You are on page 1of 7

Eur J Trauma Emerg Surg

DOI 10.1007/s00068-017-0836-0


Antegrade intramedullary Kirschner-wire fixation of displaced
metacarpal shaft fractures
E. M. van Bussel1 · R. M. Houwert1 · T. J. M. Kootstra1 · M. van Heijl1 ·
D. Van der Velde1 · Ph. Wittich1 · J. Keizer1 

Received: 30 December 2016 / Accepted: 12 September 2017
© The Author(s) 2017. This article is an open access publication

Abstract  Conclusions  If surgical treatment for metacarpal shaft
Purpose  The objective of this study was to analyze com- fractures is considered, we recommend antegrade intramed-
plications and patient-related functional outcome after ante- ullary K-wire fixation. This technique results in low compli-
grade intramedullary Kirschner-wire fixation of metacarpal cation rates and excellent functional outcome.
shaft fractures.
Methods  All consecutive patients treated from January Keywords  Metacarpal · Shaft · Fractures · Internal
2010 until December 2015 were retrospectively analyzed fixation · Intramedullary · Kirschner wire · Minimal
using patient logs and radiographic images. Indications for invasive · Patient-related outcome
operative fixation were angulation > 40°, shortening > 2 mm,
or rotational deficit. Complications were registered from
the patient logs. Functional outcome was assessed with the Introduction
Patient-rated wrist/hand evaluation (PRWHE) and Disabili-
ties of the Arm, Shoulder, and Hand score (DASH) question- Fractures of the metacarpal bones account for a significant
naire both ranging from 1 to 100 after a minimum follow-up part of fractures in the hand; percentages up to 40% are
of 6 months. described in the literature with a shaft neck ratio of roughly
Results  During the study period, 34 fractures of 27 patients 1:2 [1]. These fractures are frequently observed in young
could be included. Mean outpatient follow-up was 11 weeks and active adults. Fractures of the metacarpal shaft are com-
(range 4–24 weeks). The mean interval for functional assess- monly observed after a punch or direct trauma. Most of these
ment was 30 months (range 8–62 months) and 19 patients fractures can be treated conservatively with an intrinsic plus
(70%) responded to the questionnaires. During outpatient position cast. Surgical treatment is indicated for unstable
follow-up, all fractures proceeded to union with no signs fractures, large dislocations or shortenings, as well as mal-
of secondary fracture dislocation or implant migration. rotations and communitive fractures [2].
One re-fracture after a new adequate trauma was seen and When surgical intervention is considered, multiple tech-
one patient underwent tenolysis due to persistent pain and niques are advocated in the literature such as transverse
impaired function. In 26 cases (81%), the K-wires were pinning, minifragment lag screws, and plate fixation [3, 4].
removed of which 23 (68%) were planned removals. Func- Although multiple studies have shown that plate fixation
tional outcome was excellent with mean PRWHE and DASH leads to a very rigid fixation, this technique requires sig-
scores of 7 and 5 points, respectively. nificant soft-tissue dissection. Multiple studies have shown
that complications are not uncommon after this technique.
Complications such as infections, adhesions, and stiffness
might be related to the relatively large incision [5, 6].
* E. M. van Bussel An alternative surgical technique is the insertion of one
or multiple intramedullary K-wires through a minimal inva-
Department of Traumatology, St Antonius Hospital, sive incision in the metacarpal shaft. Both durations of the
Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands surgical procedure as the iatrogenic tissue damage might


