It’s 8AM. You are done with your night shift. All you can think about is a toasted whole wheat bagel with cream cheese and hot cup of single origin, organically grown, locally brewed and roasted cup of coffee.
As you are biking, two elderly bikers pass you in a second. You start to pedal fast and faster. Chain comes off and you flip forward. Luckily you had your helmet on. You get up feeling embarrassed for falling. As you pick up your bike, you notice your swollen bruised R hand.
You come to Fast Track, where your colleague examines your hand. You suspect R hand fracture. After prescribing pain control, what are some important physical examination findings to look for? -Inspect for open wounds and associated injuries (i.e. tendon injury). -Deformity indicates location. For instance, shortening can be assessed by comparing with the contralateral hand. Malrotation should be vassessed by lining up fingernail in partial flexion and full flexion if possible – compare to the contralateral side. -Assess motor function: Typically there are no motor deficits unless open wounds are present. -Assess nerve damage: Median nerve can be assessed by flexing the thumb, the ulnar nerve by spreading fingers, and the radial nerve by maintaining extension of wrist and fingers. Dorsal wounds may affect the dorsal sensory branch of radial/ulnar nerve, and volar wounds can involve digital nerves. There is tenderness to palpation at the base of 4th and 5th metacarpal and moderate swelling. There are no open wounds. The extremity is n eurovascularly intact, and motor function is within normal limits. The resident orders R hand Xray and graciously gives you percocet and performs a hematoma block for pain control. The radiology attending calls you: There is intra-articular fracture of the 4th metacarpal base. What are different types of metacarpal fractures? Metacarpal fractures are divided into fractures of metacarpal head, neck, shaft, and base and account for 40% of all hand injuries. Treatment based on which metacarpal is involved and the location of fracture. Xray already shows fracture. Do I need to get a R hand CT? What are indications for getting hand CT? -Inconclusive radiographs of carpometacarpal fractures/dislocations -Multiple carpometacarpal dislocations -Complex metacarpal head fractures CT result shows intra-articular displaced fracture of 4th and 5th metacarpal base. There is no associated wrist fracture. Which fractures need to be reduced? Acceptable angulation varies by location. Angulation that is more than 40 degrees in 5th MC, 30 in 4th MC, and 20 in 2nd and 10 degrees in 3rd MC needs reduction. (10, 20, 30, 40 degrees angulation: index to small finger respectively) -No degree of malrotation is acceptable. What kind of splint will you place? Ulnar gutter for fractures of 4th and 5th MC. Radial gutter for fractures of 2nd and 3rd MC. The wrist should be extended at 20-30 degrees and MCP joint flexed at 90 degrees. What is a Boxer’s Fracture? Fracture of 4th and 5th metacarpal bones. A Boxer’s Fracture is the most common type of metacarpal fracture. What is the most feared complication of Metacarpal fracture? Compartment Syndrome. This may result from crush injury. The patient will complain of pain out of proportion to exam findings. Bonus Question: What are indications for operative repair? General indications: -Open fracture -Intra-articular fractures -Rotational malalignment of digit -Significantly displaced fractures -Multiple metacarpal shaft fractures You end up getting ORIF given your fracture was intra-articular. K wires were placed, and your hand was placed in cast for 6 weeks. This is how it looks post-surgery *Inspired by True Events Special thanks to Dr. Willis Reference: 
 
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