Published online Dec 9, 2026. doi: 10.5409/wjcp.120900
Revised: April 5, 2026
Accepted: June 1, 2026
Published online: December 9, 2026
Processing time: 212 Days and 17.4 Hours
Intramedullary headless screws (IMHS) have become increasingly popular for metacarpal and phalangeal fracture fixation in adults. However, evidence regar
To evaluate the safety and clinical outcomes of IMHS fixation for pediatric hand fractures.
A systematic review was conducted using predefined inclusion criteria to identify clinical studies reporting IMHS fixation in patients aged < 16 years with meta
Thirteen pediatric patients (14 fractures) were analyzed, with a mean age of 9.5 years (range 5-12). Fracture patterns were predominantly proximal phalangeal (n = 12, 85.7%), with two metacarpal shaft fractures. IMHS fixation was performed via retrograde (n = 9) or antegrade (n = 4) approaches. The mean follow-up across studies was 26.1 months (range 6-36). Radiographic union was achieved in all fractures, with no implant migration, screw breakage, infection, or physeal disturbance reported. Functional outcomes were excellent in nearly all cases, with full restoration of range of motion in 12 patients and mild, non-limiting motion restriction in one patient. The overall complication rate was 0% among all patients.
Although limited to small case reports and a single series, current evidence suggests that IMHS fixation may be a safe and effective option for selected pediatric metacarpal and phalangeal fractures. Larger prospective com
Core Tip: Pediatric hand fractures are primarily treated with conservative approaches using immobilization, with acceptable outcomes. A subset of these fractures is amenable to operative management, especially those with malalignment or displacement, or when conservative management fails. Closed reduction and fixation using intramedullary headless screws (IMHS) is an operative management option that has proven efficacy in adults. Although the current systematic review included a small number of patients, IMHS fixation of pediatric metacarpal or proximal phalanx fractures resulted in excellent functional outcomes, 100% union rate, and 0% complications. These early results are encouraging and suggest that IMHS should be considered for operative management of pediatric hand fractures.
- Citation: Khalifa AA, Megahed AA, Imran A. Safety of intramedullary headless screw fixation for pediatric hand fractures: A systematic review. World J Clin Pediatr 2026; 15(4): 120900
- URL: https://www.wjgnet.com/2219-2808/full/v15/i4/120900.htm
- DOI: https://dx.doi.org/10.5409/wjcp.120900
Pediatric hand fractures are a considerably common injury, and they represent one of the most frequent fractures presenting to emergency departments[1-3]. Metacarpal fractures account for 18%-40% of all hand fractures, commonly affecting the fifth metacarpal, while phalangeal fractures account for approximately 23%, commonly affecting the proximal phalanx[4-7].
As is usually observed in this population, fractures unite quickly and remodel more rapidly than in adults[8]. Therefore, for non- or minimally displaced fractures, immobilization is the preferred treatment with acceptable outcomes. However, in cases of displaced fracture, intraarticular extension or acceptable fracture reduction cannot be maintained with splints; various options of surgical fixation, such as closed or open reduction followed by pinning, have been suggested to avoid residual deformities that could potentially affect hand function[3,9-12].
One popular management option in adult hand fractures but rarely used in the pediatric population is intramedullary headless screws (IMHS) fixation, which has had excellent results in adults[13,14]. However, concerns have arisen over its use in the pediatric population, including potential for iatrogenic epiphyseal injuries and later epiphyseal growth arrest and resultant deformities[13,15].
Some previous studies on IMHS fixation in hand fractures included patients as young as 14 years old; however, the outcomes for this particular young population were not reported in isolation[15,16]. Therefore, this systematic review aimed to evaluate the role of IMHS in the management of pediatric hand fractures, with specific emphasis on functional outcomes and complication rates.
This systematic literature review was performed in accordance with PRISMA guidelines (Supplementary material)[17], and it was registered in PROSPERO (registration ID: CRD420251118138) beforehand.
The inclusion criteria were English language studies (randomized controlled trials, cohort studies, case series, and case reports) reporting the outcomes (clinical, radiological, and complications) of IMHS fixation in the management of pediatric (patients younger than 16 years old) hand fractures (including metacarpal and phalangeal fractures).
The exclusion criteria were as follows: Studies not published in English, performed on animal models, other publication types (reviews, editorials, abstracts, technical notes, and commentaries), and studies where the outcomes of interest could not be retrieved, or if studies included mixed populations (adults and pediatrics) and the authors did not isolate pediatric outcomes.