shortening > 2 mm. [7]. age. while surgery was performed either under loco-regional anes- thesia or under general anesthesia. degree of radiographical angulation. After sterile exposure. lent in the available literature. The local neously to facilitate implant removal (Fig. radio- from January 2010 until December 2015 were retrospec. and wound control were performed in the tively reviewed and invited to participate in this follow-up study. main indication for surgery. and days until surgery. M. case of insufficient stability. the K-wires were cut at the level of the periost This study was performed according to the Institutional for permanent intramedullary fixation (Fig. Postoperative treatment Study design Patients received dorsal cast immobilisation for a period A single center retrospective observational cohort was of 3 weeks or a compression bandage for 24 h with direct defined. 1) or subcuta- Review Board (IRB) medical ethics standards. Final fracture reduction was done by manipu- analyze complications and patient-related functional out.8–1. This technique was already described in at the base of the affected metacarpal bone—at the ulnar side 1976 by Foucher et al. the biggest hiatus might be A prebended 0. a second prebended K-wire was inserted through the same cortical opening. Patients received either a found IRB approval unnecessary due to the non-invasive compression bandage for 24 h or a dorsal blocking cast. All patients received pre-operative anti- biotic prophylaxis (Cefazolin 2 gram intravenous). Patients were referred to a spe- cht). the bony cortex of the metaphysis with a 2. or other external force]. but not many studies focusing for the fourth and fifth metacarpal bones and ulnar or radial solely on metacarpal shaft fractures have been published side for the third metacarpal bone—followed by opening of since then [8–10]. During follow-up. smoking. Indications for operative fixation were angulation > 40°.4 mm drill. a second drill hole was created at the contralateral side of the Materials and methods base of the metacarpal bone. especially after the first inserted in the metacarpal bone passing the fracture under few weeks of bone healing. graphic. diabetes. trauma mechanism [punch. Use of a tourniquet was based on the surgeon’s preference. Surgical technique Surgical procedures were performed by different trauma surgeons with various levels of experience as well as super- vised residents. lation of the inserted intramedullary K-wire. If closed reduction was Fig. (down) fall.and postoperative image of short K-wire fixation 13 . Antonius Hospital Nieuwegein/Utre. All consecutive patients who underwent fixation of an cialised hand physiotherapist for guided mobilisation when acute metacarpal shaft fracture (within 3 weeks after trauma) full function was not seen within 2 weeks after surgery or with one or more intramedullary Kirschner wires (K-wires) 2 weeks after cast immobilisation. The skin was medical ethical committee analyzed the study protocol and closed using absorbable sutures. performed post-operatively. Stability and comes longer than 6 months post-operatively after antegrade position of the K-wire were assessed under fluoroscopy. Alignment was and improved functional outcome while maintaining frac. E. All patients included in this study were identified by chart review using diagnosis treatment codes. checked under fluoroscopy. or rotational deficits. dominance of the affected hand. Later cases were not included to obtain follow-up of at least 6 months. The study was performed in a large level 2 regional functional aftercare. open or closed fracture.5 mm K-wire was then intramedullary patient-related functional outcomes. In intramedullary K-wire fixation of metacarpal shaft fractures. The aim of this study was to fluoroscopy. character of the questionnaires. Depending on the surgeon’s preference. open reduction was performed. 2). A small skin incision was made ture reduction. If necessary. This might result in lower complication rates unsuccessful. side.0–2. Although fracture healing seems excel. Conventional radiographic images were teaching hospital (St. The following baseline characteristics were collected: gender. van Bussel et al. function. closed reduction was attempted. 1  Pre. be reduced.

room. the periosteal buried K-wires were only removed from 0 to 50. A superficial wound infection was defined as described complications and patient-related outcomes. and unplanned implant removal. as well as complica- up. A deep wound infection included the association with the recorded complications. Non-union Statistical analysis was defined as lack of radiologic bony healing 6 months after surgery with clinical evidence of pain and/or motion Baseline characteristics. weeks. characteristics of a superficial wound infection with addi- tient department follow-up after full recovery. All patients were contacted and invited to participate in a mid-term functional evaluation using the PRWHE (patient- Implant removal rated wrist hand evaluation) and DASH (Disabilities of the Arm.Antegrade intramedullary Kirschner-wire fixation of displaced metacarpal shaft fractures Fig. impaired function at the end of clinical follow. Therefore. disability is tested on indication. a clinical suspicion of a wound infection based on redness In addition. were analyzed. but and differences in postoperative care were analyzed con- without the need for additional pharmacological or surgical cerning their potential statistical association with the intervention. implant other metacarpal fractures in separate sub-analyses.and postoperative images of long subcutaneous K-wires outpatient department. If possible this procedure was performed under local pain and disability are separately tested with scores ranging anesthesia. For both questionnaires. infections. differences in surgical treatment at the fracture site. by 30 questions next to an optional high-performance score. tional necessity of incision and irrigation in the operating each patient received clinical follow-up. All migration. tions and functional outcome. 2  Pre. In the DASH questionnaire. Potential complications were registered like the presence of The fifth metacarpal shaft fractures were compared to the non. as any deviation in the postoperative healing process. Shoulder and Hand) questionnaires. secondary fracture dislocation.or malunion. Both question- All subcutaneously buried K-wires were removed after 6 naires have a score ranging from 0 to 100. Malunion was defined as a rotational deficit in combina- tion with complete radiographic bony healing. baseline and perioperative parameters. the official Dutch translations were Outcome assessment used [11–13]. the patient-related outcome scores were also and pus and/or fever in combination with the necessity of analyzed concerning overall results and their statistical antibiotic treatment. Patients were released from outpa. dysesthesia. “Wound healing problems” were defined such as the number of K-wires and type of anesthesia. In the PRWHE. Statistical 13 . All clinical logs were analyzed for short-term postoperative Sub‑analysis of the fifth metacarpal shaft fractures recovery of function and pain during outpatient follow-up.

