Non-thumb metacarpal fracture: Difference between revisions
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*Consider "Brewerton" view if collateral ligament avulsion fx suspected | *Consider "Brewerton" view if collateral ligament avulsion fx suspected | ||
===Treatment=== | ===Treatment=== | ||
*Ulnar or | *[[Ulnar Gutter Splint]] 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=== | ||
| Line 34: | Line 34: | ||
*Assess skin integrity | *Assess skin integrity | ||
===Treatment=== | ===Treatment=== | ||
*Gutter | *[[Ulnar Gutter Splint]] 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 | ||
*Acute reduction indicated: | *Acute reduction indicated: | ||
| Line 56: | Line 56: | ||
* 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 | *[[Ulnar Gutter Splint]] or [[Radial 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 | ||
| Line 78: | Line 78: | ||
* 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 | * Dorsal and [[Forearm Volar Splint]] with the wrist in 30 deg of extension and MCP joints free | ||
===Dispo=== | ===Dispo=== | ||
* Refer for: | * Refer for: | ||
Revision as of 06:03, 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 Gutter Splint 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
- Head-to-neck angle of the metacarpals is normally 15 degrees
- Assess rotational alignment
- Assess extensor apparatus
- Assess skin integrity
Treatment
- Ulnar Gutter Splint 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
- 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
- Ulnar Gutter Splint or Radial 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 Forearm Volar Splint 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