Metacarpal Fracture Notes

Metacarpal Fracture

Definition

A metacarpal fracture is a break in one of the five long bones (metacarpals) that make up the palm of the hand.

  • Common due to trauma such as falls, direct blows, or accidents.

  • Can severely impact hand function.

  • Usually due to direct trauma involving the head, neck, shaft, or base.

  • Fractures involving the head and base could be intra-articular or extra-articular.

Mechanism of Injury

  • Direct Blow or Trauma:

    • Punch to a hard object, often resulting in a Boxer’s Fracture (typically the 5th metacarpal).

  • Falls or Sports Injuries:

    • Falling onto an outstretched hand.

    • Engaging in activities like basketball, hockey, or cycling.

  • Twisting or Bending:

    • A twisting injury can cause a fracture.

  • Crushing Injuries:

    • Industrial or workplace accidents can crush the hand.

  • Repetitive Stress:

    • Stress fractures can develop from overuse, common in athletes or manual laborers.

Clinical Features

  • Pain:

    • Most common symptom, localized to the fracture site.

    • Worsens with movement or pressure.

  • Swelling and Bruising:

    • Observed around the affected area.

    • Can extend to the fingers or wrist.

  • Deformity:

    • Visible misalignment of the metacarpal or abnormal angulation in displaced fractures.

    • Particularly with a Boxer's Fracture.

  • Reduced Range of Motion (ROM):

    • Difficulty in flexing, extending, or gripping objects due to pain and swelling.

  • Tenderness:

    • Area around the fracture is tender to touch.

    • Especially over the metacarpal bones.

  • Inability to Grasp Objects:

    • Lack of hand strength due to pain or structural integrity of the bone.

  • Numbness or Tingling:

    • Rare, indicates nerve involvement, requires urgent medical attention.

Types of Metacarpal Fractures

  • Boxer’s Fracture:

    • Fracture of the 5th metacarpal neck, caused by punching an object with a closed fist.

  • Comminuted Fracture:

    • The bone breaks into several pieces, often requiring surgical intervention.

  • Displaced Fracture:

    • The bone fragments are misaligned and may need reduction (surgical or manual realignment).

  • Non-Displaced Fracture:

    • The bone cracks, but the parts remain in alignment, often treated conservatively with splints or casts.

  • Stress Fracture:

    • A hairline fracture often caused by repetitive pressure or overuse of the hand.

  • Open Fracture:

    • The bone protrudes through the skin; this requires urgent medical treatment to prevent infection.

  • Bennett's Fracture:

    • A fracture-dislocation of the base of the thumb metacarpal, involving the carpometacarpal joint.

Normal Finger Joint Movements

  • Interphalangeal Joints:

    • Proximal:

      • Flexion: 0−100∘0-100^\circ

      • Extension: 0−7∘0-7^\circ

    • Distal:

      • Flexion: 0−70∘0-70^\circ

      • Extension: 0−8∘0-8^\circ

  • Thumb:

    • Flexion: 0−80∘0-80^\circ

    • Extension: 0−5∘0-5^\circ

  • Metacarpophalangeal Joints:

    • II, IV, V fingers:

      • Flexion: 0−90∘0-90^\circ

      • Extension: 0−5∘0-5^\circ

    • Thumb:

      • Flexion: 0−80∘0-80^\circ

      • Extension: 0∘0^\circ

Physiotherapy Assessment

  • Patient History:

    1. Mechanism of injury

    2. Time since injury

    3. Treatment received (e.g., surgical or non-surgical)

    4. Any associated injuries or complications (nerve or soft tissue involvement)

    5. Previous medical history (e.g., any chronic hand conditions)

  • Inspection:

    1. Visual inspection for swelling, bruising, deformity, and signs of infection (in the case of an open fracture).

    2. Assess any scars if surgery was performed.

  • Palpation:

    1. Tenderness over the fracture site and the surrounding structures.

    2. Assessment for any bony deformity or malalignment.

    3. Check for signs of nerve involvement (e.g., sensation loss, tingling).

  • Range of Motion (ROM):

    1. Active Range of Motion (AROM):

      • The ability of the patient to move their fingers, wrist, and hand actively.

      • A decrease in ROM indicates possible stiffness due to pain or immobilization.

    2. Passive Range of Motion (PROM):

      • Gently moving the joints by the therapist to check for joint stiffness or pain during the movement.

    3. Assess for joint integrity (e.g., metacarpophalangeal joints, interphalangeal joints).

  • Strength Testing:

    1. Testing grip strength, finger strength, and thumb opposition using tools like a dynamometer.

    2. Check for any weakness or inability to hold objects.

  • Neurovascular Assessment:

    1. Ensure there is no nerve injury or blood supply impairment, especially if the fracture is open.

    2. Check for distal pulses (radial and ulnar pulse), sensation (light touch, pinprick, vibration), and motor function (thumb and finger movements).

Rehabilitation for Metacarpal Fracture

Weeks 1-2: Acute Phase (Protection and Pain Management)

  • Goals:

    • Protect the fracture site.

    • Control pain and swelling.

    • Prevent stiffness in the unaffected joints.

