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THUMB METACARPAL FRACTURES

Introduction

Fracture Nomenclature for Thumb Metacarpal Fractures

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Thumb Metacarpal Fractures, the historical and specifically named fractures include:

Bennett's Fracture

Rolando's Fracture

By selecting the name (diagnosis), you will be linked to the introduction section of this Diagnostic Guide dedicated to the selected fracture eponym.

Metacarpal fractures represent some of the most common injuries seen in emergency departments. Metacarpal fractures account for 18-44% of all hand fractures, and the little metacarpal is the most frequently affected. Fractures of the thumb metacarpal rank second in prevalence, representing 12-25% of all metacarpal fractures. Bennett’s fractures and Rolando’s fractures are two of the most typical fracture patterns seen in the thumb metacarpal. These injuries typically result from an axial load on the thumb with a clenched fist or the thumb abducted or extended. Most thumb metacarpal fractures can be treated similarly to fractures of other metacarpals, and a variety of conservative and surgical options are available. However, some unique features of the thumb must be taken into consideration when determining treatment to prevent long-term complications and impaired hand function.1-6

Definitions

  • Thumb metacarpal fractures are a disruption of the mechanical integrity of the thumb metacarpal.
  • Thumb metacarpal fractures produce a discontinuity in the thumb metacarpal contours that can be complete or incomplete.
  • Thumb metacarpal fractures are caused by direct forces that exceed the breaking point of the bone.

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

  • Universally accepted definitions of clinical fracture stability is not well defined in the hand surgery literature.7-9
  • Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragment’s alignment is maintained with simple splinting. However, most definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion (ROM).
  • Unstable: fracture fragment will not remain anatomically or nearly anatomically aligned after a successful closed reduction and simple splinting. Typically unstable thumb metacarpal fractures have significant deformity with comminution, displacement, angulation, and/or shortening.
  • Fractures of the thumb metacarpal base are inherently unstable, and appropriate treatment is necessary to avoid complications like osteoarthritis, weakness, and loss of thumb carpometacarpal (CMC) joint function.10,11

P - Pattern

  • Thumb metacarpal head: oblique, transverse, or comminuted, these fractures are uncommon because the longitudinally directed force that produces them is usually dissipated at the proximal metaphysis or thumb CMC joint; they can also involve the metacarpophalangeal (MP) joint.1,2
  • Thumb metacarpal neck: this fracture pattern is possible but extremely rare.
  • Thumb metacarpal shaft: transverse, oblique, or comminuted, with or without shortening; each fracture type presents characteristic deformities that may lead to complications if unrecognized or not managed appropriately.1,2
    • Rare fracture pattern: due to the absence of firm fixation of the proximal portion of the metacarpal, force directed to the shaft is often transferred to the base and results in a fracture at that location.12
    • Comminuted thumb metacarpal shaft fractures are usually the result of direct trauma and are often associated with soft tissue injury.1
  • Thumb metacarpal base: by far the most common site of fracture in the thumb metacarpal, they can involve the thumb CMC joint, and may be either intra-articular or extra-articular.
    • Intra-articular base fractures are high-energy injuries typically associated with thumb CMC joint dislocation or subluxation.2
    • Extra-articular fractures are usually transverse or mildly oblique. They generally occur at the proximal metaphyseal-diaphyseal junction and are referred to as epibasal fractures.1

O - Open

  • Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk of developing osteomyelitis. Therefore, open fractures of the thumb metacarpal require antibiotics with surgical irrigation and wound debridement.7,13,14
  • Open thumb metacarpal shaft fractures may require an external fixator to prevent shortening and to allow soft tissue healing.1

R - Rotation

  • Thumb metacarpal fracture deformity can be caused by rotation of the distal fragment on the proximal fragment.
  • Degree of malrotation of the fracture fragments can be used to describe the fracture deformity.
  • Oblique and spiral thumb metacarpal shaft fractures are usually the result of torsional forces and can cause rotational malalignment. These fractures may also angulate or shorten.
    • Unlike other metacarpals, extra-articular fractures of the thumb metacarpal base can tolerate moderate malunion in rotation.1

A - Angulation (fracture fragments in relationship to one another)

