At the Bedside

  • History
  • Mechanism: punch injury, crush, fall, axial load, twisting.
  • Ask about fight bite/human bite, open wounds, occupation/hand dominance, prior hand injury.
  • Pain location: neck, shaft, base, thumb metacarpal.
  • Exam
  • Inspect for swelling, deformity, skin breaks, fight bite over MCP.
  • Palpate each metacarpal and CMC joint.
  • Assess neurovascular status: cap refill, radial/ulnar pulses, 2-point discrimination if available.
  • Check rotation carefully: have patient flex MCP/PIP/DIP; fingertips should point toward scaphoid tubercle. Any finger overlap/scissoring = unacceptable.
  • Assess extensor lag, tendon function, compartment firmness if crush/high-energy.
  • Imaging
  • Hand XR: PA, lateral, oblique.
  • Dedicated thumb views if 1st metacarpal injury.
  • Consider CT for complex intra-articular base fractures or suspected CMC fracture-dislocation.
  • ED Management
  • Analgesia, ice, elevation.
  • Closed injuries without malrotation and acceptable alignment: immobilize.
  • Splinting
  • 2nd/3rd metacarpal: radial gutter.
  • 4th/5th metacarpal: ulnar gutter.
  • Thumb metacarpal: thumb spica.
  • MCPs flexed ~70–90°, IP joints generally extended unless specific injury dictates otherwise.
  • Reduction
  • Indicated for unacceptable angulation, obvious deformity, or shortening.
  • Use hematoma block, digital block, ulnar/radial nerve block, or procedural sedation.
  • Recheck XR and neurovascular status after reduction/splint.
  • Acceptable angulation, rough ED thresholds
  • Index/middle neck: ~10–20°.
  • Ring neck: ~30°.
  • Small finger neck: ~40–50°, sometimes up to ~70° tolerated if no rotation, but hand follow-up is important.
  • Shaft fractures tolerate less angulation than neck fractures.
  • Any malrotation is not acceptable.
  • Urgent hand/ortho consultation
  • Open fracture or fight bite.
  • Neurovascular compromise.
  • Compartment syndrome concern.
  • Intra-articular fracture with displacement/step-off.
  • CMC fracture-dislocation.
  • Bennett/Rolando thumb base fracture.
  • Multiple metacarpal fractures.
  • Significant shortening, unstable pattern, malrotation.
  • Failed reduction or unacceptable post-reduction alignment.
  • Disposition
  • Stable closed fractures: splint, analgesia, hand follow-up usually within 1 week.
  • Open/contaminated/unstable/neurovascular compromise: ED antibiotics, tetanus, urgent operative evaluation.
A Classic Presentation
A 24-year-old right-handed man presents after punching a wall. He has swelling and tenderness over the 5th metacarpal neck. XR shows a 5th metacarpal neck fracture with 45° volar angulation. No open wound, normal sensation, and no rotational deformity when making a fist. He receives analgesia, closed reduction is attempted, post-reduction XR is acceptable, and he is placed in an ulnar gutter splint with hand follow-up in 1 week.

Study Directive

  • Draw a hand diagram and label splint choice for each metacarpal: radial gutter, ulnar gutter, thumb spica.
  • Memorize acceptable angulation trend: index/middle least, ring intermediate, small finger most.
  • Practice rotational exam on your own hand: flex fingers and identify the normal cascade toward the scaphoid.
  • Review 10 hand XRs: identify neck vs shaft vs base fractures and whether CMC alignment is preserved.
  • Make a one-line consult script: “open/closed, digit, location, angulation, rotation, NV status, reduction attempt, splint.”

Recent Literature