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Metacarpal Fractures (including Boxer's Fracture)

Metacarpal neck/shaft/base fractures: angulation tolerance by ray, malrotation assessment, non-operative vs K-wire/plate fixation, WALANT, complications.

71 citationsUpdated Oct 2026

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Overview

Metacarpal fractures are common injuries, predominantly resulting from low-energy mechanisms such as direct blows or striking an object [20]. The OTA A3.1 “Boxer’s fracture” of the fifth metacarpal neck is the most frequent variant, accounting for 23.4% of all metacarpal fractures [20]. In pediatric populations, the metacarpal neck is the most common site, representing 75% of cases, with peak incidence between 13 and 16 years of age [5]. While most metacarpal fractures are simple, closed, and stable, achieving excellent outcomes without surgery [6], the majority are managed nonoperatively [4]. Conservative functional techniques remain the optimum treatment for the majority of patients with single metacarpal fractures [13]. However, surgical fixation offers distinct advantages in properly selected cases to improve patient-centered outcomes [21, 22].

Nonoperative management is the standard of care for stable isolated fractures, typically involving buddy strapping and mobilization [20]. For malreduced or unstable fractures, a Burkhalter or James type cast or splint is maintained for three weeks, followed by physical therapy [20]. A Bruner cast is indicated for base of thumb metacarpal fractures or fracture dislocations and should be worn for four to six weeks [20]. Follow-up radiographs are not indicated for most fifth metacarpal base and neck fractures [8]. An evidence-based pathway for metacarpal fractures demonstrated that 92% of patients returned to full function without complications at 10 weeks [11]. There appears to be very little role for surgery in the management of closed spiral metacarpal fractures [12].

Operative intervention prevalence increases from the ulnar to the radial side of the hand, with rates of 4.6% for fifth metacarpal fractures, 3.7% for fourth, 6.3% for third, 14.9% for second, and 24.4% for thumb metacarpal fractures [20]. In children, most metacarpal fractures can be treated closed with cast immobilization [5]. Metacarpal shaft fractures are usually stable due to intermetacarpal ligaments, while neck fractures are typically managed with closed reduction and cast immobilization [5]. Up to 30 to 40 degrees of residual angulation is acceptable for fourth and fifth metacarpal neck fractures in children, compared to 10 to 20 degrees for the second and third metacarpal necks [5]. Displaced intraarticular metacarpal head fractures in older children or adolescents may require open reduction and internal fixation [5]. Pediatric Bennett fractures, which are Salter-Harris type III intraarticular fractures, are indicated for closed reduction and percutaneous pin fixation or open reduction and internal fixation with smooth pins [5]. There is a lack of high-quality evidence to guide treatment for metacarpal shaft fractures in adults, supporting the need for well-designed, multicenter trials [37].

Anatomy & Pathophysiology

Bony Anatomy and Biomechanics

The metacarpals form a cascade similar to a Roman arch, with the index and small fingers forming the borders and the middle finger forming the keystone [78]. The metacarpal neck is the weakest portion of the metacarpal bone [38]. The diaphyseal portion provides better purchase for fixation due to its tubular structure and thick cortices, whereas the metaphyseal portion has a thinner cortex [78]. The middle and ring fingers possess the most inherent stability due to their central location, while border digits are more prone to shortening, rotation, and angulation [78]. The ring metacarpal is a transitional element with approximately 10 degrees of mobility in flexion and extension at the carpometacarpal joint [50]. The fifth metacarpal is semi-independent and has a range of flexion–extension of approximately 20 degrees at the carpometacarpal joint [50]. The second to fifth metacarpals are bound together by fibrous structures, including the deep transverse intermetacarpal ligament, which ties together the anterior glenoid ligaments of the metacarpophalangeal articulations [50].

The metacarpal head has a cam-shaped articular surface in the sagittal plane with a larger volar-dorsal diameter than a proximal-distal diameter [78]. In the transverse plane, the metacarpal head resembles a trapezoid [78]. Collateral ligaments attach on the dorsal aspect of the metacarpal head within a recess and are elongated in flexion [78]. The combination of the trapezoidal shape of the metacarpal head, collateral ligament origins, and cam-shaped morphology contributes to inherent stability during metacarpophalangeal flexion [78]. The metacarpals are subcutaneous in position, making them susceptible to penetrating and crush injuries that may result in open fractures [78]. The curvature of the metacarpal diaphyseal segment and its flexion during fist formation make the metacarpal necks susceptible to fracture during punching [78]. The fifth metacarpal has the most anterior–posterior arc at the carpometacarpal joint, increasing its susceptibility to fracture during punching [78].

Carpometacarpal Joint Mechanics

Carpometacarpal joints increase in stability and decrease in dorsal-volar mobility when moving from the small to the index finger metacarpal [78]. The small and ring fingers are more tolerant to deformity than the index and middle finger metacarpals due to greater carpometacarpal mobility [78]. Range of motion at the carpometacarpal joints increases from 5 degrees at the index and long finger joints to up to 25 to 30 degrees at the small finger joint [81]. The ring and small finger carpometacarpal joints demonstrate a biconcave hamate articular surface with two facets separated by a central ridge [81]. The bony articulation of the ring and small finger carpometacarpal joints allows the largest amount of volar to dorsal movement, which aids in grip strength [81]. The hand can accommodate dorsal angulation by compensating with metacarpophalangeal hyperextension and carpometacarpal motion [52]. Carpometacarpal motion is greatest at the little finger (30 degrees), followed by the ring finger (20 degrees) [52]. The carpometacarpal joints of the long and index fingers are fixed and thus tolerate less angular deformity [52].

