MOC-CME

Evidence-Based Medicine: Management of

Metacarpal Fractures
Victor W. Wong, M.D.
Learning Objectives: After reading this article, the participant should be able to: 1.
James P. Higgins, M.D. Understand metacarpal anatomy and its role in fracture pathology. 2. Determine
Baltimore, Md. when surgical intervention is needed for metacarpal fractures. 3. Understand the
various treatment options for surgical fixation of metacarpal fractures. 4. Describe
the role for external fixation in managing difficult metacarpal fractures.
Background: Metacarpal fractures are common injuries that plastic surgeons
should be able to evaluate and treat. The goal of this review is to highlight
current evidence for managing metacarpal fractures. This Continuing Medical
Education article consists of a literature review, illustrations, videos, and an
online Continuing Medical Education examination.
Methods: The authors reviewed the scientific literature from 2000 to 2015
regarding treatment of metacarpal fractures. Cadaver models were used for
instructional videography demonstrating common surgical techniques. Multi-
ple-choice questions were created to review pertinent topics. A discussion and
references are provided.
Results: Numerous treatment options have been described for metacarpal frac-
tures, including splinting, percutaneous fixation, open reduction with internal
fixation, and external fixation. All modalities are acceptable strategies for treat-
ing metacarpal fractures. The ultimate goal is to maximize hand function with
minimal morbidity.
Conclusions: A thorough understanding of treatment modalities is helpful in
evaluating and managing metacarpal fractures. Although the current litera-
ture supports a wide array of treatment strategies, high-level evidence to guide
­fracture management remains lacking.  (Plast. Reconstr. Surg. 140: 140e, 2017.)

T
his purpose of this article is to review the and/or “therapy.” Relevant articles were assigned
current evidence for treating metacarpal a level of evidence according to the American
fracture and build on prior Maintenance of Society of Plastic Surgeons Evidence Rating Scale
Certification articles on metacarpal fractures.1–3 for Therapy.

PATIENTS AND METHODS Anatomy

A literature search was performed using The word “metacarpal” is derived from the
PubMed, Embase, and Cochrane databases from Greek meta meaning “beyond”, and carpus mean-
2000 to 2015. Articles were limited to human sub- ing “wrist.” Accordingly, the metacarpals are five
jects, English-language journals, and clinical stud-
ies. Search terms included the following: “bone,”
“fracture,” “hand,” “metacarpal,” “thumb,” Disclosure: The authors have no financial interest
“Rolando,” “Bennett,” “boxer’s,” “intraarticu- to declare in relation to the content of this article.
lar,” “extraarticular,” “surgery,” “splint,” “cast,”
“Kirschner wire,” “lag screw,” “plate fixation,”
“percutaneous,” “closed reduction,” “anesthe- Supplemental digital content is available for
sia,” “radiograph,” “complications,” “outcome,” this article. Direct URL citations appear in the
text; simply type the URL address into any Web
From The Curtis National Hand Center. browser to access this content. Clickable links
Received for publication December 30, 2015; accepted June to the material are provided in the HTML text
1, 2016. of this article on the Journal’s website (www.
Copyright © 2017 by the American Society of Plastic Surgeons PRSJournal.com).
DOI: 10.1097/PRS.0000000000003470

140e www.PRSJournal.com
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 140, Number 1 • Management of Metacarpal Fractures

