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INDEX, LONG AND RING METACARPALS FRACTURES

Introduction

Fracture Nomenclature for Index, Long and Ring Metacarpals Fractures

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Index, Long and Ring Metacarpals, the historical and specifically named fractures include:

Extensor carpi radialis longus avulsion fracture at the index metacarpal base

Index CMC joint dislocation and fracture-dislocation without avulsion

ECRB avulsion fracture at the long metacarpal base

Long CMC joint dislocation and fracture-dislocation without avulsion

Ring CMC joint dislocation and fracture-dislocation

By selecting the name (diagnosis), you will be linked to the introduction section of this Diagnostic Guide dedicated to the selected fracture eponym.

Fractures of the metacarpals occur less frequently than phalangeal fractures, but still represent some of the most common injuries seen in emergency departments. Reports suggest that metacarpal fractures comprise between 18-44% of all hand fractures, and about 88% of these occur in non-thumb metacarpals. The little metacarpal is the most commonly fractured of these bones, followed by the ring metacarpal, where shaft fractures also occur frequently. The incidence of index and long metacarpal fractures is similar and quite low, due in part to the rigid stability of their respective carpometacarpal (CMC) joints The neck is the most common fracture site in the metacarpals.  The most typical injury mechanisms for all metacarpal fractures are accidental falls and direct blows. Most index, long, and ring metacarpal fractures are isolated, simple, closed, and stable injuries, and can be effectively managed conservatively, but surgical intervention may be necessary when closed reduction fails or is likely to fail, when associated with multiple metacarpal fractures.1-4

Definitions

  • Index, long, and ring metacarpal fractures are a disruption of the mechanical integrity of these metacarpals.
  • Index, long, and ring metacarpal fractures produce a discontinuity in the metacarpal contours that can be complete or incomplete.
  • Index, long, and ring metacarpal fractures are caused by direct forces that exceed the breaking point of the bones. 

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

  • Universally accepted definitions of clinical fracture stability is not well defined in the hand surgery literature.5-7
  • Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragment’s alignment is maintained with simple splinting. However, most definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion.
  • Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and simple splinting. Typically unstable index, long, and ring metacarpal fractures have significant deformity with comminution, displacement, angulation, and/or shortening.
  • Most metacarpal shaft fractures are inherently stable and can be treated conservatively.1
  • Fractures of the border metacarpals generally tend to be less stable and more difficult to control than those of the central metacarpals.  However, intra-articular metacarpal base fractures are relatively stable.1,8,9  This stability is primarily due to the osseous architecture of the CMC joints and the interosseous and dorsal and volar CMC ligaments which also provide significant stability.9  The base of the index metacarpal is the most stable of the four non-thumb metacarpals, with stability and CMC joint motion gradually decreasing towards the little metacarpal.9

P - Pattern

  • Metacarpal head: oblique, transverse, or comminuted. Comminuted fractures are most common at this location.
    • These fractures can involve the metacarpophalangeal (MP) joint.  Although rare, these fractures appear to be more common in the index than other metacarpals.  These are usually intra-articular fractures that affect one or both condyles of the metacarpal head, with or without displacement. Displaced fractures can affect joint congruity.1,2
  • Metacarpal neck: most common site of fracture in the metacarpals, with the highest incidence in the ring and little metacarpals; closed metacarpal neck fractures are typically angulated with an apex dorsal position due to the deforming force of the interosseous muscles.1,2  These fractures typically result from direct axial force, causing failure of the volar cortex and flexion deformity at the fracture site.10
  • Metacarpal shaft: transverse, oblique, or comminuted with or without shortening. Each fracture type presents characteristic deformities that may lead to complications if unrecognized or not managed appropriately.1,2
    • In the ring metacarpal, fractures of the shaft occur most frequently, often due to punching injuries. For this reason, some consider them to be a variant of a boxer’s fracture.11
  • Metacarpal base: can involve the CMC joints, and may be either intra-articular or extra-articular; intra-articular metacarpal base fractures are high-energy injuries associated with CMC dislocations, and are uncommon in the index finger, but occur more frequently in the ring and little metacarpal bases.  Most extra-articular base fractures are only minimally displaced due to stability from the intermetacarpal ligaments.2
    • Fractures of the ring metacarpal base typically occur with axial loading of this bone with the ring and little CMC joints flexed, causing impaction of the ring metacarpal volar base into the hamate. Fractures through this mechanism are therefore commonly associated with ring and small finger CMC joint dislocations.9

O - Open

  • Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for development of osteomyelitis. Therefore, open fractures of the index, long, and ring metacarpals require antibiotics with surgical irrigation and wound debridement.5,12,13
  • Open fractures to the metacarpal head/neck area, especially those resulting from fistfights, mandate exploration to exclude involvement of the MP joint and/or extensor mechanism. After irrigation and debridement, these wounds are generally left open and internal fixation—if needed—is delayed until the wound shows no sign of infection.1,2

R - Rotation

  • Index, long, and ring metacarpal fracture deformity can be caused by rotation of the distal fragment on the proximal fragment.
  • Degree of malrotation of the fracture fragments can be used to describe the fracture deformity.
  • Oblique and spiral metacarpal shaft fractures are usually the result of torsional forces and can cause rotational malalignment. These fractures may also angulate or shorten.1
  • In contrast to angulation, rotation is poorly tolerated in metacarpal fractures, as it is magnified with flexion and often results in scissoring, which interferes with grip.4
  • Fragment rotation may be difficult to appreciate on imaging, even if a fracture line is identified.  Clinical exam with finger in flexion facilitates identification of malrotation. 

A - Angulation (fracture fragments in relationship to one another)

  • Angulation is measured in degrees after identifying the direction of the apex of the angulation.
  • Straight: no angulatory deformity
  • Angulated: bent at the fracture site
    • The tolerable limit of angulation deformity in the neck of the index metacarpal is 15°, 20° in the long metacarpal, 30° in the ring metacarpal, and 50-70° in the little metacarpal. 2
  • Malunion after a transverse metacarpal shaft fracture can also result in apex dorsal angulation in the sagittal plane, and healing of these fractures may lead to cosmetic and functional complications. 2  Metacarpal shaft dorsal open angulation interferes with function more than angulation at the neck of the metacarpal.
    • The tolerable limit of angulation deformity in the shaft of the index and long metacarpals is 10° and 20-30° in the ring and little metacarpals.4

D - Displacement (Contour)

  • Displaced: disrupted cortical contours
  • Nondisplaced: fracture line defining one or several fracture fragment fragments; however, the external cortical contours are not significantly disrupted
  • Most transverse fractures of the metacarpal shaft are minimally displaced.14

I - Intra-articular involvement

  • Fractures that enter a joint with one or more of their fracture lines.
  • Index, long, and ring metacarpal fractures can have fragment involvement with their respective MP or CMC joints.
  • If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to posttraumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface, then the congruity of the joint will be compromised and the risk of posttraumatic osteoarthritis increases significantly.
  • Intra-articular fractures of the metacarpal bases occur infrequently. These are high-energy injuries often concomitant with a CMC dislocation, and they occur most commonly in the ring and little metacarpals. Some have suggested that intra-articular metacarpal base fractures are underreported and underdiagnosed, due in part to the anatomic structure of the area and because of the limitation of standard x-rays when evaluating the metacarpal bases.2,9
  • Differentiating between extra- and intra-articular fractures is crucial for planning an appropriate treatment protocol.2

