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Metacarpal Fracture Fixation

78 citationsUpdated Sep 2026
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For patients: a plain-language version of this topic is available. See the patient guide.

Overview

The primary objectives of metacarpal fixation are to obtain reduction, maintain that reduction, and achieve good function [2]. While manipulation and external fixation is considered an excellent method for fractures requiring these interventions [1], surgical fixation is indicated for specific fracture patterns. Intramedullary fixation is a relatively simple, cost-effective, and safe technique with good published outcomes for closed, extra-articular metacarpal shaft and neck fractures [8, 41, 12]. Although definite advantages over other techniques or simple early mobilization have not been clearly demonstrated [41], intramedullary screw fixation is safe with a low incidence of complications (2.5%) that can be safely and effectively managed [18, 5]. This modality exhibits improved functional outcomes compared to open reduction internal fixation (ORIF) with comparable complication rates [14]. Retrograde intramedullary screw use provides adequate stability with satisfactory clinical outcomes and minimal complications, though more high-quality studies are needed to fully examine this modality [10]. Modified retrograde percutaneous intramedullary Kirschner wire fixation is a simple and reliable technique for displaced, unstable fractures that provides sufficient stability with low morbidity [6]. Antegrade intramedullary fixation is a minimally invasive technique that provides adequate fixation of displaced metacarpal fractures with good functional results and low morbidity [7]. Intramedullary nail fixation is reliable for select transverse and oblique metacarpal fractures for which surgery is indicated [25]. Premeasured intramedullary nails propose novel instrumentation for the minimally invasive treatment of unstable metacarpal fractures [16]. A minimally invasive hybrid fixation technique appears safe and effective for unstable metacarpal shaft fractures not typically suited for standard intramedullary fixation [21].

Plates are the most stable means of fixation of midshaft metacarpal fractures [4]. When compared to plate fixation, metacarpal intramedullary nailing more closely restores the ultimate load to failure of the native metacarpal after midshaft fracture [15]. Bicortical interfragmentary screw fixation is an effective treatment option for oblique metacarpal fractures [3]. Miniature plates and screws are a possible choice in the treatment of low-severity metacarpal and phalangeal fractures [9]. Plate fixation in closed multiple metacarpal fractures is a safe, reliable and consistently reproducible treatment method [11]. It is particularly useful when fracture patterns are unsuitable for screw fixation alone [17]. Dorsal bridge plating to the second or third metacarpal both result in acceptable outcomes and can be considered based on the fracture pattern and surgeon preference [13]. Medial plating offers no clear advantage over K-wire fixation in treating metacarpal neck fractures [112]. The stacking concept using cannulated screws for extra-articular metacarpal base fracture of the thumb is contraindicated for intra-articular fractures, pediatric fractures, and cases with fragmentation of the metacarpal base [27].

Anatomy & Pathophysiology

Bony Anatomy

The hand skeleton comprises 27 bones, 19 of which are long bones [55]. It is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [55]. The base of each metacarpal articulates with the distal row of the carpus [55]. The thumb metacarpal is the shortest, while the index metacarpal is the longest [55]. In the long and ring fingers, the proximal and middle phalanges are longer than those of the index finger [55]. The first metacarpal forms an angle of approximately 45 degrees with the second metacarpal in the sagittal plane [55]. Additionally, the transverse axis of the palm forms an acute angle of approximately 75 degrees with the longitudinal axis [55]. Epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, and at the distal ends of the other metacarpals [55].

The index metacarpal is the most firmly fixed among the metacarpals [76]. In contrast, the ring metacarpal exhibits about 10 degrees of mobility in flexion and extension [76], while the fifth metacarpal has a range of flexion–extension of approximately 20 degrees [76]. The second to fifth metacarpals are bound together by the deep transverse intermetacarpal ligament, also known as the interglenoid ligament [76]. This ligament ties together the anterior glenoid ligaments of the metacarpophalangeal articulations, known as the volar plates [76]. The metacarpophalangeal joints serve as the keystones of the longitudinal arches of the hand [76]. The volar plates prevent hyperextension at the metacarpophalangeal joints [76]. Metacarpal fractures are common injuries, comprising approximately one-third of all hand fractures [34].