  • Angulation is measured in degrees after identifying the direction of the apex of the angulation.
  • Straight: no angulatory deformity
  • Angulated: bent at the fracture site
  • Example: thumb metacarpal shaft fractures are often angulated with its apex dorsal such that the distal fragment is adducted and flexed.1
  • Given the large ROM of the thumb, higher degrees of angulation are well tolerated, as the deformity can be compensated for without functional deficit.15
  • The surrounding soft tissue attachments determine the direction deforming forces for both extra- and intra-articular thumb metacarpal fractures. Extra-articular fractures become angulated dorsally owing to extension of the metacarpal base by the abductor pollicis longus (APL) and flexion of the distal shaft by thenar muscles.
    • Apex dorsal angulation up to 30° is acceptable for extra-articular thumb metacarpal base fractures, but angulation beyond this limit will narrow the thumb web space and cause compensatory MP joint hyperextension, which is poorly tolerated.6

D - Displacement (Contour)

  • Displaced: disrupted cortical contours
  • Nondisplaced: fracture line defining one or several fracture fragment fragments; however, the external cortical contours are not significantly disrupted
  • In Bennett’s fractures, the anterior oblique, or beak ligament prevents displacement of the volar fragment, but the dorsal fragment displaces via the APL with the shaft displaced by the extensor pollicis longus (EPL) and adductor pollicis6, resulting in shortening and joint subluxation.
  • Isolated thumb CMC joint dislocations almost always displace dorsally, although volar displacement is also possible.16

I - Intra-articular involvement

  • Fractures that enter a joint with one or more of their fracture lines.
  • Thumb metacarpal fractures can have fragment involvement with its MP or CMC joint.
  • If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to posttraumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface, then the congruity of the joint will be compromised and the risk of posttraumatic osteoarthritis increases significantly.
  • Differentiating between extra- and intra-articular fractures is crucial for planning an appropriate treatment protocol for thumb metacarpal fractures.2
  • Intra-articular thumb metacarpal base fractures, like those of the little metacarpal base, lack ligamentous support and are prone to subluxation.2
  • The majority of intra-articular thumb metacarpal base fractures are described as either Bennett’s or Rolando’s fractures, and they present treatment challenges secondary to the deforming forces acting at the base of the thumb.17

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.7-9

Thumb metacarpal fractures: named fractures, fractures with eponyms, and other special fractures

Bennett’s fracture

  • Intra-articular avulsion fracture of the thumb metacarpal base that consists of a single, variable-sized, volar-ulnar fracture fragment and results in subluxation or dislocation of the thumb CMC joint.1,10
    • These fractures account for about one-third of all thumb metacarpal fractures in adults and are inherently unstable.10
  • Occur when the thumb metacarpal is axially loaded and partially flexed, and most are caused by indirect forces such as falling on an extended or abducted thumb or an impact onto a clenched fist.1,10
    • This force can result from punching injuries in which a flexed and adducted thumb strikes the opponent’s head or jaw, but the incidence from falls, motor vehicle accidents, and work injuries appears to be similar.10
    • Adult males are most likely to experience this injury, and it usually occurs in the dominant hand.10
    • The resultant avulsed volar-ulnar fragment of the metacarpal base is of variable size and pyramidal in shape, and it is held to the trapezium by the anterior oblique ligament. The metacarpal shaft is then pulled radially, proximally, and dorsally by the APL, EPL, extensor pollicis brevis (EPB), and adductor pollicis, and the remaining metacarpal base subluxates in these directions, which can lead to complete dislocation.1,2,6
  • Isolated thumb CMC joint dislocation without associated fracture is a very rare injury that accounts for <1% of all hand injuries. Some refer to this injury as a "Bennett’s fracture without the fracture."
    • These injuries almost always displace dorsally—although there are reports of volar dislocation—and are classified as simple or complex.
    • The mechanism of injury is axial loading and flexion of the thumb metacarpal. This force causes flexion and axial loading of the metacarpal base, and results in dorsolateral ligament rupture and dorsal subluxation.16

Imaging

  • In addition to lateral radiographic views, Bett’s and Robert’s views are typically required to visualize the injury.1
  • CT scan is typically unnecessary, but may be used if comminution is suspected.1 (It is also helpful in determining the size and positino of the volar ulnar fracture fragment.)