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.5-7

Index metacarpal fractures: named fractures, fractures with eponyms and other special fractures

Extensor carpi radialis longus avulsion fracture at the index metacarpal base

  • Isolated articular fractures of the index metacarpal base—including extensor carpi radialis longus (ECRL) avulsion fractures—are believed to be rare due to the lack of motion of the index CMC joint; however, it may be a more common injury than the literature suggests, primarily because it is often missed on standard radiograph views, which do not allow the avulsion to be easily seen.1,15,16
  • The mechanism of injury for ECRL avulsion fractures seems to be either axial loading of the index metacarpal—often from a punching injury—or forced hyperflexion of the hand and wrist, such as from a fall on the back of the hand with a palmar flexed wrist. In both cases, this force combines with contraction of the ECRL while the metacarpal is rigidly held in place, which avulses the ECRL at its insertion.1,15,17  The rigidity of the index metacarpal base due to its bony relations and ligamentous attachments prevents dorsal dislocation of the index CMC joint.15,17
  • In some cases, an ECRL avulsion fracture may be misdiagnosed as a scaphoid injury.17

Imaging

  • ECRL avulsion fractures are not easily seen on standard radiograph views, as the avulsed fragment overlies the trapezium and trapezoid and can be easily missed. A posteroanterior view with the hand adducted or a 30° anterior oblique view may allow the fragment to be more easily seen.15
  • If radiographs still fail to show the injury, a bone scan or a CT scan may be necessary to detect the injury.17,18

Treatment

  • Due to the rarity of ECRL avulsion fractures, there is no universal consensus regarding the optimal treatment for these injuries. There are proponents of conservative and surgical management strategies, and positive outcomes have been found with both.1,15,17,19
  • Conservative treatment may include rest and immobilization with a neutral forearm cast or splint for approximately 4 weeks, followed by early mobilization.15,17  Conservative treatment may result in a small dorsal bony prominence, which can be removed if necessary.15
  • Operative management is theoretically attractive, and justification for surgical reattachment includes restoration of the integrity of the ECRL, reconstitution of the articular surface of the second CMC joint, and elimination of a potentially irritating fragment of dorsal bone.1  When surgery is indicated, open reduction and internal fixation (ORIF) has been advocated as the preferred surgical intervention by most authors.19

Complications

  • Post-traumatic osteoarthritis
  • Metacarpal boss
  • Impaired grip strength and wrist extension
  • Wrist deformity

Outcomes

  • Outcomes following conservative treatment for ECRL avulsion fractures have been mixed, with some studies reporting success and others revealing reduction failures or notable complications.15,16,17,20
  • Surgical intervention for these injuries, primarily through ORIF, is generally associated with positive outcomes in which joint surface integrity and grip stability are restored.  There has been no difference in outcomes demonstrated between non-fragment and fragment avulsions, and there is no direct comparison of surgical techniques and subsequent outcomes, but several different methods of ORIF have been successful. In most reported cases, a K-wire has been used while others used suture anchors.17,18,19
    • Internal fixation has also been found to be well tolerated and may provide a more stable fixation than K-wires alone. In addition, headless screws provide excellent compression at the fracture site and may cause less soft tissue irritation.19

Index CMC joint dislocation and fracture-dislocation without avulsion

  • The index CMC joint is an arthrodial diarthrosis, which is inherently stable due to the geometry of its articular surfaces, ligamentous integrity about the joint, and the tethering action of the long extrinsic wrist extensors. With the long CMC joint and distal carpal row, it forms the stable keystone of the transverse and longitudinal arches of the hand.8,21  The index CMC joint also has an intimate relationship with the ECRL and ECRB tendons, which help generate additional stability.22  As a result of its extreme stability, the index CMC joint also has very limited mobility: it only allows approximately 1-11° of motion in the flexion-extension plane.8,9,22
  • Dislocations and fracture-dislocations of the index CMC joint are rare, especially when compared to equivalent injuries in the thumb and ulnar-sided digits.23  Most cases are isolated dorsal dislocations of the index CMC joint, while isolated volar fracture-dislocations are extremely rare; however, some authors state that it is difficult to understand how dislocation can occur without a fracture on account of the limited mobility of the index CMC joint.15,23  The suspected injury mechanism is hyperflexion of the hand and wrist, but some reports have found that forced hyperextension of the hand with adduction and axial shear around the index CMC can also be responsible.23,24  In some cases, dislocation and/or fracture-dislocation of other CMC joints can occur concomitantly with this injury.8

Imaging

  • These injuries are often missed on routine radiograph views because they are difficult to visualize. Using images in 30° of supination with the thumb abducted may therefore be needed to observe the joint surfaces better.22,24
  • CT scans may also be necessary to show the joint and bony structures in greater detail.22,23

Treatment

  • It is difficult to make definitive treatment recommendations for index CMC joint dislocations and fracture-dislocations because there are no studies with an adequate number of patients to derive a strong conclusion.22
  • Nonsurgical treatment consists of closed reduction, in which traction of the index finger is performed and dorsal pressure is applied on the deformity at the index metacarpal base. Immobilization should be used for 6 weeks.  After removal, a physical therapy program is initiated. If there is loss of reduction or no possible reduction, surgical management is performed.22
  • Various types of surgical interventions have been described for these injuries, including closed reduction and percutaneous pinning (CRPP), ORIF, open reduction and osteosynthesis with K-wires, arthrodesis, and primary fusion of the central CMC joints.22  Some authors suggest immediately performing closed reduction with K-wire fixation as the initial treatment for these injuries, which is used to maintain the reduction for 6-8 weeks. However, this may not always be possible, and open surgery is usually necessary if it is difficult to apply a closed reduction.8,22  The goal of open reduction is to restore the anatomical part that has not been established by nonsurgical treatment or closed methods.22
  • For multiple CMC joint dislocations, CRPP or ORIF is nearly always indicated. The dislocated joints are well visualized through a dorsal longitudinal incision. Reduction is usually simple and can be maintained with K-wires extending from the metacarpals into the carpus.1

Complications

  • Pain
  • Impaired grip strength
  • Deformity
  • Post-traumatic joint arthritis

Outcomes

  • The majority of studies on index CMC dislocations and fracture-dislocations have reported good outcomes regardless of the type of treatment performed, without report of pain or functional alterations.22

ECRB avulsion fracture at the long metacarpal base

  • The rigid fixation of the long metacarpal base to its surrounding structures prevents dorsal dislocation of the long CMC joint during forced wrist hyperflexion; this is why an avulsion fracture is the more common outcome of this force, rather than a dislocation.27
  • Current literature shows that isolated ECRB avulsion fractures are always accompanied with fracture of the long metacarpal base.28

Imaging

  • Anteroposterior, lateral, and oblique radiograph views are usually necessary to identify the avulsed fracture fragment.  Diagnosing an isolated ECRB avulsion fracture may be difficult if the injury is closed. If irregularity is seen on the X-ray at the long metacarpal base, then advanced radiographic imaging may be needed.  In some cases a CT scan or MRI may be used to visualize the fragment and rule out significant soft-tissue injuries.29

