Edited by Jonathan Lans and CJ Nessralla - 7/1/2021
Descriptors
Metacarpal Fractures
Exam Pearls
Upper extremity neurovascular exam
Assess cascade and tenodesis – note presence of scissoring and angular deformity
Boxer’s fracture: small finger MC neck fracture; ensure there is no intra-articular laceration over the dorsum of MCP joints or tendon laceration.
CMC fracture-dislocation: often missed, high energy, risk of compartment syndrome
Workup
Radiographs:
All injuries: AP/lat/oblique hand
Brewerton view for metacarpal head fracture.
Internal rotation oblique for 2nd/3rd CMC fracture/dislocation, external rotation oblique for 4th/5th CMC fracture/dislocation.
CMC dislocations are often missed; can use “parallel M lines”; formed by parallel CMC joints of 2-5th ray.
Other imaging: Metacarpal base and intraarticular fractures may merit CT scan - discuss with fellow
Labs: None
Other: None
Management
Need for acute intervention:
Boxer’s fractures do not need to be reduced
PIP/MCP dislocations need reduction by recreating deformity, maintaining articular surface contact, and translation. Straight longitudinal traction can convert to irreducible dislocation if the volar plate slips intraarticular!
CMC/IP dislocations need reduction prior to splinting
Weight-bearing and range of motion: NWB UE, ROMAT elbow.
Type of immobilization: Metacarpal fracture: 2nd/3rd volar resting splint in intrinsic plus, 4th/5th ulnar gutter in intrinsic plus, PIP joints free.
Admission or discharge status: Non-operative injury 2 weeks f/u; operative injury f/u 2-4 days.
Anticoagulation: None
Antibiotics: Open fracture: Ancef IV in the ED, then a course of Keflex.
Surgical Indications
Absolute: open, intra-articular, rotational malalignment, multiple metacarpal fractures.