TECHNIQUE
Iliac Crest Bone Graft With Intramedullary Headless
Implant for Metacarpal Bone Loss
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Madison Milhoan, MD, Victoria Hoelscher, MD, and William F. Pientka, II, MD
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Abstract: Metacarpal bone loss presents a challenging reconstructive
dilemma for hand surgeons. While multiple bone grafting techniques
have been described, complications including nonunion, graft resorp-
tion, fixation requiring prolonged immobilization, stiffness, and the
need for multiple procedures are well-documented. We present a
technique for managing metacarpal bone loss utilizing a tri-cortical iliac
crest graft and an intramedullary metacarpal nail for the treatment of
metacarpal fractures and nonunions that is technically simple, fast, and
allows for early initiation of motion to decrease postoperative
complications.
Level of Evidence: Level IV- Therapeutic
Key Words: metacarpal, bone loss, iliac crest, bone graft,
intramedullary
(Tech Hand Surg 2023;27: 120–124)
ultiple fixation techniques exist for metacarpal neck and
M axially stable metacarpal shaft fractures, including
Kirschner wire fixation, plate fixation, and fixation using either
retrograde or antegrade intramedullary implants. Each of these
comes with its own advantages and disadvantages, and surgeon
preference often dictates which method is utilized, even in
simple fracture patterns. An especially unique challenge is
presented in those metacarpal fractures with extensive commi-
nution and bone loss, necessitating adjuvants to the above
treatment options.
When presented with significant metacarpal bone loss, the
addition of early bone grafting to traditional fixation is crucial to
recovery. Described sources for autologous bone grafting include
the iliac crest, rib, distal radius, fibula, and olecranon.1 Recon-
struction utilizing such grafts can be performed primarily or in a
staged fashion, depending on the success of adequate debride-
ment and soft tissue coverage during the index procedure. The
advantages of primary reconstruction include a faster return to
maximum range of motion and work, fewer operations, lower
cost, and decreased infection risk.2 Supplementation of internal
fixation with iliac crest bone graft has shown to achieve high rates
of osseous union.3
We present a technique for intramedullary metacarpal
fixation supplemented by iliac crest bone grafting for open
metacarpal fractures with significant bone loss.
ANATOMIC CONSIDERATIONS
Each metacarpal articulates with the carpus at a carpometa-
carpal (CMC) joint. Mobility of the various CMC joints differs
depending on the digit, with the second and third being
From the JPS Health Network Department of Orthopaedic Surgery, Fort
Worth, TX.
Conflicts of Interest and Source of Funding: The authors report no conflicts of
interest and no source of funding.
Address correspondence and reprint requests to JPS Health Network
Department of Orthopaedic Surgery, 1500 S. Main St, Fort Worth, TX
76104. E-mail: Wpientka1@gmail.com.
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relatively stiff and immobile compared with the fourth and fifth.
The main determinants of the level of stability of these joints
are the stabilizing and deforming forces applied to each bone
from the various ligamentous attachments. Specifically, the
deep transverse metacarpal ligaments secure each metacarpal
head, while the interossei muscles collectively cause dorsal
angulation of the metacarpal shafts.4
Iliac crest is a preferred donor site for bone defects of the
hand due to the large volume of obtainable cancellous bone. In
addition, this grafting location confers the ability to raise an
associated soft tissue flap supplied by the superficial and deep
circumflex iliac vessels.1 Furthermore, the tri-cortical nature of
iliac crest bone graft is uniquely helpful in restoring structural
integrity to the metacarpal5 However, as with any surgical
procedure, harvesting iliac crest graft confers the risk of addi-
tional complications, including donor site pain, damage to the
lateral femoral cutaneous nerve or superior gluteal artery,
avulsion fracture of the anterior-superior iliac spine, hernia, and
hematoma formation.
INDICATIONS AND CONTRAINDICATIONS
General indications for intramedullary fixation of metacarpal
fractures include those fractures with transverse or short oblique
fracture patterns. Recent advances in intramedullary metacarpal
nails have expanded these indications to include fractures with
significant comminution, as they are noncompressive in nature
and provide relative stability. Other indications include patients
necessitating an early range of motion, those undergoing
osteotomies, and hands with multiple ipsilateral metacarpal
shaft fractures. General contraindications include head-splitting
fractures, active infection, significant bone loss, and fractures in
pediatric patients with open physes.
Augmentation of intramedullary metacarpal fixation with
bone grafting should be considered in those defects greater than
50% diaphyseal diameter loss of the diaphysis or when there is
an unsupported articular fragment.1 Contraindications to bone
grafting include active infection, significant contamination, or
lack of soft tissue coverage.
Surgical Technique
Setup
The patient is placed supine on an operating room table, and
regional or general anesthesia is induced. The operative
extremity is extended 90 degrees on a standard hand table. A
nonsterile tourniquet is applied to the extremity, and standard
sterile preparation and draping are performed. The operative
extremity is exsanguinated, and the pneumatic tourniquet is
inflated.
Exposure
A dorsal longitudinal incision is made over the affected
metacarpal. The extensor tendons are gently retracted, and the
fracture site is exposed with periosteal elevation as needed. The
fracture site is debrided using a curette and/or rongeur, and the
extent of the bony deficit is determined. The length of the bony
 Techniques in Hand & Upper Extremity Surgery  Volume 27, Number 2, June 2023 Iliac Crest Graft With Metacarpal Nail