Treatment

  • Since ECRB avulsion fractures are so rare, consensus is lacking on the optimal management of these injuries, and both conservative and surgical approaches have been utilized.27
  • Some experts claim that long metacarpal avulsions result in minimal disability, and therefore only require supportive conservative treatment.29
  • Others point out that while closed reduction of these injuries can be easily obtained, it is extremely difficult or impossible to maintain with closed means. According to this reasoning, surgical management is needed for all ECRB avulsions.29  ORIF with anatomic repair of the detached tendon is conceptually and technically simple, and the associated risks are manageable when the appropriate technique is used. ORIF has been found to offer several advantages over closed treatment:
  • With low-profile internal fixation, reduction is easily maintained, thus avoiding the formation of metacarpal boss.  Anatomic reduction and repair of the ECRB improves grip and dorsiflexion strength.
  • Open reduction and interfragmentary screw fixation allows for fracture compression, provides direct access to the tendon for repair, and avoids the complications inherent with percutaneous fixation.29
    • Different surgical techniques may be used for fixation of the long metacarpal base, including tension band and K-wire fixation, screw fixation, or suture anchors.28
    • Simple ECRB avulsion fractures—in which the tendon is still attached to the fragment—can be reduced by tension-band wiring or screw fixation. But when the tendon is also avulsed from the fragment, both injuries must be addressed. This is usually accomplished with screw fixation of the bony fragment and a suture anchor to reattach the ECRB.26
    • After surgery, the wrist should be immobilized in a below-elbow cast with the wrist in slight extension for up to 6 weeks.25,26
  • It is believed that the ECRB is the most effective wrist extensor and serves an important role as a wrist stabilizer. This is on account of a smaller moment arm for radial deviation and the availability of the entire muscle for wrist extension, since it is unaffected by elbow position. This capacity of the ECRB is commonly cited as the reason to preserve it and reattach the avulsed fragment whenever possible.30  Additionally, the reduction of the bony fragment restores the integrity of the joint surface and prevents it from abrading the finger extensor tendons, which could lead to late rupture.26

Complications

  • Posttraumatic osteoarthritis
  • Metacarpal boss
  • Weak wrist extension strength
  • Impaired grip strength
  • Wrist deformity

Outcomes

  • Although case series and cohort studies of ECRB avulsion fractures are lacking, case reports have shown that positive outcomes are feasible using both conservative and surgical interventions.25,26,30,31

Long CMC joint dislocation and fracture-dislocation without avulsion

  • Long CMC joint dislocations are rare, primarily due to the robust stability of the joint.25,31
    • The base of the long metacarpal is bordered by 3 flat articular surfaces and bound by stout volar and dorsal ligaments, making it the keystone of the transverse and longitudinal arches of the hand. The relationship between the flat articular surfaces and stout ligaments creates a rigid central pillar about which the thumb and ulnar digits move.31
    • Dislocations and fracture-dislocations of the long CMC joint therefore require considerable energy and are frequently associated with concomitant injures to the other CMC joints and adjacent soft tissues.31
    • The most common mechanism of injury is dorsal or volar levering of a clenched hand, such as around handlebars or in a closed fist.31
  • Dorsal dislocations of the long CMC joint are more common than volar dislocations, and divergent dislocations are extremely rare.32

Imaging

  • Anteroposterior, profile, and oblique views are typically taken, but long CMC dislocations and fracture-dislocations are frequently missed at initial presentation, especially when only routine radiographs are taken.8,33
    • On posteroanterior radiographs, the dislocation can be suspected when loss of parallelism between CMC joints is found or when an apparent shortening of metacarpals is noticed.34
  • A CT scan may be needed if radiographs fail to identify the injury.34

Treatment

  • Due to insufficient evidence, treatment guidelines for long CMC dislocations are lacking. Both conservative and surgical treatment methods have been utilized for these injuries.31
  • Some authors recommend initially treating long CMC dislocations diagnosed early with conservative closed reduction under procedural sedation using splint immobilization; however, this may be difficult to perform, and the approach is associated with a high risk of redislocation.32,34,35
  • Given this information, most long CMC dislocations are treated surgically, especially in cases of symptomatic chronic dislocation or if there is excessive swelling or an associated fracture.31,34
  • The most common surgical procedures used are ORIF and CRPP.34
    • Fracture-dislocations in which closed reduction and K-wire fixation is used are often difficult to reduce because of the pull of the extensor carpi radialis tendon. If it is difficult to apply a closed reduction, open reduction should be considered.8
    • In ORIF, the goal is to reconstruct the rigid central column of the hand, and joint debris and impediments to reduction such as trapped tendons need to be removed before definitive treatment begins. Transverse and oblique incisions are most often recommended for exposure of the CMC joint.31
  • The method of fixation most frequently used for long CMC dislocations is multiple K-wires.31
    • Some patients treated with open reduction may experience problems like residual pain at the long CMC joint and grip weakness. Arthrodesis may be needed in such cases.
  • Some studies have even suggested that arthrodesis be considered as the primary treatment for certain unstable long CMC fracture-dislocations.31
    • After surgery, the wrist should be immobilized for up to 6 weeks to allow fusion.

Complications

  • Neurovascular injury
  • Chronic CMC joint instability
  • Posttraumatic osteoarthritis
  • Complex regional pain syndrome
  • Interosseous muscle weakness
  • Impaired finger ROM

Outcomes

  • Reports have been published of long CMC dislocations managed with closed reduction that have yielded good long-term results.31
  • In one series of 11 dislocations of the index and long CMC joints, 1 was treated with primary CMC arthrodesis and the other 10 with reduction and K-wire fixation alone.
    • There were 4 unsatisfactory results, 1 related to an ulnar nerve palsy and the other 3 related to CMC joint arthrosis, but successful fusion of the involved CMC joint provided an excellent result in 2 of these 3 patients.31
  • Delayed treatment of long CMC dislocations has been found to result in poor functional outcomes and chronic residual pain.32
  • Intense postoperative physiotherapy has also been associated with increased chances of achieving a satisfactory outcome.35

Ring CMC joint dislocation and fracture-dislocation

  • While still generally rare, the rate of dislocation is much higher in the ring and little CMC joints than the index and long CMC joints, and concomitant hand injuries are common.36  Although isolated dislocations are possible, ring CMC joint fracture-dislocations are far more common.37
  • As opposed to the first three digits, the ring CMC joint is extremely mobile due to its saddle shape anatomy and loose ligamentous attachments, which makes it more vulnerable to injury.36
  • The likely mechanism of injury in ring CMC dislocations is longitudinal trauma upon a volarly flexed wrist, such as in a fistfight or from a biking accident.36,38  An indirect injury to the ring metacarpal is unlikely to lead to an isolated fracture, and when a bending or torsional stress is applied, it can lead to an associated small CMC joint dislocation.37
  • Fracture-dislocations of the ring and little CMC joints are potentially more severe than those of the little CMC joint alone.39
  • Strong dorsal ligaments with additional dynamic support of wrist extensors make dorsal ring CMC dislocations more common than volar ones.38
  • Isolated fractures of the ring metacarpal should raise suspicion of an associated ring CMC joint dislocation, since the two injuries can occur together.1

Imaging

  • Ring CMC dislocations are subtle and can be easily overlooked with routine radiographic views. Several special views are therefore recommended:
  1. Oblique radiographic views with the hand pronated 30° are considered mandatory.38
  2. A posteroanterior view may be needed to look for features that suggest joint disruption. If the diagnosis is clinically suspected, several special radiographic views have been recommended.37
  • A CT scan may also be needed to visualize the dislocation and assess the hamate for fracture of the articular surface or hook.

