Low Rate of Complications Following Intramedullary Headless Compression Screw Fixation of Metacarpal Fractures

Advances in the Treatment of Hand and Wrist Injuries in the Elite Athlete

Caring for hand and wrist injuries in the elite athlete brings distinct challenges, with case-by-case decisions regarding surgical intervention and return-to-play. Metacarpal fractures, thumb ulnar collateral ligament tears, and scaphoid fractures are common upper-extremity injuries in the elite athlete that can be detrimental to playing time and future participation. Treatment should therefore endure the demand of accelerated rehabilitation and return-to-activity without compromising long-term outcomes. Fortunately, the literature has supported emerging management options that support goals specific to the athlete. This review examined the advances in surgical and perioperative treatment of metacarpal fractures, thumb ulnar collateral ligament injuries, and scaphoid fractures in the elite athlete.

Screw Position Following Percutaneous Versus Mini-Open Intramedullary Retrograde Screw Fixation of Metacarpal Fractures

BACKGROUND

Metacarpal fracture fixation using the retrograde intramedullary screw technique can be performed through two different approaches. The mini-open approach requires greater soft tissue dissection but allows for direct visualization of the metacarpal head compared with the percutaneous approach. Our aim was to determine which approach resulted in optimal screw position.

METHODS

Eighty-one consecutive patients that underwent intramedullary screw fixation for metacarpal fractures from 2016 to 2021 were identified. Patients were treated by 4 fellowship-trained orthopedic hand surgeons who employed the mini-open or percutaneous approach. Postoperative radiographs were reviewed for screw position.

RESULTS

A total of 81 patients (41 mini-open, 40 percutaneous) were included in this study. There were no significant differences between the two groups in age, sex, hand dominance, or affected digit. Postoperative screw position at first postoperative visit was not significantly different between the two groups on anteroposterior or lateral radiographs.

CONCLUSION

Postoperative screw position is not significantly different between the mini-open and percutaneous approaches for intramedullary screw fixation of metacarpal fractures.

LEVEL OF EVIDENCE

Level III, therapeutic.

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.

Metacarpal Shortening with Intramedullary Screw Fixation: A Cadaveric Study

Background  Intramedullary screw fixation is a commonly used technique for the management of metacarpal fractures. However, compression across the fracture site can lead to unintentional shortening of the metacarpal. Questions/Purposes  Our aim was to evaluate the risk of overshortening with differing intramedullary device designs for fixation of metacarpals. Methods  The small finger metacarpal of nine fresh-frozen cadavers were included. A metacarpal neck fracture was simulated with a 5-mm osteotomy. Three different intramedullary screw designs were compared. Each screw was placed in a retrograde fashion into the intramedullary canal and the amount of shortening measured. Screws were reversed and the number of reverse turns with the screwdriver needed to release overshortening were measured. Results  The average shortening at the osteotomy site was 2.5 mm. The mean shortening was 80%, 58%, and 12% for the partially threaded screw, fully threaded screw, and threaded nail, respectively. The mean differences of the distance shortened were statistically significant for the threaded nail compared with the partially and fully threaded screws. The partially threaded screw had the most shortening, while the threaded nail provided the least amount of shortening. When the screws were reversed, the screws did not disengage until the screw was fully removed from the osteotomy site. Conclusion  The fully threaded nail demonstrates less shortening and possibly minimizes overshortening of fractures compared with partially threaded and fully threaded screw designs. Overshortening cannot be corrected by unscrewing the screw unless completely removed from the distal fragment. Clinical Relevance  Orthopaedic surgeons may select intermedullary screws based on the design that is suited for the particular metacarpal fracture pattern.

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.

Fracture Fixation Strength in Metacarpal Plating Versus Intramedullary Nailing Using a 3-Point Bending Model: A Cadaveric, Biomechanical Study

PURPOSE

The purpose of our study was to evaluate the ultimate load to failure for 2 metacarpal fracture fixation strategies, plating versus intramedullary nailing, and then compare them to the native metacarpal. Our hypothesis was that the intramedullary nail after fracture fixation would more closely restore the native strength of the metacarpal when compared to plate fixation.