Mechanisms of Injury and Deforming Forces

Metacarpal neck fractures (boxer’s fracture) occur when a clenched fist strikes an immobile object, resulting in fracture with apex dorsal angulation [3]. Apex dorsal angulation occurs because impact on the dorsum of the metacarpal head causes comminution of the volar metacarpal neck [3]. Additionally, forces of intrinsic muscles crossing the metacarpophalangeal joint lie volar to its axis of rotation, creating a bending moment on the fracture [3]. Most metacarpal diaphyseal fractures have apex dorsal angulation because of the pull of the interossei, which results in flexion of the distal fragment [52]. The interossei are the deforming forces that cause dorsal angulation in metacarpal neck fractures [41]. Metacarpal neck fractures are inherently unstable because of volar comminution [52]. The metacarpal head displaces in the direction of flexion and tends to heal poorly due to the destruction of the volar cortex and deforming force of intrinsic muscles [134].

Rotational deformity of more than 5 degrees can lead to overlapping of the fingers in flexion (scissoring) [52]. Angular deformity at the metacarpal neck or metaphysis influences tendon balance less than deformity at the diaphyseal level [52]. Metacarpal shortening or angulation greater than 30 degrees can result in shortening of the intrinsics, with the potential for extensor lag at the proximal interphalangeal joint [52]. Cadaver experiments estimate 7 degrees of extensor lag per 2 mm of metacarpal shortening [52]. Metacarpophalangeal hyperextension usually can compensate for up to 4 mm of metacarpal shortening [52]. Every 2 mm of metacarpal shortening leads to 7 degrees of extensor lag [38]. Metacarpal shaft fractures are inherently stable because of the connections at the carpometacarpal joints and the intermetacarpal ligaments [52]. The intermetacarpal ligaments and interosseous muscles provide relative stability to nonborder digits in metacarpal shaft fractures [48]. Multiple metacarpal fractures inherently have increased instability because of disruption of secondary soft-tissue stabilizers [48].

Pathophysiology of Malunion and Deformity

Nonunion virtually never occurs in metacarpal neck fractures, but malunion may be a problem [3]. Patients with malunion may complain of a loss of the contour of the metacarpal head, diminished range of motion, prominence of the metacarpal head in the palm, and occasionally rotational malalignment or crossover [3]. Deformity at the metacarpal neck level does not affect tendon balance, motion, or strength [52]. Patients with little finger metacarpal neck malunion may have a "lump in palm" sensation or painful callosities with gripping because of the volar prominence of the metacarpal head [52]. A 30-degree angulation is associated with a flexor digiti minimi grip strength of 92% maximum and preserves 78% of the intact finger's range of motion [58]. The presence of pseudoclawing caused by excessive metacarpophalangeal joint hyperextension to counteract excessive metacarpal neck flexion is a relative surgical indication [48]. Axial shortening is correlated with malrotation and extensor lag at the metacarpophalangeal joint, and the resulting crossover deformity is poorly tolerated [48].

Classification

Metacarpal Neck Fractures: Metacarpal neck fractures, commonly referred to as boxer’s fractures, usually involve the ring and small metacarpals [3]. These injuries are far more common in brawlers and individuals who strike solid objects than in professional boxers [3]. The mechanism of injury involves a clenched fist striking an immobile object, resulting in fracture with apex dorsal angulation [3]. This apex dorsal angulation occurs due to impact on the dorsum of the metacarpal head causing comminution of the volar neck and bending moments from intrinsic muscles crossing the MCP joint volar to its axis of rotation [3]. Ring and little finger metacarpal fractures usually occur from punching-type mechanisms [19]. The little finger metacarpal is prone to fracture at the neck with punching injuries, whereas ring finger metacarpal fractures typically occur at the shaft [19]. Consequently, ring finger metacarpal shaft fractures may be considered a variant of boxer's fracture [19].

Pediatric Metacarpal Fractures: In children, the most common site of metacarpal fractures is the metacarpal neck, accounting for 75% of cases, usually in the small and ring fingers [5]. The peak incidence of metacarpal neck fractures in children is 13 to 16 years of age [5].

First Metacarpal Fractures: Fractures of the first metacarpal are classified as intra-articular or extra-articular [147]. Intra-articular fractures of the first metacarpal are subdivided into Bennett, Rolando, and severely comminuted fractures [147]. Extra-articular fractures of the first metacarpal are subdivided into oblique/spiral and transverse types, including basilar and diaphyseal fractures [147]. A previously undescribed Y-shaped fracture of the base of the first metacarpal exists, occurring in 3 of 10 base fractures [30].

Other Considerations: Hamatometacarpal fracture-dislocation is a rare injury consisting of a fourth metacarpal fracture and a fifth carpometacarpal joint injury [129]. The definition of metacarpal nonunion remains highly variable and lacks standardization with respect to clinical and radiographic criteria [43].

Clinical Presentation

Metacarpal fractures are common injuries that mostly present as simple, closed, and stable patterns [6]. These injuries have a minimal effect on patient well-being [10] and are mostly treated nonsurgically [10]. The estimated incidence of metacarpal fractures presenting for acute hospital care in the USA is 13.6 per 100,000 person-years [132]. Metacarpal neck fractures are a common injury in young and active patients [29] and result in substantial missed time from work [29].