Treatment

  • Common treatment options for ring CMC dislocations included closed or open reduction followed by stabilization with K-wires, screws, or screws and plates.39
  • Closed reduction and K-wire fixation is recommended for ring CMC joint dislocations that are diagnosed within 7-10 days.  Diffuse edema, overlapping of metacarpal bases and interposition of ligamentous structures may cause failure of closed reduction attempts.36  Therefore, open reduction is often necessary if a fracture-dislocation is present.36

Complications

  • Pain
  • Infection
  • Arthrosis
  • Ulnar nerve injury
  • Joint incongruity
  • Metacarpal shortening
  • Loss of range of motion
  • Posttraumatic osteoarthritis
  • Reduced grip strength

Outcomes

  • Delayed diagnosis and treatment of ring CMC dislocations has been associated with negative outcomes and complications.  Up to 43% of patients with neglected single CMC joint injuries experience residual pain and impaired function, but with appropriate management, up to 87% of patients return to full work and sporting activities with negligible pain.40
  • In one study, 15 patients with ring and little CMC fracture-dislocations were treated with either CRPP or open reduction and percutaneous pinning (ORPP). Results indicated that the CRPP group experienced greater improvements in pain, function, and grip strength than the ORPP group.38

Related Anatomy for metacarpals index, long and ring.

Index metacarpal

  • The index metacarpal consists of a distal head that articulates at the MP joint with the proximal phalanx, a supportive neck, a narrow diaphyseal shaft, a proximal metaphysis, and a base that articulates at the index CMC joint, primarily with the trapezoid. The base is shaped like a fork, with radial and ulnar condyles that envelop the trapezoid. The radial condyle articulates with the trapezium, while the longer ulnar condyle articulates with the base of the long metacarpal and capitate.24
  • Ligamentous attachments include a deep capsular ligament on its volar surface that extends from the trapezium to the base of the index metacarpal, and a superficial ligament. On its dorsal aspect, the base of the index metacarpal has a deep capsular ligament that connects it to the trapezium and a superficial ligament that inserts on the trapezoid. Four strong interosseous ligaments attach the bases of the metacarpals, and the strongest of these is the ligament between the index and long metacarpals.9,15
  • The tendons associated with the index metacarpal include the flexor carpi radialis tendon, which inserts onto its volar surface, and the ECRL tendon, which passes through a dorsal groove on the trapezoid to insert on the radial condyle of the index metacarpal.15,24
  • The index CMC joint is an arthrodial diarthrosis, which is inherently stable due to the geometry of its articular surfaces, ligamentous integrity about the joint, and the tethering action of the long extrinsic wrist extensors.21

Long metacarpal

  • The long metacarpal consists of a distal head that articulates at the MP joint with the proximal phalanx, a supportive neck, a narrow diaphyseal shaft, a proximal metaphysis, and a base that articulates at the long CMC joint with the distal pole of the capitate and 2 small facets of the index and ring metacarpals. The long metacarpal articulates with the capitate by means of a facet that is concave in its dorsal portion, where it covers the styloid process that projects proximally. This articulation distinguishes the long CMC joint and is considered a keystone due to its more proximal location than the carpal articulations of the other metacarpals.25,26,32
  • The articulation of the ulnar base of the long metacarpal and the radial base of the ring metacarpal is secured by an interosseous ligament on the volar surface and a carpometacarpal ligament on the dorsal surface joins that the long and ring metacarpals to the capitate. There is also a transverse interosseous ligament between the long and index metacarpal, which is the strongest of the intermetacarpal ligaments.9,25
  • The primary tendon associated with the long metacarpal is the ECRB tendon, which inserts on the dorsoradial aspect of its base, immediately beyond the styloid process. The ECRB has much greater involvement in wrist extension than the ECRL, and it stabilizes the wrist in extension during gripping.9,26

Ring metacarpal

  • The ring metacarpal consists of a distal head that articulates at the MP joint with the proximal phalanx, a supportive neck, a narrow diaphyseal shaft, a proximal metaphysis, and a base that articulates at the ring CMC joint with the long metacarpal, little metacarpal, capitate, and hamate. The quadrilateral base is small and considerably variable, with 5 different morphologies. It can either articulate solely with the radial half of the hamate articular surface or it can articulate with both the hamate and the capitate through a smaller radial facet.9
  • Ligaments associated with the ring metacarpal include an interosseous ligament on the volar surface and a carpometacarpal ligament on the dorsal surface.9
  • The ring metacarpal is the only metacarpal that does not have any proximal tendon attachments to act as a deforming force when a fracture occurs. This is one of the main reasons that reports of isolated fractures of the ring metacarpal base are very rare.4,9
  • The ring CMC joint has far greater ROM than the index and long CMC joints. It allows marked flexion-extension of up to 20°, radial-ulnar deviation of up to 7°, and pronation-supination of up to 27°. The motion of the ring CMC joint also must be intact to afford the full ROM to the very mobile little CMC joint, and its motion in all 3 directions is paramount for grasping and palmar cupping in normal hand functioning.9

Incidence and Related injuries/conditions

  • Metacarpal and phalangeal fractures account for nearly half of all hand injuries that present to the emergency room.41
  • Metacarpal fractures are less common than phalangeal fractures, but comprise between 18-44% of all hand fractures.42,43
    • It is estimated that over 250,000 metacarpal fractures occur in the U.S. each year.42
    • One study reported an overall incidence rate of 13.7 metacarpal fractures per 100,000 person-years, with these injuries comprising 33% of all hand fractures in the U.S.3
  • Non-thumb metacarpals account for around 88% of all metacarpal fractures, with the little metacarpal being most commonly involved.42
    • In one study on 400 participants, fractures of the little metacarpal accounted for 75.5% of all metacarpal fractures, followed by the ring metacarpal (16.3%), long metacarpal (4.1%), and index metacarpal (4.1%).44
    • In another study on 785 participants, the little finger sustained 302 fractures, or 38% of all fractures distal to the carpal bones, which was primarily due to the high prevalence of little metacarpal fractures (11% of all hand fractures).45
  • Men between the ages of 10-29 have been identified as the population with the highest incidence of metacarpal fractures, with a peak incidence between ages 10-19.3
  • Punching a wall or door is by far the most commonly involved mechanism of injury for metacarpal fractures, while sporting activities—particularly football and basketball—account for the next largest portion.10
    • Another study found that bicycle accidents accounted for a large proportion of metacarpal fractures across all demographics, while accidental falls were the mechanism of injury over a bimodal distribution of age groups less than 9 and older than 50 years old.3
  • CMC dislocations and fracture-dislocations account for less than 1% of all hand injuries.35
ICD-10 Codes

