Quick clinical tip: Rotational angulation of metacarpal fracture

Metacarpal fractures are commonly present to the Emergency Department for care. The plain film shown here shows metacarpal neck fractures of the middle and ring finger shown. There are specific criteria requiring closed reduction in the ED (PV Card). Generally ANY rotational angulation requires reduction. Detection of such angulation depends on the clinical exam rather than the plain film. How does one diagnose it?

Clinical exam to check for metacarpal fracture rotational angulation

You can check for rotational angulation using two approaches:

1. With a closed fist, the fingers (excluding the thumb) should point to the scaphoid.
2. When the fingers are loosely flexed, the fingernails should lie in a similar parallel plane. The fingers should not overlap, or “scissor”.

This photo above demonstrates a third metacarpal neck fracture with rotational angulation requiring closed reduction in the ED. Because rotationally angulated metacarpal fractures require urgent reduction, be sure to document the absence of rotational angulation in your medical chart before discharging a patient home.

Reference

Mailhot T, Lyn ET. “Hand” in Marx, Hockberger, Walls (eds), Rosen’s Emergency Medicine: Concepts and Clinical Practice, 8th ed. Mosby, Inc, 2013.

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