No shaft fractures were seen located in  I 22 (69%) the second metacarpal bone in this study group. The mean regular outpa. 34 shaft fractures in 27 patients  Punch 11 (41%) could be included. analysis was done with IBM SPSS statistics (version Table 1  Baseline characteristics 22. contrary to the planned K-wire removal of the K-wires. Twenty fractures were located in the fifth Pre-operative days 8 (SD 4) metacarpal bone. persistent complaints of pain and functional impairment 13 .  Other (direct) force 10 (37%) tient follow-up was 11 weeks (range 4–24 weeks).02). Most  Rotation 3 (9%) patients were young men with a metacarpal shaft fracture  Shortening 3 (9%) after a punch. No patients were lost to follow up  Downfall 6 (22%) in the outpatient department. ranges and if Characteristics Total patients (n = 27) appropriate standard deviations (SD) were reported. or the type of aftercare. removals which were done under local anesthesia in 68% One patient underwent tenolysis of the extensors due to of the cases. Functional aftercare was initiated in the end of outpatient department follow-up. Complications and implant removal In 26 fractures (81%). flexion lag of 10°. the buried K-wires were removed under general ing bone 6 weeks after primary surgery and 2 days after anesthesia in all three cases. the K-wires were inserted with the intention Postoperative cast 22 (69%) of subsequent planned removal by protruding the wires in Physiotherapy 12 (38%) the subcutaneous tissue for easy removal. For continuous variables. Male 21 (78%) Age in years 25 (SD 11) Patient characteristics Results  Right hand 21 (78%)  Smoking 6 (22%) Inclusion of study population  Diabetes 1 (4%) Trauma mechanism During the study period. A postoperative plaster immobilisation was sig.00-2013). The Characteristics Total fractures (n = 32) mean interval for mid-term functional assessment was 30 Metacarpal months (range 8–62 months) after primary surgery with a  Third 3 70% response rate or both questionnaires.  Fourth 9  Fifth 20 Baseline characteristics Main surgical indication  Angulation 26 (81%) The baseline characteristics are shown in Table 1. Three of the seven fractures with buried K-wires— radiographic and clinical union with no signs of second. In all three patients. the K-wire removal malunion were observed. Two patients experienced persistent local nificantly more frequent given after a single intramedullary dysesthesia in the area of proximal incision after 11 weeks of K-wire fixation compared to two intramedullary K-wires (82 follow-up. Complications were not significantly associated vs 40%) (p = 0. the number of k-wires. One patient was subject to a new resulted in complete relief of complaint. intended to be permanent—were eventually removed due to ary fracture dislocation or implant migration. with the baseline characteristics. necessary in one fracture. with an accepted ten cases. van Bussel et al. of which 23 removals were During outpatient follow-up. M. In the other nine fractures. A total of nine patients received but no full recovery of pain was seen after the tenolysis in physiotherapy due to suspected impaired function during this patient. and nine fractures in the fourth meta- Surgery time in minutes 22 (SD 9) carpal of which two had an additional fracture in the third Number of K-wires metacarpal bone. As depicted in trauma resulting in a re-fracture of the radiographically heal. One other patient did not reach full function at outpatient follow-up. Relief of complaints. No cases of pain or stiffness. E. The mean time of the total proce- dure from start of anesthesia until the endo of the surgical procedure was 22 min (SD 9). Table 2. In 23 frac-  II 10 (31%) tures (72%). the K-wires were cutoff at the level of the periost SD standard deviation for a permanent fixation. Open fracture reduction was 4 months after removal of the K-wires. all 32 fractures resulted in planned. the K-wires were removed after a mean of 6 weeks (Table 2).

