A metacarpal fracture is a relatively common condition characterised by a break in one of the long bones of the hand known as the metacarpals (figure 1).
Figure 1 – Relevant Anatomy for a Metacarpal Fracture
The palm of the hand primarily comprises of 5 long bones known as the metacarpals (figure 1). The metacarpal bones form joints with the small bones of the wrist known as the carpal bones and the small bones of the fingers known as the phalanges (figure 1).
During certain activities such as a punch or direct impact to the hand, stress is placed on the metacarpal bones. When this stress is traumatic and beyond what the bone(s) can withstand a break in one or more metacarpals may occur. This condition is known as a metacarpal fracture.
Due to the relatively large forces required to break a metacarpal bone, a metacarpal fracture is often seen in association with other injuries to the wrist or fingers such as joint sprains, dislocations or other fractures of the hand or wrist.
Metacarpal fractures can be divided into fractures of the metacarpal head, neck and shaft. Each fracture can vary in location, severity and type including displaced fracture, un-displaced fracture, compound fracture, greenstick, comminuted etc.
Appropriate treatment and management for each fracture is determined by a number of factors including:
Which metacarpal bone is involved (the 5th metatarsal bone is most commonly fractured)
The location of the fracture (the metatarsal neck is the most common fracture site)
The degree of angulation of each fracture (with acceptable angulation varying by location)
The presence or absence of malrotation (with no degree of malrotation being acceptable)
Metacarpal fractures account for 18 – 44% of all hand injuries and most commonly affect males between the ages of 10 – 29 years.
Cause of a metacarpal fracture
A metacarpal fracture most commonly occurs as a result of a punch (particularly into a hard object). Occasionally they may occur due to a direct impact to the hand from an object travelling at high speed (such as a hockey stick or cricket ball) or a fall onto the fingers or thumb. High speed injuries such as a motor vehicle accident may result in multiple fractures.
Signs and symptoms of a metacarpal fracture
Patients with this condition typically experience a sudden onset of intense hand pain at the time of injury. Pain may be felt on the front, back or sides of the hand and can occasionally settle quickly leaving patients with an achiness of the hand that is particularly prominent at night or first thing in the morning. Pain may also radiate into the fingers or wrist of the affected hand.
Patients with a metacarpal fracture may also experience weakness, swelling, bruising and pain on firmly touching the affected region of bone. Pain may also increase with certain movements of the wrist and fingers such as opening and closing the hand and fingers, general gripping activity, lifting, carrying objects and pushing through the affected hand. In severe metacarpal fractures with bony displacement, an obvious deformity may be present. Occasionally, patients may also experience pins and needles or numbness in the hand or fingers.
Diagnosis of a metacarpal fracture
A thorough subjective and objective examination from a physiotherapist, doctor or orthopaedic surgeon is essential to assist with diagnosis of a metacarpal fracture. X-rays are usually required to confirm diagnosis and assess the severity. Further investigations such as a CT scan, MRI, or bone scan may be required, in some cases, to assist with diagnosis and assess the severity of injury.
Prognosis of a metacarpal fracture
Most minor undisplaced metacarpal fractures, managed with appropriate immobilisation and physiotherapy, can recover and return to sport or full activities in approximately 6 -12 weeks (a protective splint may be required). In more severe cases, particularly those patients with displaced fractures, injuries to other structures or those fractures requiring surgery or anatomical reduction, recovery may take greater than 12 weeks, with a greater period of rehabilitation and physiotherapy. It is important to note however that the fracture may take many months to regain full bony strength.
Treatment for a metacarpal fracture
For those metacarpal fractures that are:
significantly displaced (or angulated)
involve the joint surface of the metacarpal
include rotational malalignment of the digit
are open fractures (i.e. penetrating the skin)
involve multiple metacarpal bones or for long spiral fractures
Treatment typically involves anatomical reduction (i.e. re-alignment of the fracture by careful manipulation under anaesthetic) followed by plaster cast or splint immobilisation for a number of weeks (often 4 weeks), or surgical internal fixation or external fixation (using pins that are inserted through the skin and bony fragments) to stabilise the fracture and aid healing. For those fractures undergoing surgery, early mobilisation is vital to optimise recovery. An orthopaedic surgeon can determine the most appropriate fracture management based on a variety of factors.
