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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.

81 citationsUpdated Sep 2026

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Overview

Metacarpal fractures are common injuries that are predominantly simple, closed, and stable, with the majority achieving excellent outcomes without surgery [4, 7, 9]. Conservative functional techniques represent the optimum treatment for most patients with single metacarpal fractures, as these injuries generally have a minimal effect on patient well-being [5, 9]. While nonsurgical management is the standard of care for the vast majority of cases, surgical fixation offers distinct advantages in properly selected cases and can improve patient-centered outcomes for specific fracture patterns [12, 16]. In pediatric populations, the metacarpal neck is the most common site of injury (75%), typically affecting the small and ring fingers, with a peak incidence between 13 and 16 years of age [6]. Mechanisms in children often involve contact sports or striking an object, while shaft fractures usually result from direct blows [6]. Thumb metacarpal fractures in children occur proximally near the physis, unlike the distal metacarpal location seen in other digits [6].

Epidemiological data indicate that 96.3% of metacarpal fractures are treated nonoperatively, with operative rates varying significantly by digit location [23]. The OTA A3.1 “Boxers fracture” of the fifth metacarpal neck accounts for 23.4% of all metacarpal fractures [23]. Operative treatment prevalence increases from the ulnar to the radial side of the hand, with rates of 4.6% for fifth, 3.7% for fourth, 6.3% for third, 14.9% for second, and 24.4% for thumb metacarpal fractures [23]. Closed treatment is more often successful in metacarpal shaft fractures in children than in adults, and early motion is rarely indicated [18]. There appears to be very little role for surgery in the management of closed spiral metacarpal fractures [13].

Current evidence supports a high success rate for conservative pathways, with 92% of patients returning to full function without complications at 10 weeks following injury [10]. The only variables that lessen return-to-play time are involvement of lesser digit metacarpals and operative intervention for thumb metacarpal fractures [11]. Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures [17]. Despite these established patterns, 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 [26]. A prospective randomized controlled trial of operated versus unoperated, nonscissoring metacarpal fractures is warranted [1].

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 [80]. Stability increases and dorsal-volar mobility decreases when moving from the small to index finger metacarpal [80]. The index metacarpal is the most firmly fixed, while the ring metacarpal is a transitional element with about 10 degrees of mobility in flexion and extension [51]. The fifth metacarpal is semi-independent, articulating with the hamate and having a range of flexion–extension of approximately 20 degrees [51]. The small and ring fingers are far more tolerant to deformity than the index and middle finger metacarpals due to increased CMC mobility [80].

The metacarpal head has a cam-shaped articular surface in the sagittal plane with a larger volar-dorsal diameter than a proximal-distal diameter [80]. In the transverse plane, the metacarpal head resembles a trapezoid [80]. Collateral ligaments attach on the dorsal aspect of the metacarpal head within a recess and are elongated in flexion [80]. The combination of the trapezoidal head shape, collateral ligament attachments, and cam-shaped morphology contributes to inherent stability during MCP flexion [80]. The ring and small finger CMC joints demonstrate a biconcave hamate articular surface with two facets separated by a central ridge [83]. This bony articulation allows the largest amount of volar to dorsal movement, which aids in grip strength [83]. Range of motion at the finger CMC joints increases from 5 degrees at the index and long CMC joint to up to 25 to 30 degrees at the small finger CMC joint [83].

The metaphyseal portion of the metacarpal has a thinner cortex and does not provide rigid purchase for cortical fixation [80]. The diaphyseal portion of the metacarpal provides better purchase for fixation due to its tubular structure and thick cortices [80]. The middle and ring fingers have the most inherent stability secondary to their central location, while border digits are more prone to shortening, rotation, and angulation [80]. The metacarpal neck is the weakest portion of the metacarpal [38]. Metacarpal neck fractures are inherently unstable because of volar comminution [53]. The hand can accommodate dorsal angulation by compensating with metacarpophalangeal (MCP) hyperextension and carpometacarpal (CMC) motion [53]. CMC motion is greatest at the little finger (30°), followed by the ring finger (20°) [53]. The long and index fingers CMCs are fixed and thus can tolerate less angular deformity [53]. Angular deformity at the metacarpal neck/metaphysis influences tendon balance less than at the diaphyseal level [53]. Metacarpal shortening or angulation >30° can result in shortening of the intrinsics, with the potential for extensor lag at the proximal interphalangeal joint [53]. Metacarpal shaft fractures are inherently stable because of the connections at the CMC joints and the intermetacarpal ligaments [53].

Ligamentous Anatomy

The deep transverse intermetacarpal ligament ties together the anterior "glenoid ligaments" of the metacarpophalangeal articulations, known as the "volar plates" [51]. The volar plates are interconnected by the transverse interglenoid ligament [51]. The stability of the metacarpophalangeal joints is essential to the support of the longitudinal arch as well as of the transverse metacarpal arch [51]. The metacarpals are inherently stable secondary to the origins of the intrinsic muscles of the hand as well as the stout attachments of the deep transverse intermetacarpal ligaments [80]. The central digits are more protected from deformity secondary to the stabilizing effect of the deep transverse intermetacarpal ligaments and bony constraints imparted at the CMC joint [37]. The lack of bony constraints of the CMC joint to the ring and small fingers adds to their propensity for injury [37].

Vascular & Neural Anatomy

The ulnar motor branch is located volar to the small finger CMC joint [83]. The palmar arch is located volar to the middle finger CMC joint [83].

Mechanisms of Injury and Deforming Forces

Metacarpal neck fractures (boxer’s fracture) invariably occur when a clenched fist strikes an immobile object and the metacarpal neck fractures with an apex dorsal angulation [3]. Apex dorsal angulation in metacarpal neck fractures occurs because impact on the dorsum of the metacarpal head causes comminution of the volar metacarpal neck [3]. Apex dorsal angulation in metacarpal neck fractures also occurs because forces of the intrinsic muscles that cross the MCP joint lie volar to its axis of rotation and create a bending moment on the fracture [3]. The interossei are the deforming forces that cause dorsal angulation in metacarpal neck fractures [41]. Intrinsic muscles lead to apex dorsal angulation in metacarpal neck fractures [38]. Most metacarpal diaphyseal fractures have apex dorsal angulation because of the pull of the interossei, which results in flexion of the distal fragment [53].

