Fracture of the metacarpal bone with and without displacement: symptoms, treatment, rehabilitation

The metacarpals represent the bony framework of the palm and are important to the function of the hand, connecting the bones of the wrist and fingers. Bone fractures can affect hand grip strength and movement. They are the result of high-energy injuries such as direct impact, motor vehicle accidents, and work-related injuries. Although sometimes a pathological fracture occurs due to minor trauma or stress, when there is an oncological lesion of the bone structure. But, nevertheless, fractures of the metacarpal bones can often be treated conservatively with the help of reposition and proper immobilization, and have a favorable prognosis.

The metacarpal bones are part of the group of small tubular bones of the human body. They have a base, a body and a head. In this regard, fractures of the head, neck (subcapitate), body and base are possible. The most common fracture is a fracture of the neck of the fifth metacarpal (Boxer's fracture).

There are also rare specific fractures of the metacarpal bones, named after the author who first described this fracture. However, these fractures deserve special attention.

In particular, the Bennett fracture and the more severe Rolando fracture. These two fractures are accompanied by subluxation of the first metacarpal.

Bennett's fracture is an intra-articular fracture of the base of the first metacarpal bone with subluxation of the base. Essentially this is a fracture-dislocation. It was first described by the English trauma surgeon Bennet in 1882. A fracture of the base of the metacarpal bone through the joint along the axis, resulting in displacement and subluxation in the joint.

Rolando's fracture is a comminuted (3 fragments) intra-articular fracture of the base of the first metacarpal bone with subluxation of the base. The fracture occurs due to a strong blow to the axis of the finger. Fracture of the base of the metacarpal bone through the joint along the axis and also across. And on the radiograph it resembles the letter U or T. Subluxation in the joint also often occurs.

If these fractures are not treated, the finger remains deformed, and later arthrosis of the trapezio-metacarpal joint, pain and limitation of movements will occur.

Prevalence (epidemiology) of metacarpal fracture

Fractures of the metacarpal bones and phalanges of the fingers account for approximately 10% of all fractures of the bones of the human body and approximately 30% - 40% of all fractures of the upper limb. In men, fractures of the metacarpal bones occur 3 times more often than in women.

People who engage in combat sports such as football, basketball, boxing, karate, etc. are much more at risk of getting a similar fracture. Everything is clear here - injuries, blows. But there are patients who received a fracture without much stress or trauma. Such fractures are called pathological. For example, there is an intraosseous tumor, benign or malignant, which weakens the structure and strength of the bone, and the patient does not know about it, since they are asymptomatic. And he learns about the pathology during an X-ray at the emergency room for a fracture. Sometimes fractures occur due to osteoporosis (weakening of bones due to decreased calcium levels). Most metacarpal fractures occur in the active and working population, especially young people and adolescents.

Recovery in a supine position

Exercise and loading after a limb injury should be started immediately. The muscles relax. The fragments grow together correctly. Here is an approximate complex of therapeutic exercises for the rehabilitation of a patient:

Elbow and shoulder raises.
Leg flexion and extension.
Foot movements.
Hand rotations.

Manipulations with the load should be performed approximately 10 times. They are carried out by healthy parts of the body. As for the sore leg, here it is necessary to lower, raise, abduct, and bring the leg to the body. At the initial stage, gymnastics should be performed with an assistant. Then, during rehabilitation, you can study independently.

At the initial stage of rehabilitation, the patient has swelling. To remove it, it is useful to wear support bandages and perform the following movements:

Lying in bed, raise your legs slightly, hold them, lower them.
Contraction and relaxation of the muscles of the limb.
Flexion, subsequent extension of the fingers.
Rotation of the feet.
Pulling your legs to your chest.

As soon as the doctor realizes that the patient can walk, he is prescribed another exercise. The load increases. Medication treatment is stopped. The process of resuming walking is carried out with the help of a crutch. You can use a cane. After removing the plaster, do gymnastics:

Lying on your back, hug your leg with your arms. Unbend, bend it.
While sitting, move your leg quickly back and forth.
Move your foot, drawing a figure eight.

From the day the cast is removed, the load is increased gradually, not quickly, under the supervision of a doctor. This is expressed in the use of weighting agents. The number of repetitions and the total load also increases.

