Review Question - QID 219433

Scissoring of the digits as an indicator of malrotation which is an absolute indication for surgical fixation of metacarpal fractures (Answer 3).

Metacarpal neck fractures are quite common, especially in athletes who are involved in contact activities or play ball-related sports. Most can be treated conservatively with simple orthoses or casts. While there may be some residual deformity, most of these fractures go on to an uneventful union and patients have minimal functional issues. This said, there are certain settings where operative fixation is indicated. These include open fractures, intra-articular involvement, rotational malalignment, displacement/angulation above tolerances, and the setting of multiple metacarpal fractures. Specifically in regards to malrotation, this is seen on an exam with scissoring of the digits when asking the patient to make a fist. Failure to recognize and address malrotation of the digits will leave the patient with a deformity and lack of function.

Wahl and Richard reviewed the management of metacarpal and phalangeal fractures in athletes, noting they occur most frequently in contact/ball-handling sports. Most commonly, fractures that are minimally displaced can be treated with a short period of immobilization followed by early range of motion. Unstable or intra-articular fractures are indicated for ORIF. They also mention that in the athletic population, additional considerations are important such as the type of sport, timing of injury, and level of play.

Wong and Higgins published a review of metacarpal fracture management with a discussion of the relevant anatomy and surgical indications. They talk about the indications being open fractures, unstable or intra-articular fractures, fractures with malrotation, and those with significant angulation/displacement. They also review different methods of treatment including percutaneous fixation, ORIF, and external fixation.

Kodama et al. looked at early return to play in 105 athletes after both conservative treatment and ORIF of metacarpal and phalangeal fractures. They noted that 20 athletes returned to play "early," before 1 month, and all experienced bony union without a loss of motion. They ultimately concluded that early return to play was safe in certain settings in the athletic population.

Incorrect Answers:
Answer 1: In the setting of metacarpal neck fractures, tolerances increase for angulation. For 4th metacarpal neck fractures, up to 30° of apex dorsal angulation is acceptable for nonoperative management.
Answer 2: Metacarpal shaft fractures result in more shortening than metacarpal neck fractures but even in shaft fractures, up to 5mm of shortening is acceptable to prevent clinically relevant extensor lag.
Answer 4: Fracture pattern can help dictate the need for operative intervention, especially in the setting of length unstable fractures (long oblique, spiral) and intra-articular patterns. However, comminution provides a large surface area for healing and is not, by itself, an indication for surgical fixation.
Answer 5: While occupation and hobbies must always be considered prior to treatment, many patients with metacarpal neck fractures who are treated nonoperatively are able to return to all lines of work without residual functional deficits provided that indications for nonoperative treatment are appropriate.