Clinical and Radiological Outcomes of Intramedullary Screw and Plate-Screw Fixation in Extra-Articular Metacarpal Fractures: A Comparative Study

Introduction

Metacarpal fractures are common injuries that constitute a significant proportion of upper extremity trauma and account for approximately 30–40% of all hand fractures1,2. They occur most frequently in young individuals and may lead to functional limitations in daily activities as well as loss of work capacity3,4. Given the essential role of the metacarpals in grip strength and fine motor function of the hand, the goal of treatment is not only to achieve radiological union but also to preserve painless motion, strong grip, and full joint range of motion as much as possible5,6.

Although a substantial proportion of metacarpal fractures can be successfully managed with conservative treatment when they are closed, stable, and minimally displaced, surgical intervention becomes necessary in the presence of significant angulation, shortening, rotational deformity, or comminution5–7. Various surgical techniques have been described, including closed reduction with percutaneous K-wire fixation, intramedullary headless compression screws, and plate-screw systems5,8,9. In recent years, intramedullary headless compression screws have gained popularity due to their minimal soft tissue dissection, ability to provide stable internal fixation allowing early joint mobilization, shorter operative time, and low implant profile8,10. However, retrograde insertion of the screw through the joint is considered a potential disadvantage because of concerns regarding articular cartilage injury, intra-articular irritation, and the risk of long-term degenerative changes11.

Plate-screw systems, particularly in unstable and comminuted fractures, remain a widely used surgical option due to their ability to provide strong mechanical stability5. However, the more extensive soft tissue dissection required for plate fixation has been associated with complications such as extensor tendon scarring, tendon adhesions, joint stiffness, implant irritation, infection, and the need for implant removal5,12. Therefore, in the surgical management of metacarpal fractures, increasing emphasis has been placed on selecting fixation strategies that optimize both biomechanical stability and functional outcomes.

Although numerous studies in the literature have independently evaluated the clinical and radiological outcomes of metacarpal fractures treated with intramedullary screw fixation or plate-screw fixation, the number of studies directly comparing these two techniques and simultaneously assessing functional outcomes, complication rates, and radiological parameters remains relatively limited10,13. In this context, a comparative evaluation of the clinical and radiological outcomes of intramedullary screw and plate-screw fixation in metacarpal fractures represents a relevant and timely research topic that may help clarify surgical indications and contribute to the rational development of treatment algorithms. Therefore, the aim of this study was to compare the clinical and radiological outcomes of intramedullary headless compression screw fixation and plate-screw fixation in extra-articular metacarpal fractures.

Methods

Results

A total of 53 patients with acute, traumatic, extra-articular metacarpal fractures were evaluated, including 24 in the intramedullary (IM) screw group and 29 in the plate-screw (PS) group. The median age of the study population was 24 years (IQR: 21–37) for the IM group and 27 years (IQR: 22–39) for the PS group (p=0.35), with no significant differences found between the cohorts regarding sex, affected side, involved metacarpal, or comorbidities such as diabetes and smoking (p>0.05) (Table 1).

Fracture morphology was classified using the AO/OTA system as strictly extra-articular, involving the metacarpal shaft and neck (Table 1). Both groups demonstrated a balanced distribution of complexity, including simple (Type A), wedge (Type B), and multifragmentary (Type C) patterns (Table 1).

Table 2. Functional and clinical outcomes

Values are presented as median (interquartile range). ᵃ Mann–Whitney U test. QuickDASH: Quick Disability of the Arm, Shoulder, and Hand. TAM: Total Active Motion.

Regarding clinical outcomes at the 6-month follow-up, the IM group achieved significantly superior functional results, demonstrated by a lower median QuickDASH score of 0.0 compared to 5.9 in the PS group (p=0.029) and a significantly higher median grip strength of 39.2 kg versus 33.9 kg (p=0.025). Notably, the IM group showed a significantly greater median total active motion (TAM) of 245° compared to 221° in the PS group (p<0.001). The recovery profile was also significantly faster in the IM group, with a shorter median time to return to work (8.5 weeks vs. 10.0 weeks; p=0.001) and an earlier median radiological union (7.0 weeks vs. 8.0 weeks; p=0.045) (Table 2).

No cases of nonunion were observed in either treatment group. While superficial infection and delayed union rates were similar (p=1.000), complications such as deep infection (6.9%), implant irritation (13.8%), and the subsequent need for implant removal (13.8%) occurred exclusively in the plate-screw group (Table 3), although these differences did not reach statistical significance (p>0.05) (Table 3).

Table 3. Postoperative complications

Values are presented as number (%). ᵃ Fisher’s exact test.

