Metacarpal fracturesMANAGEMENT

FOREARM, WRIST & HAND · 12 SECTIONS

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512 items

☷ Legend

01Approach to the Critical Patient/attcp64

Immediate priorities

›Limb threat triage

›Open injury suspicion

›Skin break near fracture

›Laceration over MCP joint after punch

›Neurovascular status

›Radial pulse

›Ulnar pulse

›Capillary refill

›Median nerve sensation

›Ulnar nerve sensation

›Radial nerve sensation

›Median nerve motor thumb opposition

›Ulnar nerve motor finger abduction

›Radial nerve motor wrist extension

›Compartment syndrome risk

›Pain out of proportion

›Pain with passive finger extension

›Tense compartments

›Progressive paresthesia

›Pallor or cool digits

›If evolving findings then emergent hand surgery or orthopedics

›Time critical actions

›Ring removal

›If swelling then immediate cutting

›If open fracture then antibiotics first when feasible

›If fight bite then treat as contaminated open injury

›Immobilization before transport

›Position of function

›Elevation

›Imaging timing

›Radiographs before reduction when stable

›If threatened skin or neurovascular compromise then reduce then radiographs

›Post reduction radiographs

›Immediately after splinting

Escalation triggers

›Surgical activation

›Any malrotation

›Overlap or scissoring with finger flexion

›Open fracture

›Visible bone

›Deep wound contamination

›Intra articular step off

›MCP joint involvement

›CMC joint involvement

›Multiple metacarpals

›Hand instability

›CMC fracture dislocation

›Fifth CMC instability

›Persistent neurovascular deficit after reduction

›Immediate consultation

›Transfer triggers

›Need for urgent operative washout

›Fight bite over MCP

›Suspected vascular injury

›Absent pulses

›Doppler only signal

›Compartment syndrome concern

›Rapidly worsening pain and swelling

Key concepts

›Functional priorities

›Rotation correction as highest priority

›Small angulation tolerated

›Rotation not tolerated

›Early motion strategy

›Stable fractures favor early mobilization

›Prolonged immobilization increases stiffness

02History/hx41

Injury context

›Mechanism

›Punching object or person

›Laceration over MCP

›Mouth contamination risk

›Fall on hand

›Axial load through metacarpal

›Crush injury

›Compartment syndrome risk

›Twisting injury

›Spiral fracture risk

›High energy trauma

›Multiple fractures

›Timing

›Time since injury

›Interval swelling progression

›Any attempted reduction

›Hand factors

›Dominant hand

›Occupation and sport demands

›Baseline hand function

›Prior fracture or surgery

›Symptoms suggesting complications

›Numbness or tingling

›Weakness

›Increasing tightness

›Cold digits

›Severe pain with finger motion

›Bleeding and infection risks

›Anticoagulants

›Diabetes

›Immunosuppression

›Tetanus status

›Bite or saliva exposure

Pain and function

›Pain pattern

›Rest pain

›Pain with MCP motion

›Pain with gripping

›Functional deficits

›Inability to make fist

›Finger scissoring with flexion

›Extensor lag

03Physical Exam/exam42

Hand survey

›Inspection

›Dorsal hand swelling

›MCP knuckle depression

›Finger cascade at rest

›Rotational alignment with flexion

›Skin tenting

›Lacerations

›Fight bite wound over MCP

›Palpation

›Metacarpal tenderness

›Crepitus

›Step off

›CMC joint tenderness

›Range of motion

›MCP flexion extension

›PIP flexion extension

›DIP flexion extension

›Wrist range of motion

›Tendon function

›Finger extension against resistance

›Finger flexion against resistance

›Thumb extension

›Thumb opposition

›Neurovascular

›Radial pulse

›Ulnar pulse

›Capillary refill

›Two point discrimination if concern

›Median nerve sensory index fingertip

›Ulnar nerve sensory small fingertip

›Radial nerve sensory dorsal first web space

Rotational assessment

›Rotation checks

›Fingertips point toward scaphoid with flexion

›Nail plates parallel in flexion

›No overlap of digits

›Any scissoring treated as malrotation

PITFALLS

›Common misses

›Normal appearing radiograph with clinical rotation

›Fight bite treated as simple laceration

›CMC fracture dislocation missed without true lateral

