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Updated: 2/3/2023

Metacarpal Fractures

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Images mc fractures.jpg rotation.jpg shaft fx.jpg
  • summary
    • Metacarpal Fractures are the most common hand injury and are divided into fractures of the head, neck, or shaft.
    • Diagnosis is made by orthogonal radiographs the hand.
    • Treatment is based on which metacarpal is involved, location of the fracture, and the rotation/angulation of the injury.
  • Epidemiology
    • Incidence
      • metacarpal fractures account for 40% of all hand injuries
    • Demographics
      • men aged 10-29 have highest incidence of metacarpal injuries
    • Anatomic location
      • metacarpal neck is most common site of fracture
      • fifth metacarpal is most commonly injured
  • Etiology
    • Mechanism of injury
      • direct blow to hand or rotational injury with axial load
      • high energy injuries (ie. automobile) may result in multiple fractures
    • Associated conditions
      • wounds may indicate open fractures or concomitant soft tissue injury
        • tendon laceration
        • neurovascular injury
      • compartment syndrome
        • closed injuries with multiple fractures or dislocations
        • crush injuries
  • Anatomy
    • Metacarpal anatomy
      • concave on palmar surface
      • 1st, 4th, and 5th digits form mobile borders
      • 2nd and 3rd digits form stiffer central pillar
        • index metacarpal is the most firmly fixed, while the thumb metacarpal articulates with the trapezium and acts independently from the others
      • three palmar and four dorsal interossei muscles arise from metacarpal shafts
    • Insertional anatomy
      • extensor carpi radialis longus/brevis
        • insert on the base of metacarpal II, III (respectively); assist with wrist extension and radial flexion of the wrist
      • extensor carpi ulnaris
        • inserts on the base of metacarpal V; extends and fixes wrist when digits are being flexed; assists with ulnar flexion of wrist
      • abductor pollicis longus
        • inserts on the trapezium and base of metacarpal I; abducts thumb in frontal plane; extends thumb at carpometacarpal joint
      • opponens pollicis
        • inserts on metacarpal I; flexes metacarpal I to oppose the thumb to the fingertips
      • opponens digiti minimi
        • inserts on the medial surface of metacarpal V; Flexes metacarpal V at carpometacarpal joint when little finger is moved into opposition with tip of thumb; deepens palm of hand.
  • Presentation
    • Physical exam
      • inspect for open wounds and associated injuries
        • fight wounds over MCP joint are open until proven otherwise
        • extensor tendon can be lacerated and retracted
        • dorsal wounds over metacarpal fractures are almost always open fractures
      • deformity indicates location
        • deformity at metacarpal base may indicate CMC dislocation
        • shortening can be assessed by comparing contralateral hand
          • may be prevented by transverse intermetacarpal ligaments in isolated fracture of the 3rd or 4th metatcarpal shafts
        • malrotation assessed by lining up fingernail in partial flexion and full flexion if possible, compare to contralateral side
      • motor examination
        • typically no motor deficits unless open wounds present
        • check integrity of flexor/extensor tendons in presence of open wounds
      • neurovascular examination
        • dorsal wounds may affect dorsal sensory branch of radial/ulnar nerve
        • volar wounds can involve digital nerves
  • Imaging
    • Radiographs
      • recommended views
        • PA
        • lateral
        • ER oblique
          • best view to see 4th/5th CMC fracture/dislocation
        • IR oblique
          • best view to see 2nd/3rd CMC fracture/dislocation
      • optional views
        • brewerton
          • best view to see metacarpal head fractures
        • roberts
          • best view to see thumb CMC fracture/dislocation
    • CT
      • indications
        • inconclusive radiographs of CMC fractures/dislocations
        • multiple CMC dislocations
        • complex metacarpal head fractures
  • Diagnosis
    • Radiographic
      • diagnosis confirmed by history, physical exam, and radiographs
  • General Treatment
    • Nonoperative
      • immobilization
        • indications
          • must be stable pattern
          • no rotational deformity
          • acceptable angulation & shortening (see table)
      • Acceptable nonoperative criteria 
      • Acceptable shaft angulation (degrees)
      • Acceptable shaft shortening (mm)
      • Acceptable neck angulation (degrees)
      • Index & Long finger
      • 10-20
      • 2-5
      • 10-15
      • Ring finger
      • 30
      • 2-5
      • 30-40
      • Little finger
      • 40
      • 2-5
      • 50-60
    • Operative
      • operative treatment
        • general indications
          • open fx
          • intra-articular fxs
          • rotational malalignment of digit
          • significantly displaced or angulated fractures (see above criteria)
          • multiple metacarpal shaft fractures
          • loss of inherent stability from border digit during healing process
        • postoperative
          • early motion is critical
          • remove pins/ cast at ~ 4 weeks
  • Treatment - Metacarpal Head Fractures
    • Operative
      • ORIF
        • indications
          • no degree of articular displacement acceptable
          • majority requires surgical fixation
      • external fixation
        • indications
          • severely comminuted fractures
      • MCP arthroplasty
        • indications
          • severely comminuted fractures
      • MCP fusion
        • indications
          • arthritis late disease
    • Techniques
      • ORIF
        • approach
          • dorsal incision
          • either centrally split extensor apparatus or release and repair sagittal band
        • fixation
          • hardware cannot protrude from joint surface
          • fix with multiple small screws in collateral recess, headless screws, or k-wires
          • ideal fixation should allow for early motion
    • Complications
      • stiffness
        • most common
        • prevented with early motion
  • Treatment - Metacarpal Shaft Fractures
    • Nonoperative
      • immobilization
        • indications
          • nondisplaced metacarpal neck fractures
          • acceptable angulation (see above table)
          • no malrotation
        • immobilize MCP joints in 70-90 degrees of flexion
        • cast for 4 weeks
    • Operative
      • ORIF vs. CRPP
        • indications
          • open fractures
          • unacceptable angulation (see above table)
          • any malrotation
          • multiple fractures
    • Techniques
      • closed reduction percutaneous pinning
        • place antegrade through metacarpal base or retrograde through collateral recess
          • remove pins at 4 weeks
      • open reductions with lag screw
        • can use multiple lag screws for long spiral fractures
          • try to get at least two lag screws
      • open reduction with dorsal plating
        • works best for transverse fractures
        • try to cover plate with periosteum to prevent tendon irritation
        • begin early motion to prevent tendon irritations
  • Treatment - Metacarpal Neck Fractures
    • Nonoperative
      • reduction and casting
        • acceptable degrees of apex dorsal angulation (varies by study, see above table)
        • immobilize MCP joints in 70-90 degrees of flexion, leave PIP joints free
        • cast for 4 weeks
        • reduce using Jahss technique
          • 90 degrees MCP flexion, dorsal pressure through proximal phalanx while stabilizing metacarpal shaft
    • Operative
      • reduction and fixation
        • indications
          • unacceptable angulation (see above table)
          • open fractures
          • any malrotation
          • intraarticular fractures
    • Technique
      • CRPP with MCP's flexed
        • antegrade through metacarpal base
        • retrograde through collateral recess
      • ORIF
        • perform if cannot get reduction for CRPP
        • difficult to plate because limited bone for distal fixation
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Questions (10)
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(OBQ18.144) For which of the metacarpal fractures shown in Figures A-E is buddy taping and an optional follow-up appropriate?

