Metacarpal Fracture and Dislocation Treatment & Management

Updated: Sep 07, 2018
  • Author: David R Steinberg, MD; Chief Editor: Craig C Young, MD  more...
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Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

In the acute phase, minimally displaced or angulated fractures of the index finger through the small fingers should be immobilized in a forearm-based splint or cast for 3-4 weeks. The metacarpophalangeal joint (MCPJ) is flexed at 60-70°, and the proximal interphalangeal joint (PIPJ) is in the resting position (0-15°).

Injuries to which these principles apply include fractures and/or dislocations of the structures, as listed below, with their angulations.

  • Metacarpal head

  • Metacarpal neck (The exact amount of acceptable angulation may be controversial.)

    • Index and/or long finger (< 10-15°)

    • Ring finger (< 30°)

    • Small finger (< 40-50°)

  • Metacarpal shaft (The exact amount of acceptable angulation may be controversial.)

    • Index and/or long finger (< 10°)

    • Ring finger (< 20°)

    • Small finger (< 30°)

Minimally displaced or angulated extra-articular fractures of the thumb metacarpal (< 30°) can be immobilized in a forearm-based thumb spica cast for approximately 4 weeks. The IPJ is free, and the MCPJ is in 0-10° degrees of flexion. A satisfactory outcome can be expected, even with angulation up to 30°. A thumb metacarpal fracture angulated >30° may require surgical intervention. This fracture differs from intra-articular fractures of the thumb metacarpal (Bennett fracture or Rolando fracture), most of which require surgical stabilization. [9, 10]

CMC fracture-dislocations require the application of a forearm-based cast, usually for 6 weeks. Direct pressure can be applied dorsally to the metacarpal base to reduce the CMC joint.

Radiographs should be obtained immediately after the cast is applied and weekly for the first 3 weeks to ensure that the reduction of these usually unstable injuries is maintained.

Occupational Therapy

Gentle active range of motion (ROM) of the uninvolved digits, as well as the shoulder and elbow, should be encouraged. The physician, trainer, or therapist can instruct the patient to perform these exercises on a daily basis at home. Formal therapy is usually unnecessary at this point.

Minimally displaced avulsion injuries of the collateral ligament in the MCPJ can be treated with early buddy taping to the adjacent uninjured finger for 3 weeks. A hand-based splint may provide additional protection at nighttime during sleep.

Medical Issues/Complications

Malrotation, if present, must be corrected. This condition remains a clinical diagnosis because radiographs often inadequately demonstrate rotational deformities. In extension, the fingernails should be within 10° of alignment. Scissoring (crossover) of the digits should be absent during simultaneous finger flexion. Make sure to examine both hands, as some individuals have a normal degree of small-finger overlap with the ring finger in flexion.

Penetrating injuries caused by a tooth (see Human Bites) are often encountered in association with fractures of the metacarpal neck and head that are sustained during an altercation. Maintain a high level of suspicion, carefully obtain the patient's history, and closely look for a small, dorsal laceration over the MCPJ. If penetrating injuries are not diagnosed and treated early with irrigation and debridement, the incidence of infection is high (see Human Bite Infections). This is particularly true of penetrating injuries into the joint, which require surgical arthrotomy to prevent septic arthritis. These injuries are also associated with extensor tendon injuries.

CMC dislocations can easily be missed. As subluxations, in particular, they may be difficult to diagnose. Have a high level of suspicion when a patient presents with dorsal tenderness and swelling of the proximal portion of the hand. An isolated fracture of the ring metacarpal should suggest a possible concomitant injury to the fifth CMC joint. [11] The dorsal prominence of the metacarpal base may be palpable. Lateral and oblique radiographs must be examined closely. Strongly consider CT scanning if the radiographic findings are inconclusive.

With an isolated metacarpal fracture, a border digit obtains intact skeletal and ligamentous support from only 1 neighboring metacarpal, a situation that renders it more unstable than a central digit. In addition, a transverse fracture is more unstable and vulnerable to malrotation than is an oblique fracture, which has an increased area of bony contact and an increased likelihood of fragment interdigitation.