provides a clear overview of the literature and com- plication rates of both transverse pinning and plate fixation of metacarpal shaft fractures [3]. cut off the implant subcutaneously and routinely remove the ity in the PRWHE questionnaire. Just like intramedullary Discussion fixation. 6]. perio- Functional outcome stal positioning of K-wires resulted in unplanned implant removal in half of the patients. Mean follow-up of both ques. complications and easy implant removal (68% under local tionnaires was 30 months (SD 17 months) with a response anesthesia in the outpatient department). et al. soft-tissue complications after plate fixation are observed in tive period of 30 month average. this is the first study focusing solely opportunity of direct functional aftercare. Shoulder and Hand (DASH) score  General 3 (100%) 8 (32%)  Number of responses (t = 51) 19 (70%)  Local 0 (0%) 17 (68%)  Total score (0–100) 5 (range 0–28) Surgery time in minutes 25 (SD 13) 7 (SD 3) SD standard deviation functional aftercare is a safe treatment option as it did not result in higher short-term complication rates. 8]. and short-term complications and outcome. highest DASH and PRWHE scores included the patient with The incidence of our complications appears to be lower a re-fracture and the patient who underwent tenolysis. The recently published systematic review of Greeven and PRWHE questionnaires (Table 4).Antegrade intramedullary Kirschner-wire fixation of displaced metacarpal shaft fractures Table 2  Removal of K-wires Table 3  PRWHE and DASH questionnaire scores Characteristics Short K-wires Long w-wires Patient-rated wrist/hand evaluation (PRWHE) (n = 7) (n = 25)  Number of responses (t = 51) 19 (70%) Number (% total) 7 (22%) 25 (78%)  Total score (0–100) 7 (range 0–37) Removed (% subgroup) 3 (43%) 25 (100%)  Pain score (0–50) 4 (range 0–24) Weeks until removal 20 (SD 10) 6. aftercare. As the review illustrates. The other method reviewed by Greeven et al. 5. and implant removal. respectively. Functional limitations are more frequently No differences were found for the incidence of complica. surgical intervention done under loco-regional anes. Although not mentioned in the review but fractures with low complication rates in a selected group of imaginable based on the transverse technique. these rate of 70%. adhesions. but also the results a higher rate of surgical re-interventions (up to 14%). Second. ing on antegrade intramedullary K-wire fixation of shaft 13 . Although promising could theoretically lead to more stiffness and pain of the results of surgical treatment could be reported. conservative affected hand. This is probably due to the extra-cutaneous intramedullary K-wire fixation of displaced metacarpal shaft ends of the pins. The average score for the PRWHE and DASH results support operative treatment under loco-regional questionnaires was. 7 and 5 out of a maximum anesthesia with functional aftercare. In addition. compared to other frequently used techniques such as plate fixation and transverse pinning [3. plate on metacarpal shaft fractures that has not only analyzed the fixation seems prone to high rates of stiffness. It is recommended to score of 100. Our findings suggest that ante- lessons could be conducted from this retrospective cohort grade intramedullary K-wire fixation with subcutaneous regarding type of anesthesia. Therefore. Patient-related functional outcome scores showed fixation limits the possibility of functional aftercare and excellent function of the injured hand. The five patients with the implant in the outpatient department. Third. treatment still remains the gold standard for the great major.7 (SD 4)  Disability score (0–50) 2 (range 0–13) Anesthesia The Disabilities of the Arm. encountered. with a higher score for pain than for disabil. plate fixa- ity of patients with metacarpal shaft fractures in our hospital. tion seems a reliable method of fracture fixation with the To our knowledge. transverse patients. burying of K-wire ends does not bear the negative charac- First. However. This finding is supported by other studies focus- patients were converted to general anesthesia. but shows a high incidence of (pin tract) infec- This study demonstrates uncomplicated bone healing after tions up to 25%. In contrast. teristics of transverse pinning nor open reduction and plate thesia was well tolerated in this cohort as none of these fixation. several clinical other studies as well [5. nor the functional outcome as reported by the DASH tissue. is fixation using a plate. transverse pinning is characterized by minimal soft- tissue injury. probably due to postoperative adhesions or scar tions. cutting off the Table 3 shows the functional outcome using the PRWHE K-wires subcutaneously resulted in a low rate of wound and DASH questionnaires. These of two well-known PROMs after a significant postopera. Bone-healing disor- Sub‑analysis of the fifth metacarpal fractures ders after surgical treatment of metacarpal shaft fractures in general are rare.

