Metacarpal fractureMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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536 items

☷ Legend

01Approach to the Critical Patient/attcp56

Triage priorities

›Immediate threats

›Open fracture

›Gross contamination

›Bone or tendon exposure

›Neurovascular compromise

›Absent capillary refill

›Pulseless digit

›Progressive sensory loss

›Compartment syndrome

›Pain out of proportion

›Pain with passive stretch

›Tense compartments

›Fight bite

›Dorsal MCP laceration

›Human bite contamination

›Early actions

›Analgesia strategy

›Oral and intranasal options first when stable

›Regional anesthesia if expertise available

›Remove constrictors

›Rings

›Tight wraps

›Elevation and ice

›Skin protection with barrier

›Reassess swelling trend

Immediate decision points

›Stability and alignment

›Rotational deformity

›None acceptable for nonoperative pathway

›Open wound communication

›Treat as open fracture if uncertain

›Intra-articular involvement

›Low threshold for hand surgery

›Consultation triggers

›Hand surgery or orthopedics now

›Open fracture

›Neurovascular compromise

›Irreducible deformity

›Malrotation after reduction attempt

›Multiple metacarpals fractured

›Suspected fight bite

›Transfer triggers

›No local hand surgery coverage

›Open fracture with contamination

›Compartment syndrome concern

Monitoring and reassessment

›Reassessment cadence

›Post-analgesia neurovascular exam

›Capillary refill

›Two-point discrimination

›Motor function

›Post-reduction check

›Finger cascade alignment

›Rotational alignment with fist

›Post-splint check

›Pain

›Skin pressure points

›Distal perfusion

02History/hx59

Core history

›Injury context

›Mechanism

›Direct blow

›Axial load

›Crush

›Punching injury

›Time since injury

›Immediate swelling

›Delayed presentation

›Hand dominance

›Dominant hand involvement

›Occupation and sport

›Need for grip strength

›Return to play timeline

›Symptoms and function

›Pain location

›Metacarpal head and neck

›Shaft

›Base and CMC region

›Mechanical symptoms

›Malalignment sensation

›Clicking

›Functional loss

›Grip weakness

›Finger motion limitation

›Wound and contamination

›Skin break

›Small puncture

›Laceration

›Human bite risk

›Altercation history

›Tooth contact

›Risk modifiers

›Anticoagulants

›Warfarin

›DOACs

›Diabetes

›Infection risk

›Smoking

›Delayed union risk

›Prior hand injury

›Baseline deformity

›Immunization and medications

›Tetanus status

›Unknown or incomplete series

›Drug allergies

›Beta-lactam reaction type

Focused red flags

›Red flag features

›Numbness or tingling

›Median distribution

›Ulnar distribution

›Cold digit

›Color change

›Escalating pain

›Disproportionate pain

›Severe swelling

›Tight skin

›Fever or drainage

›Delayed infection concern

03Physical Exam/exam65

Inspection and alignment

›Visual survey

›Skin integrity

›Laceration over MCP

›Puncture wound

›Swelling pattern

›Dorsal hand swelling

›Localized knuckle flattening

›Deformity

›Dorsal apex angulation

›Shortening

›Finger alignment

›Resting cascade

›Fingertips toward scaphoid tubercle

›Rotational alignment

›Nail plate parallelism

›Finger overlap with fist

›MCP knuckle prominence

›Loss of contour

Palpation and range

›Bony tenderness

›Metacarpal head and neck

›Fifth metacarpal neck focus

›Shaft

›Step-off

›Base and CMC

›First metacarpal base pain

›Joint assessment

›MCP stability

›Collateral ligament tenderness

›CMC stability

›Dorsal subluxation

›Tendon function

›Extensor mechanism

›Active MCP extension

›Flexor tendons

›FDS and FDP function

›Intrinsics

›Finger abduction and adduction

Neurovascular and compartment

›Perfusion

›Capillary refill

›Delayed refill threshold 2 seconds

›Skin temperature

›Asymmetry

›Radial and ulnar pulses

›Proximal vascular status

›Sensation

›Median nerve

›Index fingertip sensation

›Ulnar nerve

›Small fingertip sensation

›Radial nerve

›Dorsal first web space sensation

›Motor

›Median

›Thumb opposition

›Ulnar

›Finger abduction

›Radial

›Wrist and finger extension

›Compartment syndrome screening

›Pain with passive stretch

›Finger extension stretch pain

›Firm compartments

›Dorsal interosseous spaces

›Progressive neurologic deficit

›Worsening paresthesia

04Differential Diagnosis/ddx37

Traumatic hand conditions

›Fracture and dislocation differentials

›Phalangeal fracture

›Proximal phalanx fracture

›Middle phalanx fracture

›MCP dislocation

›Dorsal MCP dislocation

›CMC dislocation

›Fifth CMC dislocation

›Carpal fracture

›Scaphoid fracture

›Hamate fracture

›Bennett fracture

›First metacarpal base intra-articular fracture

›Rolando fracture

›Comminuted first metacarpal base fracture

›Soft tissue and neurovascular

›Extensor tendon rupture

›Loss of active extension

›Flexor tendon rupture

›Loss of DIP or PIP flexion

›Digital nerve injury

›Two-point discrimination loss

›Digital artery injury

›Poor perfusion

›Compartment syndrome

›Escalating pain

›Infection and foreign body

›Fight bite infection

›Septic MCP joint

›Retained foreign body

›Glass

›Tooth fragment

Coding considerations

›Coding anchors

›ICD-10 S62.3

›Fracture of metacarpal bone

›SNOMED CT concept

›Fracture of metacarpal bone (disorder)

