Metacarpal Fractures

Other Names

• Metacarpal fracture
• Hand fracture
• Handstand Fracture

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Background

Fracture of 3rd Metacarpal

Oblique fracture of the 5th metacarpal proximal shaft.

• This page refers fracture of one or more Metacarpal Bones
  • Boxers Fracture (5th), Rolando Fracture (1st), and Bennett Fracture (1st) are discussed separately

History

• Needs to be updated

Epidemiology

• Represents 5-10% of emergency department visits
• Accounts for 35-40% of all hand fractures (need citation)

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Pathophysiology

General

• Involves fracture of one or more Metacarpal Bones
• Can be divided into base, head, neck and shaft fractures; neck is most common

Etiology

• Common mechanisms:
  • Motor vehicle accidents
  • Bicycle accidents
  • Blunt trauma
  • Assault
  • Typically occur due a direct blow
  • Fist fight

Pathoanatomy

• Muscles insertions to consider
  • Extensor Carpi Radialis Longus
  • Extensor Carpi Radialis Brevis
  • Extensor Carpi Ulnaris
  • Abductor Pollicis Longus
  • Opponens Pollicis
  • Opponens Digiti Minimi

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Risk Factors

• Male
• Ages 10-29

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Differential Diagnosis

Differential Diagnosis Finger And Hand Pain

• Fractures
  • Phalanx Fractures of the Hand
  • Metacarpal Fractures
    • Boxers Fracture
    • Rolando Fracture
    • Bennett Fracture
• Dislocations
  • Metacarpophalangeal Joint Dislocation
  • Interphalangeal Joint Dislocation (Proximal and Distal)
  • Carpometacarpal Joint Dislocation
• Tendinopathies
  • Extensor Tendon Injuries of the Hand
  • Central Slip Extensor Tendon Injury
  • Flexor Tendon Injuries of the Hand
  • Boutonniere Deformity
  • Swan Neck Deformity
  • Jersey Finger
  • Mallet Finger
  • Trigger Finger
  • De Quervains Tenosynovitis
  • Volar Plate Avulsion Injury
  • Sagittal Band Injury
  • Mannerfelt Lesion (FPL Rupture)
• Ligament Injuries
  • Gamekeepers Thumb (UCL)
  • Radial Collateral Ligament of the Thumb Injury (RCL)
• Neuropathies
  • Wartenbergs Syndrome
  • Carpal Tunnel Syndrome
  • Guyon Canal Syndrome
• Arthropathies
  • Carpometacarpal Arthritis
  • Finger Arthritis
  • Rheumatoid Arthritis
• Nail Bed Injuries
  • Nail Bed Lacerations
  • Nail Bed Avulsions
  • Subungual Hematoma
  • Paronychia
  • Felon
• Pediatric Considerations
  • Proximal Phalanx Avulsion Fracture (Thumb)
  • Middle and Distal Phalanx Avulsion Fracture
• Other
  • Dupuytrens Contracture
  • Intrinsic Plus

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Clinical Features

History

• Important to characterize mechanism
• Patients report pain, swelling, trouble closing hand

Physical: Physical Examination Hand

• Inspection may reveal ecchymosis, swelling, deformity
• Important to exclude rotational deformity, open wounds
• Palpation reveals focal tenderness of the affected bone(s)
• Range of motion is often reduced
• Assess for "scissoring" of digits which suggests rotational component
• Radial and ulnar pulse most often normal, check 2-point discrimination

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Evaluation

Images of fracture of the fifth metacarpal. Radiographic image (left) shows an impacted fracture (arrow). In the same patient, the longitudinal ultrasonography scan (right) shows interruption of the bone cortex (white arrow).

There are transverse fractures through the shafts of the second to fifth metacarpal bones with no intra-articular extension

Radiographs

• Standard Radiographs Hand
  • Typically sufficient to make the diagnosis
  • Take note of any intra-articular involvement
• Brewerton View
  • Useful for metacarpal head fractures, subtle or occult findings
• Roberts View
  • Useful for thumb CMC fracture-dislocation

Ultrasound

• Role of ultrasound remains undefined
  • 5% sensitivity and 98.3% specificity
  • Water bath technique can help

CT scan

• Indication
  • Diagnosis is uncertain
  • multiple dislocations or complex fractures

MRI

• Indication
  • If the diagnosis is uncertain or if soft tissue injuries are suspected

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Classification

• N/A

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Management

Long Thumb Spica Brace

Metacarpal	Shaft Angulation	Shaft Shortening	Neck Angulation
2nd, 3rd	10-20	2-5	10-15
4th	30	2-5	30-40
5th	40	2-5	50-60

Nonoperative

• Indications
  • Stable, extra-articular
  • No rotational deformity
  • See table for acceptable parameters
• Immobilization
  • Can cast/ splint as appropriate
  • Generally consider Short Arm Cast or Sugar Tong Splint
  • 1st digit consider Thumb Spica Splint, Thumb Spica Cast
  • 2nd or 3rd digit consider Radial Gutter Splint, Radial Gutter Cast
  • 4th or 5th digit consider Ulnar Gutter Splint, Ulnar Gutter Cast
  • Can consider Club Cast for athletes looking to RTP sooner

Operative

• Indications
  • Open
  • Intra-articular
  • Rotational deformity
  • Significant displacement
  • Multiple fractures
  • Instability
• Technique
  • ORIF

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Rehab and Return to Play

Rehabilitation

• Post operative care at discretion of surgeon

Return to Play/ Work

• Typically after 6-8 weeks of healing whether managed operatively or non-operatively
• May consider protective casting in some cases (i.e. football lineman) and allow RTP sooner

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Prognosis and Complications

Prognosis

• Most patients have an excellent prognosis

Complications

• Tendon Laceration
• Neurovascular Injury
• Acute Compartment Syndrome

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See Also

• Hand and Wrist Anatomy (Main)
• Hand Pain (Main)
• Wrist Pain (Main)
• Physical Examination Hand

External

• Sports Med Review Hand Pain: https://www.sportsmedreview.com/by-joint/hand/
• https://www.sportsmedreview.com/blog/evidence-behind-the-non-operative-management-of-metacarpal-fractures/

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