The search strategy was based on the predefined population, intervention, comparison, and outcome model. The population of interest was pediatric patients with hand fractures (metacarpal or phalangeal, either fresh or old). The intervention was IMHS fixation, and it was compared with other management modalities if present, such as closed reduction and pinning or non-operative management. The main outcomes were clinical (functional), radiological, complications, and the need for secondary surgery.
A comprehensive English literature search was performed on August 1, 2025 and included studies over the past 15 years, as this marks the first description of IMHS fixation for hand fractures[18] through three databases (PubMed, EMBASE through Ovid, and Scopus), using the following search terms:
For PubMed and EMBASE: (“Metacarpal Bones”[Mesh] OR metacarpal* OR phalangeal OR phalanx OR “hand fracture*” OR “finger fracture*”) AND (“Intramedullary screw*” OR “headless screw*” OR “compression screw” OR “Acutrak” OR “Herbert screw”) AND (“Pediatrics”[Mesh] OR pediatric* OR child* OR adolescent* OR teen* OR “young patient*” OR “skeletally immature”) AND (fracture* OR fixation OR treatment OR repair).
For Scopus: (TITLE-ABS-KEY (metacarpal* OR metacarpal bone fracture OR phalangeal fracture OR phalanx fracture OR “hand fracture*”)) AND (TITLE-ABS-KEY (“intramedullary screw*” OR “headless compression screw*” OR “Herbert screw”) AND (TITLE-ABS-KEY (pediatric* OR child* OR adolescent* OR teen* OR “skeletally immature”)) AND (TITLE-ABS-KEY (fracture fixation OR fracture internal fixation OR treatment)).
All of the results (176 articles) were downloaded into EndNote 21, and duplicates were removed. Two authors (Ahmed A Megahed and Ahmad Imran) performed initial screening and selection based on the predefined inclusion criteria. For the initially eligible studies, their titles, abstracts, and full texts were screened and reviewed to determine final inclusion and suitability for data extraction. Controversies were resolved through discussion with the first author (Ahmed A Khalifa). After deciding which articles to include, backward and forward snowballing was performed to identify any references within the articles or any studies that cited them, and to determine whether any of these were eligible for further inclusion.
Details of included citations and the inclusion and exclusion of records at each step are presented according to the PRISMA flowchart (Figure 1).
For final data extraction, the articles were assigned to one author (Ahmad Imran), who extracted all relevant data into a predefined Excel sheet, followed by review by another author (Ahmed A Khalifa) to confirm that all necessary data were included. Before the final data extraction, the search was re-conducted to confirm that no additional eligible articles had been published.
The following data were extracted: (1) Articles’ characteristics: Author(s), year of publication, country of origin, type of study; (2) Patient characteristics: Age, sex, injury side, hand dominance; (3) Fracture characteristics: Fracture location and description; (4) Surgery details: Time from injury to surgery, surgical approach, implant characteristics; and (5) Outcomes: Clinical, radiological (including fracture union), complications, and the need for secondary surgery. Any further data that seemed suitable for reporting were extracted.
The Joanna Briggs Institute tools for risk of bias (ROB) of case series[19] and case reports[20] were used for evaluating the included articles.
Only three studies met the inclusion criteria - two case reports and one case series -making a quantitative meta-analysis infeasible. Consequently, the evidence was analyzed descriptively and summarized using a narrative synthesis.
Three studies were ultimately included[21-23]: Two case reports (one published from Uruguay[22] and one from Belgium[21]) and one case series published from Turkey[23]. There were 13 patients in total, with a mean age of 9.5 ± 3.6 years (ranging from 5 to 15). The majority were males (76.9%), and the right hand was injured in 76.9% of the patients (Table 1).