tubular bones connecting the carpus to the pha- and are interconnected by deep transverse meta-
langes and form the volar concavity of the palm carpal ligaments that prevent metacarpal fracture
(Fig. 1). The cuboidal base of nonthumb metacar- shortening.4,5 Lumbricals and interossei cross
pals articulates with the distal carpal row (as con- these metacarpal ligaments in the volar and dor-
dyloid joints) with minimal motion at the second sal positions, respectively, en route to the proxi-
and third carpometacarpal joints and increasing mal phalanx and extensor expansion. Because the
mobility from the fourth to the fifth carpometa- aggregate vector of these muscles crosses volar to
carpal joints. The nonthumb metacarpal bases the metacarpophalangeal joint, metacarpal shaft
articulate with each other and are supported by fractures tend to displace in an apex dorsal posi-
strong transverse ligaments and weaker volar and tion. Extending around the metacarpophalangeal
dorsal longitudinal ligaments. The metacarpal joint from the volar plate are radial- and ulnar-side
narrows distally as a shaft with three longitudinal sagittal bands that connect to the dorsal extensor
surfaces: volar-radial and volar-ulnar surfaces (for mechanism. Each metacarpophalangeal joint is
attachment of interossei muscles) and a flat dorsal also reinforced directly by the laterally positioned
surface (to accommodate extensor tendons). proper and accessory collateral ligaments, which
The metacarpal shaft widens into the neck and are taut at 30 and 0 degrees of flexion, respectively.
cam-shaped head that articulates with the proxi- The thumb metacarpal is shorter and stouter
mal phalanx (forming a condyloid joint). The than the other metacarpals and articulates exclu-
metacarpophalangeal joints are stabilized by stout sively with the trapezium as a highly mobile saddle
volar plate ligaments that prevent hyperextension joint, permitting motion in the flexion/extension,

Fig. 1. (Above, left) Schematic of bony structure of the hand with close-up of the metacarpal. (Above, right) The deep transverse
metacarpal ligaments connect the volar plates of the metacarpophalangeal joints, forming a thick fibrous transverse arch linking
the metacarpal heads. (Below, left) Oblique view of the ligaments stabilizing the metacarpophalangeal joint. The extensor hood/
sagittal band has been reflected to reveal the underlying collateral ligaments. (Below, right) Axial cross-section at the level of the
metacarpal head showing the relationship between the soft tissue structures that influence metacarpal fracture displacement and
stability. P1, proximal phalanx.

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 Plastic and Reconstructive Surgery • July 2017

palmar abduction/adduction, and opposition metacarpals, respectively. The extensor carpi

planes. Also known as the first carpometacarpal or ulnaris inserts onto the dorsoulnar base of the
trapeziometacarpal joint, this complex joint has fifth metacarpal, creating the classic deformity in
little intrinsic articular stability and is stabilized fifth metacarpal base (reverse Bennett) fractures.
by numerous ligaments, including the deep volar Volarly, the flexor carpi radialis and flexor carpi
anterior oblique “beak” ligament and increasingly ulnaris insert onto the base of the second and fifth
recognized dorsal ligaments.6,7 metacarpals, respectively.
In addition to ligamentous attachments, In the thumb, the abductor pollicis longus
several tendinous insertions terminate on the inserts onto the dorsoradial base of the first meta-
metacarpals (Fig.  2). The extensor carpi radialis carpal, contributing to the classic deformity in first
longus and extensor carpi radialis brevis insert metacarpal base (Bennett) fractures. The adductor
onto the dorsoradial base of the second and third pollicis, consisting of transverse (originating from

Fig. 2. (Above) Schematic depiction of muscle insertions onto the metacarpal bases. Note the inser-
tion of the abductor pollicis longus (APL) onto the dorsoradial aspect of the thumb metacarpal base.
In Bennett fractures, this deforming force will pull the distal fragment proximally. (Below) The palmar
and dorsal interossei are positioned between adjacent metacarpals and are reflected to expose the
metacarpal shaft for plate or lag screw fixation. ECRL, extensor carpi radialis longus; ECRB, extensor
carpi radialis brevis; ECU, extensor carpi ulnaris; FCU, flexor carpi ulnaris; FCR, flexor carpi radialis.

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 Volume 140, Number 1 • Management of Metacarpal Fractures

