Poll: How would manage a metacarpal fracture in the ED?

I am in the process of creating a PV card on metacarpal fractures, divided into anatomical areas (base, shaft, neck, head), and am realizing that the EM and orthopedic literature don’t quite agree. Actually they are quite vague on whether reductions should occur in the ED vs orthopedics clinic in the next few days.

• Do you need to close-reduce all angulated fractures in the ED, which are outside of “acceptable” angulations?
• What exactly are “acceptable” angulations? Some sources say that angulations of 10, 20, 30, and 40 degrees are acceptable for MC neck fractures and only 10, 10, 20, and 20 degrees are acceptable for MC shaft fractures. These numbers, though, vary from reference to reference.

The only consistent thing I’ve read is that rotational angulation (where not all the fingers point to the patient’s scaphoid bone) requires reduction in the ED because of the concern for functional impairment.

School of thought #1:

Reduce all angulated fractures. Heck, it’s bent. Straighten it.

School of thought #2:

Leave all fractures alone. As many of 50% of fractures, especially unstable ones, will lose their realigned position when the patient is seen at the outpatient orthopedic visit. Just splint it and follow-up.

School of thought #3:

I reduce some but not all angulated fractures.

Would love to hear the variations in people’s practice. Feel free to use the Comments section of the blog to explain.

A patient presents with a 5th metacarpal SHAFT fracture with 45 deg angulation (no rotational angulation). What’s your management plan? Check all that apply.

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