Metacarpal and Phalangeal Fractures

Buddy Strapping Posi Z-Splint (Position of Safe immobilisation Splint) Elevation of the Limb

Initial Evaluation

  1. All open injuries (open fractures as well as associated nail bed injuries) associated with fractures, warrant admission for intravenous antibiotics and surgical debridement. Check for fight-bites.
  2. The management is generally centred around the clinical evaluation and the X-rays are secondary in the decision for surgery or not
  3. Movement is life: These injuries generally do best when mobilised in the early phase, instead of being splinted for too long.
  4. Three factors are usually considered:
    • Length of the finger (compared to the other side) or the height of the knuckle).
    • The function of the musculo-tendinous units facilitating flexion/extension.
    • Rotation of the finger: In extension, viewed from dorsal, all the nails must be in the same plane. Consider subtle pronation or supination deformities secondary to the fracture. Always compare to the uninjured hand. In flexion all the fingers must point towards the scaphoid tubercle on the palm. Scissoring is a phenomenon where the fingers cross like the blades of scissors when the patient is asked to flex the fingers. This indicates a rather serious rotational deformity.

Metacarpal and Phalangeal Fractures Evaluation Evaluation of Metacarpal and Phalangeal Fractures

Radiological Evaluation

  1. If a metacarpal fracture is suspected, request PA, lateral and oblique x-ray views of the hand.
  2. If a digital fracture is suspected, request x-rays views of only the affected finger:
    (PA & Lateral)
  3. Boxer’s fractures: Fracture of the fifth metacarpal neck. Accept up to 45°of volar angulation, providing that function and rotation is normal.
  4. Keep in mind that fractures on the proximal volar edge of the middle phalanx represent a fracture dislocation of the PIPJ.
  5. Fractures of the distal phalanx are most commonly crush injuries and are generally associated with nail bed injuries.

Definitive Management

  1. All rotational deformities will require surgical intervention.
  2. All open fractures need to be admitted.
  3. Loss of length with substantial extension lag will require surgical intervention and should be reviewed by a hand surgeon.
  4. Loss of length with no extension lag will do well but will require rehabilitation to improve function.

Splinting / Immobilisation in Trauma Setting

Buddy Strapping Posi Z-Splint (Position of Safe immobilisation Splint)

  1. Buddy strap adjacent neighbouring fingers in uncomplicated metacarpal and phalangeal fractures where the swelling is minimal. Encourage early mobilisation.
  2. Apply a POSI splint where the hand is globally swollen to facilitate the soft tissue envelope to settle first, before any other therapy is considered.

Buddy Strapping the fingers  POSI Z Splint to immobilise the fracture


  1. The therapist will educate the patient regarding the injury/surgery, anatomy, healing timeframes, prognosis, complications, and safe use of the hand. A realistic timeframe for healing is 8-12 weeks.
  2. Splinting for 4 weeks to protect the fracture and facilitate healing is recommended. The splint can be removed for hand hygiene and range of movement exercises. This is followed by 2 weeks of protective splint wear (at night and in vulnerable situations).
  3. Oedema management through elevation, compression wrap and anti-oedema exercises is encouraged.
  4. Early active mobilisation is commenced to prevent stiffness of the fingers. The patient is taught an exercise programme to complete at home. This is upgraded, based on clinical signs of healing, to include passive and resisted exercises at 6-8 weeks post surgery.
  5. Splints may be used to facilitate stretching of stiff joints.
  6. The therapist assists with scar management i.e. scar massage, silicon products and pressure garments.
  7. Hand strengthening is commenced at 6 - 8 weeks post injury, depending on clinical signs of healing.
  8. The therapist may facilitate return to function and work, if deficits remain.

Metacarpal and Phalangeal Fractures Rehabilitation
Rehabilitation of Hand and Arm Fractures
Metacarpal and Phalangeal Fractures Rehabilitation