Introduction: Extra-articular fractures of the long bones of the hand are common but consensus on the best mode of treatment has not been established. Open treatment with plates or screws is frequently followed by extensor tendon adhesions and/or unsightly scars. Flexible intramedullary nailing is a proven minimally invasive technique that provides limited stability. We introduce a new method of locking these miniature hand nails to enhance fixation and expand their indications.

Methods: Extra-articular metacarpal and phalangeal fractures including those with spiral patterns or segmental comminution were treated with close fluoroscopically assisted reduction and locked percutaneous flexible nails. A manually operated slotted awl was used for nail insertion and proximal locking was provided by a captured transverse pin. The nails were routinely removed after fracture healing. Standard principles of hand rehabilitation including early motion and splinting were used in the post-operative period.

Results: We reviewed retrospectively 84 consecutive patients treated at our center with this technique between July 1999 and June 2000. We were able to follow 73 patients for a minimum of one year. There were 45 metacarpal and 28 phalangeal fractures. All fractures healed. There were no rotational deformities or significant shortening. Metacarpal fractures generally recovered full range of motion. Average total active motion for phalangeal fractures was 240. Loss of PIP joint extension with proximal phalanx fractures averaged 15 deg. Complications consisted of delayed healing (>8weeks) due to distraction in one metacarpal and one phalangeal fractures and two cases of tendon irritation over the base of the 4th metacarpal.

Conclusion and Significance: This is a minimally invasive technique that avoids exposure of the fracture, dissection around the extensor mechanism and scar problems. It obtains excellent functional results and has a low complication rate. Locking the nails controls length and rotation. Phalangeal fractures present a more serious challenge.