Discussion

Various fixation methods are available for the surgical treatment of metacarpal fractures; however, there is currently no fixation technique accepted as the gold standard in the literature. In this study, the clinical and radiological outcomes of intramedullary headless compression screw fixation and plate-screw fixation in metacarpal fractures were compared, and intramedullary screw fixation was observed to provide more favorable results in terms of time to return to work and functional outcomes. The lower QuickDASH scores, higher grip strength, greater total active motion (TAM), shorter time to return to work, and faster fracture union observed in the intramedullary screw group suggest that the reduced extent of soft tissue dissection required by this technique may have contributed to the improved clinical outcomes.

Recent studies in the literature have reported that intramedullary fixation yields functional outcomes that are at least comparable to, and in some parameters superior to, alternative techniques such as plate-screw fixation and K-wire fixation. In the meta-analysis published in 2025 by DelPrete et al., patients treated with intramedullary screws demonstrated significantly lower DASH scores, higher grip strength, and lower reoperation rates compared with those treated with plate-screw or K-wire fixation16. Similarly, in the systematic review by Beck et al., a 100% union rate, the ability to make a full fist, and the absence of major complications were reported following intramedullary fixation in 169 metacarpal fractures17. The lower QuickDASH scores (p=0.022), higher grip strength (p=0.021), and greater total active motion (TAM) values (p<0.001) observed in our study are consistent with these findings and suggest that intramedullary fixation may offer functional advantages.

Published clinical series have reported that intramedullary fixation provides stable fixation that allows early mobilization and is associated with satisfactory functional outcomes. In a series of 20 patients, Ruchelsman et al. reported full active extension by the third postoperative week, radiographic union by the sixth week, and a mean contralateral grip strength of 105%, with no cases requiring secondary surgery18. In a retrospective study including 91 patients, Eisenberg et al. observed full functional range of motion at a mean of 10 weeks in all patients, radiographic union at 6 weeks in 76% of cases, and a minor complication rate of only 3% (MCP flexion <65°)19. Similarly, in a series of 48 metacarpal fractures, Del Piñal et al. reported a mean total active motion (TAM) of 249° and a mean return-to-work time of 76 days, with all patients returning to full work and sports activities20. In our study, the higher TAM values, shorter time to return to work, and faster fracture union observed in the intramedullary group are consistent with these clinical series and suggest that intramedullary fixation may represent an effective option in terms of functional outcomes.

When complications associated with plate-screw fixation are considered, recent studies suggest that although complication rates have decreased over time, similar issues continue to be reported. In the classic series published in 1998 by Page and Stern, major complications—including stiffness, nonunion, plate irritation, infection, and tendon rupture—were observed in 36% of 63 metacarpal fractures treated with conventional plate fixation, and total active motion (TAM) exceeding 220° was achieved in only 76% of patients21. Similarly, in a study of 104 metacarpal fractures, Fusetti et al. reported an overall complication rate of 35%, with notable rates of union-related problems, stiffness, and implant-related issues12. Although the introduction of low-profile plates has been associated with reduced complication rates, Baumgartner et al. reported a complication rate of 10% in a series of 110 metacarpal fractures published in 202122. In the present study, complication rates in the plate-screw group were also higher than those in the intramedullary group; however, this difference did not reach statistical significance.

One of the main concerns regarding intramedullary screw fixation is potential cartilage injury related to retrograde intra-articular entry through the metacarpal head. However, recent three-dimensional computed tomography (3D-CT) studies have demonstrated that this effect is limited. In a quantitative 3D-CT analysis by ten Berg et al., use of a 3.0-mm headless screw affected only 4–5% of the metacarpal head surface area and approximately 4% of the subchondral volume; moreover, the screw entry point did not contact the base of the proximal phalanx throughout most of the range of motion23. Similarly, Bachoura et al. also reported limited involvement of the articular surface24. These findings suggest that the dorsal entry point is located in a functionally less critical region of the metacarpal head. In the present study, no clinically significant intra-articular complications were observed in the intramedullary group during follow-up. Nevertheless, longer-term follow-up may be required to adequately assess potential long-term effects, particularly in young and highly active patients.

The strengths of this study include the comparison of two surgical groups treated at a single center with similar indications, as well as the comprehensive evaluation of functional and radiological outcomes together with complication rates. However, the retrospective study design, the relatively small sample size, the lack of randomization, and the insufficient follow-up duration to fully assess long-term degenerative changes should be considered the main limitations of this study.

Conclusion

Intramedullary headless compression screw fixation appears to be an effective treatment option for metacarpal shaft and neck fractures, providing favorable functional outcomes, earlier return to work, and shorter time to union compared with plate-screw fixation, while demonstrating a comparable complication profile. Owing to its minimally invasive nature and limited soft tissue dissection, intramedullary fixation may be particularly advantageous in extraarticular fracture patterns. Nevertheless, further prospective studies with larger sample sizes and longer follow-up periods are warranted to better define its long-term outcomes and optimal indications.