the third metacarpal shaft) and oblique (originat- an indication for operative treatment. Additional
ing from the second and third metacarpal bases and indications include degree of metacarpal shorten-
volar wrist) heads, inserts onto the ulnar aspect of ing (>5  mm), extent of articular surface stepoff
the thumb carpometacarpal joint and thumb prox- (>1  mm), or greater than 25 percent articular
imal phalanx. In Bennett fractures, the adductor surface involvement.5,10 The presence of multiple
pollicis pulls the distal fragment into an adducted metacarpal fractures may also be an indication for
and supinated position. On the volar surface, the surgery because the stabilizing effect of adjacent
opponens pollicis originates from the trapezium metacarpals is disrupted.11
and transverse carpal ligament and inserts onto the Jahss described the classic maneuver to perform
voloradial aspect of the thumb metacarpal. closed reduction of metacarpal fractures in 1938.12
(See Video, Supplemental Digital ­Content 1, which
Radiographic Evaluation shows closed reduction and percutaneous pinning
of fourth and fifth metacarpal neck fractures. This
No clinical studies comparing radiographic
video is available in the “Related Videos” section of
modalities were identified. In general, three-
the full-text article on PRSJournal.com or at http://
view (i.e., anteroposterior, oblique, and lateral)
links.lww.com/PRS/C217.) With the metacarpopha-
radiographs should be obtained for all suspected
langeal and proximal interphalangeal joints of the
hand/digit injuries. Special metacarpal views
affected ray held in 90 degrees of flexion, dorsally
include the Brewerton, Roberts, and Betts views,
directed pressure on the distal fragment will help
which have been recently reviewed.1
to reduce the fracture. A modified Jahss maneu-
ver has also been described whereby the proximal
Nonoperative Treatment interphalangeal joint is held in extension while
Although high-level evidence is lacking, gen- the metacarpophalangeal is flexed to reduce ten-
eral guidelines state that metacarpal fractures sion on the intrinsic and facilitate reduction.
that are more distal and/or more ulnar are bet- The majority of studies on nonoperative ther-
ter tolerated and may not need surgical fixation. apy examined fifth metacarpal neck (boxer’s)
Metacarpal shaft fractures of the index and long fractures. Statius Muller et al. performed a pro-
fingers can tolerate up to 20  degrees of angula- spective randomized study of 35 patients with
tion, whereas the ring and small fingers can tol- fifth metacarpal neck fractures (15 to 70 degrees
erate up to 30 and 40  degrees of angulation, of angulation), comparing immobilization for 3
respectively. Neck fractures of the ring and small weeks versus 1 week of pressure dressing followed
fingers can tolerate up to 40 and 70  degrees of by immediate mobilization.13 At 3 months, there
angulation, respectively.8 For thumb metacarpal was no difference in range of motion, pain, or
fractures, up to 30 degrees of angulation is accept- patient satisfaction. Hofmeister et al. prospectively
able because of the mobility of the trapeziometa- compared closed reduction and short arm cast-
carpal joint.9 Any degree of rotational deformity is ing for 1 month with metacarpophalangeal joint

Video 1. Supplemental Digital Content 1, which shows closed reduc-

tion and percutaneous pinning of fourth and fifth metacarpal neck
fractures, is available in the “Related Videos” section of the full-text
article on PRSJournal.com or at http://links.lww.com/PRS/C217.

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 Plastic and Reconstructive Surgery • July 2017

in flexion or cast extended to the proximal inter- the metacarpophalangeal joint in flexion. How-
phalangeal joint (metacarpophalangeal joint in ever, Tavassoli et al. retrospectively examined 263
extension) in 81 patients.14 At 3 months, there was patients with extraarticular metacarpal fractures
no difference in range of motion, grip strength, immobilized for 5 weeks with either metacarpo-
or fracture angulation on radiography. In a ret- phalangeal joint in flexion and full interphalan-
rospective study, Harris et al. describe a method geal joint motion, metacarpophalangeal joint in
of traction and three-point immobilization in extension with interphalangeal joint motion, or
59 patients with fifth metacarpal neck fractures, metacarpophalangeal joint in flexion with inter-
demonstrating good radiographic alignment and phalangeal joints in extension.20 On cast removal,
range of motion at over 3 months’ follow-up.15 fracture alignment was acceptable in all patients.
In a 2005 Cochrane review, Poolman et al. exam- At 9 weeks, there was no difference in range of
ined five studies on nonoperative management of motion or grip strength between groups.
closed fifth metacarpal neck fractures and con-
cluded that no single method of immobilization Authors’ Commentary
(i.e., plaster, taping, or bracing) was superior.16 These studies suggest that nonoperative man-
For shaft fractures of the fifth metacarpal, agement with early mobility is reasonable for most
Debnath et al. prospectively evaluated 17 patients fifth metacarpal neck and minimally displaced
treated with closed reduction and hand-based cast- shaft fractures. The method of immobilization
ing (wrist and metacarpophalangeal joints free) for does not appear to considerably influence long-
1 month. Although three patients lost their reduc- term outcomes. In our practice, we do not attempt
tion (residual angulation of 15 to 20  degrees), reduction in the majority of metacarpal neck and
all fractures healed and there were no functional minimally displaced shaft fractures because of the
restrictions at greater than 6-month follow-up.17 Al- difficulty in maintaining closed reduction and
Qattan reported his experience treating 42 patients the nearly universally good functional outcomes
with minimally displaced spiral shaft fractures without reduction. Patients are permitted to pur-
using a volar wrist splint (wrist in 20 to 30 degrees sue immediate range of motion as tolerated, with
of extension) for 2 weeks and immediate finger a removable wrist splint for comfort only. Patients
mobilization.18 At 6 weeks, all fractures healed, but are reevaluated at 6 to 8 weeks after fracture to
extensor lag was observed in all fractured fingers; ensure that fracture tenderness is resolved and
however, full extension was achieved at greater than that digital range of motion is recovered.
6 months in all patients. Similarly, Khan and Gid-
dins treated 25 spiral metacarpal fractures nonop- Surgical Treatment
eratively with early mobilization, all of which healed
and resulted in good to excellent range of motion Nonthumb Metacarpals
and grip strength at greater than 6 months.19 Multiple options exist for operative fixation
For nonoperative management of metacar- of metacarpal fractures (Table  1). Percutaneous
pal fractures, the classic teaching is to immobilize Kirschner wires remain an important technique