deficit is measured to restore the native metacarpal length or
cascade in relation to adjacent metacarpals. Radiographs of the
contralateral hand may be utilized to template the native
metacarpal length preoperatively to further assist in determining
the true extent of the metacarpal bone defect. The authors prefer
to use a sagittal saw to create transverse cuts at the fracture sites
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together in a flexed position during implant insertion to ensure
appropriate rotation is restored.
Closure
If possible, the periosteum is reapproximated over the graft with
3-0 PDS suture, but in many gunshot wounds, the periosteum is

proximally and distally to increase cortical contact with the not conducive to closure. The tourniquet is released before skin
cortical bone graft. After the desired bone graft size is closure to ensure hemostasis, and a layered skin closure is then
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determined, the ipsilateral iliac crest tri-cortical bone graft is
harvested through a skin incision in line with the iliac crest
centered over the iliac tubercle. This incision is carried to the
fascia overlying the iliac crest, where a longitudinal incision is
made through the fascia, and a subperiosteal dissection is
performed to expose the iliac wing. A sagittal saw is used to
carefully harvest an appropriately sized graft from the anterior-
superior aspect of the iliac wing. The graft is then modified to
fit the metacarpal bone defect.
Reconstruction
Utilizing the double ended 0.045-inch guidewire for the
Exsomed Innate Metacarpal Nail (Exsomed), the guidewire is
inserted through the fracture site in an antegrade fashion and
passed through the metacarpal head, exiting the skin through
the flexed metacarpophalangeal joint (Fig. 1A). This is then
retracted until the proximal aspect of the guidewire is flush with
the distal fracture line. The tri-cortical bone graft is then
inserted into the bone defect (Fig. 1B), and the guidewire is
passed in a retrograde fashion through the graft into the prox-
imal aspect of the metacarpal (Fig. 1C). For cases with a short
residual proximal metacarpal, the guidewire (and subsequent
metacarpal nail) may be placed across the CMC joint.
After the guidewire is appropriately seated in the meta-
carpal base or the carpus, the cannulated drill is used to prepare
the metacarpal and bone graft for implant insertion. An
appropriately sized implant is then inserted by hand (Fig. 1D).
The authors generally utilized a 3.6 mm Exsomed Innate met-
acarpal nail for the fourth metacarpal and a 4.5 mm nail for the
second, third, and fifth metacarpals. It is important to confirm
the appropriate seating of the implant intraoperatively and
restore digital rotation. The authors prefer to position the fingers
performed. The iliac crest harvest site is closed by repairing the
fascial incision with vicryl suture and a layered subcutaneous
skin closure with monocryl suture. Dermabond is then utilized
on the skin incision.
Rehabilitation
Patients are immobilized for 7-10 days before beginning the
range of motion. Early referral to hand therapy is helpful in scar
management, edema control, and recovery of motion. Patients
are instructed to avoid lifting until radiographic signs of healing
are noted, usually around 6 weeks postoperatively.
Expected Outcomes
The surgical technique presented here allows for reliable
restoration of metacarpal stability, bony union, and return to
activities in patients with significant metacarpal bone loss. Our
technique has allowed for the early initiation of motion
postoperatively and decreases the need for subsequent surgical
procedures for hardware removal, further bone grafting, and
tenolysis.
Complications
As can be expected in any metacarpal fracture with significant
bone loss, there is a risk of nonunion despite adequate fixation
and bone grafting. We believe the augmentation of an
intramedullary metacarpal fixation with iliac crest bone graft
reduces this risk by yielding a more stable construct compared
with kirchner wire or dorsal plate fixation. There is a theoretical
risk of graft fracture during metacarpal nail placement,
however, in our experience, the implant may be easily placed
across the graft without undue tension/stress. We also believe
intramedullary fixation decreases the risk of soft tissue irritation
caused by dorsal plates, thus decreasing the risk of stiffness due

