641319

research-article2016
JHS0010.1177/1753193416641319Journal of Hand SurgeryBorbas et al.

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JHS(E)
The Journal of Hand Surgery

Treatment of proximal phalangeal (European Volume)

XXE(X) 1­–5
© The Author(s) 2016
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intramedullary screw: a cadaver study DOI: 10.1177/1753193416641319

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P. Borbas1, M. Manuel2, A. Poggetti1, M. Calcagni1 and T. Giesen1

Abstract
The aim of this study was to quantify the articular cartilage defect created with two different antegrade
techniques of intramedullary osteosynthesis with a headless compression screw inserted through the
metacarpophalangeal joint. In 12 out of 24 fingers from six cadaveric hands, a trans-articular technique with
cannulated headless compression screws (2.2 and 3.0 mm diameter) was used; whereas in the other 12 fingers,
an intra-articular fixation technique was used. The areas of the articular surface and the defects created were
measured with a digital image software program. All measurements were made twice by two observers. In
the intra-articular technique, the average defect in the base of the articular surface of the proximal phalanx
was 4.6% with the 2.2 mm headless compression screw and 8.5% with the 3.0 mm screw. In the trans-articular
technique, the defect size was slightly smaller; 4.2% with the 2.2 mm screw and 8% with the 3.0 mm screw, but
the differences were not statistically significant. The main advantage of the intra-articular technique was that
it avoided damage to the articular surface of the metacarpal head.

Keywords
Proximal phalanx, finger fracture, intramedullary osteosynthesis, cartilage defect, headless compression
screw

Date received: 1st October 2015; revised: 21th February 2016; accepted: 2nd March 2016

Introduction
Operative treatment may be required for displaced
transverse and short oblique fractures of the proxi-
mal phalanges. Options include closed reduction and
percutaneous pinning with Kirschner-wires, which
often requires some form of post-operative immobi-
lization and removal of metal after bone healing.
Open surgery and fixation with plates or pins
often result in adhesions and limited range of motion
(Brei-Thoma et al., 2015; Henry, 2008) and removal of
the fixation material is also often required.
A recent study by del Piñal et al. (2015) has shown
good clinical results with retrograde intramedullary
fixation of metacarpal and proximal phalanx frac-
tures using cannulated headless screws. This tech-
nique requires minimal exposure and provides
immediate stability for early active mobilization.
Furthermore, there is no material exposed on the
proximal phalanx, a defect of the articular cartilage
of the distal proximal phalanx is created and there is
a potential for damage to the central slip of the exten-
sor tendon at the level of the proximal interphalan-
geal joint. For this reason, we prefer to use an
antegrade technique (Giesen et al., in press). The
drawback of this approach is that the cartilage of the
metacarpal head and the base the proximal phalanx
might be damaged as the screw is passed through
the metacarpophalangeal (MCP) joint.
The aim of this study on cadavers was to quantify
the damage to the cartilage of the MCP joint by ante-
grade intramedullary fixation.
1Plasticand Hand Surgery Department, University Hospital of
Zurich, Zurich, Switzerland
2Anatomic Institute, Medical University of Graz, Graz, Austria

surface of the bones, minimizing the risk of adhe-

Corresponding author:
sions. The completely buried screw will potentially T. Giesen, Plastic and Hand Surgery Department, University
not need removal. However, with the retrograde Hospital of Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
technique of intramedullary fracture fixation of the Email: t_giesen@hotmail.com

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2 The Journal of Hand Surgery (Eur)

Figure 1.  Intra-articular technique. (a) Driving the cannulated headless compression screw over the 0.8 mm guide wire.
(b) Lateral radiograph of a little finger with a 0.8 mm guide wire inserted before screw placement. (c) Posteroanterior
radiograph of a little finger after insertion of a 2.2 mm headless compression screw. (d) Photograph of the MCP joint after
disarticulation. A black arrow indicates a partial-thickness cartilage defect on the dorsal part of the metacarpal head cre-
ated by a 2.2 mm screw.

