Summary
Management of each form of metacarpal (MC) fracture is based on which metacarpal is involved, the location, angulation and mal-rotation. Treatment is primarily conservative followed by closed reduction under sedation or local anaesthesia. Goals of management are to obtain alignment and stability to encourage finger and wrist motion as soon as possible.
Management of phalangeal fractures when closed and minimally displaced with good alignment is also conservative. Unstable fractures, open fractures and joint injuries (usually dislocations) are often best managed by referral to orthopaedic teams, hand specialists and physiotherapy.
Non-operative management is generally acceptable in phalangeal and MC fractures when the fracture is stable, has no deformity and there are acceptable degrees of angulation and shortening. Immobilisation should suffice.
Operative intervention is usually necessary with intra-articular fractures, rotation malalignment of digit, significant displacement and multiple metacarpal shaft fractures.
Recovery is improved with early motion and removal of ORIF hardware and casts no greater than four weeks post injury.
Drag the table right to view more columns or turn your phone to landscape
Fracture type | Management | Follow-up |
|---|---|---|
Metacarpal base fractures | Require reduction if >2mm of articular surface displacement or significant angular deformity or dislocation of carpometacarpal exist. | Immobilisation for minimum of 3 weeks Active finger interphalangeal joint (IPJ) motion exercise during MC immobilisation One follow-up x-ray to check alignment Physiotherapy |
Metacarpal shaft | If closed, mostly treated non-operatively. Acceptable angulation
Reduction of MC fractures can be best accomplished using the Jahss technique. | Immobilisation should be no longer than 4 weeks One follow-up x-ray to check alignment Physiotherapy |
Metacarpal neck | Minimally angulated or displaced fractures can be managed with simple immobilisation for 3–4 weeks. No rotation is acceptable and operative intervention may be required if Jahss technique is not effective. | Immobilisation 3–4 weeks One follow-up x-ray to check alignment Physiotherapy |
Metacarpal head fractures | Non-displaced fractures can be managed conservatively with splinting for three weeks, then gentle range of motion (ROM) exercises. >1mm articular surface displacement should be managed operatively. Splinting of MC head fractures should involve the MCP joint. Gutter splints on 4th and 5th MC fractures are very effective. | One follow-up x-ray to check alignment Physiotherapy |
Proximal phalanx | Up to 3 weeks immobilisation in safe position. Begin active exercises early. | Orthopaedic review if intra-articular surface >30%, unstable, rotation, excessive angulation, multiple fingers One follow-up x-ray to check alignment |
Middle phalanx | Up to 3 weeks immobilisation with IPJ extension. Begin active exercises early. | Orthopaedic review if intra-articular surface >30%, unstable, rotation, excessive angulation, multiple fingers One follow-up x-ray to check alignment |
Volar plate avulsion fracture | One week of slight flexion immobilisation. Flexion exercises at 1 week, with splinting between. Extension exercises at 3 weeks. | Large avulsion fragments, or fragment within joint space require orthopaedic review |
Distal phalanx | 2–3 weeks splinting. | Large loss of soft tissue, nail bed injuries and >30% intra-articular surface involvement require orthopaedic review |
Mallet fracture | 6–8 weeks of distal interphalangeal joint in slight hyperextension. | Avulsion fractures and >30% intra-articular surface require orthopaedic review |
Classification
Metacarpal
Fractures of the metacarpal are classified by location (i.e. base, shaft, neck or head) and type:
- Head: sub-capital, intra-articular, transverse
- Shaft: transverse, oblique and multi-fragmentary
- Base: intra-articular
Proximal phalanges
Fractures of proximal phalanges are classified according to location (i.e. distal-articular, distal-metaphyseal, shaft, proximal-metaphyseal and proximal-articular) and type:
- Distal articular: oblique, unicondylar, bicondylar
- Distal metaphyseal: transverse, oblique, multi-fragmentary
- Shaft: transverse, oblique, multi-fragmentary
- Proximal metaphyseal: transverse, oblique
- Proximal articular: avulsion, shearing, multi-fragmentary
Middle phalanx
Fractures of the middle phalanx are classified according to location (i.e. distal, shaft and proximal) and type:
- Distal: unicondylar, bicondylar
- Shaft: oblique, transverse, multi-fragmentary
- Proximal: multi-fragmentary, avulsion and dislocation
Distal phalanges
Fractures of the distal phalanges are classified according to location -(i.e. distal, shaft and proximal) and type of fracture:
- Distal and shaft: transverse, multi-fragmentary
- Proximal: avulsion and dislocation
Thumb
Thumb fractures are classified according to location (i.e. distal phalanx shaft, distal phalanx base, proximal phalanx articular, proximal phalanx metaphyseal, proximal phalanx base/shaft and metacarpal) and type of fracture:
- Distal phalanx-distal shaft: transverse, multi-fragmentary
- Distal phalanx-base: dislocation, avulsion
- Proximal phalanx-articular: oblique, unicondylar with dislocation, bicondylar
- Proximal phalanx-metaphyseal: transverse, oblique, multi-fragmentary
- Proximal phalanx-base/shaft: skier's thumb, pilon, multi-fragmentary
- Metacarpal-base, Bennett, Rolando
Interphalangeal joint and metacarpophalangeal joint
Additional to phalanges fractures, interphalangeal joint and metacarpophalangeal (MCP) joint injuries may occur with injury to flexor and/or extensor tendons with or without fracture. Appropriate management will prevent chronic deformities.
Epidemiology
MC fractures account for ~40% of all hand injuries and are the second-most common fracture presentation to emergency departments (EDs) after distal radius fractures. Men have the highest incidence of MC fracture presentation accounting for 85% of presentations. The metacarpal neck is the most common site of fracture and the 5th metacarpal is the most commonly injured (punching injury).
Finger phalanx fractures are reported as the fourth-most common fracture presentation to EDs. Many phalanx fractures will not present for any medical intervention.
Presentation
Physical exam for hand injuries includes inspection, deformity, motor and neurovascular checks.
Open wounds and associated injuries should always be deemed high risk of compound fracture, when fight-associated wounds exist over MCP joint, potential for osteomyelitis is increased with or without fracture. Wounds on the dorsal surface of the hand with MC fracture are almost always open.
Deformity in MC injury is indicative of location of injury. Deformity at the proximal metacarpal should increase suspicion of carpal MC dislocation. Shortening is best assessed by contralateral comparison, and mal-rotation is shown in misalignment of fingernails in partial and full flexion of fingers, compared with opposite uninjured hand.
Motor examination by assessment of ROM in active and passive motion should be compared with the uninjured hand. Results may be affected by swelling, pain and skin surface wounds. If open wounds exist, check integrity of extension and flexor tendons.
Neurovascular exam should be assessed prior to any local anaesthetic. Sensation and circulation by light touch and capillary refill assessment is usually suffice.
Imaging
When serious injury is suspected, imaging should be attended prior to physical testing:
- Most hand fractures are usually detected by anteroposterior, lateral and oblique views of the specific injured joint or limb rather than the entire hand.
- Direct posterior-anterior (PA) and lateral views of the thumb should be obtained if the thumb is suspected of injury. Fractures of the middle and proximal phalanx may angulate palmar or dorsally.
- Post-reduction radiographs should show no more than 10° of angulation and rotational displacement.
Management options
As per fracture type in summary table.
Splinting is by aluminium and foam strips cut to size, thermoplastic as available or pre-made plastic splints, e.g. for mallet finger.
Referral and follow-up requirements
See summary table.
Potential complications
Open MC fractures increase the likelihood of tendon laceration and/or neurovascular injury and potential for osteomyelitis. Closed and crush injuries, especially when multiple fractures or dislocations occur, have the potential for compartment syndrome.
Prolonged immobilisation during management increases the probability of loss of joint ROM. Where possible, avoiding immobilising unnecessary joints is preferred.
Resources
- Blomberg J. Metacarpal Fractures
Source: Orthobullets - Eddy M. Hands, fingers, thumbs - assessment and management of common hand injuries in general practice. Aust Fam Physician. 2012;41(4):202-209.
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/networks/eci/clinical/tools/metacarpals-phalanges