Treatment

  • Several options are available for treating Bennett’s fractures, but a consensus has not yet been reached on the best technique. There are advocates for both conservative and surgical approaches, and each comes with associated advantages and disadvantages.1,10
  • Closed reduction methods involve traction on the thumb to pull the metacarpal distally with concurrent gentle pressure pushing the metacarpal base medially to return it to anatomical position.
    • Because these fractures are unstable, the primary goal is to obtain and maintain adequate reduction to allow healing in an anatomical position, as failure to do so can lead to long-term consequences like osteoarthritis, weakness, or loss of thumb CMC joint function.10
    • The most basic method is reduction under adequate analgesia followed by plaster cast immobilisation for up to 6 weeks with the thumb in a position of moderate adduction and opposition 10 however, due to fracture instability, redisplacement is common.
    • Closed reduction and percutaneous pinning (CRPP) typically involves reduction followed by percutaneous insertion of a K-wire through the base of the metacarpal across the joint and into the fracture fragmentto hold the reduction in place. The wire remains in place for ~4-6 weeks and removal is followed by rehabilitation.10
  • The K-wire can also be fixated between the thumb and index metacarpals with intermetacarpal pinning.1
  • An alternative approach places the K-wire into the distal metacarpal fragment and then applies traction on the wire via a frame and rubber bands to reduce the fracture and maintain this position.10
    • CRPP is generally considered the preferred method of treatment for small Bennett’s fractures when: the fragment is <15-20% of the articular surface, there is <3 mm of displacement, and the concave dome is maintained.1,2
  • Bennett’s fractures that involve >25% of the joint surface, with >3 mm displacement, and irreducible by closed techniques should treated with open reduction and internal fixation (ORIF).2
    • A Wagner incision is recommended, and either K-wires or lag screws may be used to hold the reduction in place.1,10
  • If pins are used, the thumb should be postoperatively immobilized in a thumb spica cast for up to 4 weeks, and the transarticular pin is removed. The pins holding the fracture fragment are removed at 6 weeks.
  • Screw fixation, although technically more demanding, is more secure, and active ROM may be initiated 5-10 days postoperatively.1
  • Arthroscopic reduction and fixation is another option for any Bennett’s fracture that necessitates surgery, but this approach is not recommended for complex articular fractures that are not amenable to percutaneous pinning or screw fixation. Chronic injuries requiring osteotomy and reduction may also require open treatment.
    • About 7-10 days after the procedure, the sutures are removed and a thermoplastic forearm-based thumb spica splint is fabricated for the patient with the thumb interphalangeal (IP) joint left free.
  • A plaster splint or cast may be necessary if the patient is unable to cooperate with restrictions.
    • Percutaneous pins are usually removed at 4-6 weeks, and gentle motion of the thumb is allowed at 4-6 weeks if the examination warrants it. Full motion of the index, long, ring, and little fingers are encouraged immediately after surgery.18
  • Debate exists regarding the optimal management for isolated thumb CMC joint dislocations; options include closed reduction and casting, percutaneous fixation, ligamentous repair or reconstruction, and capsular placation followed by K-wire fixation ligament reconstruction.
    • If the joint is stable, closed reduction and a plaster cast with the thumb in abduction for 4-6 weeks is the preferred treatment.
    • If the joint is unstable, it is preferable to hold the reduction with K wires, with or without capsulorrhaphy16 or ligament reconstruction.

Complications

  • Instability
  • First web space contracture
  • Pin tract infection
  • Pin loosening
  • Malunion
  • Nonunion
  • Stiffening
  • Posttraumatic osteoarthritis
  • Complex regional pain syndrome (CRPS)

Outcomes

  • Studies generally suggest that ORIF for Bennett’s fractures is associated with more reliable reduction and better long-term outcomes that other approaches, but the technique is technically demanding.10
  • One study evaluated patients nearly 10 years after conservative management of Bennett’s fractures and noted little evidence of symptomatic arthritis despite imperfect reduction.19 Another study noted a higher incidence of symptomatic arthritis when articular incongruity persisted after reduction.20
  • Some experts claim that there is no significant difference in clinical outcomes between ORIF and CRPP, as long as anatomic alignment is achieved. Long-term degenerative changes may also become evident radiographically after these interventions.1
  • Conservative management using a spica cast elicited equally good outcomes for isolated thumb CMC joint dislocations compared to various ligamentous reconstructive procedures. However, recurrent instability is a concern, and ligament reconstruction should be considered in unstable cases.16
  • ORIF combined with an early, active rehabilitation program led to satisfactory functional and radiological outcomes in treating Bennett’s fractures, and are considered an efficient option.11
  • In a study that compared arthroscopically assisted screw fixation to ORIF, there were fewer complications, shorter immobilization time, and diminished tourniquet time in the former versus the latter group.21

