A 23-year-old male player presented after a collision with an opponent. He describes experiencing immediate pain as his hand was caught in his opponent’s shirt. He was however able to play a further 30 minutes without much restriction. After the game, he was noted to have localised tenderness over his fourth metacarpal as well as pain with gripping tasks. There was no rotational deformity.
An x-ray series of the right hand shows that the fourth metacarpal has an oblique fracture of the proximal shaft with mild overlap and separation but no significant angulation.
This player was treated with a four week period of immobilisation. He was managed in a thermoplastic splint that allowed him to continue to play and train. Repeat x-rays at two weeks and four weeks post-injury showed that the fracture position had been maintained and demonstrated evidence of fracture healing.
Metacarpal fractures account for about 40% of all hand fractures. They generally occur after a direct blow to the hand or due to a rotational injury with an associated axial load. The majority of fractures involve the 5th metacarpal with the ‘neck’ being the most common single site.
The treatment of choice for metacarpal fractures is based on which metacarpal is involved, the presence of any ‘clinical’ rotation and the presence of angulation. The acceptable degree of angulation depends on the location. Angulation is tolerated better on the ulnar side of the hand. Up to 40° of angulation can be allowed when the fifth metacarpal is involved, 30° at the ring finger and 10-20° at the middle and index fingers. Fractures involving the neck, rather than the shaft, of the 4th (30-40°) and 5th (50-60°) metacarpals can have more angulation. A clinical assessment must exclude rotation as this is not tolerated well.
Non-surgical treatment can be used for most injuries. The hand should be immobilised in 70-90 degrees of MCPJ flexion for four weeks. When there is a rotational deformity, when multiple fractures are present or when there is significant displacement or angulation operative treatment should be considered.
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