  • Physiotherapy Focus:

    • Immobilization: The hand is typically immobilized with a splint or cast. The patient should avoid using the injured hand.

    • Rest: Adequate rest and elevation to reduce swelling.

    • Ice Therapy: Apply ice to reduce swelling and manage pain.

    • Passive Range of Motion (PROM): Begin gentle passive ROM for the fingers (if permitted by the physician), especially for unaffected joints, to avoid stiffness.

    • Gentle Soft Tissue Mobilization: For the unaffected parts of the hand and wrist.

    • Patient Education: Educate on avoiding movements that could stress the fracture site and emphasizing proper posture to avoid further injury.

Weeks 2-4: Early Recovery Phase (Gentle Mobilization and Pain Reduction)

  • Goals:

    • Begin restoring pain-free motion in the fingers and wrist.

    • Prevent excessive stiffness in surrounding joints.

  • Physiotherapy Focus:

    • Active Range of Motion (AROM): Once the fracture is stable, gentle active ROM exercises for the non-injured joints in the hand (e.g., wrist, unaffected fingers). Start ROM exercises on the affected metacarpal if the doctor allows.

    • Isometric Exercises: Light isometric contractions of the hand muscles to promote circulation and maintain muscle tone.

    • Swelling Control: Continue ice therapy, elevating the hand, and using compression bandages or sleeves to minimize swelling.

    • Soft Tissue Mobilization: Gentle massage or stretching of non-injured tissues to avoid the formation of adhesions and muscle tightness.

Weeks 4-6: Mid Recovery Phase (Strengthening and Increased Mobility)

  • Goals:

    • Increase range of motion (ROM).

    • Begin strengthening exercises.

    • Reduce swelling further.

  • Physiotherapy Focus:

    • Active and Passive Range of Motion: Continue ROM exercises for the hand, wrist, and fingers, progressively increasing the range as tolerated.

    • Strengthening Exercises:

      • Isometric and resisted exercises to strengthen the muscles around the hand and wrist.

      • Use therapy putty or stress balls to strengthen the muscles of the hand.

      • Gentle grip strengthening exercises.

    • Scar Tissue Mobilization: If surgery was done, work on mobilizing the surgical site and scar tissue to prevent adhesions.

    • Light Functional Tasks: Start functional hand movements (e.g., grasping small objects) to prepare for daily activities.

Weeks 6-8: Late Recovery Phase (Functional Training and Strength Development)

  • Goals:

    • Restore strength, flexibility, and functional abilities.

    • Gradually return to normal hand movements.

  • Physiotherapy Focus:

    • Strengthening: Focus on improving grip strength and fine motor coordination. Progress exercises to include more resistance.

    • Functional Training: Incorporate more functional tasks relevant to the patient’s daily life (e.g., holding a cup, opening a door, writing, typing).

    • Dexterity Training: Use small objects for finger manipulation exercises (e.g., picking up coins, buttons, or using a keyboard).

    • Stretching: Continue to stretch the hand and fingers, ensuring the joints regain full range of motion.

Weeks 8-12: Return to Activity (Full Rehabilitation Phase)

  • Goals:

    • Full functional recovery.

    • Return to work, sports, or other regular activities.

  • Physiotherapy Focus:

    • Advanced Strengthening: Gradual return to full strength with more complex tasks like lifting light weights or using resistance bands.

    • Sport-Specific/Occupation-Specific Tasks: Tailor rehabilitation to return to sports or work activities, such as adjusting grip strength for athletes or manual laborers.

    • Endurance Training: Build stamina for the hand and forearm muscles through prolonged use and repetitive tasks.

    • Return to High-Level Functional Tasks: Tasks that mimic daily life, work, or hobbies.

Additional Considerations

  • Splinting/Bracing: Depending on the fracture, a splint or cast may be required for a longer period, and physiotherapy should work around it to ensure no further damage occurs.

  • Surgical Fractures: If surgery was involved, more attention will be needed for scar tissue mobilization and rehabilitation will likely be slower.

  • Work/School Adjustments: Occupational therapists may be involved to help with adjustments at work or school during recovery.

Summary of Key Phases (in weeks)

  1. Weeks 1-2: Protection, pain management, passive movement of non-injured joints.

  2. Weeks 2-4: Gentle ROM, isometric strengthening, and edema control.

  3. Weeks 4-6: Active ROM, strengthening, scar mobilization (if surgery), and functional tasks.

  4. Weeks 6-8: Advanced strengthening, functional rehabilitation, dexterity exercises.

  5. Weeks 8-12: Full return to activities, high-level functional tasks, and specific strengthening.

Factors That Can Affect Rehabilitation Timeline

  • Severity of the Fracture: More complex fractures (e.g., comminuted or displaced) may require a longer rehabilitation process.

  • Age and General Health: Younger individuals or those in good health may heal faster than older individuals or those with comorbidities.

  • Adherence to Treatment: Consistent participation in physiotherapy and adherence to home exercise programs are critical for a full recovery.

  • Complications: Any delays in healing or complications, such as infection, joint stiffness, or nerve damage, can extend the rehabilitation process.