Hands are, obviously, useful. They allow kids (and all of us) to explore, interact, and manipulate the world. This utility, however, often places them in precarious situations and hazardous locations. Hand injuries are commonly encountered in our EDs (ex, Subungal Hematoma, Wrist Fractures) and, since the hand is such an important tool, it deserves specific attention. Let us take a moment to digest a Morsel of Metacarpal Fractures:
Metacarpal Fractures: Basics
The hand is one of the most frequently injured body part of a child. [Mahabir, 2001;Hastings, 1984]
The most common metacarpal fracture is the Boxer’s Fracture (neck of the 5th metacarpal). [Vadivelu, 2006; Mahabir, 2001]
Fracture displacement is more common with metacarpal fractures. [Hastings, 1984]
Almost all metacarpal fractures will heal clinically by 3-4 weeks. [Hastings, 1984]
Metacarpal Fractures: Age Matters
Pediatric hand fractures have a biphasic peak. [Vadivelu, 2006]
Small peak in toddlers and preschool children.
More mobile and curious, but not super coordinated to get out of trouble
Younger children are more often injury their fingers (ex, getting them crushed in doors– little fingers vs doors — never a good thing).
Larger peak in 2nd decade of life (10-20 years). [Godfrey, 2017;Mahabir, 2001;Hastings, 1984]
Sporting events are often associated [Vadivelu, 2006; Mahabir, 2001]
Repeated hand fractures found to be associated with psychiatric illness. [Ozer, 2010]
The physis makes pediatric hand fractures unique.
Angular forces can lead to epiphyseal injuries.
Salter-Harris type II fractures are the most common type of epiphyseal fracture.
Nonepiphyseal fractures are more common, though, in the metacarpals than in the phalangeal bones. [Vadivelu, 2006; Mahabir, 2001]
Metacarpals usually get axial compressive forces, which the epiphyses is resistant to.
Fighting / punching and sporting events lead to compressive forces.
Metacarpal Fractures: Location Matters
Metacarpal fractures are categorized as involving the:
Head
Rare
Intra-articular
Associated with avascular necrosis and growth arrest. [Williams, 2013]
Require anatomic fixation
Can be challenging to appreciate in children. [Godfrey, 2017]
Neck
Commonly seen with 2nd-5th metacarpals. [Mahabir, 2001]
Compressive forces are more likely to lead to fractures here. [Mahabir, 2001]
Shaft
Uncommon
Distributed among 2nd-5th metacarpals
Often have an oblique or spiral pattern (rotational forces)[Sivit, 2013]
Base
Commonly seen with 1st digit and 5th metacarpals [Sivit, 2013]
In skeletally immature children, these may involve the physis.
Bennett’s Fracture [Godfrey, 2017]
An intra-articular fracture and dislocation at the base of the 1st metacarpal.
Mechanism = fall on flexed thumb
The metacarpal subluxes proximally and radially with small fragment remaining attached to the ligaments.
Pediatric variants include Salter-Harris type III and IV fractures. [Godfrey, 2017]
These are unstable and require surgical repair.
Reverse Bennett’s Fracture – similar fracture pattern involving the 5th metacarpal.
Metacarpal Fractures: Deformed?
Rotational deformity is not tolerable.
Angular deformity can be tolerated … to some degree:
2nd Metacarpal Neck – <10 degrees
3rd Metacarpal Neck – <20 degrees
4th Metacarpal Neck –<30 degrees
5th Metacarpal Neck – <40 degrees
Radially angulation is typically more stable than ulnarly angulated fractures. [Williams, 2013]
May require surgical repair for rotation or substantial angulation.
Moral of the Morsel
Age plays a role in hand injury patterns. Younger – fingers; Older – metacarpals
No rotation allowed! Angular deformity is ok… know the degrees!
Be leery of the thumb fracture! Bennett’s fracture is not a simple metacarpal fracture.
