TECHNIQUE

Intramedullary Headless Screw Fixation for

Metacarpal Fractures
Thomas R. Sellers, MD,* Jesse T. Lewis, MD,† Carson Smith, MD,‡
and Jason A. Nydick, DO†‡

Key Words: metacarpal fracture, intramedullary fixation, headless

Abstract: Multiple techniques have been proposed for metacarpal screw, retrograde
fracture fixation, including percutaneous Kirschner-wires, interfrag-
mentary screws, plate and screw constructs, intramedullary (IM) nails, (Tech Hand Surg 2021;25: 45–51)
and cannulated IM headless screws. Each of these treatment options has
its proposed advantages and disadvantages, and there remains no con-
sensus on the optimal mode of treatment. We describe a technique of
retrograde IM headless screw fixation for extra-articular metacarpal
M etacarpal fractures are common injuries, comprising 18% to
44% of all hand fractures.1,2 The majority of these injuries
are isolated, simple fractures involving the metacarpal neck or shaft
fractures. and can be treated nonoperatively with little to no expected

FIGURE 1. Radiographs of an 18-year-old male basketball player who sustained a displaced fracture of the fifth metacarpal neck.
Anteroposterior and oblique views demonstrate shortening and angulation. The injury occurred during the basketball season, and the
patient desired for early return to sport.

From the *Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL; †Florida Orthopaedic Institute; and ‡Department of
Orthopaedic Surgery, University of South Florida, Tampa, FL.
Source of Funding: J.A.N. has the following disclosures: Axogen—paid consultant and paid presenter or speaker; Checkpoint Surgical—paid presenter or speaker;
Depuy (A Johnson & Johnson Company)—paid consultant and paid presenter or speaker; Journal of Hand Surgery American—editorial or governing board;
Techniques in Hand & Upper Extremity Surgery—editorial or governing board; Mission Surgical—Paid consultant; Trimed—paid consultant; Conmed—paid
consultant. For the remaining authors none were declared.
Address correspondence and reprint requests to Thomas R. Sellers, MD, Department of Orthopaedic Surgery, University of Alabama at Birmingham, 12011
11th Avenue South, Suite 200, Birmingham, AL 35205. E-mail: sellerst1313@gmail.com.
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Sellers et al Techniques in Hand & Upper Extremity Surgery  Volume 25, Number 1, March 2021

functional impairment.3 Nonoperative treatment options include

splinting or casting with or without closed reduction and functional
taping.4 However, in cases of marked displacement, shortening, or
malrotation not controllable by closed means, surgical stabilization
may be warranted.
Multiple operative techniques and implants have been
utilized for the treatment of metacarpal fractures. These include
percutaneous fixation with Kirschner-wires,5,6 intramedullary (IM)
nails,7,8 and cannulated intramedullary headless screws (IHS),9–12 as
well as open reduction and internal fixation with interfragmentary
screws or plate and screw constructs.8,13 Although each of these
treatment options has its proposed advantages, no single method has
consistently proven to be superior in the literature.14 Headless
compression screws have been used successfully for a variety of
hand and wrist fractures.15–17 Moreover, IM fixation has become
the standard of care for the treatment of long bones of the lower
extremity, owing to its excellent biomechanical strength and pres-
ervation of soft tissue. In the setting of extra-articular metacarpal
fractures, IM implants have the potential to offer a less invasive
method of fixation without sacrificing stability. We describe our
preferred surgical technique for IHS fixation of the metacarpal and
report a case series from our institution.

INDICATIONS/CONTRAINDICATIONS
We consider IM screw fixation most appropriate for extra-articular
fractures of the index, long, ring, and small finger metacarpals.
Indications for surgical intervention of metacarpal fractures in
general are controversial but may include malrotation of the digit or
excessive shortening or angulation that cannot be satisfactorily
controlled with closed means. The decision for surgery must be
individualized for each patient (Fig. 1). FIGURE 3. The starting point for the wire is dorsal in the
metacarpal head to facilitate passage down the shaft.