Musculotendinous Anatomy

Extrinsic extensor muscles run through six different fibroosseous retinacular compartments at the wrist level [54]. The extensor digitorum communis tendons of the middle, ring, and little fingers are tethered together by juncturae tendinum over the dorsum of the hand proximal to the metacarpophalangeal joint [54]. Digital extensor tendons are stabilized over the midline of the metacarpophalangeal joint by their attachment to sagittal band fibers [54]. These sagittal band fibers insert onto the volar proximal phalanx and onto the lateral borders of the volar plate [54]. The sagittal bands keep the extrinsic extensor tendon balanced over the prominence of the metacarpal head, maximizing mechanical efficiency [54]. Rupture or attenuation of sagittal band fibers allows the extrinsic extensor tendon to sublux to the ulnar side of the metacarpal head, causing ulnar deviation of the finger [54].

The extrinsic finger flexors consist of the flexor digitorum profundus and the flexor digitorum superficialis [54]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx [54]. The flexor digitorum superficialis inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx [80]. There are seven interosseous muscles in the hand: four dorsal and three volar [73]. The dorsal interossei are abductors, while the volar interossei are adductors [73]. The middle finger has two dorsal interossei and no volar interossei because the central axis of the hand lies within it [73].

The deep head of each dorsal interosseous muscle forms a lateral tendon, or lateral band, at the level of the metacarpophalangeal joint [73]. The lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band [73]. The conjoined lateral bands unite at the distal third of the middle phalanx to form the terminal tendon, which inserts at the base of the distal phalanx [73]. The abductor digiti quinti and flexor digiti quinti brevis arise from the fifth metacarpal [73]. The opponens digiti quinti arises from the pisohamate ligament and the hook of the hamate, inserting onto the ulnar side of the diaphysis of the fifth metacarpal [73].

Soft Tissue & Vascular Anatomy

The dorsal skin is thin, with a horny layer only 0.02 mm thick, and possesses loose connections with deeper planes allowing free gliding [82]. Flexion of the fingers produces a significant lengthening of the dorsal skin, with an average increase of 3 cm in the middle finger from extension to full flexion [82]. The superficial palmar fascia covers a triangular area of the central palm, with four central bands extending distally toward each finger [83]. There is no central band of the superficial palmar fascia for the thumb [83]. The digital neurovascular structures are surrounded by a diffuse network of thin transverse oblique fibers [83]. Fibers dorsal to the neurovascular bundle are collectively called Cleland ligament, and those palmar to the bundle are called Grayson ligament [83].

The "princeps pollicis" artery, a terminal branch of the radial artery, crosses the first intermetacarpal space and runs along the ulnar side of the first metacarpal [77]. The princeps pollicis divides into two collateral palmar arteries at the level of the metacarpophalangeal joint flexion crease [77]. An arcade located deep in the flexor tendon joins the two palmar arteries of the thumb at the level of the distal metaphysis of the first phalanx [77].

Pathophysiology & Clinical Implications

Without adequate treatment, metacarpal fractures can cause notable morbidity for patients in both the short and long term [34]. Optimal treatment of metacarpal fractures provides enough bony stability to allow for early range of motion to facilitate expedient return to full activity [34]. Surgical fixation is considered when rotational deformity, shortening, articular surface step-off, or multiple metacarpal fractures are noted [34]. Proximal displacement of a metacarpal head indicates shortening of the corresponding metacarpal [84]. Malrotation after a metacarpal fracture is manifested by ulnar or radial deviation of the corresponding proximal phalanx when the metacarpophalangeal joint is flexed [84]. The greater the deviation of the proximal phalanx during flexion, the more severe the malrotation [84]. Flexion of all metacarpophalangeal and proximal interphalangeal joints causes the fingers to converge toward the scaphoid [84].