References
Godfrey J1, Cornwall R. Pediatric Metacarpal Fractures. Instr Course Lect. 2017 Feb 15;66:437-445. PMID: 28594520. [PubMed] [Read by QxMD]
Metacarpal fractures account for 10% to 35% of all pediatric hand fractures. Pediatric metacarpal fractures commonly occur in patients aged 13 to 16 years, with most injuries sustained during sports activities. Pseudoepiphyses can be confused with metacarpal fractures; however, a careful physical examination can help physicians distinguish the two. Thumb metacarpal base fractures that involve the physis warrant special attention. Thumb metacarpal […]
Sullivan MA1, Cogan CJ, Adkinson JM. Pediatric Hand Injuries. Plast Surg Nurs. 2016 Jul-Sep;36(3):114-20. PMID: 27606586. [PubMed] [Read by QxMD]
Pediatric hand injuries are extremely common. Although many hand injuries are adequately managed in the emergency department, some may need evaluation and treatment by a pediatric hand surgeon to ensure a good functional outcome. This article discusses the diagnosis and management of the most common pediatric hand maladies: fingertip injuries/amputation, tendon injuries, and phalangeal and metacarpal fractures. The plastic surgery nurse should be […]
Sivit AP1, Dupont EP, Sivit CJ. Pediatric hand injuries: essentials you need to know. Emerg Radiol. 2014 Apr;21(2):197-206. PMID: 24158746. [PubMed] [Read by QxMD]
The hand is a common site of injury in children and adolescents. The most common mechanism of injury in younger children is crush injury resulting from the hand caught in a closing door while most fractures in teenagers result from recreational sports. Accurate diagnosis of hand fractures is a requisite for timely management of these injuries in order to restore normal function and achieve a satisfactory outcome since poorly treated injuries can […]
Williams AA1, Lochner HV. Pediatric hand and wrist injuries. Curr Rev Musculoskelet Med. 2013 Mar;6(1):18-25. PMID: 23264097. [PubMed] [Read by QxMD]
In the last 40 years, childhood hand and wrist injuries have become progressively more common as children have become heavier and more active in high impact sports. The majority of children with such injuries do well, but treatment is not always straightforward. Distal radius fractures, scaphoid fractures, metacarpal and phalangeal fractures, nailbed injuries, and amputations are among the pediatric hand and wrist injuries most often seen by ort […]
Ozer K1, Gillani S, Williams A, Hak DJ. Psychiatric risk factors in pediatric hand fractures. J Pediatr Orthop. 2010 Jun;30(4):324-7. PMID: 20502230. [PubMed] [Read by QxMD]
Various psychopathologies are becoming more commonly recognized as a cause of violence in the pediatric population. In this study, we aimed to investigate (1) the link between the pediatric hand fractures and psychopathology and (2) the prevalence of repeated hand injuries in the same population. […]
Vadivelu R1, Dias JJ, Burke FD, Stanton J. Hand injuries in children: a prospective study. J Pediatr Orthop. 2006 Jan-Feb;26(1):29-35. PMID: 16439897. [PubMed] [Read by QxMD]
The purpose of this prospective clinical study was to identify the true incidence, pattern, and location of the injury and nature of fracture after hand injuries in different pediatric age groups attending a hand unit. Three hundred sixty children (237 boys, 123 girls) under 16 years of age who presented with hand injuries between April 1, 2000, and Sept. 30, 2000, were included in the study. Bony injuries accounted for 65.5% (236 injuries); 33.3 […]
Hastings H 2nd, Simmons BP. Hand fractures in children. A statistical analysis. Clin Orthop Relat Res. 1984 Sep;(188):120-30. PMID: 6467708. [PubMed] [Read by QxMD]
A retrospective review of 354 pediatric hand fractures was performed with a minimum follow-up period of two years. The incidence of epiphyseal injury was 34% higher than reported elsewhere in the skeleton. Growth disturbance was extremely rare, occurring only in two patients with severe crush injury and infection. Fracture displacement was most common in the border digits with displacement within a given digit most common in the metacarpal; the n […]
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Can metacarpal fractures heal successfully without surgery.