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Clinical Outcomes of Limited-Open Retrograde Intramedullary Headless Screw Fixation of Metacarpal Fractures
David Ruchelsman1; Mark Belsky1; Matthew Leibman1; Sameer Puri2; (1)Newton Wellesley Hospital, (2)Tufts University School of Medicine
Division of Hand Surgery, Newton-Wellesley Hospital/Tufts Univ., Newton, MA, USA

Background: Fixation countersunk beneath the articular surface is well-accepted for peri-articular fractures. Quantitative 3D-CT data supports the use of an articular starting point for extra-articular metacarpal fractures. Intramedullary headless compression screw (IMHS) fixation offers clinical advantages over percutaneous Kirschner wire and open techniques.

Purpose: To evaluate clinical and radiographic outcomes in patients treated with limited-open retrograde IMHS fixation for metacarpal neck and shaft fractures.

Methods: Design: Retrospective review of prospectively collected data on a consecutive series of 20(18M; 2F) patients, mean age 32(range, 16-66) treated with IMHS fixation for displaced neck/subcapital fractures at a single academic hand surgical practice between 2010-2012. This technique was also used in an acute axially-stable shaft fracture (n=1) and for three nascent malunions (neck, n=2; shaft, n=1).The dominant hand was involved in 17/20 cases (85%). All patients began active motion within the first postoperative week. A hand based splint was utilized until suture removal. Clinical outcomes were assessed with digital goniometry, pad-to-distal palmar crease distance, and grip strength. Time to union and radiographic arthrosis at latest follow-up was assessed. 16 of 20 patients reached mean follow up of 6.0 months (range, 121.8).

Results: All patients achieved full composite flexion with pad-to-distal palmar crease distance=0 mm. All patients demonstrated full active MP extension or hyperextension at latest follow-up. Grip strength measured 94% (range, 65-116) of the contralateral hand. No secondary surgeries were performed. All patients achieved radiographic union by 6 weeks. There was no radiographic arthrosis at latest follow-up. One patient reported an occasional click with MP motion that did not require further treatment.

Conclusion: Limited open minimally invasive retrograde IMHS fixation is a safe and reliable technique for metacarpal neck/subcapittal and axially-stable shaft fractures; allows for early postoperative active motion without affecting union rates; obviates immobilization; and avoids complications associated with K-wire and plate/screw constructs. This technique offers distinct advantages in select patients (i.e. athletes). Technique, current indications, pearls and pitfalls are reviewed.

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