Structure and functions of the metacarpal bones of the hand

There are a total of 5 metacarpal bones on each hand. They have a tubular structure.

The bases of the metacarpal bones are cuboidal in shape, connecting through ligaments to the distal row of carpal bones.

The body of the metacarpal bone is slightly curved towards the palmar surface and resembles a rocker. Interosseous muscles are attached to the lateral surfaces of the body, which provide fine motor movements of the hand. In case of a transverse fracture of the metacarpal bone, the displacement is difficult to eliminate and maintain precisely because of these muscles, because they constantly pull the fragments onto themselves. The extensor tendons of the fingers are attached to the dorsal surface. The body of the metacarpal bone passes into the neck and then into the head, on which there is an articular surface for connection with the proximal phalanx of the finger. The weakest point of the metacarpal bone can be called the neck; it is at this level that most fractures occur, due to the anatomy and mechanism of injury.

The first metacarpal is unique in that it is shorter and wider than the others and has more extreme angles with the carpus, opposing the axes of the other bones, which characterizes the primary function of the first digit. The second and third metacarpal bones are most rigidly attached to the bones of the wrist with their base. In contrast, the fourth and fifth are more loosely attached and allow the hand to perform more movements and securely grip objects and tools of various shapes.

Working with gait

Along with the listed exercises, you need to add a complex for quick gait restoration and rehabilitation. Here are some effective options:

Use your toes to grab and hold a small object;
Roll a ball with the foot of the sore limb;
Standing on your toes, on your heels;
Walking sideways and backwards.

If possible, you can exercise on exercise bikes. The listed exercises and prescribed treatment after an injury cannot be neglected. Physical education during rehabilitation quickly restores and heals the body from the day the cast is removed.

Recovery after a fracture should continue until the body is completely restored. You can stop exercising after you have regained mobility, swelling has subsided, and there is no pain. The success of rehabilitation depends not only on the will of the patient and the treatment program.

Symptoms of metacarpal fractures

Metacarpal fractures usually occur after a fight, car accident, or fall. Less commonly, these are open injuries (circular saw, axe, production machine). Symptoms include:

pain (most intense in the fracture area);
edema;
shortening of the finger;
deformities (for example, lack of a “knuckle”);
subcutaneous hemorrhage.

What are the possible treatment options for brachymetacarpy and how does it work?

To lengthen the bones of the hand, there are three main options for operations: one-stage bone grafting, two-stage bone grafting and distraction osteosynthesis according to G.A. Ilizarov. The method of choice in the treatment of brachymetacarpy is the third option - distraction osteosynthesis or lengthening with a distraction device according to the method of G.A. Ilizarov. With brachymetacarpy, the shortening of the metacarpal bone always exceeds 1 cm, and one-stage bone grafting does not eliminate the shortening of the metacarpal bone by more than 1 cm at a time, so the choice of this technique for the treatment of brachymetacarpy is not the most competent decision. Two-stage bone grafting can be used to treat this pathology, however, lacking the advantages of one-stage bone grafting (only one operation and a relatively short recovery period), it has the same disadvantage - the need for bone grafting from another area. Lengthening with a distraction device allows one to avoid significant postoperative scars and does not require trauma to the donor area, despite the rather long period of wearing the device (about 3 months), and therefore this technique is the operation of choice for brachymetacarpy.

Diagnosis of metacarpal fractures

Any significant hand injury requires examination by a traumatologist and radiography. The patient may think that this is a bruise, but there may be a fracture, for example, of the scaphoid bone, which can create a lot of problems. A simple x-ray will not take much time, but the patient will already know for sure whether it is a bruise or a fracture.

Questioning the Patient: Most fractures are a direct result of trauma. Complains of pain, swelling, limitation of movements, subcutaneous hemorrhage in the injured arm. Typically, the patient will clearly acknowledge the injury and explain how he received it. Based on this, the doctor can already guess the diagnosis and location of the fracture. The patient may also complain of numbness if the blood supply is disrupted due to compression of the vessels by edema after serious extensive trauma (compartment syndrome or compartment syndrome).

Examination by a traumatologist: examination may reveal visible deformities if the fracture is clearly displaced. If the displacement is small or not at all, the anatomy of the hand may be completely normal. Local swelling and pain on palpation (touch) will be in the projection of the fracture. Possible decrease in grip strength.