Table 1.  Comparison of Common Operative Fixation Techniques

Technique Advantages Disadvantages
Percutaneous pinning Flexibility in technique and stabilization Inherently less stable than rigid fixation;
­patterns; minimizes soft-tissue trauma; less ­achieving reduction can be more challenging
expensive materials than open ­treatment; pin-site care needed if
not buried; ­infection/pin migration risk
Plate fixation More rigid and stable construct; open approach Soft-tissue stripping/dissection necessary; more
may allow better anatomical reduction ­expensive than Kirschner wires; extensor
tendon adhesions/attrition; requires adequate
soft-tissue envelope
Lag or interfragmentary Rigid fixation with less soft-tissue stripping than Requires soft-tissue dissection; only ideal for
screws plate fixation; less prominent and irritating to ­specific fracture patterns (long oblique
extensor tendons ­orientation); not as rigid as plate fixation
Intramedullary fixation More rigid fixation with minimal soft- Rotational control may be difficult; hardware
tissue dissection; anterograde or r­ etrograde removal may be difficult in the setting of
approaches feasible ­infection or ­refracture
External fixation Allows soft-tissue injuries to heal while ­stabilizing Commercial devices expensive; risk of pin-site
fracture; can span segments of bone loss; ­infections; pin sites may impede tendon
­provides distraction of joint if needed for reduc- ­gliding and cause adhesions; prominence of
tion (e.g., thumb metacarpal base fractures) hardware is difficult for activities of daily living

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 Volume 140, Number 1 • Management of Metacarpal Fractures