The most common mechanism for CMC joint dislocations or fracture–dislocations of the fingers is an axial load with a clenched fist [37]. If force is applied when the metacarpal head is depressed, a dislocation of the fourth and fifth CMC joint will result [37]. In higher-energy injuries, a fracture of the base of the small finger metacarpal (reverse Bennett's fracture) or of the hamate articular surface may occur [37]. Fractures of the metacarpal base can represent CMC fracture–dislocations [53]. Fracture–dislocations are often associated with high-energy trauma, which may produce axial carpal injuries [53]. Fracture–dislocations of the CMC joint of the little finger and the metacarpal diaphysis are displaced proximally and ulnarly as a result of the pull of the extensor carpi ulnaris tendon [53]. The extensor carpi ulnaris (ECU) tendon is a major deforming force in metacarpal base fractures and CMC joint dislocations [38]. Accompanying distal row carpal fractures, especially of the hamate and capitate, may be seen and can signify a high-energy mechanism [38].

The mechanism of injury in Bennett and Rolando fractures is an axially directed force through the partially flexed metacarpal shaft [70]. In the Bennett fracture, the main portion of the thumb metacarpal is usually subluxated radially and dorsally by the combined pull of the thumb extensors, the abductor pollicis longus, and the adductor pollicis longus [70]. The volar carpal ligament prevents displacement of the volar fragment in Rolando and comminuted fractures [70]. The dorsal fragment in Rolando fractures is displaced by the abductor pollicis longus [70]. In extra-articular thumb metacarpal fractures, dorsal angulation occurs due to extension of the base by the abductor pollicis longus and flexion of the distal shaft by the thenar muscles [70]. The abductor pollicis longus is attached at the base of the thumb metacarpal and is the main deforming force in Bennett's and Rolando's fractures [83]. The adductor pollicis is attached distally on the thumb metacarpal shaft [83]. The thenar muscles are attached on the volar aspect of the thumb metacarpal [83].

The abductor pollicis longus displaces the metacarpal base proximally in Bennett fractures [41]. The anterior oblique ligament pulls the Bennett fragment to the base of the second metacarpal [41]. The abductor pollicis longus (APL) and radial extensors cause proximal, dorsal, and radial displacement of the metacarpal shaft in Bennett fractures [38]. The APL causes supination and adduction of the metacarpal shaft in Bennett fractures [38]. The anterior oblique or “beak” ligament keeps the volar-ulnar base fragment reduced to the trapezium in Bennett fractures [38]. The volar oblique ligament is attached to the volar ulnar fragment of the base in Bennett fractures [53]. The abductor pollicis longus displaces the distal metacarpal proximally in Bennett fractures [53]. The adductor pollicis displaces the metacarpal into adduction in Bennett fractures [53]. The metacarpal base is displaced dorsally and rotated into supination in Bennett fractures [53].

The metacarpals have a curvature to their diaphyseal segment and often flex during the making of a fist, making the metacarpal necks susceptible to fracture during punching [80]. The fifth metacarpal has the most anterior–posterior arc at the CMC joint, making it especially susceptible to fracture during punching [80]. Ring and little finger metacarpal fractures usually occur from punching-type mechanisms [22]. The little finger metacarpal is notoriously prone to fracture at the neck with punching-type injuries [22]. The ring finger metacarpal fractures in punching-type injuries occurred at the shaft [22]. The ring finger metacarpal shaft fracture might reasonably be considered a variant of boxer's fracture [22].

Epidemiology and Demographics

The incidence of metacarpal fractures is third in frequency only to phalangeal fractures and distal radius fractures in the upper limb [52]. Approximately 70% of metacarpal fractures occur during the second and fifth decades of life [52]. Metacarpal fractures are among the most prevalent injuries evaluated in the emergency setting, comprising approximately 30% of all hand fractures and 18% of all below-elbow fractures in the United States [44]. The majority (70%) of metacarpal fractures occur within the second and third decades of life [44]. Most metacarpal fractures are due to either accidental falls or direct blows to another object or individual [44]. Small-finger neck fractures and ring-finger shaft fractures are among the most common metacarpal fractures [44]. Metacarpal fractures are among the most common upper extremity fractures and typically occur in patients in their teens and twenties [47]. The commonest fracture in the study year was the OTA A3.1 “Boxers fracture” of the fifth metacarpal neck, which accounted for 23.4% of all metacarpal fractures [23]. Operative treatment increases in prevalence as one goes from the ulnar to the radial side of the hand [23]. Crushed hands are far less common than in the post–World War II period, and metacarpal fractures are now mainly caused by low-energy injuries, often by direct blows [23]. The reduction in operative treatment of metacarpal fractures likely relates to industrial and workplace safety legislation [23].

Pediatric Considerations

The most common mechanisms of injury for metacarpal fractures in children are contact sports and striking an object [6]. Metacarpal shaft fractures in children are usually the result of trauma such as a direct blow [6]. Most thumb metacarpal fractures in children occur proximally near the physis rather than the distal metacarpal [6]. As a rare variant, the thumb metacarpal may have a physis at the proximal and distal ends [6]. The physeal fracture that occurs most often at the base of the thumb metacarpal in children is a Salter-Harris type II injury [6]. Pediatric Bennett fractures are Salter-Harris type III fractures [6]. A displaced intraarticular metacarpal head fracture, which usually is seen in older children or adolescents, may require open reduction and internal fixation [6]. Phalangeal fractures are common in children, with the most common mechanism being sports activity [6]. Up to two thirds of phalangeal fractures in children occur in the proximal phalanx at a peak age of 12 years [6]. The majority of proximal and middle phalangeal shaft fractures in children can be treated with cast immobilization for 3 to 4 weeks [6]. Salter-Harris type II fractures of the proximal phalanx are the most common physeal fractures in children [6]. Growth arrest is uncommon in Salter-Harris type II fractures of the proximal phalanx in children [6]. Salter-Harris type III fractures of the base of the proximal or middle phalanx are intraarticular and often require open reduction and internal fixation [6].