Boxer’s fractures are rarely seen in professional boxers and are far more common in brawlers or individuals who strike solid objects such as walls [3]. These injuries invariably occur when a clenched fist strikes an immobile object, resulting in a metacarpal neck fracture with apex dorsal angulation [3]. Apex dorsal angulation also occurs because forces from intrinsic muscles crossing the MCP joint lie volar to its axis of rotation, creating a bending moment on the fracture [3]. The little finger metacarpal is prone to fracture at the neck with punching-type injuries [19]. Ring finger metacarpal fractures from punching-type mechanisms typically occur at the shaft [19]. The ring finger metacarpal shaft fracture may be considered a variant of boxer's fracture [19].

In children, the most common site of metacarpal fractures is the metacarpal neck, accounting for 75% of cases [5]. In children, metacarpal neck fractures usually occur in the small and ring fingers [5].

Simple, closed, and stable metacarpal fractures often achieve excellent outcomes without surgery [6]. Patients with malunion may complain of a loss of the contour of the metacarpal head [3]. Patients with malunion may complain of diminished range of motion [3]. Patients with malunion may complain of prominence of the metacarpal head in the palm [3]. Patients with malunion may occasionally present with rotational malalignment or crossover [3].

Metacarpal stress fractures can present with significant pain in athletes who perform sports involving repetitive movements of the hand and wrist [140]. Metacarpal stress fractures can impact performance in athletes who perform sports involving repetitive movements of the hand and wrist [140].

Investigations

Plain radiography: Standard radiographic assessment of metacarpal fractures requires specific views to ensure accuracy and detect associated injuries. True lateral radiographs are essential for accurate angular measurements, as Lamraski et al. demonstrated high interobserver and intraobserver reliability using these projections [3]. However, measurement of fracture angulation in small finger metacarpal neck fractures remains subject to a high degree of inter- and intraobserver variability [26]. While measured angulation positively influences surgeons’ decisions to operate on small finger metacarpal neck fractures, this influence has not been linked to improved functional outcomes [3]. Additionally, measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures [44]. The reverse oblique x-ray position is recommended as a standard view for evaluation [69], although a series of conservative treatment for fourth or fifth metacarpal fractures did not demonstrate additional value in performing standardized additional straight lateral X-rays [71].

For specific injury patterns, the CMC joints of the ring and small fingers are best evaluated on a 30-degree pronated oblique lateral view [102]. A semi-pronated PA radiograph provides a true PA projection of the ring and small finger metacarpals and associated CMC joints, helping visualize the ulnar side of the hand [102]. Oblique radiographs, specifically supinated oblique views, help assess displacement of metacarpal base fractures [52]. A Brewerton view (20° of MCP flexion) may assist with visualization of metacarpal head fractures [52]. A Roberts view (an AP of the CMCJ with the hand hyperpronated) can help when evaluating the thumb CMC joint surfaces [102]. A true lateral radiograph is needed for accurate diagnosis of carpometacarpal fracture-dislocations because swelling can obscure the deformity [105]. Loss of parallel joint surfaces at the carpometacarpal articulations in a posteroanterior radiograph is indicative of carpometacarpal dislocation [105]. Hamato-metacarpal injuries are uncommon and radiographic findings are often subtle, with the extent of injury often not appreciated [68]. The presence of an apparently isolated ring finger metacarpal fracture due to an indirect force should raise the possibility of an associated carpometacarpal joint injury [31].

CT: CT scans of the hand and wrist are often necessary to evaluate the extent and aid in surgical planning for concomitant fractures with significant comminution [102]. Concomitant carpal fractures can often be missed on plain radiographs [102]. CT is helpful when articular impaction is suspected in metacarpal base fractures [52]. A CT scan may also assist with visualization of metacarpal head fractures [52].

Clinical Examination: The history and physical examination is often the most important guide to treatment next to radiographs for metacarpal fractures [51]. Skin integrity should be evaluated first, and any injury indicating an open fracture should be noted [51]. Malrotation should be tested with particular attention toward the border digits [51]. Digit rotation is assessed statically with wrist tenodesis and dynamically as the patient initiates making a fist [38]. All fingertips should point toward the volar scaphoid tubercle during rotation assessment and should be compared with the contralateral side [38]. The examiner should check for malrotation, pseudoclawing, and MCP joint extensor lag in metacarpal neck fractures [38]. Inspection of the hand for CMC joint injuries should look for obvious deformities, malrotation of the digits, loss of knuckle height, excessive CMC extrusion, or scissoring [36]. Pain with range of motion of the hand, tenderness to palpation about the CMC joints, or lack of ability to open and close the hand warrants radiographs [36]. The motor branch of the ulnar nerve must be evaluated given its proximity to the fifth CMC joint [36]. Multiple CMC dislocations should be identified and compartment syndrome should be considered given the significant amount of force involved and resulting hand swelling [36].

Treatment

Non-Operative

Nonoperative management remains the mainstay of treatment for metacarpal fractures, as the majority are closed, simple, and stable injuries amenable to conservative care with external immobilization and subsequent rehabilitation [155, 156]. Most metacarpal fractures are simple, closed, and stable, often achieving excellent outcomes without surgery [6]. Conservative functional techniques are the optimum treatment for the majority of patients with single metacarpal fractures [13]. The vast majority of metacarpal fractures are treated nonoperatively with a splint or taping for less than 4 weeks [38]. Most metacarpal fractures can be successfully managed with immobilization for 3 to 4 weeks [48].