QID: 213040

Figure A



Figure B



FIgure C



Figure D



FIgure E



L 2 A

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(SBQ17SE.24) After a night out on the town, a 21-year-old college student strikes an inanimate object. The next morning the brash young man notes that his hand is swollen, tender, and painful to move. He presents that day to your clinic with the images seen in Figures A and B. You are able to reduce the injury and the reduction is initially maintained in an appropriately-molded splint. You obtain follow-up radiographs one week later which demonstrate recurrent dislocation. The next step in management should be:

QID: 211369

Discontinue immobilization, discharge non-weight-bearing but with early active range of motion



Repeat reduction, follow up in 7-10 days for splint removal



Repeat reduction, follow-up in 7-10 days for repeat images in plaster, immobilization for 4 weeks so long as reduction is maintained



Schedule for closed reduction and percutaneous pinning



Schedule for open reduction, CMCJ arthrodesis with plate application



L 1 A

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(SBQ17SE.29) After losing an arm-wrestling match, an enraged orthopaedic resident punches a wall and has immediate pain and swelling about his dominant right hand. His co-resident examines his hand under fluoroscopy and identifies the injury noted in Figures A and B. The muscle responsible for the primary deforming force in this injury is innervated by which nerve?

QID: 211424

Anterior interosseous nerve (AIN)



Radial nerve



Posterior interosseous nerve (PIN)



Ulnar nerve



Extensor branch of ulnar nerve



L 1 A

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(OBQ11.18) A 25-year-old female is involved in a motorcycle collision and presents with the injuries seen in Figures A through D. What is the best option for definitive management of the injuries seen in Figure D?

QID: 3441

Open reduction and internal fixation



Closed reduction and casting



External fixation



Immediate therapy



Removable splint



L 1 C

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Evidence (16)
Private Note