to control and stabilize fracture fragments (see Mumtaz et al. treated 42 metacarpal and pha-
Video, Supplemental Digital Content 1, http:// langeal fractures with either miniplates or lag
links.lww.com/PRS/C217). screws. At 1 year, all fractures healed, and poor
Potenza et al. used percutaneous transverse range of motion was observed in one patient.26
pinning in 28 fifth metacarpal neck fractures Tan et al. reported good range of motion
(>30-degree angulation), demonstrating excel- and 100 percent bony union in 10 patients at 16
lent range of motion; Disabilities of the Arm, months using interfragmentary screws to treat dif-
Shoulder, and Hand scores; and radiographic out- ficult intraarticular metacarpal and phalangeal
comes at 25 months.21 fractures.27 Soni et al. treated 21 patients (55 meta-
Plate fixation provides more rigid support, carpal fractures) using miniplates and obtained
and newer low-profile plates have been designed good to excellent function in 20 patients at 1
to minimize complications. (See Video, Supple- year.28 Another option for metacarpal fractures is
mental Digital Content 2, which displays the open intramedullary fixation. (See Video, Supplemen-
dorsal approach and compression plate fixation tal Digital Content 3, which displays intramedul-
of fourth metacarpal shaft fracture. This video is lary pinning of a fifth metacarpal neck fracture.
available in the “Related Videos” section of the This video is available in the “Related Videos” sec-
full-text article on PRSJournal.com or at http:// tion of the full-text article on PRSJournal.com or
links.lww.com/PRS/C218.) at http://links.lww.com/PRS/C219.)
Agarwal and Pickford compared their outcomes Bach et al. treated 10 comminuted metacarpal
treating 11 metacarpal fractures with low-profile shaft fractures from gunshot wounds using locked
(0.6 mm) plates versus a matched group with 1.3- intramedullary nails (with iliac crest bone graft-
mm plates and found no difference in range of ing in nine cases).29 There were no infections;
motion.22 Souer and Mudgal plated 43 metacarpal metacarpophalangeal joint range of motion and
fractures (19 patients) using 2-mm plates and dem- radiographic outcomes were good at 26 months.
onstrated excellent range of motion and recovery Balfour showed that anterograde intramedullary
at over 2 months.23 Omokawa et al. used low-profile techniques are useful for multiple metacarpal
titanium plates to treat periarticular comminuted shaft fractures.30 Itadera et al. also successfully
fractures of the metacarpals and phalanges, demon- used an anterograde intramedullary technique
strating maintained reduction and reasonably low for 19 metacarpal shaft or neck fractures.31 Bous-
complication rates at 1 year.24 Dumont et al. treated sakri et al. treated 28 fifth metacarpal neck frac-
14 metacarpal fractures with absorbable plates, tures with a single anterograde intramedullary
demonstrating union and acceptable functional Kirschner wire (1.6 or 2.0 mm).32 At 21 months,
scores and range of motion at 26 weeks.25 However, all fractures healed with good radiographic and
the authors recommended additional support with functional outcomes.
an orthotic for 3 weeks total and noted that metal Lee et al. described a retrograde intramedul-
plates remain the gold standard. lary technique for 65 consecutive metacarpal shaft

Video 2. Supplemental Digital Content 2, which displays the open

dorsal approach and compression plate fixation of fourth metacarpal
shaft fracture, is available in the “Related Videos” section of the full-
text article on PRSJournal.com or at http://links.lww.com/PRS/C218.

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 Plastic and Reconstructive Surgery • July 2017

Video 3. Supplemental Digital Content 3, which displays intramed-

ullary pinning of a fifth metacarpal neck fracture, is available in the
“Related Videos” section of the full-text article on PRSJournal.com or
at http://links.lww.com/PRS/C219.

or neck fractures, resulting in good Disabilities interosseous wires, demonstrating full range
of the Arm, Shoulder, and Hand scores; range of of motion in 23 of 24 patients, with minimal
motion; and radiographic union and alignment at complications.41
13 months.33 Rhee et al. also used retrograde intra- External devices have also been successfully
medullary Kirschner wires to treat 121 displaced used to treat metacarpal fractures. Dailiana
neck and shaft fractures and reported good func- et al. used a mini-external fixator to treat 37
tional and radiographic results at 10 months.34 metacarpal fractures and reported satisfactory
Kim and Kim randomly treated 46 patients with Disabilities of the Arm, Shoulder, and Hand
fifth metacarpal neck fractures (>30  degrees scores; range of motion; and grip strength at
angulation) with either anterograde or retro- 29 months.42 Kömürcü et al. reviewed 51 meta-
grade intramedullary Kirschner wires.35 Although carpal fractures from handgun injuries that
patients treated with anterograde intramedullary were fixated (i.e., plate, plate with bone graft,
pinning showed improved function at 3 months, external fixation, and Kirschner wire) within 24
there were no differences in functional or radio- hours.43 Plate fixation was associated with bet-
graphic parameters at 6 months. ter range of motion and fewer complications
Both Doarn et al. and Ruchelsman et al. compared with Kirschner wire or external fixa-
reported excellent functional results and healing tion; however, treatment was not randomized.
using retrograde intramedullary headless screws Similarly, Margić used an external fixator to
to treat metacarpal neck and shaft fractures.36,37 treat 100 consecutive metacarpal and/or pha-
Similarly, del Piñal et al. used intramedullary can- langeal fractures and reported good to excellent
nulated headless compression screws to treat 48 range of motion in all metacarpal fractures at
transverse metacarpal fractures.38 At 19 months, 19 months.44 Langford et al. treated 10 patients
range of motion was good and all fractures healed with comminuted pilon-type metacarpophalan-
with acceptable radiographic outcomes. A system- geal joint fractures using a distraction pinning
atic review of eight studies concluded that intra- technique and reported good Disabilities of the
medullary fixation may have a role in treating Arm, Shoulder, and Hand scores and range of
certain metacarpal fractures but that more studies motion at greater than 6 months.45
are needed.39 As demonstrated above, a myriad of low-level
Al-Qattan published his experience using studies support various operative techniques.
interosseous wiring to treat 36 metacarpal shaft Guidance in selecting between these techniques
fractures.40 Finger mobilization was started is better provided by the available studies directly
immediately and the wrist was immobilized for comparing techniques.
3 weeks. At 8 weeks, almost all patients had full
range of motion and all fractures healed. Al-Qat- Comparative Studies
tan also reported treating 24 patients with spi- Several groups have attempted to compare
ral metacarpal shaft fractures with cerclage and treatment options for metacarpal fractures.

