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Fix the Phalanx: A Systematic Review and Meta-Analysis Comparing Intramedullary Screws, Pinning, Plates, and Lag Screws for Closed Extra-Articular Proximal Phalanx Fractures
Brandon Hall, MD
1, Ahmad Essa, M.D. MPH
1, Shawn Khan, M.D.
1, Ryan Paul, MD
1, Andrea HW Chan, MD, MA, FRCSC
2, Kevin Zuo, MD, MASc
3; Jonathan Persitz, M.D.
1(1)University of Toronto, Toronto, ON, Canada, (2)Hospital for SickKids, Toronto, ON, Canada, (3)Toronto Western Hospital, University Health Network, Toronto, ON, Canada
Introduction:Proximal phalanx fractures are common hand injuries with several fixation options for management. The purpose of this study was to compare outcomes in closed extra-articular proximal phalangeal fractures treated with intramedullary screws (IMS), percutaneous pinning (PCP), plating, or lag screws.
Materials & Methods:A systematic literature review using MEDLINE, Embase, CINAHL and Cochrane databases from January 2010 to May 2025 was performed to identify studies assessing closed, extra-articular proximal phalangeal fractures managed with IMS, PCP, plating, or lag screws. A meta-analysis was then performed. Primary outcomes were complications and revision rates, and secondary outcomes were immobilization time and functional outcomes (total active motion [TAM] and grip strength). The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, and the risk of bias was assessed using Cochrane risk-of-bias tools.
Results:Twelve studies comprised of 19 treatment arms evaluating the aforementioned four fixation techniques for closed extra-articular proximal phalanx fractures were identified. Altogether, these studies had 403 patients with 528 fractures. Among these, 104 fractures were managed with IMS, 285 with PCP, 100 with plating, and 39 with lag screws. The mean patient age was 39 years, and the average follow-up duration was 16.4 months. IMS had the lowest rates of major (0.96%) and minor (2.13%) complications, compared to PCP (major: 6.67%, minor: 17.5%), plate (major: 8.10%, minor: 10.6%), and lag screws (major: 5.13%, minor: 47.4%). Plate fixation had significantly more major complications in comparison to IMS (
p = 0.02), while minor complications were significantly higher with lag screws (
p = 0.005) and PCP (
p = 0.02). Revision rates were lowest with IMS (5.77%) compared to PCP (5.94%), plate fixation (10.0%) and lag screws (10.3%), although statistical significance was not reached. IMS also had the shortest immobilization time (0.63 weeks vs. plate 0.87, lag 1.00 and PCP 3.87;
p = 0.01), highest grip strength (72.0 kg vs. plate 40.4, PCP 37.0, lag 35.0), and greatest TAM (231° vs. PCP 191°, plate 187°, lag 163°).
Conclusions:
This systematic review and meta-analysis suggest that intramedullary screw fixation is associated with fewer complications, shorter immobilization, and improved functional outcomes compared to plate fixation, lag screws, and K-wires. These benefits likely reflect its minimally invasive yet stable construct. However, given study heterogeneity, further long term prospective research is needed to confirm these findings and define the optimal fixation strategy for proximal phalanx fractures.
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