  • ECRL AVULSION FRACTURE

    Diagnostic Guide Name

    ECRL AVULSION FRACTURE

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    ECRL AVULSION FRACTURE S62.310_S62.311_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S62
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
History of trauma
Fracture pain and deformity
Swelling and ecchymosis
Typical History

A classic patient is a 20-year-old, right-handed man who sustained an injury to his right hand after punching a wall. The man had gotten into a verbal altercation with his girlfriend and subsequently punched the nearest structure—an exterior concrete wall—with a significant amount of force. The impact of the strike axially loaded his ring metacarpal and resulted in a fracture of its shaft, which led to immediate pain, swelling, and deformity that propelled him to seek out medical attention.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Metacarpal Fractures (II-IV)
  • Index metacarpal comminuted fracture CT
    Index metacarpal comminuted fracture CT
  • Index metacarpal comminuted fracture CT reconstruction views
    Index metacarpal comminuted fracture CT reconstruction views
Treatment Options
Treatment Goals
  • When treating closed index, long, and ring metacarpal fractures, the treating surgeon has 4 basic goals:5,13
    1. A hand with a normal appearance. The X-ray may not need to be perfect, but the metacarpal should have no obvious deformity (ie, the hand looks normal!)
    2. Avoid stiffness by maintaining a normal functional ROM (ie, the hand works!)
    3. The metacarpal is not painful (ie, the hand does not hurt!)
    4. Congruent joint surface with none-to-minimal joint surface irregularities (ie, the CMC joint does not develop early posttraumatic arthritis!)
    5. One additional goal is mandatory for open fractures.  Fracture care should minimize the risk for infection and osteomyelitis.
Conservative
  • The majority of index, long, and ring metacarpal fractures are isolated, simple, closed, and stable injuries that can be treated nonsurgically. Typical fractures that are closed, nondisplaced, and minimally angulated without significant malrotation can be managed in a plaster, fiberglass, or custom splint.2,4,7
    • Even index, long, and ring metacarpal fractures that require a reduction to correct fracture-related deformity usually can be held in anatomic or near-anatomic alignment with a splint without internal or external surgical fixation.
    • Initial immobilization in the intrinsic plus position—wrist extension 25°, 80° MP flexion and full interphalangeal (IP) extension or the position of function—is recommended to avoid shortening of the collateral ligaments and digital stiffness. Conversion to a short cast with the MP and IP joints free is contingent on fracture location, stability, and patient compliance.2
  • Conservative treatment is indicated for closed metacarpal head fractures with articular congruency, demonstrated MP stability, and less than 20% articular surface involvement.2  Metacarpal head fractures typically require longitudinal traction only, and finger trap traction is a simple and effective maneuver.2
  • Most closed metacarpal neck fractures are treated nonsurgically, as they produce minimal functional problems in the absence of pseudoclawing or rotational malalignment despite angulation on the lateral radiograph and shortening in the frontal projection.1
    • Criteria for acceptable reduction of closed metacarpal neck fractures vary depending on the mobility at the CMC level. The index metacarpal has minimal CMC motion and can accommodate less than 15° of apex dorsal angulation, while the long metacarpal can accommodate up to 20° and the ring metacarpal up to 30°. Conservative treatment is recommended up to these limits.2,4
    • The Jahss maneuver remains the best technique for closed reduction of metacarpal neck fractures; however, the fingers should never be immobilized in the “Jahss position” (MP and PIP joints flexed 90 degrees) because of the risk of skin necrosis over the dorsum of the PIP joint, damage to the extensor hood, or permanent PIP stiffness.1,2
    • Casting for metacarpal neck fractures should be removed after 4-6 weeks.
  • Most transverse metacarpal shaft fractures are minimally displaced and treated conservatively; however, shaft fractures are generally less forgiving than neck fractures. Mobility at the CMC joint allows up to 20-30° of apex dorsal angulation in the ring metacarpal without functional impairment, while the index and long metacarpals can only tolerate minimal apex dorsal angulation, and reduction should be attempted with greater than 10-20° of angulation.4,14  Closed reduction of metacarpal shaft fractures is performed with longitudinal traction, dorsal pressure at the fracture site, and rotation as needed. Three-point molding is useful for transverse patterns, in which dorsal pressure is placed at the fracture site and palmar pressure applied proximally and distally. 2
    • Casting options for these fractures include the ulnar gutter splint, and the short hand cast.14
    • Conservative management of spiral/long oblique metacarpal shaft fractures almost always results in shortening and hence these fractures have the reputation of ending up with an extension lag at the MP joint and reduced grip strength.14
    • When casting is used, it should be left in place for 4 weeks.
    • Custom fracture braces also can be used effectively for metacarpal fracture care.
  • Most extra-articular base fractures are stabilized by the intermetacarpal ligament and are only minimally displaced. If rotational alignment is preserved, cast immobilization is sufficient.  Optimal treatment strategies for ring metacarpal base fractures is controversial, but in general, all patients should be treating with initial immobilization using a dorsal and volar splint with the wrist in 30° of extension and the MP joints unimpeded by the splint.9
  • Intra-articular base fractures without dislocation can also occur after avulsions of the wrist extensors. For small comminuted intra-articular metacarpal base fractures with preserved joint congruency, immobilization with the wrist extended at 20-30° is indicated. 2  Closed reduction and casting is also generally recommended for minimally displaced intra-articular fractures of the ring metacarpal base, but in the presence of marked displacement, comminution, or complete avulsion of a tendinous insertion, most authors recommend either CRPP or ORIF.9
  • Metacarpal fractures typically unite within about 6 weeks.
Operative
  • Surgical treatment of index, long, and ring metacarpal fractures must always be an individualized therapeutic decision. However, surgical metacarpal fracture care is most frequently recommended when:
    1. Closed reduction fails or the splint, fracture brace, or cast immobilization does not maintain the reduction. For these irreducible or unstable fractures, operative treatment is recommended to achieve the 4 treatment goals of fracture care.
    2. There is a significantly displaced base of the metacarpal fracture involving the CMC joint. Surgical fracture care is often required in these cases.
    3. There is an open metacarpal fracture, which requires surgical care in the form of irrigation and debridement to prevent chronic infection.
  • Subacute malaligned metacarpal fractures that are more than 3-4 weeks from injury are also indications for operative treatment.4
  • Most metacarpal head fractures have articular involvement and are often comminuted, meaning they are best treated operatively in most cases. Another way of identifying the need for surgery in these fractures is when there is >1 mm of articular step-off.1,2,4
    • ORIF is indicated when articular displacement is unacceptable (>1 mm).
    • When fixation is required, the decision between pins, screws, and plates depends on the size and number of fracture fragments.
    • Large, 2-part fractures are amenable to fixation with small screws, while a minicondylar plate may be useful in sagittal and coronal patterns and head fractures with proximal metaphyseal extension.
    • Highly comminuted head fractures are problematic, but fare better with CRPP than open reduction because of the risk for avascular necrosis. Direct fracture fixation with multiple K-wires or cerclage wires can be effective in stabilizing tenuous reductions of these fractures. Unstable reductions may require immobilization for 2-3 weeks before range of motion exercises are started.1,2
  • MP arthroplasty and external fixation are other options for late reconstruction of severe intra-articular fractures.
    • Displaced ligament avulsion fractures and osteochondral fractures of the metacarpal head can be satisfactorily managed by ORIF.1
    • When the articular surface is not amenable to repair, replacement arthroplasty or arthrodesis may be considered.4
  • Index, long, and ring metacarpal neck fractures that are irreducible, open, or intra-articular, and those with any malrotation or unacceptable angulation require surgical reduction and fixation.
    • Open fractures to the metacarpal head/neck area, especially those resulting from fistfights, mandate exploration to exclude involvement of the MP joint and/or extensor mechanism.
    • Delayed presentation of metacarpal neck fractures occurs commonly, and closed reduction techniques may be ineffective if the fracture is more than 10 days old.
    • ORIF may be needed if CRPP cannot accomplish the reduction, but these fractures are difficult to plate due to limited bone for distal fixation.1
  • Surgical indications for metacarpal shaft fractures include greater than 10° of angulation in the index or long metacarpals, and greater than 30-40° of angulation in the ring metacarpal. Spiral metacarpal shaft fractures often shorten and rotate, and therefore necessitate fixation as well.1,4
    • Surgical options for fracture fixation include CRPP, intramedullary fixation, tension band wiring, cerclage and interosseous wiring, K-wires, interfragmentary compression screws, plate fixation, and external fixation.1,2
    • CRPP is useful when early mobilization is not essential.1,2
    • Plates provide the most rigid fixation and are of varying thickness and strength. There appears to be no difference between miniplates (1.3 mm) and microplates (0.6 mm) in terms of outcome or failure rate.4
    • Open reduction is recommended in cases of multiple metacarpal fractures when the support of the intermetacarpal ligaments has been lost.2
    • External fixation is reserved for metacarpal fractures with segmental bone loss or exposed dorsal structures requiring access for wound care.2
    • The ring metacarpal is the narrowest of the metacarpals, and special care must therefore be taken when placing hardware in this bone. Screws that are too big may greatly reduce bone strength and can cause additional fracture.11
  • For intra-articular base fractures of the index, long, and ring metacarpals, closed reduction is often insufficient to maintain congruity at the CMC joints, and surgery is indicated in the presence of joint subluxation or incongruity. CRPP is preferable to open reduction if the articular surface can be restored adequately.2
    • For comminuted intra-articular base fracture-dislocations, 2 approaches have been championed:
      • 1) Reduction, pin fixation, and subsequently arthrodesis if pain persists.
      • 2) Primary arthrodesis of the second or third CMC joint. 2
  • Corrective osteotomy is considered by some to be the treatment-of-choice for metacarpal shaft and neck malunions, whereas osteotomy or arthrodesis can be performed for malunion at the base. 2