Retrograde metacarpal screw fixation produces a focal cartilage defect on the metacarpal head that tracks across the entire proximal phalanx articular surface during metacarpophalangeal joint motion [102]. Articular surface loss of the metacarpal head following retrograde headless compression screw insertion is negligible in a cadaveric model, with minimal engagement between the defect and the proximal phalanx base during functional range of motion [103]. A dorsal retrograde entry hole at the metacarpal head did not change metacarpophalangeal joint contact area, mean pressure, or peak pressure in full extension across all five digits [95].

Classification

Fracture Pattern and Location

Intramedullary screw fixation: This modality is considered current practice for treating extra-articular unstable fractures of metacarpals and phalanges, including complex cases [23]. It is applicable to subcapital fractures or those involving the metacarpal neck where lack of distal purchase can preclude plate and screw fixation [48]. For oblique metacarpal fractures, intramedullary fixation may achieve adequate fixation regardless of fracture obliquity [47].

Antegrade intramedullary headless compression screw fixation: This technique is most feasible for proximal metacarpal fractures of the thumb, middle, and little finger metacarpals due to larger dorsal or ulnar overhang allowing screw placement without violating the carpometacarpal joints [116].

Internal fixation: This method is reliable for fractures with significant displacement, rotation, angulation and/or instability [31]. Short oblique, transverse, comminuted, or multiple metacarpal shaft fractures typically require more rigid fixation with lag screws or plate and screw constructions [48].

Indications for Operative Fixation

Manipulation and external fixation: This approach is considered excellent for metacarpal fractures requiring manipulation and fixation [1].

Intramedullary Kirschner wire fixation: Modified retrograde percutaneous intramedullary Kirschner wire fixation is a simple and reliable technique for displaced, unstable metacarpal fractures that provides sufficient stability to the fracture site with low morbidity [6]. Intramedullary k-wire fixation is a minimally invasive method for stabilizing metacarpal fractures [44].

Intramedullary nails and screws: Premeasured intramedullary nails provide a method for the minimally invasive treatment of unstable metacarpal fractures [16]. Intramedullary screw fixation is a comparable method of fixation to K-wires and plating for metacarpal fractures [22].

Hybrid fixation: The modified internal fixation method using Kirschner wires and locking plate is an alternative treatment for the fifth metacarpal neck fracture with good curative effects [40].

Non-Operative Management

Conservative treatment: This approach has comparable outcomes with bouquet pinning for little finger metacarpal neck fractures [26].

Clinical Presentation

Metacarpal fractures comprise approximately one-third of all hand fractures [34]. Males in their second and third decades of life are most frequently affected [34]. A punching mechanism is a common etiology for these injuries [34]. Without adequate treatment, metacarpal fractures can cause notable morbidity for patients both in the short and long term [34].

Little finger metacarpal neck fractures account for approximately 10% of all hand fractures [26]. These fractures are often related to aggressive, intentional punching [26]. Due to palmar compression of the bone and intrinsic muscle pull, the metacarpal head angulates palmarly in little finger metacarpal neck fractures [26]. Cadaveric studies have indicated that 30° is the maximum mal-union where normal hand function can be maintained for little finger metacarpal neck fractures [26]. Many surgeons regard that angulation of 30° is an indication for surgery for little finger metacarpal neck fractures [26].

Surgical fixation should be considered when rotational deformity, shortening, articular surface step-off, or multiple metacarpal fractures are noted [34]. Surgical fixation is recommended for open injuries, segmental bone loss, multiple metacarpal fractures, irreducible fractures, and unstable fracture patterns to restore function [42].

Investigations

Other Considerations: A careful physical examination is essential to direct care and future testing if indicated [53]. Diagnostic tests such as imaging and serum laboratory studies are useful in the determination of pathology but can be expensive, time consuming, and often nonspecific [53].

Treatment

Non-Operative

Conservative management remains a viable option for select injuries; specifically, conservative treatment yields outcomes comparable to bouquet pinning for little finger metacarpal neck fractures [26]. However, without adequate treatment—whether surgical or nonsurgical—metacarpal fractures can cause notable morbidity for patients in both the short and long term [34].

