Metacarpal and Phalangeal Fracture Fixation

Metacarpal and Phalangeal Fracture Fixation, radiograph of a fourth metacarpal neck fracture
Radiograph of a fourth metacarpal neck fracture. Image by Louis Philippe Lessard, Wikimedia Commons, CC BY-SA 3.0.

Indications

  • Rotational malalignment, seen as scissoring on flexion
  • Unstable or shortened fractures
  • Intra-articular step
  • Multiple or open fractures
  • Most metacarpal and phalangeal fractures are treated without surgery
  • Boxer fractures of the fifth metacarpal neck tolerate up to about 70 degrees of angulation
  • Rotational deformity of even 5 degrees can cause scissoring

Position

  • Supine, hand table, tourniquet
  • Image intensifier with a mini C arm
  • WALANT allows assessment of active tendon gliding

Operative Steps

  1. Check rotation with tenodesis or active flexion under WALANT
  2. K wires, crossed or intramedullary, for closed reduction
  3. Lag screws for long oblique or spiral fractures at least twice the bone diameter
  4. Dorsal plates for unstable shaft fractures, at the cost of tendon adhesion
  5. Intramedullary headless screws for transverse metacarpal fractures
  6. Bennett fractures need reduction of the metacarpal shaft against the volar beak
  7. Condylar fractures of the phalanx are unstable and need fixation
  8. Avoid placing plates on the dorsum of proximal phalanges where possible

Postoperative Care

  • Early motion in a hand therapy program
  • Buddy strapping
  • Position of safe immobilisation with MCP joints flexed and IP joints extended
  • K wires removed at about 4 weeks

Complications

  • Stiffness and extensor tendon adhesions
  • Malrotation
  • Pin tract infection
  • Nonunion is rare
  • Loss of reduction with early motion after wire fixation

Related Pages

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.