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Metacarpal Fracture

Fracture of any of the five metacarpal bones in the hand, accounting for 30-50 percent of all hand fractures with annual incidence 13-67 per 100,000; common in young males from punch injury (boxer's fracture of 5th metacarpal neck), sports, falls, and crush injuries; classified by location (head, neck, shaft, base) and pattern; most treated conservatively with closed reduction and immobilization, surgical fixation for unstable patterns.

Written by: Saygı Hospital Health Guide Editorial Board
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This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

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What is Metacarpal Fracture?

Metacarpal fracture is the breakage of any of the five metacarpal bones (numbered 1-5 from thumb to little finger) that form the bony framework of the palm. They constitute 30-50 percent of all hand fractures and 18 percent of fractures distal to elbow. Annual incidence 13-67 per 100,000 population, peak age 15-30 years (young males with high-energy injuries), male-to-female ratio 4:1. Mechanisms include direct trauma (most common — fall, crush injury, sports), indirect (forceful axial loading during punching — boxer's fracture of 5th metacarpal neck most common), and torsion (twisting injuries — spiral fractures).

Anatomy and biomechanics: Each metacarpal has a base (proximally articulating with carpal bones at carpometacarpal CMC joint), shaft (diaphysis), neck (subcapital metaphyseal), and head (distally articulating with proximal phalanx at metacarpophalangeal MCP joint). 1st MC (thumb) has unique saddle CMC joint allowing thumb opposition; 2nd and 3rd MC are immobile (firmly attached to capitate and trapezoid); 4th and 5th MC have mobile CMC joints (15-30° flexion) accommodating power grip. The deep transverse intermetacarpal ligaments link MC heads (palmar plate function), preventing isolated proximal migration of fragments. Intrinsic muscles (interossei, lumbricals) span between metacarpals; their pull on volar fragment of metacarpal neck fracture causes characteristic apex dorsal angulation.

Classification: 1) Location — Head (intra-articular MCP joint), Neck (extra-articular metaphyseal — 'boxer's fracture' if 5th MC, named after its association with poor punch technique), Shaft (diaphyseal — transverse, oblique, spiral, comminuted, segmental), Base (articular CMC joint involvement — Bennett fracture-dislocation of 1st MC base, Rolando fracture three-part comminuted of 1st MC base, reverse Bennett of 5th MC base extra-articular extension); 2) Pattern — closed vs open (Gustilo classification), simple vs comminuted, displaced vs non-displaced, angulated, malrotated, shortened (each pattern has different stability and treatment implications).

Pathophysiology: Forces involved in metacarpal fractures vary by mechanism — punch injury (axial load + bending) causes apex dorsal angulation of MC neck due to flexor and intrinsic pull; crush injury causes transverse or comminuted shaft fractures; twisting causes spiral or oblique shaft fractures; falls onto outstretched hand can cause base fractures (especially Bennett of 1st MC). Healing is complicated in displaced or unstable patterns by ongoing displacement from intrinsic muscle pull. Malrotation (rotational deformity) is the most clinically significant deformity — even minor malrotation (5°) at MC level causes 1.5 cm overlap of fingers when making a fist (scissoring deformity), interfering with grip and function. Acceptable angulation tolerance varies by location — 5th MC neck tolerates up to 30° apex dorsal angulation due to mobile 5th CMC joint compensating, 4th MC tolerates 15°, 2nd-3rd MC only 10° due to immobile CMC joints; shaft fractures less tolerant of angulation.