Treatment for stable fractures that are not displaced or rotated typically involves splinting or plaster cast immobilisation for a number of weeks. Following removal of the cast or splint, re-evaluation of the fracture clinically and with investigations, such as X-rays, is usually required to ensure healing. Once the bone has healed sufficiently, rehabilitation can begin as guided by your physiotherapist.
One of the most important components of rehabilitation following a metacarpal fracture is that the patient rests sufficiently from any activity that increases their pain. Activities placing large amounts of stress through the affected metacarpal should also be avoided particularly punching, lifting, gripping activity, pushing or pulling or placing excessive weight through the wrist and hand. Resting from aggravating activities allows the healing process to take place in the absence of further damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated. This should take place over a period of weeks to months with direction from the treating physiotherapist.
Ignoring symptoms or adopting a ‘no pain, no gain’ attitude is likely to cause further damage and may slow healing or prevent healing of the metacarpal fracture all together. Immediate, appropriate treatment in all patients with this condition is essential to ensure an optimal recovery.
Gently icing the metacarpal in the initial phase of injury (first 72 hours) and keeping it elevated above the level of the heart can assist in reducing swelling and pain. This should generally be implemented on the way to receiving urgent medical attention. Ice can be applied for 20 minutes and repeated every 2 hours.
Patients with a metacarpal fracture should perform pain free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. The treating physiotherapist and orthopaedic surgeon can advise which exercises are most appropriate for the patient and when they can commence. Early appropriate mobilisation is vital to optimise recovery.
Manual “hands-on” therapy from the physiotherapist such as massage, joint mobilisation, dry needling, stretches and electrotherapy can also assist with improving range of movement, pain and function following a metacarpal fracture. This can generally commence once the physiotherapist or surgeon has indicated it is safe to do so.
In the final stages or rehabilitation, a gradual return to activity or sport can occur as guided by the treating physiotherapist and surgeon provided symptoms do not increase. A protective splint or brace may be required when returning to sport.
Physiotherapy for a metacarpal fracture
Physiotherapy treatment is vital in all patients with this condition to hasten healing, ensure an optimal outcome and reduce the likelihood of recurrence. Treatment may comprise:
soft tissue massage
electrotherapy (e.g. ultrasound)
taping, bracing or splinting
exercises to improve strength and flexibility
a graduated return to activity plan
Other intervention for metacarpal fracture
Despite appropriate physiotherapy management, some patients with this condition do not improve and require other intervention to ensure an optimal outcome. The treating physiotherapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, extended periods of plaster cast or splint immobilization, surgery or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the metacarpal fracture. Occasionally, a bone graft may be required to aid fracture healing.
Exercises for a metacarpal fracture
The following exercises are commonly prescribed to patients with a metacarpal fracture following confirmation that the fracture has healed or that pain free mobilisation and strengthening can commence as directed by the surgeon. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.
Begin this exercise with your forearm supported by a table or bench and your wrist and fingers over the edge (figure 2). Slowly bend your wrist forwards and backwards until you feel a mild to moderate stretch pain free. Repeat 10 times.
Figure 2 – Wrist Bends (right side)
Hand Open and Close
Curl your fingers and thumb making a tight fist then straighten your fingers as far as possible pain free (figure 3). Repeat 10 times provided there is no increase in symptoms.
Figure 3 – Hand Open and Close (right hand)
Finger Adduction to Abduction
Begin this exercise with your fingers together as demonstrated (figure 4). Spread your fingers apart as far as possible pain free then return to the starting position. Repeat 10 times provided there is no increase in symptoms.
Figure 4 – Finger Adduction to Abduction (right hand)
Tennis Ball Squeeze
Begin this exercise holding a tennis ball (figure 5). Squeeze the tennis ball as hard as possible and comfortable without pain. Hold for 5 seconds and repeat 10 times.
Figure 5 – Tennis Ball Squeeze (right hand)
Physiotherapy products for a metacarpal fracture
Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with a metacarpal fracture include:
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