For central metacarpal fractures with minimal displacement, shortening, and no malrotation, nonoperative management is indicated [143]. A removable wrist splint in addition to buddy taping of the affected digit to an adjacent uninjured digit is preferred [143]. The wrist splint may be discontinued at 3 to 4 weeks, and the buddy taping may be removed at 6 weeks [143]. Casting or more rigid splinting is indicated in noncompliant patients or those with associated injuries [143]. Isolated metacarpal shaft fractures are usually stable and are treated with cast immobilization [154]. Nondisplaced or minimally displaced metacarpal base fractures are treated with 3 to 4 weeks of cast immobilization [154].

The intrinsic-plus splint position for metacarpal fractures involves the wrist in 15 to 30 degrees of extension, MCP joints in 70 to 90 degrees of flexion, and IP joints in neutral [38]. Closed reduction for metacarpal neck fractures can be achieved using the Jahss technique, which involves flexing the metacarpophalangeal joint to 90 degrees and using the proximal phalanx to push the metacarpal head dorsally [20]. Closed reduction of a metacarpal neck fracture almost always has a satisfactory result [48]. Nonoperative management for malreduced or unstable metacarpal fractures usually involves a Burkhalter or James type cast or splint maintained for 3 weeks, followed by physical therapy [20]. Most metacarpal neck fractures can be treated with closed reduction and 3 to 4 weeks of immobilization [38].

Acceptable angulation thresholds vary by digit. For index and long finger metacarpal neck fractures, acceptable angulation is less than 15 to 20 degrees [38]. For ring finger metacarpal neck fractures, acceptable angulation is less than 30 to 40 degrees [38]. For small finger metacarpal neck fractures, acceptable angulation is less than 60 to 70 degrees, a threshold described as controversial [38]. Greater compensation for metacarpal neck angulation is possible in the fourth and fifth rays due to more mobile carpometacarpal joints [38]. The amount of angulation tolerated in metacarpal neck fractures ranges from 10 degrees in the index finger to more than 50 degrees in the small finger [48]. For index and long finger metacarpal shaft fractures, acceptable angulation is less than 10 degrees [38]. For ring and small finger metacarpal shaft fractures, acceptable angulation is less than 30 degrees [38]. Less than 5 mm of shortening in metacarpal shaft fractures is acceptable without significant functional deficit [38]. Five degrees of malrotation in a metacarpal shaft fracture results in 1.5 cm of digital overlap [38]. Stability for ring or middle finger metacarpal shaft fractures is provided by the transverse intermetacarpal ligament, which prevents shortening [38]. Acceptable angulation for extraarticular basilar thumb metacarpal fractures is up to 30 degrees, secondary to compensatory CMC joint motion [38]. The mnemonic for the reduction maneuver of thumb metacarpal fractures is TAPE: traction, abduction, pronation, and extension [38].

Conservative treatment of little finger metacarpal neck fractures provides equivalent functional outcomes to surgical intervention, with an earlier return to work and no risk of surgical complications [1]. An evidence-based patient pathway for metacarpal fractures resulted in 92% of patients returning to full function without complications at 10 weeks following injury [11]. Metacarpal fractures are common, mostly treated nonsurgically, and have a minimal effect on patient well-being [10]. The moulded short metacarpal cast is an effective non-surgical treatment for angulated extra-articular metacarpal fractures of the diaphysis and diametaphyseal junction [53]. The short hand cast appears effective for isolated little finger metacarpal shaft fractures, maintaining acceptable fracture reductions in all but three of 17 patients with complete follow-up [45]. Patients reported better satisfaction when managed with neighbour strapping and without regular follow-up visits for fifth metacarpal neck fractures [85]. The time to return to work was a mean of 5 weeks for patients managed with plaster and 2.7 weeks for those managed with neighbour strapping for fifth metacarpal neck fractures [85]. There was no significant difference in the functional outcome at 12 weeks, as assessed by the DASH score, between plaster and neighbour strapping groups for fifth metacarpal neck fractures [85].

Historically, patients with transverse metacarpal fractures of the shaft and neck were left to mobilize freely and healed with some deformity but good function [90]. A Cochrane review has shown there is no good evidence that more marked malunion causes reduced hand function or unacceptable deformity for metacarpal neck fractures [90]. The outcome of non-operative treatment for metacarpal neck fractures is typically an excellent functional outcome, apart from a mild cosmetic abnormality [90]. No one technique of non-operative management has been shown to be superior in the published studies for metacarpal neck fractures [90]. The vast majority of metacarpal fractures in athletes are managed nonoperatively with protective bracing and rapid return to play [103]. Most central metacarpal fractures can be treated conservatively due to the inherent stability provided by stout ligamentous and muscular attachments [143]. Lack of compliance and access to therapy can worsen long-term results in nonoperative management of metacarpal fractures [156].

In children, most fractures of the metacarpals can be treated closed with cast immobilization [5]. Salter-Harris type II fractures of the finger metacarpals in children are treated in a manner analogous to extraphyseal metacarpal neck fractures [33]. Late attempts at reduction of finger metacarpal physeal fractures in children should be avoided to prevent additional injury to the growth plate [33]. Displaced finger metacarpal physeal fractures in children should be followed radiographically until normal growth can be confirmed [33].