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 Volume 140, Number 1 • Management of Metacarpal Fractures

Westbrook et al. retrospectively evaluated 218 non- neck or shaft fractures treated with either trans-
reduced, nonoperative fifth metacarpal shaft and verse or antegrade intramedullary Kirschner wire
neck fractures with 44 operatively treated (plates or pinning wires.52 At 28 months, there was no dif-
Kirschner wires).46 Patients with significant soft-tis- ference in range of motion or grip strength, but
sue injury, additional fractures, or complete stepoffs eight of 45 patients in the transverse Kirschner
were excluded from this study. The nonoperative wire group developed a superficial infection at
group of metacarpal shaft fractures presented with the exposed wire sites. Moon et al. retrospectively
less volar angulation and at 4-year follow-up dem- reviewed 41 metacarpal neck fractures treated
onstrated better Disabilities of the Arm, Shoulder, with anterograde intramedullary or percutane-
and Hand and aesthetic scores compared with the ous Kirschner wire pinning.53 The percutaneous
operative group. In contrast, there were no func- pinning group had three cases (of 22) of superfi-
tional or cosmetic differences between treatment cial infection and greater pain and discomfort at
groups with metacarpal neck fractures. 2 weeks. At 10 weeks, there were no differences
Strub et al. prospectively randomized 40 in range of motion or radiographic parameters
patients with fifth metacarpal neck fractures between treatment groups.
(angulated 30 to 70  degrees) to either closed Ozer et al. retrospectively compared 52
reduction/intramedullary Kirschner wires or extraarticular metacarpal fractures treated with
splinting without reduction.47 Patients with rota- either 1.6-mm intramedullary nailing or plate/
tional deformities (>10  degrees), concomitant screw fixation.54 There were no differences
injuries, open fractures, or intraarticular involve- in angulation; radiographic healing; range of
ment were excluded. At 12 months, there were no motion; or Disabilities of the Arm, Shoulder, and
differences in range of motion or grip strength; Hand scores at greater than 4 months. Facca et
however, reduction/intramedullary stabilization al. prospectively compared locking plates and
provided improved appearance. Similarly, Sletten anterograde intramedullary fixation in 38 patients
et al. performed a randomized, controlled trial with fifth metacarpal neck fractures.55 Despite
treating 85 patients with fifth metacarpal neck immediate mobilization in the plate group (ver-
fractures (>30-degree volar angulation) with sus 6 weeks’ immobilization with intramedullary
closed reduction/antegrade intramedullary pin- Kirschner wires), range of motion was significantly
ning versus splinting with no reduction. At 1 year, decreased at 3 months with plate fixation. Disabil-
there was no difference in functional outcome, ities of the Arm, Shoulder, and Hand scores and
satisfaction, or quality of life.48 There were signifi- radiographic outcomes were similar.
cantly more complications and time off work in Wong et al. retrospectively examined 84
the operative group. patients with fifth metacarpal neck fractures and
Wong et al. performed a prospective non- found that dorsal plating produced better radio-
randomized study examining 59 patients with graphic alignment and range of motion com-
fifth metacarpal neck fractures treated with pared with tension-band wiring.56
either transverse or anterograde intramedullary Bannasch et al. reviewed their 10-year expe-
Kirschner wires.49 At 24 months, there were no rience treating 365 patients with metacarpal or
differences in functional outcome or compli- phalangeal fractures and reported no difference
cations. Winter et al. conducted a prospective in infection or nonunion when comparing open
randomized study treating 36 patients with fifth or closed fractures treated with internal plate or
metacarpal neck fractures with either transverse screw fixation.57 (See Video, Supplemental Digi-
or intramedullary Kirschner wire pinning and tal Content 4, which displays lag screw fixation of
found that the latter provided better functional the fifth metacarpal spiral shaft fracture and dor-
outcomes at 3 months.50 Schädel-Höpfner et al. sal plating of short oblique fracture of the fourth
retrospectively reviewed 30 fifth metacarpal neck metacarpal shaft. This video is available in the
fractures treated with a single antegrade intra- “Related Videos” section of the full-text article on
medullary pin (1.6-mm Kirschner wire) versus PRSJournal.com or at http://links.lww.com/PRS/
retrograde percutaneous pinning wires.51 At 18 C220.) Başar et al. treated 24 spiral or oblique
months, metacarpophalangeal joint motion was metacarpal fractures with either miniplate and
better and pain was lower in the intramedul- screws or screws alone.58 Time to return-to-work
lary pin group, although Disabilities of the Arm, was significantly shorter (30 versus 40 days) and
Shoulder, and Hand scores were not significantly early grip strength at 1 month was significantly bet-
different. Sletten et al. retrospectively compared ter (9 percent versus 23 percent loss) for the mini-
67 patients with small or ring finger metacarpal plate/screw versus screw group. No difference in

