TECHNIQUE

Double Barrel Screw Fixation for Proximal Phalanx Fracture

Robert R. L. Gray, MD,* Francisco Rubio, MD,† John J. Heifner, MD,‡
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Nathan A. Hoekzema, MD,§ and Deana M. Mercer, MD∥

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rotate and shorten, increasing the propensity for extensor lag

Abstract: A variety of fixation options exist for treatment of unstable and rotational malalignment.9 Some authors have discouraged
proximal phalanx fractures. Variables which require consideration the use of intramedullary screw fixation for these fracture pat-
include the strength of fixation, the invasiveness of the technique and terns due to the potential for shortening and rotation.8
the postoperative rehabilitation protocol. Here we present a minimally Dual intramedullary screw constructs provide the
invasive technique for dual headless compression screw fixation of advantage of additional stability in comminuted or length-
proximal phalanx fractures which reduces extensor tendon violation and unstable fractures compared with single screw fixation. Del
allows early motion in the immediate postoperative period. Pinal et al8 described a retrograde centrally placed cannulated
Key Words: proximal phalanx fracture, PIP fracture, unstable PIP screw with an additional smaller diameter cannulated screw.
fracture, PIP fracture dislocation Two patterns of dual screw fixation were described. One
technique used an oblique “Y-strutting” screw, typically in
(Tech Hand Surg 2022;26: 214–217)
metacarpal neck fractures, and the other used a parallel “axial
strutting” screw in the dorsal aspect of the proximal phalanx.
The “strutting” terminology is derived from the conceptual
origin in structural engineering. Gaspar et al7 describe a slightly
H and fractures account for 19% of all adult fractures and
proximal phalanx fractures account for 22% of all hand
fractures.1 Treatment options for these fractures are determined
different technique involving antegrade insertion of dual can-
nulated headless screws through the base of the proximal
phalanx with a crossed configuration. Both of these techniques
by the stability of the fracture pattern at the time of pre- necessitate an intentional split of the extensor mechanism, and
sentation. Stable fractures can be conservatively managed with Gaspar’s crossed screw technique risks malrotation when used
splinting and protected motion. Several fixation options are in canals that are not wide enough for 2 screws in the
available for unstable fractures requiring operative treatment,
each with notable characteristics. Kirschner wire (K-wire) fix-
ation minimizes soft tissue insult, but fixation strength is lim-
ited, and a period of postoperative immobilization is often
required.2,3 Plate and screw constructs offer robust fixation
strength but require more extensive dissection which can lead to
soft tissue adhesions, flexion contracture, subsequent loss of
motion, and functional deficits.4,5 Intramedullary compression
screws have yielded promising results,6,7 but questions remain
about their efficacy for certain fracture patterns.8 The ideal
fixation construct would impart ample rigidity to resist the
deforming forces which occur during early motion while also
minimizing soft tissue disruption.
A common proximal phalanx fracture presentation
includes an apex palmar angular deformity. This is due to the
force of the intrinsic muscles on the proximal fracture fragment
and of the central slip on the middle phalanx leading to
hyperextension of the distal fragment. When anatomic reduc-
tion is not attained or when loss of fixation occurs, shortening
with resultant extensor lag is a predictable complication. Long
oblique and spiral fracture patterns have a greater tendency to

From the *NorthShore Orthopaedic Institute, Skokie, IL; †Miami Bone and
Joint Institute, Miami, FL; ‡St.George’s University School of Medicine,
Great River, NY; §UCSF Department of Orthopaedic Surgery, Fresno, CA;
and ∥Department of Orthopaedics and Rehabilitation, University of New
Mexico, Albuquerque, NM.
Conflicts of Interest and Source of Funding: F.R., R.R.L.G., N.A.H., and
D.M.M. disclose a relationship with Skeletal Dynamics that includes
consulting and speaking. J.J.H. reports no conflicts of interest and no
source of funding.
Address correspondence and reprint requests to John J. Heifner, MD, 8905
SW 87th Avenue, Miami, FL 33176. E-mail: johnjheifner@gmail.com.
Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the FIGURE 1. Lateral fluoroscopy showing dorsal subluxation of the
work provided it is properly cited. The work cannot be changed in any proximal phalangeal base to facilitate antegrade introduction of a
way or used commercially without permission from the journal. guide wire to attain reduction.