05Laboratory Tests/lt18

When labs matter

›Lab strategy

›No routine labs for closed isolated fracture

›Normal vitals

›No open wound

›Open fracture or deep wound

›Complete blood count for infection baseline

›C-reactive protein for delayed presentation

›Basic metabolic panel for operative planning context

›Anticoagulation

›INR for warfarin

›Platelets for bleeding concern

›Infection concern

›Blood cultures for systemic toxicity

Point-of-care testing

›Point-of-care considerations

›Glucose for diabetes and infection risk

›Hyperglycemia threshold 11.1 mmol/L

›Pregnancy test

›Reproductive age with imaging needs

06Diagnostic Tests/dt62

Scoring Systems

›Classification and decision support

›Open fracture grading

›Gustilo-Anderson type I

›Gustilo-Anderson type II

›Gustilo-Anderson type III

›Pediatric physeal classification

›Salter-Harris I

›Salter-Harris II

›Salter-Harris III

›Salter-Harris IV

›Salter-Harris V

›Acceptable alignment concepts

›Rotational deformity

›Any malrotation requires reduction or operative evaluation

›Fifth metacarpal neck angulation

›Up to 70 degrees may be acceptable in select closed injuries

MRI

›MRI indications

›Occult fracture with persistent pain and negative radiographs

›Suspected associated carpal fracture

›Ligament injury assessment

›CMC ligament disruption

›Tendon injury evaluation

›Extensor tendon disruption

›MRI constraints

›Limited ED utility for straightforward metacarpal fracture

›Delays in disposition

›Metal contraindications

›Retained metallic foreign body concern

›CT indications

›Intra-articular fracture complexity

›First metacarpal base fracture pattern

›Comminution and surgical planning

›Multiple metacarpals

›CMC fracture-dislocation suspicion

›Subtle base injury on radiographs

›CT pearls

›Axial and sagittal reconstructions

›Articular step-off quantification

›Radiation minimization

›Focused hand protocol when available

Ultrasound

›Ultrasound applications

›Tendon integrity

›Extensor tendon continuity

›Retained foreign body

›Radiolucent foreign body detection

›Hematoma and vascular flow

›Doppler for perfusion concern

›Ultrasound limitations

›Operator dependency

›Expertise requirement

›Bony alignment characterization

›Radiographs remain primary

Plain radiography

›Radiographs

›Standard hand series

›PA view

›Lateral view

›Oblique view

›Dedicated finger views

›Isolated digit alignment

›Post-reduction films

›Confirm angulation correction

›Confirm no new displacement

07Disposition/dispo23

Site of care

›Disposition pathways

›ED discharge with splint

›Closed fracture

›No malrotation

›Acceptable angulation by digit and fracture location

›Neurovascularly intact

›ED observation or admission

›Uncontrolled pain

›Recurrent displacement after reduction

›Multiple metacarpals

›Urgent operative pathway

›Open fracture

›Fight bite with joint involvement suspicion

›Neurovascular compromise

›Compartment syndrome concern

Follow-up timing

›Follow-up plan

›Hand surgery or orthopedics follow-up

›3 to 7 days typical for stable injuries

›24 to 48 hours for borderline alignment

›Repeat radiographs

›7 to 10 days for displacement risk

›Therapy referral

›Early mobilization plan when safe

08Treatment/t108

Analgesia and anesthesia

›Pain control

›Non-opioid foundation

›Acetaminophen PO 1000 mg

›Maximum 4000 mg per 24 hours