Also, during the examination, the doctor pays attention to possible rotation of the fingers (rotation around an axis). You can evaluate this moment by bending your fingers into a fist. The fingers should be lined up without turning around and the nails should be parallel.

Instrumental examination methods:

Radiography. To diagnose a fracture of the metacarpal bone(s), radiography is performed in three projections: direct (antero-posterior), lateral (sagittal) and oblique (3/4).

CT (computed tomography) is used in complex cases when the fracture is comminuted or intra-articular, as well as to confirm the diagnosis of fracture nonunion.

Stages

In order not to harm your health after a hip or lower leg injury, it is important to follow a certain course of action during rehabilitation. It consists of the following stages:

The first stage from the date of plaster removal. Thoroughly rubbing the affected area. Carrying out a massage. Doing light exercises. Application of local drugs to stimulate bone regeneration.
Second phase. Performing complex sets of exercises. Exercise therapy is prescribed. Physiotherapy is carried out.
Third stage. Activity increases. Walks are available. Referrals for spa treatment are given.

It is important to accompany each stage of rehabilitation after removing the cast with a diet. It will speed up your metabolism. Quickly strengthens bone tissue and muscles after injury.

Treatment of metacarpal fractures

Treatment has three goals: maintaining the shape, length, and mobility of the metacarpal bones and fingers. Simply put, preserving the function of the hand.

To determine treatment tactics, the following characteristics of the fracture should be analyzed. Treatment will be surgical (open reposition) or conservative (closed reposition).

Other factors that can be considered for or against surgery are the patient’s age and his or her personal and professional requirements for hand function.

Conservative treatment

Treatment of metacarpal fractures is mainly conservative. It is aimed at eliminating displacement of fragments, if any. immobilization of the hand, pain relief and development of finger movements.

Reposition is performed under local, regional or general anesthesia. Reduction is accomplished by a combination of finger traction and direct pressure, usually from the thumb. Immobilization (plastering, splinting) of metacarpal fractures must comply with international treatment standards:

The fixator should capture the lower third of the forearm and the proximal phalanges of the fingers. So that the fingers move in the interphalangeal joints;
Fixation of the metacarpal bones is carried out along the palmar surface or circularly;
Immobilization of the wrist joint in the physiological position of 20° extension; fingers (proximal phalanges) should be in a flexion position of 70°;

Fractures of the base of the metacarpal bone

Fractures of the base require reduction (elimination of displacement) if the displacement is more than 2 mm or there is angular deformity.

Fractures of the base of the 5th metacarpal through the articular surface require special attention. They are similar to Bennett fracture dislocations of the thumb and require surgical treatment, which will be discussed in the next section.

Immobilization of fractures of the base of the metacarpal bones continues for at least 3-4 weeks. Active finger movements should be performed throughout the entire period of immobilization.

Fractures of the metacarpal body

Most closed metacarpal body fractures are best treated conservatively. Due to the fact that the adjacent metacarpal bone acts like a splint and is firmly held by ligaments, displacements do not occur often. Thus, fractures of the 3rd or 4th metacarpal are the most stable.

If on control radiographs after 7-10 days we see secondary displacement, then the issue of surgery is decided. A fracture of 2 or more metacarpal bones at once is obviously unstable and requires surgical treatment.

Fracture of the neck (subcapitate fracture) of the metacarpal bone

A fracture of this section of the metacarpal bone is often impacted. Considering the mechanism of injury, and this is usually a blow with a fist, the head at the moment of fracture is, as it were, driven into the body of the metacarpal bone and fixed. The fracture becomes stable and does not move. But there may be shortening of the bone if the head is strongly inserted into the body of the metacarpal bone. And this will be immediately noticeable, we will see a retraction in place of the “knuckle”.

In other cases, a similar closed fracture of the neck occurs with an angular displacement to the palmar side. If the angle of deviation does not exceed 30 degrees from the norm, then it can be treated conservatively (without surgery). If the angle is more than 25-30 degrees and the patient needs a healthy hand without restriction of movement, then, as a rule, surgery is needed, since it is practically impossible to keep the head in a straight position with a cast. The pull of muscles and tendons bends this fragment towards the palm. If it is possible to keep the head in the desired position, then immobilization continues for 3-4 weeks and a plaster or plastic polymer bandage is applied to the distal phalanges to limit movement and minimize the risk of displacement. It is imperative to perform control radiographs 7-14-30 days after the injury in order not to miss secondary displacement, if any. Otherwise, the fracture may heal in the wrong position, and surgery will be necessary.

