Hold On Tight!
Author: Joel Poliskey, MD
Peer-Reviewer & Final Editor: Alex Tomesch, MD, CAQ-SM
A 34-year-old female presents after a waterslide accident. She was traveling down a water slide with her fourth and fifth digits of her right hand in the handle of the inner tube when the inner tube was ripped out from under her at the bottom of the slide. She instantly noted pain and swelling in the middle of her hand. She complains that she can not make a fist.
Image 1: AP, Oblique, and Lateral view of the patient’s right hand. Author’s own images
What is the diagnosis?
This is a spiral fracture of the 4th metacarpal.
Image 2: AP View of the right hand. The author’s own image with fracture highlighted.
What is the mechanism of injury?
In general, metacarpal fractures typically occur via a direct blow or twisting force. Oblique and spiral fractures are most commonly caused by a twisting force, as experienced by this patient. Comminuted fractures are typically caused by a crush injury or gunshot wound. Transverse fractures are often the result of a direct blow.
What physical exam findings are expected?
Typically, the patient will demonstrate tenderness and swelling to the dorsum of their hand. Range of motion is often decreased, particularly at the MCP joint. Make sure to check a neurovascular exam. A sensory exam is frequently normal, but the fracture may result in neurovascular deficits.
- Pearl:4th and 5th metacarpal fractures may damage the motor branch of the ulnar nerve [1].
Which imaging modalities can be used?
X-ray is the preferred imaging modality. The standard of care is three views of the hand (AP, Lateral, and oblique). Examine the x-rays for shortening, angulation, and comminution.
What is the management in the ED?
In this patient's injury, the ED provider should splint the fracture with an ulnar gutter splint and have the patient follow up with orthopedics on an outpatient basis. If the fracture is angulated the patient may benefit from closed reduction.
- Pearl: If the angulation is >10 degrees in the 2nd or 3rd metacarpal, >20 degrees in the 4th, or >30 degrees in the 5th the patient should undergo closed reduction [2]. A hematoma block or wrist ulnar nerve block may be utilized for reduction.
When do you consult Orthopedics?
Orthopedics should be consulted for any open fractures or neurovascular injuries. Intraarticular, comminuted, displaced, multiple fractures, or fractures demonstrating malrotation, or shortening should be referred to orthopedics within a few days. Surgery may be indicated for long oblique fractures as these may require operative fixation to maintain alignment [3, 4].
References
[1] Miller, T.J., Kamal, R.N., & Fox, P.M. (2022). Nerve injury after distal radius, metacarpal, and finger fractures. In C.J. Dy, D.M. Brogan, & E.R. Wagner (Eds.), Peripheral nerve issues after orthopedic surgery. Springer. https://doi.org/10.1007/978-3-030-84428-8_7
[2] Day, C.S., & Stern, P.J. (2011). Fractures of the metacarpals and phalanges. In S.W. Wolfe, W. Pederson, & S.H. Kozin (Eds.), Green’s operative hand surgery (6th ed., Vol. 1, pp. 245). Elsevier.
[3] Üstün, G.G., Kargalıoğlu, F., Akduman, B., Arslan, R., Kara, M., Gürsoy, K., & Koçer, U. (2022). Analysis of 1430 hand fractures and identifying the ‘Red Flags’ for cases requiring surgery. Journal of Plastic, Reconstructive & Aesthetic Surgery, 75(1), 286–295. https://doi.org/10.1016/j.bjps.2021.06.011
[4] Kozin, S. H. , Thoder, J. J. & Lieberman, G. (2000). Journal of the American Academy of Orthopaedic Surgeons, 8 (2), 111-121.