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 Techniques in Hand & Upper Extremity Surgery  Volume 26, Number 4, December 2022
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FIGURE 2. Anteroposterior (A) and lateral (B) fluoroscopy showing guide wires inserted on the radial and ulnar sides of the centrally
placed reduction wire.
anteroposterior dimension. There is a biomechanical rationale
for the augmented stability of dual screw constructs. Screw
convergence provides resistance to shortening and screws of
similar length more widely distribute implant loads. Max-
imizing screw length provides greater resistance to bending and
rotational forces and greater bony purchase for stability.10
Here we describe a technique of percutaneous dual ante-
grade screw fixation for proximal phalanx fractures with min-
imal violation of the extensor mechanism which facilitates
immediate postoperative range of motion without splinting,
utilizing only a soft dressing and buddy strapping.
ANATOMY
Extension at the second to fifth metacarpophalangeal (MCP)
joints is actuated by the extensor digitorum communis tendon
slip to each digit and the sagittal bands.11 The extrinsic extensor
digitorum communis tendons run over the MCP joints, then
trifurcate in a central slip that inserts at the base of the middle
phalanx, and into 2 lateral slips that finally conjoin at the dorsal
base of the distal phalanx as a terminal extensor tendon.12
Iatrogenic disruption or injury to this extensor mechanism
should be minimized during placement of fracture fixation.
TECHNIQUE
The patient is placed supine after induction of appropriate
anesthesia with the arm extended onto a hand table. Anesthesia
options include regional or local block with or without adjuvant
sedation. A tourniquet is not necessary for closed fractures
given the percutaneous nature of the procedure. A mini c-arm is
utilized to assess reduction. The MCP joint is flexed ~60
degrees over a rolled towel or Esmarch as a bump. Dorsally
directed pressure is applied to the proximal phalangeal base to
subluxate the base dorsally with respect to the metacarpal head.
A 0.062-inch K-wire is advanced centrally through the base of
the proximal phalanx into the intramedullary canal to maintain
reduction (Fig. 1). In very unstable fractures, this wire can be
Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.
Double Barrel Screw Fixation
placed over the metacarpal head into the proximal phalanx base
in a dorsally subluxated position then advanced after the shaft is
reduced to the base, provisionally stabilizing the reduction. This
allows antegrade access to the proximal phalanx intramedullary
canal from the phalangeal base. After fracture reduction is
confirmed radiographically, flexion at the MCP is manually
maintained throughout the process of fixation. Small stab
incisions are made at the level of the collateral recess of the
metacarpal heads, both medially and laterally. A guidewire is
inserted through each incision into the proximal phalanx base
on the radial and ulnar aspect of the central wire, minimizing
trauma to the central portion of the extensor mechanism. The
wire is advanced distally across the fracture site, spanning the
entire length of the phalanx into the subchondral bone of the
proximal phalangeal head. If placement into the proximal
phalangeal head is not practical, maximizing the length of the
wire is advantageous. Subchondral placement helps prevent
premature wire pullout during drilling. A second guidewire is
placed on the other side of the central wire in similar manner
(Figs. 2A, B). The type of screws used for fixation will be
determined by surgeon preference and intramedullary canal
diameter. The anteroposterior width at the isthmus of the pha-
langeal neck is the limiting dimension. A smaller diameter
screw often permits a longer length compared to larger diameter
screws. To protect surrounding structures, drilling is done
manually. If smaller diameter noncannulated screws are used
due to intramedullary space constraints, each guidewire is
removed before screw insertion. If cannulated screws are used,
the guide wire remains in position during drilling and screw
insertion. Depth measurements are taken to determine appro-
priate screw length. After drilling and measurement, the screw
is inserted using a hand driver. Drilling, measuring, and screw
placement are done in sequential manner for each screw in
order to maintain stable reduction with either a wire or screw
crossing the fracture site along with the central wire at all times
(Figs. 3A, B). Maintaining the hand in a fist position from the
placement of the guidewires until the placement of the final
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 Gray et al Techniques in Hand & Upper Extremity Surgery  Volume 26, Number 4, December 2022
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FIGURE 3. Anteroposterior fluoroscopy showing insertion of first (A) and second (B) intramedullary headless cannulated screw over a
guide wire.

FIGURE 4. Anteroposterior (A) and lateral (B) fluoroscopy showing final construct of dual intramedullary headless screws used for fixation
of unstable proximal phalanx fracture.

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 Techniques in Hand & Upper Extremity Surgery  Volume 26, Number 4, December 2022
screw aids in reduction and minimizes the potential for mal-
rotation. Special attention should be paid to keeping the hand in
a fist position during screw insertion, as the torque can rotate
the bone through the fracture site if the reduction is not
maintained.
If difficulty is encountered finding the cortical entry dur-
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ing noncannulated screw insertion, the wire can be reinserted
into the drilled entry hole and a Freer elevator is placed under
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the wire. The elevator is held in place while the wire is
removed, and the screw is then guided into the entry hole over
the top of the elevator. Alternatively, if cannulated screws are
used, the drill bit may be used as an entry awl with the guide
wire being placed through it once the path is re-established.
Maintenance of fracture reduction and alignment are confirmed
with fluoroscopic imaging (Figs. 4A, B). Closure of the per-
cutaneous incision is done with absorbable suture and a buddy
strap with a soft dressing is applied. Active and passive range of
motion is begun immediately following surgery. The finger is
typically strapped or taped to a neighboring digit for added
stabilization during the postoperative period.
EXPECTED OUTCOMES
We believe one of the significant advantages of this technique
over temporary percutaneous K-wire fixation is that the soft
tissue envelope remain untethered as the screw is completely
contained within bone. When compared with single screw
fixation techniques, our technique provides ample stability
which allows immediate motion without the need for rigid
immobilization. Furthermore, the hand drilling and peripheral
insertion of screws minimizes extensor tendon violation. With
increased attention given to the financial burden of surgical
procedures, implant cost is an important consideration in these
cases. Our technique of 2 screws comes with a higher cost than
the commonly used technique of K-wires. With the advantages
of immediate motion which may reduce rehabilitation time and
the rigidity of fixation which may reduce the risk of failure, we
think this technique provides added value.
COMPLICATIONS
Expected complications are similar to other methods of fracture
fixation including infection, malunion, nonunion, or implant
failure. Management of malunion or nonunion with this fixation
method is similar to other techniques. More specific to this
percutaneous fixation method is the possibility of errant screw
trajectory and subsequent loss of screw capture by the screw
Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.
Double Barrel Screw Fixation
driver before placement of the screw in the intended position.
To avoid this complication, one must ensure appropriate
fracture reduction on orthogonal views before advancing the
wires and screws.
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