Operative

Indications: Surgical intervention is indicated for displaced, unstable metacarpal fractures [6]. Percutaneous intramedullary nailing is recommended for all metacarpal neck fractures, particularly when severe hand swelling is present, due to good functional results and low morbidity [24]. Intramedullary nail fixation is reliable for select transverse and oblique metacarpal fractures requiring surgery [25].

Surgical Approach / Technique: Intramedullary screw fixation with wide-awake anesthesia represents a reliable option for transverse, oblique, and select comminuted fractures, facilitating early active mobilization and a quick return to work and ordinary activities [70]. A prospective multicenter trial identified modified retrograde percutaneous intramedullary Kirschner wire fixation as a simple and reliable technique for displaced, unstable metacarpal fractures, providing sufficient stability with low morbidity [6]. For metacarpal shaft fractures, the palmar approach provides satisfactory cosmesis and function with minimal tendon adhesion, though it presents challenges with surgical exposure and transient paraesthesiae [121]. The antegrade approach for intramedullary headless compression screw placement avoids defects in the metacarpal head and extensor mechanism, allowing stable fixation of more proximal fractures with minimal violation of the carpal surface of the CMC joint [65]. Postoperative screw position is not significantly different between mini-open and percutaneous approaches for intramedullary screw fixation [58].

Implant Selection: Intramedullary screws exhibit improved functional outcomes compared to ORIF, with comparable complication rates [14]. Complications following intramedullary screw fixation are relatively uncommon [5]. Retrograde intramedullary screw use provides adequate stability with satisfactory clinical outcomes and minimal complications [10]. Intramedullary nailing more closely restores the ultimate load to failure of the native metacarpal after midshaft fracture compared to plate fixation [15]. A cannulated headless screw placed intramedullary through the articular surface can secure proximal and distal bone purchase in comminuted subcapital fractures without excessive soft tissue stripping or disruption of the fracture hematoma [61]. A hybrid technique appears safe and effective for unstable metacarpal shaft fractures not typically suited for standard intramedullary fixation [21].

For plate and screw fixation, new generation locking plates achieve higher stability [35]. A standard dorsal plate fixed with either six bicortical nonlocking screws or four bicortical locking screws provides equivalent biomechanical properties [46]. A 4-screw bicortical nonlocking construct is noninferior to a 6-screw bicortical nonlocking construct [107]. Bicortical screws offer a biomechanical advantage under cyclic loading, with significantly higher load to failure and less plastic deformation compared to unicortical fixation [51]. An orthogonal (90/90) configuration of mini-plates provides comparable construct stability to a standard dorsal plating technique in transverse metacarpal fracture models [64]. Absorbable fixation of the metacarpal shaft appears to have comparable complication rates and biomechanical properties when compared with metallic fixation [19]. A modified internal fixation method using Kirschner wires and a locking plate is an alternative treatment for fifth metacarpal neck fractures with good curative effects [40].

K-wire and external fixation options include closed reduction intermetacarpal Kirschner wire fixation, which resulted in all patients with extra-articular fractures returning to previous work, with no patient reporting a visual analogue score higher than 4 at 24-month follow-up [20]. External fixation combined with Kirschner wire and hollow screw fixation exhibited similar curative effects in treating first metacarpal base fractures [57]. When using external fixation for distal radius fractures, distal pin fixation should be limited to 4 cortices to avoid impeding thumb motion [33].

Other Considerations: The proximity of metacarpal plates to adjacent joints is associated with subsequent implant removal [36]. Professional athletes who sustain a non-thumb metacarpal fracture can safely return to professional play without restriction two weeks after internal fixation [30].

