Metacarpal Fractures Treatment & Management

Most metacarpal injuries are managed by closed reduction and immobilization or sometimes controlled mobilization utilizing a dorsal block splint. Indications for operative treatment include the following:

• Failure to achieve or maintain acceptable reduction using closed techniques
• Open fractures
• Multiple hand fractures
• Complex injuries
• Displaced intra-articular fractures
• Fractures with severe soft-tissue loss requiring a stable skeleton

No absolute contraindications exist for treatment of metacarpal injuries. Almost all injuries are amenable to either immobilization or closed or open reduction, with or without fixation.

Bioresorbable implants are being used more frequently for fixation of fractures. Biomechanical testing of polyglycolic acid (PGA) and poly–L-lactic acid (PLLA) plates compare favorably in rigidity to titanium but are inferior in torsional testing. Self-reinforced PGA rods used in place of K-wires for intramedullary fixation have an initial bending stiffness of only 60% of stainless-steel wires. When subjected to saline bath, PGA rods lose stability within 4 weeks.

New techniques and equipment may make these implants more cost-effective, and their use precludes the need for implant removal at a second operation. Further development of low-profile implants may allow more rigid fixation for certain problem fractures, thereby minimizing postoperative stiffness and perhaps diminishing the need for metal removal.

Approaches to specific injuries

Fractures and dislocations of metacarpal base

Impaction fractures of the metacarpal bases that are not significantly displaced can be treated with splinting, followed by early mobilization.

Carpometacarpal (CMC) dislocations and fracture-dislocations, especially when multiple, are unstable injuries. In the past, these fractures were managed by closed reduction and external immobilization, which frequently lead to grip weakness and residual pain. The current literature supports closed reduction, if joint congruity can be obtained, but with the addition of internal fixation.

Displaced fracture-dislocations of the fourth and fifth metacarpals, which are accompanied by fracture of the dorsal hamate, require open reduction and internal fixation (ORIF). Reverse Bennett fractures frequently need Kirschner-wire (K-wire) stabilization to counteract the deforming forces. If little articular incongruity is present, this may be a closed procedure.

Fractures of metacarpal shaft

Metacarpal shaft fractures tend to angulate apex dorsal with the head displaced palmarly due to the deforming pull of the interossei muscles. Only small amounts of angulation (≤10°) are acceptable in the second and third metacarpals. The fourth and fifth finger metacarpals are much more mobile, and angulation of 20° and 30°, respectively, can be accepted. The more proximal the fracture, the more pronounced the deformity and the less angulation that can be accepted. Any malrotation is an indication for surgical intervention. Shortening from 3-4 mm is well tolerated.

In addition to fractures that cannot be reduced and stabilized closed, fractures such as open fractures, multiple fractures, and malreduced subacute fractures are best addressed surgically.

Fractures of metacarpal neck

Metacarpal neck fractures rarely require surgery. Although the acceptable degree of angulation is controversial, as much as 50-60° of angulation can be tolerated with little or no functional deficit. This level of angulation is especially true for boxer's fractures of the fifth metacarpal neck. Despite overall good functional results, this degree of angulation alters dorsal knuckle contour and may result in a tender palmar mass with heavy gripping. Though quite unusual, fracture rotation is an indication for surgical intervention.

Fractures and dislocations of metacarpal head

Except for some collateral ligament avulsion fractures, metacarpal head fractures are intra-articular and, if displaced, should be treated with ORIF, the goal being anatomic reduction and early mobilization.

Treatment of metacarpal fractures and dislocations is primarily nonoperative. ^{[13, 14, 15]} Management usually consists of sedation or local anesthesia, followed by closed reduction of the fracture or dislocation. A forearm-based splint is then applied and held in place with a loose compressive wrap. The goals of nonoperative management are to obtain alignment and stability and to begin motion of the fingers and wrist as soon as possible.

Generally acceptable reduction of metacarpal fractures includes articular congruity of less than 2 mm and angulation and rotation that do not interfere with function or cause significant cosmetic deformity. Specifics on acceptable reduction and indications for surgical management are discussed below (see Surgical Therapy).