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 Plastic and Reconstructive Surgery • July 2017

Video 4. Supplemental Digital Content 4, which displays lag screw

fixation of the fifth metacarpal spiral shaft fracture and dorsal plating
of short oblique fracture of the fourth metacarpal shaft, is available
in the “Related Videos” section of the full-text article on PRSJournal.
com or at http://links.lww.com/PRS/C220.

range of motion, long-term grip strength, or func- metacarpal base fractures using locking mini-
tional score was detected at 21 months. plates.59 At 10 months’ follow-up, functional
and strength scores were good and all fractures
Authors’ Commentary
healed. However, three of five patients treated
In aggregate, these comparative studies sug-
with T-shaped plates had secondary displacement,
gest that intramedullary pinning for fifth meta- whereas none of the double-row locking plates
carpal neck fractures may produce better results displaced. Greeven et al. used intermetacarpal
versus other modalities, with variable improve- Kirschner wires to treat 25 thumb metacarpal frac-
ments in range of motion, complication rates, or tures (15 extraarticular and 10 intraarticular).60 At
function. Outcomes following plate versus screw 24 months, three patients had greater than 20 per-
fixation do not appear to be significantly different. cent loss of strength compared with the contralat-
In our practice, the majority of metacarpal eral side, but none had functional limitations and
neck fractures are treated nonoperatively. For all fractures united.
those with excessive displacement, we favor inter- Bennett fractures have also been treated
metacarpal pinning and intramedullary nailing to using different techniques. Lutz et al. compared
provide fracture stability without disturbing the transarticular Kirschner wire versus lag screw
extensor tendons. We favor intramedullary fixa- fixation in 32 patients. At 7 years, there was no
tion for significantly angulated metacarpal neck difference in pain, range of motion, or strength.61
fractures without rotational deformity. In cases of Sawaizumi et al. used percutaneous “leverage”
excessively angulated metacarpal shaft fractures, pinning to treat 12 patients with Bennett fracture
we prefer plate fixation or interfragmentary screw (>2-mm displacement).62 In this technique, the
fixation if the soft-tissue envelope is adequate. In first Kirschner wire is inserted parallel to the tra-
open fractures with concern for soft-tissue heal- peziometacarpal joint space and used to reduce
ing, Kirschner wire fixation is preferred. In open the metacarpal against the base fragment before
fractures with bone loss, we prefer locking plate being drilled into the trapezium. At 51-month
fixation to preserve length and alignment if the follow-up, good to excellent radiographic and
soft-tissue envelope will permit. If bone loss and/ functional results were obtained in the majority
or soft-tissue compromise is present, we use exter- of patients. Leclère et al. treated 24 patients with
nal fixation techniques. Bennett fractures using lag-screw fixation.63 At 4
months, excellent strength was regained, but at
Thumb Metacarpals up to 7 years, seven patients developed arthritis
Most authors favor surgery for thumb base after surgery, an outcome that did not correlate
fractures because of their inherent instability with anatomical reduction. Zemirline et al. used
and risk of first-webspace narrowing.9 Diaconu et arthroscopic reduction and percutaneous screw
al. treated 15 patients with extraarticular thumb fixation for seven Bennett fractures.64 At 4.5

