Orthopaedic Emergencies 297INJURIES TO THE WRIST AND HAND2 It is often missed and must be suspected whenever pain and swelling are seen
around the metacarpophalangeal (MCP) joint of the thumb, after an abduc-
tion injury.
3 Look for tenderness over the ulnar aspect of the MCP joint.
(i) Test for laxity of the ulnar collateral ligament by applying a gentle
abduction stress to the proximal phalanx, which reproduces the
pain and demonstrates movement at the MCP joint.
(ii) Pinch grip and power are lost.
4 X-ray may show an avulsion fracture of the proximal phalanx or a degree of
MCP joint subluxation.
MANAGEMENT1 Immobilize the thumb in a thumb spica cast or splint, and refer to the ortho-
paedic team, as permanent disability may follow missed or untreated ruptures.
Fractures of the other metacarpals
DIAGNOSIS
1 These are caused by direct trauma and may be multiple. The classical,
isolated, little-finger metacarpal neck fracture or ‘boxer’s fracture’ is due to
punching a hard object.
2 Examine all cases for any rotational deformity. On f lexing the fingers into
the palm, the fingertips should point to the scaphoid. If not, a rotational
deformit y of t hat f inger exists.
3 Obtain anteroposterior, lateral and oblique X-rays of the hand.
MANAGEMENT1 Refer multiple fractures, rotated fractures, compound fractures, and
fractures associated with marked soft-tissue swelling from crushing to the
orthopaedic team.
2 Otherwise, for an undisplaced, isolated fracture, give the patient a high-arm
sling, an analgesic such as paracetamol 500 mg and codeine phosphate 8 mg
and either a padded crêpe bandage, or a plaster of Paris volar slab with the
hand in the ‘position of safe splintage’.
3 Position of safe splintage
(i) Hold the wrist extended, the MCP joints flexed, the
interphalangeal joints extended, and the thumb abducted with
the volar slab, which is kept in place with a crêpe bandage.
(ii) Pad well with cotton-wool, and extend the volar slab over the flexor
aspect of the forearm, on to the palm of the hand to the fingertips.
(iii) Instruct the patient to keep the hand elevated.
(iv) Refer all patients to the next fracture clinic.