FIGURE 1. Technique for the placement of cannulated metacarpal implant through tri-cortical iliac crest bone graft. A guidewire is
placed in an antegrade fashion through the fracture site and retracted until flush with the distal fracture (A). The iliac crest tri-cortical graft
is positioned at the site of metacarpal bone loss (B). The guidewire is advanced through the graft into the proximal fracture fragment (or
carpus if the metacarpal base is lost) (C). The graft is held in place during cannulated drilling and final implant placement (D).

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FIGURE 2. Injury posteroanterior (A), oblique (B), and lateral (C) radiographs of the left hand in a 66-year-old-man who sustained a
gunshot wound to the hand with a third and fourth metacarpal fracture with significant bone loss in the fourth metacarpal base.

to scarring and hardware removal. While we have not
encountered a postoperative infection or nonunion, removal
of the intramedullary implant is more difficult than with a dorsal
plate construct or K-wires. If there is a question of bony union
postoperatively, CT scan may be considered to assess for union
before the initiation of weight bearing per surgeon preference.
motion had improved, but the patient continued to complain of
hand pain and residual stiffness (Fig. 4–C). The patient refused
tenolysis procedures and elected to discontinue further treatment
at that time.

Case Illustrations Case 2

Case 1
A 66-year-old man presented after a self-inflicted gunshot wound
to the nondominant left hand with third and fourth metacarpal
fractures, fifth CMC joint instability/dislocation, and extensor
tendon injury to the ring finger (Fig. 2A–C). He underwent initial
wound debridement and splinting to allow for soft tissue stabi-
lization. Seven days after the injury, the patient underwent fix-
ation of the third metacarpal base fracture and fifth CMC joint
instability with K-wires and ring finger extensor tendon repair.
Due to significant bone loss of the fourth metacarpal, including
the CMC joint, the patient underwent tri-cortical iliac crest bone
grafting and fixation of the fourth metacarpal fracture with an
Exsomed Innate metacarpal nail extended into the hamate
(Fig. 3–C). Postoperatively, K-wires were removed at 4 weeks
and immobilization was discontinued, and the patient began
intensive hand therapy. At 4 month follow-up, the range of
A 19-year-old boy presented 13 months after a gunshot wound
where he underwent open reduction internal fixation of the
nondominant left fourth metacarpal and ring finger extensor
tendon repair after a cabinet fell on the previously treated hand.
He was noted to have resorption at the previous fracture site
with nonunion and hardware failure (Fig. 5A–C). He underwent
hardware removal with tri-cortical iliac crest bone grafting and
conversion to intramedullary fixation (Fig. 6A–C). Post-
operatively, he was immobilized in an ulnar gutter splint for 2
weeks. He reported pain resolution at his 2-week follow-up, and
range of motion was initiated without advancing his weight
bearing. Following this, he recovered full active and passive
digital motion and was cleared to resume normal activities at 6
weeks postoperatively (Fig. 7A–C). At the final 6-month
postoperative follow-up, the patient was without pain or
functional limitation and had returned to all normal activities.

FIGURE 3. Immediate postoperative posteroanterior (A), oblique (B), and lateral (C) radiographs of the left hand in a 66-year-old-man
after ORIF of a third metacarpal fracture, stabilization of a fifth CMC joint dislocation, and iliac crest bone grafting with ORIF of the fourth
metacarpal with an intramedullary implant. Given the bone loss at the fourth metacarpal base, the implant was placed into the hamate.

