Metacarpal fractures,

Phalangeal fractures, Mallet

finger injury
By Muskan-e Muhemmed
Metacarpal fractures
• 30% of all hand fractures, most common 5th metacarpal
• Fatigue fractures in rare cases (e.g., stress injuries in athletes, occupational injuries due to
repetitive strain)
• Common mechanisms of injury
• Direct trauma (e.g., a fall, striking a firm object with a clenched
fist)→ transverse fracture
• Torsional trauma → oblique or spiral fracture
• Crush injury → comminuted fracture
• Diagnosis: Definitive diagnosis typically requires three radiographic
views: anteroposterior, lateral, and oblique
• Complications: Permanent deformity (e.g., malrotation, misalignment, bone reduction), Reduced grip
strength, Joint stiffness, Recurrent joint dislocation, Osteoarthritis
Clinical features
• Pain, swelling, and tenderness at the site of the affected metacarpal
• Reduced range of motion at the carpometacarpal (CMC)
and metacarpophalangeal joints
• Palpable or visible bone and/or joint deformity
• Angulation (mostly dorsal angulation → loss of the knuckle contour and/or
pseudoclaw deformity) 
• Malrotation → digital overlap 
• Shortening
• Displacement
• Concomitant injuries
• Tissue/skin injuries (e.g., laceration, protrusion of bone fragments)
• Neurovascular lesions
• Fractures of the scaphoid and/or distal radius/ulna
Classification
• Anatomical location
• Fractures of the metacarpal head, neck, base, and shaft 
• Fracture of the 4th or 5th metacarpal neck is called Boxer's
fracture  usually caused by a closed fist forcibly coming into
contact with a solid surface
• Type of fracture: transverse, oblique, spiral, comminuted
• First metacarpal fractures
• Intraarticular
• Type I metacarpal base fracture (Bennett fracture-dislocation) 
• Two-part fracture of the metacarpal base
• 1st metacarpal shaft fragment is radially and proximally dislocated by the
pull of the abductor pollicis longus muscle
• Type II metacarpal base fracture (Rolando fracture) 
• Comminuted fracture of the metacarpal base
• fragments often form a T- or Y-shaped pattern
• Extraarticular
• Type III metacarpal base fracture: transverse or oblique fracture of
the metacarpal base 
• Type IV metacarpal base fracture: a pediatric physeal fracture, most
commonly a type II Salter-Harris fracture
Treatment
• Conservative treatment
• Indication
• Simple, closed, and stable metacarpal fractures
• Mild deformity is often preferable to surgical treatment.
• Treatment options
• Closed reduction, if necessary
• Immobilization for approx. 4 weeks, depending on physical examination findings 
• 1st metacarpal fractures: short-arm thumb spica splint
• 2nd–4th metacarpal fractures: palmar wrist splint/cast
• 5th metacarpal fractures : ulnar gutter splint/cast or twin taping to the ring finger

• Surgical treatment
• Indication
• Open fractures
• Intraarticular fractures occupying > 25% of the articular surface
• Displaced fractures with a step-off of > 1 mm or subluxation/dislocation of the CMC joint
• Deformities leading to functional impairment: severe angulation , shortening  , or malrotation
• Treatment options: fracture fixation with K-wires, interfragmentary screws, or mini plates

• Ensure concomitant injuries and/or infections are also treated

Phalangeal Fractures
Classified as
• Open/Closed,
• Displaced/Nondisplaced
• By presence and type of growth plate involvement (Salter-Harris classification)
• By anatomical location of which phalanx is affected
• … and by co-existing tendon or nailbed injuries
• Appear due to crushing mechanisms, work and sporting injuries
• Usually present with localised swelling, bruising, tenderness, with or without deformity
• Significant angulation or displacement of fingers is sometimes mistaken for dislocation
clinically
• There may be ‘scissoring’ of the fingers if there is a rotational deformity
present

• Diagnosis: anteroposterior, lateral and oblique Xray of the affected hand

• Distal Phalanx fracture:

• Tuft Fracture (crush injury):

Soft tissue injury is often more

obvious; Xray required to detect
underlying fracture
• Management consists mainly of
treating any associated soft
tissue or nailbed injury or tip
avulsion. Place in a neutral hand
splint and start oral antibiotics
for any open fractures.
• Follow up is with GP for most
injuries, but Hand Surgery team
if nailbed repair required
• Seymour Fracture:

Crush/hyperflexion injury distal phalanx with

associated nailbed injury (often seemingly
mild), and injury to growth plate.  The nail
plate is often displaced superficial to the
eponychium
• Management requires washout,
debridement, reduction, nailbed repair
and antibiotics, as this is an open fracture
Mallet Finger Injury
• Mechanism of injury:
• Sudden hyperflexion of the DIP (forced flexion) → avulsion/rupture of
the distal portion of the ED tendon from the distal phalanx
• May be associated with an avulsion fracture of the distal phalanx
• Affected tendon: Extensor digitorum tendon
• Clinical feature: loss of extension of DIP
• Treatment:
• Conservative: splint in extension position 
• Surgical repair for:
• Displaced fracture
• ≥ 45-degree extension deficit
• Complications:
• Tendon adhesions (most common) → flexion contracture of joints
• Joint stiffness
• Tendon rupture
• Chronic mallet finger deformity 
•  Can cause significant disability of fine motor skills (e.g., playing a
musical instrument, removing objects from a pocket)
• Middle or proximal phalanx fracture:
• Shaft Fracture
• Management: Reduction if angulated or displaced.
• Place in neutral hand splint. (Buddy taping may be ok for non-displaced fracture)
• Condyle fracture (a.k.a. Head fracture)
• One or both condyles may be affected - a unicondylar fracture is shown
• Management: these require early exact anatomical reduction by the Hand Surgery
team to prevent joint deformity developing.
This usually involves placement of K-wires or Open Reduction with Internal
Fixation
• Phalangeal Neck Fracture
• On examination there is usually evident dorsal displacement along with
bruising swelling and tenderness
• Management requires early expert anatomical reduction by the Hand
Surgery team (ie within a few days). This is to prevent an extension
deformity developing.
Place in neutral hand splint until surgical repair.
Sources
• https://next-amboss-com.db.rsu.lv/us/article/Wl0PDT?
q=metacarpal+fracture#Z10fb52133d4a0b409f733c062c8d92fc
• https://next-amboss-com.db.rsu.lv/us/article/N30-if?
q=mallet+finger#Z0d236d3cbaf4bd18ca563993206f766c
• https://www.rch.org.au/clinicalguide/guideline_index/fractures/
Phalangeal_Finger_Fractures/#:~:text=Fractures%20of%20the%20finger%20usually,is
%20a%20rotational%20deformity%20present.