›Multiple metacarpal instability underestimated

›Over tight splint causing worsening swelling pain

04Differential Diagnosis/ddx33

Traumatic mimics and co injuries

›Fracture patterns

›Metacarpal head fracture

›Metacarpal base fracture

›Bennett fracture

›Rolando fracture

›Phalangeal fracture

›Carpal fracture

›Dislocations and instability

›MCP dislocation

›CMC dislocation

›Fifth CMC fracture dislocation

›Soft tissue injuries

›Extensor tendon rupture

›Flexor tendon injury

›Sagittal band injury

›Collateral ligament injury MCP

›Infection related

›Septic MCP joint after fight bite

›Flexor tenosynovitis

›Cellulitis

Coding anchors

›ICD 10 and SNOMED mapping

›Metacarpal fracture unspecified

›ICD 10 S62.30

›SNOMED CT Metacarpal fracture concept

›Fifth metacarpal fracture

›ICD 10 S62.306

›SNOMED CT Fifth metacarpal fracture concept

›Open metacarpal fracture

›ICD 10 S62.3 with open fracture qualifier

›SNOMED CT Open fracture of metacarpal concept

›Human bite of hand

›ICD 10 S61.45

›SNOMED CT Human bite of hand concept

05Laboratory Tests/lt20

Standard ED use

›Labs usually not required

›Isolated closed fracture

›No planned sedation

›Pre procedure pathway

›If procedural sedation planned then glucose bedside when indicated

›If anticoagulants or bleeding concern then INR and CBC

›Infection pathway

›If fight bite then CBC for systemic features

›If deep infection concern then CRP

›If febrile or toxic then blood cultures

Open fracture pathway

›Baseline labs for operative pathway

›CBC

›Hemoglobin trend if bleeding concern

›Creatinine

›Antibiotic dosing

›Type and screen

›If major trauma

PITFALLS

›Interpretation limits

›Normal labs do not exclude deep hand infection early

›Pain severity does not correlate with radiographic displacement

06Diagnostic Tests/dt73

Scoring Systems

›Classification and decision frameworks

›Anatomic location

›Head

›Neck

›Shaft

›Base

›Pattern

›Transverse

›Oblique

›Spiral

›Comminuted

›Gustilo Anderson open fracture

›Type I wound under 1 cm

›Type II wound 1 to 10 cm

›Type III wound over 10 cm or high energy

›Type IIIA adequate coverage

›Type IIIB periosteal stripping

›Type IIIC vascular injury requiring repair

›Management implications

›Any malrotation favors operative fixation

›Open fracture favors operative washout

›Intra articular step off favors fixation

Radiographs

›Standard imaging

›Hand radiographs

›PA view

›Oblique view

›Lateral view

›True lateral importance

›CMC alignment

›Metacarpal base injury

›Post reduction films

›Before discharge

›Alignment assessment

›Rotation assessed clinically not radiographically

›Angulation thresholds guidance

›Index metacarpal

›Neck angulation target under 15 degrees

›Shaft angulation target under 10 to 20 degrees

›Middle metacarpal

›Neck angulation target under 15 degrees

›Shaft angulation target under 10 to 20 degrees

›Ring metacarpal

›Neck angulation target under 30 to 40 degrees

›Shaft angulation target under 30 degrees

›Small metacarpal

›Neck angulation commonly tolerated up to 70 degrees in selected cases

›Shaft angulation target under 40 degrees

›Shortening

›Typical tolerance 2 to 5 mm

›Diagnostic adjuncts

›Skyline view for metacarpal head

›If suspected head fracture

MRI

›Indications

›Occult fracture with negative radiographs

›Persistent focal tenderness

›High demand hand use

›Ligament injury suspicion

›MCP collateral injury

›CMC ligament injury

›Osteomyelitis concern

›Delayed presentation after fight bite

›Limitations

›Availability delays

›Motion artifact

›Indications

›Intra articular extension uncertainty

›Metacarpal head

›Metacarpal base CMC

›CMC fracture dislocation characterization

›Surgical planning for comminution

›Limitations

›Radiation exposure

›Soft tissue detail less than MRI

07Disposition/dispo30

ED disposition tiers

›Discharge with splint

›Closed fracture

›Neurovascularly intact

›No malrotation

›Acceptable alignment for ray

›Pain controlled with oral regimen

›Admission or urgent transfer

›Open fracture

›Fight bite with fracture or joint involvement concern

›Neurovascular compromise

›Compartment syndrome concern

›Irreducible deformity