Operative

Indications: Surgical intervention for metacarpal fractures is indicated for open injuries, intra-articular fractures, irreducible fractures, digit malrotation (scissoring), shortening, and multiple associated fractures [38]. The general indications for surgical management of metacarpal fractures include rotational malalignment, significant shortening or angulation, and involvement of multiple bones [48]. Multiple metacarpal shaft fractures are unstable injuries that often necessitate surgical intervention [38]. The presence of pseudoclawing caused by excessive MCP joint hyperextension to counteract excessive metacarpal neck flexion is a relative surgical indication [48]. Excessive angulation in thumb metacarpal fractures resulting in MCP joint hyperextension requires CRPP or ORIF [38]. More than 1 mm of articular step-off in metacarpal head fractures is an indication for ORIF [38]. Ring and small CMC joint fracture-dislocations are unstable injuries that often require surgical stabilization via CRPP or ORIF [38].

Surgical Approach / Technique: Irreducible metacarpal neck fractures are treated with closed reduction and percutaneous pinning (CRPP) using antegrade, retrograde, or transverse techniques [38]. Irreducible displaced metacarpal shaft fractures are treated with CRPP or open reduction and internal fixation (ORIF) [38]. Intramedullary pinning or screw fixation for metacarpal shaft fractures can be performed antegrade or retrograde [38]. Fixation techniques for metacarpal shaft fractures include Kirschner wires, plates and screws, intramedullary devices, and interfragmentary screw fixation [48]. Simpler fixation techniques are preferred to minimize soft-tissue dissection and subsequent scarring and tendon or joint dysfunction [48]. A recent trend exists toward retrograde percutaneous fixation of displaced metacarpal neck and shaft fractures using retrograde headless screws [48]. A recent review of 169 fractures treated with retrograde percutaneous fixation demonstrated a radiographic union rate of 100%, excellent functional outcomes, and minor complications [48].

Implant Selection: Lag screw fixation for metacarpal shaft fractures requires the fracture length to be twice the bone diameter [38]. Plate fixation increases biomechanical strength but can cause complications including stiffness and tendon irritation, necessitating hardware removal as a secondary procedure [48]. Prominent dorsal plates used for metacarpal fixation can irritate or injure extensor tendons [38]. Bioabsorbable plates and screws used for metacarpal fixation may cause a delayed foreign body reaction resulting in osteolysis or an inflammatory soft-tissue response necessitating surgical débridement [48]. A prospective study of plate fixation in 21 patients with closed multiple metacarpal fractures found fewer complications than previously reported [48]. Eighteen patients (86%) in a prospective study of plate fixation for closed multiple metacarpal fractures had 100% union with an excellent functional outcome [48].

Other Considerations: Careful assessment of axial shortening is required because it is correlated with malrotation and extensor lag at the MCP joint [48]. The resulting crossover deformity from axial shortening is poorly tolerated [48]. Standard radiographs for metacarpal fractures include AP, lateral, and oblique views, as well as a 30-degree pronated view for ring or small finger injuries or a 30-degree supinated view for index, middle, or ring finger injuries [48]. The goals of metacarpal fracture treatment are stable reduction, edema control, and early range of motion [38].

Surgical treatment is typically required for Bennett fractures to maintain the reduction [48]. Percutaneous Kirschner wire fixation is the most commonly used technique for Bennett fractures after an appropriate reduction [48]. It is not necessary for the Kirschner wire to pass through the small palmar fragment in Bennett fracture fixation because a reduced thumb ray will heal and maintain the thumb-index finger web span and pinch function [48]. A long-term follow-up study of 24 Bennett fractures managed with screw fixation found good clinical results with maintenance of reduction [48]. Seven patients in a study of 24 Bennett fractures managed with screw fixation had radiographic signs of arthritis that were not correlated with clinical symptoms or the accuracy of fracture reduction [48]. In a report of arthroscopically assisted fixation for Bennett fractures, the 1R and 1U portals were used for intra-articular visualization and confirmation of reduction [48].

Plate fixation is generally indicated for Rolando fractures [48]. Ligamentotaxis provided by monolateral external fixation is an alternative to plate fixation for Rolando fractures [48]. Displaced ligament avulsion fractures and osteochondral fractures of the metacarpal head can be satisfactorily managed by ORIF [75]. Small osteochondral fragments in metacarpal head fractures should not be discarded but instead "trapped in place" by larger fragments and not separately internally fixed [75]. Two-part coronal, sagittal, and oblique articular fractures of the metacarpal head are best managed by ORIF with Kirschner wires, small headless compression screws, or interfragmentary screws [75]. A recent study of 13 patients managed with open reduction and headless compression screws, Kirschner wires, or both for metacarpal head fractures achieved union in all cases, 89 degrees MCP range of motion, and a DASH score of 3.8 at 1-year follow-up [75]. The role of arthroscopic-assisted reduction with pinning or internal fixation for metacarpal head fractures is expanding in recent years [75].