The consequences of improper treatment or lack thereof can be varied. The function of the hand may be impaired, boxers will be unable to play sports at all due to pain and deformation, etc. So no fracture should be underestimated.

Metacarpal head fracture

The vast majority of fractures of the metacarpal head pass through the articular surface, since the head is 50-60% covered with cartilage, forming a joint with the corresponding finger. Such fractures mainly occur as a result of a blow with a fist, less often - direct injuries to the hand during an accident, the fall of a heavy object on the hand, etc.

If the fracture is not displaced, it can be treated conservatively, with immobilization for 3 weeks, and then development of the joint with a gradual increase in volume. If the fracture is displaced or comminuted, surgery, open reduction, fixation of fragments with screws, or prosthetics in case of complete destruction are usually required.

Metacarpal dislocation

A metacarpal dislocation is a severe, high-energy hand injury that almost always involves torn ligaments. The dislocation must be corrected immediately. Under local or local anesthesia, the dislocated bone is reduced and fixed with a plaster cast. It is not uncommon for a dislocation to immediately recur (recur) or not be reduced at all due to bone fragments or areas of torn ligaments, then surgical treatment is necessary: open removal of the dislocation and fixation with knitting needles or a plate with screws.

Physical therapy

The goal of rehabilitation is to restore strength and full range of motion.

For this purpose, hand exercises with light resistance are prescribed. This is where resistance bands and a ball can be helpful, especially if there is scarring and limited flexor motion develops.
Soft tissue repair can be more challenging (compared to bone repair).
Rest and elevation are important, as is splinting (poor splinting can lead to stiffness, pressure sores, or even compartment syndrome).

Friends, on July 17 in Moscow, as part of the #RehabTeam project, Anna Ovsyannikova’s seminar “Rehabilitation of the hand after a fracture of the distal radius (fracture of the “radius in a typical place”)” will take place.” Find out more... In addition, on July 18, she will conduct a seminar “Rehabilitation of the hand after fractures of the metacarpal bones (Boxer fracture).” Find out more...

Physical therapists use a range of techniques to restore movement in the hand, wrist and fingers. These include:

Eliminate swelling with massage and compression clothing.
Soft tissue massage helps relieve muscle tension and pain.
Developing a home exercise program for patients with specific recommendations for movement and strengthening exercises.

Here are the steps to follow for a stable fracture (you can use this or another of the stabilization methods below):

A non-operative treatment involves strapping the injured finger to another finger. This can be done with or without a splint.
Splinting for a fracture should be as follows: wrist extension 20 degrees; flexion of the metacarpophalangeal joint by 60-70 degrees and extension of the interphalangeal joint.
If we are dealing with a stable fracture, it makes sense to start movements earlier.
As a rule, active exercises to increase the range of motion without resistance can begin 2-3 weeks after surgical treatment (on intact or adjacent joints).
Active movement. If the fracture is fixed, an active increase in range of motion may begin earlier. Most fractures are treated with immobilization, but active motion can begin after three weeks of therapy, starting with joints not affected during the initial immobilization. This phase usually lasts 3-6 weeks.
Active movements involve sliding of tendons.
Tendon gliding is important to prevent adhesions, increase circulation, and reduce swelling and compression at the fracture site.

Tendon gliding exercises

Exercises for tendon gliding

The claw hand exercise can be used to improve the glide of the extensor digitorum tendon over the metacarpal bones.
An exercise to block the deep flexor digitorum to improve the sliding of its tendon along the phalanges.
A hook fist position that promotes selective gliding of the flexor digitorum profundus tendon.
An exercise to block the superficial flexor digitorum to improve the sliding of its tendons along the middle phalanges.
A straight fist position that promotes selective gliding of the superficial digital flexor tendons.