Rolando's fracture

  • Rolando’s fractures are comminuted intra-articular fractures of the thumb metacarpal base that may have a Y- or T-type fracture pattern.15
    • Rolando’s fractures are less prevalent than Bennett’s fractures, but the deforming forces involved are the same.
    • First described in 1910 as a Y-shaped pattern with 3 major segments: metacarpal shaft, volar fragment, and dorsal fragment. However, the term has come to mean all intra-articular thumb metacarpal base fractures with ≥3 segments, and highly comminuted fractures are often placed in this category.17
  • Often caused by an axial load crushing the articular surface. The base is usually split into a volar and dorsal fragment, with the volar oblique ligament attached to the volar segment and the shaft pulled proximally and dorsally, primarily by the APL and the adductor pollicis.17

Imaging

  • Because Rolando’s fractures can appear deceptively benign on plain radiographs, a CT scan may be needed to assess the comminution and extent of articular disruption.1

Treatment

  • In general, treatment options available for Rolando’s fractures are similar to those for Bennett’s fractures, but surgical management appears to be preferable over conservative management, especially for unstable fractures.15,17
  • For classic three-part Rolando’s fractures when there are large dorsal and volar fragments, ORIF with either multiple K-wires or a plate is recommended, but this approach may be unproductive if there is significant comminution.1,17
    • The surgical exposure for plate fixation is the same as for Bennett’s fractures: longitudinal traction is applied, and a provisional reduction of the two articular fragments is held with K-wires, a reduction clamp, or both.1
    • Neurovascular damage is a major complication of this approach, and care should be taken not to damage the branches of the superficial radial nerve, the lateral antebrachial cutaneous nerve, or the radial artery.17
    • A bone graft may also be needed if there is a metaphyseal void secondary to compaction of the cancellous subchondral bone.1
  • In the absence of large volar and dorsal fragments, closed reduction with external fixation is indicated. Several options are available, including CRPP with K-wires. To achieve reduction, the thumb is abducted and pronated, and longitudinal traction is applied.17
    • Successful CRPP is usually difficult to accomplish in Rolando’s fractures because of the difficulty involved in reducing all the articular fragments. Articular reduction is most likely to be successful when there are two fragments with minimal comminution.1
  • If there is persistent pain after surgery, patients should not be treated for ≥6 months. If pain persists, or there is radiographic evidence of articular incongruity, arthrodesis of the thumb CMC joint is recommended.1

Complications

  • Stiffness
  • Infection
  • Neurovascular damage
  • Posttraumatic osteoarthritis
  • Malunion
  • Nonunion

Outcomes

  • Rolando’s fractures are typically associated with a poorer prognosis than Bennett’s fracture, primarily due to its comminuted nature.
    • Studies have shown decreased palmar abduction, key pinch strength, and impairment scores in patients with Rolando’s fractures versus Bennett’s fractures.
    • Exact anatomic reduction of the articular surface may not be necessary to obtain a good functional result; however, reduction to ≤1 mm is thought to reduce the risk of arthritis.17
  • The best prognosis is for the classic 3-part Rolando’s fractures in which the volar-ulnar and dorsal articular fragments can be anatomically reduced and stabilized. For more comminuted fractures, anatomic reduction is more challenging or may be impossible, making distraction and external fixation more appropriate.15

Related Anatomy

  • The thumb metacarpal consists of a distal head that articulates at the MP joint with the proximal phalanx, a supportive neck, a narrow diaphyseal shaft, a proximal metaphysis, and a base that articulates at the thumb CMC joint with the trapezium. The thumb CMC joint is a double saddle that is concave in one direction and convex on the other. It moves in flexion/extension, abduction/adduction, and pronation/supination planes, but this greater ROM results in less inherent stability.6,10,16
  • Ligaments associated with the thumb metacarpal include the posterior oblique ligament, the dorsal central ligament, the dorsoradial ligament, the first intermetacarpal ligament, and the volar beak (anterior oblique) ligament, which inserts at the thumb metacarpal base and opposes the action of the APL.6,10
  • Tendons associated with the thumb metacarpal include the APL tendon, which inserts onto the base of the volar side of the thumb metacarpal base, and the opponens pollicis tendon, which inserts on the anterior and lateral surfaces of the thumb metacarpal shaft.6
  • The biconcave structure of the thumb CMC joint has been reported to provide as much as 47% of the joint stability while in opposition.6

