|
|
| Line 1: |
Line 1: |
| ==Background==
| |
| *Splinting is used in initial immobilization of, and often is definitive tx for, metacarpal fractures
| |
| *Maintenance of MCP joint in flexion is important to avoid immobility contractures of collateral ligaments
| |
|
| |
| ==DDX== | | ==DDX== |
| *[[Thumb Fracture]] | | *[[Thumb Fracture]] |
| *[[Non-Thumb Metacarpal Fracture]] | | *[[Non-Thumb Metacarpal Fracture]] |
|
| |
|
| ==Non-Thumb Metacarpal Head Fracture==
| |
| *Intra-articular Fx
| |
| *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 Fracture==
| |
| *Examination
| |
| **TTP or ecchymosis on the palmar bony surface is highly suggestive of fracture
| |
| **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 Fracture==
| |
| * Examination
| |
| ** TTP along affected metacarpal
| |
| ** 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 Fracture==
| |
| * 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
| |
| *** Extraarticular fx with malrotation
| |
| *** Dislocation of metacarpal base CMC joint;
| |
| *** Ulnar nerve injury
| |
| *** 5th metacarpal base fx (typically require sx)
| |
|
| |
|
| ==See Also== | | ==See Also== |