Metacarpal Head Fractures

Metacarpal head fractures most commonly occur in the index or middle finger [38]. Some condylar injuries of the metacarpal head represent ligamentous avulsions [38]. The proposed mechanism of injury for coronal intra-articular and epiphyseal fractures of the metacarpal head in early adolescence is a force applied from the distal phalanx transmitted unevenly to the volar side when the metacarpophalangeal joint was slightly flexed [110].

Imaging and Assessment

The standard radiographs for metacarpal fractures include the AP, lateral, and oblique views as well as a 30° pronated view for a ring or small finger injury or a 30° supinated view for an index, middle, or ring finger injury [47]. Fracture location, comminution, angulation, rotation, and shortening must be carefully scrutinized on postinjury and postreduction radiographs [47]. Oblique radiographs help assess displacement in metacarpal base fractures (supinated oblique views) [53]. CT is helpful when articular impaction is suspected in metacarpal base fractures [53]. The fracture is best visualized on the true lateral and hyperpronated AP (Robert) views for Bennett fractures [53]. Radiographs for ring and small CMC joint fracture-dislocations include a pronated 30-degree oblique view [38]. CT is used for complex injuries of ring and small CMC joint fracture-dislocations [38]. The assessment of CMC joint injuries includes looking for obvious deformities and malrotation of the digits [37]. Loss of knuckle height

The Brewerton view (MCP joint flexed 65 degrees with the dorsum of the fingers lying flat on the x-ray plate and the tube angled 15 degrees in an ulnar-to-radial direction) can be helpful in delineating collateral ligament avulsion fractures of the metacarpal head not seen on routine views [74]. A skyline metacarpal view may also be helpful in visualizing the dorsal articular profile of the metacarpal head following a clenched-fist injury [74]. The MCP and interphalangeal (IP) joints are fully flexed and the beam is directed parallel to the dorsal shaft of the proximal phalanx for the skyline metacarpal view [74]. Computed tomography (CT) is often necessary if fracture visualization remains suboptimal on radiographs or operative intervention is contemplated [74]. A Brewerton view (20° of MCP flexion) or CT scan may assist with visualization of metacarpal head fractures [53].

Biomechanical and Surgical Considerations

The ring finger metacarpal shaft is significantly narrower than the little finger among men [22]. The mean radiographic diameters of both the ring and little finger metacarpal shafts were significantly greater in predominantly white men compared with Asian men [22]. The mean radiographic diameters of both the ring and little finger metacarpal shafts were significantly larger in men compared with women [22]. Women and Asians have smaller metacarpals [22]. Screw diameter greater than 30% of bone diameter may greatly reduce bone strength [22]. A 2.3- or 2.4-mm screw would be too large for a ring finger metacarpal shaft fracture in men, although acceptable for the little finger metacarpal [22]. A 2.0-mm screw would be too large for a ring finger metacarpal shaft fracture in women [22]. Metacarpal stress fractures can present with significant pain and impact performance in athletes who perform sports involving repetitive movements of the hand and wrist [69].

Classification

General Metacarpal Fracture Patterns

Metacarpal fractures can occur at any location [6]. In children, the metacarpal neck is the most common site, accounting for 75% of cases, with peak incidence between 13 and 16 years of age [6]. Shaft fractures typically result from direct blow trauma [6]. Fractures are broadly divided into intra-articular and extra-articular patterns [70]. Intra-articular fractures are subdivided into Bennett, Rolando, and severely comminuted types [70]. Extra-articular fractures are subdivided into oblique/spiral and transverse patterns [70], with transverse fractures including basilar and diaphyseal locations [70]. A previously undescribed Y-shaped fracture of the first metacarpal base occurs in 3 of 10 base fractures [30].

First Metacarpal (Thumb) Fractures

Intra-articular fractures of the first metacarpal base include Bennett and Rolando types [62]. Extra-articular fractures of the first metacarpal base include transverse, oblique, and complicated patterns [62]. The mechanism for Bennett and Rolando fractures is an axially directed force through the partially flexed metacarpal shaft [70]. In a Bennett fracture, avulsion of the main substance of the thumb metacarpal from the volar ulnar portion of the base occurs [70]. The main portion is usually subluxated radially and dorsally due to the combined pull of the thumb extensors, abductor pollicis longus, and adductor pollicis longus [70]. Rolando and comminuted fractures present as a Y-shaped intra-articular fracture of the base [70]. In Rolando fractures, the volar carpal ligament prevents displacement of the volar fragment, while the dorsal fragment is displaced by the abductor pollicis longus [70]. In extra-articular first metacarpal fractures, dorsal angulation occurs due to extension of the base by the abductor pollicis longus and flexion of the distal shaft by the thenar muscles [70]. In children, most thumb metacarpal fractures occur proximally near the physis rather than at the distal metacarpal [6]. The most common physeal fracture at the thumb metacarpal base in children is a Salter-Harris type II injury [6]. A rare variant of the thumb metacarpal may have a physis at both the proximal and distal ends [6].

