The Case:
A 40-year-old male with no past medical history presented to the emergency department after he was assaulted with closed fists just prior to arrival. The patient’s injuries included a blow to the back of his right hand. On exam he was found to have swelling and tenderness to the dorsal aspect of his right hand. He had brisk capillary refill and normal sensation to light touch in all fingers. There was no malrotation of fingers with a closed fist.
Patient Course:
Radiographs demonstrated a displaced, comminuted midshaft fracture of the fourth metacarpal. Closed reduction was attempted, but was unsuccessful. The patient was placed in an ulnar gutter splint, and he was given outpatient orthopedic follow up. Two weeks later the patient returned to the ED after having missed his orthopedic clinic appointment, and a second unsuccessful attempt at closed reduction was performed. Orthopedic surgery saw the patient in clinic two weeks later, and given the irreducible fracture, the patient underwent open reduction and percutaneous pinning the next day.
Why it Matters:
Fractures of the second through fourth metacarpals should initially be managed by attempting closed reduction with splinting in either a palmar wrist splint or an ulnar gutter splint. If there are no indications for surgery, the patient can be immobilized in a cast for four weeks with good outcomes. Indications for operative treatment include:
· Multiple fractures
· Severe soft tissue injury
· Unstable open fractures
· Shortening >2-6 mm
· Residual angulation >30° in ring finger or >10° in middle or index finger
· Malrotation
· Irreducible fractures
After treatment with surgery or casting, early range of motion and occupational therapy are important to prevent stiffness and loss of function.
Written by:
Matt Hughes, MD
Emergency Medicine, PGY-2
Cook County Health
Reviewed by:
Dr. Scott Sherman, MD
Associate Program Director
Cook County Health
References:
Kollitz KM, Hammert WC, Vedder NB, Huang JI. Metacarpal fractures: treatment and complications. Hand (N Y). 2014;9(1):16-23. doi:10.1007/s11552-013-9562-1
Stern PJ. Management of fractures of the hand over the last 25 years. J Hand Surg Am. 2000 Sep;25(5):817-23. doi: 10.1053/jhsu.2000.4214. PMID: 11040296