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Introduction There has been a recent increase in the use of headless compression screws for fixation of metacarpal neck and shaft fractures as they offer several advantages and minimal complications have been reported. This study aimed to evaluate the clinical complications and their solutions following retrograde intramedullary headless compression screw fixation of metacarpal fractures. We describe complications and the approach to their management. Our hypothesis is that intramedullary fixation of metacarpal fractures is safe, with rare complications that can be easily managed.

Methods We performed a multicenter case series through retrospective review of all patients treated with intramedullary headless screw fixation of metacarpal fractures by three fellowship trained hand surgeons. Patient demographics, implant used, type of complication, pre- and post-operative radiographs, operative reports and sequelae were reviewed for each case. We defined complications as infection, loss of fixation, hardware failure, malrotation, nonunion, malunion, metal allergy and any repeat surgical intervention.

Results Four complications (2.59%) were identified through review of 154 total cases. One complication was a Nickel allergy that occurred two weeks after surgery. The screw was subsequently removed after fracture healing and there were no sequelae. One patient presented 10 months after surgery with a broken screw after repeat blunt trauma to the surgical area. This was treated with removal of the broken intramedullary screw and plate fixation of the resulting re-fractured metacarpal. Two patients had bent intramedullary screws. One of these patients had also sustained repeat blunt trauma to the surgical area at 6 months postoperatively. This was treated with removal of the bent hardware and plate fixation of the re-fractured metacarpal. The final patient presented at 18 months postoperatively for clearance into the military with a bent screw but was completely asymptomatic, the fracture was healed and the screw was left in place.

Conclusion To our knowledge, this is the first case series to report on the complications and their management following intramedullary screw fixation of metacarpal fractures. From this large series, the rate of complication is low at 2.59%. Of these, 1 was asymptomatic and 2 were patient driven secondary to repeat blunt trauma to the surgical area. There were no cases of infection or extensor tendon disruption. Intramedullary headless screws are a safe option for fixation of metacarpal neck and shaft fractures. Future work is needed to report on the long term implant survivorship, functional outcomes and arthritis rates of adjacent joints.