›Multiple metacarpals with instability

›Unstable CMC injury

Follow up timing

›Routine hand surgery or orthopedics

›5 to 7 days

›Repeat radiographs

›Swelling reassessment

›Urgent clinic

›Within 24 to 72 hours

›Borderline alignment

›Significant swelling

›High risk compliance concerns

›Wound check

›24 to 48 hours

›Fight bite or contaminated wound

Activity restrictions

›Work and sport limits

›No gripping or punching

›Keep splint dry

›Elevation above heart for swelling

08Treatment/t102

Immediate life-saving interventions

›Early limb protection

›Elevation

›Ice as tolerated

›Ring removal

›If open fracture then infection prevention bundle

›Sterile saline moist dressing

›Antibiotics as soon as possible

›Tetanus prophylaxis per status

›If fight bite then high risk infection pathway

›Avoid primary closure over MCP

›Early hand surgery involvement

Immobilization and Splinting

›Splint selection

›Ulnar side metacarpals

›Ulnar gutter splint

›Ring metacarpal

›Small metacarpal

›Radial side metacarpals

›Radial gutter splint

›Index metacarpal

›Middle metacarpal

›Thumb metacarpal

›Thumb spica

›First metacarpal base injury suspicion

›Positioning targets

›Wrist extension about 20 degrees

›MCP flexion 60 to 90 degrees for injured rays

›IP joints full extension

›Splint technique

›Padding over ulnar styloid and metacarpal heads

›Three point molding for angulation control

›Two finger tightness check

›Recheck neurovascular after splint

Reduction

›Reduction indications

›Threatened skin

›Significant angulation with functional deformity

›Fracture dislocation

›Neurovascular compromise

›Reduction cautions

›Suspected metacarpal head fracture

›Avoid ED manipulation

›Suspected base fracture with CMC instability

›Hand surgery consultation

›Analgesia and anesthesia

›Non opioid

›Acetaminophen 1000 mg PO

›Ibuprofen 600 mg PO

›Opioid for severe pain

›Hydromorphone 0.5 mg IV

›Repeat every 10 to 15 minutes as needed

›Monitoring for sedation and respiratory depression

›Regional anesthesia

›Hematoma block

›Lidocaine 1 percent without epinephrine 5 to 10 mL

›Aspirate before injection

›Max lidocaine dose 4.5 mg per kg

›Digital nerve block for adjacent finger pain

›Lidocaine 1 percent without epinephrine 2 to 3 mL per side

›Procedural sedation when required

›Ketamine IV 1 mg per kg

›Repeat 0.5 mg per kg if needed

›Minimum 5 minutes between doses

›Airway equipment ready

›Reduction principles

›Traction and countertraction

›Deformity exaggeration then reverse

›Gentle sustained pressure

›Avoid repeated forceful attempts

›Boxer fracture technique options

›Jahss maneuver

›MCP flexion 90 degrees

›Dorsal pressure through proximal phalanx

›Stabilize metacarpal shaft

›Post reduction requirements

›Immediate rotation reassessment

›Immediate neurovascular reassessment

›Post reduction radiographs

›Splint in stable position

Open fracture medications and timing

›Antibiotics goals

›Early IV dosing as soon as feasible

›Gram positive coverage as baseline

›Type I and II open fracture typical approach

›Cefazolin 2 g IV every 8 hours

›Continue for 24 hours after closure when operative plan

›If severe cephalosporin allergy then clindamycin 900 mg IV every 8 hours

›Type III open fracture typical approach

›Cefazolin 2 g IV every 8 hours

›Add gentamicin 5 mg per kg IV every 24 hours

›If soil or fecal contamination then add anaerobic coverage per local protocol

›Fight bite antibiotics

›Amoxicillin clavulanate 875 mg 125 mg PO twice daily

›Duration 3 to 5 days for prophylaxis

›Longer course if infection present

›If penicillin allergy then clindamycin plus trimethoprim sulfamethoxazole

›Tetanus prophylaxis

›If unknown or incomplete then vaccine

›If dirty wound and under immunized then add immune globulin

DVT prophylaxis when relevant

›Generally not indicated

›Isolated upper extremity splint

›Consider per local protocol

›Polytrauma admission

›Prolonged immobility

›Multiple injuries

09Special Populations/sp31

Pregnancy

›Pregnancy considerations

›Imaging approach

›Radiographs acceptable with shielding when feasible

›CT rarely needed for isolated hand injury

›Analgesia selection