Incidence and Related injuries/conditions

  • Metacarpal and phalangeal fractures account for nearly half of all hand injuries that present to the emergency room.22
  • Metacarpal fractures are less common than phalangeal fractures, but comprise between 18-44% of all hand fractures.23,24
    • It is estimated that >250,000 metacarpal fractures occur in the U.S. each year.23
    • An overall incidence rate of 13.7 metacarpal fractures per 100,000 person-years has been reported, with these injuries comprising 33% of all hand fractures in the U.S.3
  • Thumb metacarpal fractures account for ~12-25% of all metacarpal fractures, which places them second only to little metacarpal fractures in terms of prevalence.6,23
  • Of all thumb metacarpal fractures, >80% involve the base.6
ICD-10 Codes

  • BENNETT'S FRACTURE

    Diagnostic Guide Name

    BENNETT'S FRACTURE

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    BENNETT'S FRACTURE (THUMB METACARPAL FRACTURE) S62.212_S62.211_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S62
     Closed Fractures
    Initial EncounterA
    Subsequent Routine HealingD
    Subsequent Delayed HealingG
    Subsequent NonunionK
    Subsequent MalunionP
    SequelaS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Thumb metacarpal shaft fracture with displacement and angulation
    Thumb metacarpal shaft fracture with displacement and angulation
  • Thumb metacarpal displaced angulated base fracture not involving the joint.
    Thumb metacarpal displaced angulated base fracture not involving the joint.
  • Thumb metacarpal intra-articular displaced angulated base fracture (Bennett's Fracture)
    Thumb metacarpal intra-articular displaced angulated base fracture (Bennett's Fracture)
  • Thumb metacarpal intra-articular displaced comminuted base fracture (Rolando Fracture)
    Thumb metacarpal intra-articular displaced comminuted base fracture (Rolando Fracture)
Symptoms
Pain in the injured thumb
Swelling in the injured thumb
Ecchymosis in the injured thumb
Deformity in the injured thumb
Typical History

