Outcomes of Metacarpal Shaft Fractures Treated by Open Reduction Internal Fixation With Plates and Screws Versus Intramedullary Screws

Abstract

Background:

Metacarpal fractures are among the most common orthopedic injuries. When metacarpal shaft fractures require surgical fixation, common options include closed reduction percutaneous pinning, open reduction internal fixation (ORIF) using plates and screws (PS), and intramedullary screw fixation (IMS). Certain metacarpal shaft fractures are amenable to ORIF with either PS or IMS. The purpose of this study is to compare the functional outcomes and complication rates between these techniques.

Methods:

A retrospective review was performed of all patients that underwent ORIF with PS or IMS of metacarpal shaft fractures between the years 2015-2021 at a single, large private-academic institution. Postoperative patient-reported outcome measures were collected and medical records were reviewed for complications and range of motion (ROM). In addition, complications were subdivided into major and minor complications in accordance with previously published data on the subject.

Results:

A total of 120 patients (60 PS, 60 IMS) were included in this study, and each of the groups were similar in age at the time of procedure, sex, hand dominance, laterality, and mechanism of injury. Postoperative functional scores were similar among both groups. Metacarpophalangeal joint ROM in the acute postoperative period was significantly greater in the IMS group when compared with PS. The overall complication rate was not significantly different between the 2 groups.

Conclusion:

When treating metacarpal shaft fractures, both ORIF with PS and IMS can achieve acceptable outcomes. Patients treated with either fixation method should be counseled on the risk of developing symptomatic hardware that may require removal.

Keywords

complications fracture intramedullary screw metacarpal open reduction internal fixation

Introduction

Metacarpal fractures are common, accounting for 10% to 40% of all hand injuries.^1-3 Most metacarpal fractures can be treated nonoperatively, but if the fracture is displaced and/or unstable, surgical treatment may be indicated. Surgical treatment options include external fixation, closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF) with plate and screws (PS), or ORIF with intramedullary screw (IMS).^4-8 Closed reduction percutaneous pinning requires less soft tissue dissection, however, complications include stiffness due to postoperative immobilization and pin tract infection due to exposed hardware.^5,9-11 Comparatively, open reduction internal fixation with PS requires increased soft tissue disruption but permits for greater fracture exposure allowing for easier fracture reduction and provides rigid fixation allowing for earlier mobilization.^7,12 Of these, IMS fixation with headless screws has been shown to provide earlier return to activity and good functional outcomes.^8,13 This technique is ideal for axially stable shaft fractures, as IMS can lead to displacement and shortening with oblique, spiral, and comminuted fracture patterns.^14-18 However, recent IMS designs are noncompressive and can be used with the aforementioned fracture patterns.^19,20 While ORIF with PS is an appropriate option, especially for fracture patterns not amenable to CRPP or IMS, it is a more invasive procedure that disrupts soft tissue, potentially leading to postoperative stiffness and tendon adherence.²¹

For fractures amenable to ORIF with either PS or IMS, there is no current consensus regarding which technique is better. Open reduction internal fixation with PS allows for increased fracture exposure at the expense of soft tissue disruption.^1,5 Commonly reported complications following ORIF with PS include stiffness, extensor lag, tendon adhesions, and revision surgery for hardware removal.¹ Intramedullary screw fixation minimizes soft tissue disruption, but since access is obtained through the metacarpophalangeal joint it risks joint stiffness and theoretically arthrosis.^{1,2,10,20,22-25} In addition, fracture reduction can be more challenging or incomplete and fixation is generally less rigid fixation compared with ORIF with PS.^1,2,10,22 Furthermore, insertion of the IMS violates the articular cartilage of the metacarpal head, which has the potential to cause future arthritis.²⁶ However, patients treated with IMS may be treated with a relatively short period of immobilization or no immobilization at all postoperatively, allowing for immediate active range of motion (ROM) compared with other techniques.^20,25

The purpose of this study is to compare the patient reported outcome measures (PROMs), ROM, and complication rates between metacarpal shaft fractures treated with PS and IMS. We hypothesized that the PROMS, ROM, and complications would not differ significantly between the 2 techniques.