›Acetaminophen preferred

›Avoid NSAIDs in later pregnancy per obstetric guidance

›Procedural sedation

›Shared decision making with obstetrics if viable gestation

Geriatric

›Geriatric considerations

›Fragility mechanism evaluation

›Fall risk

›Osteoporosis risk

›Lower threshold for follow up support

›Splint care assistance

›Return precautions reliability

›Medication safety

›Opioid delirium risk

›Renal dosing for antibiotics if needed

Pediatrics

›Pediatric considerations

›Growth plate risk

›Physeal injury at metacarpal base

›Remodeling potential

›Greater tolerance for angulation than adults in selected cases

›Non accidental trauma context when appropriate

›Inconsistent history

›Multiple injuries

›Weight based dosing

›Acetaminophen 15 mg per kg PO

›Ibuprofen 10 mg per kg PO

›Lidocaine max 4.5 mg per kg without epinephrine

10Background/b36

Epidemiology

›Frequency and demographics

›Metacarpal fractures common within hand fractures

›Reported around 40 percent of hand fractures in some series

›Fifth metacarpal neck fracture common

›Reported around 20 percent of hand fractures

›Higher rates in adolescents and young adults

›Contact sport and punching mechanisms

›Male predominance in many cohorts

›Higher exposure to risk activities

Pathophysiology

›Biomechanics

›Apex dorsal angulation tendency

›Interossei and intrinsic muscle forces

›Rotational deformity mechanism

›Oblique and spiral patterns

›CMC stability differences

›Index and middle more rigid

›Ring and small more mobile

›Injury pattern mapping

›Neck fractures

›Axial load through clenched fist

›Volar comminution at neck

›Shaft fractures

›Bending and torsion forces

›Base fractures

›CMC joint injury risk

›Intra articular extension risk

Therapeutic Considerations

›Nonoperative rationale

›Many angulated fractures function well if no rotation

›Early motion reduces stiffness when stable

›Operative rationale

›Rotation leads to scissoring and grip dysfunction

›Intra articular incongruity risks arthritis

›Multiple metacarpals risk hand collapse

›Evidence highlights

›Small finger neck angulation sometimes acceptable up to 70 degrees in selected studies

›Reduction not routinely required for all boxer fractures if function acceptable

11Patient Discharge Instructions/pdi25

copy discharge instructions

›Discharge guidance

›Elevation above heart most of the day for first 48 hours

›Ice 15 to 20 minutes up to 4 times daily if tolerated

›Keep splint clean and dry

›No punching

›No heavy gripping or lifting with injured hand

›Finger range of motion for free joints

›Pain plan

›Acetaminophen as directed on label

›Ibuprofen as directed on label if allowed

›Opioid only if prescribed

›Wound care if laceration

›Daily inspection for redness drainage odor

›Return to ED immediately

›Increasing pain not controlled

›New numbness or tingling

›Blue pale or cold fingers

›Increasing tightness in splint

›Unable to move fingers

›Fever

›Pus or spreading redness

›Follow up plan

›Hand surgery or orthopedics within 5 to 7 days

›Earlier 24 to 72 hours if reduction performed or alignment borderline

›Wound check 24 to 48 hours for fight bite or contaminated wound

12References/r15

Evidence based sources

›Core reviews and epidemiology

›Malik S and colleagues Fifth Metacarpal Fracture StatPearls 2024

›Kollitz KM and colleagues Metacarpal fractures treatment and complications 2013

›Carreño A and colleagues Management of metacarpal fractures 2020

›Deuschl J and colleagues Epidemiology of metacarpal fractures 2025

›Alignment and management thresholds

›Orthobullets Metacarpal Fractures Hand updated 2025

›Medscape Metacarpal Fractures Treatment and Management updated 2024

›Royal Childrens Hospital Melbourne Metacarpal fractures ED guideline

›Open fracture antibiotics

›EAST practice management guideline Open fractures prophylactic antibiotics archived

›UNMC open fracture antibiotic prophylaxis guideline PDF

›Bite and fight bite antibiotics

›Appelbaum RD and colleagues Antibiotic prophylaxis in injury AAST consensus 2024

›Hussain MH and colleagues Boxers fracture literature review 2020

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.