Post-treatment Management

  • The care and precautions related to immobilization devices for the index, long, and ring metacarpal fractures must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive splint tightness are red flags and should be reported to the surgeon or his team.
  • Pain should be managed with properly fitting splints, reassurance, elevation, ice in the initial post-fracture period, and mild pain medications. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
  • Joints that are splinted for closed stable fractures are usually immobilized.
  • Joint mobilization is contingent on fracture location and stability.
  • Patients should be instructed to carefully exercise all joints in the injured hand that do not require immobilization. Patients usually can exercise on their own; however, signs of generalized finger or hand stiffness are indications for referral to hand therapy (PT or OT).
    • Metacarpal fractures that involve the distal shaft, neck, and head treated nonsurgically have a greater tendency for secondary displacement, and aggressive rehabilitation should be delayed for 3-4 weeks after injury.
    • Metacarpal base and proximal shaft fractures are immobilized in an intrinsic plus splint with IP joints free to start active and passive ROM exercises.
  • Gentle active motion at the MP level is allowed in the most proximal stable fractures.
  • Passive MP mobilization is added when there are signs of clinical union, typically at 5-6 weeks after injury. Strengthening exercises are added at 8 weeks.2
  • Surgically managed metacarpal fractures are immobilized for at least 2 weeks in a bulky intrinsic plus splint until sutures are removed.
    • The rehabilitation plan is individualized based on rigidity of internal fixation, patient compliance, and the complexity of associated soft-tissue injuries and repairs.
    • Active MP and active/passive IP motion is initiated within days of surgery in compliant patients with rigid internal fixation. Passive MP motion is added at 4 weeks after surgery.
    • Cast immobilization is used for 4-6 weeks in noncompliant patients with rigid fixation. Mobilization follows thereafter, according to the protocol described previously for nonsurgical fractures.2
  • If an infection does occur, management should focus on eradicating sepsis with thorough debridement, appropriate antibiotics (eg, cephalosporin, penicillin), and fracture stabilization, followed by obtaining fracture union and regaining a functional extremity.1  Hardware removal after fracture healing may be needed to finally control metacarpal osteomyelitis.
Treatment Photos and Diagrams
Metacarpal Fracture (II-IV) Treatment
  • Pinning of metacarpal head fracture. Note potential for AVN of metacarpal head fracture fragments.
    Pinning of metacarpal head fracture. Note potential for AVN of metacarpal head fracture fragments.
  • Long oblique ring metacarpal fracture treated in fracture brace
    Long oblique ring metacarpal fracture treated in fracture brace
  • Index transverse non-displaced metacarpal fracture (arrow) treated in fracture brace.
    Index transverse non-displaced metacarpal fracture (arrow) treated in fracture brace.
  • Ring metacarpal base fracture (arrow). Treated in plaster splint.
    Ring metacarpal base fracture (arrow). Treated in plaster splint.
  • Long and ring spiral oblique metacarpal fractures (AP view) undergoing closed reduction and percutaneous pinning.
    Long and ring spiral oblique metacarpal fractures (AP view) undergoing closed reduction and percutaneous pinning.
  • Long and ring spiral oblique metacarpal fractures (Lateral view) undergoing closed reduction and percutaneous pinning.
    Long and ring spiral oblique metacarpal fractures (Lateral view) undergoing closed reduction and percutaneous pinning.
  • Index, long and ring displaced unstable metacarpal fractures (AP view)after open reduction and internal fixation with plates and screws.
    Index, long and ring displaced unstable metacarpal fractures (AP view)after open reduction and internal fixation with plates and screws.
CPT Codes for Treatment Options

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Common Procedure Name
ORIF metacarpal fracture
CPT Description
Open treatment of metacarpal fracture, single, includes internal fixation when performed, each bone
CPT Code Number
26615
CPT Code References