Methods

Following institutional review board waiver, a retrospective review was performed to identify all patients who had undergone surgical fixation of a metacarpal fracture between 2015 and 2021 by 1 of 19 board certified, orthopedic hand surgeons at a single, private academic institution. The surgical database was searched using the Current Procedural Terminology (CPT) code 26615 (open treatment of metacarpal fracture, single, with or without internal or external fixation, each bone). Radiographs and operative reports were reviewed for all patients captured by the query to identify isolated, closed, non-thumb, skeletally mature metacarpal shaft fractures. Patients were included in the study if their fracture involved the metacarpal shaft, if their fracture was treated with PS or IMS, and if they had at least 1 postoperative follow-up visit. Patients were excluded from the study if their fracture did not meet inclusion criteria, such as metacarpal neck fractures, metacarpal base fractures, thumb metacarpal shaft fractures, multiple metacarpal shaft fractures, open fractures, and fractures in the skeletally immature. In addition, patients with prior metacarpal injuries, polytrauma, and/or inadequate follow-up were excluded.

Eight hand surgeons performed PS fixation only, 3 hand surgeons performed IMS fixation only, and 8 hand surgeons performed both PS and IMS fixation. Patients were indicated for PS or IMS fixation dependent on the discretion of the operative surgeon. Indications for operative management included rotational malalignment, shortening with extensor lag, angulation greater 20 degrees in the index and long fingers, angulation greater than 30 degrees in the ring finger, and angulation greater than 40 degrees in the small finger. Plate and screw fixation was selected for patients with long oblique fractures or comminution that precluded IMS fixation.

Surgical Technique

Fixation for patients in the PS group was performed using a dorsal incision over the metacarpal. The extensor tendons were identified and protected with retractors. Exposure and debridement of the proximal and distal fracture fragments was then performed, and the fracture was reduced and held with a reduction clamp or 0.035 k-wire. If the fracture pattern was amenable, lag screw fixation was performed. An appropriately sized plate with screws was then selected for fracture fixation (Figure 1a-c). Patients in the IMS group underwent an initial closed reduction maneuver. A guide pin was then placed in the metacarpal head midline in the coronal plane and in the dorsal two-thirds in the sagittal plane. At the discretion of the operative surgeon, fixation was then performed through a minimally invasive or percutaneous approach. The IMS was advanced in a retrograde fashion over the guide wire into subchondral bone (Figure 2a-c). Patients in both groups were immobilized in either a bulky, soft dressing or splint until first postoperative visit.

The 8 hand surgeons that performed PS fixation immobilized patients postoperatively until their first follow up visit in 1-2 weeks. Six of the 8 then transitioned patients into a prefabricated or custom occupational therapy (OT) splint that they were allowed to remove for OT and ROM. The other 2 surgeons discontinued immobilization at the first postoperative visit. Similarly, 2 of 3 hand surgeons that performed IMS fixation immobilized patients until their first preoperative visit and then transitioned patients to a splint that was removed for OT and ROM. The other surgeon discontinued immobilization at the first follow up visit (1-2 weeks). Amongst the 8 surgeons who performed both PS and IMS fixation, the postoperative protocols were the same between patients treated with PS and IMS. Six surgeons immobilized patients until their first postoperative visit and then transitioned patients to a removable splint for OT and ROM. One surgeon immobilized patients until their first postoperative visit and 1 surgeon placed patients into a bulky, soft dressing following surgery and allowed for immediate ROM postoperatively.

Electronic medical records (EMR) were reviewed for demographic characteristics including age, sex, and hand dominance. Postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) and QuickDASH (qDASH) scores, metacarpophalangeal (MCP) joint ROM, and complications were also recorded. Patients were seen at 1 to 2 weeks, 5 to 6 weeks, and 3 months postoperatively. Complications were classified into major and minor based on criteria which were modified from Page and Stern.²⁷ Complications meeting major criteria included extensor lag ≥ 35°, MCP or PIP joint flexion contracture ≥ 35°, nonunion, symptomatic hardware or symptomatic hardware failure, deep infection, and tendon rupture. Complications meeting minor criteria included extensor lag > 15° but < 35°, stiffness, total flexion MCP < 75°, MCP or PIP flexion contracture between 15-35°, asymptomatic malunion, asymptomatic hardware failure, superficial infection, and any adverse outcome not meeting major criteria. All postoperative radiographs were evaluated for metacarpal alignment, hardware placement, and radiographic healing defined as bony consolidation of at least 3 cortices.