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 Volume 140, Number 1 • Management of Metacarpal Fractures

months, pain and outcomes scores were accept- For comminuted thumb metacarpal base frac-
able, but four secondary displacements occurred. tures, we prefer to treat with locking miniplate
Uludag et al. treated nine Bennett fractures with fixation if the fragments are large enough. If the
screw or locking-plate fixation and early range fragments are too small to allow screw purchase,
of motion at postoperative day 10.65 At 15-month external fixation is performed between the trape-
follow-up, all fractures healed (with excellent ana- zium and distal metacarpal with at least two points
tomical alignment and no signs of arthritis) and of fixation in each.
pain and range-of-motion scores were acceptable.
Rolando fractures (intraarticular comminuted
Conclusions
thumb metacarpal base fractures classically with
T- or Y-shaped pattern) are difficult to treat and Review of the current literature suggests that
prone to develop late arthritis and poor functional most extraarticular nonthumb metacarpal frac-
outcomes.66 Prognosis should be guarded in the tures can be treated with splint alone or closed
setting of significant impaction and/or comminu- reduction and splinting. Comparative studies
tion because it is often challenging to reduce and demonstrate support for minimally invasive tech-
stabilize these bony fragments. However, if the frag- niques, particularly intramedullary fixation and
ments appear amenable to fixation, several authors intermetacarpal pinning. Thumb base fractures
have reported promising outcomes. Uludag et al. are commonly treated with operative interven-
used locking plates to fix seven Rolando fractures tion because of their instability and displacement
and reported excellent functional and radio- of the trapeziometacarpal joint. A single superior
graphic results at 15 months.65 Although Kirschner method of operative treatment of metacarpal frac-
wires and lag screws may also be used if fragment tures has not been established. Many studies are
sizes permit, recent groups have reported positive available to support various methods and demon-
outcomes using external fixation. Niempoog and strate satisfactory long-term results. Early active
Waitayawinyu reported satisfactory results treating range of motion after operative fixation is recom-
six patients with Rolando fractures using external mended by most authors.1–3,8,65 Because high-level
fixation and an intermetacarpal Kirschner wire.67 comparative studies are lacking, most fracture
At 4 months, all patients healed, maintained their management remains guided by surgeon training
reduction, and had excellent range of motion. El- and experience.
Sharkawy et al. used a dynamic external fixation James P. Higgins, M.D.
for seven Rolando fractures and reported excellent c/o Anne Mattson
range-of-motion, strength, and radiographic out- The Curtis National Hand Center
comes at 3 months.68 Similarly, Houshian and Jing MedStar Union Memorial Hospital
3333 North Calvert Street, Suite 200 JPB
used external fixation and Kirschner wires to treat Baltimore, Md. 21218
16 comminuted Rolando-type fractures and noted anne.mattson@medstar.net
excellent functional outcomes at 20 months.69
Authors’ Commentary ACKNOWLEDGMENTS
Consensus seems to exist that these frac-
The authors thank Adrian Paez, Brent Parks, and
tures should be treated operatively to avoid tra-
Sione Fanua for providing material support for the
peziometacarpal joint displacement and prevent
cadaver dissection and Michael Rodman for video film-
adduction contractures. The main goal of sur-
ing and editing. Hardware for fracture fixation was pro-
gery should be to obtain joint reduction. In our
vided by Medartis, Inc. (APTUS Hand fixation system),
practice, Bennett fractures with a large fracture
Basel, Switzerland.
fragment are treated with interfragmentary screw
fixation, performed with direct visualization of
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