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

Abstract

Sir: We read with interest the article entitled “Intramedullary Screw Fixation of Metacarpal Fractures Results in Excellent Functional Outcomes: A Literature Review.” We agree with the authors that this technique can provide a successful fixation in many metacarpal and phalangeal fractures.1,2 However, it is a shame that available evidence does not include a reliable comparison with traditional methods, such as bouquet wiring, Kirschner wire fixation, and plating. An average follow-up of 11 months in the pooled data is far too short to determine the long-term outcome, including clinical sequelae to the metacarpophalangeal joint. In our hospital, we have experienced a number of complications with cannulated screw fixation for both elective and trauma scenarios. On one occasion, a cannulated screw could not be advanced farther and eventually jammed, the device snapped, and we were not able to retrieve the implant. We were forced to burr the exposed end of the implant with a diamond burr (Fig. 1).Fig. 1.: Failed cannulated screw fixation in the middle proximal phalanx. The implant could not be retrieved, and intraosseous wiring was performed to salvage fixation.We have also experienced two cases where rotational stability could not be controlled in metacarpal shaft and neck fractures. Eventually, these fractures shifted and healed by secondary bone union (Fig. 2). We have also had two cases where the implant for a fifth metacarpal shaft fracture bent postoperatively at the fracture site, and since this time, we have been more cautious with our rehabilitation regimen.Fig. 2.: Demonstration of fracture rotation and displacement with healing by secondary bone union in a metacarpal fixation with cannulated screw.We would not recommend its use in patients with severe osteoporosis or rheumatoid arthritis, as we have had an inability to gain purchase of the bone in such cases and have had to use traditional fixation methods for salvage. It is important to appreciate that cannulated screws work best in the absence of comminution. On one occasion, as the screw compressed through a slightly comminuted fracture, it shortened the long bone axis. This resulted in the right size screw ending up being vaguely longer than expected. With regard to fifth metacarpal fractures, unless the patient has significant shortening, extensor lag, and a rotational deformity, many of these can be managed conservatively. Cannulated fixation has a place in those patients who have high-demand jobs and want to go back to work quickly. However, it may act as a strut3 and will not be as robust as plate fixation. Sletten et al., in a randomized controlled trial, found no difference between conservative treatment of neck fractures and bouquet pinning; however, they did find a significantly higher amount of sick leave and complications in the operative group.4 Bouquet wiring has advantages that the metacarpophalangeal joint does not need to be violated5; however, it is a difficult technique, and often it is hard to get at least three round 0.8-mm wires in the medullary canal. We routinely use headless compression screws for fixation at our unit; however, their indications and long-term safety profile have yet to be determined. Indications for metacarpal fractures should include noncomminuted head, neck, and shaft fractures. A multicenter trial will be necessary to compare headless compression fixation with other methods of fixation or no fixation at all. DISCLOSURE None of the authors has a financial interest in any of the products or devices mentioned in this communication. Dariush Nikkhah, F.R.C.S.(Plast.)Royal Perth HospitalPerth, Western Australia, Australia Juan Enrique Berner, M.R.C.S.Queen Victoria HospitalEast Grinstead, United KingdomKellogg CollegeUniversity of OxfordOxford, United Kingdom Mark Pickford, F.R.C.S.(Plast.)Queen Victoria HospitalEast Grinstead, United Kingdom