Symptoms

Pain and swelling over dorsum of hand at fracture site
Bruising and ecchymosis over hand
Visible deformity (depressed knuckle in MC neck fracture, dorsal angulation, shortening)
Tenderness over fracture site on palpation
Inability or difficulty making a fist
Decreased grip strength
Crepitus on palpation or movement
Open wound with bone visible (open fracture, especially from punch through teeth — 'fight bite')
Malrotation deformity — finger overlap (scissoring) when attempting to make a fist (key examination finding)
Decreased range of motion of MCP joint or finger flexion

Risk Factors

Punch injury (boxer's fracture of 5th MC neck most common — fight, wall punch, anger management issue)
Sports injury (boxing, mixed martial arts, football, soccer, basketball, baseball, hockey, rugby, lacrosse)
Direct trauma (workplace injuries — construction, factory, machinery)
Crush injury (machinery, doors, falling objects)
Motor vehicle accident
Fall onto outstretched hand
Osteoporosis (postmenopausal women, elderly, vitamin D deficiency)
Athletic activities at all levels
Domestic violence (consider in suspicious pattern of injuries)
Substance abuse (alcohol, drugs — impaired judgment leading to punch injuries)
Pathologic fracture (rare — enchondroma in proximal phalanx most common, metastatic disease)
Repetitive use (stress fractures rare in metacarpals, more common in radius)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Significant hand pain after punch injury or trauma to hand
  • Visible deformity, swelling, or bruising of hand
  • Inability or difficulty making a fist
  • Open wound on hand from punching (especially over knuckles after fight — high infection risk)
  • Suspicion of finger overlap (scissoring) when making fist (malrotation requiring evaluation)
  • Decreased grip strength after recent hand injury
  • Persistent hand pain 24-48 hours after injury
  • Numbness or tingling in fingers (neurovascular injury)
  • Cold or pale hand after recent injury (vascular emergency)
  • Suspected fight bite injury (laceration over knuckles after punching mouth — emergency for infection prophylaxis)

