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| | [[File:Hand bones.svg|thumb|Hand bones]] |
| ==Background== | | ==Background== |
| *Splinting is used in initial immobilization of, and often is definitive tx for, metacarpal fractures
| | {{Hand and finger fractures DDX}} |
| *Maintenance of MCP joint in flexion is important to avoid immobility contractures of collateral ligaments
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| ==Thumb Fracture== | | ==Clinical Features== |
| ===Classification===
| | *History of trauma |
| * Type I (Bennett's Fx)
| | *Pain over fracture site |
| ** Fx-dislocation of the base of the metacarpal (intraarticular)
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| * Type II (Rolando's Fx) | |
| ** Comminuted version of a Bennett's fracture (intraarticular)
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| * Type III
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| ** Extraarticular (transverse or oblique)
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| * Type IV
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| ** Extraarticular pediatric fx involving the proximal physis
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| ===Diagnosis===
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| *Examination
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| ** Important to distinguish tenderness at base of 1st MC from injury to scaphoid, trapezium, or distal radius
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| ** If pain or ecchymosis occurs more distally at the MCP (particularly on the ulnar side) consider ulnar collateral ligament injury (Game Keeper's Thumb)
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| * Imaging
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| ** AP, lateral, oblique
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| ===Treatment===
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| * Splinting
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| ** Type I, II - Thumb-spica with the IP joint free and wrist in 30 deg of extension
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| ** Type III - Short arm thumb-spica extening to the IP joint and wrist in 30 deg of extension
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| * RICE
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| ** Significant swelling or overly aggressive icing to radial side of thumb may result in temporary palsy to the superficial radial nerve (numbness over the dorsum of the thumb)
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| * Reduction
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| ** Indicated for:
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| *** Angulated extraarticular fx if clinician is comfortable with the procedure
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| ===Disposition===
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| * Refer within 3-5 days:
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| ** All intraarticular fractures warrant referral (most require sx)
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| ** Extraarticular fractures that cannot be adequately reduced
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| ==Non-Thumb Metacarpal Head Fracture== | | ==Differential Diagnosis== |
| *Intra-articular Fx
| | {{Hand and finger injury DDX}} |
| *Examination
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| **Swelling, decreased ROM, and TTP of MCP joint
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| **Assess for rotational alignment (rotational malalignment is not tolerated)
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| **Assess for skin integrity (r/o fight bite)
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| *Imaging
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| **AP, lateral, oblique
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| ***Angulation assessed on lateral view
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| **Consider "Brewerton" view if collateral ligament avulsion fx suspected
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| *Treatment
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| **Ulnar or radial gutter splint
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| ***MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
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| *Dispo
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| **Almost always refer b/c are intraarticular and typically comminuted
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| **Non-displaced fx can be splinted for 2-3 weeks followed by ROM exercises
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| ==Non-Thumb Metacarpal Neck Fracture== | | ==Evaluation== |
| *Examination
| | ===Workup=== |
| **TTP or ecchymosis on the palmar bony surface is highly suggestive of fracture | | *XR hand and/or finger(s) |
| **Loss of the normal knuckle contour
| | *Consider need for more proximal or distal plain films |
| ***Due to dorsal angulation of fracture apex due to pull of the interosseous muscles
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| **Assess angulation
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| ***Head-to-neck angle of the metacarpals is normally 15 degrees
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| ****Fracture angulation = measured angle minus 15 deg
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| ***Angle toleration (below which there is no adverse functional outcome)
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| ****2nd MC < 10 deg | |
| ****3rd MC < 20 deg
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| ****4th MC < 30 deg
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| ****5th MC < 30 deg
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| **Assess rotational alignment
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| **Assess extensor apparatus
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| **Assess skin integrity
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| *Treatment
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| **Gutter splint
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| ***MCP joints in 70-90 deg flexion, wrist in 20-30 deg extension, PIP and DIP joints in 5-10 deg of flexion
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| **Acute reduction indicated:
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| ***Pseudoclawing
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| ***Significantly angulated 4th or 5th MC fx
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| *Dispo
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| **Refer for:
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| ***Comminution
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| ***Rotational malalignment
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| ==Non-Thumb Metacarpal Shaft Fracture== | | ===Diagnosis=== |
| * Examination
| | <gallery mode="packed"> |
| ** TTP along affected metacarpal
| | File:Tufts_fracture.jpg|[[Finger (phalanx) fracture]] |
| ** Flexion at MCP is difficult
| | File:Neck Fracture of the Fourth Metacarpal Bone.png|[[Non-thumb metacarpal fractures]] |
| ** Assess for extensor dysfunction; pt may exhibit "pseudo-clawing" during attempts at finger extension
| | File:Bennetts Fracture.jpg|[[Thumb fracture]] |
| ** Assess angulation
| | </gallery> |
| *** >10 deg in 2nd and 3rd and >20 deg in 4th and 5th metacarpal shaft fractures requires reduction
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| ** Assess rotational alignment
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| * Imaging
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| ** Oblique fx are more prone to shorten and rotate
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| ** Transverse fx generally stable (particularly isolated 3rd or 4th MC shaft fx)
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| * Treatment
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| ** Gutter splint
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| ** Acute reduction indicated if there is pseudo-clawing or significant angulation
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| *** Closed reduction generally corrects angulation but typically does not restore length
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| * Dispo
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| ** Refer:
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| *** Malrotation
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| *** Comminution
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| *** Shortening > 5mm (refer all shortening if not familiar with fx management)
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| *** 2 or more metacarpal fractures
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| *** Unacceptable angulation
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| *** Long oblique fractres
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| ==Non-Thumb Metacarpal Base Fracture== | | ==Management & Disposition== |
| * Examination
| | {{Hand Fracture Management Chart}} |
| ** Movement at the wrist elicits pain
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| ** Assess for ulnar deficits (finger abduction/adduction)
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| ** Assess for rotational alignment
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| * Imaging
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| ** AP, lateral, oblique
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| ** 30 deg obliques pronated and supinated if usual films unable to visualize the MC bases
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| ** Consider CT if index of suspicion high for occult fx despite "negative" plain films
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| * Treatment
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| ** Dorsal and volar splints with the wrist in 30 deg of extension and MCP joints free
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| * Dispo
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| ** Refer for:
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| *** Intraarticular fx
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| *** Extraarticular fx with malrotation
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| *** Dislocation of metacarpal base CMC joint;
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| *** Ulnar nerve injury
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| *** 5th metacarpal base fx (typically require sx)
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| ==See Also== | | ==See Also== |
| *[[Fractures]] | | *[[Fractures (Main)]] |
| | *[[Hand Diagnoses (Main)]] |
| | *[[Splinting]] |
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| | ==External Links== |
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| ==Source== | | ==References== |
| UpToDate
| | <references/> |
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| [[Category:Ortho]] | | [[Category:Orthopedics]] |