Complications

Intramedullary Fixation

Intramedullary screw fixation of metacarpal fractures demonstrates a low complication incidence of 2.5%, which can be safely and effectively managed [18]. Retrograde intramedullary screw (RIS) use is similarly associated with minimal complications [10]. Compared to plate and screw constructs, intramedullary screw fixation provides similar time to union with fewer complications [37]. However, specific mechanical failures may occur; in a study of 44 metacarpal fractures treated with intramedullary nails, 10 complications occurred [39]. Incidences of loss of reduction, penetration to the metacarpal-phalangeal joint, and secondary surgeries for hardware removal were higher in the intramedullary nailing group compared to plate-screw fixation [96]. Furthermore, the removal of intramedullary nails used for metacarpal or phalanx fracture fixation in the case of infection is theorized to be more difficult than the removal of plates and wires [59].

Plate and Screw Fixation

Closer distance between the plate edge and joint line is associated with a more limited range of finger motion [49]. In a comparison of locking plates and intramedullary pinning, operative time was significantly longer in fractures fixated by plates (58 minutes vs 41 minutes) [38]. Radiographic bone healing time was also significantly longer in fractures fixated by plates (59 days vs 50 days) [38]. Pre-curved metacarpal plates are associated with less invasiveness and fewer postoperative complications [62].

K-Wire and Pinning

Modified retrograde percutaneous intramedullary Kirschner wire fixation for displaced metacarpal fractures is associated with low morbidity [6]. Antegrade intramedullary fixation of displaced fifth metacarpal fractures provides good functional results and low morbidity [7]. Percutaneous intramedullary nailing for metacarpal neck fractures is recommended due to good functional results and low morbidity, especially when severe swelling of the hand is present [24].

General and Comparative

Intramedullary screw fixation exhibits comparable complication rates when compared against open reduction internal fixation (ORIF) [14]. Absorbable fixation of the metacarpal shaft appears to have comparable complication rates when compared with metallic fixation [19]. Locked intramedullary nailing for low-velocity gunshot metacarpal fractures is associated with low complication rates [119].

Recovery

Light activity (weeks): Intramedullary screw fixation facilitates a quicker return to work compared to K-wire fixation for metacarpal neck and shaft fractures [120]. When performed with wide-awake anesthesia, intramedullary screw fixation allows for early active mobilization and a quick return to work and ordinary activities [70]. Similarly, retrograde headless intramedullary screw fixation of fifth metacarpal neck and shaft fractures permits early motion without cast immobilization and an early return to work [115].

Full activity (months): In a cohort of 44 metacarpal fractures treated with intramedullary nails, the average time to full activity was 6.32 weeks [39].

Rehabilitation protocol: Intramedullary screw fixation provides quicker return to motion and faster time to full range of motion compared to plate and screw constructs [37]. Biodegradable hemi-cerclage fixation produces sufficient stability to permit early motion exercises [108]. Percutaneous flexible stable intramedullary nailing for metacarpal neck fractures allows for early and reliable active rehabilitation [111].

Functional milestones: In the cohort of 44 metacarpal fractures treated with intramedullary nails, the mean postsurgical active total arc of motion was 250° and the mean postsurgical passive total arc of motion was 259.74° [39]. At 3 months postoperatively, the median range of motion of the fifth metacarpophalangeal joint was 80° for patients treated with antegrade pinning and 69° for those treated with retrograde pinning [32]. Correspondingly, the median grip strength at 3 months was 81% for antegrade pinning and 71% for retrograde pinning [32].

Other Considerations: In a cohort of 44 metacarpal fractures treated with intramedullary nails, the average time to radiographic healing was 5.5 weeks [39]. In a study of percutaneous intramedullary nailing for fifth metacarpal neck fractures, no patient reported residual pain at final follow-up [24]. For first metacarpal base fractures treated with closed reduction intermetacarpal Kirschner wire fixation, all patients with extra-articular fractures returned to their previous work, and no patients showed arthrotic changes on radiographs at 24-month follow-up [20]. All patients with intra-articular fractures were able to return to their work and hobbies [20].