| Ref. | Country of origin | Study type | Patient number (fracture number) | Age (years) | Gender | Side | Dominant side | Fracture location | Fracture location and description | Injury to surgery time | Indication for surgery | Treatment details | Size of screws | Postoperative protocol |
| d’Oliveira and Craviotto[22], 2023 | Uruguay | Case report | 1 (2) | 8 | M | Right side | No | Metacarpal of the middle and ring finger | Shaft spiral fractures | NR | Spiral configuration, rotational malalignment with scissoring | Closed reduction and fixation using antegrade IMHS | 30-mm length headless screw for the 4th metacarpal, and a 32-mm screw for the 3rd metacarpal. Both screws were 2.4 mm in diameter | Splint for 1 week, followed by early mobilization |
| Ayık et al[23], 2025 | Turkey | Case series | 11 (11) | 9.4 (5-15) | 8 M and 3 F | 8 right and 3 left | 8 hands | Proximal phalanx: 5 index fingers; 3 middle fingers; 2 ring fingers; and 1 little finger | 4 at the neck level, 4 at the shaft, and 3 at the base | 2.5 days (0-9) | Unstable fractures (rotation, shortening, or displacement), fractures involving the neck, shaft, or closed physeal base; loss of reduction after conservative treatment | Closed reduction and 7 had retrograde IMHS fixation, 4 had antegrade IMHS fixation | NR | Same day discharge- Immobilization for 3-5 days. At the 5th postoperative day, home exercises and early ROM were started under supervision by a physiotherapist |
| Maes et al[21], 2025 | Belgium | Case report | 1 (1) | 12 | M | Right | NR | Proximal phalanx of the ring finger | Mid-diaphyseal | 4 weeks (initially treated conservatively) | Malunion with volar angulation of 50 degrees (impeding finger ROM) | Closed reduction and retrograde IMHS fixation | A cannulated compression headless screw of 2 mm diameter | A protective orthosis and buddy loop were applied, and physical therapy was initiated early |
The included patients had a total of 14 fractures, as one patient had two metacarpal fractures), 12 of which (85.7%) were proximal phalanx fractures, and 2 (14.3%) were metacarpal fractures. All fractures were acute traumatic, except for one proximal phalanx fracture, which was an old fracture (1 month) with malunion.
All fractures required closed reduction, followed by antegrade fixation for the two metacarpal fractures. Eight (66.7%) of the proximal phalangeal fractures had retrograde fixation, while the remaining 4 (33.3%) had antegrade fixation. All patients started early mobilization within the first postoperative week.
After a mean final follow up of 26.1 ± 8.5 months (ranging from 6 to 36), all patients were assessed for the outcomes described below and summarized in Table 2.
| Ref. | Follow up period (months) | Functional outcome | Radiological outcome | Complications | Hardware removal |
| d’Oliveira and Craviotto[22], 2023 | 6 | No pain - no limitation of daily activities - DASH score was zero | Adequate bony union was achieved, and no displacement or rotational malalignment | None | NR |
| Ayık et al[23], 2025 | 29.1 (24-36) | 10 patients had normal finger function; 1 patient had mild restriction | Fracture union was achieved within the first month in 9 patients, and within 2 months in 2 patients. No signs of joint degeneration | None | No routine removal was recommended. One patient had a retrograde screw removal at the parents’ request |
| ROM compared with the contralateral side showed the following deficits: MCP joint: 1.8 (range 0-10), PIP joint: 2.7 (range: 0-10), and DIP joint: 0.9 (range: 0-10) | |||||
| Pain VAS score of 0.09 (range: 0-1) | |||||
| Functional VAS score of 9.7 (range: 8-10) | |||||
| Aesthetic satisfaction VAS score of 9.9 (range: 9-10) | |||||
| Grip strength showed an average 10% (range: 0-20) deficit compared to the contralateral hand (tested in patients > 10 years of age) | |||||
| Overall, 10 patients had excellent outcomes, while 1 had a good outcome1 | |||||
| Maes et al[21], 2025 | 12 | Full finger ROM was restored after 4 weeks postoperatively | Stable screw positioning without any signs of breakage or loosening- no degeneration at the PIP joint | None | Neither performed nor planned |
| At 1 year, finger length growth was normal - no pain - full ROM in all fingers and a symmetrical power grip |
Functional outcomes: All patients regained normal finger range of motion (ROM), except for one patient with a proximal phalanx fracture who complained of some motion restriction. No pain was reported in any of the patients by the last follow up. Grip strength was evaluated in five (38.5%) patients with proximal phalanx fractures and was comparable to the contralateral side.
Radiological outcomes: All fractures showed bony union with no malalignment of hardware protrusion, breakage, or loosening.
Complications: None were reported perioperatively, and no joint degeneration was observed.
Secondary surgeries: Only one (7.7%) patient required hardware removal upon request from the parents. No revision surgeries were required.
The ROB assessment revealed that the two case reports had a low risk and the case series had a moderate ROB (Supplementary material).
The current systematic review evaluated a small group of pediatric patients who presented with 14 hand fractures and were successfully treated with closed reduction and IMHS. The initial results are promising, with nearly all patients achieving full functional recovery, including painless ROM, all fractures achieving bony union, and a high safety profile, indicated by a 0% complication rate. These results suggest that IMHS should be considered as a fixation method for selected pediatric metacarpal and proximal phalanx fractures. However, the results should be interpreted cautiously owing to the limited number of included patients and the relatively low evidence level of the included studies.