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 Techniques in Hand & Upper Extremity Surgery  Volume 27, Number 2, June 2023 Iliac Crest Graft With Metacarpal Nail
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FIGURE 4. Final posteroanterior (A), oblique (B), and lateral (C) radiographs of the left hand in a 66-year-old-man after ORIF of a third
metacarpal fracture, stabilization of a fifth CMC joint dislocation, and iliac crest bone grafting with ORIF of the fourth metacarpal with an
intramedullary implant showing bony union.

FIGURE 5. Initial posteroanterior (A), oblique (B), and lateral (C) radiographs of the left hand in a 19-year-old-boy with nonunion and
hardware failure of a previously treated fourth metacarpal fracture.

FIGURE 6. Immediate posteroanterior (A), oblique (B), and lateral (C) radiographs of the left hand in a 19-year-old-boy after removal of
broken hardware and tri-cortical iliac crest bone graft placement with ORIF of a fourth metacarpal shaft fracture nonunion using an
intramedullary metacarpal nail.

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FIGURE 7. Final posteroanterior (A), oblique (B), and lateral (C) radiographs of the left hand in a 19-year-old-boy after ORIF of a fourth
metacarpal shaft fracture nonunion with iliac crest bone grafting using an intramedullary metacarpal nail.

DISCUSSION technique that allows for an earlier range of motion. An intra-

Open metacarpal fractures with comminution and significant
bone loss present a unique challenge regarding treatment and
fixation. Current literature focuses on the use of early
reconstruction with tri-cortical iliac crest bone grafting to fill
segmental defects with high resultant rates of osseous union and
earlier return to the full range of motion. It is important to note
that bone grafting can be used in conjunction with several types
of metacarpal fixation, while our technique focuses on its use in
conjunction with intramedullary devices.
Significant metacarpal bone loss is often associated with
extensive soft tissue injury, such as that caused by a ballistic
injury. The significant bone loss sustained by the 2 patients
presented here occurred through this mechanism of injury
(initially in case 2, however, subsequent injury led to the dis-
covery of a metacarpal nonunion). Timing of bone grafting in
patients such as these requires adequate initial debridement of
debris and necrotic tissues within the wound and management
of a patient’s other injuries or conditions that may affect the
hand’s ability to heal, such as infection. Special attention must
be paid to the zone of injury, with consideration of how the
state of soft tissues surrounding an injury may worsen or
improve in the days following an injury. In cases where this is a
particular concern, staged reconstruction can be performed with
temporary stabilization to allow for repeat debridement and
declaration of tissues. One option involves utilizing the
Masquelet technique, often used in long bone injuries with
significant bone loss, to induce pseudomembrane formation
around an area of bone loss with theoretically increased rates of
union after graft placement.6
In regards to the type of metacarpal fracture fixation in
general, no one method has been shown to be superior. Less
invasive techniques include the use of Kirschner wires and
external fixation with the known drawbacks of malunion and
nonunion, the need for subsequent hardware removal, pin site
infection, and stiffness. Open reduction with plate fixation
allows for adequate reduction and enhanced stability, but the
disadvantages include a larger incision, increased stiffness, and
extensor lag.7 An alternative for fixation depending on the
fracture pattern is the intramedullary screw, a less invasive
medullary screw was utilized in both of our patients after graft
placement to restore bony continuity and allow for resistance to
bending and torsional forces.
Our study does have limitations. The overall number of
patients treated is low, mainly due to the relative rarity of
metacarpal fractures presenting with extensive bone loss. It is
also difficult to assess postoperative outcomes given the lack of
clinical follow-up in our cohort. As all fractures were treated
with iliac crest bone grafting and intramedullary screw place-
ment, we do not have patients with alternate graft sources or
fixation methods to whom we can compare our results.
In summary, we believe our surgical technique offers a
treatment strategy for open metacarpal fractures with exten-
sive bone loss that allows for both increased chances of
osseous union and an earlier return to motion with decreased
postoperative stiffness.
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3. Gonzalez MH, McKay W, Hall RF. Low-velocity gunshot wounds of the
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4. Malik S, Herron T, Rosenberg N. StatPearls. Fifth metacarpal fractures.
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