Metacarpal Fractures and Dislocations Workup

  • Author: James Neal Long, MD, FACS; Chief Editor: Joseph A Molnar, MD, PhD, FACS   more...
 
Updated: Jan 31, 2012
 

Laboratory Studies

  • Choose appropriate studies base on patient comorbidities as determined by the history and physical examination.
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Imaging Studies

  • Radiographs
    • The primary means of evaluating hand injuries beyond the history and physical examination is through plain radiographs.
    • Significant injury to the hand should be assessed first with posteroanterior (PA), lateral, and oblique views.
    • The Roberts view is helpful in more fully assessing the first metacarpal base. See the image below.Roberts view. Roberts view.
    • The Brewerton view is helpful in detailing the anatomy of fractures and chips of the metacarpal heads. See the image below.Brewerton view. Brewerton view.
    • The clenched fist view can reveal ligamentous injuries at the metacarpal bases and intercarpally.
    • CMC injury
      • Fractures in this area of the hand are hard to diagnose as the radiographic evidence is often subtle, and additional rotated views may be necessary. The key to radiographic diagnosis lies in the subtle loss of joint space seen on AP projections. This is often seen as a "broken saw tooth" sign at the CMC joint. This sign may be accompanied by displacement noted on the lateral or oblique views. Tomograms may be necessary to accurately diagnose these injuries.
      • It is important to look closely for multiple injuries; the interosseous ligaments are strong, and a fracture-dislocation of one metacarpal is often accompanied by that of one or more of its neighbors. Displacement in dislocation is usually dorsal, as the dorsal ligaments are weaker.
    • Metacarpal shaft and neck injury: Usually, a diagnosis can be made by observing edema, ecchymoses, pain, and deformity at the fracture site, although swelling can mask the deformity. AP, lateral, and oblique radiographs typically will demonstrate the fracture and displacement.
    • Metacarpal head fractures: Evaluation of these injuries may require additional imaging studies, such as Brewerton view radiography, tomography, or CT scan, to evaluate for fracture and displacement.
    • MCP dislocation: MCP dislocations are readily apparent on physical examination. AP radiographs show overlap of the metacarpal head and base of the proximal phalanx. The lateral radiograph is diagnostic with the presence of dorsal displacement of the proximal phalanx.
  • CT
    • Plain tomography or CT scans can be helpful in diagnosing intra-articular injuries to determine fracture alignment and displacement.
    • These studies may be indicated to evaluate carpometacarpal fracture-dislocations or metacarpal head injuries.
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Diagnostic Procedures

  • Traction radiographs
    • Radiographs taken in the PA and lateral dimensions while applying traction to the injured digit(s) can be helpful in evaluating injuries when there is significant comminution of the fracture. This is especially true with intra-articular injuries.
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Contributor Information and Disclosures
Author

James Neal Long, MD, FACS  Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children's Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center

James Neal Long, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, Southeastern Society of Plastic and Reconstructive Surgeons, and Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Coauthor(s)

James A Chambers, MD, MPH  Consulting Surgeon, Hand and Upper Extremity Service, Massachusetts General Hospital

James A Chambers, MD, MPH is a member of the following medical societies: American Society for Surgery of the Hand, American Society of Plastic Surgeons, American Society of Tropical Medicine and Hygiene, and Special Operations Medical Association

Disclosure: Nothing to disclose.

Jorge I de la Torre, MD, FACS  Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Specialty Editor Board

Milton B Armstrong, MD, FACS  Associate Professor of Clinical Surgery, Associate Professor of Clinical Orthopedics, Department of Surgery, University of Miami Miller School of Medicine

Milton B Armstrong, MD, FACS is a member of the following medical societies: American Association for Hand Surgery, American Association of Plastic Surgeons, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, and National Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Garry S Brody, MD, MSc, FACS  Professor Emeritus, Department of Surgery, Division of Plastic Surgery, Keck School of Medicine, University of Southern California

Garry S Brody, MD, MSc, FACS is a member of the following medical societies: American Association for Hand Surgery, American Association of Plastic Surgeons, American College of Surgeons, American Society of Plastic Surgeons, California Medical Association, Canadian Society of Plastic Surgeons, and Plastic Surgery Research Council

Disclosure: Nothing to disclose.

Nicolas (Nick) G Slenkovich, MD  Director, Colorado Plastic Surgery Center

Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Joseph A Molnar, MD, PhD, FACS  Director, Wound Care Center, Associate Director of Burn Unit, Associate Professor, Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine

Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Peripheral Nerve Society, Undersea and Hyperbaric Medical Society, and Wound Healing Society

Disclosure: KCI, Inc. Honoraria Speaking and teaching; Integra Life Sciences Honoraria Speaking and teaching; Clincal Cell Culture Grant/research funds Co-investigator; KCI, Inc Wake Forest University receives royalties Other

Additional Contributors

In honor of John H Miller MD, a gentleman scholar, who taught me a great deal about the hand.

References

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  9. Jahss S. Fractures of the metacarpals - a new method of reduction and immobilization. J Bone Joint Surg. 1938;20(1):178-186.

  10. Maruyama T, Saha S, Mongiano DO, Mudge K. Metacarpal fracture fixation with absorbable polyglycolide rods and stainless steel K wires: a biomechanical comparison. J Biomed Mater Res. Spring 1996;33(1):9-12. [Medline].

  11. Foucher, G. Bouquet osteosynthesis in metacarpal neck fractures: A series of 66 patients. J. Hand Surg. (Am.). May 1995;20:S 86 -90. [Medline].

  12. Mockford BJ, Thompson NS, Nolan PC, Calderwood JW. Antegrade intramedullary fixation of displaced metacarpal fractures: a new technique. Plast Reconstr Surg. Jan 2003;111(1):351-4. [Medline].

  13. Ashkenaze DM, Ruby LK. Metacarpal fractures and dislocations. Orthop Clin North Am. Jan 1992;23(1):19-33. [Medline].

  14. Nunez VA, Citron ND. Short-term results of the Ascension pyrolytic carbon metacarpophalangeal joint replacement arthroplasty for osteoarthritis. Chirurgie de la Main. Jun-Aug 2005;24(3-4):161-4. [Medline].

  15. Tajima T. Considerations on the use of the tourniquet in surgery of the hand. J Hand Surg [Am]. Sep 1983;8(5 Pt 2):799-802. [Medline].

  16. Waris E, Ashammakhi N, Raatikainen T. Self-reinforced bioabsorbable versus metallic fixation systems for metacarpal and phalangeal fractures: a biomechanical study. Journal of Hand Surgery - American Volume. Sep 2002;27(5):902-9. [Medline].

 
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Displaced fourth and fifth metacarpal fractures, anteroposterior view.
Displaced fourth and fifth metacarpal fractures, lateral view.
Fourth and fifth metacarpal fractures, oblique view.
Fourth and fifth metacarpal fractures after intramedullary pinning, anteroposterior view.
Fourth and fifth metacarpals after intramedullary pinning, lateral view.
Complex second metacarpophalangeal dislocation in a skeletally immature patient. Note the position of the finger and dimpling of skin on volar hand.
Radiograph of the hand of the patient in Image 6.
Intraoperative photo of the second metacarpophalangeal joint of the patient in Images 6 and 7. Note the displaced volar plate between the metacarpal head and the proximal phalanx.
Metacarpophalangeal ligaments.
Metacarpophalangeal musculoskeletal structure.
Brewerton view.
Roberts view.
 
 
 
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