Although the results are promising, they must be considered and interpreted considering current limitations, primarily attributed to the small number of included studies and the small number of analyzed patients. First, the search was limited to three databases and to publications in English, and no other sources were searched, such as grey literature or publications in other languages, which might have led to omission of some eligible articles. Second, given the nature of the included studies (case reports and case series), even though their ROB assessments were moderate and low, the scientific evidence derived from them could be considered weak or of poor methodological quality. Third, given the small number of included studies, with few patients and the descriptive design, quantitative pooling or meta-analysis was not appropriate. The heterogeneity of reporting and the absence of comparable outcome measures precluded meaningful statistical synthesis. Accordingly, the results are presented as a narrative summary of the available evidence. Fourth, some studies included pediatric patients; however, we were unable to retrieve the data or outcomes for those patients. In one study[24] on retrograde IMHS fixation of metacarpal fractures, the minimum patient age was 15 years. In the another study[16] on IMHS fixation of metacarpal fractures, the youngest patient was 14 years old. In a technical report by Megahed et al[25], the authors described a case of pediatric proximal phalanx fracture treated with IMHS fixation with favorable outcomes; however, this report did not meet our inclusion criteria. Lastly, none of the included patients were followed up until skeletal maturity to evaluate fracture behavior, physis status, and any possible resultant deformities.
Most pediatric hand fractures are amenable to conservative management and have been considered the gold standard for treatment; however, a subset of fractures require surgical intervention, with the literature reporting an intervention rate ranging from 2.2% to 16%[26,27].
The exact indications for surgical intervention, including the use of IMHS, varied among studies. According to Ayık et al[23], indications for IMHS fixation in proximal phalanx fractures included the following: Unstable fractures (rotation, shortening, or displacement) or loss of reduction during conservative management. In their series, three patients were treated surgically after loss of reduction after conservative management. Furthermore, Maes et al[21] indicated that fractures with > 25° of palmar or dorsal angulation and radial or ulnar angulation of > 10° are candidates for operative management.
A large study by Schutz et al[26] evaluated 634 proximal phalanx fractures in pediatric population, with a mean age of 10.8 years (range: 1.2 to 17.0). Only 14 patients were treated operatively, and the criteria for operative management (closed or open reduction and pinning) were late presentation of presence of rotation or angular malalignment in preoperative radiographs.
For metacarpal fractures, d’Oliveira and Craviotto[22] reported that multiple fractures, spiral or long oblique configuration, are amenable to surgical fixation to avoid secondary displacement, shortening, and malunion with residual malrotation.
Wei et al[8] evaluated 524 pediatric hand fractures, and only 2.3% of them required surgery, most likely in those that had > 10° of angulation [odds ratio (OR) = 7.3, 95% confidence interval (CI): 2.1-24.7], > 2 mm of displacement (OR = 14.8, 95%CI: 4.3-50.6), being intra-articular (OR = 12.5, 95%CI: 3.8-40.5), or having a transverse configuration (OR = 6.3, 95%CI: 1.9-20.6).
The described surgical technique for IMHS fixation in pediatric hand fractures is similar to what has been reported in adults[25,28]. However, two fundamental differences should be noted.
First, in the case of metacarpal fractures, d’Oliveira and Craviotto[22] described an antegrade insertion technique that preserves the metacarpal head physis, unlike the commonly used retrograde technique for metacarpal fracture fixation in adults. Second, the screws used are relatively small in pediatric patients to accommodate the smaller proximal phalanx and metacarpal bones.
Although the functional and radiological outcomes of the included patients are favorable, owing to the noncomparative nature of the studies, a direct comparison with other fixation methods was unfeasible. Boyer et al[11] evaluated 105 patients with a mean age of 11 years (range 5-16) who had proximal phalanx fractures and were treated with closed reduction and percutaneous pinning. Apart from the need for postoperative immobilization for at least 4 weeks, in contrast to IMHS fixation where patients started ROM within 1 week, 36 (34.3%) patients had ROM limitation by the second follow up visit and required active hand therapy.
Kiely et al[29] evaluated 313 pediatric hand fractures in patients with a mean age of 9.83 years (SD: 4.17), with 39% of these fractures requiring operative fixation (either open or percutaneous). The authors reported significantly better functional outcomes in proximal phalangeal fractures that were treated with splint only compared with those who had operative management. In contrast, there was no significant difference between different management options for metacarpal fractures.