Large defects in the metacarpal head have been successfully managed with osteochondral grafting [75]. Osteochondral autografts taken from a corresponding toe have reported successful short-term results for metacarpal head defects [75]. A nonarticulating portion of the dorsal aspect of the same metacarpal head has been utilized successfully for osteochondral grafting [75]. Osteochondral autografts are more commonly obtained from the knee and press-fit into the corresponding defect in the metacarpal head [75]. Osteochondral grafting can be done acutely for focal defects or as a salvage for posttraumatic osteonecrosis [75]. Alternative forms of treatment for comminuted articular metacarpal head fractures include skeletal traction, volar plate interposition arthroplasty, or silicone arthroplasty [75]. In a series of 14 patients, immediate silicone arthroplasty was recommended for open nonsalvageable articular fractures of the PIP and MCP joints [75].

Open fight bites associated with metacarpal head fractures require early surgical débridement and assessment of extensor mechanism injury [38]. Severe open or comminuted metacarpal head fractures, such as those from gunshot wounds, are treated with spanning external fixation [38]. Severe comminuted closed metacarpal head fractures may be treated with arthroplasty or arthrodesis, especially in the index MCP joint [38]. Joint stiffness is the most common complication with both nonoperative and operative treatment of metacarpal head fractures [38]. Care must be taken not to injure the nerve dorsal sensory branch of the ulnar nerve during open approaches over the fourth and fifth CMC joints [38]. Delayed treatment, painful malunion, or post-traumatic osteoarthritis of metacarpal base fractures may require arthrodesis [38].

A prospective comparison study of intramedullary pinning and functional immobilization for small finger metacarpal neck fractures with 30 to 70 degrees of angulation found no significant difference in range of motion or grip strength at 1-year follow-up [48]. Satisfaction and appearance were superior in patients surgically treated for small finger metacarpal neck fractures with 30 to 70 degrees of angulation, suggesting surgical treatment may offer aesthetic rather than functional improvement [48].

Complications

Malunion and Deformity

Malunion is a recognized complication of metacarpal neck fractures, potentially resulting in loss of the metacarpal head contour, diminished range of motion, palmar prominence of the metacarpal head, rotational malalignment, or digit crossover [3]. Although malunion is common after these fractures, it rarely causes a functional deficit in athletes [41]. When boxer's fractures heal with malrotation and/or volar angulation of the metacarpal head, patients may experience loss of grip strength and an extension deficit of the little finger [60]. Rotational malalignment is particularly significant; even less than 10 degrees of malalignment can create digit overlap during flexion and cause functional limitations [5], with 5° of malrotation specifically resulting in 1.5 cm of digital overlap [41]. Pseudoclawing, caused by excessive MCP joint hyperextension to counteract excessive metacarpal neck flexion, constitutes a relative surgical indication [48]. Additionally, displaced fractures at the base of the metacarpal can result in arthrosis [41].

Nonunion and Avascular Necrosis

Nonunion virtually never occurs in metacarpal neck fractures [3]. In a series of 28 patients treated with percutaneous transverse pinning for fifth metacarpal neck fractures, no nonunion or avascular necrosis of the fifth metacarpal head was observed at follow-up [60].

Surgical Complications

An unplanned early reoperation rate of 8.0% was observed after operative fixation of acute metacarpal fractures, with the majority of cases involving removal of symptomatic hardware and an average time to reoperation of approximately 2.1 months [70]. Complications following intramedullary screw fixation are relatively uncommon [28], with the procedure considered safe and associated with a low incidence of complications (2.5%) that can be safely and effectively managed [137]. Flexible intramedullary nailing of specific metacarpal fractures affords excellent results with a low complication rate [142]. In a literature review of 169 metacarpal fractures treated with intramedullary screw fixation, no serious complications were reported, and nine minor complications were reported, including four cases of hardware removal in asymptomatic patients [146]. Plate fixation increases biomechanical strength, but complications including stiffness and tendon irritation can occur, necessitating hardware removal as a secondary procedure [48]. Bioabsorbable plates and screws may cause a delayed foreign body reaction resulting in osteolysis or an inflammatory soft-tissue response necessitating surgical débridement [48]. RIS use in metacarpal fractures appears to provide adequate stability with satisfactory clinical outcomes and minimal complications [15].

Functional and Other Outcomes

A secondary metacarpal fracture in a patient with a previous little metacarpal fracture is more likely to occur at the original fracture site in patients with a previous shaft fracture than in those with a neck fracture [18].

Recovery

Non-Operative Recovery: Conservative management of little finger metacarpal neck fractures yields functional outcomes equivalent to surgical intervention [1], with an earlier return to work [1] and no risk of surgical complications [1]. Metacarpal fractures are predominantly treated nonsurgically and have a minimal effect on patient well-being [10]. Small amounts of shortening or dorsal angulation cause minimal functional impairment [74]. Early motion of adjacent joints in closed simple metacarpal fractures expedites recovery of motion and strength without adversely affecting fracture alignment [74]. Functional bracing leads to more rapid return to work and faster clinical improvement compared to casting for small finger metacarpal neck fractures [3]. In comparisons of buddy taping versus casting for small finger metacarpal neck fractures, the buddy taping group had fewer days off work [3]. A systematic review found that immobilization is unnecessary when comparing reduction and immobilization to soft wraps without reduction for small finger metacarpal neck fractures [3]. Nonoperative treatment of small finger metacarpal neck and shaft fractures is superior to pinning in terms of DASH and esthetic outcome [3]. A meta-analysis of six randomized controlled trials identified conservative treatment as the optimal treatment for small finger metacarpal neck fractures due to the lowest complication rate compared with pinning, plate fixation, and antegrade intramedullary nailing [3]. The short hand cast appears effective for isolated little finger metacarpal shaft fractures, maintaining acceptable fracture reductions in all but three of the 17 patients with complete follow-up [45].