Methods in place. A 3.0 mm headless compression screw was

We studied 24 fingers from six cadaver hands (three
female, three male) with a mean age of 75 years
(range 67–82). There were three left hands and three
right hands. The thumbs were not studied. The cadav-
ers were preserved using the technique of Thiel
(1992). A radiograph of each digit was taken before
dissection to confirm that there was no evidence of
advanced arthritis, previous major injury or other
pathological changes.
No actual fractures were created in the proximal
phalanges. In each finger a 2.2 mm diameter head-
less compression screw (SpeedTip CCS, Medartis,
Basel, Switzerland) was used first and then a 3 mm
screw. We tested both available sizes of the CCS
screws, as in clinical practice we tend to use the
larger size, when possible, to improve stability. All
fingers were operated on using an antegrade tech-
nique through the MCP joint. An intra-articular
approach was used in 12 fingers and a trans-
articular approach was used in the other 12 fingers.
Surgical technique
then inserted under visual control through the same
approach using the same technique and the mea-
surements were repeated.
Trans-articular technique. Under fluoroscopic
control, a 0.8 mm guide wire was inserted ante-
grade from the dorsum into the metacarpal head
with the MCP joint in about 60° of flexion and then
into the proximal phalanx along the longitudinal
axis. A cannulated 2.2 mm headless compression
screw was driven in over the guide wire with a can-
nulated screwdriver without pre-drilling, until the
screw head was beneath the cartilage (Figure 2).
Afterwards a dissection was carried out to assess
any damage to the extensor tendon (Figure 3). The
MCP joint was examined to assess any damage to
the articular cartilage of the metacarpal head and
the base of the proximal phalanx. The 2.2 mm
headless screw was then removed, leaving the
guide wire in place. A 3.0 mm headless compres-
sion screw was then inserted under visual control
through the same approach and measurements
were repeated.

Intra-articular technique.  Under fluoroscopic control

a 0.8 mm guide wire was inserted dorsally through
the MCP joint, which was held in about 60° of flexion,
into the centre of the base of the proximal phalanx
and along the longitudinal axis. To facilitate the
insertion of the wire, the base of the proximal pha-
lanx was gently pushed dorsally. A cannulated
2.2 mm headless compression screw was driven in
over the guide wire using a cannulated screwdriver
without pre-drilling, until the screw head was
beneath the cartilage (Figure 1). Once the defect had
been assessed and measurements taken, the 2.2 mm
headless screw was removed, leaving the guide wire
Measurement and quantification of
defects in the surface of the joint
After disarticulation, specimens were placed under
a digital camera. Photographs were taken in a stand-
ardized way, perpendicular to the base of the proxi-
mal phalanx. The surface area of the articular
cartilage was measured and calculated by two
observers using Image J image processing software
(National Institute of Health, Chicago, IL, USA)
(Figure 4). The area of the defect in the metacarpal
cartilage surface was not measured separately, but
was inspected visually.

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Borbas et al. 3

Figure 2.  Trans-articular technique. (a) Lateral radiograph of a small finger with wire inserted antegrade across the MCP
joint. (b) Posteroanterior radiograph after insertion of a 2.2 mm headless compression screw. (c) Photograph of the MCP
joint after disarticulation with visible joint surface defects (black and white arrows) created by a 3.0 mm screw in the trans-
articular technique.

Figure 3.  Photograph of the extensor tendon, taken after
dissection to assess any damage to the tendon.
Figure 4.  Photographs of the joint surfaces for measure-
ments of the areas of (a) the defect and (b) the surface.
Statistical analysis
Measurements were taken twice by two independent
observers. Intra- and interclass correlation coefficients
were calculated to assess reliability. Mean values of the
four measurements were used for final analyses.
Student’s t-test was used to compare the sizes of the
defect in the articular cartilage produced by the two
techniques. Statistical significance was set at p < 0.05.
Results
The average defect of the proximal articular surface
of the proximal phalanx was 4.6% (range 3.4–5.9) with
the 2.2 mm headless compression screw in the intra-
articular technique and 4.2% (range 3.5–4.8) in the
trans-articular technique. These differences were not
statistically significant (p >  0.1). With the 3.0  mm
screw, the joint surface defect was 8.5% (range 4.7–
12.3) in the intra-articular technique and 8% (range
6.3–9.1) in the trans-articular technique. These were
also not statistically significant (p > 0.4). The detailed
results are listed in Tables 1 and 2.
Absolute value measurement of the articular sur-
face and defect size had an average intra- and inter-
observer correlation of 0.88 and 0.85.
Damage to the articular cartilage of the metacar-
pal head was assessed. With the intra-articular tech-
nique, we noticed no full-thickness cartilage defect
on the dorsum of the metacarpal head. In eight of the
12 fingers, a small partial-thickness cartilage defect
in the form of an abrasion was seen. The defect in the
cartilage was located more in the palmar area of the
articular surface with the trans-articular technique,
as the screws were inserted through the MCP joint in
about 60° of flexion. The area of damage to the meta-
carpal head was not measured separately, but
appeared to be the same size as the defect on the
proximal phalanx and was smaller in relation to the
area of the cartilage because of the convex shape of
the metacarpal head.
No relevant damage to the extensor tendons could
be seen, except for small partial tears less than 20%
of the width of the tendon in some cases.
Discussion
Intramedullary fixation of metacarpal and phalan-
geal fractures is not new and has been done