METHODS

Matched pairs of cadaveric hands (age range, 19-49; 5 men and 6 women) were dissected to produce 88 intact and equally distributed metacarpals (little, ring, middle, and index fingers). The metacarpals were then randomly selected to undergo either plate fixation or intramedullary nail fixation. A 3-point bending model was used to test the native metacarpal strength to the point of fracture and, subsequently, the fracture fixation construct. The data were then compared against the native metacarpal for normalized load to failure, normalized displacement, and stiffness.

RESULTS

The normalized maximum force (ratio of fixation:native) for the intramedullary nail specimens was significantly closer to normal than for the plated specimens for the little, middle, and index fingers, as well as for all metacarpals combined. We did not detect a difference in maximum force for the ring finger.

CONCLUSIONS

When compared to plate fixation, metacarpal intramedullary nailing more closely restores the ultimate load to failure of the native metacarpal after midshaft fracture.

CLINICAL RELEVANCE

For metacarpal fracture patterns amenable to intramedullary screw fixation, an intramedullary nail has biomechanical properties that are superior to a plate and screws in a 3-point bending model.

Intramedullary Fixation of Hand Fractures and Arthrodeses

Intramedullary fixation has long been popular for fracture fixation in the upper extremity from the shoulder through the carpus. Recently, intramedullary fixation in the hand has gained increasing interest, specifically in the metacarpals and phalanges, corresponding with the development of improved cannulated headless screw technology. Along with the advantages of increased operative speed and less surgical dissection, which can promote rapid healing, many benefits exist, supporting their use despite some drawbacks. This article reviews the background and biomechanics of intramedullary fixation with a specific focus on cannulated headless screws, describes the application and techniques of intramedullary screw fixation in the hand, and details the associated outcomes and costs for metacarpal fractures, phalangeal fractures, and interphalangeal joint arthrodesis.

Outcomes Following Fully Threaded Intramedullary Nailing of Metacarpal Fractures

Purpose

Intramedullary screw fixation has emerged as a popular approach for the treatment of displaced metacarpal fractures. The purpose of this study was to investigate the functional and radiographic outcomes of a newly designed, headless noncompressive fully threaded intramedullary nail (TIMN) for the treatment of metacarpal fractures.

Methods

A retrospective chart review was performed on patients who were treated with the INnate TIMN (ExsoMed) at a single academic institution with a minimum of 1-year follow-up. Patient-reported functional outcomes included Quick Disabilities for the Arm, Shoulder, and Hand (QuickDASH) questionnaires, return to work and physical activity time, and overall satisfaction. Radiographs were retrospectively reviewed to determine radiographic union, change in angulation, and metacarpal shortening.

Results

A total of 49 patients (58 fractures) with a mean age of 36 years (range: 17-75 years) were included. The mean follow-up time was 2.7 years (range: 1.4-4.3 years). Overall, the mean patient satisfaction rating was 4.9 of 5 (range: 3-5). The mean return to work time was 7.2 weeks (range: 0.14-28 weeks), and the mean return to sport or activity was 8.3 weeks (range: 1-28 weeks). Average QuickDASH scores across all patients were 4 (range: 0-56.9). The median radiographic healing time was 6.1 weeks (range: 4.7-15.4 weeks). Mean postoperative shortening in the fifth metacarpal fracture was 3 mm (range: -4.2 to 8 mm) at the initial postoperative visit and 3.6 mm (range: -3.3 to 7.9 mm) at the final radiographic follow-up. Subgroup analysis showed that postoperative shortening was similar, regardless of the fracture pattern. The following four complications were reported: one case of persistent pain and stiffness, one case of carpal tunnel syndrome, one nonunion, and one fractured intramedullary nail.

Conclusions

Our findings suggest that the TIMN allows for a reliable return to work and physical activity, high patient satisfaction, low complication rate, and minimal shortening at the final radiographic follow-up.

Type of study/level of evidence

Therapeutic IV.

