What's the diagnosis? By Dr. Becca Fieles


27 year old male with no significant past medical history presents with right hand pain and swelling after punching his assailant in the face.  Xrays shown below. What’s the diagnosis? Scroll down for answer.






Answer:  Second Metacarpal Shaft Fractrure






Metacarpal Fractures

Etiology: More common in men; most often from fistfight, car accident, fall or sometimes a crush injury.  The incidence of fracture of each metacarpal bone increases from ulnar to radial side of the hand with the fifth metacarpal being fractured most often. 

Presentation:  Young man presenting after punching a wall or another person or an elderly woman after falling onto hand.  They present with hand pain, swelling, ecchymosis, deformity or finger misalignment. 

Labs/Imaging: Xray of hand with three views

Diagnosis:  Ddx: carpal bone fracture, carpal bone dislocation, metacarpal dislocation, ligamentous injury.  Fracture can be seen on Xrays

Management:  Tetanus and antibiotics as indicated by cause of injury (dirty wound, fight bite, etc.) 

Factors determining operative vs nonoperative management:

  • Degree of angulation
      • Acceptable angulation: 10 degrees in 2nd metacarpal, 20 degrees in 3rd metacarpal, 30 degrees in 4th metacarpal, 40 degrees in 5th metacarpal
  • Amount of displacement or rotation


Splint should place metacarpal-phalangeal joint in full flexion. Within the cast, the affected finger should be buddy-taped to its neighbor. Patient should have ortho follow up within 1-2 weeks.