gov/ fixation with subsequent planned implant removal. Greeven APA. Complications of plate fixation in metacarpal fractures.9 PRWHE 6. Open reduc- but comparable outcome.nlm.05 Postoperative cast 12 10 r = 0. 18]. 2016. Meyer H.42:169– Court-Brown C. we recommend antegrade intramedullary K-wire Trauma (Internet). van Bussel et al. R. T. Thoder JJ. Lieberman G. as Creative Commons Attribution 4. and the choice of aftercare were completely surgeon dependent. Low YP. van Bussel. Low CK.ncbi. Philadelphia: LWW. Fusetti C.5 (range Conflict of interest  E. Stern R. which permits unrestricted use.03 DASH 4. Bezstarosti S. 2016. this technique is generally applica. metacarpal neck fractures and measured a mean DASH score of only 0. Wittich. Although this lack of standardization 1. J. Schipper IB. Papaloï- If surgical treatment for metacarpal shaft fractures is con. In line with common clinical 2. for the fifth stra. Van der Velde. M.52:535–9. Wong HC. provide a link to This retrospective study must be assessed in the light of the Creative Commons license. Koot- 1–26) after 3 months and Schädel-Höpfner et al. M. is the fact on the extension and flexion force ratios of the index and little that the procedures were performed or supervised by six fingers. med/10799096. J Hand Surg Br Scotl. A cadaver study of the effects of dorsal angulation and shortening of the metacarpal shaft practice as well and in favor of clinical feasibility. the follow-up rate of 70% for the PROMs might introduce a type 2 error regarding functional outcome. 1995.nih. This after 30 months on average. using both PRWHE and the DASH questionnaire. Ozer et al. We were able to report the mid-term functional outcome Ethical approval  This research did not involve any animal partici- using the validated patient-related outcome measurement pation. Stern PJ. http://www. 2002. tion and internal fixation versus percutaneous transverse Kirsch- ner wire fixation for single. optimal treatment essentials series). J Am Acad Orthop Surg Conclusion (Internet). pp 187–188 could not be fully assessed. McQueen MM. Especially.ncbi. Houwert.3) 8. The local ethical committee wrote a declaration which stated that the patients involved in this study could be contacted for the used tools (PRWHE and DASH) in 70% of the study population questionnaires and that no further ethical approval was mandatory. different surgeons. Page SM.0/).9 (SD 13. Due to their variable levels of experience 3. and reproduction in any medium. Eur J Trauma Emerg Surg. Kozin SH. provided you give appro- priate credit to the original author(s) and the source. E. 1st ed. M. Krijnen P. Wong HP. closed second to fifth metacarpal ble for most surgeons with interest in fractures of the hand. Keizer declare that they have no conflict of interest. gives an even more precise idea of the tivecommons. M.0 International License (http://crea- is done in our study. 13 . J Hand functional outcome. Ph. Complications and range of motion follow- ing plate fixation of metacarpal and phalangeal fractures. J sidered. Operative treatment of meta- carpal and phalangeal shaft fractures. van Heijl. 4. Neverthe. its limitations. http://www. 14–17]. for intramedullary fixation of metacarpal fractures in gen- eral.8 SD standard deviation *Significance r = Independent student T test or Pearson Chi–Square test fractures and literature of metacarpal fractures in general Compliance with ethical standards  [3.nih. and indicate if changes were made. with a mean DASH of 5 and a mean PRWHE of 7 show that the functional outcome of this technique is excellent. This pubmed/11901331.6 (SD 8) 5. Furthermore. M. zos M. Open Access  This article is distributed under the terms of the less.02 Fractures with two K-wires 9 1 r = 0. Accessed 1 Dec 2016 5.1) r = 0.3 (SD 10.2) r = 0. Trauma (orthopaedic surgery does illustrate common clinical practice.1 (SD 6. measured a mean DASH score of 9. distribution.8 (range 0–15) after 17 months [17.05 Treatment with a short K-wire 7 0 r = 0. the number References of K-wires used. The results of these PROMs declaration is in possession of the first author. Della. 2006. 8–10.20:609–13. and J.8:111–21. This is Informed consent  All involved patients gave their informed consent in line with the two other studies found measuring PROMs for usage of the anonymized results of these questionnaires. the use of a tourniquet. functional outcome than shown in the existing literature. Santa D. Table 4  Fifth metacarpal Characteristics Fifth Other Significance* (r) versus other (third and fourth) metacarpal shaft fractures Number 21 11 Surgery time in minutes 24 (SD 10) 18 (SD4) r = 0. Accessed 9 Nov 2016 technique results in low complication rates and excellent 6. Borisch N.nlm. shaft fractures: a systematic review.