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Complications
  • The rate of complications associated with metacarpal fractures is between 32-36%, and the presence of more than one fractured metacarpal increases the likelihood of complication.4,47
  • Stiffness can develop after prolonged immobilization or delayed rehabilitation, and it is the most common complication of articular metacarpal head fractures. This stiffness may result from extensor tendon adhesions, collateral ligament or dorsal capsular contracture, devascularization of small articular fragments, or articular incongruity, and it is generally more difficult to treat than other complications.1,2,5,13
  • Malunion is less common than stiffness but more likely in open, severe, unstable metacarpal fractures. It primarily manifests as malrotation or dorsal angulation.2,43
    • Extra-articular malunions may be angulatory in transverse shaft fractures, rotational in spiral or oblique fractures, or shortened after crush injuries with bone loss.1
    • Metacarpal malunion after a transverse shaft fracture results in apex dorsal angulation in the sagittal plane, and healing of these fractures is particularly bothersome cosmetically and functionally.1
  • Angulation of the metacarpal shaft in the sagittal plane is better tolerated than angulation in the coronal plane.4  In contrast to angulation, rotation is poorly tolerated, as it transmits down the entire finger shaft and is exaggerated in flexion.4
  • Nonunion is a rare complication of metacarpal fractures, but is more common in transverse fracture patterns.2,4
  • Posttraumatic osteoarthritis can occur in the CMC joints after some metacarpal base fractures.
  • After crush injuries or open fractures, there may be shortening and associated soft tissue problems, such as tendon adhesions, ischemic injuries to the interosseous muscles, poor skin coverage, and neurologic deficit.1
  • Complications of not treating intra-articular metacarpal base fractures include weakness of grip strength and of wrist extension, decreased range of motion, posttraumatic osteoarthritis, tendon rupture, unstable metacarpal boss, and poor appearance.9
  • Osteomyelitis in the metacarpal is rare but can occur in open fractures, especially in diabetic patients or those with a compromised immune system. When this does occur, it can be serious: in one series, 39% of patients with osteomyelitis went on to amputation.4
Outcomes
  • Most outcomes for index, long, and ring metacarpal fractures are very good.1,2,16,19,25,26,30,31 Fortunately, the complications noted above are rare, and significant stiffness can usually be avoided with appropriate immobilization that allows unaffected joints and bones to stay mobile.
  • In one study on metacarpal neck fractures, there was no statistically significant difference between nonoperative and operatively treated patients, although the data trended towards favoring the nonoperative treatment group.4
  • Highly comminuted metacarpal head fractures have been found to fare better with CRPP than open reduction because of the risk for avascular necrosis.2
  • The several ORIF techniques available for metacarpal shaft fractures are associated with varying outcomes, so the least invasive method that can reliably restore and maintain anatomic alignment is typically recommended to achieve a successful outcome.
    • K-wire fixation has been reported to result in an 18% complication rate.
    • Outcomes of cerclage wiring have generally been positive, with full ROM reported in 34 of 36 patients.
    • Intramedullary fixation allows for early active motion, with only one nonunion in 27 fractures reported in a single cohort study.
    • Screw fixation also typically results in successful outcomes, especially in long oblique and spiral shaft fractures.
    • Plate fixation shows good to excellent outcomes, but has been associated with a complication rate of 35%.1
  • In one study, 24 patients with isolated oblique and spiral ring metacarpal fractures without substantial rotational or angular deformities were treated conservatively with casting, results were positive and functional outcomes were not influenced by initial metacarpal shortening or small amounts of residual metacarpal shortening.48
    • These fractures may be expected to shorten 3.1 mm, but some patients with shortening up to 6.9 mm had no complaints.
    • Researchers therefore believe that as long as there is no rotational or severe angular malalignment, ring metacarpal fractures may be adequately treated conservatively in a cast or a splint.48
  • In general, index and long metacarpal base fractures have been treated more successfully with ORIF than with conservative management.9  The sparse reports of ring metacarpal base fractures in the literature also suggest that ORIF leads to more favorable long-term outcomes in helping patients regain normal ROM and decreasing pain.9
Key Educational Points
  • Index, long, and ring metacarpal fractures must be mobilized before radiographic fracture healing is complete to avoid stiffness.
  • Immobilization of metacarpal fractures for 4-6 weeks is rarely needed.1
  • Today, metacarpal fractures can usually be treated without surgery.1,7
  • Underlying pathological conditions such as bone tumors—like enchodromas—and osteoporosis should be expected in fractures that occur from trivial trauma.
  • The functional needs of each patient must be considered when recommending treatment for index metacarpal fractures.
  • Although the percentage of intra-articular involvement associated with an unstable joint is not known, it has been suggested that avulsion fractures involving greater than 20% of the articular surface benefit from ORIF with lag screws. 2
  • In most cases, signs of clinical union will be present at 4 weeks after a closed metacarpal fractures. Although the fracture has not yet radiographically united, transitioning the patient to a removable splint and initiation of rehabilitation at this time can minimize stiffness.2
  • Controversy exists regarding the optimal treatment of metacarpal neck fractures, and the following factors should be considered when making treatment decisions: which metacarpal neck is fractured, the degree of angulation, and if there is a rotational deformity. Angulation can be better compensated for in the ring and little metacarpals than the index and long metacarpals.1
  • There is considerable controversy regarding the amount of shortening that is acceptable. Regardless of fracture geometry, certain situations may influence the surgeon to perform operative fixation, including the presence of multiple fractures—especially spiral and oblique—open fractures, especially with bone loss or concomitant soft tissue injury, and fractures in polytrauma victims who cannot cooperate or tolerate cast immobilization.1
  • While many metacarpal fractures have excellent outcomes without surgery, there is a paucity of available literature and persistent controversy to guide physicians on the optimal treatment approach for these injuries.4
  • Lag screws may provide strong fixation in long oblique fractures and allow for early motion but should only be used when the fracture length is at least two times the width of the metcarpal.4
References