Treatment Methods

01
Initial assessment: detailed history (mechanism, timing, dominant hand, occupation, hand activities, prior hand injuries), physical examination (location of pain, swelling, ecchymosis, deformity, range of motion of MCP and IP joints, ability to make full fist, neurovascular examination — radial/ulnar/median nerves and pulses), assessment for malrotation (look for finger overlap when patient attempts to make fist — scissoring of digits indicates rotational deformity), open wound inspection (especially over MC heads and knuckles for fight bite — high suspicion for human bite injury, wound exploration mandatory)
02
Imaging: 1) AP, lateral, and oblique X-rays of hand — visualize fracture pattern, displacement, angulation, comminution, articular involvement (oblique view best for shaft and head/neck fractures, AP and lateral for base fractures); 2) CT scan — for complex articular fractures (intra-articular CMC fractures, comminuted patterns, surgical planning); 3) MRI — for occult fractures, soft tissue injury, ligamentous disruption (rare in acute setting); 4) Ultrasound — soft tissue assessment, suspected tendon injuries
03
Conservative management: 1) Closed reduction — under local anesthesia (digital block or hematoma block with 1 percent lidocaine) or sometimes general anesthesia for 1st MC fractures; 'Jahss maneuver' for 5th MC neck (boxer's) fracture — flex MCP and PIP to 90° each, apply dorsal pressure on PIP and volar pressure on MC head, achieving reduction; verify reduction with check X-ray; 2) Immobilization — ulnar gutter splint or cast for 4th-5th MC fractures (extends from forearm to fingertips of involved fingers, MCP at 60-90° flexion to allow extrinsic ligament tightness for stability), radial gutter for 2nd-3rd MC, thumb spica for 1st MC; alternative buddy taping for stable simple fractures; duration 3-4 weeks for stable patterns, 4-6 weeks for less stable; 3) Indications for conservative — non-displaced fractures, stable closed patterns within acceptable angulation tolerances (5th MC neck up to 30° apex dorsal, 4th 15°, 2nd-3rd 10°, shaft fractures less tolerant up to 10° apex dorsal in any), no rotational deformity, no shortening > 5 mm; non-displaced base fractures with good CMC alignment
04
Surgical management: indications include displaced or unstable fractures exceeding angulation tolerance, malrotation (any rotational deformity is unacceptable — must be corrected), open fractures (especially fight bite — surgical irrigation and debridement, broad-spectrum antibiotics covering oral flora — Eikenella corrodens, anaerobes), multiple metacarpals (segmental instability), intra-articular displacement > 2 mm, segmental fractures, polytrauma, failure of closed reduction, irreducible fractures, articular fractures (Bennett, Rolando) of 1st MC base; surgical techniques include 1) Percutaneous pinning with K-wires (1.0-1.5 mm) — quick, minimally invasive, removed at 4-6 weeks, complications include pin tract infection, pin loosening, scar formation; 2) Open reduction internal fixation with mini-fragment plates (Synthes, Acumed, Medartis) — 2.0-2.4 mm modular hand plates allow rigid fixation for shaft and base fractures, immediate motion possible; 3) Intramedullary fixation with Bouquet pinning — multiple pre-bent K-wires inserted through MC base into cancellous head fragments, useful for 5th MC neck fractures; 4) Lag screw fixation — for long oblique or spiral fractures of shaft; 5) External fixation — for severely comminuted, contaminated, or open fractures with bone loss
05
Special fracture patterns: 1) Bennett fracture — intra-articular fracture-dislocation of 1st MC base (small palmar-ulnar fragment retained by anterior oblique ligament; abductor pollicis longus pulls remaining MC dorsoradially) — requires surgical fixation with K-wires (closed reduction with traction-pronation, percutaneous K-wires) or ORIF with mini-screws if larger fragment; 2) Rolando fracture — three-part T or Y comminuted intra-articular 1st MC base — challenging to fix, often ORIF with miniplate or external fixation; 3) Reverse Bennett (or 'baby Bennett') — fracture of 5th MC base with subluxation, similar treatment principles; 4) Fight bite — laceration over knuckle from punching mouth, contaminated by oral flora — emergent treatment with irrigation, debridement, broad-spectrum antibiotics (amoxicillin-clavulanate, third-generation cephalosporin), tetanus prophylaxis, do NOT close primarily (allow secondary intention healing or delayed primary closure); high infection rate if missed
06
Open fracture management: emergency IV antibiotic prophylaxis (cefazolin for I/II, add gentamicin for III), tetanus, irrigation and debridement within 6-24 hours, soft tissue assessment, immediate or staged wound coverage, internal or external fixation depending on contamination
07
Postoperative rehabilitation: 1) Immediate postoperative (0-1 week) — splint maintenance, edema control (elevation, ice, compression), gentle finger motion of uninvolved digits, pain control; 2) Early (1-4 weeks) — protected motion in splint allowing limited MCP flexion (avoid full grip if recently reduced), grip strengthening with putty exercises gentle, occupational therapy for ROM and strengthening, gradual increase in activities; 3) Intermediate (4-6 weeks) — discontinue splint for non-essential activities, full active and passive ROM exercises, dynamic splinting if stiff (PIP or MCP), strengthening with theraband; 4) Late (6-12 weeks) — return to sports and heavy manual work depending on healing radiographically (typically 6-8 weeks for stable closed, 8-12 weeks for surgical), full grip strength recovery 3-6 months
08
Long-term complications: 1) Loss of reduction (10-20 percent in conservative — re-displacement requires re-reduction or surgery); 2) Malunion (5-15 percent — angulation > 30° for 5th MC neck causes only cosmetic concern, > 60° causes pseudoclawing; rotational malunion requires corrective osteotomy); 3) Stiffness (PIP and MCP joint contracture from prolonged immobilization or scar — physical therapy, dynamic splinting, capsular release if severe); 4) Pain (chronic pain at fracture site or arthritis — analgesics, intra-articular injections); 5) Tendon adhesions (extensor tendon scarring over fracture — tenolysis); 6) Avascular necrosis (rare, MC head — observation, eventual joint replacement if symptomatic); 7) Infection (1-5 percent for closed surgery, 5-30 percent for open or fight bite); 8) Hardware-related symptoms (40 percent palpable hardware — removal at 6-12 months if symptomatic); 9) Post-traumatic arthritis CMC joint after Bennett fracture (50-70 percent at 10+ years even with good treatment — analgesics, splinting, eventual CMC arthrodesis or arthroplasty)

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