The primary outcome measure was DASH and QuickDASH scores. Secondary outcome measures included postoperative MCP joint ROM and complications. All statistical analyses were performed using R Studio (Version 3.6.3, Vienna, Austria). Demographic outcomes were analyzed using Chi-Square or Fisher’s Exact Tests. All parametric data between treatment groups were tested for normality and then compared between the fixation modalities using T-tests or Mann-Whitney tests as appropriate. P values <.05 were deemed significant.

Results

A total of 120 patients (60 treated with PS and 60 treated with IMS) were included in the study. All patients had at least 1 postoperative follow-up appointment (average: 12 days; range: 3–25). One hundred and twelve patients (93%) had at minimum of 2 follow-up appointments. The average age regardless of fixation modality was 35 years (SD 17 years; range: 14 – 87). Age, sex, and hand dominance were similar among both groups. The small finger was the most commonly affected digit both groups (Table 1). There was no difference between the groups in mechanism of injury. However, the PS group had significantly more patients with oblique fracture patterns (71%) compared with the IMS group (P < .05). Transverse fracture patterns (51%) were the most commonly treated in the IMS group.

Table 1.

Mean Demographic and Fracture Characteristics of Study Population.

Variable	Total data	Plate	IMS
Variable	N = 120	N = 60	N = 60	P value
Age (SD)	35 (17)	37 (18)	33 (16)	.24
Sex:				.85
Men (%)	40 (33%)	21 (35%)	19 (32%)
Women (%)	80 (67%)	39 (65%)	41 (68%)
Hand dominance:				.36
Right (%)	101 (84%)	48 (79%)	53 (90%)
Left (%)	15 (12%)	10 (17%)	5 (8%)
Ambidextrous (%)	4 (4%)	2 (4%)	2 (3%)
Digit:				< .05
Index finger (%)	7 (6%)	6 (10%)	1 (2%)
Long finger (%)	12 (10%)	11 (18%)	1 (2%)
Ring finger (%)	26 (22%)	13 (22%)	13 (21%)
Small finger (%)	75 (62%)	30 (50%)	45 (75%)
Mechanism of injury:				.72
Low (%)	112 (93%)	55 (92%)	57 (95%)
High (%)	8 (7%)	5 (8%)	3 (5%)
Fracture pattern:				< .05
Oblique (%)	67 (57%)	41 (71%)	26 (44%)
Transverse (%)	41 (35%)	11 (19%)	30 (51%)
Wedge/multifragmentary (%)	9 (8%)	6 (10%)	3 (5%)

Note. IMS = intramedullary screw.

Disabilities of the Arm, Shoulder, and Hand and QuickDASH scores were similar among groups, with an average of 22.8 (SD 26.2) for IMS and 14.5 (SD 21.2) for PS at an average of 25 weeks postoperatively (Table 2). Range of motion at the MCP joint was collected by fellowship trained orthopedic hand surgeons and hand therapists until postoperative week 6 is presented in Table 3 and Figure 3. The IMS group had significantly greater MCP joint flexion at 2 weeks compared with the PS group (P < .05). However, both groups exhibited similar postoperative ROM by postoperative week 6.

Table 2.

Comparison of Mean Postoperative Functional Scores, Complications, and Time to Radiographic Healing.

Variable	Total	Plate	IMS	P value
Variable	N = 120	N = 60	N = 60
Postop DASH (SD)	17.7 (23.5)	14.5 (21.2)	22.8 (26.2)	.19
Time of Postop DASH (Weeks; SD)	25 (30)	30 (35)	16 (17)	< .05
Patients with complications (%)	22 (18%)	14 (23%)	8 (13%)	.24
Major complications (%)	10 (8%)	8 (13%)	2 (3%)	.10
Minor complications (%)	15 (13%)	9 (15%)	6 (10%)	.58
Weeks to radiographic healing (SD)	11 (8)	11 (7)	11 (9)	.56

Note. IMS = intramedullary screw; DASH = disabilities of the arm, shoulder, and hand.

Table 3.

Comparison of Postoperative Mean Range of Motion.