Key Evidence

  • [L4] The method is considered excellent for metacarpal fractures requiring manipulation and fixation. [1] (10.2106/00004623-198264050-00027)
  • [L5] The objectives of metacarpal fixation are to obtain reduction, maintain reduction, and achieve good function. [2] (10.1016/s0749-0712(21)00117-7)
  • [L5] The results support previously established clinical data that bicortical interfragmentary screw fixation is an effective treatment option for oblique metacarpal fractures. [3] (10.1007/s11552-008-9108-0)
  • [L5] Plates are the most stable means of fixation of midshaft metacarpal fractures. [4] (10.1111/os.12195)
  • [L4] Complications following IMS fixation of metacarpal fractures are relatively uncommon. [5] (10.1016/j.jhsa.2023.01.012)
  • [L4] This is a simple and reliable technique for displaced, unstable metacarpal fractures that provides sufficient stability to the fracture site and with low morbidity. [6] (10.1097/prs.0b013e3182402e6a)
  • [L4] We recommend that this minimally invasive technique combined with the simple modifications described above provides adequate fixation of displaced metacarpal fractures with good functional results and low morbidity. [7] (10.1016/s0020-1383(99)00201-6)
  • [L1] IM fixation may have a role in the treatment of certain metacarpal fractures. [8] (10.1007/s11552-013-9531-8)
  • [Paper] These very favourable results suggest that miniature plates and screws are a possible choice in the treatment of low-severity metacarpal and phalangeal fractures. [9] (10.1007/s00402-004-0745-7)
  • [L2] RIS use in metacarpal fractures appears to provide adequate stability with satisfactory clinical outcomes and minimal complications, although more high-quality studies are needed to fully examine this modality. [10] (10.1177/1558944720988073)
  • [L4] Plate fixation in closed multiple metacarpal fractures is a safe, reliable and consistently reproducible treatment method. [11] (10.1177/1753193408090101)
  • [L4] Intramedullary fixation should be considered for closed, extra-articular metacarpal fractures. [12] (10.1016/j.jhsg.2024.08.020)
  • [L4] Dorsal bridge plating to the second or third metacarpal both result in acceptable outcomes and can be considered based on the fracture pattern and surgeon preference. [13] (10.1016/j.jhsa.2024.12.016)
  • [L3] Intramedullary screw exhibited improved functional outcomes when compared against ORIF, exhibiting improved patient outcomes with comparable complication rates and should be considered as a method for fixation of metacarpal fractures within appropriate settings. [14] (10.1177/15589447241312416)
  • [L5] When compared to plate fixation, metacarpal intramedullary nailing more closely restores the ultimate load to failure of the native metacarpal after midshaft fracture. [15] (10.1016/j.jhsa.2022.04.020)
  • [L4] The presented technique proposes both novel instrumentation and a method for the minimally invasive treatment of unstable metacarpal fractures. [16] (10.1016/j.jhsg.2020.04.009)
  • [L4] Plate fixation is safe and reliable for closed multiple metacarpal fractures with consistently reproducible outcomes, particularly when fracture patterns are unsuitable for screw fixation alone. [17] (10.1177/1753193409105451)
  • [L4] Intramedullary screw fixation of metacarpal fractures is safe with a low incidence of complications (2.5%) that can be safely and effectively managed. [18] (10.1177/1558944719836214)
  • [L4] When compared with metallic fixation of the metacarpal shaft, absorbable fixation appears to have comparable complication rates and biomechanical properties. [19] (10.1177/1558944718798856)
  • [L4] [20] (10.1016/j.injury.2011.10.038)
  • [L4] This hybrid technique appears safe and effective for unstable metacarpal shaft fractures not typically suited for standard intramedullary fixation. [21] (10.1016/j.jhsa.2026.04.012)
  • [L1] These findings suggest that intramedullary screw fixation is a comparable method of fixation to K-wires and plating for metacarpal fractures. [22] (10.1177/15589447241232094)
  • [L4] On the basis of the results of this multicentre study with a long-term follow-up, we believe that IHSF could be considered as the current practice to treat extra-articular unstable fractures of metacarpals and phalanges, not only in case of single fractures but also in complex cases. [23] (10.1177/1753193420980324)