Intramedullary K-wires versus Alternate Techniques for Metacarpal Shaft and Neck Fractures: A Systematic Review and Meta-analysis

Intramedullary K-wire (IMKW) fixation is one of the mainstays for surgically treating metacarpal shaft and neck fractures. However, there remains a lack of literature comparing outcomes of the various available surgical repair techniques in all indicated metacarpals. Therefore, we conducted a systematic review and meta-analysis to investigate the clinical advantages and drawbacks of IMKW compared with alternate fracture repair techniques. A comprehensive systematic literature review was performed to identify studies that compared clinical outcomes of IMKW to alternate metacarpal fixation modalities. Outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH/ quick DASH) scores, grip strength, union rate, visual analog scale pain, operative time, and complications. A random-effects model was used to compare IMKW to the pooled effect of other fixation techniques. A total of 10 studies were included in our analysis, comprising 497 metacarpal fractures (220 shafts and 277 necks). IMKW fixation was identified as the control group in all studies. The pooled experimental group included plates, transverse K-wires (TKWs), interfragmentary screws (IFSs), and K-wire cross-pinning (CP). In treating metacarpal shaft fractures, IMKW showed significantly shorter operative time ( p  = 0.04; mean difference = - 13; 95% confidence interval = -26 to -0.64). No significant differences were observed in treating metacarpal neck fractures for disability, grip strength, healing rate, pain, operative time, or complication rate. This systematic review and meta-analysis found no difference in clinical outcomes among various surgical techniques for treating metacarpal shaft and neck fractures. Further high evidence studies are required that investigate the efficacy and safety of IFS, CP, TKW, and intramedullary screws versus IMKW for treating closed, unstable metacarpal fractures.

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.

Prospective Comparison of the Early Outcomes of Headless Compression Screw and Percutaneous K-Wire Fixation in Metacarpal Fractures

PURPOSE

The study aimed to assess early clinical outcomes achieved by headless compression screws (HCS) in fixation of metacarpal fractures, and to compare them with outcomes of percutaneous K-wire fixation. The hypothesis was that HCS would show better arc of motion and superior early clinical outcomes.

METHODS

This was a randomized study of nonthumb metacarpal neck and shaft fractures. To compare the 2 surgical techniques, 23 patients treated for metacarpal neck and shaft fractures were divided into 2 groups: 11 treated with K-wire fixation and the other 12 with HCS fixation. We followed the patients for 12 weeks. The primary objective was to compare metacarpophalangeal arc of motion, and the secondary aim was to determine clinical union, radiographic union, and recovery time before returning to employment in the 2 groups.

RESULTS

At each follow-up visit, patients in the group treated with HCS had better metacarpophalangeal arc of motion than those treated with K-wire fixation. The HCS group showed a shorter time interval to return to work (at 3 weeks) and no complications, while the K-wire group had 1 pin track infection, which was treated with oral antibiotics and pin removal.

CONCLUSIONS

Compared with K-wire fixation, limited-open HCS fixation for metacarpal neck and shaft fractures was superior in terms of the early postoperative metacarpophalangeal arc of motion and return to work.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

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.

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 Role of the Hand Surgery Consultant in the Care of the Basketball Athlete

Basketball presents several characteristics that distinguishes it from other contact sports and can influence the manner by which a Team Physician and Hand Surgery Consultant interact. An abbreviated list of pathologies that affect the basketball athlete and the approach to their evaluation and treatment by a Hand Surgeon are described in context of return-to-play.

Anterograde Intramedullary Headless Compression Screw for Managing Extra-articular Thumb Metacarpal Base Fracture: Technique and Report

Extra-articular base fractures of the thumb are typical in hand surgeon practice. Nonoperative methods (spica) and operative methods are available for its management. There are operative methods described, such as plate and screws, Kirschner wires, and intramedullary screws. However, there is only a retrograde technique described. This study aims to present a new technique of an anterograde intramedullary headless compression screw to manage the extra-articular thumb metacarpal base fracture. This minimally invasive method allows an early range of motion and does not cross the articular surface of the thumb. This alternative fixation method has the advantage of low damage to soft tissues and good functional outcomes.

