(Also known as a Fractured Metacarpal)
What is a metacarpal fracture?
A metacarpal fracture is a relatively common condition characterized by a break in one of the long bones of the hand known as the metacarpals.
The palm of the hand primarily comprises of five long bones known as the metacarpals. The metacarpal bones form joints with the small bones of the wrist known as the carpal bones and the small bones of the fingers known as the phalanges.
During certain activities such as a punch or direct impact to the hand, stress is placed on the metacarpal bones. When this stress is traumatic and beyond what the bone(s) can withstand a break in one or more metacarpals may occur. This condition is known as a metacarpal fracture.
Due to the relatively large forces required to break a metacarpal bone, a metacarpal fracture is often seen in association with other injuries to the wrist or fingers such as joint sprains, dislocations or other fractures of the hand or wrist.
Metacarpal fractures can vary in location, severity and type including displaced fracture, un-displaced fracture, compound fracture, greenstick, comminuted etc.
Cause of a metacarpal fracture
A metacarpal fracture most commonly occurs as a result of a punch (particularly into a hard object). Occasionally they may occur due to a direct impact to the hand from an object travelling at high speed (such as a hockey stick) or a fall onto the fingers or thumb.
Signs and symptoms of a metacarpal fracture
Patients with this condition typically experience a sudden onset of intense hand pain at the time of injury. Pain may be felt on the front, back or sides of the hand and can occasionally settle quickly leaving patients with an achiness of the hand that is particularly prominent at night or first thing in the morning. Pain may also radiate into the fingers or wrist of the affected hand.
Patients with a metacarpal fracture may also experience weakness, swelling, bruising and pain on firmly touching the affected region of bone. Pain may also increase with certain movements of the wrist and fingers such as opening and closing the hand and fingers, general gripping activity, lifting, carrying objects and pushing through the affected hand. In severe metacarpal fractures with bony displacement, an obvious deformity may be present. Occasionally, patients may also experience pins and needles or numbness in the hand or fingers.
Diagnosis of a metacarpal fracture
A thorough subjective and objective examination from a physician is essential to assist with diagnosis of a metacarpal fracture. An X-ray is usually required to confirm diagnosis and assess the severity. Further investigations such as an MRI, CT scan or bone scan may be required, in some cases, to assist with diagnosis and assess the severity of injury.
Prognosis of a metacarpal fracture
Most minor undisplaced metacarpal fractures, managed with appropriate immobilization and physical therapy, can recover and return to sport or full activities in approximately 6 -12 weeks (a protective splint may be required). In more severe cases, particularly those patients with displaced fractures, injuries to other structures or those fractures requiring surgery or anatomical reduction, recovery may take greater than 12 weeks, with a greater period of rehabilitation and physical therapy. It is important to note however that the fracture may take many months to regain full bony strength.
Treatment for a metacarpal fracture
For those metacarpal fractures that are displaced, involve the joint surface of the metacarpal or for long spiral fractures, treatment typically involves anatomical reduction (i.e. re-alignment of the fracture by careful manipulation under anaesthetic) followed by plaster cast or splint immobilization for a number of weeks, or surgical internal fixation or external fixation (using pins that are inserted through the skin and bony fragments) to stabilize the fracture and aid healing.
Treatment for fractures that are not displaced typically involves splinting or plaster cast immobilization for a number of weeks. Following removal of the cast or splint, re-evaluation of the fracture clinically and with investigations, such as X-rays, is usually required to ensure healing. Once the bone has healed sufficiently, rehabilitation can begin as guided by your physical therapist.
One of the most important components of rehabilitation following a metacarpal fracture is that the patient rests sufficiently from any activity that increases their pain. Activities placing large amounts of stress through the affected metacarpal should also be avoided particularly punching, lifting, gripping activity, pushing or pulling or placing excessive weight through the wrist and hand. Resting from aggravating activities allows the healing process to take place in the absence of further damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated. This should take place over a period of weeks to months with direction from the treating physical therapist.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to cause further damage and may slow healing or prevent healing of the metacarpal fracture all together. Immediate, appropriate treatment in all patients with this condition is essential to ensure an optimal recovery.
Gently icing the metacarpal in the initial phase of injury (first 72 hours) and keeping it elevated above the level of the heart can assist in reducing swelling and pain. This should generally be implemented on the way to receiving urgent medical attention. Ice can be applied for 20 minutes and repeated every 2 hours.
Patients with a metacarpal fracture should perform pain free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. The treating physical therapist can advise which exercises are most appropriate for the patient and when they can commence.
Manual "hands-on" therapy from the physical therapist such as massage, joint mobilization, dry needling, stretches and electrotherapy can also assist with improving range of movement, pain and function following a metacarpal fracture. This can generally commence once the physical therapist or surgeon has indicated it is safe to do so.
In the final stages or rehabilitation, a gradual return to activity or sport can occur as guided by the treating physical therapist and surgeon provided symptoms do not increase. A protective splint or brace may be required when returning to sport.
Physical therapy for a metacarpal fracture
Physical therapy treatment is vital in all patients with this condition to hasten healing, ensure an optimal outcome and reduce the likelihood of recurrence. Treatment may comprise:
Other intervention for metacarpal fracture
- soft tissue massage
- joint mobilization
- electrotherapy (e.g. ultrasound)
- taping, bracing or splinting
- exercises to improve strength and flexibility
- activity modification
- a graduated return to activity plan
Despite appropriate physical therapy management, some patients with this condition do not improve and require other intervention to ensure an optimal outcome. The treating physical therapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, extended periods of plaster cast or splint immobilization, surgery or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the metacarpal fracture. Occasionally, a bone graft may be required to aid fracture healing.