By: Terry R. Yochum, DC, DACBR, Fellow, ACCR, and Chad J. Maola, DC
A young male patient injures his hand in a traumatic event. Do you see the fracture? (See next page for Diagnosis.)
Barroom fracture of the 5th metacarpal with palmer displacement of the 5th metacarpal head.
The phalanges and metacarpals are the most common sites of skeletal injury in the entire skeleton.1,2 Phalangeal fractures are more common than metacarpal fractures. In the majority of cases only a single bone or joint will be affected. Most can be treated conservatively, with only a few requiring open reduction and soft tissue repair or pin fixation.
Radiological examination routinely should have no less than three projections, including posteroanterior, oblique, and lateral views. If a single digit is involved, collimated views in these positions should be done to enhance detail. Examination of the thumb requires specialized projections. Knowledge of the locations and appearances of the many sesamoid bones and nutrient canals will reduce the probability of misdiagnosis.
FRACTURES OF THE HAND
Second to Fifth Metacarpal Fractures. Of all the metacarpals, the fifth is the most commonly fractured, the majority of which occur in the distal half.
Boxer’s Fracture. This is a transverse fracture of the neck of the second or third metacarpal, the result of a straight, jabbing type of blow with the fist.3
Barroom Fracture. This type of fracture is also transverse in nature, involving the neck of the fourth or fifth metacarpals and is the result of a “roundhouse” type of blow characteristic of the inexperienced fighter.3,4 This exposes the fourth and fifth metacarpal heads to absorption of the force of the delivered blow.
In most metacarpal neck fractures there will be anterior angulation of the metacarpal head, with variable degrees of shortening and rotation of the fracture fragment.
Shaft Fracture. When present, these usually involve the third and fourth metacarpals, often simultaneously. Dorsal angulation and displacement across the fracture site quite commonly occur.
Base Fracture. These fractures are rarely seen.
1. Yochum TR, Rowe LJ. Essentials of Skeletal Radiology, 3rd ed. Baltimore: Williams & Wilkins, 2005:513.
2. Rockwood CA, Green DP. Fractures. Philadelphia: JB Lippincott, 1975.
3. Brown PS. Management of phalangeal and metacarpal fractures. Surg Clin North Am 1973; 53:1393.
4. Terrett AGJ, Molyneux TP. Hit or mis? The impact of three cases. J Aust Chiro Assoc 1984; 14(4):153.