FIGURE 2. A guidewire may be placed percutaneously into the FIGURE 4. The guidewire is advanced retrograde down the shaft
metacarpal head in line with the shaft. into the metacarpal base.

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Techniques in Hand & Upper Extremity Surgery  Volume 25, Number 1, March 2021
We have found IM screw fixation to be most beneficial for
those patients who desire early return to work or sport, partic-
ularly manual laborers and high-level athletes. It may also be
advantageous in the setting of multiple metacarpal fractures,
where open dissection of multiple bones can be time-
consuming and may cause excessive soft tissue trauma.
Contraindications include comminuted, intra-articular
fractures of the metacarpal head or base. Simple, partial articular
fractures can be considered for IM screw fixation if the fracture
pattern allows, but extensive articular involvement may compromise
fixation in the metacarpal head segment. Furthermore, length
unstable fracture patterns (eg, long spiral oblique, comminuted) may
be less amenable to IM screw fixation.
TECHNIQUE
Set-up
The patient is positioned supine with the operative arm on a
hand-table. The procedure is performed under general anes-
thesia or local block with monitored anesthesia care.
Exposure
The metacarpophalangeal (MCP) joint of the affected digit is
placed into flexion. A closed reduction of the fracture is
performed. If closed reduction is unsatisfactory, an incision can
FIGURE 5. With the skin and extensor mechanism retracted, the
cannulated drill may be advanced by hand down the metacarpal.
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IHS Fixation for Metacarpal Fractures
be made at the fracture site to achieve anatomic reduction.
A reduction clamp may be used as necessary to maintain
reduction. A guidewire is placed percutaneously or through a
small incision in retrograde fashion into the metacarpal head
under fluoroscopic guidance (Fig. 2). The starting point for the
wire should be central in the metacarpal head on the ante-
roposterior view and dorsal in the metacarpal head on the lateral
view aiming down the metacarpal shaft (Fig. 3). The wire is
advanced by oscillating retrograde down the metacarpal shaft
into the metacarpal base, taking care not to perforate the cortex
(Fig. 4). Finger cascade and rotation are monitored and con-
trolled throughout.
Through a small incision, the skin is retracted and the
underlying extensor mechanism is exposed. The guidewire may
be placed adjacent to or directly through the extensor tendon. A
longitudinal split is then made in the extensor mechanism and
capsule at the entry site of the wire to expose the metacarpal
head just enough to allow safe passage of the drill and screw.
Fixation
With the skin and underlying soft tissues retracted with 2 blunt
Ragnell retractors, a cannulated depth gauge is inserted over the
wire to measure the desired screw length. We prefer to use the
longest screw that will fit inside the bone. However, screw
length may be limited by the manufacturer. We most commonly
FIGURE 6. The drill may be advanced across the fracture site and
down the metacarpal shaft to prepare a path for the screw.
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Sellers et al Techniques in Hand & Upper Extremity Surgery
use a screw of 40 mm in length, as this has often been the
longest screw available. Shorter screws (eg, 25 mm or less) are
not recommended. After measuring screw length, the guidewire
may be advanced further through the base of the metacarpal for
enhanced fixation, which will help prevent inadvertent removal
of the wire during drilling.
A partially threaded headless compression screw with a
diameter of 3.0 mm is generally chosen. Although larger screws
may provide enhanced fixation, we are cognizant of the
increased articular defect in the metacarpal head. Furthermore,
we have found a 3.0 mm screw to provide adequate stability to
allow for early mobilization for most patients. Occasionally, a
smaller screw (eg, 2.4 mm) may be considered for certain cases,
particularly when the fracture involves the fourth metacarpal,
which on average has a narrower isthmus compared with the
neighboring metacarpals. We prefer to use a partially threaded
versus a fully threaded compression screw. We feel that com-
pression across the fracture site is not generally necessary, and a
fully threaded compression screw may over-compress the
fracture site and potentially generate excess torque, risking
breakage of the screw head or driver.
Next, the appropriate cannulated drill is inserted over the
guidewire and advanced by hand through the articular surface and
subchondral bone of the metacarpal head up to the fracture site
(Fig. 5). Avoiding drilling by power may help minimize the risk of
tendon injury or irritation. It is not routinely necessary to advance
the drill past the fracture site down the entire length of the meta-
carpal. However, for patients with a narrow medullary canal, it may
necessary to advance the drill across the fracture site and through
the isthmus to allow easier passage of the screw (Fig. 6). The screw
is then advanced with a screwdriver by hand (Fig. 7) until the head
FIGURE 7. The screw is inserted retrograde by hand down the
metacarpal with a driver.
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 Volume 25, Number 1, March 2021
of the screw is buried deep to the articular surface within the sub-
chondral bone (Fig. 8). Care is taken to ensure maintenance of
fracture reduction during screw insertion, particularly with regard to
metacarpal rotation with final tightening.
Final fluoroscopic views are obtained to ensure adequate
fracture reduction and proper position of the screw (Fig. 9). The
hand is assessed clinically for appropriate rotation and digital
cascade with passive wrist motion and the tenodesis effect.
Closure
The wound is irrigated with sterile saline. The small hole in the
capsule and extensor mechanism are not routinely repaired. The
skin is closed with a single 4-0 nylon suture and a sterile dressing is
applied. Patients are typically placed into a bulky soft dressing.
Patients with multiple metacarpal fractures, comminution or more
extensive soft tissue injury may be placed into a plaster splint.
Rehabilitation
Our typical protocol involves hand therapy initiated within 3 to
5 days for edema control, active and passive range of motion, and
application of a resting orthosis. Patients are encouraged to remove
the orthosis for bathing and motion, and it is discontinued once they
obtain full range of motion and satisfactory healing is suspected
based on clinical exam. Radiographs are also assessed throughout
follow-up to ensure maintenance of fracture reduction and
satisfactory metacarpal alignment. The rehabilitation protocol can
be accelerated or modified based on the individual patient and injury
characteristics.
FIGURE 8. The head of the screw is buried within the
subchondral bone of the metacarpal head.
Techniques in Hand & Upper Extremity Surgery  Volume 25, Number 1, March 2021 IHS Fixation for Metacarpal Fractures

