Intramedullary Fixation of Metacarpal Fractures Using Headless Compression Screws

Abstract

BackgroundThere is a lack of consensus on optimal treatment methods for operative fixation of metacarpal fractures. 1 Classic treatment options include plate and screw fixation or percutaneous fixation with Kirschner wires (K-wires). 1,2 For subcapital fractures or those fractures involving the metacarpal neck, the lack of distal purchase can preclude plate and screw fixation. Short oblique, transverse, comminuted, or multiple metacarpal shaft fractures typically require more rigid fixation with lag screws or plate and screw constructions. Plate and screw fixation can be associated with considerable metacarpophalangeal stiffness, necessitating secondary implant removal and joint release. While K-wire fixation for metacarpal fractures often results in bony union, it necessitates a period of immobilization and has a complication rate up to 16%. 3,4 Bouquet pinning with intramedullary wires placed in an antegrade manner can often be satisfactory but requires immobilization, future implant removal, and may not always offer secure fixation or rotational control. 5 Periarticular fractures of the upper extremity can be reliably treated with buried intra-articular fixation. 6-14 This series presents the clinical results of a relatively new technique of fixation for metacarpal fractures using retrograde intramedullary headless screws (IMHS) that allows early mobilization with minimal complications. Keywords► metacarpal fracture ► intramedullary fixation ► headless compression screw ► minimally invasive AbstractIntroduction The purpose of this study is to examine the clinical results of retrograde intramedullary headless screw (IMHS) fixation for metacarpal fractures. Methods A retrospective review was performed on 16 patients with 18 metacarpal fractures who underwent IMHS fixation at a single institution. The average age was 32 years. The indications for surgery included rotational malalignment (five patients), multiple metacarpal fractures (five patients), angular deformity (four patients), and shortening greater than 5 mm (two patients). The average length of follow-up was 19.4 weeks (median 10.2 weeks). Results Functional outcome was considered excellent in all patients with total active motion in excess of 240 degrees. Active motion was initiated within 1 week of surgery. No secondary surgeries were performed related to a complication of IMHS fixation. Conclusion IMHS fixation of metacarpal fractures is an efficacious treatment modality for patients with comminution, multiple fractures, malrotation, and those who require rapid mobilization. It obviates the need for immobilization or more extensive plate and screw fixation techniques with excellent clinical results.

A Comparative Study of Tensile Strength of Three Operative Fixation Techniques for Metacarpal Shaft Fractures in Adults: A Cadaver Study

“…Many studies have already attempted to prove clinical usefulness of headless compression screws in metacarpal fractures. Tobert et al16) suggested that intramedullary headless screw fixation of metacarpal fractures was an efficacious treatment modality for patients with comminution, multiple fractures, malrotation, and those who required rapid mobilization. Ruchelsman et al17) concluded that limited open retrograde intramedullary headless screw fixation was safe and reliable for metacarpal neck and subcapital and axially stable shaft fractures, allowed for early postoperative motion without affecting union rates, and obviated immobilization.…”

Management of Fifth Metacarpal Neck Fracture (Boxer's Fracture): A Literature Review

“…When compared to K-wire cross pinning, intramedullary fixation was shown to produce an improved range of motion and lower incidences of shortening [ 24 , 30 ]. A study retrospectively followed the outcomes with the usage of headless intramedullary screws for metacarpal neck and shaft fractures and concluded that the functional outcomes were excellent, producing a total range of motion of more than 240 degrees [ 26 ]. However, Padegimas et al support the use of headless screws for neck fractures only [ 24 ].…”

“…The screw is buried into the bone, which precludes the need for subsequent removal. Tobert et al suggested that this characteristic, along with improved rotational stability of the fracture reduction, offers an advantage over other techniques, such as K-wires, which require a repeat procedure to remove the wire [ 26 ]. Since the MCP joint surface is implicated during the insertion of the screw, violation of the articular surface is a concern to bear in mind.…”

“…Since the MCP joint surface is implicated during the insertion of the screw, violation of the articular surface is a concern to bear in mind. However, the study does not report any long-term consequences [ 26 ]. Headless intramedullary screws have been reported to produce similar biomechanical stability as compared to Kirschner wires [ 26 ].…”

“…Other potential benefits of the plate and screw fixation include ease of fixation when there is significant comminution is present or there are multiple metacarpal neck fractures [ 24 ]. However, a small distal fragment can reduce distal purchase for screw fixation, making this method unusable [ 26 ]. The method has also been reported to produce significant stiffness and extensor mechanism complications [ 24 ].…”