Non-thumb metacarpal fracture: Difference between revisions

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==Non-Thumb Metacarpal Head Fracture==
==Head==
===Background===
*Intra-articular Fx
*Intra-articular Fx
*Examination
===Examination===
**Swelling, decreased ROM, and TTP of MCP joint
*Swelling, decreased ROM, and TTP of MCP joint
**Assess for rotational alignment (rotational malalignment is not tolerated)
*Assess for rotational alignment (rotational malalignment is not tolerated)
**Assess for skin integrity (r/o fight bite)
*Assess for skin integrity (r/o fight bite)
*Imaging
===Imaging===
**AP, lateral, oblique
*AP, lateral, oblique
***Angulation assessed on lateral view
**Angulation assessed on lateral view
**Consider "Brewerton" view if collateral ligament avulsion fx suspected
*Consider "Brewerton" view if collateral ligament avulsion fx suspected
*Treatment
===Treatment===
**Ulnar or radial gutter splint
*Ulnar or radial gutter splint
***MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
**MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
*Dispo
===Dispo===
**Almost always refer b/c are intraarticular and typically comminuted
*Almost always refer b/c are intraarticular and typically comminuted
**Non-displaced fx can be splinted for 2-3 weeks followed by ROM exercises
*Non-displaced fx can be splinted for 2-3 weeks followed by ROM exercises


==Non-Thumb Metacarpal Neck Fracture==
==Neck==
*Examination
===Examination===
**TTP or ecchymosis on the palmar bony surface is highly suggestive of fracture
*TTP or ecchymosis on the palmar bony surface is highly suggestive of fracture
**Loss of the normal knuckle contour
*Loss of the normal knuckle contour
***Due to dorsal angulation of fracture apex due to pull of the interosseous muscles
**Due to dorsal angulation of fracture apex due to pull of the interosseous muscles
**Assess angulation
*Assess angulation
***Head-to-neck angle of the metacarpals is normally 15 degrees
**Head-to-neck angle of the metacarpals is normally 15 degrees
****Fracture angulation = measured angle minus 15 deg
***Fracture angulation = measured angle minus 15 deg
***Angle toleration (below which there is no adverse functional outcome)
**Angle toleration (below which there is no adverse functional outcome)
****2nd MC < 10 deg
***2nd MC < 10 deg
****3rd MC < 20 deg
***3rd MC < 20 deg
****4th MC < 30 deg
***4th MC < 30 deg
****5th MC < 30 deg
***5th MC < 30 deg
**Assess rotational alignment
*Assess rotational alignment
**Assess extensor apparatus
*Assess extensor apparatus
**Assess skin integrity
*Assess skin integrity
*Treatment
===Treatment===
**Gutter splint
*Gutter splint
***MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
**MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
**Acute reduction indicated:
*Acute reduction indicated:
***Pseudoclawing
**Pseudoclawing
***Significantly angulated 4th or 5th MC fx
**Significantly angulated 4th or 5th MC fx
*Dispo
===Dispo===
**Refer for:
*Refer for:
***Comminution
**Comminution
***Rotational malalignment
**Rotational malalignment


==Non-Thumb Metacarpal Shaft Fracture==
==Shaft==
* Examination
===Examination===
** TTP along affected metacarpal
* TTP along affected metacarpal
** Flexion at MCP is difficult
* Flexion at MCP is difficult
** Assess for extensor dysfunction; pt may exhibit "pseudo-clawing" during attempts at finger extension
* Assess for extensor dysfunction; pt may exhibit "pseudo-clawing" during attempts at finger extension
** Assess angulation
* Assess angulation
*** >10 deg in 2nd and 3rd and >20 deg in 4th and 5th metacarpal shaft fractures requires reduction
** >10 deg in 2nd and 3rd and >20 deg in 4th and 5th metacarpal shaft fractures requires reduction
** Assess rotational alignment
* Assess rotational alignment
* Imaging
===Imaging===
** Oblique fx are more prone to shorten and rotate
* Oblique fx are more prone to shorten and rotate
** Transverse fx generally stable (particularly isolated 3rd or 4th MC shaft fx)
* Transverse fx generally stable (particularly isolated 3rd or 4th MC shaft fx)
* Treatment
===Treatment===
** Gutter splint
* Gutter splint
** Acute reduction indicated if there is pseudo-clawing or significant angulation
* Acute reduction indicated if there is pseudo-clawing or significant angulation
*** Closed reduction generally corrects angulation but typically does not restore length
** Closed reduction generally corrects angulation but typically does not restore length
* Dispo
===Dispo===
** Refer:
* Refer:
*** Malrotation
** Malrotation
*** Comminution
** Comminution
*** Shortening > 5mm (refer all shortening if not familiar with fx management)
** Shortening > 5mm (refer all shortening if not familiar with fx management)
*** 2 or more metacarpal fractures
** 2 or more metacarpal fractures
*** Unacceptable angulation
** Unacceptable angulation
*** Long oblique fractres
** Long oblique fractures