Degrees of motion	Total data	Plate	IMS	P value
Degrees of motion	N = 59	N = 24	N = 35
2-week flexion (SD)	67 (23)	57 (25)	74 (18)	< .05
2-week extension (SD)	3 (11)	0 (15)	4 (9)	.28
	N = 26	N = 18	N = 8
3-week flexion (SD)	59 (20)	56 (21)	65 (17)	.27
3-week extension (SD)	2 (13)	-3 (12)	10 (10)	< .05
	N = 23	N = 16	N = 7
4-week flexion (SD)	67 (21)	66 (17)	71 (28)	.24
4-week extension (SD)	-1 (10)	-3 (13)	1 (4)	.61
	N = 27	N = 16	N = 11
5-week flexion (SD)	77 (17)	72 (19)	84 (11)	< .05
5-week extension (SD)	1 (4)	1 (4)	1 (3)	.56
	N = 43	N = 24	N = 19
6-week flexion (SD)	85 (11)	84 (14)	86 (8)	.90
6-week extension (SD)	1 (5)	2 (7)	1 (3)	.96

Note. IMS = intramedullary screw.

Ten patients had complications meeting major criteria. Eight patients treated with PS developed symptomatic hardware, with 7 patients undergoing removal of hardware (ROH). One patient treated with PS had symptomatic hardware failure involving screw backout and required revision ORIF. Two patients treated with IMS developed symptomatic hardware, with 1 undergoing ROH.

A total of 15 patients developed complications meeting minor criteria, with some patients having more than 1 complication. Complications meeting minor criteria include the following: stiffness (6 PS, 4 IMS), MCP or PIP flexion contracture between 15° and 35° (1 PS), and any adverse outcome not meeting major criteria (2 PS, 2 IMS). Of those not meeting major criteria in the PS group, 1 patient had delayed osseous healing requiring a bone stimulator, 1 patient developed tenosynovitis requiring corticosteroid injection, and neither required reoperation. Of those not meeting major criteria in the IMS group, 2 patients developed tenosynovitis requiring corticosteroid injection that did not require reoperation.

Patients who underwent PS had a similar rate of overall complications when compared with those who underwent IMS (14% vs 8%, P = .24). When accounting for major complications, the PS group had a higher complication rate than IMS, but this did not reach statistical significance (8% vs 2%, P = .10). There was no difference when comparing rate of minor complications for the PS group and IMS group (9% vs 6%, P = .58).

Discussion

Surgical management of metacarpal shaft fractures with ORIF can consist of PS and IMS constructs. To date there remains no consensus as to the optimal treatment of these injuries.^1-8 The purpose of this study was to compare the short-term outcomes and complication profiles of metacarpal shaft fractures treated with these 2 constructs.

Previous studies have examined the outcomes and complications for different ORIF techniques in isolation. Fusetti et al¹² retrospectively examined a cohort of 129 patients treated with PS fixation and found that 35% of patients had complications including nonunion, stiffness, and hardware failure. Page and Stern reported a similar complication rate of 36% for metacarpal fractures treated with plate and screws, but included both open and closed fractures.²⁷ Comparatively, lower rates of complications (3%-5%) including stiffness, extension lag, and loss of reduction have been reported in patients treated with IMS.^8,13,24,28 Increased complications seen in PS compared with IMS might be attributed to the greater soft tissue disruption required for ORIF, which can lead to scarring, adhesions, and delays in mobilization.^12,27,28 Eisenberg et al²⁸ found that a study of 91 patients treated with IMS all had full functional ROM by last follow up (Average: 10 weeks) with 3% of patients experiencing a minor complication of < 65° of MCP flexion and that 76% had reached radiographic union by 6 weeks.

We found no statistically significant difference in postoperative functional scores as illustrated by DASH and QuickDASH scores, which were similar to QuickDASH scores for surgically managed metacarpal fractures reported in Southam et al.²⁹ In this study, patients who underwent PS fixation did not have a significant difference in major complications when compared with those who underwent IMS. When accounting for minor complications and overall rate of complications, both groups had a similar rates. The majority of reported complications for ORIF with PS were limitations in ROM, which is likely reflective of the more extensive soft tissue dissection required for PS compared with IMS.

Our study has several strengths. First, our study includes a considerably larger sample size compared with previous studies.²² Second, we isolated metacarpal shaft fractures that were amenable to ORIF with PS or IMS from other fractures patterns. Therefore, our findings are directly applicable to metacarpal shaft fractures and PS or IMS fixation, compared with other studies that included multiple types of fixation.