Operative Recovery: An unplanned early reoperation rate of 8.0% was observed after operative fixation of acute metacarpal fractures [70]. The majority of these unplanned early reoperations involved removal of symptomatic hardware [70]. The average time to unplanned early reoperation was approximately 2.1 months [70]. Intramedullary screw fixation exhibits improved functional outcomes compared against open reduction and internal fixation (ORIF) for metacarpal fractures [32], with comparable complication rates to ORIF [32]. Antegrade intramedullary pinning offers some clinical advantages during the early recovery period over percutaneous retrograde intramedullary pinning for displaced fifth metacarpal neck fractures [164], though these advantages are not evident at 6 months postoperatively [164]. In a study of 28 cases of fifth metacarpal neck fractures treated by percutaneous intramedullary nailing, no patient reported residual pain at final follow-up [153]. For football players, the only variables that lessen return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures [42]. Surgical treatment of displaced metacarpal shaft fractures allows for immediate return to play as tolerated for in-season football players [163].

Malunion and Complications: Patients with a malunion of a metacarpal neck fracture may complain of a loss of the contour of the metacarpal head [3], diminished range of motion [3], prominence of the metacarpal head in the palm [3], or occasionally rotational malalignment or crossover [3]. Westbrook et al. found no correlation between the degree of malunion and grip strength or DASH in a series of 105 metacarpal neck fractures [3]. Lowdon noted no relationship between the presence of symptoms and residual angulation in a prospective series of 73 small finger metacarpal neck fractures [3]. Pace et al. demonstrated that while closed reduction improves the initial alignment, the ultimate alignment of the healed fracture is not affected [3].