Fifth Metacarpal (Little Finger) Fractures

Most metacarpal neck fractures involve the ring and small finger metacarpals [3]. "Boxer's fracture" is a misnomer, as these injuries are rarely seen in professional boxers [3]. Boxer's fractures are far more common in brawlers and in people who hit solid objects such as walls [3]. Boxer's fractures occur when a clenched fist strikes an immobile object, causing the metacarpal neck to 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 MCP joint lie volar to its axis of rotation, creating a bending moment [3]. The little finger metacarpal is prone to fracture at the neck with punching-type injuries [22]. Ring finger metacarpal fractures from punching-type mechanisms usually occur at the shaft [22]. Ring finger metacarpal shaft fractures may be considered a variant of boxer's fracture [22]. Intra-articular fractures of the base of the fifth metacarpal can be classified based on fracture pattern, ulnar and proximal subluxation, intraarticular step-off, and arthrosis [72]. The degree of arthrosis in the fifth carpometacarpal joint is graded from zero (normal) to three (extensive) based on the Knirk and Jupiter scale [72].

Hamatometacarpal Fracture-Dislocations

Hamatometacarpal fracture-dislocation consists of a fourth metacarpal fracture and a fifth carpometacarpal joint injury [112]. A novel classification scheme designates Type I as a simple combined dislocation of the fourth and fifth CMC joints without a fourth metacarpal fracture [129]. Type I can involve an accompanying hamate fracture with a tiny avulsion fragment [129]. A tiny avulsion fragment is defined as a dorsal cortical shell fragment of the hamate not involving the articular surface [129]. Type IIA involves a combined dislocation of the fourth and fifth CMC joints with a fourth metacarpal base intra-articular fracture [129]. Type IIB involves a combined dislocation of the fourth and fifth CMC joints with a hamate fracture of a small dorsal fragment [129]. A small dorsal fragment is defined as less than one-third of the length of the articular surface [129]. Type III involves a combined fourth and fifth CMC fracture-dislocation with a hamate fracture of a large dorsal fragment [129]. A large dorsal fragment is defined as more than one-third of the length of the articular surface [129].

Clinical Presentation

Epidemiology and Demographics

Metacarpal fractures are common injuries that comprise approximately 30% of all hand fractures and 18% of all below-elbow fractures in the United States [44]. The estimated incidence of metacarpal fractures presenting for acute hospital care in the USA is 13.6 per 100,000 person-years [64]. These injuries predominantly affect young patients, with the majority occurring within the second and third decades of life [44]. Men aged 10-29 have by far the highest incidence rates, exceeding the population injury incidence rates for their age groups [34]. In children, the most common site is the metacarpal neck (75%), usually in the small and ring fingers, with a peak incidence of 13 to 16 years of age [6]. Little finger metacarpal neck fractures account for approximately 10% of all hand fractures [40]. The OTA A3.1 “Boxers fracture” of the fifth metacarpal neck accounted for 23.4% of all metacarpal fractures in a study year [23].

Mechanism and Anatomy

Metacarpal fractures are now mainly caused by low-energy injuries, often by direct blows [23]. “Boxer’s fracture” is a misnomer as these injuries are rarely seen in professional boxers; they are far more common in brawlers and in people who hit solid objects such as walls [3]. Metacarpal neck fractures are common and usually involve the ring and small metacarpals [3]. The little finger metacarpal is notoriously prone to fracture at the neck with punching-type injuries, whereas the ring finger metacarpal fractures at the shaft [22]. Apex dorsal angulation in boxer’s fractures occurs because forces of the intrinsic muscles that cross the MCP joint lie volar to its axis of rotation and create a bending moment on the fracture [3]. The mean radiographic diameters of both the ring and little finger metacarpal shafts were significantly greater in predominantly white men compared with Asian men and women [22].

Clinical Findings and Symptoms

Metacarpal neck fractures are a common injury in young and active patients that results in substantial missed time from work [29]. Patients with a malunion of metacarpal neck fractures 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]. When metacarpal neck fractures heal in malrotation and/or in volar angulation of the metacarpal head, the result may be a loss of the grip strength and an extension deficit of the little finger [42]. Even a small amount (<10 degrees) of rotational malalignment can create overlap of the digits during flexion and cause functional limitations [6].

Radiographic Assessment

It is difficult to consistently measure the degree of angulation in boxer’s fractures [3]. Using lateral x-rays, angulation can be measured by lines that pass through the shaft (medullary canal) of the metacarpal and center of the metacarpal head or by lines that run tangential to the dorsal cortices of the proximal and distal fragments [3]. Lamraski et al. found high interobserver and intraobserver reliability using angular measurements on lateral radiographs but emphasized the importance of true lateral radiographs for accuracy [3]. Measured fracture angulation has been shown to positively influence surgeons’ decisions to operate on small finger metacarpal neck fractures, though this has not been linked to improved functional outcomes [3]. A 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 [33].

CMC Joint Injury Indicators

Loss of knuckle height, excessive CMC extrusion (shelf deformity for the thumb), or scissoring can alert the examiner to a CMC joint injury [37]. 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 [37].

Investigations

Plain radiography: Standard posteroanterior and true lateral radiographs are the primary diagnostic tools, with lateral views required for accurate measurement of angulation in metacarpal neck fractures [3]. Lamraski et al. demonstrated high interobserver and intraobserver reliability for angular measurements on these lateral radiographs [3]. For the ring and small fingers, a 30-degree pronated oblique lateral view best evaluates the carpometacarpal (CMC) joints, while a semi-pronated PA radiograph provides a true PA projection of the ulnar-sided metacarpals and associated CMC joints [101]. Thumb injuries require standard orthogonal views, supplemented by a Roberts view (an AP of the CMC joint with the hand hyperpronated) to evaluate joint surfaces [101]. Specific techniques include supinated oblique views to assess displacement in metacarpal base fractures [53] and a true lateral radiograph for carpometacarpal fracture-dislocations, as swelling can obscure deformity on other views [103]. Loss of parallel joint surfaces at the CMC articulations on a PA radiograph indicates dislocation [103]. For thumb CMC injuries, standard PA and true lateral radiographs rule out existing joint pathology and Bennett fracture-dislocation, where widening of the joint space or slight dorsoradial shift may be apparent [102]. A stress radiograph, performed with both thumbs parallel to the plate and distal phalanges pressed together along radial borders, is useful for diagnosing thumb CMC ligament injuries [102]. Obtaining a true lateral view of the thumb CMC joint requires placing the palmar surface flat on the film, pronating the hand and wrist 15 to 35 degrees, and directing the x-ray tube obliquely 15 degrees distal-to-proximal centered over the trapeziometacarpal joint [96].