Although most fractures and dislocations can be treated nonoperatively, it may be beneficial to perform closed reduction in a setting where percutaneous pinning can be performed if the reduction cannot be maintained without some form of internal stabilization. ^{[12, 16, 17, 18, 19, 20, 21]}

Immobilization of most metacarpal fractures follows a few simple guidelines, including the following:

• Fracture splints should be forearm-based and should allow for motion of the interphalangeal (IP) joints
• Splints should extend over the dorsal and palmar aspect of the entire metacarpal being treated
• Generally, the wrist should be placed in 20-30° of extension; the metacarpophalangeal (MCP) joints should be immobilized in 70-90° of flexion, with the dorsal aspect of the splint extending to the IP joints; and the volar aspect should end at the distal palmar crease
• Buddy taping the fingers of the involved metacarpal can aid in maintaining rotational control
• After a short period of immobilization, patients may be encouraged to use the fingers on the affected hand to maintain motion

Metacarpal base fractures

Fractures of the metacarpal base require reduction if there is greater than 2 mm of articular surface displacement or if there is significant angular deformity or dislocation of the CMC joint. Anesthesia for the reduction is usually accomplished by conscious sedation or regional block; local hematoma block is usually inadequate.

The reduction is accomplished using a combination of traction and direct digital pressure, usually by the physician's thumb. The wrist should be splinted in 20-30° of extension after reduction in order to decrease the deforming pull of the wrist extensors, and the MCP joints should be flexed.

Fractures through the base of the fifth metacarpal require special consideration. These fractures are often intra-articular, with the fracture line between the insertion of the strong intermetacarpal ligaments and the insertion of the extensor carpi ulnaris (ECU) tendon. The pull of the ECU becomes a deforming force, causing the fractured metacarpal to displace proximally and dorsally. This is similar to the Bennett fracture of the thumb ("reverse Bennett fracture").

Management of these fractures usually requires ORIF or closed reduction and percutaneous pinning. Minimally or nondisplaced fractures should be splinted in the same manner described for other CMC injuries.

Immobilization of reduced metacarpal base fractures or nondisplaced fractures should be continued for a minimum of 3-4 weeks. Active motion of the finger IP joints should be encouraged throughout the immobilization period.

Metacarpal shaft fractures

Most closed metacarpal shaft fractures are best treated nonoperatively. Because of the adjacent intact metacarpals and the strong intermetacarpal ligaments, isolated third and fourth metacarpal fractures are particularly stable.

The amount of acceptable angulation varies depending on the location of the fracture and the specific metacarpal involved. Less angulation can be accepted in fractures closer to the CMC joints, as the amount of deformity appears accentuated. Greater angular deformity can be accepted in the fourth and fifth metacarpals, because the greater mobility of the CMC joints compensates for this deformity. General guidelines for acceptable angulation are 10° for the second and third metacarpals, 20° for the fourth metacarpal, and 30° for the fifth metacarpal.

Reduction of displaced metacarpal shaft fractures is best accomplished by using a technique developed by Jhass. ^[22] The fracture is anesthetized with the hematoma block. The affected finger MCP joint and the proximal IP (PIP) joints are flexed to 90°, and the fracture is reduced by applying upward pressure on the middle phalanx and downward pressure over the dorsal apex of the fracture. Flexing of the MCP joint tightens the collateral ligaments and provides a rigid lever for reduction. The finger then can be used to control or correct the rotation.

After reduction, the fracture is held via splinting or can be pinned to maintain reduction. Do not use the Jahss splinting technique (ie, the finger is kept in flexion with upward force applied across the PIP joint), because the risk of skin necrosis and flexor contracture is prohibitive. Immobilization should be limited to less than 4 weeks, as stiffness and tendon adhesion limit range of motion and lead to an unfavorable result.

Metacarpal neck fractures

Minimally angulated or displaced fractures can be managed with simple immobilization for 3-4 weeks. The degree of acceptable angulation is controversial.

Most surgeons agree that no more than 10-15° of angulation in the second and third metacarpals should be accepted without reduction. The lateral digits are more mobile at the CMC joint and function well with greater amounts of angulation of the metacarpal shaft or neck. Though some studies have shown little disability associated with fifth metacarpal neck fractures angulated as much as 70°, most surgeons advocate reduction of those fractures with more than 45° of angulation.

As in other fractures of the hand, no rotational deformity is acceptable, as the resultant finger overlap with grip leads to weakness and disability. Reduction of metacarpal neck fractures is accomplished by the same method as metacarpal shaft fractures (see above). Closed reduction and immobilization with splints or casts has been shown to maintain approximately 50% of the initial deformity correction.