==Non-Thumb Metacarpal Base Fracture==
==Base==
* Examination
===Examination===
** Movement at the wrist elicits pain
* Movement at the wrist elicits pain
** Assess for ulnar deficits (finger abduction/adduction)
* Assess for ulnar deficits (finger abduction/adduction)
** Assess for rotational alignment
* Assess for rotational alignment
* Imaging
===Imaging===
** AP, lateral, oblique
* AP, lateral, oblique
** 30 deg obliques pronated and supinated if usual films unable to visualize the MC bases
* 30 deg obliques pronated and supinated if usual films unable to visualize the MC bases
** Consider CT if index of suspicion high for occult fx despite "negative" plain films
* Consider CT if index of suspicion high for occult fx despite "negative" plain films
* Treatment
===Treatment===
** Dorsal and volar splints with the wrist in 30 deg of extension and MCP joints free
* Dorsal and volar splints with the wrist in 30 deg of extension and MCP joints free
* Dispo
===Dispo===
** Refer for:
* Refer for:
*** Intraarticular fx
** Intraarticular fx
*** Extraarticular fx with malrotation
** Extraarticular fx with malrotation
*** Dislocation of metacarpal base CMC joint;
** Dislocation of metacarpal base CMC joint;
*** Ulnar nerve injury
** Ulnar nerve injury
*** 5th metacarpal base fx (typically require sx)
** 5th metacarpal base fx (typically require sx)


==See Also==
==See Also==

Revision as of 06:00, 4 January 2014

Head

Background

  • Intra-articular Fx

Examination

  • Swelling, decreased ROM, and TTP of MCP joint
  • Assess for rotational alignment (rotational malalignment is not tolerated)
  • Assess for skin integrity (r/o fight bite)

Imaging

  • AP, lateral, oblique
    • Angulation assessed on lateral view
  • Consider "Brewerton" view if collateral ligament avulsion fx suspected

Treatment

  • Ulnar or radial gutter splint
    • MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion

Dispo

  • Almost always refer b/c are intraarticular and typically comminuted
  • Non-displaced fx can be splinted for 2-3 weeks followed by ROM exercises

Neck

Examination

  • TTP or ecchymosis on the palmar bony surface is highly suggestive of fracture
  • Loss of the normal knuckle contour
    • Due to dorsal angulation of fracture apex due to pull of the interosseous muscles
  • Assess angulation
    • Head-to-neck angle of the metacarpals is normally 15 degrees
      • Fracture angulation = measured angle minus 15 deg
    • Angle toleration (below which there is no adverse functional outcome)
      • 2nd MC < 10 deg
      • 3rd MC < 20 deg
      • 4th MC < 30 deg
      • 5th MC < 30 deg
  • Assess rotational alignment
  • Assess extensor apparatus
  • Assess skin integrity

Treatment

  • Gutter splint
    • MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
  • Acute reduction indicated:
    • Pseudoclawing
    • Significantly angulated 4th or 5th MC fx

Dispo

  • Refer for:
    • Comminution
    • Rotational malalignment

Shaft

Examination

  • TTP along affected metacarpal
  • Flexion at MCP is difficult
  • Assess for extensor dysfunction; pt may exhibit "pseudo-clawing" during attempts at finger extension
  • Assess angulation
    • >10 deg in 2nd and 3rd and >20 deg in 4th and 5th metacarpal shaft fractures requires reduction
  • Assess rotational alignment

Imaging

  • Oblique fx are more prone to shorten and rotate
  • Transverse fx generally stable (particularly isolated 3rd or 4th MC shaft fx)

Treatment

  • Gutter splint
  • Acute reduction indicated if there is pseudo-clawing or significant angulation
    • Closed reduction generally corrects angulation but typically does not restore length

Dispo

  • Refer:
    • Malrotation
    • Comminution
    • Shortening > 5mm (refer all shortening if not familiar with fx management)
    • 2 or more metacarpal fractures
    • Unacceptable angulation
    • Long oblique fractures

Base

Examination

  • Movement at the wrist elicits pain
  • Assess for ulnar deficits (finger abduction/adduction)
  • Assess for rotational alignment

Imaging

  • AP, lateral, oblique
  • 30 deg obliques pronated and supinated if usual films unable to visualize the MC bases
  • Consider CT if index of suspicion high for occult fx despite "negative" plain films

Treatment

  • Dorsal and volar splints with the wrist in 30 deg of extension and MCP joints free

Dispo

  • Refer for:
    • Intraarticular fx
    • Extraarticular fx with malrotation
    • Dislocation of metacarpal base CMC joint;
    • Ulnar nerve injury
    • 5th metacarpal base fx (typically require sx)

See Also

Source

UpToDate

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