Treatment of Impacted Metacarpal Fractures
Most impacted metacarpal fractures can be managed non-operatively with immobilization and early mobilization, as these fractures are inherently stable due to their impacted nature. 1, 2
Initial Assessment and Imaging
- Obtain a standard 3-view radiographic examination (posteroanterior, lateral, and 45° semipronated oblique) to properly visualize the fracture pattern and assess for displacement or angulation 3
- Add an internally rotated oblique projection to increase diagnostic yield for metacarpal fractures 3
- CT imaging is typically not indicated unless there is concern for complex articular involvement 3
Treatment Algorithm
Non-Operative Management (First-Line for Impacted Fractures)
Impacted fractures are inherently stable and rarely require surgical intervention. 2, 4
- Immobilize with appropriate splinting or casting for 3-4 weeks 4
- Initiate active finger motion exercises immediately following diagnosis to prevent stiffness, which is the most common functionally disabling complication 3
- Wrist motion does not need to be started early following stable fracture management 3
- Consider vitamin C supplementation for prevention of disproportionate pain 3
Indications for Surgical Intervention
Operative fixation is reserved for impacted fractures with:
- Significant rotational deformity that cannot be maintained with closed reduction 1, 5
- Intra-articular involvement with >2 mm articular step-off 6
- Multiple metacarpal fractures requiring stabilization 7
- Patient functional demands that necessitate rigid fixation 1
Surgical Options (When Indicated)
Available fixation methods include:
- Percutaneous Kirschner wire fixation for simple patterns 5
- Plate and screw fixation for unstable or complex fractures requiring rigid fixation 7
- Intramedullary fixation tailored to specific fracture patterns 5
When surgical fixation is performed, choose a construct that can withstand early postoperative motion to prevent stiffness. 1
Postoperative Care (If Surgery Required)
- Initiate active finger motion exercises immediately following stable fixation 3
- Limit duration of external fixation if used to reduce complications 3
- Monitor closely for finger stiffness, the most common functionally disabling complication 3
Common Pitfalls to Avoid
- Relying on only 2 radiographic views is inadequate; obtain minimum 3 views 8
- Over-treating stable impacted fractures with surgery when non-operative management provides satisfactory results 2, 4
- Prolonged immobilization leading to stiffness—early mobilization is critical 1
- Failure to recognize rotational deformity on clinical examination, which may require operative correction despite radiographic appearance 5