengths of 38 mm would be needed to ensure 6 mm fixation past the midshaft of the metacarpals. Antegrade IMHCS for fixation of proximal metacarpal fractures may be most feasible with thumb, middle, and little finger metacarpals because there was larger dorsal or ulnar overhang to allow screw placement without violating the carpometacarpal joints.

CLINICAL RELEVANCE

Our analysis provides a reference guide for intramedullary screw sizes for each metacarpal of the hand to achieve interference fit with fracture fixation. Furthermore, the dorsal and ulnar overhangs of the metacarpal bases suggest the practicality of antegrade IMHCS fixation.

Single versus dual elastic nails for closed reduction and antegrade intramedullary nailing of displaced fifth metacarpal neck fractures

Closed reduction and internal fixation with antegrade intramedullary nails is a feasible and effective treatment for displaced fifth metacarpal neck fractures (FMNFs). The present study aimed to compare clinical and radiological outcomes in patients with displaced FMNFs after treatment with single or dual antegrade elastic intramedullary nails (AEIMNs). Thirty-three patients were treated with a single 2.0 mm AEIMN and 34 patients were treated with two 1.5 mm AEIMNs. Clinical and radiological outcomes included grip strength, active range of motion (ROM), active flexion and extension of the fifth metacarpophalangeal (MCP) joint, dorsal angulation loss, and metacarpal shortening of the fifth metacarpal at 12 months after treatment. No significant difference was observed between the two groups with respect to grip strength, ROM or flexion of the fifth MCP joint. The average values of dorsal angulation loss, metacarpal shortening, and extension of the fifth MCP joint of the dual nails group were better than those of the single nail group (dorsal angulation loss, 2.79 ± 1.93° vs. 4.05 ± 1.59°, P = 0.009; metacarpal shortening, 1.66 ± 0.80 mm vs. 2.12 ± 0.88 mm, P = 0.028; extension of the fifth MCP joint, 7.71 ± 4.43° vs. 4.82 ± 4.09°, P = 0.012). In conclusion, dual AEIMNs fixation provided better MCP extension and radiological outcomes than single AEIMN fixation.

Retrograde intramedullary headless compression screws for treatment of extra-articular thumb metacarpal base fractures

The purpose of the study was to evaluate clinical and radiological outcomes of extra-articular fractures involving the base of the thumb metacarpal treated with fixation using a retrograde intramedullary cannulated headless screw. A review of prospectively collected data was conducted on a consecutive series of 13 patients, treated with headless screw fixation for acute displaced fractures. All workers resumed full duties, while non-workers returned to unlimited leisure activities within a mean of 42 days. At 3 months follow-up, all range of motion measurements in the treated and untreated thumb were similar. Mean visual analogue pain score was 0.8 at rest and 1.4 during exercise and mean Quick Disabilities of the Arm, Shoulder, and Hand score was 5. All patients achieved radiographic union by 8 weeks. We conclude that the intramedullary headless screw fixation is safe and reliable for base of thumb metacarpal fractures, allowing for early postoperative motion and good functional recovery. Level of evidence: IV.

Cartilage and extensor tendon defects after headless compression screw fixation of phalangeal and metacarpal fractures

Osteosynthesis of metacarpal and phalangeal fractures with headless compression screws leads to a defect in the articular surface and possibly damage to the extensor tendons. This study aimed to quantify the articular surface defect and extensor tendon injuries after implant placement in cadaveric hands. Defect size was assessed with computed tomography. Extensor tendon injuries were assessed by direct visualization and measurement after dissection. In the middle phalanx, the defect size in relation to the joint surface was significantly smaller after anterograde screw placement when compared with retrograde placement. Also, a mini-open approach was found to cause significantly less tendon injury than a percutaneous approach, but there was no difference in tendon damage between retrograde and antegrade screw insertion into the middle phalanx.