Key Evidence

• [L1] Conservative treatment of little finger metacarpal neck fracture provides an equivalent functional outcome to surgical intervention with an earlier return to work and no risk of surgical complications. [1] (10.1142/s2424835520500290)
• [L5] The majority of metacarpal fractures are managed nonoperatively. [4] (10.1177/17531934231184119)
• [L5] The majority of metacarpal fractures are simple, closed, and stable, often achieving excellent outcomes without surgery. [6] (10.1007/s11552-013-9562-1)
• [L5] The authors advocate early surgical treatment for pathologic fractures of the head of the metacarpal of the fingers that have large displacement of the fracture fragments, with usual care for fractures with little or no displacement. [7] (10.1142/s0218810417720297)
• [L4] Follow-up radiographs are not indicated for most fifth metacarpal base and neck fractures. [8] (10.1177/1558944717733278)
• [L2] Metacarpal fractures are common and mostly treated nonsurgically and have a minimal effect on patient well-being. [10] (10.1016/j.jhsg.2025.02.015)
• [L4] The metacarpal fracture evidence-based pathway was successful with 92% of patients returning to full function without complications at 10 weeks following injury. [11] (10.1258/ht.2010.010026)
• [L4] There appears to be very little role for surgery in the management of closed spiral metacarpal fractures. [12] (10.1177/1753193414540408)
• [L5] Most hand fractures can be managed successfully without operation, and conservative functional techniques are the optimum treatment for the majority of patients with single metacarpal fractures. [13] (10.1177/1753193420928820)
• [L2] RIS use in metacarpal fractures appears to provide adequate stability with satisfactory clinical outcomes and minimal complications, although more high-quality studies are needed to fully examine this modality. [15] (10.1177/1558944720988073)
• [L4] A secondary metacarpal fracture in a patient with a previous little metacarpal fracture is more likely to occur at the original fracture site in patients with a previous shaft fracture than in those with a neck fracture. [18] (10.1177/17531934251313978)
• [L4] [19] (10.1016/j.jhsa.2010.05.013)
• [L4] While most metacarpal fractures can be treated nonsurgically, some fractures and patients can have improved patient-centered outcomes with surgical fixation. [21] (10.5435/jaaos-d-25-00323)
• [L5] The majority of hand fractures can be treated without surgery, though surgery offers distinct advantages in properly selected cases. [22] (10.1016/j.jhsa.2013.02.017)
• [L4] This is a simple and reliable technique for displaced, unstable metacarpal fractures that provides sufficient stability to the fracture site and with low morbidity. [23] (10.1097/prs.0b013e3182402e6a)
• [L4] [26] (10.1053/s0363-5023(06)90001-x)
• [L4] Complications following IMS fixation of metacarpal fractures are relatively uncommon. [28] (10.1016/j.jhsa.2023.01.012)
• [L4] Metacarpal neck fractures are a common injury in young and active patients that results in substantial missed time from work. [29] (10.5812/atr.32933)
• [L4] A previously undescribed Y-shaped fracture of the base of the first metacarpal exists, occurring in 3 of 10 base fractures, which requires radiographic diagnosis and special treatment similar to Bennett's fracture. [30] (10.1097/01.blo.0000205897.21233.11)
• [L4] The presence of an apparently isolated ring finger metacarpal fracture due to an indirect force should raise the possibility of an associated carpometacarpal joint injury. [31] (10.1016/j.jhsb.2004.05.003)
• [L3] Intramedullary screw exhibited improved functional outcomes when compared against ORIF, exhibiting improved patient outcomes with comparable complication rates and should be considered as a method for fixation of metacarpal fractures within appropriate settings. [32] (10.1177/15589447241312416)
• [L5] [33] (10.1016/j.hcl.2005.12.001)
• [L3] The authors suggest that both methods are comparable, good and safe methods of treating closed, displaced fractures of the metacarpal neck of the little finger, without significant complications. [34] (10.1016/j.jhsb.2005.06.022)
• [L2] There is a lack of high-quality evidence to guide treatment, supporting the need for well-designed, multicenter trials to identify the most effective and cost-efficient treatment for metacarpal shaft fractures in adults. [37] (10.1177/1558944720974363)
• [L4] The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures. [42] (10.1016/j.jhsa.2022.01.011)
• [L1] The definition of metacarpal nonunion remains highly variable and lacks standardization with respect to clinical and radiographic criteria. [43] (10.1016/j.jhsg.2023.04.014)
• [L3] Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. [44] (10.1016/j.jhsa.2014.05.023)
• [L3] The short hand cast appears effective for isolated little finger metacarpal shaft fractures, maintaining acceptable fracture reductions in all but three of the 17 patients with complete follow-up. [45] (10.1016/j.jhsb.2004.02.020)
• [L4] In this series, treatment of metacarpal fractures with low-profile plate fixation resulted in a 10% overall complication rate and a 1% reoperation rate. [47] (10.3928/01477447-20200925-02)
• [L4] We recommend that this minimally invasive technique combined with the simple modifications described above provides adequate fixation of displaced metacarpal fractures with good functional results and low morbidity. [49] (10.1016/s0020-1383(99)00201-6)
• [L4] The moulded short metacarpal cast is an effective non-surgical treatment for angulated extra-articular metacarpal fractures of the diaphysis and diametaphyseal junction. [53] (10.1177/17531934211024579)
• [L5] A 30° angulation is associated with a flexor digiti minimi grip strength of 92% maximum and preserves 78% of the intact finger's range of motion. [58] (10.1053/jhsu.1999.0835)
• [L4] [60] (10.1016/j.injury.2011.10.036)
• [L4] Hamato-metacarpal injuries are uncommon and radiographic findings are often subtle, with the extent of injury often not appreciated. [68] (10.1016/s0266-7681(05)80063-4)
• [L5] The authors recommend that this x-ray position be included as a standard view for evaluation of metacarpal fractures. [69] (10.1016/0363-5023(92)90362-s)
• [L3] An unplanned early reoperation rate of 8.0% after operative fixation of acute metacarpal fractures was observed, with the majority involving removal of symptomatic hardware and an average time to reoperation of approximately 2.1 months. [70] (10.1016/j.jhsg.2023.08.003)
• [L4] This series did not demonstrate any additional value in performing standardized additional straight lateral X-rays during the conservative treatment of fractures of the fourth or fifth metacarpal. [71] (10.1016/s0020-1383(97)00101-0)
• [L5] Recent reports confirm that small amounts of metacarpal shortening or dorsal angulation cause minimal functional impairment, and early motion of adjacent joints in closed simple metacarpal fractures expedites recovery of motion and strength without adversely affecting fracture alignment. [74] (10.1097/01.blo.0000205888.04200.c5)
• [L2] [85] (10.1016/j.jhsb.2006.09.021)
• [L4] [90] (10.1177/1753193414548170)
• [L5] The vast majority of metacarpal fractures in athletes are managed nonoperatively with protective bracing and rapid return to play. [103] (10.1016/j.hcl.2012.05.028)
• [Case_report] [129] (10.1016/j.jhsa.2010.08.035)
• [L3] The estimated incidence of metacarpal fractures presenting for acute hospital care in the USA is 13.6 per 100,000 person-years. [132] (10.1007/s11552-012-9442-0)
• [L4] [134] (10.23750/abm.v88i1.6195)
• [L4] Intramedullary screw fixation of metacarpal fractures is safe with a low incidence of complications (2.5%) that can be safely and effectively managed. [137] (10.1177/1558944719836214)
• [L4] Metacarpal stress fractures can present with significant pain and impact performance in athletes who perform sports involving repetitive movements of the hand and wrist. [140] (10.1177/15589447241266965)
• [L4] Flexible intramedullary nailing of specific metacarpal fractures affords excellent results with a low complication rate. [142] (10.1016/s0363-5023(05)80091-7)
• [L4] [146] (10.1097/prs.0000000000005478)
• [L5] [147] (10.5435/00124635-199911000-00006)
• [L4] At final follow-up, no patient reported residual pain, and the study recommends this minimally invasive technique for all metacarpal neck fractures, especially when severe swelling of the hand is present, due to good functional results and low morbidity. [153] (10.11604/pamj.2014.18.187.3347)
• [L5] The majority of metacarpal fractures are closed injuries amenable to conservative treatment with external immobilization and subsequent rehabilitation. [155] (10.1053/jssh.2002.36788)
• [L4] This study provides support for the surgical treatment of displaced metacarpal shaft fractures with immediate return to play as tolerated for in-season football players. [163] (10.1177/2325967114s00074)
• [L1] Antegrade intramedullary pinning has some clinical advantages during the early recovery period over percutaneous retrograde intramedullary pinning for treatment of displaced fifth metacarpal neck fractures, but the advantages are not evident at 6 months postoperatively. [164] (10.1007/s11999-014-4079-7)

See Also

• Dislocations

References

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