Our study also has some limitations. First, though these data demonstrate an increased rate of postoperative complications, particularly major complications in the PS group, the study was not powered to detect whether that difference was statistically significant. In addition, our study was not powered enough to detect a significant difference in patient reported outcome measures due to the relatively short follow up period. However, the differences between the 2 groups in PROM were small and a larger study population is unlikely to provide a clinically meaningful difference. Furthermore, PROM were collected at considerably different time points 30 weeks for PS and 16 weeks for IMS fixation. This is likely reflective of the differences in time to final follow up where patients who underwent PS fixation had a significantly later final follow up appointment compared with those who underwent IMS fixation. It is possible that PROM might have been superior in the IMS group if they were recorded at the same time points. Second, procedures were not performed by a single surgeon, so we were unable to control for differences in operative techniques, implant selection, and postoperative protocols. It is possible that differences in immobilization could have affected postoperative ROM. However, postoperative immobilization protocols were the same for patients in the PS and IMS groups treated by the same surgeon. Third, we included patients that had at least 1 postoperative follow-up visit which is a relatively short time period. However, our study focuses on short-term outcomes and the majority of the patients included in our study had a second postoperative follow-up visit. Finally, the study was limited by its retrospective nature, as some patients within the study cohort did not have documented postoperative ROM and PROM, which we have reported within our results. In addition, there is the possibility of selection bias due to the study’s retrospective design.

In conclusion, ORIF with PS and IMS are comparable options for the treatment of isolated metacarpal shaft fractures. There was no significant difference between each groups’ experience of postoperative complications related to symptomatic hardware, limitations in ROM, and stiffness. The results of our short-term study suggests that both PS and IMS fixation are acceptable for surgical management of metacarpal shaft fractures.

Footnotes

Acknowledgements

We would like to thank Matthew B. Sherman, BS for his assistance with statistical analysis.

Ethical Approval

This study was reviewed by the Institutional Review Board at Thomas Jefferson University and approval was waived.

Statement of Human and Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all patients for being included in the study.

Statement of Informed Consent

Informed consent was obtained from all individual participants included in the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Stephanie A. Kwan

Tiffany N. Bridges

Johnlevi S. Lazaro

Jeffrey C. Lynch

Christopher Jones

References

Kollitz

Hammert

Vedder

, et al. Metacarpal fractures: treatment and complications. Hand. 2014;9(1):16-23. doi:10.1007/s11552-013-9562-1

Diaz-Garcia

Waljee

JF.

Current management of metacarpal fractures. Hand Clinics. 2013;29(4):507-518. doi:10.1016/j.hcl.2013.09.004

Meals

Hand fractures: a review of current treatment strategies. J Hand Surg Am. 2013;38(5):1021-1031; quiz 1031. doi:10.1016/j.jhsa.2013.02.017

Black

Mann

Constine

, et al. Comparison of internal fixation techniques in metacarpal fractures. J Hand Surg Am. 1985;10(4):466-472. doi:10.1016/S0363-5023(85)80067-8

Greeven

Bezstarosti

Krijnen

, et al. Open reduction and internal fixation versus percutaneous transverse Kirschner wire fixation for single, closed second to fifth metacarpal shaft fractures: a systematic review. Eur J Trauma Emerg Surg. 2016;42(2):169-175. doi:10.1007/s00068-015-0507-y

Wong

Higgins

JP.

Evidence-based medicine: management of metacarpal fractures. Plast Reconstr Surg. 2017;140(1):140e-151e. doi:10.1097/PRS.0000000000003470

Dreyfuss

Allon

Izacson

, et al. A comparison of locking plates and intramedullary pinning for fixation of metacarpal shaft fractures. Hand. 2019;14(1):27-33. doi:10.1177/1558944718798854

Ruchelsman

Puri

Feinberg-Zadek

, et al. Clinical outcomes of limited-open retrograde intramedullary headless screw fixation of metacarpal fractures. J Hand Surg Am. 2014;39(12):2390-2395. doi:10.1016/j.jhsa.2014.08.016

Hsu

Schwartz

Kalainov

, et al. Complications of K-wire fixation in procedures involving the hand and wrist. J Hand Surg Am. 2011;36(4):610-616. doi:10.1016/j.jhsa.2011.01.023

10.

Couceiro

Ayala

Sanchez

, et al. Intramedullary screws versus Kirschner wires for metacarpal fixation, functional, and patient-related outcomes. Surg J. 2018;4(1):e29-e33. doi:10.1055/s-0038-1637002

11.

Lutsky

Edelman

Leinberry

, et al. A prospective evaluation of complications after use of exposed pins in the hand and wrist. Plast Reconstr Surg. 2019;144(3):659-664. doi:10.1097/PRS.0000000000005921

12.