A typical patient is a 35-year-old, left-handed man who injured his hand after falling off a scooter. The man was riding at a moderately fast speed when a biker suddenly cut him off and forced him to swerve to the left into a parked car. This caused him to fly over the handlebars and land directly on his outstretched left hand with this thumb extended and abducted. The impact resulted in a severe Bennett’s fracture and led him to seek immediate medical attention.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Thumb Metacarpal Fracture X-rays
  • Two years before thumb injury negative wrist X-ray shows normal metacarpal base (arrow)
    Two years before thumb injury negative wrist X-ray shows normal metacarpal base (arrow)
  • Two years after negative wrist X-ray 18 y.o. male falls and sustains a displaced extra-articular (AP) base fracture (arrow).
    Two years after negative wrist X-ray 18 y.o. male falls and sustains a displaced extra-articular (AP) base fracture (arrow).
  • Two years after negative wrist X-ray 18 y.o. male falls and sustains a displaced extra-articular (Lateral view) base fracture (arrow).
    Two years after negative wrist X-ray 18 y.o. male falls and sustains a displaced extra-articular (Lateral view) base fracture (arrow).
  • Elderly female refusing reduction and surgery. Splint applied.
    Elderly female refusing reduction and surgery. Splint applied.
  • Classic Bennett's Fracture (arrow)
    Classic Bennett's Fracture (arrow)
  • CT of classic Bennett's Fracture (arrow)
    CT of classic Bennett's Fracture (arrow)
Treatment Options
Treatment Goals
  • When treating closed thumb metacarpal fractures, the treating surgeon has 4 basic goals:7,14
    1. A hand with a normal appearance. The X-ray may not need to be perfect, but the metacarpal should have no obvious deformity (ie, the metacarpal looks normal!)
    2. Avoid stiffness by maintaining a normal functional ROM (ie, the metacarpal works!)
    3. The thumb metacarpal is not painful (ie, the metacarpal does not hurt!)
    4. Congruent joint surface with none-to-minimal joint surface irregularities (ie, the thumb CMC joint does not develop early posttraumatic arthritis!)
  • One additional goal is mandatory for open fractures:
    1. Debridgement and irrigation should minimize the risk for infection and development of osteomyelitis.
Conservative
  • The management principles of thumb metacarpal head, neck, shaft, and extra-articular base fractures are similar to those of other metacarpals. Given the large ROM of the thumb, higher degrees of angulation are well tolerated, as the deformity can be compensated for without functional deficit.15
  • As with other metacarpals, most thumb metacarpal fractures can be treated nonsurgically. Those that are closed, nondisplaced, and minimally angulated without significant malrotation can be managed in an aluminum, plaster, fiberglass, or custom splint.2,4,9
    • Even thumb metacarpal fractures that require a reduction to correct fracture-related deformity usually can be held in anatomic or near-anatomic alignment with a splint without internal or external surgical fixation.2
  • Open thumb metacarpal shaft fractures may require an external fixator to prevent shortening and to allow soft tissue healing. Extension of the frame to the index metacarpal helps prevent a first web space contracture.1
  • Closed reduction of thumb epibasal fractures is usually easy to accomplish by longitudinal traction, downward pressure on the apex of the fracture, mild pronation of the distal fragment, and thumb extension.
    • This type of reduction is often unstable because of the deforming force of the APL, so if a cast is used, the reduction should be closely monitored for displacement.
    • Angulation ≤30° is acceptable and usually well compensated because of the abundant motion at the thumb CMC joint.
    • Angulation >30° results in compensatory hyperextension of the MP joint and may require CRPP with K-wire fixation. ORIF is rarely needed for these fractures.1
  • Thumb metacarpal fractures typically unite within ~6 weeks.
Operative
  • Surgical treatment of thumb metacarpal fractures must always be an individualized therapeutic decision. However, surgical metacarpal fracture care is most frequently recommended when:
    1. Closed reduction fails or the simple splint or cast immobilization does not maintain the reduction. For these irreducible or unstable fractures, operative treatment is recommended to achieve the 4 treatment goals of fracture care.
    2. There is a significantly displaced base of the thumb metacarpal fracture involving the thumb CMC joint. Surgical fracture care is typically required in these cases.
    3. There is an open thumb metacarpal fracture, which requires surgical care in the form of irrigation and debridement to prevent chronic infection.
  • Displaced articular fractures of the thumb metacarpal head require anatomic reduction, and fixation can be obtained with percutaneous K-wire fixation or ORIF.
    • The fracture is approached by splitting the dorsal apparatus between the EPL and EPB.
    • If pin fixation is used, the thumb is immobilized for ~4 weeks before initiating motion, whereas motion is initiated at 5-7 days postoperatively with screw fixation.1
  • Comminuted thumb metacarpal shaft fractures are usually the result of direct trauma and are often associated with soft tissue injury. Fracture stabilization must be individualized in these cases.1
  • If surgery is needed for thumb epibasal fractures, the most popular options are ORIF and closed reduction with crossed K-wire fixation.6,15
    • Some experts favor ORIF because it provides a more stable construct and may permit earlier motion.6
    • Others prefer K-wire fixation and obtain reduction using a combination of traction, extension, and pronation with direct pressure on the thumb metacarpal base. As in other settings, screw fixation provides a more stable construct compared with K-wires, and may allow earlier motion and earlier return to activity after surgery.15

Post-treatment Management

  • The care and precautions related to immobilization devices for thumb metacarpal fractures must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive splint tightness are red flags and should be reported to the surgeon or his team.
  • Pain should be managed with properly fitting splints, reassurance, elevation, ice in the initial post-fracture period, and mild pain medications. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
  • Joints that are splinted for closed stable fractures are usually immobilized.
  • Surgically managed metacarpal fractures should be immobilized for ≥2 weeks in a splint until sutures are removed.
  • Patients should be instructed to carefully exercise all joints in the injured hand that do not require immobilization. Patients usually can exercise on their own; however, signs of generalized finger or hand stiffness are indications for referral to hand therapy (PT or OT).
    • The rehabilitation plan is individualized based on rigidity of internal fixation, patient compliance, and the complexity of associated soft-tissue injuries and repairs.
    • Active MP and active/passive IP motion is initiated within days of surgery in compliant patients with rigid internal fixation. Passive MP motion is added 4 weeks after surgery.
Treatment Photos and Diagrams
Thumb Metacarpal Fracture Treatment
  • Bennett's fracture (arrow) treated with closed reduction and percutaneous pinning with slight residual joint incongruity.
    Bennett's fracture (arrow) treated with closed reduction and percutaneous pinning with slight residual joint incongruity.
  • Fracture of base of first metacarpal treated in splint only. Patient has no pain and no functional complaints.
    Fracture of base of first metacarpal treated in splint only. Patient has no pain and no functional complaints.
  • Bennett's fracture treated by CRPP with anatomic joint alignment.
    Bennett's fracture treated by CRPP with anatomic joint alignment.
  • Healed Bennett's fracture treated by CRPP with normal joint congruity.
    Healed Bennett's fracture treated by CRPP with normal joint congruity.
  • Bennett's fracture (arrow) treated by CRPP with slight residual joint incongruity but no symptoms.
    Bennett's fracture (arrow) treated by CRPP with slight residual joint incongruity but no symptoms.
  • Thumb metacarpal base fracture anatomically reduced (arrow) under local block and splinted.
    Thumb metacarpal base fracture anatomically reduced (arrow) under local block and splinted.
  • Thumb metacarpal base fracture healed anatomically (arrow) at 8 weeks.
    Thumb metacarpal base fracture healed anatomically (arrow) at 8 weeks.
  • Thumb CMC Dislocation without fracture treated with closed reduction . After cast removed at 6 weeks severe CMC subluxation. Reduction, pinning and cast may have prevent symptomatic subluxation.
    Thumb CMC Dislocation without fracture treated with closed reduction . After cast removed at 6 weeks severe CMC subluxation. Reduction, pinning and cast may have prevent symptomatic subluxation.
  • Elderly medically disabled male with angulated healed base of metacarpal fracture with no complaints.
    Elderly medically disabled male with angulated healed base of metacarpal fracture with no complaints.
CPT Codes for Treatment Options