FIGURE 9. Final anteroposterior and lateral fluoroscopic views demonstrate appropriate screw position and fracture reduction.

EXPECTED OUTCOMES COMPLICATIONS

The small incision and minimally invasive procedure facilitate a
rapid recovery. Most patients are able to begin active range of
motion immediately following the procedure. Furthermore, the
IM implant imparts stable fixation that allows for return to
activity, including manual work or sport (Fig. 10).
Most patients can expect recovery of function with full
range of motion of the hand and digits. A recent series of 91
patients by Eisenberg et al18 using a similar technique reported
achievement of a full functional arc of MCP motion in all
patients and an average grip strength of 104% of the contra-
lateral hand. All patients had full, unrestricted use of their hand
at 6 weeks, with 76% of patients achieving radiographic union
by that time.
The complications of this surgical technique are similar to other
means of metacarpal fixation, including possible loss of fracture
reduction and potential for infection. There is also a risk of
stiffness of the involved MCP joint secondary to the incision in
the extensor mechanism and the capsulotomy. However, we
feel that the minimal soft tissue and bony dissection required
with this technique along with the absence of hardware on the
metacarpal surface limit scar formation and the potential for
extensor tendon adhesion, thereby preserving range of motion.
A theoretical risk of this technique is that of potential
arthrosis of the MCP joint secondary to violation of the articular
cartilage. In the series by Eisenger et al,18 there was one case of
early arthrosis noted in a patient with a head-split component to

FIGURE 10. Radiographs at 2 weeks postoperatively demonstrate maintenance of fracture reduction with improved alignment of the
fifth metacarpal.

