Fractures of the metacarpals are common injuries that can lead to deformity, stiffness, or both if not treated properly. The goal of treatment is full and rapid restoration of hand function. Key principles of treatment include achieving an anatomic or functionally acceptable reduction, providing stability, minimizing soft tissue trauma, adequate pain control, and early functional rehabilitation. The appropriate treatment depends on balancing factors like the patient's age and health, fracture characteristics like location and stability, and risks like poor blood supply.

1. Metacarpal
Fractures

2. Fractures of the Metacarpal
• The most common fracture of the upper
extremity
• Involved in 80% of hand Fx
• Incidence peaks between ages 10-40
– Greatest industrial and athletic exposure
• Outer fingers are most frequently injured

3. Complexity of Functional Anatomy
“hand fractures can be complicated by
deformity from no treatment, stiffness from
over treatment, and both deformity and
stiffness from poor treatment”.
!
(Swanson 1970)

4. !
What is the correct
treatment ?

5. Goal
Full and rapid restoration of function

6. Fracture treatment should be principle driven
• Anatomic or functionally acceptable reduction
!
• Stability
!
• Minimizing additional soft tissue trauma
!
• Adequate pain control
!
• Early functional rehabilitation

7. Balance
!
Injury severity
!
Pt. demographics
Joint & tendon
motion
Fracture
healing
Speed of
recovery
Safety
BiologyBiomechanics
Stability
Implant selection
Blood Supply
Surgical dissection
Scar tissue

8. Diagnosis - Hx
• Patient’s age
• Past medical history
• Dominant hand
• Occupational status
• Cause and circumstances
• Other injuries

9. Diagnosis
• Area of maximum tenderness
• Deformities : location, type ,severity
• Soft tissue injuries
• Neurovascular status
• Tendon injury

10. Outcome Determinants
• Patient factors
• Fracture Factors
• Wound Factors
• Management factors

11. Outcome Determinants
• Patient factors
– Age ( > 50 )
– Associated disease and arthritis
– Socioeconomic status
– Motivation and compliance
• Fracture Factors
• Wound Factors
• Management factors

12. Outcome Determinants
• Patient factors
• Fracture Factors
– Location: intra-articular, flexor tendon Zone 2
– Type : simple, comminuted, impacted, bone loss
– Geometry: transverse, oblique, spiral, avulsion
– Deformity: angulation, rotation, shortening
– Stability
• Wound Factors
• Management factors

13. Outcome Determinants
• Patient factors
• Fracture Factors
• Wound Factors
– Open Vs. Closed
– Associated injuries: tendon, soft tissue, neurovasc.
– contamination
• Management factors

14. Outcome Determinants
• Patient factors
• Fracture Factors
• Wound Factors
• Management factors
– Diagnosis and recognition
– Reduction and maintenance
– Length of immobilization
– Complication management

15. Freeland’s principles
• Anatomic or functionally acceptable reduction
• Stability
• Avoiding or minimizing additional soft tissue
trauma
• Adequate pain control
• Early functional rehabilitation

16. Open?
Displaced ?
Reducible ? Stable ?
BracingORIF or Ex-Fix
N
Y NY
YN
N
Y
CRIF
Protected motion / Immobilization
Rehabilitation
Hand fracture

17. • Deformity beyond
acceptable anatomic or
functional parameters:
– Angulation
– Rotation
– Shortening
Displacement

18. “Acceptable” ?
Variance in Compensation & accommodation
• The CMC joints of the ring and
small finger have 20°-30° mobility
in the sagital plain.
!
• The CMC joints of the Index and
long finger have less mobility.
!
• Therefore, in Fractures of the
metacarpal necks, angulation can
be better compensated for in the
ring and small fingers, without
compromising hand function.

19. What is acceptable fracture angulation?
• In the index and long finger:
– Angulation > 10°-15° is not acceptable
• Ring and small ?
> 70° : Holst-Nielsen
> 50° : Barton
> 40° : Hunter & Cowen, Eichenholz & Rizzo
> 30° : Smith & Peimer
> 30° small, 20° ring : Mayo Clinic group
> 20° : Bloem, Kilbourne & Paul

20. Displacement
Deformity beyond
acceptable anatomic or
functional parameters.

21. Stable fracture:
Can be maintained in an
anatomic or near anatomic position.
Stability

22. • Stability determinants
– Fracture configuration
– Muscle balance
– Integrity of periosteum
– Integrity of soft tissue
– External forces
– Integrity of supporting skeletal structures
Stability

23. Unstable fracture configuration

24. Intra-articular and Condylar Fractures

25. Muscle balance
Fracture of the metacarpals
• Under the joint traction
of the interosseous
muscles and the flexor
tendons, the distal
fragment of the
metacarpal flexes,
producing a dorsal
angulation.

26. Reduction & fixation
Buddy taping of a fractured finger
• Stabilizing with an
intact neighboring
finger is the best
dynamic splint that
ensures a rapid
functional result.

27. Functional bracing
• Splinting the wrist in
dorsiflexion and the
metacarpophalangeal
joints at 90°.
!
• The hand is free from
the splint in the distal
area to allow motion.

28. Closed reduction and percutaneous
pinning with K-wire of a mid-shaft fracture
• Started by the
reduction and
alignment of the
skeleton
• Two oblique K-wires
are inserted
• Compression of the
bone fragments
should be maintained
to avoid diastasis.

29. Jahss manipulation technique and
fascicular pinning
• Finger flexion to 90°
and force application
to the axis of the
proximal phalanx for
fracture reduction.
• Three K-wires are
inserted through a
hole made on the
lateral side in the
proximity of the
metacarpal.

30. Transversal pinning to adjacent
metacarpal
!
• Transfixation to
adjacent metacarpal
!
• Bone loss

31. ORIF
• Accurate anatomic reduction
• Stable fixation
– Pain control
– Early mobilization
• Functional recovery

32. ORIF-cons
• Devascularization of bone fragments
• Soft tissue damage
• Tendon adherence
• Scar formation
• Infection
• Implant removal - 2° procedure

33. Open incisions

34. Osteosynthesis by plates
• Stable
osteosynthesis
compatible with
immediate
mobilization
!
• Implant removal - 2°
procedure

35. osteosynthesis with cortical and
cancellous screws

38. external fixator
!
• Comminuted
• Small fragments
• allows the
preservation of length
• allows mobility and
approach to soft tissue
injuries.
• Ligamentotaxis

39. Balance
!
Injury severity
!
Pt. demographics
Joint & tendon
motion
Fracture
healing
Speed of
recovery
Safety
BiologyBiomechanics
Stability
Implant selection
Blood Supply
Surgical dissection
Scar tissue

40. Complications
• Failure of bone healing
– Delayed union, Nonunion, Pseudoarthrosis
• Union with deformity - Malunion
• Tendon adhesions
• Joint contractures
• Post traumatic arthritis
• Infection
• Implant failure