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Common Procedure Name
ORIF metacarpal fracture
CPT Description
Open treatment of metacarpal fracture, single, includes internal fixation when performed, each bone
CPT Code Number
26615
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Complications
  • 32-36% of all metacarpal fractures encounter a complication, and the likelihood of complication increases when there is more than one fractured metacarpal.4,25
  • Stiffness can develop after prolonged immobilization or delayed rehabilitation. It is very common and typically more difficult to treat than other complications.1,2,7,14
    • First web space contracture can also result if the thumb metacarpal has been immobilized in an adducted position.1
  • Malunion is less common than stiffness but more likely in open, severe, unstable thumb metacarpal fractures. It primarily manifests as malrotation or dorsal angulation.2,24
  • Nonunion is rare in thumb metacarpal fractures and Bennett’s fractures, but is more common in transverse fracture patterns.1,2,4
  • Posttraumatic osteoarthritis can occur in the thumb CMC joint after some thumb metacarpal base fractures and is dependent on the amount of articular incongruity.
  • After crush injuries or open fractures, there may be shortening and associated soft tissue problems, such as tendon adhesions, poor skin coverage, and neurologic deficit.1
  • Complications of not treating intra-articular thumb metacarpal base fractures include weakness of grip strength and of wrist extension, decreased ROM, posttraumatic osteoarthritis, tendon rupture, and poor appearance.26
  • Osteomyelitis in the metacarpal is rare but can occur in open fractures, especially in diabetic patients or those with a compromised immune system. When this occurs, it is extremely serious: in one series, 39% of patients with osteomyelitis went on to amputation.4
Outcomes
  • If the appropriate treatment is used, most outcomes for thumb metacarpal fractures are very good.1,2,10,11,16,17,21 Fortunately, the complications noted above are very rare, and significant stiffness can usually be avoided with appropriate immobilization that allows unaffected joints and bones to stay mobile.
Key Educational Points
  • Thumb metacarpal fractures must be mobilized before radiographic fracture healing is complete to avoid stiffness.
  • Immobilization of thumb metacarpal fractures for >6 weeks is rarely needed.1
  • Underlying pathological conditions such as bone tumors—like enchodromas—and osteoporosis should be expected in fractures that occur from trivial trauma.
  • The functional needs of each patient must be considered when recommending treatment.
  • In most cases, signs of clinical union will be present 4 weeks after a closed thumb metacarpal fracture. Although the fracture has not yet radiographically united, transitioning the patient to a removable splint and initiation of rehabilitation at this time can minimize stiffness.2
  • The thumb has a unique role in the function of the hand, and a normal thumb is essential for digital pinching and for a powerful grip. For this reason, thumb CMC joint dislocation and fracture-dislocation can lead to longstanding hand disability if not properly treated.16
  • Stable fixation and early postoperative mobilization of intra-articular fractures 11 is also very important in the treatment of CMC joint fractures.
References