A Biomechanical Comparison of Fixation Techniques in Metacarpal Shaft Fractures

Background  Typically, metacarpal shaft fractures are treated with closed reduction percutaneous pinning, intramedullary nails, or plate fixation. Recently some surgeons have begun using intramedullary headless compression screws. Questions/Purposes  The purpose of this study was to compare intramedullary screw fixation to K-wire fixation, which is the standard of care in a transverse metacarpal midshaft fracture, using a cadaveric model. Our hypothesis was that intramedullary screw fixation would have a biomechanical advantage (higher stiffness and peak load to failure) when compared with dual Kirschner wire fixation of transverse metacarpal shaft fractures. Methods  Four-point bend testing was performed to compare stiffness and failure load values of seven paired 2nd and 3rd metacarpals instrumented with headless intramedullary compression screw fixation or Kirschner wire fixation. Similar testing was performed on 14 unpaired 4th metacarpals. Results  There was no significant difference in peak load ( p  = 0.60) or stiffness ( p  = 0.85) between fixation groups for the 2nd and 3rd instrumented metacarpals. For the instrumented 4th metacarpals, there was no significant difference in peak load ( p  = 0.14), but the stiffness was significantly greater ( p  = 0.01) for the compression screw group compared with the Kirschner wire fixation. Conclusions/Clinical Relevance  In this study, the load to failure was not different between the two fixation methods and likely both techniques can sustain physiologic loads needed for rehabilitation. The greater stiffness in the 4th metacarpal compression screw group may be related to the smaller canal morphology than in the 2nd and 3rd metacarpals. Larger diameter screws may be needed to obtain a better fit particularly in the 2nd and 3rd metacarpals.

Ideal Length and Diameter for Intramedullary Screw Fixation of Metacarpal Fractures: A Biomechanical Study

Purpose

This biomechanical study evaluated the effect of intramedullary screw diameter and length relative to 3-point bending force and torsional force when used to stabilize metacarpal shaft fractures.

Methods

Transverse osteotomies were made in the proximal metacarpal shaft in 36 middle finger metacarpal fourth-generation composite Sawbones. To compare screw diameters, antegrade intramedullary screws of 30-mm length were placed in 6 metacarpals, which included 4.7-mm Acutrak 2, Standard Acutrak 2 (4.0 mm), and Mini-Acutrak 2 (3.5 mm) screws. To compare screw lengths, metacarpals were fixated with Standard Acutrak 2 screws of 26, 30, or 34 mm in length, with screw tips bypassing the osteotomy by 6, 10, or 14 mm, respectively. A 6 degrees of freedom robot was used for torsional and 3-point bending testing.

Results

Increasing screw diameter demonstrated significant differences in both 3-point bending and torsional strengths. Maximum torsional loads were 69 Ncm (4.7-mm Acutrak 2), 45 Ncm (Standard Acutrak 2), and 27 Ncm (Mini-Acutrak 2) (P < .05). Loads to failure in the 3-point bending tests were 916 N (4.7-mm Acutrak 2), 713 N (Standard Acutrak 2), and 284 N (Mini-Acutrak 2) (P < .05). Differing screw lengths demonstrated significant differences with maximum torsional loads when comparing the 26-mm screws (22 Ncm) with 30- and 34-mm screws (45 and 55 Ncm, respectively) (P < .05). The 3-point dorsal bending strengths were significantly different between the 26-mm screws (320 N) and 30- and 34-mm screws (713 N and 702 N, respectively) (P < .05).

Conclusions

The results demonstrated significantly higher torsional strength and resistance to 3-point bending with larger intramedullary screw diameters. Further, when selecting the intramedullary screw length, the screw tip should pass at least 10 mm beyond the fracture.

Clinical Relevance

This study provided biomechanical evidence to guide surgeons in selecting intramedullary screw diameter and length for treating metacarpal fractures.