New and Cited Articles

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  2. Weinstein LP, Hanel DP. Metacarpal fractures. J Hand Surg Am 2002;2(4):168–180. Link
  3. Nakashian MN, Pointer L, Owens BD, Wolf JM. Incidence of metacarpal fractures in the US population. Hand (NY) 2012;7(4):426-30. PMID: 24294164
  4. Kollitz KM, Hammert WC, Vedder NB, Huang JI. Metacarpal fractures: treatment and complications. Hand (NY) 2014;9(1):16-23. PMID: 24570632
  5. Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41:712-22. PMID: 27113910
  6. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29:1128-38. PMID: 15576227
  7. Walenkamp MM, Vos LM, Strackee SD, Goslings JC, Schep NW. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4:307-16. PMID: 26649263
  8. Makino T, Fujioka H, Kokubu T. Neglected fracture dislocation of the second and third carpometacarpal joints: a case report. Hand Surg 2007;12(2):97-100. PMID: 18098361
  9. Bushnell BD, Draeger RW, Crosby CG, Bynum DK. Management of intra-articular metacarpal base fractures of the second through fifth metacarpals. J Hand Surg Am 2008;33(4):573-83. PMID: 18406963
  10. Soong M, Chase S, George Kasparyan N. Metacarpal fractures in the athlete. Curr Rev Musculoskelet Med 2017;10(1):23-27. PMID: 28185124
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  13. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458
  14. Al-Qattan MM. Outcome of conservative management of spiral/long oblique fractures of the metacarpal shaft of the fingers using a palmar wrist splint and immediate mobilisation of the fingers. J Hand Surg Eur Vol 2008;33(6):723-7. PMID: 18662959
  15. Crichlow TP, Hoskinson J. Avulsion fracture of the index metacarpal base: three case reports. J Hand Surg Br 1988;13(2):212-4. PMID: 3385304
  16. Jena D, Giannikas KA, Din R. Avulsion fracture of the extensor carpi radialis longus in a rugby player: a case report. Br J Sports Med 2001;35(2):133-5. PMID: 11273978
  17. Shyamsundar S. Avulsion fracture of the extensor carpi radialis longus tendon: case report and literature review. Hand Surg 2012;17(2):247-9. PMID: 22745093
  18. Kim KC, Shin HD, Rhee KJ. Treatment of avulsion fractures of the second metacarpal base with a miniplate and screws. Orthopedics 2008;31(3):285. PMID: 19292224
  19. Najefi A, Jeyaseelan L, Patel A, et al. Avulsion Fractures at the Base of the 2(nd) Metacarpal Due to the Extensor Carpi Radialis Longus Tendon: A Case Report and Review of the Literature. Arch Trauma Res 2016;5(1):e32872. PMID: 27148501
  20. Jessa KK, Hodge JC. Avulsion fracture of tendon of extensor carpi radialis longus: unknown mechanism. J Emerg Med 1997;15(2):201-7. PMID: 9144063
  21. Ho PK, Choban SJ, Eshman SJ, Dupuy TE. Complex dorsal dislocation of the second carpometacarpal joint. J Hand Surg Am 1987;12(6):1074-6. PMID: 3693840
  22. Cardozo DF, Plata GV, Casas JA, Rodríguez NS. Acute Dislocation of the Metacarpal-Trapezoid Joint. Clin Orthop Surg 2016;8(2):223-7. PMID: 27247751
  23. Han KJ, Lee J, Seo H. Isolated volar fracture-dislocation of the base of the second metacarpal bone by indirect injury. J Clin Orthop Trauma 2015;6(1):42-5. PMID: 26549952
  24. Lang CJ, Ogden JA. Palmar (displaced) fracture of the proximal index metacarpal. J Orthop Trauma 1999;13(2):149-50. PMID: 10052793
  25. Cobbs KF, Owens WS, Berg EE. Extensor carpi radialis brevis avulsion fracture of the long finger metacarpal: a case report. J Hand Surg Am 1996;21(4):684-6. PMID: 8842967
  26. Tsiridis E, Kohls-Gatzoulis J, Schizas C. Avulsion fracture of the extensor carpi radialis brevis insertion. J Hand Surg Br 2001;26(6):596-8. PMID: 11884121
  27. Ghani Y, Sharma PR, Grant I. Non-surgical management of an avulsion fracture injury of extensor carpi radialis brevis. Hand Surg 2013;18(1):97-8. PMID: 23413860
  28. Turker T, Capdarest-Arest N. Open isolated extensor carpi radialis brevis avulsion injury: a case report. Hand (NY) 2013;8(3):354-7. PMID: 24426949
  29. Johnson AE, Puttler EG. Avulsion of the extensor carpi radialis brevis insertion: a case report and review of the literature. Mil Med 2006;171(2):136-8. PMID: 16578983
  30. Rotman MB, Pruitt DL. Avulsion fracture of the extensor carpi radialis brevis insertion. J Hand Surg Am 1993;18(3):511-3. PMID: 8515025
  31. Hanel DP. Primary fusion of fracture dislocations of central carpometacarpal joints. Clin Orthop Relat Res 1996;(327):85-93. PMID: 8641087
  32. Pundkare GT, Patil AM. Carpometacarpal Joint Fracture Dislocation of Second to Fifth Finger. Clin Orthop Surg 2015;7(4):430-5. PMID: 26640624
  33. Howard MB, Edmunds I. Lateral fracture dislocation of the second and third carpometacarpal joints. Hand Surg 2003;8(1):93-5. PMID: 12923941
  34. Jumeau H, Lechien P, Dupriez F. Conservative Treatment of Carpometacarpal Dislocation of the Three Last Fingers. Case Rep Emerg Med 2016;2016:4962021. PMID: 27703817
  35. Ardente PDF, Biayna JC, Sarrias JS, et al. Volar Dislocation of Second, Third and Fourth Carpometacarpal Joints in Association with a Bennet's Fracture of the Thumb Carpo-Metacarpal Dislocation: A Case Report. Open Orthop J 2017;11:1035-1040. PMID: 28979606
  36. Kural C, Başaran SH, Ercin E, et al. Fourth and fifth carpometacarpal fracture dislocations. Acta Orthop Traumatol Turc 2014;48(6):655-60. PMID: 25637730
  37. Chong AK, Chew WY. An isolated ring finger metacarpal shaft fracture?--beware an associated little finger carpometacarpal joint dislocation. J Hand Surg Br 2004;29(6):629-31. PMID: 15542229
  38. Gülabi D, Uysal MA, Çevik B, et al. Carpometacarpal fracture dislocation of the fourth and fifth finger: mid-term results of 15 patients. Eklem Hastalik Cerrahisi 2017;28(3):164-70. PMID: 29125814
  39. Gehrmann SV, Kaufmann RA, Grassmann JP, et al. Fracture-dislocations of the carpometacarpal joints of the ring and little finger. J Hand Surg Eur Vol 2015;40(1):84-7. PMID: 25538072
  40. Lawlis JF 3rd, Gunther SF. Carpometacarpal dislocations. Long-term follow-up. J Bone Joint Surg Am 1991;73(1):52-9. PMID: 1985994
  41. Mansha M, Miranda S. Early results of a simple distraction dynamic external fixator in management of comminuted intra-articular fractures of base of middle phalanx. J Hand Microsurg 2013;5(2):63-7. PMID: 24426677
  42. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 2001;26(5):908-15. PMID: 11561245
  43. Gudmundsen TE, Borgen L. Fractures of the fifth metacarpal. Acta Radiol 2009;50(3):296-300. PMID: 19173096
  44. Dichiera R, Dunn J, Bader J, et al. Characterization of Metacarpal Fractures in a Military Population. Mil Med 2016;181(8):931-4. PMID: 27483536
  45. van Onselen EB, Karim RB, Hage JJ, Ritt MJ. Prevalence and distribution of hand fractures. J Hand Surg Br 2003;28(5):491-5. PMID: 12954264
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  48. Eglseder WA Jr, Juliano PJ, Roure R. Fractures of the fourth metacarpal. J Orthop Trauma 1997;11(6):441-5. PMID: 9314153
  49. Hurst LC, Ferraro M, Lippman K, Coppola A.  Closed functional bracing of metacarpal fractures (preliminary report). Ortho Rev 1983; 12:49-56.
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Reviews

  1. Diaz-Garcia R, Waljee JF. Current management of metacarpal fractures. Hand Clin 2013;29(4):507-18. PMID: 24209950
  2. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458

Classics

  1. McInnes JD. Avulsion fracture of the base of the second metacarpal. Can Med Assoc J 1947;57(4):379. PMID: 20264807
  2. Waugh RL, Ferrazzano GP. Fractures of the metacarpals exclusive of the thumb. Am J Surg 1943;59(2): 186-194. Link
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