CT: Computed tomography scans of the hand and wrist are often necessary to evaluate the extent of concomitant fractures with significant comminution and to aid in surgical planning [101]. CT is particularly useful for revealing injuries not easily seen on plain radiographs, such as subluxation of the CMC joint with an associated comminuted hamate fracture [101]. Concomitant carpal fractures can often be missed on plain radiographs, making CT a critical adjunct in complex trauma [101].

Other Considerations: The history and physical examination serve as the most important guide to treatment alongside radiographs [52]. Skin integrity is evaluated first to identify open fractures, followed by assessment of neurovascular status, ligamentous integrity, and tendon function [52]. Malrotation is tested with particular attention to border digits; digit rotation is assessed statically with wrist tenodesis and dynamically as the patient initiates a fist [38]. All fingertips should point toward the volar scaphoid tubercle, compared with the contralateral side [38]. The examiner checks for malrotation, pseudoclawing, and MCP joint extensor lag in metacarpal neck fractures [38]. For CMC joint injuries, inspection looks for obvious deformities and malrotation [37]. The motor branch of the ulnar nerve must be evaluated due to its proximity to the fifth CMC joint [37]. Multiple CMC dislocations should be identified, and compartment syndrome considered given the significant force involved and resulting hand swelling [37]. Thumb tendons are individually examined in cases of dislocation or base fractures [37]. Fluoroscopy is often in error compared with direct visualization for assessing displacement, gap, and step-off of Bennett fractures, with displacement perceived as 0 mm by fluoroscopy but noted as 3.1 mm on direct visualization [96].

Treatment

Non-Operative

Metacarpal fractures represent approximately 30% of all hand fractures and 18% of all below-elbow fractures in the United States [44]. These injuries are common and mostly treated nonsurgically, having a minimal effect on patient well-being [9]. Most hand fractures can be managed successfully without operation, with conservative functional techniques being the optimum treatment for the majority of patients with single metacarpal fractures [5]. The vast majority of metacarpal fractures are treated nonoperatively with splint or taping for less than 4 weeks [38], and most can be successfully managed with immobilization for 3 to 4 weeks [47]. In athletes, the vast majority of metacarpal fractures are managed nonoperatively with protective bracing and rapid return to play [63].

Closed reduction 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 and control rotation [23]. Nonoperative management for malreduced or unstable fractures is usually in a Burkhalter or James type cast or splint that is maintained for 3 weeks, followed by physical therapy [23]. A Bruner cast may be used for base of thumb metacarpal fractures or fracture dislocations of the thumb metacarpal and should be worn for 4 to 6 weeks [23]. The intrinsic-plus splint positions the wrist in 15 to 30 degrees of extension, MCP joints in 70 to 90 degrees of flexion, and IP joints in neutral [38]. The moulded short metacarpal cast is an effective non-surgical treatment for angulated extra-articular metacarpal fractures of the diaphysis and diametaphyseal junction [54]. Functional taping of fractures of the 5th metacarpal results in a quicker recovery [25].

In a prospective randomized trial, soft wrap and buddy taping was noninferior to reduction and casting for boxer’s fracture with palmar angulation ≤70° and no rotational deformity [93]. In a prospective randomized trial comparing immediate mobilization with cast immobilization for boxer's fractures with volar angulation up to 70 degrees, immediate mobilization gave good results [92]. Standardized additional straight lateral X-rays did not demonstrate any additional value during the conservative treatment of fractures of the fourth or fifth metacarpal [33]. The hand therapy management of metacarpal fracture pathway accounts for the location of the fracture, stability and surgical or non-surgical management based on best available evidence [36]. These findings support the viability of nonsurgical treatment for displaced single spiral or oblique metacarpal shaft fractures of rays IIeV in patients who prefer nonsurgical treatment [141].

In children, most fractures of the metacarpals can be treated closed with cast immobilization [6]. Metacarpal neck fractures in children usually can be treated with closed reduction and cast immobilization [6]. In children, up to 30 to 40 degrees of residual angulation can be accepted with closed treatment of fourth and fifth metacarpal neck fractures due to mobility and remodeling capacity [6]. In children, between 10 and 20 degrees of angulation generally is thought to be acceptable in the second and third metacarpal necks [6]. Reduction in children can be done using the Jones technique of flexing the metacarpophalangeal joint 90 degrees and placing a dorsally directed force on the proximal phalanx with counter pressure on the metacarpal shaft [6]. Nondisplaced or minimally displaced metacarpal base injuries in children are treated with 3 to 4 weeks of cast immobilization [136]. In displaced metacarpal base injuries in children, closed reduction is performed under local anesthesia or conscious sedation using longitudinal traction and direct pressure in a volar direction over the dorsal apex of the deformity [136]. Malrotation in children can be corrected simultaneously by flexing the MCP joint of the affected ray, rotating the digit, and restoring rotational alignment [136]. Patients with initial angulation greater than or equal to 50° had significantly higher mean changes in angulation than those with initial angulation less than 50° in a study of pediatric fifth metacarpal neck fractures [56].

Operative

Indications: The general indications for surgical management of metacarpal fractures include rotational malalignment, significant shortening or angulation, and involvement of multiple bones [47]. Surgical intervention is indicated for open injuries, intra-articular fractures, irreducible fractures, digit malrotation (scissoring), shortening, and multiple associated fractures [38]. Digit rotation is assessed statically with wrist tenodesis and dynamically as the patient initiates making a fist, with all fingertips pointing toward the volar scaphoid tubercle [38]. Surgical treatment is always indicated in severely displaced and unstable fractures of the fifth metacarpal neck [42]. In a Bennett fracture, the shaft is displaced by the intact abductor pollicis longus and adductor pollicis tendons, but the proximal ulnar fragment remains attached by the volar oblique ligament [47]. Surgical treatment is typically required to maintain the reduction in Bennett fractures [47]. A Rolando fracture is characterized by comminution of the thumb metacarpal base that leaves the shaft without a bony connection to the basal joint, and plate fixation is generally indicated [47].

