|
|
| (26 intermediate revisions by 3 users not shown) |
| Line 1: |
Line 1: |
| ==Background==
| | [[File:Hand bones.svg|thumb|Hand bones]] |
| * Splinting is used in the initial immobilization of, and often is the definitive treatment for, metacarpal fractures
| |
| * Maintenance of the MCP joint in flexion is important to avoid immobility contractures of the collateral ligaments
| |
|
| |
|
| ==Thumb metacarpal Fx== | | ==Types== |
| * Classification
| | {{Hand and finger fractures DDX}} |
| ** Type I (Bennett's Fx)
| |
| *** Fx-dislocation of the base of the metacarpal (intraarticular)
| |
| ** Type II (Rolando's Fx)
| |
| *** Comminuted version of a Bennett's fracture (intraarticular)
| |
| ** Type III
| |
| *** Extraarticular (transverse or oblique)
| |
| ** Type IV
| |
| *** Extraarticular pediatric fx involving the proximal physis
| |
| * Examination
| |
| ** Important to distinguish tenderness at base of 1st MC from injury to scaphoid, trapezium, or distal radius
| |
| ** If pain or ecchymosis occurs more distally at the MCP (particularly on the ulnar side) consider ulnar collateral ligament injury (Game Keeper's Thumb)
| |
| * Imaging
| |
| ** AP, lateral, oblique
| |
| * Treatment
| |
| ** Splinting
| |
| *** Type I, II - Thumb-spica with the IP joint free and wrist in 30 deg of extension
| |
| *** Type III - Short arm thumb-spica extening to the IP joint and wrist in 30 deg of extension
| |
| ** RICE
| |
| *** 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)
| |
| ** Reduction
| |
| *** Indicated for:
| |
| **** Angulated extraarticular fx if clinician is comfortable with the procedure
| |
| * Dispo
| |
| ** Refer within 3-5 days:
| |
| *** All intraarticular fractures warrant referral (most require sx)
| |
| *** Extraarticular fractures that cannot be adequately reduced
| |
|
| |
|
| ==Non-Thumb Metacarpal Head Fx== | | ==Differential Diagnosis== |
| * Intra-articular Fx
| | {{Hand and finger injury DDX}} |
| * 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
| |
|
| |
|
| ===Non-Thumb Metacarpal Neck Fx=== | | ==See Also== |
| * Examination | | *[[Fractures (Main)]] |
| ** TTP or ecchymosis on the palmar bony surface is highly suggestive of fracture
| | *[[Hand Diagnoses (Main)]] |
| ** 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
| |
|
| |
|
| ==Non-Thumb Metacarpal Shaft Fx== | | ==References== |
| * Examination
| | <references/> |
| ** TTP along affected metacarpal
| | [[Category:Orthopedics]] |
| ** 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 fractres
| |
| | |
| ==Non-Thumb Metacarpal Base Fx==
| |
| * 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
| |
| *** Etraarticular fx with malrotation
| |
| *** Dislocation of metacarpal base CMC joint;
| |
| *** Ulnar nerve injury
| |
| *** 5th metacarpal base fx (typically require sx)
| |
| | |
| ==Source==
| |
| UpToDate
| |
| | |
| [[Category:Ortho]] | |