Regarding the complications and safety of operative management of pediatric hand fractures, Schutz et al[26] reported a radiographic malunion at final follow-up in 0.64% of fractures treated with in situ mobilization, 2.01% of fractures treated with closed reduction, and 0% of fractures treated operatively. Wei et al[8] reported similar findings, with 0% reoperation or infection rates among those treated surgically. Furthermore, in the current systematic review, using IMHS for fixation resulted in a 0% complication rate. However, it should be noted that this low incidence of complications should be considered in view of the small number of included patients and their relatively short follow up; it is possible that physeal injury effects might appear after longer follow up.
IMHS use for hand fracture fixation in adults showed a lower complication rate than other fixation methods (namely, K-wires or miniplates)[13,30]. In a systematic review by Anene et al[31] that included 26 studies (1014 fractures), the overall complication rate after IMHS fixation was 4.6%, with stiffness as the most frequently reported complication (0.9%). It is worth noting that the authors reported that tendon adhesions and degenerative arthritis were very rare.
Comparing the complications after IMHS fixation with other fixation methods, five patients (4.8%) had perioperative complications in the study by Boyer et al[11], all of which were related to the K-wires used for fixation, where two had pin migration, one had an infection, and one had pin migration with secondary fracture reduction loss leading to secondary surgical intervention.
First, there are concerns about injury to the physeal plates, which can lead to growth arrest and further deformity. Although no growth arrest or deformity was reported in the patients included in the current review, the authors noted some precautions. d’Oliveira and Craviotto[22] proposed an antegrade fixation method for metacarpal fractures to avoid physeal injury. Moreover, for proximal phalanx fractures, Ayık et al[23] reported that they preserved the retrograde technique for neck and shaft fractures where the physeal plate is still open. In contrast, the antegrade technique was applied for base or shaft fractures in those with closed physeal plates.
Second, possible articular surface damage: In a computed tomography model of metacarpal fractures with retrograde fixation (evaluating MCP joint affection), ten Berg et al[32] showed that 2.4- and 3.0-mm screws caused minimal articular cartilage defects of 4% and 5%, respectively. Moreover, for antegrade IMHS fixation of proximal phalanx fractures, Borbas et al[33] reported articular surface defects of 4.6% and 8.5% associated with 2.2 mm and 3.0 mm IMHS, respectively. If retrograde IMHS was used for proximal phalanx fixation, del Piñal et al[34] found an articular surface defect of 18% and 25% with 2.5 mm and 3.0 mm screws, respectively. Although all previous studies were conducted on adult bones, it should be noted that the screws used in pediatric patients are even smaller, proportionate to the metacarpal and proximal phalanx sizes.
Third, there are concerns regarding possible extensor tendon damage, as IMHS fixation was performed percutaneously. Urbanschitz et al[35] evaluated IMHS fixation techniques in a cadaveric model; they reported no cases with extensor tendon damage exceeding 50%, the threshold for tendon[36].
Lastly, regarding safety, we note that all previous studies were conducted on adult hands, and surgeons should always remember that they are dealing with smaller bones, for which screw lengths and diameters should be adjusted to these smaller anatomical structures.
First, its superiority over percutaneous K-wire fixation stems from the need for supplementary splinting to protect the fixation until fibrous union is achieved[37]. IMHS allows for early mobilization as soon as possible.
Second, K-wires require removal, while IMHS does not require hardware removal. However, this should not be considered a guarantee, as the follow-up period was relatively short. Moreover, unlike K-wires, which are routinely removed, IMHS removal was not clinically required in any patient; only one screw was removed at the parents’ request without clinical indication. d’Oliveira and Craviotto[22] reported that screw removal is not required, as they do not interfere with the physis.
Third, it demonstrated better biomechanical stability, with IMHS showing higher stiffness and load-to-failure during metacarpal fracture fixation compared with miniplates, as reported in a cadaveric biomechanical study by Dyrna et al[38].
Although IMHS fixation is not widely used for pediatric hand fractures compared with other treatment modalities, it may offer several advantages in appropriately selected cases. These include early mobilization, a minimally invasive surgical approach, and a reduced risk of adhesions and soft tissue complications. Based on the limited studies available in pediatric populations, IMHS fixation appears to be safe and is associated with satisfactory functional outcomes and high rates of fracture union. The decision to manage pediatric hand fractures with IMHS should be made after considering the patient's age, physis status, and fracture characteristics. Future well-designed studies comparing IMHS fixation to other techniques are required to establish the exact indications, precautions for widespread adoption of this technique, and to prove its long-term physeal safety.
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