TREATMENT
- Isolated, minimally displaced fractures may be treated
by closed methods similar to the treatment of trans-
verse fractures. - Fractures that cannot be maintained with closed meth-
ods require either percutaneous pinning or open
reduction an internal fixation. - Interfragmentary lag screw fixation may be used if
fracture length is twice the bone diameter and pro-
vides the most biomechanically stable construct. For
fractures with a shorter surface a lag screw and
dorsal neutralization plate can provide stable fixa-
tion permitting early return to sport (Black et al,
1985).
COMMINUTED FRACTURES
- May be associated with soft tissue loss.
•Treatment often requires ORIF or external fixation to
maintain length. - May require delayed or primary bone grafting.
METACARPAL HEAD FRACTURES
- Rare fractures that occur from axial loading or direct
trauma, must examine closely to assure that fracture is
not the result of a fight bite. - Nondisplaced fractures may be treated nonoperatively
with initial splint immobilization followed by buddy
taping and early range of motion (Palmer, 1998). - Displaced fractures require open reduction and internal
fixation to restore anatomic alignment and articular
congruity with Kirschner wires, screws, minifragment
plates or dynamic traction to allow for early motion; if
early motion cannot be started then immobilization in
the intrinsic plus position should be maintained until
motion can be initiated (Palmer, 1998). - Complications include limited motion and arthritis.
METACARPAL NECK FRACTURES
- Most commonly involves the ring or small finger
(Boxer’s fracture). - Apex dorsal angulation and volar comminution can
make it difficult to maintain reduction with cast
immobilization. - Angular deformity of 40°to 60°may be accepted at
the ring and small fingers secondary to the mobility of
the fourth and fifth carpometacarpal joints. More than
15 °to 20°of angulation is unacceptable at the index
or long metacarpals secondary to the lack of motion at
their carpometacarpal joints (Capo and Hastings,
1998; Henry, 2001).
•Treatment for the majority of fractures comprises
closed reduction by the technique described by Jahss
(1938) and immobilizing the fracture in a short-arm
gutter splint with the fingers in the intrinsic plus posi-
tion. Immobilization is continued for 2 weeks when
buddy taping and motion are initiated (Capo and
Hastings, 1998).- Radiographs should be obtained weekly with index
and long metacarpal fractures to assure that reduction
is not lost.
•Surgical intervention is indicated for irreducible frac-
tures or in fractures where reduction is lost. Operative
intervention may include closed-reduction and percu-
taneous pinning, open reduction, and internal fixation
with tension band or a laterally applied minicondylar
plate (Capo and Hastings, 1998; Freeland, 2000). - Bouquet pinning with the insertion of multiple small
intramedullary Kirschner wires down the metacarpal
shaft and across the fracture into the metacarpal head
can provide stable fixation and early return of unre-
stricted hand function in fractures that would other-
wise require lengthy immobilization (Capo and
Hastings, 1998; Graham and Mullen, 2003). - The hand is immobilized in a splint for 2 weeks after
which motion is initiated with return to sports at
preinjury level within 6 weeks.
METACARPAL BASE FRACTURES•Metacarpal base fractures are rare fractures. They usu-
ally have a stable configuration secondary to set of
four strong interosseous ligaments.- Index and long CMC joints have limited motion while
ring and small CMC joints have 15°and 30°of mobil-
ity respectively (Capo and Hastings, 1998). - Nondisplaced or minimally displaced fractures are
treated in a short-arm cast with the metacarpopha-
langeal joints flexed and the interphalangeal joints
free. - Immobilization is often maintained for 6 weeks fol-
lowed by buddy taping for 2 to 3 weeks to maintain
rotational control and allow initiation of motion
(Palmer, 1998). - Displaced fractures often require closed or open
reduction followed by percutaneous fixation followed
by splint immobilization and the gradual restoration
of motion at 6 to 8 weeks post injury (Capo and
Hastings, 1998; Henry, 2001; Freeland, 2000; Palmer,
1998). - Fractures that proceed to malunion may cause weak-
ness of grip or pain with evidence of arthritis and may
316 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE