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First (thumb) metacarpal fractures Author Josh Bloom, MD, MPH Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Mar 2013. | This topic last updated: nov 14, 2012. INTRODUCTION Metacarpal fractures are common [1]. They account for 30 to 40 percent of all hand fractures. First metacarpal (thumb) fractures make up almost 25 percent of all metacarpal fractures, placing them second only to fifth metacarpal fractures in terms of frequency. Of these fractures, over 80 percent involve the base of the metacarpal. Thumb fractures occur most often in children (0 to 16 years) and in older patients (>65 years). The thumb provides approximately 40 percent of hand function so metacarpal fractures can have grave consequences [2]. This topic will review issues related to fractures of the first (thumb) metacarpal. A general overview of metacarpal fractures is presented separately. (See "Overview of metacarpal fractures".) PERTINENT ANATOMY AND CLASSIFICATION The thumb is distinct from the other fingers anatomically and biomechanically. Accordingly, fractures to the thumb are considered separately from other metacarpal fractures. Thumb anatomy is discussed in greater detail separately. (See "Finger and thumb anatomy".) The majority of thumb metacarpal fractures occur at the base. Fractures of the thumb metacarpal are classified into four patterns (figure 1). Types I and II are intraarticular fractures and Types III and IV are extraarticular. Discerning whether the articular surface is involved in the fracture is critical as this dictates management. Type I injury ("Bennett's fracture") is a fracture-dislocation of the base of the metacarpal (image 2C). In this injury, a proximal metacarpal fragment maintains its ulnar aspect attachment to the trapezium via the volar ligament. The distal aspect of the metacarpal is supinated and dislocated radially by the adductor pollicis. The proximal aspect of this fragment is pulled proximally by the abductor pollicis brevis and abductor pollicis longus [3]. Type II injuries ("Rolando's fracture") can be thought of as a comminuted version of a Bennett's fracture, in which the fragments may form a T or Y pattern at the base of the MC (image 1). Severe comminution may occur and, in these cases, the classic Y or T pattern is not present. Type II fractures are quite difficult to treat, but fortunately, are a rare type of first metacarpal fracture. Type III fractures are the most common thumb fractures and are extraarticular (image 2A-B), either transverse or, less commonly, oblique. Type IV fractures are extraarticular pediatric injuries involving the proximal physis and are not addressed in this review. MECHANISM OF INJURY First metacarpal fractures typically occur with an axial load to a partially flexed thumb. Fistfights are a frequent culprit in these fractures. First metacarpal fractures can also be seen with hyperabduction and/or hyperflexion occurring with a fall. If a torsional force is included in the mechanism, the fracture will often be oblique. Intraarticular and extraarticular fractures occur from similar mechanisms. Section Editor Patrice Eiff, MD Deputy Editor Jonathan Grayzel, MD, FAAEM

SYMPTOMS AND EXAM FINDINGS Patients with first metacarpal fractures present with pain, dorsal swelling over the base of the metacarpal and difficulty with range of motion (ROM) at the metacarpophalangeal (MCP) and carpometacarpal (CMC) joints. It is important to distinguish tenderness at the base of the first metacarpal from injury to the scaphoid, trapezium, or distal radius. In addition, if pain, swelling, or ecchymosis occurs more distally at the MCP joint (particularly on the ulnar side), care should be taken to look for a potential injury to the ulnar collateral ligament ("Game Keeper's Thumb"). (See "Ulnar collateral ligament injury (gamekeeper's or skier's thumb)".) RADIOGRAPHIC FINDINGS Three views of the thumb are indicated to assess potential fractures of the thumb metacarpal. In addition to lateral and oblique views, a true AP (Robert's view) should be taken. This view, taken in maximum pronation, provides good visualization of the CMC joint. A true lateral (Betts view) of a Bennetts fracture dislocation can be obtained with the palm on the cassette, and the hand then pronated 15 to 20 degrees and the tube angled proximally 15 degrees [3]. Close inspection of an apparent extraarticular fracture is required to ensure that no portion of the fracture line involves the joint surface (image 2A-C). An oblique extraarticular injury can be confused with a Bennett's fracture. CT scanning is helpful at times, particularly with regard to potential impaction injury and to define the CMC joint and fracture fragment position in intraarticular injuries. INDICATIONS FOR REFERRAL All intraarticular first metacarpal fractures warrant referral. Because the integrity of the CMC joint is crucial to hand function, meticulous maintenance of the joint surface is required and most intraarticular fractures require surgical fixation. Less than 1 mm of displacement is desired for optimal outcome [4]. Extraarticular fractures, on the other hand, are usually managed without surgical intervention. However, if adequate reduction either cannot be attained by closed manipulation or maintained, referral is indicated. This is particularly important in transverse extraarticular fractures, which often have apex radial angulation. Due to the relatively unstable nature of oblique fractures, patients should be informed about the risk of displacement of these fractures, particularly in those requiring reduction. INITIAL TREATMENT Splinting is used in the initial immobilization of metacarpal fractures [1,5]. A detailed description of the techniques for applying splints is presented separately. (See "Splinting of musculoskeletal injuries" and "Patient information: Cast and splint care (Beyond the Basics)".) Intraarticular fractures Intraarticular fractures of the first metacarpal (ie, Type I - Bennett's fracture dislocation and Type II - Rolando's fracture) should be managed initially using a thumb-spica splint (picture 1) with the interphalangeal (IP) joint free and the wrist in 30 degrees of extension prior to being referred to orthopedics within two to three days. These patients should aggressively ice and elevate the hand and will need adequate analgesia. Extraarticular fractures Non-displaced extraarticular fractures of the first metacarpal should be placed in a short arm thumb-spica splint with the wrist in 30 degrees of extension and the splint extending to the IP joint and followed up in one week (picture 1). (See "Splinting of musculoskeletal injuries".) If the fracture is oblique or alignment is questionable, the patient should be seen back within three to five days. Up to 30 degrees of residual angularity is tolerated without functional impairment due to the inherent mobility of the thumb. Extraarticular fractures with >30 degrees of angulation require reduction (see 'Closed reduction' below). Definitive treatment for extraarticular fractures is thumb spica cast (with IP joint free) for four to six weeks. Patients should be made aware that significant swelling or overly aggressive icing to this radial side of the thumb can cause a temporary palsy to the superficial radial nerve resulting in numbness over the dorsum of the thumb. Closed reduction For angulated extraarticular fractures of the first metacarpal, closed reduction is appropriate prior to splinting. Reduction is typically performed by an orthopedic surgeon for thumb metacarpal fractures, however, if reduction is indicated and the treating clinician is comfortable with the procedure, or if there is no referral option available, reduction of extraarticular first metacarpal fractures can be achieved in the following manner: Anesthesia is generally readily achieved via hematoma block. Placement of a hematoma block for metacarpal fractures is described separately. (See "Metacarpal shaft fractures", section on 'Anesthesia'.)

Once adequate anesthesia is confirmed, apply gentle longitudinal traction to the distal fragment while applying pressure over the apex of the fracture and extending the IP joint. Mild pronation of the distal fragment may also help to achieve anatomic alignment. The fracture should then be immobilized with a thumb spica cast and post-reduction x-rays should be obtained to confirm alignment. FOLLOW-UP CARE Non-displaced fractures and those fractures with good initial reduction should be seen and reimaged in 7 to 10 days. Patients with oblique fractures or questionable reduction require imaging within three to five days. If follow-up films reveal angulation greater than 30 degrees, repeat reduction or referral is indicated. Fractures with stable position should be placed in a short arm thumb spica cast with the wrist in 30 degrees of extension and the IP joint free. Radiographs should be repeated at two-week intervals and immobilization should be continued for a total of four weeks. Following immobilization, active ROM exercise is initiated. Total healing time is six to eight weeks. RECOMMENDATIONS FOR RETURN TO WORK OR SPORT Patients requiring repetitive gripping at work can expect return to regular duty after they are pain free, the fracture site is nontender, and functional range of motion has been reestablished. If the patient desires return to contact sport, the thumb should be protected in a club-type pad or a firm thumb-spica orthosis for an additional six to eight weeks. SUMMARY AND RECOMMENDATIONS First (thumb) metacarpal fractures are common and generally involve the base of the metacarpal. The thumb is integral to normal function of the hand. Due to the unique anatomy and biomechanics of the thumb, first metacarpal fractures are described and managed differently than other metacarpal fractures. (See 'Pertinent anatomy and classification' above and 'Mechanism of injury' above.) Thumb metacarpal fractures are divided into two large groups: intraarticular and extraarticular. (See 'Radiographic findings' above.) Intraarticular fractures require orthopedic referral and generally need surgical fixation. (See 'Indications for referral' above.) Extraarticular fractures are typically managed in a closed fashion with thumb-spica immobilization and rarely require surgery. Extraarticular fractures do not require perfect anatomic reduction and can tolerate up to 30 degrees of angulation. (See 'Initial treatment' above.) Oblique extraarticular fractures should be carefully differentiated from Bennett's fractures, are prone to displacement, and need to be observed closely (particularly during the initial two weeks). ACKNOWLEDGMENTS We are saddened by the untimely death of John Marx, MD, who passed away in July 2012. We wish to acknowledge Dr. Marx's dedication and his many contributions to UpToDate, in particular, his work as editor-in-chief for Emergency Medicine and as a section editor and author for Adult Trauma. The author and editors would also like to acknowledge Kevin E Burroughs, MD, who contributed to earlier versions of this topic review. Use of UpToDate is subject to the Subscription and License Agreement. Topic 193 Version 7.0

GRAPHICS
Base of the first metacarpal fracture types

Type I (Bennet's fracture-dislocation) and type II (Rolando's fracture) are intraarticular. Type III fractures are extraarticular, either transverse (IIIA) or oblique (IIIB). Type IV fractures are seen only in children and involve the proximal epiphysis.

Reproduced with permission from: Eiff MP, Hatch RL, Calmbach WL. Fracture Management for Primary Care, 2nd ed., W.B. Saunders 2002. Copyright 2002 Elsevier.

Fracture of thumb metacarpal base: Type I (Bennett's)

Each of these anteroposterior radiographs shows an intraarticular fracture of the thumb metacarpal. The Type I or "Bennett's" fracture of the proximal 1st metacarpal illustrated here is characterized by its articular involvement and the persistent attachment of the volar fragment to the trapezium.
Courtesy of Kevin Burroughs, MD.

Fracture of the 1st metacarpal base: Type II (Rolando)

This plain radiograph shows a comminuted, intraarticular fracture of the thumb metacarpal. The eponym for this injury is Rolando's fracture.
Courtesy of Kevin E. Burroughs, MD.

Extraarticular fracture of the first metacarpal

This anteroposterior radiograph shows a type III fracture of the proximal 1st metacarpal with characteristic sparing of the articular surface. Significant shortening of the metacarpal is also apparent in this view.
Courtesy of Kevin Burroughs, MD.

Nondisplaced thumb metacarpal fracture

In this radiograph a nondisplaced fracture of the thumb metacarpal distal to the carpal metacarpal joint is seen. This is a nondisplaced type III fracture of the first metacarpal.
Courtesy of Kevin Burroughs, MD.

Thumb spica splint

The thumb spica splint provides excellent immobilization for the thumb. It is often used for carpometacarpal osteoarthritis, de Quervain's tenosynovitis, ulnar collateral ligament injury (gamekeeper's or skier's thumb), and fractures of the scaphoid, trapezium, and first metacarpal.
Courtesy of Bruce C Anderson, MD.

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