Surgical Approach / Technique: The goals of treatment are stable reduction, edema control, and early range of motion [38]. The most commonly used technique after an appropriate reduction for Bennett fractures is percutaneous Kirschner wire fixation [47]. The extent of comminution in Rolando fractures can complicate surgical management, but ligamentotaxis provided by monolateral external fixation as an alternative has been used [47]. This is a simple and reliable technique for displaced, unstable metacarpal fractures that provides sufficient stability to the fracture site and with low morbidity, referring to modified retrograde percutaneous intramedullary Kirschner wire fixation [24]. RIS use in metacarpal fractures appears to provide adequate stability with satisfactory clinical outcomes and minimal complications, although more high-quality studies are needed [14]. In a retrospective study of 28 patients with displaced fifth metacarpal neck fractures treated with percutaneous transverse fixation, no patient had any clinically detectable rotational deformity or nonunion at follow-up [42]. The authors' preferred treatment for metacarpal fractures with minimal displacement, shortening, and no malrotation is nonoperative management using a removable wrist splint and buddy taping [118]. For large articular pieces with displacement in metacarpal head fractures, headless screw fixation in multiple planes is recommended [118]. In cases where rigid headless screw or plate fixation is achieved for metacarpal head fractures, early active motion may begin as soon as 1 to 2 weeks postoperatively under the guidance of a hand therapist [118]. In injuries where the metacarpal head is comminuted and cannot be pieced adequately together by headless screws, an external fixator with distraction of the joint can help the joint heal in a reasonable position [118]. Displaced ligament avulsion fractures and osteochondral fractures of the metacarpal head can be satisfactorily managed by ORIF [74]. 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 [74]. 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 DASH 3.8 at 1-year follow-up [74]. Large defects in the metacarpal head have been successfully managed with osteochondral grafting [74]. A comminuted articular fracture of the metacarpal head is the most difficult to treat and may require alternative forms of treatment including skeletal traction, volar plate interposition arthroplasty, or silicone arthroplasty [74]. The most common complication of articular fractures of the metacarpal head is stiffness [74]. Epiphyseal arrest can follow children’s metacarpal head fractures, and open reduction and internal fixation is recommended for displaced articular metacarpal head fractures to minimize longitudinal growth arrest [74]. Avascular necrosis can occur in metacarpal head fractures, is found predominantly in young adults, and usually involves the index and middle fingers [74].

Implant Selection: Intramedullary screw exhibited improved functional outcomes when compared against ORIF, exhibiting improved patient outcomes with comparable complication rates [31]. Intramedullary fixation should be considered for closed, extra-articular metacarpal fractures [32]. Intramedullary screw fixation is a reliable and safe method for metacarpal fractures, providing quicker return to motion, faster time to full range of motion, and similar time to union with fewer complications compared to plate and screw construct [75]. Intramedullary screw fixation of metacarpal fractures is safe with a low incidence of complications (2.5%) that can be safely and effectively managed [65]. When treating metacarpal shaft fractures, both ORIF with plate and screw and intramedullary screw can achieve acceptable outcomes [127]. This hybrid technique appears safe and effective for unstable metacarpal shaft fractures not typically suited for standard intramedullary fixation [67]. Plate fixation in closed multiple metacarpal fractures is a safe, reliable and consistently reproducible treatment method [120]. Non-locking plates are appropriate for most metacarpal and phalangeal fractures necessitating plate fixation [121]. There was no significant biomechanical difference found between the four different fixation techniques with regard to both displacement and ultimate failure strength of the constructs in oblique metacarpal fractures [48]. Short-term clinical and radiographic results encouraged the authors about the efficiency of external fixation as an alternative treatment method for combined open fractures of the thumb metacarpal and trapezium [49]. The procedure is contraindicated for intra-articular fractures, pediatric fractures, and cases with fragmentation of the metacarpal base, referring to cannulated screws for extra-articular metacarpal base fracture of the thumb [59].

Other Considerations: Overall 96.3% of metacarpal fractures were treated nonoperatively in a study year where the OTA A3.1 “Boxers fracture” of the fifth metacarpal neck accounted for 23.4% of all metacarpal fractures [23]. In 218 small finger metacarpal neck and shaft fractures, nonoperative treatment was superior to pinning in terms of DASH and esthetic outcome with similar results in terms of grip strength and union rate [3]. A metaanalysis of six randomized controlled trials totaling 288 patients found conservative treatment to be the optimal treatment due to the lowest complication rate compared with pinning, plate fixation, and antegrade intramedullary nailing [3]. Several studies comparing operative and nonoperative treatment of small finger metacarpal neck fractures have failed to demonstrate superiority of operative treatment [3]. In a prospective comparison study of intramedullary pinning and functional immobilization for small finger metacarpal neck fractures with 30° to 70° of angulation, no significant difference in range of motion or grip strength was found at 1-year follow-up [47]. Satisfaction and appearance were superior in patients who were surgically treated for small finger metacarpal neck fractures, suggesting surgical treatment may offer aesthetic rather than functional improvement [47]. Intramedullary splinting for displaced fractures of the little finger metacarpal neck offers an aesthetic, but not a functional advantage, compared to conservative treatment [94]. Conservative treatment has comparable outcome with bouquet pinning of little finger metacarpal neck fractures [40]. In a prospective study of plate fixation in 21 patients with closed multiple metacarpal fractures, 18 patients (86%) had 100% union with an excellent functional outcome [47]. There has been a recent trend toward retrograde percutaneous fixation of displaced metacarpal neck and shaft fractures using retrograde headless screws [47]. A recent review of 169 fractures treated with retrograde percutaneous fixation demonstrated a radiographic union rate of 100%, excellent functional outcomes, and minor complications [47].