›Ibuprofen PO 400 mg

›Every 6 to 8 hours as needed

›Maximum 2400 mg per 24 hours

›Opioid for severe pain

›Morphine PO 0.2 mg/kg

›Maximum single dose 15 mg

›Hydromorphone PO 1 mg

›Titrate by 1 mg increments

›Regional anesthesia options

›Ulnar nerve block

›Local anesthetic per institutional protocol

›Digital nerve block

›Avoid epinephrine if digital ischemia concern

Reduction and immobilization

›Closed reduction indications

›Rotational deformity

›Immediate reduction attempt

›Angulation beyond acceptable limits

›Digit-specific tolerance

›Significant shortening

›Functional impairment risk

›Reduction techniques

›Fifth metacarpal neck reduction

›90-90 method

›MCP flexion to 90 degrees

›PIP flexion to 90 degrees

›Volar pressure over dorsal apex

›Post-reduction confirmation

›Rotational alignment with fist

›No finger overlap

›Radiographic confirmation

›Recheck angulation

›Splinting choices

›Ulnar gutter splint

›Fourth and fifth metacarpals

›MCP flexion 70 to 90 degrees

›IP joints free when possible

›Radial gutter splint

›Second and third metacarpals

›MCP flexion 70 to 90 degrees

›Thumb spica splint

›First metacarpal fractures

›CMC immobilization

›Buddy taping option

›Stable minimally displaced fracture

›No malrotation

›Pain controlled

›Early mobilization protocol

›Hand therapy follow-up

Open fracture and wound care

›Open fracture protocol

›Irrigation and debridement

›Gross debris removal

›High-pressure irrigation avoided for small clean wounds

›Antibiotics

›Initiate within 60 minutes when possible

›Cefazolin IV 2 g

›Every 8 hours

›If severe beta-lactam allergy

›Clindamycin IV 900 mg

›Every 8 hours

›Tetanus prophylaxis

›Td or Tdap if not up to date

›Tetanus immune globulin if unknown or incomplete and dirty wound

›Hand surgery consultation

›All open fractures for operative planning

Fight bite management

›Fight bite pathway

›High-risk anatomy

›MCP joint extensor hood zone

›Antibiotics

›Amoxicillin-clavulanate PO 875 mg

›Twice daily

›Typical duration 5 to 7 days for prophylaxis

›If severe penicillin allergy

›Doxycycline PO 100 mg

›Twice daily

›Metronidazole PO 500 mg

›Twice daily

›Wound handling

›Avoid primary closure for contaminated bite wounds

›Copious irrigation

›Imaging adjuncts

›Radiographs for tooth fragment

›Retained foreign body check

Procedural sedation

›Sedation options when needed

›Ketamine IV 1 mg/kg

›Additional 0.5 mg/kg as needed

›Fentanyl IV 1 mcg/kg

›Titrate by 0.5 mcg/kg

›Midazolam IV 0.05 mg/kg

›Maximum 5 mg

›Monitoring requirements

›Continuous pulse oximetry

›Blood pressure every 5 minutes

›End-tidal CO2 when available

Nonoperative versus operative indications

›Operative indications

›Rotational deformity

›Persistent after reduction

›Intra-articular step-off

›Functional impairment risk

›Unstable fracture pattern

›Recurrent displacement

›Multiple metacarpals

›Hand arch compromise

›Open fracture

›Operative debridement requirement

09Special Populations/sp31

Pregnancy

›Pregnancy considerations

›Imaging safety

›Radiographs acceptable with shielding

›CT only if needed for surgical planning

›Analgesia selection

›Acetaminophen preferred

›NSAID avoidance in third trimester

›Antibiotic selection

›Avoid doxycycline

›Beta-lactams generally preferred when appropriate

Geriatric

›Geriatric considerations