Metacarpal head fractures

Nondisplaced fractures can be managed with splinting for 3 weeks, followed by gentle motion. Fractures in which the articular surface is displaced greater than 1-2 mm should be managed operatively. Splinting of metacarpal head fractures should incorporate the MCP joint. This can be accomplished with the ulnar gutter splint for fourth and fifth metacarpal fractures.

Metacarpophalangeal dislocations

Dorsal MCP dislocations are classified as simple or complex. Both are the result of hyperextension injuries with avulsion of the palmar plate. The distinction between the two types is the difficulty of reduction.

Simple dislocations are easy to diagnose because the MCP joint rests in 60-90° of hyperextension. In this injury, the volar plate is distracted and not interposed between the bone ends.

Reduction of simple MCP dislocations is carried out easily with local or regional anesthesia in the emergency department. The wrist and IP joints are flexed—and the finger is very gently distracted—and a volarly directed force from the dorsum brings the joint into at least 50° of flexion. One must avoid hyperextension (accentuation of the deformity) during reduction so as to not interpose the volar plate. Immediate motion can then be started in a dorsal block splint that prohibits extension beyond 30°.

MCP dislocations that are not readily reducible are characterized as complex. The reduction is prevented by either interposed soft tissue or "buttonholing" of the metacarpal head. On presentation, the MCP joint is only slightly hyperextended with the distal joints mildly flexed. The involved digit deviates toward the adjacent central digit. A prominence is present in the palm with dimpling of the skin in the area of the proximal volar crease. Dorsally, a depression is palpable proximal to the base of the proximal phalanx. The patient cannot actively flex the digit. These dislocations require operative reduction.

Although closed management of these injuries is the rule rather than the exception, certain fractures and dislocations require operative intervention to ensure satisfactory restoration of function and cosmesis. ^{[16, 17, 18, 19, 21, 23, 24, 25, 26, 27, 2, 28, 29]}

Adequate surgical planning requires adequate preoperative assessment. A thorough neurovascular examination should be accomplished before any intervention. Obtaining adequate radiographs to view all potential injuries in advance of surgery is essential to avoid unexpected surprises. Intraoperative fluoroscopy or radiography should be used to ensure adequate reduction before the patient leaves the operating room. Additionally, joint motion should be assessed after fixation under anesthesia so that postoperative expectations can be established.

Carpometacarpal injuries

Adequate reduction of CMC fractures and dislocations usually can be obtained in a closed manner; however, reduction may be difficult to maintain because of the deforming forces discussed earlier. Pin fixation is an effective means of stabilization. In addition, reduction of articular fragments is difficult to judge in these poorly visualized joints. Depending on the specific injury and means of fixation, patients are immobilized postoperatively for 3-6 weeks. Often, motion may be initiated prior to pin removal.

Fractures of the fifth metacarpal base (reverse Bennett fractures) often require operative intervention. This fracture displaces dorsally and proximally due to the deforming pull from the ECU tendon and, to a lesser extent, the flexor carpi ulnaris (FCU) through the pisometacarpal ligament.

For fifth metacarpal fractures with large fragments, closed reduction often is easily accomplished; however, the reduction can be difficult to maintain without pin fixation. For comminuted intra-articular fractures, open reduction may be required to achieve an acceptable joint. Stable fixation can be achieved with K-wire fixation between the fifth and fourth metacarpals, which can be supplemented with an additional K-wire across the fifth CMC joint.

Fracture-dislocations of the mobile fourth and fifth metacarpals associated with displaced fractures of the dorsal hamate require ORIF. Fixation can be accomplished with either pins or mini-fragment screws.

Multiple CMC dislocations are high-energy injuries and often require ORIF. Closed reduction is first attempted using longitudinal traction and direct pressure over the displaced metacarpal bases. If satisfactory reduction is accomplished, percutaneous K-wires provide adequate stabilization. If reduction is difficult, carefully evaluate for intra-articular fragments, which are often difficult to see and may block reduction. If adequate closed reduction cannot be obtained, open reduction should be accomplished and the reduction internally fixed with either pins or screws.

Metacarpal shaft injuries

Open fractures require operative debridement and irrigation, followed by stable internal or external fixation. Metacarpal neck fractures with small lacerations over the MCP joint are assumed to be the result of a human bite (fight bite) and are treated operatively using joint lavage and appropriate antibiotics, usually penicillin or oxacillin.

