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Metacarpal Neck Fractures (Except Thumb)

By Danielle Campagne, MD, Assistant Clinical Professor, Department of Emergency Medicine, University of San Francisco - Fresno

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Patient Education

Metacarpal neck fractures usually result from an axial load (eg, from punching with a clenched fist).

Metacarpal neck fractures are common. They cause pain, swelling, tenderness, and sometimes deformity. Rotational deformity (see Figure: Rotational deformity due to a fracture in the hand.) may occur. The 5th metacarpal is most commonly injured by punching (boxer's fracture).

Rotational deformity due to a fracture in the hand.

Normally, when the proximal interphalangeal joints are flexed to 90°, lines from the distal phalanges converge at a point on the proximal carpal bones. Deviation of one of these lines suggests a metacarpal fracture.


  • X-rays

Typically, anteroposterior, lateral, and oblique views are diagnostic.


  • Sometimes prophylactic antibiotics for open wounds

  • Splinting

  • For certain fractures, reduction

If patients have any wounds, particularly linear punctures, near the metacarpophalangeal joint, they should be specifically questioned about whether they punched someone in the mouth. If they did, contamination with human oral flora is possible, and measures to prevent infection (eg, wound exploration and cleaning, prophylactic antibiotics) are often required.

Treatment of a metacarpal neck fracture is with a splint (eg, an ulnar gutter splint for fractures of the 4th or 5th metacarpal—see Figure: Ulnar gutter splint.), usually for at least a few weeks. Whether reduction is needed before the splint is applied depends on the fracture.

Reduction is not necessary for dorsal or volar angulation of

  • < 35° for the 4th metacarpal

  • < 45° for the 5th metacarpal

Reduction is necessary for

  • Rotational deformity of any metacarpal

  • Fractures of the 2nd and 3rd metacarpals with angulation

Usually, closed reduction is possible. Use of a hematoma block or an ulnar nerve block can help reduce the pain during reduction.

After the splint is removed, patients can gradually begin range-of-motion exercises.

Ulnar gutter splint.

Key Points

  • Metacarpal neck fractures cause pain, swelling, tenderness, and sometimes deformity (eg, rotational deformity).

  • Take anteroposterior, lateral, and oblique x-rays.

  • If patients have wounds near the metacarpophalangeal joint, ask them whether they punched someone in the mouth; if they did, take measures to prevent infection (eg, prophylactic antibiotics).

  • Treat a metacarpal neck fracture with a splint; if angulation is significant or if rotational deformity is present, reduce the fracture first, usually using closed reduction.

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