Fusetti

Meyer

Borisch

, et al. Complications of plate fixation in metacarpal fractures. J Trauma. 2002;52(3):535-539. doi:10.1097/00005373-200203000-00019

13.

del Piñal

Moraleda

Rúas

, et al. Minimally invasive fixation of fractures of the phalanges and metacarpals with intramedullary cannulated headless compression screws. J Hand Surg Am. 2015;40(4):692-700. doi:10.1016/j.jhsa.2014.11.023

14.

Urbanschitz

Dreu

Wagner

, et al. Cartilage and extensor tendon defects after headless compression screw fixation of phalangeal and metacarpal fractures. J Hand Surg Eur Vol. 2020;45(6):601-607. doi:10.1177/1753193420919060

15.

Jann

Calcagni

Giovanoli

, et al. Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws. Hand Surg Rehabil. 2018;37(2):99-103. doi:10.1016/j.hansur.2017.12.005

16.

Padegimas

Warrender

Jones

, et al. Metacarpal neck fractures: a review of surgical indications and techniques. Arch Trauma Res. 2016;5(3):e32933. doi:10.5812/atr.32933

17.

Hannah

Aboelmagd

Yip

, et al. A novel technique for accurate Poller (blocking) screw placement. Injury. 2014;45(6):1011-1014. doi:10.1016/j.injury.2014.02.029

18.

Ricci

OʼBoyle

Borrelli

, et al. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. Journal of Orthopaedic Trauma. 2008;22(suppl 3):S39-S45. doi:10.1097/BOT.0b013e31816c02a5

19.

Thomas

Muchintala

Crutchfield

, et al. Outcomes following fully threaded intramedullary nailing of metacarpal fractures. J Hand Surg Glob Online. 2024;6(1):85-90. doi:10.1016/j.jhsg.2023.10.003

20.

Chao

Patel

Shah

Intramedullary screw fixation comprehensive technique guide for metacarpal and phalanx fractures: pearls and pitfalls. Plast Reconstr Surg Glob Open. 2021;9(10):e3895. doi:10.1097/GOX.0000000000003895

21.

Le Nen

. Extra-articular fractures of the digital metacarpals and phalanges of the long fingers. Chir Main. 2014;33(1):1-12. doi:10.1016/j.main.2013.08.007

22.

Ozer

Gillani

Williams

, et al. Comparison of intramedullary nailing versus plate-screw fixation of extra-articular metacarpal fractures. J Hand Surg Am. 2008;33(10):1724-1731. doi:10.1016/j.jhsa.2008.07.011

23.

Straszewski

Dickherber

Conti Mica

MA.

Articular involvement with retrograde headless compression screw fixation of the metacarpal. J Hand Surg Am. 2024;49(1):62.e1-62.e6. doi:10.1016/j.jhsa.2022.05.010

24.

Anene

Thomas

Matzon

, et al. Complications following intramedullary screw fixation for metacarpal fractures: a systematic review. J Hand Surg Am. 2024;49:1043.e1-1043.e16. doi:10.1016/j.jhsa.2023.01.012

25.

Morway

Rider

Jones

CM.

Retrograde intramedullary screw fixation for metacarpal fractures: a systematic review. Hand. 2023;18(1):67-73. doi:10.1177/1558944720988073

26.

ten Berg

Mudgal

Leibman

, et al. Quantitative 3-dimensional CT analyses of intramedullary headless screw fixation for metacarpal neck fractures. J Hand Surg Am. 2013;38(2):322-330. doi:10.1016/j.jhsa.2012.09.029

27.

Page

Stern

PJ.

Complications and range of motion following plate fixation of metacarpal and phalangeal fractures. J Hand Surg Am. 1998;23(5):827-832. doi:10.1016/S0363-5023(98)80157-3

28.

Eisenberg

Clain

Feinberg-Zadek

, et al. Clinical outcomes of limited open intramedullary headless screw fixation of metacarpal fractures in 91 consecutive patients. Hand. 2020;15(6):793-797. doi:10.1177/1558944719836235

29.

Southam

Driessens

Burton

, et al. A retrospective cohort study of QuickDASH scores for common acute trauma conditions presenting for hand therapy. J Hand Ther. 2017;30(1):41-48. doi:10.1016/j.jht.2016.07.004