Operative treatment of metacarpal shaft fractures varies according to the type of fracture, amount of displacement, location of fracture, and degree of soft-tissue injury.

Transverse fractures

Transverse fractures can be managed with longitudinal pins, transverse pins, crossed pins, intramedullary pinning, or tension band wiring. Longitudinal pins are placed distal to proximal, starting the pin medial or lateral to the MCP joint at the origin of the collateral ligaments and driving the pin down the shaft of the metacarpal across the fracture site. Crossed pins can be started proximally or distally, should cross near the fracture site, and should exit the far cortex.

The percutaneous pins can be cut short and left under the skin, and early motion can be instituted. The pins can be removed at 4-6 weeks or when radiographic healing has occurred.

K-wires placed transversely through the fractured metacarpal into the adjacent nonfractured metacarpal can be used to stabilize transverse fractures. Usually, two K-wires are placed distal to the fracture, with one K-wire placed in the proximal fragment.

Intramedullary (bouquet) pinning is a technique that, though sometimes technically challenging, has produced good results. Intramedullary pinning is best for fairly distal metacarpal fractures. Prebent small K-wires, with the sharp point removed, are introduced through a small corticotomy proximal to the fracture site. The fracture is reduced and the pins advanced by hand across the fracture site through the medullary canal. Usually, three or four K-wires are utilized. Early motion can be instituted, and hardware removal is not necessary.

Tension band wire fixation, with the wire crossing on the dorsal shaft of the metacarpal, provides an excellent low-profile method of fixation if no significant comminution exists. The tension band is usually secured to crossed wires after the crossed pinning technique has been accomplished to provide additional stabilization. The major disadvantage of this technique is that it is an open procedure.

Short oblique fractures

Short oblique fractures of the metacarpal are generally unstable and tend to angulate and rotate. If the fracture is not rotated, shortening of up to 4-5 mm can be accepted and the fracture treated closed.

Longitudinal pin fixation or transverse pin fixation to the adjacent metacarpal can be used to supplement closed management. Care should be used with longitudinal pin fixation, as rotatory control may not be maintained.

Small low-profile plate-and-screw fixation may be necessary to maintain rotatory control and alignment.

Long oblique or spiral fractures

Long oblique fractures, in which the length of the fracture is greater than twice the bone diameter, which cannot be reduced by closed methods, is often best treated with multiple-lag-screw fixation.

Fixation with multiple lag screws usually allows early mobilization, and if the mini screws are countersunk, the metal rarely becomes symptomatic. K-wires often provide adequate fixation as well.

Comminuted fractures

Comminuted fractures, with or without the loss, can be managed by transverse K-wire fixation or ORIF. If closed reduction of the fracture is possible, placing two K-wires transversely into the adjacent metacarpal distally and placing one K-wire transversely proximally may provide adequate stabilization to maintain reduction and allow healing.

If closed reduction of the fracture with transverse K-wires is not possible, ORIF using plate-and-screw fixation, with or without supplemental bone graft, should be accomplished. Though new generation low-profile implants have lessened the incidence of postoperative tendon adhesions, plate-and-screw fixation should be used sparingly.

Severely comminuted fractures associated with bone loss may require the use of an external fixator. External fixator frames can be constructed with K-wires and cement or acrylic and are also available in commercial sets.

Metacarpal neck fractures

The treatment of metacarpal neck fractures is very similar to that of metacarpal shaft fractures (see above). Most metacarpal neck fractures can be managed nonoperatively. Requirements for operative fixation include severe angulation not treatable by closed means, unstable rotational deformity, or significant comminution or bone loss.

Operative treatment usually is best accomplished with closed reduction and percutaneous pinning. Longitudinal pinning techniques or crossed pins are usually adequate to maintain reduction. For very unstable fractures, internal fixation can be accomplished with dorsal tension band wiring.

Metacarpal head fractures

Nondisplaced fractures can be managed with splinting for 3 weeks, followed by gentle motion. Noncomminuted fractures involving more than 10-15% of the articular surface and greater than 1-2 mm of articular displacement should be reduced by means of open technique via a dorsal approach that involves either splitting the extensor tendon or incising the sagittal band laterally to view the joint. Take care to avoid stripping soft tissues from the fracture fragments, in order to minimize the chance of devascularization.

Fixation of head fractures can be accomplished with K-wires, cerclage wiring, or interfragmentary screws. Ideally, fixation should be stable enough to allow early motion.