›Osteoporosis and fragility patterns

›Low-energy mechanism still significant

›Skin fragility

›Splint pressure injury risk

›Anticoagulation

›Hematoma risk with blocks and reductions

›Functional goals

›Early therapy coordination

Pediatrics

›Pediatric considerations

›Physis risk

›Salter-Harris classification attention

›Reduction benefit limits for fifth neck

›Angulation less than 50 degrees may have limited improvement with reduction

›Immobilization strategy

›Shorter immobilization when stable to reduce stiffness

›Weight-based antibiotics for open fracture

›Cefazolin IV 30 mg/kg

›Maximum 2000 mg per dose

›Safeguarding

›Non-accidental trauma concern if mechanism inconsistent

10Background/b28

Epidemiology

›Epidemiology overview

›Common injury

›Fifth metacarpal neck common after punching

›Typical demographics

›Adolescents and young adults

›High-risk mechanisms

›Crush injuries

›Fight bite injuries

Pathophysiology

›Injury mechanics

›Dorsal apex angulation tendency

›Volar displacement of distal fragment

›Rotational deformity mechanism

›Interosseous and lumbrical pull

›Functional consequences

›Grip strength reduction with malalignment

›Scissoring with rotation

Therapeutic Considerations

›Nonoperative principles

›Rotation as primary determinant

›Any rotation unacceptable

›Angulation tolerance by ray

›Ulnar metacarpals tolerate more angulation than radial

›Early mobilization benefits

›Reduced stiffness risk when fracture stable

›Antibiotic prophylaxis in open fractures

›Infection reduction benefit

›Prophylaxis beneficial for open fractures of hand and digits

›Duration minimization

›Prolonged prophylaxis beyond 24 hours generally not needed for uncomplicated open fracture after definitive care

11Patient Discharge Instructions/pdi35

copy discharge instructions

›Home care

›Splint care

›Keep dry

›Do not insert objects into splint

›Elevation

›Above heart level for 48 hours

›Ice

›15 minutes at a time

›Several times daily

›Pain control

›Acetaminophen and ibuprofen schedule as directed

›Activity

›No punching or gripping loads

›Avoid lifting with injured hand

›Finger motion

›Move free fingers often

›Stop if severe pain

›Return to ED now

›Increasing pain not controlled

›Especially pain with finger stretch

›Numbness or tingling

›New or worsening

›Fingers turning blue or cold

›Delayed capillary refill

›Splint too tight

›Swelling with pressure pain

›Fever or wound drainage

›Redness spreading

›Follow-up

›Hand surgery or orthopedics appointment

›Within 3 to 7 days unless told sooner

›Repeat x-ray

›As arranged

›Wound check

›Within 24 to 48 hours if any skin break

12References/r14

Clinical guidelines and evidence

›Source list

›Royal Children’s Hospital Melbourne

›Metacarpal fractures emergency department guideline

›Merck Manual Professional

›Ulnar gutter splint technique and MCP flexion 70 to 90 degrees

›PubMed Central reviews

›Metacarpal fracture management review

›Fifth metacarpal neck fracture review

›EAST practice management guideline

›Prophylactic antibiotics for open fractures

›Institutional open fracture antibiotic guideline

›Cefazolin as first-line prophylaxis

›StatPearls NCBI Bookshelf

›Fifth metacarpal fracture reduction pearls

Learn More: Metacarpal fracture→

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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