Retrograde Intramedullary Screw Fixation for Metacarpal Fractures: A Systematic Review

Common forms of fixation of metacarpal fractures have historically included percutaneous Kirschner wire fixation, plates and screws, and, more recently, intramedullary screw fixation. Retrograde intramedullary screws (RISs) are a novel modality first described 10 years ago. The purpose of this review is to critically evaluate the published literature assessing outcomes of RIS fixation for metacarpal fractures and create a complication profile for this novel technique. A comprehensive literature search was performed using electronic databases for both clinical and biomechanical studies in relation to RIS fixation published from 2000 to 2020. A total of 19 studies (13 clinical and 6 biomechanical) met the inclusion criteria. The clinical studies examined 603 metacarpal fractures and demonstrated adequate functional outcomes in terms of grip strength, total active motion, and time to return to work. The biomechanical studies examined 80 metacarpal fractures, finding that load to failure in RISs was often equal to or higher than Kirschner wires but less than plate and screws. The complication rate in reviewed studies was 2.8%, with the most prevalent complications being stiffness and extension lag. RIS use in metacarpal fractures appears to provide adequate stability with satisfactory clinical outcomes and minimal complications, although more high-quality studies are needed to fully examine this modality.

Fixation of Hand Fractures with Intramedullary Headless Compression Screws

Metacarpal and phalangeal fractures remain among the most frequently encountered orthopedic injuries, accounting for 10% of all fractures. For operative fractures, there is an array of treatment options with percutaneous kirschner wire stabilization and screw and plate fixation strategies predominating. Recently, a new fixation method was introduced, intramedullary (IM) fixation with headless screws, which has advantages of a percutaneous technique and buried hardware. The purpose of this review is to highlight the indications and surgical techniques of IM screw fixation of metacarpal and phalangeal fractures. Although more research is needed, IM fixation represents a potentially reliable alternative to Kirschner-wire and plate fixation.

[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.

Corrective Fifth Metacarpal Neck Osteotomy and Intramedullary Screw Fixation Technique: Technique and Case Report

Malunion of metacarpal fractures can result in severe functional and esthetic impairment to the patient, thus requiring surgical correction. Traditionally, the fixation methods most commonly used for these fractures are the Kirschner wires or the plates and screws. However, one of the options for the fixation of metacarpal fractures is intramedullary fixation with a headless screw. This minimally invasive method can also be used for corrective metacarpal osteotomies. It has the advantages of being a minimally invasive technique and allowing the early range of motion. This minimally invasive method can also be used to stabilize the corrective metacarpal osteotomies for malunion. This case report presents a minimally invasive technique for corrective dorsal metacarpal osteotomy and fixation with a headless intramedullary screw. This alternative fixation method has the advantage of low damage to soft tissues and good functional outcomes.

Effects of full-threaded headless cannulated compression screws and anatomical plates on the efficacy, safety, and prognosis of patients with triplane fractures of the distal tibia

OBJECTIVE

To compare the clinical efficacy, safety, and prognosis of full-threaded headless cannulated compression screws (HCCSs) and anatomical plates (APs) in the treatment of triplane fractures of the distal tibia.

METHODS

In this retrospective study, 74 patients with triplane fractures of the distal tibia treated in our hospital from April 2017 to March 2019 were selected as the research subjects. Among them, 38 patients receiving full-threaded HCCSs were assigned to the research group (RG), and the remaining 36 patients receiving APs were assigned to the control group (CG). The general indices, including operation, fracture healing, and ambulation times, efficacy, and complications were recorded and compared between the two groups. Visual analogue scale (VAS) was applied to assess pain, and a quality of life (QOL) survey was conducted at 6 months after surgery.

RESULTS

Compared with the CG, the operation time, fracture healing time, and ambulation time of the RG were significantly shortened (P<0.05). The proportion of patients with excellent and good outcomes and Mazur Scores in the RG were higher than those in the CG (P<0.05). The frequency of complications in the RG was lower than that in the CG (P<0.05). The preoperative VAS score did not exhibit significant differences between the two groups (P<0.05), but the scores in the RG at T1 and T2 were significantly lower than those in the CG (P<0.001). The QOL score in the RG (76.17±8.57) was also significantly higher than in the CG (71.54±8.02) (P<0.05).