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Sellers et al Techniques in Hand & Upper Extremity Surgery
FIGURE 11. A cadaver dissection demonstrates the articular
defect in the dorsal aspect of the metacarpal head.
their fracture, but this may have been a result of the intra-
articular nature of the injury as opposed to the surgical tech-
nique. In our experience, we have not encountered any cases of
iatrogenic arthritis or the development of chronic pain at the
MCP joint secondary to screw insertion. Most activities are
performed with the MCP joint in flexion, and the screw enters
the metacarpal head dorsally in a relatively non–weight-
bearing, nonarticulating area, which may account for the
apparent lack of complications postoperatively (Fig. 11).19
Malrotation of the metacarpal is a potential complication
and preventing its occurrence during the initial operation is of
paramount importance. Although metacarpal angulation and
shortening can often be well-tolerated, malrotation can cause
significant dysfunction in addition to poor cosmesis. As men-
tioned previously, care must be taken to prevent malrotation
with final tightening of the implant. If malrotation does occur,
the screw should be backed out and the metacarpal must be
realigned and stabilized before re-insertion. Fully flexing the
interphalangeal and MCP joints into a fist during screw inser-
tion often provides sufficient rotational stability. If metacarpal
rotation is still a concern, consideration should be given to an
open reduction and potentially an alternative means of fixation.
In the event that a malunion were to occur postoperatively with
a significant rotational deformity, a corrective osteotomy may
be indicated. Although we have not yet encountered this sce-
nario, we would recommend removal of the IM screw and
application of a dorsal plate and screw construct for rigid
fixation.
Hardware complications are another potential risk. Although
the final implant is buried in bone and unlikely to be prominent, the
IM screw is not immune to standard screw-related complications,
such as stripping of the screw head and difficulty with late removal.
Fortunately, the cannulated system may help to mitigate these risks,
as the implant and driver are placed directly over a guidewire which
helps ensure a colinear trajectory and proper seating of the driver
within the screw head. In the event that late hardware removal is
necessary, the defect in the articular surface may be partially filled in
with fibrocartilaginous tissue and potentially bone. In this setting, a
formal open exposure of the metacarpal head through a dorsal
approach may be required to fully expose the screw. This should be
done with caution and only if absolutely necessary, as complete
exposure of the screw head may require creation of an even larger
defect in the articular surface. Fortunately, we have not had to
remove any IM screws to this point, but screw removal should be
facilitated by the reverse-cutting thread design of most current
implants.
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CASE SERIES
Between 2010 and 2016, 42 simple fractures of the metacarpal neck and
shaft were treated with IHS fixation by 1 of 4 fellowship-trained hand
surgeons at our institution. Exclusion criteria for this analysis included
thumb metacarpal fractures, fracture comminution, involvement of the
metacarpal head or base, long spiral or oblique fractures, polytrauma of
the ipsilateral wrist or extremity, and open injuries with soft tissue
damage that prevented primary closure. IHS fixation included implants
from DePuy Synthes (West Chester, PA) and Acumed (Hillsboro, OR).
Screw sizes included were 2.4, 3.0, and 3.5 mm.
All patients went on to fracture union at an average of 7.7 weeks.
At final follow-up, MCP motion averaged 89 degrees and Quick DASH
score averaged 0.4. Postoperative radiographic evaluation revealed an
average anteroposterior and lateral angulation of 3 and 2 degrees, respec-
tively, and an average of 0.6 mm of metacarpal shortening, indicating good
overall maintenance of fracture reduction and metacarpal alignment. There
were no documented cases of rotational deformity. There were no infections
and no instances of hardware failure.
DISCUSSION
IM fixation obviates the need for direct exposure of the fracture
site, thereby minimizing the amount of soft tissue disruption.
Particularly for simple fracture patterns that do not require
direct visualization to achieve an anatomic reduction, this may
offer a less invasive technique with the potential for lower
complication rates and shorter operative times. Although a
previous comparison study between IM nailing and plate
fixation for extra-articular fractures reported unacceptable rates
of complications with IM fixation,8 more recent techniques
using cannulated IHS fixation have shown promising short-term
results,9–12,18 and this has been our experience as well.
REFERENCES
1. Chung KC, Spilson SV. The frequency and epidemiology of hand and
forearm fractures in the United States. J Hand Surg Am.
2001;26:908–915.
2. Gudmundsen TE, Borgen L. Fractures of the fifth metacarpal. Acta
Radiol. 2009;50:296–300.
3. Kollitz KM, Hammert WC, Vedder NB, et al. Metacarpal fractures:
treatment and complications. Hand. 2014;9:16–23.
4. Ford D, Ali M, Steel WM. Fractures of the fifth metacarpal neck: is
reduction or immobilization necessary? J Hand Surg Br. 1989;14:165.
5. Foucher G. “Bouquet” osteosynthesis in metacarpal neck fractures: a
series of 66 patients. J Hand Surg Am. 1995;20:S86–S90.
6. Rhee SH, Lee SK, Lee SL, et al. Prospective multicenter trial of
modified retrograde percutaneous intramedullary Kirschner wire
fixation for displaced metacarpal neck and shaft fractures. Plast
Reconstr Surg. 2012;129:694–703.
7. Blazar PE, Leven D. Intramedullary nail fixation for metacarpal
fractures. Hand Clin. 2010;26:321–325.
8. Ozer K, Gillani S, Williams A, et al. Comparison of intramedullary
nailing versus plate-screw fixation of extra-articular metacarpal
fractures. J Hand Surg Am. 2008;33A:1724–1731.
9. Boulton CL, Salzler M, Mudgal CS. Intramedullary cannulated headless
screw fixation of a comminuted subcapital metacarpal fracture: case
report. J Hand Surg Am. 2010;35:1260–1263.
10. Ruchelsman DE, Puri S, Feinberg-Zadek N, et al. Clinical outcomes of
limited-open retrograde intramedullary headless screw fixation of
metacarpal fractures. J Hand Surg Am. 2014;39:2390–2395.
11. Del Piñal F, Moraleda E, Rúas JS, et al. Minimally invasive fixation of
fractures of the phalanges and metacarpals with intramedullary
cannulated headless compression screws. J Hand Surg Am.
2015;40:692–700.
Techniques in Hand & Upper Extremity Surgery  Volume 25, Number 1, March 2021 IHS Fixation for Metacarpal Fractures