In children, percutaneous pinning either intramedullary or to adjacent stable metacarpals can be performed for displaced or unstable metacarpal shaft fractures [6]. Occasionally, open reduction and internal fixation is necessary for long oblique length unstable metacarpal shaft fractures in children [6]. In children, a displaced intraarticular metacarpal head fracture, which usually is seen in older children or adolescents, may require open reduction and internal fixation [6]. In children, if troublesome malrotation persists and the fracture will not remodel, either percutaneous pinning or open reduction and internal fixation is indicated [6]. In children, unstable metacarpal shaft fractures or those with persistent malrotation are treated with closed reduction and percutaneous pin fixation via transmetacarpal or cross-pinning techniques [136]. In children, in cases of multiple metacarpal fractures, open reduction and internal fixation with interfragmentary compression screws or size-appropriate compression plates is performed via a dorsal approach [136]. In children, in unstable reductions or CMC fracture-dislocations of the metacarpal base, surgical stabilization is required [136]. In children, if reduction of a metacarpal base fracture is achieved with closed manipulation, percutaneous pin fixation using transmetacarpal pinning techniques or oblique pins into the proximal fracture fragment or carpus usually suffices [136]. In children, when a metacarpal base fracture is irreducible, formal open reduction is performed via a longitudinal incision, followed by pin fixation [136]. Pins are removed at 4 weeks in children, followed by range-of-motion exercises [136]. In children, a fracture of the thumb metacarpal base usually can be treated for 3 to 4 weeks in an abduction thumb spica cast [6]. In children, a Salter-Harris type II physeal fracture of the thumb metacarpal base can be treated by closed reduction [6]. In children, a pediatric Bennett fracture (Salter-Harris type III) is intraarticular and requires closed reduction and percutaneous pin fixation or open reduction and internal fixation with smooth pins [6]. In older adolescents, a fracture of the base of the first metacarpal that does not involve the physis (Rolando fracture) can be satisfactorily reduced and pinned percutaneously with the aid of image intensification [6]. In children, Type A thumb metacarpal base fractures (between physis and junction of proximal and middle thirds) are treated with closed reduction and cast, with residual angulation of 20-30 degrees acceptable depending on age and clinical appearance [6]. In children, Type B thumb metacarpal base fractures (Salter-Harris type II with

Complications

Malunion and Deformity

Malunion is common after metacarpal neck fractures but rarely causes a functional deficit in the athlete [41]. Small amounts of metacarpal shortening or dorsal angulation cause minimal functional impairment [35]. However, malunion may result in loss of the contour of the metacarpal head, diminished range of motion, prominence of the metacarpal head in the palm, rotational malalignment, or crossover [3]. Patients healing in malrotation and/or volar angulation may complain of loss of grip strength and an extension deficit of the little finger [42]. Specifically, 5° of malrotation results in 1.5 cm of digital overlap [41]. Pseudoclawing caused by excessive MCP joint hyperextension to counteract excessive metacarpal neck flexion is a relative surgical indication [47]. 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 [21].

Operative Complications

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 [66]. Intramedullary screw (IMS) fixation provides fewer complications compared to plate and screw constructs [75], and complications following IMS fixation are relatively uncommon [28]. In a literature review of 169 metacarpal fractures treated with IMS fixation, no serious complications were reported, though nine minor complications occurred, including four cases of hardware removal in asymptomatic patients [122]. Conversely, stiffness and tendon irritation can occur with plate fixation, necessitating hardware removal as a secondary procedure [47]. Bioabsorbable plates and screws may cause a delayed foreign body reaction resulting in osteolysis or an inflammatory soft-tissue response necessitating surgical débridement [47]. In a series of 28 patients treated with percutaneous transverse pinning for fifth metacarpal neck fractures, no nonunion, avascular necrosis of the fifth metacarpal head, or abnormalities of the MP joint were observed at final radiographic examination [42]. Only two patients in this series showed a minimal deficit of the extension of the little finger despite a mean period of immobilization of 5 weeks [42].

Non-Operative Complications and Outcomes

Nonunion virtually never occurs in metacarpal neck fractures [3]. Metacarpal fractures are common and mostly treated nonsurgically and have a minimal effect on patient well-being [9].

Recovery

Light activity (weeks): An evidence-based patient pathway for metacarpal fractures demonstrates that 92% of patients return to full function without complications at 10 weeks following injury [10]. Early motion of adjacent joints in closed simple metacarpal fractures expedites recovery of motion and strength without adversely affecting fracture alignment [35].

Full activity (months): Surgical treatment of displaced metacarpal shaft fractures with immediate return to play as tolerated is supported for in-season football players [151].

Other Considerations: Antegrade intramedullary pinning offers clinical advantages during the early recovery period over percutaneous retrograde intramedullary pinning for displaced fifth metacarpal neck fractures, although these advantages are not evident at 6 months postoperatively [152]. In a study of percutaneous intramedullary nailing for metacarpal neck fractures, no patient reported residual pain at final follow-up [135]. Patients who do not attend a scheduled 1-month follow-up after a single isolated metacarpal fracture are sociologically distinct from those who do attend [46].