Passive movements

Passive movements can be started after sufficient clinical healing after approximately 5-6 weeks of therapy.
The timing of the onset of joint mobilization depends on the structures involved in the injury. If structures resisting force are not involved in the injury, joint mobilization can be initiated at the same time as active movement. Compression from a fracture can result in shortening, angulation, or rotation of the bone.
Traditional passive range of motion exercises are designed to help joint cartilage heal and reduce swelling and stiffness.
Resistive movement. Four weeks after injury, light resistance can be performed (this is true for most PKCs that are treated with immobilization). Active movements should only be continued if healing has not yet begun.
Resistance exercises should also be postponed while the fracture is being fixed with pins (until the pins are removed). Light resistance exercises help in scar remodeling and improve movement. There are several types of resistance exercises, such as weight training. This type of exercise strengthens the superficial and deep flexors of the fingers.
Functional exercises and work simulations should be incorporated into resistance exercises as soon as possible.

Surgical treatment of metacarpal fractures

Although conservative treatment (closed reduction) of these injuries is the rule rather than the exception, some fractures and dislocations require surgical intervention to ensure a satisfactory outcome and complete restoration of hand function and anatomy.

The essence of the operation for fractures of the metacarpal bones in different parts comes down to one thing - osteosynthesis - open elimination of the displacement of bone fragments and fixation of them with metal structures suitable specifically for a given fracture.

Fixation is an effective means of stabilization, which, with proper treatment, eliminates secondary displacement of fragments.

The advantages of surgical treatment are the early start of rehabilitation, the development of movements in the joints of the hand, which reduces the risk of developing contractures.

Open fractures require urgent surgical treatment of the wound, and then stable external fixation with knitting needles or a rod apparatus. Since with internal fixation there is a high risk of suppuration.

The surgical tactics and choice of fixator depend on the location, type of fracture, amount of displacement, and condition of the soft tissues.

Transverse fractures can be reduced in a closed manner and fixed with cross-on-cross Kirschner wires. In rare cases, external fixation rods and intraosseous pins are used. All methods have advantages and disadvantages. The choice of method largely depends on the nature of the fracture, but there are other important factors. Dependence on the patient’s requests for quality of life and, therefore, treatment, the skills and preferences of the doctor, and the equipment of the medical institution.

Fractures of the neck and base of the metacarpal bones are usually fixed with wires, a T-plate and miniscrews.

Fractures of the body (diaphysis) are fixed with a straight plate.

Bone fractures with large fragments are often easily treated with closed reduction and Kirschner wire fixation, but movement will be limited. Comminuted, intra-articular fractures always require surgical treatment.

The operation for a neck fracture is very similar to osteosynthesis of the body of the metacarpal bone, both in terms of indications and methods of fixation. Indications for surgery, as mentioned above in conservative treatment, are displacement of the head by more than 25 degrees and the inability to hold it in the correct position.

Operations for fracture of the metacarpal head

Deserves special attention. Fractures involving more than 15% of the articular surface and displacement of more than 2 mm should be operated on. Ideally, the fixation should be stable enough to allow early movement to develop the joint.

Comminuted fractures of the head of the metacarpal bone, since complete destruction of the joint will inevitably lead to arthrosis and loss of function. In this case, prosthetics are performed.

When treating dislocations and fracture-dislocations of the metacarpal bones, the same principles of fixation and patient management are maintained.

Grade

The assessment includes:

Standard radiographs of the hand (antero-posterior, lateral and oblique). In the vast majority of cases, this will be enough to confirm the diagnosis and formulate a treatment plan. Confirmation of more subtle lesions can be obtained using specialist views such as Brewerton (metacarpal heads), Roberts and Betts (thumb).
A CT scan is sometimes necessary for base metacarpal fractures to rule out/confirm the presence of intra-articular displacement and determine whether surgery is necessary.

Fracture of the phalanges of the fingers

Fractures of the phalanges of the fingers often occur with direct and indirect injuries. As a rule, with fractures of the diaphysis, a displacement is formed with an angle open to the rear. The clinical picture is characteristic of most fractures - swelling, deformation, subcutaneous hematoma, pathological mobility, pain with axial load. You can read about injuries to the knee meniscus, clavicle fracture and dislocation of the clavicle, and arthroscopic plastic surgery in the appropriate sections.

Treatment. Closed manual reduction is performed, fixation with plaster casts or orthoses for 4–5 weeks. In cases where the displacement cannot be eliminated conservatively, surgical treatment of the fracture is resorted to.