  • [L4] At final follow-up, no patient reported residual pain, and the study recommends this minimally invasive technique for all metacarpal neck fractures, especially when severe swelling of the hand is present, due to good functional results and low morbidity. [24] (10.11604/pamj.2014.18.187.3347)
  • [L5] In the authors' experience, IMN fixation has proven to be reliable for select transverse and oblique metacarpal fractures for which surgery is indicated. [25] (10.1016/j.hcl.2010.05.005)
  • [L2] [26] (10.1177/1753193414560119)
  • [L4] The procedure is contraindicated for intra-articular fractures, pediatric fractures, and cases with fragmentation of the metacarpal base. [27] (10.1177/17531934231203165)
  • [L4] Professional athletes who sustained a non-thumb metacarpal fracture can safely return to professional play without restriction two weeks after internal fixation. [30] (10.1302/0301-620x.99b10.bjj-2016-0686.r3)
  • [L4] Internal fixation of metacarpal and phalangeal fractures is a reliable method for fractures with significant displacement, rotation, angulation and/or instability. [31] (10.1016/0020-1383(93)90283-c)
  • [L1] [32] (10.1007/s11999-014-4079-7)
  • [L5] The authors recommend limiting distal pin fixation to 4 cortices to avoid impeding thumb motion. [33] (10.1177/1558944719851231)
  • [L4] [34] (10.1177/15589447251333818)
  • [L5] The new generation of locking plates can be used to achieve a higher stability for fixation of metacarpal fractures. [35] (10.1016/j.jhsa.2010.01.002)
  • [L4] The proximity of metacarpal plates to adjacent joints is associated with subsequent implant removal. [36] (10.1016/j.jhsa.2022.01.026)
  • [L2] Intramedullary screw fixation is a reliable and safe method for metacarpal fractures, providing quicker return to motion, faster time to full range of motion, and similar time to union with fewer complications compared to plate and screw construct. [37] (10.5435/jaaos-d-24-00241)
  • [L3] [38] (10.1177/1558944718798854)
  • [L4] [39] (10.1177/15589447231222518)
  • [L4] The modified internal fixation method is one of the alternative treatments for the fifth metacarpal neck fracture with good curative effects. [40] (10.1186/s13018-021-02627-8)
  • [L4] Intramedullary stabilization of metacarpal shaft and neck fractures is a relatively simple, cost-effective, and safe technique with good published outcomes; however, definite advantages over other techniques or simple early mobilization have not been clearly demonstrated. [41] (10.1016/j.hcl.2006.02.016)
  • [L4] [42] (10.1177/15589447241306147)
  • [L4] Intramedullary k-wire fixation is a minimally invasive method for stabilizing metacarpal fractures. [44] (10.1007/s00402-004-0706-1)
  • [L5] The tested metacarpal fracture model had equivalent biomechanical properties when fixed with a standard dorsal plate and either six bicortical nonlocking screws or four bicortical locking screws. [46] (10.1007/s11552-013-9544-3)
  • [L5] Intramedullary fixation of oblique metacarpal fractures may be able to achieve adequate fixation, regardless of fracture obliquity. [47] (10.1016/j.jhsa.2025.12.017)
  • [L4] [48] (10.1055/s-0036-1593390)
  • [L2] Closer distance between the plate edge and joint line is associated with a more limited range of finger motion, and clinical outcomes approached an acceptable level at final follow-up. [49] (10.1177/1753193419899332)
  • [L5] A biomechanical advantage was found when using bicortical screws in metacarpal fracture plating under cyclic loading, with significantly higher load to failure and less plastic deformation compared to unicortical fixation. [51] (10.1177/1753193411424557)
  • [L3] External fixation combined with Kirschner wire fixation and hollow screw fixation exhibited similar curative effect in treating first metacarpal bone base fracture, indicating both surgery methods may be considered as the preferred approach. [57] (10.1186/s12891-023-06938-1)
  • [L3] Postoperative screw position is not significantly different between the mini-open and percutaneous approaches for intramedullary screw fixation of metacarpal fractures. [58] (10.1177/15589447241241765)