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4 The Journal of Hand Surgery (Eur)
Table 1.  Defect size with a 2.2 mm screw as a percentage of the area of the articular surface of the base of the proximal
phalanx. Each measurement was made in three fingers for each technique.
Intra-articular technique
Index finger 4.2
Middle finger 4.5
Ring finger 4.6
Small finger 5.2
Mean defect size 4.6
Table 2.  Defect size with a 3 mm screw as a percentage of the area of the articular surface of the base of the proximal
phalanx. Each measurement was made in three fingers for each technique.
Intra-articular technique)
Index finger 7.9
Middle finger 6.5
Ring finger 8.5
Little finger 11.1
Mean defect size 8.5
previously with Kirschner-wires (Karbelnig, 1963;
Thevenin et al., 1972). However, the use of headless
compression screws has become more popular
recently (Boulton et al., 2010; del Piñal et al., 2015;
Ruchelsman et al., 2014).
This study quantified the damage to the articular
surface damage of the MCP joint caused by two tech-
niques of antegrade osteosynthesis of the proximal
phalanx using a cannulated headless compression
screw. In our opinion, the intra-articular technique is
better as it produces only half as much defect in the
cartilage as the trans-articular technique, in which a
lesion in the cartilage of the metacarpal head is also
created. It was easy to find the correct entry point
with the intra-articular technique and little damage
to the extensor tendons was seen (Figure 3).
In the trans-articular technique, we observed less
cartilage damage to the base of the proximal phalanx
than in the intra-articular technique using the same
size screws, although this difference was not statisti-
cally significant. The base of the proximal phalanx is
more stable in the trans-articular technique. We
think that this may reduce cartilage damage caused
by movements in the axial plane of the phalanx while
inserting the screw with the screw driver.
A headless compression screw may also be intro-
duced through the proximal interphalangeal joint
using a retrograde technique (del Piñal et al., 2015).
This is technically less demanding and only one joint
surface is damaged by the screw. However, a larger
relative area of the distal joint surface of the proxi-
mal phalanx is damaged in comparison with the
antegrade trans-articular technique. The mean
articular surface defects were 13% to 18% for a
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Trans-articular technique Average of both techniques
4.5 4.4
4.3 4.4
3.9 4.2
4.3 4.8
4.2 4.4
Trans-articular technique Average of both techniques
8.4 8.2
7.6 7.1
7.6 8.0
8.2 9.7
8.0 8.3
2.5 mm screw, and 19% to 25% for a 3.0 mm screw,
estimated from computed tomographic scans of
healthy fingers (del Piñal et al., 2015). Furthermore
the central slip of the extensor mechanism may be
compromised by this retrograde technique. One pos-
sible advantage of a retrograde technique could be
that the damaged area of the joint surface is located
dorsally. However, with the antegrade intra-articular
technique, the defect in base of the proximal phalan-
geal is also located dorsally in an area that is not
loaded in grasping movements, as the MCP joint is
flexed. With the antegrade trans-articular technique,
the defect of the metacarpal head is located cen-
trally and therefore it could cause pain as this area is
loaded in grasping movements.
Transverse and short oblique fractures of the prox-
imal phalanx shaft can often be managed conserva-
tively with an intrinsic plus splint alone (Henry, 2008).
Nevertheless, immobilization is against the general
principles of the management of hand fractures
and may lead to reduction in the range of motion
(Freeland et al., 2003). A recently published study
showed acceptable results for periarticular pinning of
unstable fractures of the base and shaft of the proxi-
mal phalanx using two Kirschner-wires introduced
from the radial and ulnar aspects of the base of the
proximal phalanx (Eberlin et al., 2014). However, early
range of motion rehabilitation is not possible with this
technique. A trans-articular intramedullary fixation
technique, using two Kirschner-wires instead of a
headless compression screw, showed good results
(Hornbach and Cohen, 2001). However, since the
wires were driven through the MCP joint, fixing the
joint in 90° exercises of the joint could not be started
Borbas et al. 5
before removal of the wires at least 3 weeks post-
operatively. Other types of operative fixation also have
disadvantages, such as stiffness and adhesions after
open reduction and plate osteosynthesis.
In our opinion, intramedullary fixation of trans-
verse and short oblique fractures of the proximal
phalanx with a headless compression screw may ful-
fil the requirements for early post-operative mobili-
zation and stable fracture fixation, without the need
for implant removal.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
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