Comminuted metacarpal head fractures present a major problem. K-wire and cerclage wire techniques often fail, rigid fixation rarely is possible, and the bulk of condylar plates are problematic. For those fractures that are not amenable to internal fixation, consider external fixation, skeletal traction, or simple immobilization of the MCP joint in 70° of flexion for 2 weeks, followed by intensive therapy.

Some authors advocate immediate silicone implant arthroplasty for severely comminuted MCP joint injuries. Certainly, this prosthesis is preferred for older patients who place fewer demands on their hands and for joints other than the index MCP joint. Implant arthroplasty should not be used in cases where soft-tissue coverage is inadequate or when there is excessive bone loss. Finally, MCP joint arthroplasty is a salvage procedure and as such may be used later without disadvantage. Only in very rare and unique clinical situations should it be considered as first-line treatment.

Metacarpophalangeal dislocations

Open reduction is frequently required for complex dorsal dislocations. Like simple dislocations, these complex dislocations are most common in the index finger and the small finger (border digits).

On presentation, the MCP joint is only slightly hyperextended with the distal joints mildly flexed. The involved digit deviates toward the adjacent central digit. A prominence is present in the palm, with dimpling of the skin in the area of the proximal volar crease. Dorsally, a depression is palpable proximal to the base of the proximal phalanx. The patient cannot actively flex the digit.

In complex MCP dislocations, the volar plate avulses from the distal metacarpal and becomes interposed between the volar surface of the phalanx and the dorsal surface of the metacarpal head. In the index finger, the metacarpal head may buttonhole between the flexor tendons ulnarly and the lumbrical radially. These structures tighten around the metacarpal neck when traction is applied during attempted closed reduction.

In the small finger, the entrapping structures include the lumbricals and flexor tendons radially and the abductor and short flexor ulnarly. Also, in both digits, the collateral ligaments tighten around the narrow metacarpal neck with distraction, further preventing reduction. A single gentle attempt should be made at closed reduction. The patient's wrist and IP joints are flexed, and a dorsal-to-volar translation force is applied to the base of the proximal phalanx. Distraction is avoided or minimized.

If this attempt fails, open reduction should be performed through either a volar or a dorsal approach. Though the volar approach may provide more direct visualization of the structures preventing reduction, caution must be exercised because the neurovascular bundle is usually tented over the metacarpal head. After open reduction, internal fixation is rarely required, and early motion is instituted with the use of a dorsal extension-block splint.

Irreducible volar MCP joint dislocations are exceedingly rare. Two structures have been credited with preventing closed reduction: dorsal capsule avulsed proximally and volar plate avulsed distally. This injury should be approached dorsally to reduce the dislocation.

Most surgery on the hand is undertaken to promote function. Whenever possible, it is essential that early motion be instituted to ensure a good outcome. Delaying motion beyond 3-4 weeks can lead to arthrofibrosis and a poor functional outcome. Optimal surgical treatment should allow for near-immediate postoperative motion, and patients should be encouraged to move their fingers on a daily basis.

Complications of the treatment of CMC joint fractures and dislocations include recurrent dislocation and arthritis of the involved joint. Arthrosis is more likely to involve the relatively mobile fourth and fifth CMC joints and can best be avoided by achieving stable anatomic reduction and avoiding prolonged immobilization. Late treatment of CMC joint arthritis consists of joint fusion. Little disability is associated with this procedure.

Complications from metacarpal shaft and neck fractures are rare. The most common complication is malunion with persistent dorsal apex angulation or rotational deformity. Function is more likely to be affected if the malunion is proximal, involves either the second or the third metacarpal, and is rotatory in nature.

If excessive angulation is not corrected, the hand exhibits loss of dorsal contour, prominence of the MC head in the palm, pain with grasp, and possibly pseudoclawing of the fingers with MCP extension. A rotational malunion causes digital overlap with finger flexion. If these deformities are not corrected acutely, a metacarpal osteotomy may be required to restore anatomy and function.

MCP joint stiffness is a frequent problem following the treatment of metacarpal head fractures. This problem is minimized by achieving a stable anatomic reduction allowing early motion.

Other complications result from operative treatment. Plates and other prominent hardware frequently cause tendon adhesions and stiffness. In addition, the metal may become tender to palpation. Treatment includes hardware removal and extensor tendon tenolysis.