  • [L3] [59] (10.1177/17531934241277949)
  • [Paper] When treating metacarpal shaft fractures, both ORIF with PS and IMS can achieve acceptable outcomes. [60] (10.1177/15589447251371087)
  • [Case_report] [61] (10.1016/j.jhsa.2010.04.032)
  • [L3] Moreover, the invasiveness and postoperative complications are less in patients with pre-curved metacarpal plates. [62] (10.1186/s12891-023-06566-9)
  • [L5] [64] (10.1007/s11552-014-9673-3)
  • [L5] [65] (10.1016/j.jhsa.2020.10.026)
  • [L4] Intramedullary screw fixation with wide-awake anesthesia for transverse, oblique, and select comminuted fractures treatment metacarpal fractures represent a reliable option to early active mobilization recovery and a quick return to the work and ordinary activities. [70] (10.1055/s-0037-1618911)
  • [L5] A dorsal retrograde entry hole at the metacarpal head did not change MCP contact area, mean pressure, or peak pressure in load in full extension across all five digits. [95] (10.1016/j.jhsg.2026.100951)
  • [L3] Although operative time was shorter in the IMN group, incidences of loss of reduction, penetration to the metacarpal-phalangeal joint, and secondary surgeries for hardware removal were much higher in the IMN group. [96] (10.1016/j.jhsa.2008.07.011)
  • [L5] Retrograde metacarpal screw fixation produces a focal cartilage defect on the metacarpal head that tracks across the entire proximal phalanx articular surface during MCP joint motion. [102] (10.1016/j.jhsg.2025.100847)
  • [L5] Articular surface loss of the metacarpal head following RHCS insertion is negligible in a cadaveric model, with minimal engagement between the corresponding defect and the P1 base during functional ROM. [103] (10.1016/j.jhsa.2022.05.010)
  • [L5] A 4-screw bicortical nonlocking construct is noninferior to a 6-screw bicortical nonlocking construct for fixation of metacarpal fractures, which may be advantageous to minimize disruption of soft tissues while maintaining sufficient construct stability. [107] (10.1177/1558944720974116)
  • [L4] Biodegradable hemi-cerclage fixation of metacarpal fractures produces sufficient stability to permit early motion exercises and achieves results comparable to other standard fixation techniques, with no need for implant removal. [108] (10.1054/jhsb.1999.0296)
  • [Paper] Percutaneous flexible stable intramedullary nailing for the treatment of metacarpal neck fractures has expanded the armamentarium of the orthopaedic surgeons as an easy, cost-effective technique overcoming all possible deformities and allowing early and reliable active rehabilitation. [111] (10.1055/s-0039-3399481)
  • [L3] Medial plating offers no clear advantage over K-wire fixation in treating metacarpal neck fractures. [112] (10.1177/1753193419896518)
  • [L4] Retrograde headless intramedullary screw fixation of fifth metacarpal neck and shaft fractures has overall favorable early outcomes and offers the benefit of stable fixation, early motion without cast immobilization, and the ability for early return to work. [115] (10.1007/s11552-014-9620-3)
  • [L4] Antegrade IMHCS for fixation of proximal metacarpal fractures may be most feasible with thumb, middle, and little finger metacarpals because there was larger dorsal or ulnar overhang to allow screw placement without violating the carpometacarpal joints. [116] (10.1016/j.jhsa.2020.08.007)
  • [L4] Locked intramedullary nailing is a highly convincing fixation method for low-velocity gunshot metacarpal fractures where wound circumstances permit, with limited debridement associated with low complication rates. [119] (10.1016/j.jhsa.2007.05.013)
  • [L2] Compared with K-wire fixation, limited-open HCS fixation for metacarpal neck and shaft fractures was superior in terms of the early postoperative metacarpophalangeal arc of motion and return to work. [120] (10.1016/j.jhsa.2022.02.010)
  • [L4] The palmar approach for metacarpal shaft fractures provides satisfactory cosmesis and function with minimal tendon adhesion, making it useful for patients wishing to avoid a dorsal scar, though it presents challenges with surgical exposure and transient paraesthesiae. [121] (10.1177/17531934221079182)

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