New and Cited Articles

  1. Day CS. Fractures of the Metacarpals and Phalanges. In: Green DP, ed. Green's Operative Hand Surgery. Seventh ed. Philadelphia: Elsevier; 2016, pp. 231-77.
  2. Weinstein LP, Hanel DP. Metacarpal fractures. J Hand Surg Am 2002;2(4):168–180.
  3. Nakashian MN, Pointer L, Owens BD, Wolf JM. Incidence of metacarpal fractures in the US population. Hand (N Y) 2012;7(4):426-30. PMID: 24294164
  4. Kollitz KM, Hammert WC, Vedder NB, Huang JI. Metacarpal fractures: treatment and complications. Hand (N Y) 2014;9(1):16-23. PMID: 24570632
  5. van Onselen EB, Karim RB, Hage JJ, Ritt MJ. Prevalence and distribution of hand fractures. J Hand Surg Br 2003;28(5):491-5. PMID: 12954264
  6. Kadow TR, Fowler JR. Thumb Injuries in Athletes. Hand Clin 2017;33(1):161-173. PMID: 27886832
  7. Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41:712-22. PMID: 27113910
  8. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29:1128-38. PMID: 15576227
  9. Walenkamp MM, Vos LM, Strackee SD, Goslings JC, Schep NW. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4:307-16. PMID: 26649263
  10. Brownlie C, Anderson D. Bennett fracture dislocation - review and management. Aust Fam Physician 2011;40(6):394-6. PMID: 21655486
  11. Uludag S, Ataker Y, Seyahi A, et al. Early rehabilitation after stable osteosynthesis of intra-articular fractures of the metacarpal base of the thumb. J Hand Surg Eur Vol 2015;40(4):370-3. PMID: 23792442
  12. Carlsen BT, Moran SL. Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries. J Hand Surg Am 2009;34(5):945-52. PMID: 19411003
  13. Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (NY) 2017;12:119-26. PMID: 28344521
  14. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38:1021-31. PMID: 23618458
  15. Fufa DT, Goldfarb CA. Fractures of the thumb and finger metacarpals in athletes. Hand Clin 2012;28(3):379-88. PMID: 22883886
  16. Suresh SS, Zaki H, Ahmed A. Isolated Carpo-Metacarpal Dislocation of the Thumb. J Orthop Case Rep 2012;2(1):15-7. PMID: 27298846
  17. Sood A, Granick MS. Rolando fracture. Eplasty 2014;14:ic16. PMID: 24966997
  18. Solomon J, Culp RW. Arthroscopic Management of Bennett Fracture. Hand Clin 2017;33(4):787-794. PMID: 28991589
  19. Cannon SR, Dowd GS, Williams DH, Scott JM. A long-term study following Bennett's fracture. J Hand Surg Br 1986;11(3):426-31. PMID: 3794490
  20. Kjaer-Petersen K, Langhoff O, Andersen K. Bennett's fracture. J Hand Surg Br 1990;15(1):58-61. PMID: 2307882
  21. Pomares G, Strugarek-Lecoanet C, Dap F, Dautel G. Bennett fracture: Arthroscopically assisted percutaneous screw fixation versus open surgery: Functional and radiological outcomes. Orthop Traumatol Surg Res 2016;102(3):357-61. PMID: 26993854
  22. Mansha M, Miranda S. Early results of a simple distraction dynamic external fixator in management of comminuted intra-articular fractures of base of middle phalanx. J Hand Microsurg 2013;5(2):63-7. PMID: 24426677
  23. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 2001;26(5):908-15. PMID: 11561245
  24. Gudmundsen TE, Borgen L. Fractures of the fifth metacarpal. Acta Radiol 2009;50(3):296-300. PMID: 19173096
  25. Fusetti C, Meyer H, Borisch N, et al. Complications of plate fixation in metacarpal fractures. J Trauma 2002;52(3):535-9. PMID: 11901331
  26. Bushnell BD, Draeger RW, Crosby CG, Bynum DK. Management of intra-articular metacarpal base fractures of the second through fifth metacarpals. J Hand Surg Am 2008;33(4):573-83. PMID: 18406963

Reviews

  1. Liverneaux PA, Ichihara S, Hendriks S, et al. Fractures and dislocation of the base of the thumb metacarpal. J Hand Surg Eur Vol 2015;40(1):42-50. PMID: 25311936
  2. Soyer AD. Fractures of the base of the first metacarpal: current treatment options. J Am Acad Orthop Surg 1999;7(6):403-12. PMID: 11505928

Classics

  1. Bennett EH. On Fracture of the Metacarpal Bone of the Thumb. Br Med J 1886;2(1331):12-3. PMID: 20751614
  2. James ES, Gibson A. Fracture of the first metacarpal bone. Can Med Assoc J 1940;43(2):153-5. PMID: 20321789
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