CONCLUSION

Full-threaded HCCSs are more effective and safer than APs and can effectively improve the prognosis of patients with triplane fractures of the distal tibia.

A comparison of intramedullary cannulated screws versus miniplates for fixation of unstable metacarpal diaphyseal fractures

We carried out a prospective randomized study to compare the clinical and radiological results of metacarpal diaphyseal fractures treated with retrograde intramedullary headless cannulated screws (IHCS) and plates. Fractures were fixed with IHCS in 34 patients (37 metacarpals) and locked miniplates in 35 patients (40 metacarpals). The mean age was 33 years (range 18-61) in the IHCS group and 32 years (range 17-68) in plate group. All patients were followed up for 1 year. All fractures in the IHCS group united but there was one nonunion in the plate group. At final follow-up, there was no significant difference between the groups in total active movement, visual analogue pain score, Disabilities of the Arm, Shoulder, and Hand score and grip strength, although the study was not sufficiently powered to exclude differences with certainty. IHCS is a safe and fast technique that is a good alternative to plate fixation in metacarpal diaphyseal fractures.Level of evidence: I.

How to Manage Complications Related to the Use of Intramedullary Screws in Metacarpal Fractures: Case Series

The use of intramedullary screws has been increasing among hand surgeons in cases of metacarpal fractures due to their low morbidity, and because they minimize incisions and dissection, and require less tissue manipulation and deperiostization. However, there are few published articles on the complications that arise from its use. Therefore, the purpose of the current study is to present a series of cases of complications following the use of intramedullary screws in metacarpal fractures that required surgical intervention, and to describe the surgical technique used to solve them .

Methods We performed a retrospective multicenter study in which we reviewed the clinical history, surgical descriptions and radiographs of the patients submitted to fixation of intramedullary compression screws for metacarpal fractures. We defined as complications infection, lesion to the extensor apparatus, bending of the implant, loss of reduction, hardware failure, malrotation, and non-union.

Results Out of a total of 45 patients, we reported 3 cases of complication: 1 patient with loss of reduction, and 2 patients with bending of the implant. In the three cases, the screw was removed without complications, and the focus of the fracture was stabilized.

Conclusion Intramedullary fixation with compression screws is increasingly being used for metacarpal fractures, with reports of low rates of complications. In the series of cases herein reported, the complications were solved without difficulty, and the patients showed a good recovery in hand function in the follow-up. Knowledge of the possible complications and their management enables us to provide more safety to the patient at the time of choosing this technique.

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.

Intramedullary screw fixation of metacarpal and phalangeal fractures - A systematic review of 837 patients

Intramedullary screw (IMS) fixation is increasingly used as an alternative treatment option in metacarpal and phalangeal fractures of the hand. However, this technique is currently the subject of controversy among hand surgeons. The aim of this systematic review was to gain insight on radiological, functional and patient-rated outcomes reported in literature. A comprehensive literature search of PubMed, Embase, CENTRAL and CINAHL databases was conducted on March 1st, 2021. All studies reporting on fracture union, complications, and functional and patient-rated outcome in IMS fixation of metacarpal and/or phalangeal fractures were selected. Two prospective and 16 retrospective cohort studies were included, encompassing a total of 837 patients with 958 fractures (693 metacarpal, 222 proximal phalangeal and 43 middle phalangeal). Mean surgery duration was 26.4 min (range 5-60 min). Union was ultimately achieved in all fractures in a mean of 5.7 weeks (range 2-12 weeks). The procedure-related complication rate was 3.2%. The most frequently reported complication was limitation of joint motion, occurring in 2.0% of cases. Incidence of other complications, including loss of reduction, infection and screw protrusion did not exceed 1%. Overall mean total active motion averaged 243° and grip strength reached 97.5% of the contralateral side. The Disabilities of the Arm, Shoulder and Hand (DASH) score averaged 3.7 points. Duration of sick leave was 7.3 weeks. According to the findings of this systematic review, IMS fixation is a time-saving and safe minimally invasive solution for both metacarpal and phalangeal fractures, with a low rate of complications and promising functional and patient-rated results.

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.

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.