Metacarpal shaft Christian Dumontier, MD,

PhD

fractures
Centre de la main,
Guadeloupe

Presentation is available on www.diuchirurgiemain.org

Clinical case
 Metacarpal fractures

Frequent fractures
18% of hand and forearm
fractures,
30% of hand fractures
Peak incidence: 15-24 years old
Fracture patterns depend of the mechanism of injury

Transverse direct blow

displace in flexion
Spiral twisting injury
rotational deformity
Comminuted and oblique
axial load with torsional or
bending forces shortening
and angular deformity
 X-rays

Same patient

AP and lateral views + oblique

30 pronated for index and
middle
30 supinated for ring and little
 1st take home message: Most metacarpal fractures are non-
displaced and treated conservatively +++

In athletes, 82% of the fractures

were minimally displaced or
nondisplaced,
Average time lost from practice or
competition was 13.7 days

Rettig AC et al: Metacarpal fractures in the athlete, Am J Sports Med 1989;17:567-572.

 Goals of treatment

Allow healing in an anatomical

position
That restores the longitudinal
and transverse concavity of the
hand
 Conservative treatment ?
Avoid reduction and conservative treatment as maintaining the fracture is difficult
Most metacarpal shaft fractures are non or moderately displaced and inherently
stable and can be treated conservatively with acceptable functional outcomes.
Khan and Giddins (in press) have shown that all spiral metacarpal fractures, even
in the presence of mal-rotation, can be treated non-operatively with very good
outcomes and minimal morbidity.
Patients had to make a fist at the first outpatient visit to correct any malrotation
and ensure early mobilization.
Of 30 patients, 25 were reviewed at a minimum follow-up of 6 months.
They had full movement, grip strength of at least 90% of the other hand and
only minimal malrotation in one patient and mild discomfort in another.

Giddins GEB. The non-operative management of hand fractures. J Hand Surg Eur 2015; 40(1):33-41
 Non-operative treatment
Immobilization 3-4 weeks
(radiological healing may
take 6-8 weeks)
Intrinsic position is
recommended in literature
(claw-digger cast)
We recommend protection
shell and buddy taping (as
Tavassoli)
 Conservative treatment

Retrospective study of 263 patients comparing three

casting techniques,
MP joints in flexion or extension or the IP joints free or
immobilized resulted in no difference in motion, grip
strength, or fracture alignment.
They recommended immobilizing the MP joints in
extension and allowing full motion of the IP joints.

Tavassoli J et al: Three cast techniques for the treatment of extra-articular metacarpal fractures: comparison of short-term
outcomes and final fracture alignments, J Bone Joint Surg Am 2005;87:2196-2201
 Surgical indications

Non tolerable displaced fractures

Open fractures
Multiple fractures
 Displaced fractures ?

Rotation deformity induces

finger scissoring and cannot be
tolerated
The more proximal the
fracture, the more the
angulation is amplified distally
(1 of rotation in the
metacarpal, results in 5 in the
fingertip)
 Displaced fractures ?
Shortening is appreciated by
drawing Chmell line on plain X-
rays
 Displaced fractures: shortening
Shortening can be functionally
tolerated but leaves the patient
with the disappearance of
prominence of metacarpal
head
7 of extensor lag for every 2
mm shortening
Some consider a 3 mm
shortening an absolute
indication for surgery. Others
that 5 mm is not significant
Strauch RJ et al. Metacarpal shaft fractures. The effect of shortening on the extensor tendon mechanism. J Hand Surg
1998;23A:519-523.
Wills J et al. The effect of metacarpal shortening on digital flexion force. J Hand Surg Eur. 2013, 38: 66772.
 Displaced fractures : volar angulation ?

Angulation < 10 is accepted

for M2M3 and up to 20 for
M4M5 for shaft fractures (
neck fractures)
Angulation leads to loss of
flexor tendon efficiency
(excursion, load and work
requirements) as well as loss of
strength and range of motion

Birndorf MS et al. Metacarpal fracture angulation decreases flexor mechanical efficiency in human hands. PRS 1997; 99:1079-1085
 Surgical treatment

Per-cutaneous
ORIF
Metacarpals are triangular in transverse section with
a thinner flat dorsal surface and a thicker apex
pointed palmar plates will be placed dorsally

Ex-Fix
 Per-cutaneous fixation
Complication rate 15-20%
Many configurations proposed:
Crossed K-wires are more rigid in transverse fracture
Oblique pin configuration in oblique patterns.
Intra-medullary nailing is also effective
Transverse fixation on the adjacent metacarpal (1 k-wire
proximal, 2 k-Wires distal) is useful for index and little
finger
Stahl S et al. Complications of K-wire fixation of fractures and dislocations in the hand and
wrist. Arch Orthop Trauma Surg. 2001;121:527-530
Case Dr Polveche, Lille
 Open surgical treatment

Interfragmentary screws (at

least 2) for long oblique pattern
(screws 2 mm diameter)
Dorsal plating
To avoid fragmentation, the screw hole should be a minimum of two screw diameters
from the fracture margin.
Shaft fracture of the fifth finger - use of a long plate due to multiple fracture lines
Multiple fractures should be surgically fixed
to allow for immediate mobilisation
Case Dr Polveche, Lille of
multiple fractures treated
with a combination of
techniques
 Functional
outcome case Dr
Polveche
 Outcomes of ORIF
Major complications were encountered in 36% of fractures,
especially with phalangeal and open fractures.
Complications included stiffness, nonunion, plate
prominence, infection, and tendon rupture.
Forty-eight of 63 (76%) metacarpal fractures and 44 of 66
(67%) closed fractures had a final range of motion greater
than 220~240
To date, no series has proven surgery to do better than
conservative treatments
Page SM et al. Complications and range of motion following Plate Fixation of Metacarpal and
Phalangeal Fracture. J Hand Surg 1998;23A:827-832.
 Conclusion

Most fractures are stable or can be stabilized and

conservative treatment is the goal
Multiple fractures should be treated operatively to
allow for immediate mobilisation, in order to limit the
hand swelling which is responsible for finger stiffness