Chemorin C. et al. 18. Peterson SL. 2002. 2010. DASH (disabilities of the arm. 2016. Cole D. Pennekamp intramedullary wire fixation of metacarpal shaft fractures. Gillani S.nlm. Ulrich C. Shoul. and head).gov/pub. Med (Internet). Corkum JP. Windolf J. 2008.ncbi. El Moumni M. van Meeteren NLU. Psychometric qualities of the of extra-articular metacarpal fractures. Lalonde DH.15:347–54.ncbi.nih. wrist evaluation (PRWE-NL) in patients with hand and wrist inju- sis in fractures of the distal 3d of the 5th metacarpus. de Jonge JJ. 9. Welle K. Ozer K. 13. Nouv Presse ries. Antegrade med/12449349. Hudak PL. http://www. and Hand questionnaire (DASH-DLV).33:1724–31. Sleegers EJA. Van Eck ME. http://link. http://www. pubmed/23689855. Orbay JL. lary nails. J Hand Ther med/19084170. Elastic titanium nails for minimally invasive intramedul- Orthop Belg Belgium. Beaton D.nlm. Touhami A.2522/ptj. Arch Orthop Trauma Surg.22:365–9. Development of an upper extremity outcome measure: the Orthop Trauma Surg (Internet). Acta PH. net). http://ptjournal. 1998.124:523–6.ncbi. Windemuth M. Tech Hand 16. Accessed 2 Nov 2016 intramedullary splinting or percutaneous retrograde crossed pin- 12. Bombardier C. Injury Engl. 1976. Accessed 1 Dec 2016 17.96:908–16. parison of intramedullary nailing versus plate-screw fixation man fractures. Kingma J. Williams A. Foucher G. Accessed 1 Nov 2016 14. Com- 11.nih. Morgan S. Systematic review of the Klasen HJ.nih. Self-correcting intramedullary 2013. Schädel-Höpfner M. Wendt KW.ncbi. 10. Kirschner wire fixation of metacarpal shaft fractures. Kelsch G. 2013.151:525–31.ncbi. 2007.nlm. Intramedullary k-wire fixation of metacarpal Up Extrem Surg.29:602–8. Phys Ther (Internet). Sibilly A.nih. A new technic of osteosynthe. Chammaa org/cgi/doi/10. http://www. Zirgibel BJ. Accessed 1 Dec 2016 LB. 1994. Am J Ind Med springer. Thomas PBM. Muller MC. Veehof MM.23:827–32. 2013.20140589. lary splinting of metacarpal fractures. J Hand Surg Am (Inter- Dutch language version of the Disabilities of the Arm. Z Orthop Unfall der.76:751–7.5:1139–40.127:435–40. Burger C. Reininga IHF. Accessed 12 Dec 2016 (Internet).8:253–60. Khalil A. 2004. Wild M. Davis ning for displaced neck fractures of the fifth metacarpal? Arch A. Single retrograde 15. shaft fractures with flexible nonlocking and locking intramedul- Hand (NY) US.nlm. 1996. Schuur. Linhart W.nlm. shoulder. Mokkink gov/pubmed/9763256. Macksoud WS. Structural validity of the Dutch version of the patient-rated 7. Davison PG.nih. (cited 2016 Nov 2) pubmed/934828. Accessed 2 Nov 2016 13 . Accessed 12 Dec 2016 (Internet). van Veldhoven NHMJ.Antegrade intramedullary Kirschner-wire fixation of displaced metacarpal shaft fractures Surg Am (Internet). Amadio PC. The treatment of unstable metacarpal and phalangeal best evidence in intramedullary fixation for metacarpal fractures.17(2):87–90.apta. http://www. van der Lei B. 8.