Surgical Intervention

Surgical intervention is indicated to treat the following injuries:

  • Fractures of the metacarpal shaft and neck with unacceptable amounts of angulation or malrotation

  • Unstable injuries

    • Most CMC dislocations

    • Intra-articular fractures of the thumb metacarpal base (Bennett fracture, Rolando fracture)

    • Fracture of the fifth metacarpal base (reverse Bennett fracture)

  • Fractures associated with human bites (involvement of the MCPJ)

  • Metacarpal head fractures with a clinically significant articular step-off

A variety of surgical approaches are available. The choice of procedure depends on the nature of the fracture and the preference or experience of the surgeon. Fixation techniques described in the literature include these:

  • Open reduction and internal fixation (ORIF) to treat a displaced metacarpal head

  • Closed treatment or traction to manage a comminuted metacarpal head

  • Closed reduction and percutaneous pinning to treat an injury of the metacarpal neck

  • Closed reduction and percutaneous pinning and/or intramedullary fixation versus ORIF to manage an injury to the metacarpal shaft

Intra-articular fractures of the thumb metacarpal base usually require surgical intervention, namely, reduction and percutaneous pinning for a Bennett fracture, and pinning or ORIF for a Rolando fracture. Closed reduction is achieved with a combination of traction, extension, pronation, and direct application pressure on dorsum of the metacarpal base. Comminuted fractures may require external fixation or oblique traction through the thumb metacarpal. A study by Pomares et al reported success with arthroscopically assisted percutaneous screw fixation for intra-articular fractures. [12]

 

CMC dislocations or fracture-dislocations are poorly maintained in a splint or cast. Isolated injuries, particularly those involving the small finger, frequently require closed reduction and percutaneous pinning. [13] Multiple CMC dislocations often require open reduction. Mini external fixators are useful in severely comminuted CMC fractures. To minimize posttraumatic arthritis, pay attention to the articular step-offs of the relatively mobile ring and small fingers.

Potentially contaminated open fractures require irrigation and debridement to prevent osteomyelitis or an infected nonunion. A fight bite, in which an apparently clean laceration is most likely caused by an assailant’s tooth indicates that penetration of the MCPJ is likely. If this injury is suspected, arthrotomy and irrigation of the MCPJ is indicated to prevent septic arthritis. If elevated compartment pressures are suspected on the basis of clinical findings or measured intracompartmental pressures, urgent fasciotomy is indicated.

A retrospective study compared clinical and radiographic outcomes between intramedullary nail fixation and percutaneous K-wire fixation for fractures in the distal third portion of the metacarpal bone. The study concluded that intramedullary nailing fixation is advisable for these fractures. The authors advise that intramedullary nailing fixation provides early recovery of the range of motion, an earlier return to work, and lower complication rates. [14]

Related Medscape Reference topics:

Compartment Pressure Measurement

Compartment Syndromes

Compartment Syndrome, Upper Extremity

Consultations

A hand surgeon or an orthopedic surgeon should be consulted if the patient has any injury that requires surgery or if the diagnosis is unclear. Immediate consultation is indicated when the injuries are open or irreducible or when neurovascular compromise of the digit is present. After closed reduction is successfully accomplished, arrange for follow-up within 1 week with an orthopedic surgeon or hand surgeon.

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Recovery Phase

Rehabilitation Program

Occupational Therapy

The program of occupational therapy following a metacarpal fracture and/or dislocation should be supervised and should include the following elements:

  • Progressive range of motion

    • Active

    • Active assisted

    • Gentle passive

  • Strengthening exercises

  • Management of edema

  • Thermal modalities

Medical Issues/Complications

See the list below:

  • During the recovery phase, stiffness and weakness are the most clinically significant problems encountered.

  • Persistent or previously unrecognized malrotation may also become evident as digital motion increases.

Surgical Intervention

Therapy is usually effective in overcoming stiffness after metacarpal fractures and dislocations occur. If clinically significant functional problems persist after a minimum of 3 months, surgical intervention can be considered. Surgery can be delayed for an additional 3 months if the patient desires it, because continued improvement with therapy can be seen as long as 6 months after the injury.

Surgery to manage persistent adhesions and/or contractures usually consists of extensor tenolysis and dorsal MCPJ capsulotomy. This is immediately followed by an aggressive program of hand therapy.

Consultations

A hand surgeon should be consulted for any problem that is not responding appropriately to a supervised therapy program.

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