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What is the diagnosis?

Oblique fractures of 2nd and 3rd Metacarpal Shafts extending into the bases 

What is the mechanism of injury?

Commonly, this occurs when the distal portion of the affected metacarpal undergoes a torsional force relative to the base (ie getting one’s hand grabbed and twisted or getting it stuck in other’s equipment). This can also occur from direct trauma to the area, as the metacarpal bones are superficial, or from a significant axial load (punch).

What physical exam findings are expected?

Most commonly, swelling and tenderness of the dorsum of the hand. You may also see irregularities when trying to align the fingers [1, 2, 4].

• Pearl: The 3 major components to assess during evaluation are shortening, angulation, and rotation, with rotation being the most important. This can be assessed by:  Position the MCP and PIP joints at 90 degrees. The fingers should converge/point to tuberosity of scaphoid. Also with the MCP at 90° flexion and PIP, DIP fully extended, the fingernails should be in the same plane [1].

Image 2. Case courtesy of Pir Abdul Ahad Aziz Qureshi, Radiopaedia.org, rID: 47786

Which imaging modalities can be used?

Plain radiographs of the hand in AP, lateral, and oblique views. Additional oblique plain radiographs with the hand internally rotated (2nd and 3rd MC) and externally rotated (3rd and 4th MC) can be obtained to better assess fractures and CMC dislocations.

CT can be useful to better evaluate for base fractures to check for intra-articular displacement to determine if surgery is indicated [1,2].

Image 3. Comminuted intra-articular fracture of the right 2nd metacarpal base. Case courtesy of Naqibullah Foladi, Radiopaedia.org, rID: 73741

What is the management in the ED?

Stable single metacarpal fractures with no rotation and limited angulation and shortening can  be splinted [1,2,3]. All others require consultation for evaluation for surgery (see below)

When do you consult Orthopedics?

Immediate orthopedic consultation must happen for all open fractures and any with nerve injury or vascular compromise [1,2,4]. Orthopedic consultation should happen within 3-5 days for fractures with intra-articular components, rotational malalignment, significant displacement/angulation, multiple metacarpal shaft fractures, loss of inherent alignment from border digit during healing [2].

• Pearl: Any degree of rotational deformity is an absolute indication for surgical management [4].