12. Doarn MC, Nydick JA, Williams BD, et al. Retrograde headless
intramedullary screw fixation for displaced fifth metacarpal
neck and shaft fractures: short term results. Hand. 2015;10:
314–318.
13. Sohn R, Jahng KH, Curtiss SB, et al. Comparison of metacarpal plating
methods. J Hand Surg Am. 2008;33:316–321.
14. Friedrich JB, Vedder NB. An evidence-based approach to metacarpal
fractures. Plat Reconstr Surg. 2010;126:2205–2209.
15. Gereli A, Nalbantoglu U, Sener IU, et al. Comparison of headless
screws used in treatment of proximal nonunion of scaphoid bone. Int
Orthop. 2011;35:1031–1035.
16. Henry M. Variable pitch headless compression screw treatment of distal
phalangeal nonunions. Tech Hand Up Extrem Surg. 2010;14:230–233.
17. Ruchelsman DE, Tejwani NC, Kwon YW, et al. Open reduction and
internal fixation of capitellar fractures with headless screws. J Bone
Joint Surg Am. 2008;90:1321–1329.
18. Eisenberg G, Clain JB, Feinberg-Zadek N, et al. Clinical outcomes of limited
open intramedullary headless screw fixation of metacarpal fractures in 91
consecutive patients. Hand. 2019. Doi: 10.1177/1558944719836235.
19. Ten Berg PWL, Mudgal CS, Leibman MI, et al. Quantitative
3-dimensional CT analyses of intramedullary headless screw fixation
for metacarpal neck fractures. J Hand Surg Am. 2013;38:322–330.

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