Key Evidence

• [L4] A prospective randomized controlled trial of operated versus unoperated, nonscissoring metacarpal fractures is warranted. [1] (10.1177/229255031402200406)
• [L5] The majority of metacarpal fractures are managed nonoperatively. [4] (10.1177/17531934231184119)
• [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. [5] (10.1177/1753193420928820)
• [L5] The majority of metacarpal fractures are simple, closed, and stable, often achieving excellent outcomes without surgery. [7] (10.1007/s11552-013-9562-1)
• [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. [9] (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. [10] (10.1258/ht.2010.010026)
• [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. [11] (10.1016/j.jhsa.2022.01.011)
• [L4] While most metacarpal fractures can be treated nonsurgically, some fractures and patients can have improved patient-centered outcomes with surgical fixation. [12] (10.5435/jaaos-d-25-00323)
• [L4] There appears to be very little role for surgery in the management of closed spiral metacarpal fractures. [13] (10.1177/1753193414540408)
• [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. [14] (10.1177/1558944720988073)
• [L5] The majority of hand fractures can be treated without surgery, though surgery offers distinct advantages in properly selected cases. [16] (10.1016/j.jhsa.2013.02.017)
• [L3] Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. [17] (10.1016/j.jhsa.2014.05.023)
• [L5] Closed treatment is more often successful in metacarpal shaft fractures in children than in adults, and early motion rarely is indicated. [18] (10.1016/j.hcl.2005.12.001)
• [L1] No included studies reported the primary outcome measure of interest, validated hand function. [19] (10.1002/14651858.cd003210.pub3)
• [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. [21] (10.1177/17531934251313978)
• [L4] [22] (10.1016/j.jhsa.2010.05.013)
• [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. [24] (10.1097/prs.0b013e3182402e6a)
• [L1] [25] (10.1016/s0020-1383(97)00106-x)
• [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. [26] (10.1177/1558944720974363)
• [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)
• [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. [31] (10.1177/15589447241312416)
• [L4] Intramedullary fixation should be considered for closed, extra-articular metacarpal fractures. [32] (10.1016/j.jhsg.2024.08.020)
• [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. [33] (10.1016/s0020-1383(97)00101-0)
• [L4] Men aged 10-29 have by far the highest incidence rates for metacarpal fractures, exceeding the population injury incidence rates for their age groups. [34] (10.1016/0020-1383(94)90127-9)
• [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. [35] (10.1097/01.blo.0000205888.04200.c5)
• [L4] The hand therapy management of metacarpal fracture pathway accounts for the location of the fracture, stability and surgical or non-surgical management based on best available evidence. [36] (10.1258/ht.2010.010018)
• [L2] [40] (10.1177/1753193414560119)
• [L4] [42] (10.1016/j.injury.2011.10.036)
• [Paper] [44] (10.1016/j.hcl.2013.09.004)
• [L4] Patients who do not attend a scheduled 1-month follow-up after a single isolated metacarpal fracture are sociologically distinct from those who do attend. [46] (10.1016/j.jhsa.2011.08.003)
• [L5] There was no significant biomechanical difference found between the four different fixation techniques with regard to both displacement and ultimate failure strength of the constructs. [48] (10.1007/s11552-008-9108-0)
• [L4] Short-term clinical and radiographic results encouraged the authors about the efficiency of external fixation as an alternative treatment method for combined open fractures of the thumb metacarpal and trapezium. [49] (10.1007/s11552-007-9026-6)
• [L4] The moulded short metacarpal cast is an effective non-surgical treatment for angulated extra-articular metacarpal fractures of the diaphysis and diametaphyseal junction. [54] (10.1177/17531934211024579)
• [L3] [56] (10.1177/1558944720942890)
• [L4] The procedure is contraindicated for intra-articular fractures, pediatric fractures, and cases with fragmentation of the metacarpal base. [59] (10.1177/17531934231203165)
• [L4] [62] (10.2106/00004623-195436040-00012)
• [L5] The vast majority of metacarpal fractures in athletes are managed nonoperatively with protective bracing and rapid return to play. [63] (10.1016/j.hcl.2012.05.028)
• [L3] The estimated incidence of metacarpal fractures presenting for acute hospital care in the USA is 13.6 per 100,000 person-years. [64] (10.1007/s11552-012-9442-0)
• [L4] Intramedullary screw fixation of metacarpal fractures is safe with a low incidence of complications (2.5%) that can be safely and effectively managed. [65] (10.1177/1558944719836214)
• [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. [66] (10.1016/j.jhsg.2023.08.003)
• [L4] This hybrid technique appears safe and effective for unstable metacarpal shaft fractures not typically suited for standard intramedullary fixation. [67] (10.1016/j.jhsa.2026.04.012)
• [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. [69] (10.1177/15589447241266965)
• [L5] [70] (10.5435/00124635-199911000-00006)
• [L4] [72] (10.1054/jhsb.2000.0413)
• [L2] Intramedullary screw fixation is a reliable and safe method for metacarpal fractures, providing quicker return to motion, faster time to full range of motion, and similar time to union with fewer complications compared to plate and screw construct. [75] (10.5435/jaaos-d-24-00241)
• [L3] [92] (10.1016/j.jhsa.2015.05.013)
• [L1] [93] (10.1007/s00402-015-2361-0)
• [L2] [94] (10.1177/1753193410377845)
• [Case_report] The proposed mechanism of injury is a force applied from the distal phalanx transmitted unevenly to the volar side when the metacarpophalangeal joint was slightly flexed. [110] (10.1055/s-0040-1709214)
• [Case_report] [112] (10.1016/j.jhsa.2010.08.035)
• [L4] Plate fixation in closed multiple metacarpal fractures is a safe, reliable and consistently reproducible treatment method. [120] (10.1177/1753193408090101)
• [L5] Non-locking plates are appropriate for most metacarpal and phalangeal fractures necessitating plate fixation. [121] (10.1016/j.jhsa.2011.09.023)
• [L4] [122] (10.1097/prs.0000000000005478)
• [Paper] When treating metacarpal shaft fractures, both ORIF with PS and IMS can achieve acceptable outcomes. [127] (10.1177/15589447251371087)
• [Paper] [129] (10.1016/j.injury.2012.02.019)
• [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. [135] (10.11604/pamj.2014.18.187.3347)
• [L2] These findings support the viability of this treatment option for displaced single spiral or oblique metacarpal shaft fractures of rays IIeV in patients who prefer nonsurgical treatment. [141] (10.1016/j.jhsa.2025.06.018)
• [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. [151] (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. [152] (10.1007/s11999-014-4079-7)

See Also

• Dislocations

References

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